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Dolia JN, Grossberg JA, Martins PN, Tarek MA, Pabaney A, Al-Bayati AR, Nogueira RG, Haussen DC. Reliability assessment of distal occlusion eTICI scoring. Interv Neuroradiol 2024:15910199241262844. [PMID: 39034141 DOI: 10.1177/15910199241262844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND The eThrombolysis in Cerebral Infarction (eTICI) score has been validated in proximal large artery occlusion (pLAOs). Despite the growing number of distal medium vessel occlusions (DMVOs) mechanical thrombectomies (MT) and the widespread utilization of the eTICI scoring system, its reliability and standardization for more distal occlusions have not been validated. We aim to evaluate the interrater reliability of eTICI scores in primary DMVOs. METHODS This was a retrospective analysis of a prospectively maintained database for consecutive patients with pLAO and DMVO MT at a single comprehensive stroke center from 2015 to 2022. Two fellowship-trained neurointerventionalists blindly/independently assessed digital subtraction angiograms for final eTICI, followed by consensus reads for discrepancies. RESULTS 59 DMVO of 2248 thrombectomies [M3:29(50%)/M4:1(2%)/A1:3(5%)/A2:12(22%)/A3: 5(9%)/P1:7(12%)/P2:1(2%)] and 124 pLAOs of 308 thrombectomies [i-ICA:13(11%)/MCA-M1: 111(90%)] were included. The distribution of final eTICI scores was comparable between pLAO vs DMVOs (p = 0.82). The pLAO final eTICI score assessment between two readers demonstrated moderate reliability with a kappa0.77 (95%CI: 0.67-0.88), while the DMVO eTICI score assessment exhibited almost-perfect agreement with kappa 0.94 (95%CI: 0.90-0.99). The agreement between the consensus read and the original report in DMVOs was 0.86 (95% CI: 0.71-1.00) while for pLAO it was 0.83(95% CI: 0.76-0.90). The performance of eTICI was comparable amongst different DMVO territories as well as for distal vs. very distal occlusions. CONCLUSION eTICI score exhibited comparable performance for DMVO as compared to pLAO strokes. Further studies investigating DMVO eTICI grading and clinical outcomes are warranted.
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Affiliation(s)
- Jaydevsinh N Dolia
- Department of Neurology, Emory University School of Medicine-Atlanta, Atlanta, GA, USA
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, Atlanta, GA, USA
| | - Jonathan A Grossberg
- Department of Neurology, Emory University School of Medicine-Atlanta, Atlanta, GA, USA
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, Atlanta, GA, USA
| | - Pedro N Martins
- Department of Neurology, Emory University School of Medicine-Atlanta, Atlanta, GA, USA
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, Atlanta, GA, USA
| | - Mohamed A Tarek
- Department of Neurology, Emory University School of Medicine-Atlanta, Atlanta, GA, USA
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, Atlanta, GA, USA
| | - Aqueel Pabaney
- Department of Neurology, Emory University School of Medicine-Atlanta, Atlanta, GA, USA
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, Atlanta, GA, USA
| | | | - Raul G Nogueira
- Department of Neurology, UPMC, Stroke Institute, Pittsburgh, PA, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University School of Medicine-Atlanta, Atlanta, GA, USA
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, Atlanta, GA, USA
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van der Sluijs PM, Su R, Cornelissen S, van Es ACGM, Lycklama A Nijeholt GJ, van Doormaal PJ, van Zwam WH, Dippel DWJ, van Walsum T, van der Lugt A. Assessment of automated TICI scoring during endovascular treatment in patients with an ischemic stroke. J Neurointerv Surg 2024:jnis-2024-021892. [PMID: 39019506 DOI: 10.1136/jnis-2024-021892] [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: 04/24/2024] [Accepted: 06/18/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND The extended Thrombolysis in Cerebral Infarction (eTICI) score is used in digital subtraction angiography (DSA) to quantify reperfusion grade in patients with an ischemic stroke who undergo endovascular thrombectomy (EVT). A previously developed automatic TICI score (autoTICI), which quantifies the ratio of reperfused pixels after EVT, demonstrates good correlation with eTICI. OBJECTIVE To evaluate the autoTICI model in a large multicenter registry of patients with an ischemic