The aim of the current study was to explore the whole‐brain dynamic functional connectivity patterns in acute ischemic stroke (AIS) patients and their relation to short and long‐term stroke severity. ...We investigated resting‐state functional MRI‐based dynamic functional connectivity of 41 AIS patients two to five days after symptom onset. Re‐occurring dynamic connectivity configurations were obtained using a sliding window approach and k‐means clustering. We evaluated differences in dynamic patterns between three NIHSS‐stroke severity defined groups (mildly, moderately, and severely affected patients). Furthermore, we built Bayesian hierarchical models to evaluate the predictive capacity of dynamic connectivity and examine the interrelation with clinical measures, such as white matter hyperintensity lesions. Finally, we established correlation analyses between dynamic connectivity and AIS severity as well as 90‐day neurological recovery (ΔNIHSS). We identified three distinct dynamic connectivity configurations acutely post‐stroke. More severely affected patients spent significantly more time in a configuration that was characterized by particularly strong connectivity and isolated processing of functional brain domains (three‐level ANOVA: p < .05, post hoc t tests: p < .05, FDR‐corrected). Configuration‐specific time estimates possessed predictive capacity of stroke severity in addition to the one of clinical measures. Recovery, as indexed by the realized change of the NIHSS over time, was significantly linked to the dynamic connectivity between bilateral intraparietal lobule and left angular gyrus (Pearson's r = −.68, p = .003, FDR‐corrected). Our findings demonstrate transiently increased isolated information processing in multiple functional domains in case of severe AIS. Dynamic connectivity involving default mode network components significantly correlated with recovery in the first 3 months poststroke.
By employing dynamic functional connectivity analyses, Bonkhoff et al. demonstrate that severe acute ischemic stroke is linked to transiently increased isolated information processing in multiple functional domains. Additionally, they show that dynamic connectivity involving default mode network components significantly correlates with recovery in the first three months poststroke.
OBJECTIVETo assess the association of baseline imaging markers of cerebral small vessel disease (SVD) and brain frailty with clinical outcome after acute stroke in the Efficacy of Nitric Oxide in ...Stroke (ENOS) trial.
METHODSENOS randomized 4,011 patients with acute stroke (<48 hours of onset) to transdermal glyceryl trinitrate (GTN) or no GTN for 7 days. The primary outcome was functional outcome (modified Rankin Scale mRS score) at day 90. Cognition was assessed via telephone at day 90. Stroke syndrome was classified with the Oxfordshire Community Stroke Project classification. Brain imaging was adjudicated masked to clinical information and treatment and assessed SVD (leukoaraiosis, old lacunar infarcts/lacunes, atrophy) and brain frailty (leukoaraiosis, atrophy, old vascular lesions/infarcts). Analyses used ordinal logistic regression adjusted for prognostic variables.
RESULTSIn all participants and those with lacunar syndrome (LACS; 1,397, 34.8%), baseline CT imaging features of SVD and brain frailty were common and independently associated with unfavorable shifts in mRS score at day 90 (all participantsSVD score odds ratio OR 1.15, 95% confidence interval CI 1.07–1.24; brain frailty score OR 1.25, 95% CI 1.17–1.34; those with LACSSVD score OR 1.30, 95% CI 1.15–1.47, brain frailty score OR 1.28, 95% CI 1.14–1.44). Brain frailty was associated with worse cognitive scores at 90 days in all participants and in those with LACS.
CONCLUSIONSBaseline imaging features of SVD and brain frailty were common in lacunar stroke and all stroke, predicted worse prognosis after all acute stroke with a stronger effect in lacunar stroke, and may aid future clinical decision-making.
IDENTIFIERISRCTN99414122.
