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Busto G, Casetta I, Morotti A, Barra A, Maccaglia MG, Bianchi A, Moretti M, Capasso F, Toffali M, Arba F, Limbucci N, Padovani A, Fainardi E. Multi-phase CT-Angiography outperforms angiographic careggi collateral score and predicts functional outcome in acute ischemic stroke. Neurol Sci 2024:10.1007/s10072-024-07703-5. [PMID: 39023711 DOI: 10.1007/s10072-024-07703-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 07/12/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Collaterals are a strong determinant of clinical outcome in acute ischemic stroke (AIS) patients undergoing Endovascular Treatment (EVT). Careggi Collateral Score (CCS) is an angiographic score that demonstrated to be superior to the widely suggested ASITN/SIR score. Multi-phase CT-Angiography (mCTA) could be alternatively adopted for collateral assessment. We investigated whether mCTA had an equivalent predictive performance for functional outcome compared to CCS. METHODS Consecutive AIS patients undergoing EVT for large vessel occlusion within 24 h from onset were analyzed. Receiver operating characteristic curves and multivariable logistic regression were investigated to evaluate the predictive performance of mCTA collateral score (range 0-5) and CCS (range 0-4) for good functional outcome (three-months modified Rankin Scale 0-2). RESULTS We included 201 subjects (59.7% females, mean age 75), of whom 96 (47.7%) had good outcome at three-months. Both CCS (OR = 14.4, 95% CI = 6.3-33.8) and mCTA (OR = 23.8, 95% CI = 10.1-56.4) collateral scores were independent predictors of outcome. The AUC of CCS was 0.80 (95% CI 0.73-0.86) and the best cut-off was ≥ 3 (87% sensitivity, 71% specificity), while the AUC of mCTA collateral score was 0.84 (95% CI 0.78-0.90) with an optimal cut-off of ≥ 4 (85% sensitivity, 87% specificity). Patients with good mCTA collaterals experienced smaller (16.6 vs. 63.7 mL, p < 0.001) infarct lesion as compared to those with mCTA poor collaterals. CONCLUSION mCTA discriminative ability for three-months 0-2 mRS was found to be comparable to CCS. mCTA appears a valid, non-invasive imaging modality for evaluating collaterals of AIS patients potentially eligible for EVT.
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Affiliation(s)
- Giorgio Busto
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy.
- Struttura Organizzativa Dipartimentale di Neuroradiologia, Dipartimento di Scienze Biomediche, Sperimentali e Cliniche "Mario Serio", Università degli Studi di Firenze, Ospedale Universitario Careggi, Largo Brambilla 3, 50134, Firenze, Italy.
| | | | - Andrea Morotti
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angelo Barra
- Department of Technical Health Professions and Rehabilitation, Careggi University Hospital, Florence, Italy
| | - Maria Giulia Maccaglia
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Andrea Bianchi
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Marco Moretti
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Francesco Capasso
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Maddalena Toffali
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Francesco Arba
- Stroke Unit, Careggi University Hospital, Florence, Italy
| | - Nicola Limbucci
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Alessandro Padovani
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
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Busto G, Morotti A, Casetta I, Barra A, Fiorenza A, Di Pasquale F, Maccaglia MG, Toffali M, Mancini S, Carlesi E, Palumbo V, Lombardo I, Padovani A, Fainardi E. Hypoperfusion intensity ratio correlates with collaterals and predicts outcome and infarct volume in acute ischemic stroke patients. Eur J Clin Invest 2024:e14264. [PMID: 38858830 DOI: 10.1111/eci.14264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 05/16/2024] [Accepted: 05/29/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Hypoperfusion Intensity Ratio (HIR) is associated with collaterals and outcome in acute ischemic stroke (AIS). We investigated whether a combined assessment of HIR and collaterals could provide an added value. METHODS Retrospective single-center study, including AIS patients with large vessel occlusion and endovascular treatment 0-24 h from onset. Predictors of FIV and outcome (90 days modified Rankin Scale 0-1) were investigated with linear and logistic regression respectively. Subjects were stratified in three groups: poor collaterals (grade 0-3) with poor HIR (≥.4), good collaterals (grade 4-5) with poor HIR/poor collaterals with good HIR (<.4) and good collaterals with good HIR. RESULTS We included 337 patients (median age 77, 53.1% males), of whom 100 (29.7%) had excellent outcome. One hundred and forty five patients with favourable collateral and HIR profiles had smaller infarct (median poor collaterals with poor HIR 41 mL, good collaterals with poor HIR/poor collaterals with good HIR 21 mL and good collaterals with good HIR 11 mL, p <.001) and higher rates of excellent outcome (poor collaterals with poor HIR 15.7%, good collaterals with poor HIR/poor collaterals with good HIR 26.2% and good collaterals with good HIR 39.3% p =.001). Logistic regression showed that patients with favourable collateral and HIR profiles had the highest odds of good outcome (OR: 3.83, 95% CI 1.62-9.08, p =.002). CONCLUSION Collaterals and HIR are independent predictors of final infarct lesion and outcome in stroke patients and their integration provides an added value. These findings might inform clinical practice and future trials.