stroke, investigate the association with visual eTICI, and compare prediction of functional outcome between autoTICI and eTICI. METHODS Patients in the MR CLEAN Registry with an internal carotid artery, M1, and M2 occlusion were selected if both anteroposterior and lateral views were present in pre- and post-EVT DSA scans. The autoTICI score was compared with eTICI in predicting favorable functional outcome (modified Rankin Scale score 0-2), using area under the receiver operating characteristics curve (AUC) with a multivariable logistic regression model including known prognostic characteristics. RESULTS In total 421 of 3637 patients were included. AutoTICI was significantly associated with eTICI non-linearly (below 70% cOR=2.3 (95% CI 2.1 to 2.5), above 70% cOR=1.6 (95% CI 1.6 to 1.7) per 10% increment). The AUC of the model predicting favorable functional outcome was similar for autoTICI and eTICI (0.86, 95% CI 0.82 to 0.92 vs 0.86, 95% CI 0.83 to 0.90, P=0.73) and was higher than for a model with prognostic patient characteristics alone (0.86 vs 0.84, P=0.01). CONCLUSION Automatic quantitative assessment of reperfusion after EVT is associated with eTICI, and prediction of functional outcome is similar to that with visual eTICI. Therefore, autoTICI could be used as an alternative or additional review for visual reperfusion assessment to facilitate reproducible and uniform reporting.
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Affiliation(s)
| | - Ruisheng Su
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Sandra Cornelissen
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Adriaan C G M van Es
- Department of Radiology, Leiden Universitair Medisch Centrum, Leiden, Zuid-Holland, The Netherlands
| | | | - Pieter Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Wim H van Zwam
- Department of Radiology, Maastricht UMC+, Maastricht, Limburg, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - T van Walsum
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
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Fruhwirth V, Berger L, Gattringer T, Fandler-Höfler S, Kneihsl M, Eppinger S, Ropele S, Fink A, Deutschmann H, Reishofer G, Enzinger C, Pinter D. White matter integrity and functional connectivity of the default mode network in acute stroke are associated with cognitive outcome three months post-stroke. J Neurol Sci 2024; 462:123071. [PMID: 38850772 DOI: 10.1016/j.jns.2024.123071] [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] [Received: 03/21/2024] [Revised: 05/27/2024] [Accepted: 05/29/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Knowledge about factors that are associated with post-stroke cognitive outcome is important to identify patients with high risk for impairment. We therefore investigated the associations of white matter integrity and functional connectivity (FC) within the brain's default-mode network (DMN) in acute stroke patients with cognitive outcome three months post-stroke. METHODS Patients aged between 18 and 85 years with an acute symptomatic MRI-proven unilateral ischemic middle cerebral artery infarction, who had received reperfusion therapy, were invited to participate in this longitudinal study. All patients underwent brain MRI within 24-72 h after symptom onset, and participated in a neuropsychological assessment three months post-stroke. We performed hierarchical regression analyses to explore the incremental value of baseline white matter integrity and FC beyond demographic, clinical, and macrostructural information for cognitive outcome. RESULTS The study cohort comprised 34 patients (mean age: 64 ± 12 years, 35% female). The initial median National Institutes of Health Stroke Scale (NIHSS) score was 10, and significantly improved three months post-stroke to a median NIHSS = 1 (p < .001). Nonetheless, 50% of patients showed cognitive impairment three months post-stroke. FC of the non-lesioned anterior cingulate cortex of the affected hemisphere explained 15% of incremental variance for processing speed (p = .007), and fractional anisotropy of the non-lesioned cingulum of the affected hemisphere explained 13% of incremental variance for cognitive flexibility (p = .033). CONCLUSIONS White matter integrity and functional MRI markers of the DMN in acute stroke explain incremental variance for post-stroke cognitive outcome beyond demographic, clinical, and macrostructural information.
