TICI and Age: What's the Score?

Post-stroke infection in acute ischemic stroke patients treated with mechanical thrombectomy does not affect long-term outcome

Introduction

The impact of an infection that requires antibiotic treatment (IRAT) after an acute ischemic stroke (AIS) treated with mechanical thrombectomy (MT) remains unclear.

Aim

Here, we studied the prevalence and the profile of IRAT in patients with AIS treated with MT, aiming to identify predictive factors and prognostic implications at 90 days after stroke.

Material and methods

We analyzed parameters available within 24 h after AIS including demographics, risk factors, National Institutes of Health Stroke Scale (NIHSS) upon admission and 24 h later, hemorrhagic transformation (HT) on computed tomography, and several clinical and biochemical markers. The outcome measures were the modified Rankin Scale (mRS) 0-2 and 90 days post-stroke mortality.

Results

We included 291 patients; in 184 (63.2%) patients MT was preceded by intravenous thrombolysis (IVT), and 83 (28.5%) patients developed IRAT. Multivariate analysis showed that male sex and hemorrhagic transformation on CT taken 24 h after stroke increased the risk of IRAT. We found that younger age, male sex, lower delta NIHSS, shorter time from stroke onset to groin puncture, better recanalization and a lack of hemorrhagic transformation on CT taken 24 h after stroke favorably affected outcome at day 90. Multivariate analysis showed that older age, higher delta NIHSS, unknown stroke etiology and lack of treatment with IVT were independent predictors of death up to day 90. Infection that required antibiotic treatment did not enter in the models for the studied outcome measures.

Conclusions

In AIS patients treated with MT, IRAT is not an independent factor that affects favorable outcome or mortality 90 days after stroke.

Endovascular treatment in older adults with acute ischemic stroke in the MR CLEAN Registry

Objective

To explore clinical outcomes in older adults with acute ischemic stroke treated with endovascular thrombectomy (EVT).

Methods

We included consecutive patients (2014–2016) with an anterior circulation occlusion undergoing EVT from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry. We assessed the effect of age (dichotomized at ≥80 years and as continuous variable) on the modified Rankin Scale (mRS) score at 90 days, symptomatic intracranial hemorrhage (sICH), and reperfusion rate. The association between age and mRS was assessed with multivariable ordinal logistic regression, and a multiplicative interaction term was added to the model to assess modification of reperfusion by age on outcome.

Results

Of the 1,526 patients, 380 (25%) were ≥80 years of age (referred to here as older adults). Older adults had a worse functional outcome than younger patients (adjusted common odds ratio [acOR] for an mRS score shift toward better outcome 0.31, 95% confidence interval [CI] 0.24–0.39). Mortality was also higher in older adults (51% vs 22%, adjusted odds ratio 3.12, 95% CI 2.33–4.19). There were no differences in proportion of patients with mRS scores of 4 to 5, sICH, or reperfusion rates. Successful reperfusion was more strongly associated with a shift toward good functional outcome in older adults than in younger patients (acOR 3.22, 95% CI 2.04–5.10 vs 2.00, 95% CI 1.56–2.57, pinteraction = 0.026).

Conclusion

Older age is associated with an increased absolute risk of poor clinical outcome, while the relative benefit of successful reperfusion seems to be higher in these patients. These results should be taken into consideration in the selection of older adults for EVT.

Endovascular Thrombectomy of Calcified Emboli in Acute Ischemic Stroke: A Multicenter Study

BACKGROUND AND PURPOSE

Large intracranial vessel occlusion due to calcified emboli is a rare cause of major stroke. We assessed the prevalence, imaging appearance, the effectiveness of mechanical thrombectomy, and clinical outcome of patients with large-vessel occlusion due to calcified emboli.

MATERIALS AND METHODS

We performed a retrospective analysis of clinical and procedural data of consecutive patients who underwent mechanical thrombectomy due to calcified emboli in 7 European stroke centers.

RESULTS

We screened 2969 patients, and 40 patients matched the inclusion criteria, accounting for a prevalence of 1.3%. The mean maximal density of the thrombus was 327 HU (range, 150-1200 HU), and the mean thrombus length was 9.2 mm (range, 4-20 mm). Four patients had multiple calcified emboli, and 2 patients had an embolic event during an endovascular intervention. A modified TICI score of ≥2b was achieved in 57.5% (23/40), with minimal-to-no reperfusion (modified TICI 0-1) in 32.5% (13/40) and incomplete reperfusion (modified TICI 2a) in 10% (4/40). Excellent outcome (mRS 0-1) was achieved in only 20.6%, functional independence (mRS 0-2) in 26.5% and 90-day mortality was 55.9%.

CONCLUSIONS

Acute ischemic stroke with large-vessel occlusion due to calcified emboli is a rare entity in patients undergoing thrombectomy, with considerably worse angiographic outcome and a higher mortality compared with patients with noncalcified thrombi. Good functional recovery at 3 months can still be achieved in about a quarter of patients.