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Affiliation(s)
- Giorgio Busto
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Andrea Morotti
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Ilaria Casetta
- Section of Neurology, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy
| | - Angelo Barra
- Department of Technical Health Professions and Rehabilitation, Careggi University Hospital, Florence, Italy
| | - Alessandro Fiorenza
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Francesca Di Pasquale
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Maria Giulia Maccaglia
- Diagnostic Imaging Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Maddalena Toffali
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Sara Mancini
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Edoardo Carlesi
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | | | - Ivano Lombardo
- Neuroradiology Unit, Department of Radiology, Careggi University Hospital, Florence, Italy
| | - Alessandro Padovani
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
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Krawchuk LJ, Sharrock MF. Prognostic Neuroimaging Biomarkers in Acute Vascular Brain Injury and Traumatic Brain Injury. Semin Neurol 2023; 43:699-711. [PMID: 37802120 DOI: 10.1055/s-0043-1775790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Abstract
Prognostic imaging biomarkers after acute brain injury inform treatment decisions, track the progression of intracranial injury, and can be used in shared decision-making processes with families. Herein, key established biomarkers and prognostic scoring systems are surveyed in the literature, and their applications in clinical practice and clinical trials are discussed. Biomarkers in acute ischemic stroke include computed tomography (CT) hypodensity scoring, diffusion-weighted lesion volume, and core infarct size on perfusion imaging. Intracerebral hemorrhage biomarkers include hemorrhage volume, expansion, and location. Aneurysmal subarachnoid biomarkers include hemorrhage grading, presence of diffusion-restricting lesions, and acute hydrocephalus. Traumatic brain injury CT scoring systems, contusion expansion, and diffuse axonal injury grading are reviewed. Emerging biomarkers including white matter disease scoring, diffusion tensor imaging, and the automated calculation of scoring systems and volumetrics are discussed.
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Affiliation(s)
- Lindsey J Krawchuk
- Department of Neurology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Matthew F Sharrock
- Department of Neurology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Dolotova DD, Blagosklonova ER, Muslimov RS, Ramazanov GR, Zagryazkina TA, Stepanov VN, Gavrilov AV. Inter-Rater Reliability of Collateral Status Assessment Based on CT Angiography: A Retrospective Study of Middle Cerebral Artery Ischaemic Stroke. J Clin Med 2023; 12:5470. [PMID: 37685536 PMCID: PMC10487547 DOI: 10.3390/jcm12175470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/12/2023] [Accepted: 08/15/2023] [Indexed: 09/10/2023] Open
Abstract
The importance of assessing the collateral status (CS) in patients with ischaemic stroke (IS) has repeatedly been emphasised in clinical guidelines. Various publications offer qualitative or semiquantitative scales with gradations corresponding to the different extents of the collaterals, visualised mostly on the basis of CTA images. However, information on their inter-rater reliability is limited. Therefore, the aim of this study is to investigate the inter-rater reliability of the scales for collateral assessment. CTA images of 158 patients in the acute period of IS were used in the study. The assessment of CS was performed by two experts using three methodologies: the modified Tan scale, the Miteff scale, and the Rosenthal scale. Cohen's kappa, weighted kappa and Krippendorff's alpha were used as reliability measures. For the modified Tan scale and the Miteff and Rosenthal scales, the weighted kappa values were 0.72, 0.49 and 0.59, respectively. Although the best measure of consistency was found for the modified Tan scale, no statistically significant differences were revealed among the scales. The impact of the CS on the degree of neurological deficit at discharge was shown for the modified Tan and Rosenthal scales. In conclusion, the analysis showed a moderate inter-rater reliability of the three scales, but was not able to distinguish the best one among them.