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Affiliation(s)
- Viktoria Fruhwirth
- Department of Neurology, Medical University of Graz, Graz, Austria; Department of Neurology, Research Unit for Neuronal Plasticity and Repair, Medical University of Graz, Graz, Austria; Institute of Psychology, Department of Biological Psychology, University of Graz, Graz, Austria
| | - Lisa Berger
- Institute of Psychology, Department of Neuropsychology - Neuroimaging, University of Graz, Graz, Austria
| | - Thomas Gattringer
- Department of Neurology, Medical University of Graz, Graz, Austria; Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | | | - Markus Kneihsl
- Department of Neurology, Medical University of Graz, Graz, Austria
| | | | - Stefan Ropele
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Andreas Fink
- Institute of Psychology, Department of Biological Psychology, University of Graz, Graz, Austria
| | - Hannes Deutschmann
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Gernot Reishofer
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Christian Enzinger
- Department of Neurology, Medical University of Graz, Graz, Austria; Department of Neurology, Research Unit for Neuronal Plasticity and Repair, Medical University of Graz, Graz, Austria; Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Daniela Pinter
- Department of Neurology, Medical University of Graz, Graz, Austria; Department of Neurology, Research Unit for Neuronal Plasticity and Repair, Medical University of Graz, Graz, Austria.
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Puggaard R, Laugesen NG, Hansen K, Brandt AH, Stavngaard T, Truelsen TC. Outcome and safety of mechanical thrombectomy in patients with acute ischemic stroke due to internal carotid artery dissection. Interv Neuroradiol 2024:15910199241261753. [PMID: 38870399 DOI: 10.1177/15910199241261753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Mechanical thrombectomy (MT) in patients with symptoms of acute ischemic stroke (AIS) due to internal carotid artery dissection (ICAD) remains controversial. In this study, we present clinical outcome and safety of MT in acute ICAD compared to other acute carotid artery pathology. METHODS Patients with symptoms of AIS due to internal carotid artery pathology, treated with MT from 2017-2021, were categorized as ICAD or non-ICAD. Baseline and procedural characteristics, complications, and functional outcome at 90 days were compared between the two groups. Factors associated with a favorable outcome (modified Rankin Scale 0-2) were analyzed using multivariate logistic regression. Safety analyses included in-stent thrombosis, perforation, intracranial hemorrhage, and mortality. RESULTS Sixty-seven ICAD patients (14.8%) and 387 non-ICAD patients (85.2%) were enrolled. ICAD patients were younger, median age 53 years (interquartile range (IQR) 47-61) vs. non-ICAD 72 years (IQR 64-79), p < 0.001. Favorable outcome was more common in ICAD patients, 49 ICAD patients (76.6%) vs. 158 non-ICAD patients (42.4%), p < 0.001. Post-procedural symptomatic intracranial hemorrhage occurred in 41 patients, 5 (7.5%) ICAD patients vs. 36 (9.3%) non-ICAD patients, p = 0.6. Mortality differed significantly, 6 (9%) ICAD patients vs. 94 (24.3%) non-ICAD patients, p = 0.01. ICAD was not associated with functional outcome in multivariate analysis, OR = 1.25 [95%confidence interval:0.55-2.86]. CONCLUSION ICAD patients achieved a better 90-day functional outcome compared with non-ICAD patients. ICAD patients did not perform worse in safety measures than non-ICAD patients. Our data provide indirect evidence that MT is of clinical benefit in ICAD patients with symptoms of AIS.