IMPORTANCE: In nonurban areas with limited access to thrombectomy-capable centers, optimal prehospital transport strategies in patients with suspected large-vessel occlusion stroke are unknown. ...OBJECTIVE: To determine whether, in nonurban areas, direct transport to a thrombectomy-capable center is beneficial compared with transport to the closest local stroke center. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, population-based, cluster-randomized trial including 1401 patients with suspected acute large-vessel occlusion stroke attended by emergency medical services in areas where the closest local stroke center was not capable of performing thrombectomy in Catalonia, Spain, between March 2017 and June 2020. The date of final follow-up was September 2020. INTERVENTIONS: Transportation to a thrombectomy-capable center (n = 688) or the closest local stroke center (n = 713). MAIN OUTCOMES AND MEASURES: The primary outcome was disability at 90 days based on the modified Rankin Scale (mRS; scores range from 0 no symptoms to 6 death) in the target population of patients with ischemic stroke. There were 11 secondary outcomes, including rate of intravenous tissue plasminogen activator administration and thrombectomy in the target population and 90-day mortality in the safety population of all randomized patients. RESULTS: Enrollment was halted for futility following a second interim analysis. The 1401 enrolled patients were included in the safety analysis, of whom 1369 (98%) consented to participate and were included in the as-randomized analysis (56% men; median age, 75 IQR, 65-83 years; median National Institutes of Health Stroke Scale score, 17 IQR, 11-21); 949 (69%) comprised the target ischemic stroke population included in the primary analysis. For the primary outcome in the target population, median mRS score was 3 (IQR, 2-5) vs 3 (IQR, 2-5) (adjusted common odds ratio OR, 1.03; 95% CI, 0.82-1.29). Of 11 reported secondary outcomes, 8 showed no significant difference. Compared with patients first transported to local stroke centers, patients directly transported to thrombectomy-capable centers had significantly lower odds of receiving intravenous tissue plasminogen activator (in the target population, 229/482 47.5% vs 282/467 60.4%; OR, 0.59; 95% CI, 0.45-0.76) and significantly higher odds of receiving thrombectomy (in the target population, 235/482 48.8% vs 184/467 39.4%; OR, 1.46; 95% CI, 1.13-1.89). Mortality at 90 days in the safety population was not significantly different between groups (188/688 27.3% vs 194/713 27.2%; adjusted hazard ratio, 0.97; 95% CI, 0.79-1.18). CONCLUSIONS AND RELEVANCE: In nonurban areas in Catalonia, Spain, there was no significant difference in 90-day neurological outcomes between transportation to a local stroke center vs a thrombectomy-capable referral center in patients with suspected large-vessel occlusion stroke. These findings require replication in other settings. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02795962
Background
The Indian data concerning the endovascular mechanical thrombectomy (MT) in acute ischemic strokes (AIS) with large vessel occlusion (LVO) is still scarce and evolving. Tenecteplase (TNK) ...has been recently approved for intravenous stroke thrombolysis prior to the MT.
Methods
This study is a single-center retrospective study. We performed data analysis of the AIS patients who consecutively presented during the study period with LVO and underwent thrombectomy. Procedural success was defined by the post-thrombectomy angiographic picture of grades 2b and 3 on modified Thrombolysis in Cerebral Infarction (mTICI) scale. Primary efficacy outcome was defined as an improvement of ≥4 points in National Institute of Health Stroke Scale (NIHSS) score at 24 h. Secondary efficacy outcome was based on modified Rankin Scale (mRS) score at 90 days. We also performed a comparative analysis of TNK and alteplase subgroups.
Results
Successful recanalization (mTICI 2b/3) was achieved in 65 (86.67%) patients. There was a significant mean difference between the NIHSS scores on admission and at 24 h (P < .001). Likewise, mRS score at 3 months also showed a significant mean difference as compared to baseline (P < .001). A faster recanalization was observed in those who were thrombolyzed with TNK, needed fewer number of passes, and if the procedure was performed under conscious sedation.
Conclusion
This study further strengthens the Indian data on efficacy and safety of MT in LVO ischemic strokes. Besides, whether the observation of TNK resulting in a faster revascularization is due to some factors unaccounted in our study, or an actual effect on thrombus due to a high fibrin specificity, needs to be tested further in larger randomized studies with matched sample sizes.