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Affiliation(s)
- Daria D. Dolotova
- Department of Bioinformatics, Department of Pediatric Surgery, Pirogov Russian National Research Medical University, Russian Ministry of Health, 117997 Moscow, Russia
- Research Department, Gammamed-Soft, Ltd., 127473 Moscow, Russia
| | | | - Rustam Sh. Muslimov
- Department of Radiology, Scientific Department of Emergency Neurology and Rehabilitation Treatment, N.V. Sklifosovsky Research Institute for Emergency Medicine, Moscow Health Department, 129090 Moscow, Russia
| | - Ganipa R. Ramazanov
- Department of Radiology, Scientific Department of Emergency Neurology and Rehabilitation Treatment, N.V. Sklifosovsky Research Institute for Emergency Medicine, Moscow Health Department, 129090 Moscow, Russia
| | | | - Valentin N. Stepanov
- Department of Radiology, Scientific Department of Emergency Neurology and Rehabilitation Treatment, N.V. Sklifosovsky Research Institute for Emergency Medicine, Moscow Health Department, 129090 Moscow, Russia
| | - Andrey V. Gavrilov
- Research Department, Gammamed-Soft, Ltd., 127473 Moscow, Russia
- Scobeltsyn Nuclear Physics Research Institute, Lomonosov Moscow State University, 119991 Moscow, Russia
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Fukuda KA, Liebeskind DS. Evaluation of Collateral Circulation in Patients with Acute Ischemic Stroke. Radiol Clin North Am 2023; 61:435-443. [PMID: 36931760 DOI: 10.1016/j.rcl.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
The cerebral collateral circulation is an increasingly important consideration in the management of acute ischemic stroke and is a key determinant of outcomes. Growing evidence has demonstrated that better collaterals can predict the rate of infarct progression, degree of recanalization, the likelihood of hemorrhagic transformation and various therapeutic opportunities. Collaterals can also identify those unlikely to respond to reperfusion therapies, helping to optimize resources. More randomized trials are needed to evaluate the risks and benefits of endovascular reperfusion with consideration of collateral status. This reviews our current understanding of the pathophysiologic mechanisms, effect on outcomes and strategies for improvement of the collateral system.
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Affiliation(s)
- Keiko A Fukuda
- Department of Neurology, University of California, Los Angeles, UCLA Comprehensive Stroke Center, UCLA Neurovascular Imaging Research Core, 635 Charles East Young Drive South, Suite 225, Los Angeles, CA 90095-7334, USA
| | - David S Liebeskind
- Department of Neurology, University of California, Los Angeles, UCLA Comprehensive Stroke Center, UCLA Neurovascular Imaging Research Core, 635 Charles East Young Drive South, Suite 225, Los Angeles, CA 90095-7334, USA.
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Lu Q, Zhang H, Cao X, Fu J, Pan Y, Zheng X, Wang J, Geng D, Zhang J. Quantitative collateral score for the prediction of clinical outcomes in stroke patients: Better than visual grading. Front Neurosci 2022; 16:980135. [PMID: 36389251 PMCID: PMC9641373 DOI: 10.3389/fnins.2022.980135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 10/04/2022] [Indexed: 11/24/2022] Open
Abstract
Objectives To identify preoperative prognostic factors for acute ischemic stroke (AIS) patients receiving mechanical thrombectomy (MT) and compare the performance of quantitative collateral score (qCS) and visual collateral score (vCS) in outcome prediction. Methods Fifty-five patients with AIS receiving MT were retrospectively enrolled. qCS was defined as the percentage of the volume of collaterals of both hemispheres. Based on the dichotomous outcome assessed using a 90-day modified Rankin Scale (mRS), we compared qCS, vCS, age, sex, National Institute of Health stroke scale score, etiological subtype, platelet count, international normalized ratio, glucose levels, and low-density lipoprotein cholesterol (LDL-C) levels between favorable and unfavorable outcome groups. Logistic regression analysis was performed to determine the effect on the clinical outcome. The discriminatory power of qCS, vCS, and their combination with cofounders for determining favorable outcomes was tested with the area under the receiver-operating characteristic curve (AUC). Results vCS, qCS, LDL-C, and age could all predict clinical outcomes. qCS is superior over vCS in predicting favorable outcomes with a relatively higher AUC value (qCS vs. vCS: 0.81 vs. 0.74) and a higher sensitivity rate (qCS vs. vCS: 72.7% vs. 40.9%). The prediction power of qCS + LDL-C + age was best with an AUC value of 0.91, but the accuracy was just increased slightly compared to that of qCS alone. Conclusion Collateral scores, LDL-C and age were independent prognostic predictors for patients with AIS receiving MT; qCS was a better predictor than vCS. Furthermore, qCS + LDL-C + age offers a strong prognostic prediction power and qCS alone was another good choice for predicting clinical outcome.