Outcomes of endovascular thrombectomy in the elderly: a ‘real-world’ multicenter study

Background

The efficacy of endovascular thrombectomy (ET) for acute ischemic stroke (AIS) in octogenarians is still controversial.

Objective

To evaluate, using a large multicenter cohort of patients, outcomes after ET in octogenarians compared with younger patients.

Methods

Data from prospectively maintained databases of patients undergoing ET for AIS at seven US-based comprehensive stroke centers between January 2013 and January 2018 were reviewed. Demographic, procedural, and outcome variables were collected. Outcomes included 90-day modified Rankin Scale (mRS) score, postprocedural National Institutes of Health Stroke Scale score, postprocedural hemorrhage, and mortality. Univariate and multivariate analyses were performed to assess the independent effect of age ≥80 on outcome measures. Subgroup analyses were also performed based on location of stroke, success of recanalization, or ET technique used.

Results

Rates of functional independence (mRS score 0–2) after ET in elderly patients were significantly lower than for younger counterparts. Age ≥80 was independently associated with increased mortality and poor outcome. Age ≥80 showed an independent negative prognostic effect on outcome even when patients were divided according to thrombectomy technique, location of stroke, or success of recanalization. Age ≥80 independently predicted higher rate of postprocedural hemorrhage, but not success of recanalization. Baseline deficit and number of reperfusion attempts, but not Thrombolysis in Cerebral Infarction score were associated with lower odds of good outcome.

Conclusion

The large effect size of ET on AIS outcomes is significantly diminished in the elderly population when using comparable selection criteria to those used in younger counterparts. This raises concerns about the risk–benefit ratio and the cost-effectiveness of performing this procedure in the elderly before optimizing patient selection.

Unfavorable Vascular Anatomy Is Associated with Increased Revascularization Time and Worse Outcome in Anterior Circulation Thrombectomy

BACKGROUND

Reperfusion time influences patient outcome in mechanical thrombectomy for large vessel occlusion. We analyzed anatomic features that could be used to make preoperative and intraoperative decisions to minimize revascularization time.

METHODS

We reviewed a prospectively maintained database for patients with stroke evaluated from February 2015 to July 2016. Patients received a score based on bovine arch, aortic arch, and internal carotid artery dolichoarteriopathy (B.A.D. score), which we correlated with procedural times and outcomes. Univariate analysis was performed to identify predictors of procedural times, revascularization, complications, and outcome. Relevant variables were assessed via multivariate regression.

RESULTS

We identified 61 patients (31 men) who underwent transfemoral thrombectomy. Mean puncture to reperfusion time was 46 minutes. Age >75 years (odds ratio [OR] = 3.98; 95% confidence interval [CI], 1.17-13.54; P = 0.027) and high B.A.D. score (OR = 2.55; 95% CI, 1.17-5.57; P = 0.019) were significant predictors of puncture to reperfusion time >40 minutes. Mean puncture to first-pass time was 24 ± 14.2 minutes. Age >65 years (OR = 4.68; 95% CI, 1.07-20.55; P = 0.041) and high B.A.D. score (OR = 2.84; 95% CI, 1.18-6.85; P = 0.020) were independently predictive of time to first pass >20 minutes. Lower scores predicted higher Thrombolysis In Cerebral Infarction score (OR = 0.07; 95% CI, 0.01-0.81; P = 0.033). Higher scores predicted hemorrhagic transformation (OR = 4.8; 95% CI, 1.19-12.29; P = 0.024) and modified Rankin Scale score >4 (OR = 3.0; 95% CI, 1.15-7.92; P = 0.025) after thrombectomy.

CONCLUSIONS

Bovine variation, aortic arch type, and internal carotid artery dolichoarteriopathy are associated with increased revascularization time and poor outcomes in thrombectomy. We developed the B.A.D. score to predict reperfusion time and outcomes, demonstrating need for preoperative anatomic evaluation to guide treatment.

Association between age and outcomes following thrombectomy for anterior circulation emergent large vessel occlusion is determined by degree of recanalisation

BACKGROUND

Older patients undergoing thrombectomy for emergent large vessel occlusion have worse outcomes. However, complete or near-complete reperfusion (modified Thrombolysis in Cerebral Ischemia (mTICI) score of 2 c/3) is associated with improved outcomes compared with partial recanalisation (mTICI 2b).

OBJECTIVE

To examine the relationship between outcomes and age separately for the mTICI 2c/3, 2b and 0-2a groups in patients undergoing thrombectomy for anterior circulation emergent large vessel occlusion.

METHODS

Retrospective review of 157 consecutive patients undergoing thrombectomy at a single centre with an occlusion of the internal carotid artery (ICA), M1 or proximal M2 segments of the middle cerebral artery (MCA). Angiograms were graded in a blinded fashion. Patients were divided into three groups: mTICI 0-2a, mTICI 2b, and mTICI 2c/3. Demographics and workflow parameters were compared. Outcomes at 90 days were compared as a function of age, using both the conventional modified Rankin scale (mRs) and utility weighted mRs (UWmRs).