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Affiliation(s)
- Rikke Puggaard
- Cerebrovascular Research Unit Rigshospitalet, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
| | - Nicolaj Grønbæk Laugesen
- Cerebrovascular Research Unit Rigshospitalet, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
| | - Klaus Hansen
- Cerebrovascular Research Unit Rigshospitalet, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andreas H Brandt
- Neurovascular Section, Department of Radiology, Rigshospitalet, Copenhagen, Denmark
| | - Trine Stavngaard
- Neurovascular Section, Department of Radiology, Rigshospitalet, Copenhagen, Denmark
| | - Thomas C Truelsen
- Cerebrovascular Research Unit Rigshospitalet, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Virtanen P, Tomppo L, Georgiopoulos G, Brandstack N, Peltola E, Kokkonen T, Lappalainen K, Korvenoja A, Strbian D. Recanalization status and temporal evolution of early ischemic changes following stroke thrombectomy. Eur Stroke J 2024; 9:320-327. [PMID: 37991143 PMCID: PMC11318421 DOI: 10.1177/23969873231214207] [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] [Received: 08/14/2023] [Accepted: 10/29/2023] [Indexed: 11/23/2023] Open
Abstract
INTRODUCTION Present-day computer tomography (CT) scanners have excellent spatial resolution and signal-to-noise ratio and are instrumental detecting early ischemic changes (EIC) in brain. We assessed the temporal changes of EIC based on the recanalization status after thrombectomy. PATIENTS AND METHODS The cohort comprises consecutive patients with acute ischemic stroke in anterior circulation treated with thrombectomy in tertiary referral hospital. All baseline and follow-up scans were screened for any ischemic changes and further classified using Alberta Stroke Program Early CT Score (ASPECTS). Generalized linear mixed models were used to analyze the impact of recanalization status using modified Thrombolysis in Cerebral Infarction (mTICI) on temporal evolution of ischemic changes. RESULTS We included 614 patients with ICA, M1, or M2 occlusions. Median ASPECTS score was 9 (IQR 7-10) at baseline and 7 (5-8) at approximately 24 h. mTICI 3 was achieved in 207 (33.8%), 2B 241 (39.3%), 2A in 77 (12.6%), and 0-1 in 88 (14.3%) patients. Compared to patients with mTICI 3, those with mTICI 0-1 and 2A had less favorable temporal changes of ASPECTS (p < 0.001). Effect of recanalization was noted in the cortical regions of ICA/M1 patients, but not in their deep structures or patients with M2 occlusions. All ischemic changes detected at baseline were also present at all follow-up images, regardless of the recanalization status. CONCLUSIONS Temporal evolution of the ischemic changes and ASPECTS are related to the success of the recanalization therapy in cortical regions of ICA/M1 patients, but not in their deep brain structures or M2 patients. In none of the patients did EIC revert in any brain region after successful recanalization.
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Affiliation(s)
- Pekka Virtanen
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Liisa Tomppo
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Georgios Georgiopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Nina Brandstack
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Erno Peltola
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Tatu Kokkonen
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Kimmo Lappalainen
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Antti Korvenoja
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Jan K, Chong JY. Treatment of Acute Ischemic Stroke: The Last 30 Years of Trials and Tribulations. Cardiol Rev 2024; 32:203-216. [PMID: 38520336 DOI: 10.1097/crd.0000000000000663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2024]
Abstract
The landscape of acute ischemic stroke management has undergone a substantial transformation over the past 3 decades, mirroring our enhanced comprehension of the pathology and progress in diagnostic techniques, therapeutic interventions, and preventive measures. The 1990s marked a pivotal moment in stroke care with the integration of intravenous thrombolytics. However, the most significant paradigm shift in recent years has undoubtedly been the advent of endovascular thrombectomy. This article endeavors to deliver an exhaustive analysis of this revolutionary progression.
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Affiliation(s)
- Kalimullah Jan
- From the Vascular Neurology Fellow, New York Medical College, Westchester Medical Center, Valhalla, NY
| | - Ji Y Chong
- Stroke Center, New York Medical College, Westchester Medical Center, Valhalla, NY
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Xu X, Shao X, Cao J, Huang X, Li L. Contact aspiration and stent retriever versus stent retriever alone following mechanical thrombectomy for patients of acute ischemic stroke: A recanalization success analysis. Clinics (Sao Paulo) 2023; 78:100262. [PMID: 37633124 PMCID: PMC10470391 DOI: 10.1016/j.clinsp.2023.100262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/07/2023] [Accepted: 07/17/2023] [Indexed: 08/28/2023] Open
Abstract
OBJECTIVE Second-generation catheters used in mechanical thrombectomy have different advantages and disadvantages. The objective of this study was to evaluate the effectiveness and safety of the combination of contact aspiration and stent retriever technique on the rate of reperfusion after mechanical thrombectomy for large vessel occlusion. METHODS Patients who underwent contact aspiration alone (CAA cohort, n = 150), stent retriever alone (SRA cohort, n = 129), or combined contact aspiration and stent retriever (CSR cohort, n = 122) techniques following mechanical thrombectomy were included in the analysis. A balloon guide catheter was used for all thrombectomies. Digital subtraction angiography was used to identify thrombolysis in cerebral infarction. RESULTS The number of patients with thrombolysis in cerebral infarction score of ≥ 2c (near complete or complete antegrade reperfusion) was significantly higher in the CSR cohort than those in the CAA cohort (101 [83%] vs. 90 [60%], p < 0.0001) and those of SRA cohort (101 [83%] vs. 77 [59%], p = 0.0001). Arterial perforation was higher in patients in the CSR cohort than in those in the CAA (p < 0.0001) and SRA (p = 0.015) cohorts. Intracerebral hemorrhage was lower in patients in the CSR cohort than in those in the CAA (p = 0.0001) and SRA (p = 0.0353) cohorts. All-cause mortality at 1 year was fewer in the CSR cohort than in the CAA cohort (p = 0.018). CONCLUSIONS The combination of thrombo aspiration by large bore aspiration catheter and stent retriever is the most effective technique but has some related risks. LEVEL OF EVIDENCE IV. TECHNICAL EFFICACY STAGE 1.