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Affiliation(s)
- Qingqing Lu
- State Key Laboratory of Medical Neurobiology, Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
- Department of Radiology, Ningbo First Hospital, Ningbo, China
| | - Haiyan Zhang
- State Key Laboratory of Medical Neurobiology, Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xin Cao
- State Key Laboratory of Medical Neurobiology, Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Junyan Fu
- State Key Laboratory of Medical Neurobiology, Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yuning Pan
- Department of Radiology, Ningbo First Hospital, Ningbo, China
| | - Xiaodong Zheng
- Department of Radiology, Ningbo First Hospital, Ningbo, China
| | - Jianhong Wang
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
- *Correspondence: Jianhong Wang,
| | - Daoying Geng
- State Key Laboratory of Medical Neurobiology, Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Daoying Geng,
| | - Jun Zhang
- State Key Laboratory of Medical Neurobiology, Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
- Center for Shanghai Intelligent Imaging for Critical Brain Diseases Engineering and Technology Research, Huashan Hospital, Fudan University, Shanghai, China
- Jun Zhang,
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Potreck A, Scheidecker E, Weyland CS, Neuberger U, Herweh C, Möhlenbruch MA, Chen M, Nagel S, Bendszus M, Seker F. RAPID CT Perfusion-Based Relative CBF Identifies Good Collateral Status Better Than Hypoperfusion Intensity Ratio, CBV-Index, and Time-to-Maximum in Anterior Circulation Stroke. AJNR Am J Neuroradiol 2022; 43:960-965. [PMID: 35680162 DOI: 10.3174/ajnr.a7542] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 04/27/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Information of collateral flow may help to determine eligibility for thrombectomy. Our aim was to identify CT perfusion-based surrogate parameters of good collateral status in acute anterior circulation ischemic stroke. MATERIALS AND METHODS In this retrospective study, we assessed the collateral status of 214 patients who presented with acute ischemic stroke due to occlusion of the MCA M1 segment or the carotid terminus. Collaterals were assessed on dynamic CTA images analogous to the multiphase CTA score by Menon et al. CT perfusion parameters (time-to-maximum, relative CBF, hypoperfusion intensity ratio, and CBV-index) were assessed with RAPID software. The Spearman rank correlation and receiver operating characteristic analyses were performed to identify the parameters that correlate with collateral scores and good collateral supply (defined as a collateral score of ≥4). RESULTS The Spearman rank correlation was highest for a relative CBF < 38% volume (ρ = -0.66, P < .001), followed by the hypoperfusion intensity ratio (ρ = -0.49, P < .001), CBV-index (ρ = 0.51, P < .001), and time-to-maximum > 8 seconds (ρ = -0.54, P < .001). Good collateral status was better identified by a relative CBF < 38% at a lesion size <27 mL (sensitivity of 75%, specificity of 80%) compared with a hypoperfusion intensity ratio of <0.4 (sensitivity of 75%, specificity of 62%), CBV-index of >0.8 (sensitivity of 60%, specificity of 78%), and time-to-maximum > 8 seconds (sensitivity of 68%, specificity of 76%). CONCLUSIONS Automated CT perfusion analysis allows accurate identification of collateral status in acute ischemic stroke. A relative CBF < 38% may be a better perfusion-based indicator of good collateral supply compared with time-to-maximum, the hypoperfusion intensity ratio, and the CBV-index.
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Affiliation(s)
- A Potreck
- From the Department of Neuroradiology (A.P., E.S., C.S.W., U.N., C.H., M.A.M., M.B., F.S.)
| | - E Scheidecker
- From the Department of Neuroradiology (A.P., E.S., C.S.W., U.N., C.H., M.A.M., M.B., F.S.)
| | - C S Weyland
- From the Department of Neuroradiology (A.P., E.S., C.S.W., U.N., C.H., M.A.M., M.B., F.S.)
| | - U Neuberger
- From the Department of Neuroradiology (A.P., E.S., C.S.W., U.N., C.H., M.A.M., M.B., F.S.)
| | - C Herweh
- From the Department of Neuroradiology (A.P., E.S., C.S.W., U.N., C.H., M.A.M., M.B., F.S.)
| | - M A Möhlenbruch
- From the Department of Neuroradiology (A.P., E.S., C.S.W., U.N., C.H., M.A.M., M.B., F.S.)
| | - M Chen
- Neurology (M.C., S.N.), Heidelberg University Hospital, Heidelberg, Germany
| | - S Nagel
- Neurology (M.C., S.N.), Heidelberg University Hospital, Heidelberg, Germany
| | - M Bendszus
- From the Department of Neuroradiology (A.P., E.S., C.S.W., U.N., C.H., M.A.M., M.B., F.S.)
| | - F Seker
- From the Department of Neuroradiology (A.P., E.S., C.S.W., U.N., C.H., M.A.M., M.B., F.S.)