RESULTS

There were 72, 61 and 24 patients in the mTICI 2c/3, 2b and 0-2a groups, respectively. Outcomes were significantly worse with increasing age for the mTICI 2b group, but not for the mTICI 0-2a and 2c/3 groups (P=0.0002). With increasing age, outcomes of the mTICI 2b group approached those of the mTICI 0-2a group. However, outcomes of the mTICI 2c/3 groups were similar for all ages. This association was present for both the original mRs and UWmRs.

CONCLUSION

Increasing age was associated with worse outcomes for those with partial (mTICI 2b) recanalisation, not in patients with complete (mTICI 2c/3) recanalisation.

Endovascular Treatment of Anterior Circulation Large Vessel Occlusion in the Elderly

Endovascular treatment of anterior circulation large vessel occlusion in the elderly population presents special challenges and opportunities. In this review, we discuss the published literature regarding thrombectomy in elderly patients and also discuss specific issues related to treatment in this patient population. In summary, while the overall outcomes following thrombectomy in elderly patients are worse than following thrombectomy in younger patients, there appears to be a similar benefit as in young patients. While there are challenges with successfully delivering thrombectomy in older patients, age alone should not be an independent exclusion from thrombectomy.

Diffusion-Weighted MRI Stroke Volume Following Recanalization Treatment is Threshold-Dependent

PURPOSE

Infarct lesion segmentation has been problematic as there are a wide range of relative and absolute diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) thresholds that have been used for this purpose. We examined differences of stroke lesion volume and evolution evaluated by magnetic resonance imaging (MRI) during the immediate post-treatment phase (<5 h) and at 24 h.

METHODS

In this study 33 acute ischemic stroke patients were imaged with MRI <5 h and 24 h post-reperfusion treatment. Lesion volumes were segmented on ADC maps and average DWI using literature cited absolute ADC and relative DWI thresholds. The segmented lesion volumes within both time points were compared and the absolute change in lesion volume (infarct growth) between the two time points was calculated and compared using Bland-Altman analysis.

RESULTS

Lesion volumes differed significantly when different relative DWI or absolute ADC thresholds were used (p < 0.05), which held true for baseline as well as follow-up lesions. The median absolute changes in lesion volume from baseline to follow-up for ADC thresholds of 550 × 10^-6 mm²/s, 600 × 10^-6 mm²/s, 630 × 10^-6 mm²/s and 650 × 10^-6 mm²/s were 3.5 ml, 4.2 ml, 4.5 ml, and 6.5 ml, respectively (p < 0.05). Likewise, the median absolute changes in lesion volume from baseline to follow-up for DWI thresholds, k = 0.85, 1.28, 1.64, 1.96, and 2.7 were 10.1 ml, 7.3 ml, 5.7 ml, 5.4 ml and 4.2 ml, respectively (p < 0.05).

CONCLUSION

Absolute lesion volumes and changes in lesion volumes (infarct growth) measured after recanalization treatment were dependent on absolute ADC and relative DWI thresholds, which may have clinical significance. Standardization of techniques for measuring DWI lesion volumes requires immediate attention.

Mechanical Thrombectomy for Acute Ischemic Stroke Patients Aged 80 Years or Older

BACKGROUND

There are limited data about the prognostic factors predicting outcomes after mechanical thrombectomy with stent retrievers for the elderly. Here, we evaluated outcomes in elderly patients in a real-world setting.

METHODS

Between April 2015 and January 2017, 80 patients with anterior intracranial acute large vessel occlusion, who had lived independently before ictus, were treated with mechanical thrombectomy using a stent retriever at our institute. We compared outcomes between patients ≥80 years old (n = 36) and those <80 years old (n = 44), and assessed prognostic factors for favorable outcomes (modified Rankin Scale score 0-2) at 90 days in all patients.

RESULTS

There was no significant difference in baseline National Institutes of Health Stroke Scale score and Alberta Stroke Program Early Computed Tomography Score between the 2 groups. Successful revascularization (modified Thrombolysis in Cerebral Infarction [mTICI] scores 2b/3) (83% versus 93%, P = .286), complete recanalization (mTICI 3) (47% versus 50%, P = .826), and favorable outcomes (42% versus 57%, P = .261) were achieved more often in those <80 years old, but differences did not reach statistical significance. Multivariate regression analysis showed that baseline National Institutes of Health Stroke Scale (P = .013) and mTICI scores of 3 (P = .006) were significant predictive factors, but being ≥80 years old and baseline Alberta Stroke Program Early Computed Tomography Score were not. In those ≥80 years old, mTICI score of 3 was an influential factor for favorable outcome (P = .017).

CONCLUSIONS

Being aged 80 years or older was not a significant predictor for outcomes after mechanical thrombectomy, whereas complete recanalization was an influential predictor of outcome in the elderly.