BackgroundEndovascular thrombectomy is the gold standard treatment for emergent proximal large vessel occlusion stroke. The safety and efficacy of thrombectomy in distal branch occlusion is not well ...understood. We aimed to evaluate the technical safety and feasibility of thrombectomy in distal vessel occlusion (DVO).MethodsWe performed a retrospective analysis of consecutive acute stroke patients with distal intracranial occlusion (defined as M3, A2 or P2 occlusion) who underwent thrombectomy within 24 hours from the time of last known well. The primary efficacy outcome was successful reperfusion (TICI≥2B). Secondary outcomes included successful recanalization with ≤3 passes. The safety outcome included the rate of subarachnoid hemorrhage (SAH), all intracranial hemorrhages (ICH) and symptomatic ICH (sICH).ResultsTotal of 72 patients with acute DVO treated with thrombectomy were identified. The median (IQR) age was 70 (20), 38% women, and 21% African-American. The site of occlusion included M3 (54%), P2 (28%), and A2 (18%) segments of middle, posterior and anterior cerebral arteries, respectively. Admission NIHSS score median (IQR) was 12 (11), and 90% of the patients had baseline mRS≤ 2. Thirty six percent of the patients had received intravenous thrombolytic therapy. Successful recanalization was achieved in 90% of the patients. Forty six percent of the procedures were performed under general anesthesia. Direct aspiration technique was used in 64% of the patients. The median number of passes was 2, with successful thrombectomy achieved with ≤3 passes in 83% of the patients. ICH was seen in 16% of the patients, including 3 SAH. However, only one patient (1.3%) had sICH. Among 48 patients in whom 90-day outcome data was available, 44% had favorable clinical outcome (mRS≤2).ConclusionThis single center, consecutive real-world experience demonstrates that thrombectomy in DVO stroke patients is safe and leads to high rate of successful recanalization. Further studies are warranted to evaluate the efficacy of thrombectomy in DVO in comparison to best medical management.Disclosures S. Majidi: None. S. Matsoukas: None. R. De Leacy: None. T. Oxley: None. H. Shoirah: None. T. Shigematsu: None. C. Kellner: None. J. Fifi: None. J. Mocco: None.
IntroductionElderly individuals are at an increased risk for stroke and are responsible for a substantial portion of the total stroke burden. The safety and efficacy of thrombectomy in nonagenarians ...is not fully understood, as they have traditionally been excluded from major endovascular trials. Recent literature suggests 7% of patients have functional independence at 3 months following medical management. This research aims to determine the outcomes of thrombectomy in patients ≥ 90 years with proximal intracranial occlusion.MethodsWe performed a multicenter retrospective analysis of consecutive acute ischemic stroke patients with M1 occlusion treated within 24 hours from the time of last known well who were greater than 89 years of age. Patient demographics, periprocedural metrics, and discharge and 90-day modified Rankin Scale (mRS) scores were collected. Successful recanalization was defined as TICI 2B or better. Favorable outcome was defined as 90-day mRS≤2 for patients prestroke mRS<2, and no worsening of prestroke mRS at 90-day in patients with prestrike mRS>2.ResultsSeventy-one patients over 89 years old were identified. Fifty-two (73.2%) were female. Pre-stroke mRS scores were available for 70 patients. The baseline median mRS was 2. Successful recanalization was achieved in 95.8% of patients. TICI 2C or greater was accomplished in 64.8% of cases. Functional outcome data at 90-days were available for 57 patients (80.2%). At three months, 7 total patients had an mRS between 0–2 (12.3%), and an additional 11 patients had an mRS of 3 (19.2%). The rate of 90-day mortality was 42%.ConclusionsMechanical thrombectomy in nonagenarians is technically feasible with high rate of successful reperfusion and it may improve clinical outcome. More research is needed to determine if thrombectomy results in significantly better functional outcomes than medical management for nonagenarians.Disclosures S. Majidi: None. J. Vargas: 2; C; Cerenovus, Medtronic. 4; C; Truvic. J. Blalock: None. H. Hawk: None. S. Nimjee: None. A. Zakeri: None. M. Mokin: 2; C; Medtronic, Cerenovus. 4; C; Endostream, Serenity medical. R. Kellogg: None. G. Cortez: None. A. Aghaebrahim: None. E. Sauvageau: None. R. Hanel: 1; C; Stryker, Medtronic. 2; C; Stryker, Medtronic, Balt, Cerenovus, Microvention, Q’Apel, Rapid Medical. 4; C; Scientia, RisT, Corindus. R. DeLeacy: None. A. Siddiqui: 1; C; NIH-NINDS R21 NS109575-01. 2; C; Cerenovus, Imperitive Care, Medtronic, Microvention, Penumbra, Q’Apel. 4; C; Imperitive Care, Q’Apel, Rist, Truvic. A. Turk: 2; C; Imperitive Care, Stryker, Microvention, Penumbra, BALT, Cerenovus. 4; C; Imperitive Care. M. Oselkin: None. E. Marlin: None. R. Turner: 2; C; Q’apel, Cerenovus, Siemens. 4; C; Q’APel. I. Chaudry: 2; C; Cerenovus, Q’Apel. 4; C; Q’Apel. J. Milburn: None.