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Wang JQ, Wang YJ, Qiu J, Li W, Sun XH, Zhao YG, Liu X, Zhao ZA, Liu L, Nguyen TN, Chen HS. Cerebral Circulation Time After Thrombectomy: A Potential Predictor of Outcome After Recanalization in Acute Stroke. J Am Heart Assoc 2022; 11:e025853. [PMID: 35621204 PMCID: PMC9238696 DOI: 10.1161/jaha.122.025853] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Despite successful recanalization, up to half of patients with acute ischemic stroke caused by large‐vessel occlusion treated with endovascular treatment (EVT) do not recover to functional independence. We aim to evaluate the role of cerebral circulation time (CCT) as outcome predictor after EVT. Methods and Results We retrospectively enrolled consecutive patients with acute ischemic stroke–large‐vessel occlusion undergoing EVT. Three categories of CCT based on digital subtraction angiography were studied: CCT of the stroke side, CCT of the healthy side), and change of CCT of the stroke side versus CCT of the healthy side. Dramatic clinical recovery was defined as a 24‐hour National Institutes of Health Stroke Scale score ≤2 or ≥8 points drop. A modified Rankin Scale score ≤2 at 3 months was considered a favorable outcome. Logistic regression analysis was performed to evaluate the prediction of CCT on prognosis. One hundred patients were enrolled, of which 38 (38.0%) experienced a dramatic clinical recovery and 43 (43.0%) achieved a favorable outcome. Logistic regression analysis found that shorter change of CCT of the stroke side versus CCT of the healthy side and CCT of the stroke side were independent positive prognostic factors for dramatic clinical recovery (odds ratio [OR], 0.189; P=0.033; OR, 0.581; P=0.035) and favorable outcomes (OR, 0.142; P=0.020; OR, 0.581; P=0.046) after adjustment for potential confounders. A model including the change of CCT of the stroke side versus CCT of the healthy side also had significantly higher area under the curve values compared with the baseline model in patients with dramatic clinical recovery (0.780 versus 0.742) or favorable outcome (0.759 versus 0.713). Conclusions To our knowledge, this is the first report that CCT based on digital subtraction angiography data exhibits an independent predictive performance for clinical outcome in patients with acute ischemic stroke–large‐vessel occlusion after EVT. Given that this readily available CCT can provide alternative perfusion information during EVT, a prospective, multicenter trial is warranted.
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Affiliation(s)
- Jia-Qi Wang
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
| | - Ying-Jia Wang
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
| | - Jin Qiu
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
| | - Wei Li
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
| | - Xian-Hui Sun
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
| | - Yong-Gang Zhao
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
| | - Xin Liu
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
| | - Zi-Ai Zhao
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
| | - Liang Liu
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
| | | | - Hui-Sheng Chen
- Department of Neurology General Hospital of Northern Theater Command Shenyang China
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Kaloss AM, Theus MH. Leptomeningeal anastomoses: Mechanisms of pial collateral remodeling in ischemic stroke. WIREs Mech Dis 2022; 14:e1553. [PMID: 35118835 PMCID: PMC9283306 DOI: 10.1002/wsbm.1553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/09/2022] [Accepted: 01/11/2022] [Indexed: 12/13/2022]
Abstract
Arterial collateralization, as determined by leptomeningeal anastomoses or pial collateral vessels, is a well‐established vital player in cerebral blood flow restoration and neurological recovery from ischemic stroke. A secondary network of cerebral collateral circulation apart from the Circle of Willis, exist as remnants of arteriole development that connect the distal arteries in the pia mater. Recent interest lies in understanding the cellular and molecular adaptations that control the growth and remodeling, or arteriogenesis, of these pre‐existing collateral vessels. New findings from both animal models and human studies of ischemic stroke suggest a multi‐factorial and complex, temporospatial interplay of endothelium, immune and vessel‐associated cell interactions may work in concert to facilitate or thwart arteriogenesis. These valuable reports may provide critical insight into potential predictors of the pial collateral response in patients with large vessel occlusion and may aid in therapeutics to enhance collateral function and improve recovery from stroke. This article is categorized under:Neurological Diseases > Molecular and Cellular Physiology
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Affiliation(s)
- Alexandra M Kaloss
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland Regional College of Veterinary Medicine, Virginia Tech, Blacksburg, Virginia, USA
| | - Michelle H Theus
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland Regional College of Veterinary Medicine, Virginia Tech, Blacksburg, Virginia, USA.,School of Neuroscience, Virginia Tech, Blacksburg, Virginia, USA.,Center for Regenerative Medicine, Virginia-Maryland Regional College of Veterinary Medicine, Virginia Tech, Blacksburg, Virginia, USA
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10
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Scheidecker E, Pereira-Zimmermann B, Potreck A, Vollherbst DF, Möhlenbruch MA, Gumbinger C, Bendszus M, Herweh C, Seker F. Role of diabetes in collateral status assessed in CT perfusion-derived dynamic CTA in anterior circulation stroke. Neuroradiology 2021; 64:1195-1199. [PMID: 34888703 PMCID: PMC9117374 DOI: 10.1007/s00234-021-02873-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 12/01/2021] [Indexed: 12/15/2022]
Abstract
Purpose Diabetes is associated with vascular dysfunction potentially impairing collateral recruitment in acute ischemic stroke. This retrospective study aimed at analyzing the impact of diabetes on collateralization assessed on dynamic CTA. Methods Collaterals were retrospectively assessed on CT perfusion–derived dynamic CTA according to the mCTA score by Menon in a cohort of patients with an acute occlusion of the M1 segment or carotid T. The extent of collateral circulation was related to the history of diabetes and to admission blood glucose and HbA1c levels. Results Two hundred thirty-nine patients were included. The mCTA collateral score was similar in patients with diabetes (median 3, interquartile range 3–4) and without diabetes (median 4, interquartile range 3–4) (P = 0.823). Diabetes was similarly frequent in patients with good (18.8%), intermediate (16.1%), and poor collaterals (16.0%) (P = 0.355). HbA1c was non-significantly higher in patients with poor collaterals (6.3 ± 1.5) compared to patients with intermediate (6.0 ± 0.9) and good collaterals (5.8 ± 0.9) (P = 0.061). Blood glucose levels were significantly higher in patients with poor compared to good collaterals (mean 141.6 vs. 121.8 mg/dl, P = 0.045). However, there was no significant difference between good and intermediate collaterals (mean 121.8 vs. 129.5 mg/dl, P = 0.161) as well as between intermediate and poor collaterals (129.5 vs. 141.6 mg/dl, P = 0.161). Conclusion There was no statistically significant difference among patients with good, intermediate, and poor collaterals regarding the presence of diabetes or HbA1c level on admission. However, stroke patients with poor collaterals tend to have higher blood glucose and HbA1c levels.
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Affiliation(s)
- Emilia Scheidecker
- Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | | | - Arne Potreck
- Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Dominik F Vollherbst
- Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | | | - Martin Bendszus
- Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Christian Herweh
- Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Fatih Seker
- Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
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11
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Role of modified TAN score in predicting prognosis in patients with acute ischemic stroke undergoing endovascular therapy. Clin Neurol Neurosurg 2021; 210:106978. [PMID: 34653924 DOI: 10.1016/j.clineuro.2021.106978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/21/2021] [Accepted: 10/04/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The study aimed to evaluate the prognostic role of modified TAN collateral score in predicting functional independence in ischemic stroke patients, who underwent endovascular therapy. INTRODUCTION Identifying the group of patients, who will benefit most from arterial recanalization in patients with acute ischemic stroke, is the basis of success. Collateral circulation is a physiological condition that protects the brain against ischemia and inhibits the growth of a damaged area. The presence of collaterals is a well-known determinant for functional independence. Numerous collateral scoring systems are used for this purpose. The aim of this study was to evaluate the prognostic role of modified TAN collateral score (MTCS) in predicting functional independence in patients, who received endovascular therapy. MATERIALS AND METHODS Prospective data of 101 patients, who received endovascular therapy from the stroke team of Eskisehir Osmangazi University (ESOGÜ) between 2016 and 2017, were examined retrospectively for this purpose. Collateral assessments were performed in Computed Tomography Angiography (CTA) according to the modified TAN scoring system (< 50% refers to poor collateral status, ≥ 50% refers to good collateral status). Good clinical outcome was assessed as mRS 0-2 in the 3rd month. The TICI scoring system was used in the evaluation of recanalization. Patients treated within the first 6 h of symptom onset, patients with NCCT and contrast CTA, patients with internal carotid artery and middle cerebral artery occlusion were included in the study. Posterior system stroke was not included in the study. CONCLUSION Of the 101 patients, 50 (49%) had poor MTCS. Presentation and 24th hour NIHSS values of the patients with poor MTCS were higher (p:0.003). The third month mRS values were low in patients with good MTCS on admission, while these values were high in patients, who presented with poor MTCS. Mortality rates were significantly higher in the patient group with poor collateral circulation score (32-5.9%) (p:0.001). No significant differences were found in the presentation ASPECT values and (TICI 2b/3) recanalization rates of the patients. The rate of futile recanalization was significantly higher in the group with poor collateral circulation (52-8%) (p:0.0001). Presentation glucose, NIHSS, mTAN, symptom-puncture time, and good ASPECT score were found to be predictive markers for good outcome by univariate analysis. The major risk factors were determined by performing multiple logistic regression analysis. Presentation glucose, NIHSS, and mTAN (OR:1.013, 1.29, 0.198, respectively) were found to be strong and independent predictors for good clinical outcome. According to Multiple Binary Logistic Regression analysis Backward-ward model, Baseline NIHSS, poor collaterals and baseline glucose are found as predictors for poor outcome. DISCUSSION This study shows that good collateral score is associated with good clinical response, small final infarct volume, third month low mRS, low admission, and 24-hour NIHSS rates. The likelihood of having long term prognosis is 7 fold higher in patients with poor collaterals. The use of the MTCS system is recommended and supported due to its easy and rapid applicability.