BackgroundMedium-vessel occlusions (MeVOs) account for 25%-40% of all acute ischemic stroke (AIS) cases. With peri-procedural embolization occurring in up to 9% of all EVT cases, secondary MeVOs are ...of particular interest to neurointerventionalists. There is currently no reliable evidence regarding whether EVT is safe and effective for MeVO strokes. We sought to gain insight into the current management approaches regarding EVT in AIS caused by secondary MeVOs.MethodsWe conducted an international case-based survey (MeVO-Finding Rationales and Objectifying New Targets for IntervEntional Revascularization in Stroke; MeVO-FRONTIERS) among stroke physicians to gain insight into the current management approaches regarding EVT in AIS caused by secondary MeVOs. Survey participants were presented three cases involving secondary MeVO, each consisting of three case-vignettes with differences in the neurological status of the described patient (improvement, no change, unable to assess due to general anaesthesia). Univariate and multivariate logistic regression analyses clustered by respondent identity were performed to assess factors influencing the decision to treat.Results366 physicians (56 women, 308 men, 2 of undisclosed gender) of different specialities from 44 countries completed the survey for a total of 3294 responses. The majority of physicians (54.1%, 1782/3294) were in favor of EVT. Participants were more likely to treat patients if the occlusion site was in the anterior M2/3 (74.3%; risk ratio RR 2.62, 95%CI:2.27-3.03) and A3 (59.7%; RR 2.11, 95%CI:1.83-2.42) segments, compared to those in the M3/4 segment (28.3%; reference). An improvement in neurological status led to a significant decrease in the likelihood to pursue EVT compared to patients whose neurological deficit remained unchanged (49.9% versus 57% responses in favor of EVT, respectively; RR 0.88, 95%CI:0.83-0.92). Interventionalists and more experienced physicians were more likely to treat secondary MeVOs.ConclusionOur findings suggest that physician’s willingness to treat secondary MeVOs endovascularly is limited and varies per occlusion location and change in neurological status. More evidence on the safety and efficacy of EVT for secondary MeVO stroke is needed.Disclosures P. Cimflova: None. R. McDonough: None. M. Kappelhof: None. J. Ospel: None. N. Singh: None. N. Kashani: None. A. Demchuk: None. B. Menon: None. M. Chen: 2; C; Medtronic, Genentech, Stryker, Microvention, Cerenovus, Penumbra. N. Sakai: None. J. Fiehler: None. M. Goyal: 2; C; Mentice, Medtronic, Microvention, Stryker.
IntroductionCharacteristics of clots from stroke patients have gained a lot of interest in recent years as they could provide insights to improve the endovascular and medical management of ischemic ...stroke. Histology have been used to quantify the clot compositions, but analysis of clot structural pattern has been limited to qualitative description.MethodsFrom the STRIP (stroke thromboembolism registry of imaging and pathology) registry, we analyzed clots from 157 passes retrieved by mechanical thrombectomy from stroke cases where TICI 2c/3 was achieved. The clots were stained with Martius Scarlet Blue. To quantify the clot heterogeneity, we developed an algorithm to automatically segment scanned images into uniform grids and calculate the composition within each grid. Using the variance of compositions across neighboring grids, we proposed and implemented a formula to calculate the spatial heterogeneity index (SPI) value. To validate the clinical significance, we compared the clot SPI and clot compositions (red blood cells, fibrin, platelets, white blood cells) between cases with first pass effect (FPE) and cases without. SPI values of clots from cases with different etiologies, thrombectomy techniques, and tPA admission were also compared.ResultsThe average SPI value was 0.040 (SD 0.019) with a large range (0.001-0.091) with a grid size of 0.3 mm. For cases with FPE (n = 107), SPI was significantly smaller (0.038 vs 0.044, p =0.05) compared to those without (n = 50). In comparison, none of the clot compositions was significantly different between cases with FPE and cases without. There was no significant difference in heterogeneity for clots from cases with different etiologies or retrieved with different thrombectomy techniques. Admission of tPA didn’t change the clot heterogeneity either.ConclusionSPI is a useful measure of clot structural heterogeneity and could provide more insights to improve the thrombectomy outcome compared to clot compositions.Disclosures Y. Liu: None. W. Brinjikji: None. M. Abbasi: None. D. Dai: None. J. Arturo Larco: None. D. Kallmes: None. L. Savastano: None.