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12
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Pfaff JAR, Füssel B, Harlan ME, Hubert A, Bendszus M. Variability of acquisition phase of computed tomography angiography in acute ischemic stroke in a real-world scenario. Eur Radiol 2021; 32:281-289. [PMID: 34129068 PMCID: PMC8660718 DOI: 10.1007/s00330-021-08084-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/04/2021] [Accepted: 05/20/2021] [Indexed: 11/24/2022]
Abstract
Objectives The informative value of computed tomography angiography (CTA) depends on the contrast phase in the vessels which may differ depending on the level of local expertise. Methods We retrospectively measured vessel contrast density from CTA scans in patients presenting with acute ischemic stroke to a comprehensive stroke center (CSC) or to one of eight primary stroke centers (PSC). CTAs were classified into arterial or venous phases as well as into 1 of 5 phases (early arterial, peak arterial, equilibrium, peak venous, and late venous). Results Overall, n = 871 CTAs (CSC: n = 431 (49.5%); PSC: n = 440 (50.5%)) were included in the final analysis. A higher venous than arterial contrast density at the level of the circle of Willis was only rarely observed (overall n = 13 (1.5%); CSC: n = 3/431 (0.7%); PCS: n = 10/440 (2.3%); p = 0.09). CTAs acquired in the CSC showed more often an early arterial contrast phase (CSC: n = 371 (86.1%); PSC: n = 153 (34.8%), p < 0.01). Equilibrium contrast phase, i.e., a slightly stronger arterial contrast with clear venous contrast filling, was more frequent in CTAs from the PSCs (CSC: n = 6 (1.4%); PSC: n = 47 (10.7%); p < 0.01). Conclusions Despite different technical equipment and examination protocols, the overall number of CTAs with venous contrast was low and did not differ between the CSC and the PCSs. Differences between the further differentiated contrast phases indicate potential for further improvement of CTA acquisition protocols. Key Points • Despite different technical equipment and examination protocols in the diagnostic workup of acute ischemic stroke, the total number of computed tomography angiography (CTA) with venous contrast was low (n = 13/871; 1.5%). • A higher venous than arterial contrast density at the level of the circle of Willis was not more frequent in CTAs from the centers with a high patient volume (comprehensive stroke center) compared to the hospital with lower patient volume (primary stroke centers). • Differences between the further differentiated contrast phases indicate that there is potential for further improvement of CTA acquisition protocols. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-021-08084-5.
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Affiliation(s)
- Johannes A R Pfaff
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. .,University Institute for Neuroradiology at Paracelsus Medical University (PMU), University Hospital Salzburg, Christian-Doppler-Klinik, Ignaz-Harrer Straße 79, A-5020, Salzburg, Austria.
| | - Bianka Füssel
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Marcial E Harlan
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Alexander Hubert
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
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13
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Broocks G, Jafarov H, McDonough R, Austein F, Meyer L, Bechstein M, van Horn N, Nawka MT, Schön G, Fiehler J, Kniep H, Hanning U. Relationship between the degree of recanalization and functional outcome in acute ischemic stroke is mediated by penumbra salvage volume. J Neurol 2021; 268:2213-2222. [PMID: 33486602 PMCID: PMC8179901 DOI: 10.1007/s00415-021-10410-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/13/2021] [Accepted: 01/13/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The presence of metabolically viable brain tissue that may be salvageable with rapid cerebral blood flow restoration is the fundament rationale for reperfusion therapy in patients with large vessel occlusion stroke. The effect of endovascular treatment (EVT) on functional outcome largely depends on the degree of recanalization. However, the relationship of recanalization degree and penumbra salvage has not yet been investigated. We hypothesized that penumbra salvage volume mediates the effect of thrombectomy on functional outcome. METHODS 99 acute anterior circulation stroke patients who received multimodal CT and underwent thrombectomy with resulting partial to complete reperfusion (modified thrombolysis in cerebral infarction scale (mTICI) ≥ 2a) were retrospectively analyzed. Penumbra volume was quantified on CT perfusion and penumbra salvage volume (PSV) was calculated as difference of penumbra and net infarct growth from admission to follow-up imaging. RESULTS In patients with complete reperfusion (mTICI ≥ 2c), the median PSV was significantly higher than the median PSV in patients with partial or incomplete (mTICI 2a-2b) reperfusion (median 224 mL, IQR: 168-303 versus 158 mL, IQR: 129-225; p < 0.01). A higher degree of recanalization was associated with increased PSV (+ 63 mL per grade, 95% CI: 17-110; p < 0.01). Higher PSV was also associated with improved functional outcome (OR/mRS shift: 0.89; 95% CI: 0.85-0.95, p < 0.0001). CONCLUSIONS PSV may be an important mediator between functional outcome and recanalization degree in EVT patients and could serve as a more accurate instrument to compare treatment effects than infarct volumes.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Hashim Jafarov
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Friederike Austein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Marie Teresa Nawka
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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14
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Qian J, Fan L, Zhang W, Wang J, Qiu J, Wang Y. A meta-analysis of collateral status and outcomes of mechanical thrombectomy. Acta Neurol Scand 2020; 142:191-199. [PMID: 32342996 DOI: 10.1111/ane.13255] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/19/2020] [Accepted: 04/23/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To perform a systematic review and meta-analysis to investigate pretreatment collaterals and outcomes of mechanical thrombectomy in patients with acute ischemic stroke of large-vessel occlusion in anterior circulation. METHODS We systematically searched Embase, PubMed, and the Cochrane Library from their dates of inception to March 5, 2020, and also manually searched reference lists of relevant articles. Pooled relative risk with 95% confidence interval on the association between good collaterals and functional independence (in terms of mRS 0-2), symptomatic intracranial hemorrhage, mortality, and successful reperfusion were synthesized using a random-effects model. RESULTS Thirty-four studies enrolling 5768 patients were included in analysis. Good collaterals were significantly associated with functional independence (RR 1.93, 95%CI 1.64-2.27, P < .0001), successful reperfusion (RR 1.23, 95%CI 1.12-1.35, P < .0001), decreased rate of symptomatic intracranial hemorrhage (RR 0.68, 95%CI 0.47-0.97, P = .032), and mortality (RR 0.37, 95%CI 0.27-0.52, P < .0001). The results were consistent in sensitivity analysis. The associations between good collaterals and reperfusion remained stable after adjusting for publication bias. CONCLUSIONS Good pretreatment collaterals were associated with functional independence, successful reperfusion, and decreased rate of sICH and mortality after receiving mechanical thrombectomy in patients with acute ischemic stroke of large-vessel occlusion.
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Affiliation(s)
- Jiacheng Qian
- Department of Neurology Cerebrovascular Disease Center People's HospitalChina Medical University Shenyang China
- China Medical University Shenyang China
| | - Lu Fan
- Department of Neurology Cerebrovascular Disease Center People's HospitalChina Medical University Shenyang China
- Dalian Medical University Dalian China
| | - Weiqing Zhang
- Department of Neurology Cerebrovascular Disease Center People's HospitalChina Medical University Shenyang China
- Dalian Medical University Dalian China
| | - Jian Wang
- Department of Neurology Cerebrovascular Disease Center People's HospitalChina Medical University Shenyang China
| | - Jianting Qiu
- Department of Neurology Cerebrovascular Disease Center People's HospitalChina Medical University Shenyang China
| | - Yujie Wang
- Department of Neurology Cerebrovascular Disease Center People's HospitalChina Medical University Shenyang China
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15
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van Horn N, Kniep H, Leischner H, McDonough R, Deb-Chatterji M, Broocks G, Thomalla G, Brekenfeld C, Fiehler J, Hanning U, Flottmann F. Predictors of poor clinical outcome despite complete reperfusion in acute ischemic stroke patients. J Neurointerv Surg 2020; 13:14-18. [PMID: 32414889 DOI: 10.1136/neurintsurg-2020-015889] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/07/2020] [Accepted: 04/07/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND In patients suffering from acute ischemic stroke from large vessel occlusion (LVO), mechanical thrombectomy (MT) often leads to successful reperfusion. Only approximately half of these patients have a favorable clinical outcome. Our aim was to determine the prognostic factors associated with poor clinical outcome following complete reperfusion. METHODS Patients treated with MT for LVO from a prospective single-center stroke registry between July 2015 and April 2019 were screened. Complete reperfusion was defined as Thrombolysis in Cerebral Infarction (TICI) grade 3. A modified Rankin scale at 90 days (mRS90) of 3-6 was defined as 'poor outcome'. A logistic regression analysis was performed with poor outcome as a dependent variable, and baseline clinical data, comorbidities, stroke severity, collateral status, and treatment information as independent variables. RESULTS 123 patients with complete reperfusion (TICI 3) were included in this study. Poor clinical outcome was observed in 67 (54.5%) of these patients. Multivariable logistic regression analysis identified greater age (adjusted OR 1.10, 95% CI 1.04 to 1.17; p=0.001), higher admission National Institutes of Health Stroke Scale (NIHSS) (OR 1.14, 95% CI 1.02 to 1.28; p=0.024), and lower Alberta Stroke Program Early CT Score (ASPECTS) (OR 0.6, 95% CI 0.4 to 0.84; p=0.007) as independent predictors of poor outcome. Poor outcome was independent of collateral score. CONCLUSION Poor clinical outcome is observed in a large proportion of acute ischemic stroke patients treated with MT, despite complete reperfusion. In this study, futile recanalization was shown to occur independently of collateral status, but was associated with increasing age and stroke severity.
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Affiliation(s)
- Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | | | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | - Goetz Thomalla
- Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
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