IntroductionLimited data is available about the outcomes of mechanical thrombectomy (MT) in stroke patients presenting with a large core infarct. We aim to investigate the safety and efficacy of MT ...in patients with large vessel occlusion and Alberta Stroke Program Early CT Score (ASPECTS) of 2-5.MethodsData from Stroke Thrombectomy and Aneurysm Registry (STAR), which combined the prospectively maintained databases of 28 thrombectomy-capable stroke centers in the US, Europe, and Asia, was interrogated. We identified thrombectomy patients presenting with an occlusion in the Internal carotid artery (ICA) or M1 segment of the middle cerebral artery (MCA). Multivariable regression analysis was performed to assess factors associated with favorable 90-day outcome (modified Rankin scale 0-3), including interaction terms between ASPECTS 2-5 and receiving MT in the extended window (≥ 6 hours from symptom-onset).ResultsAmong MT patients who presented with ICA or M1 occlusion, 2132 had ASPECTS≥6 and 213 patients had ASPECTS 2-5. Patients in the low ASPECTS group were younger (70 vs. 72 years old, P=0.003) and more likely to present with an ICA occlusion (47.9% vs. 28.8%, P<0.001) compared to patients with ASPECTS≥6. At 90 days, mRS 0-3 was observed in 36.6% of the patients who presented with ASPECTS 2-5 (42% in patients who had successful recanalization and 10.8% in patients who had failed recanalization, P=0.001) (figure 1). Lower ASPECTS and presenting in the extended window were both associated with worse 90- day outcomes after controlling for potential confounders, without significant interaction between these two factors.ConclusionMore than one in three patients presenting with ASPECTS (2-5) may achieve favorable 90-day functional outcome following MT. Favorable outcome was 4 times higher in low ASPECTS patients who had successful recanalization. The effect of low ASPECTS on 90-day outcome did not differ in patients presenting in the early versus extended MT window.Abstract O-011 Figure 1Disclosures E. Almallouhi: None. S. Al Kasab: None. Z. Hubbard: None. G. Porto: None. A. Alawieh: None. R. Chalhoub: None. E. Bass: None. P. Jabbour: None. R. Starke: None. S. Wolfe: None. A. Arthur: None. I. Maier: None. J. Grossberg: None. A. Rai: None. M. Park: None. J. Mascitelli: None. M. Psychogios: None. R. De Leacy: None. D. Raper: None. T. Dumont: None. M. Levitt: None. A. Polifka: None. J. Osbun: None. R. Crosa: None. J. Kim: None. W. Casagrande: None. M. Mokin: None. C. Matouk: None. A. Shaban: None. I. Fragata: None. A. Yoo: None. A. Spiotta: 1; C; Stryker, Penumbra, and Medtronic. 2; C; Penumbra, Stryker, Cerenovus, Terumo.
Achieving substantial reperfusion in the first pass is a strong predictor of clinical outcomes. Its role in preventing symptomatic ICH (sICH) is incompletely characterized.We assess the association ...of increasing number of passes with sICH using a large multicenter, prospectively collected international registry with core-lab adjudicated blinded imaging endpoints.We analyzed all patients receiving EVT for LVO in the COMPLETE (Penumbra, Inc) registry. SICH at 24 hours was defined as greater than four-point increase in NIHSS associated with ICH after review by two independent physicians. Multivariable analysis adjusted for age, NIHSS, occlusion location, and ASPECTS were used to assess the likelihood of developing sICH.Among 650 patients included in the analysis, median age was 70 IQR 60–79 and 54% were female. Average number of passes was 1.5. First pass mTICI 2b-3 was achieved in 55.5% (358/645) while 32.2% (208/645) required two or greater attempts. SICH occurred in 25 (3.8%) and PH-2 in 20 (3.1%). We identified an increased likelihood of sICH with increasing number of attempts to achieve TICI 2b or greater (3 vs 1 pass, OR = 3.98 95% CI, 1.05–15.0, and 4 vs 1 pass, OR = 5.04 95% CI, 1.35–18.8). Failure to achieve mTICI 2b or greater (79/645) was associated with increased incidence of sICH compared to first pass reperfusion (OR = 4.66, CI 95%, 1.43–15.1).Achieving substantial reperfusion with the fewest number of thrombectomy attempts was associated with decreasing likelihood of sICH.ReferencesZaidat OO, Castonguay AC, Linfante I, et al. First pass effect: a new measure for stroke thrombectomy devices. Stroke 2018;49(3):660–666. doi:10.1161/STROKEAHA.117.020315Maros ME, Brekenfeld C, Broocks G, et al. Number of retrieval attempts rather than procedure time is associated with risk of symptomatic intracranial hemorrhage. Stroke 2021;52(5):1580–1588. doi:10.1161/STROKEAHA.120.031242DisclosureAll COMPLETE trial investigators received support from Penumbra Inc
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