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Affiliation(s)
- Xiaowei Xu
- Department of Neurology, Haian People's Hospital, Haian, Jiangsu, China
| | - Xiangzhong Shao
- Department of Neurology, Haian People's Hospital, Haian, Jiangsu, China.
| | - Jian Cao
- Department of Neurology, Haian People's Hospital, Haian, Jiangsu, China
| | - Xiaoyong Huang
- Department of Neurology, Haian People's Hospital, Haian, Jiangsu, China
| | - Lin Li
- Department of Neurology, Haian People's Hospital, Haian, Jiangsu, China
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Siddiqi AZ, Wadhwa A. Treatment of Acute Stroke: Current Practices and Future Horizons. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 49:56-65. [PMID: 36443221 DOI: 10.1016/j.carrev.2022.11.012] [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] [Received: 07/20/2022] [Revised: 11/06/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE This review will discuss revascularization of acute ischemic stroke (AIS), discussing the concept of the ischemic penumbra and how thrombolysis and thrombectomy take advantage of it. SUMMARY The goal of AIS revascularization is to rescue the ischemic penumbra and the approach to has gone from a time-based to tissue-based approach. Patients must be carefully selected for thrombolysis, which traditionally was limited to those whose last known normal time (LKNT) was known and within 4.5 h. However, newer imaging techniques involving MRI and CT perfusion (CTP) can select patients for thrombolysis whose LKNT is unknown. Alteplase, or tPA, is still the agent of choice for thrombolysis in patients with AIS but tenecteplase (TNK) may be just as effective and more efficient to use. Endovascular thrombectomy (EVT) has shown considerable efficacy for treating large-vessel occlusions and using CTP, patients can be selected for hours after symptom-onset if viable tissue remains. Further research is underway to determine if EVT can be used for medium vessel occlusions and for basilar artery thromboses as well as to determine whether an "EVT-alone" strategy is superior to "tPA + EVT" strategy.
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Affiliation(s)
- A Zohaib Siddiqi
- University of Manitoba Max Rady College of Medicine, Winnipeg, Canada.
| | - Ankur Wadhwa
- University of Manitoba Max Rady College of Medicine, Winnipeg, Canada.
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9
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Ibrahim MK, Shehata MA, Ghozy S, Bilgin C, Jabal MS, Heiferman DM, Kadirvel R, Kallmes DF. Operator assessment versus core laboratory adjudication of recanalization following endovascular treatment of acute ischemic stroke: a systematic review and meta-analysis. J Neurointerv Surg 2023; 15:133-138. [PMID: 36163347 DOI: 10.1136/jnis-2022-019266] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 08/29/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Successful recanalization after endovascular thrombectomy serves as the primary endpoint in clinical trials and is a crucial predictor of long-term outcomes. Radiographic outcomes for various interventions have been shown to vary based on the type of interpreter, including the site interventionalist compared with an independent reader. OBJECTIVE To compare angiographic outcomes in stroke thrombectomy procedures based on the type of reader. METHODS A systematic literature search was conducted in Medline, EMBASE, Scopus, and Web-of-Science through February 2022. We included primary studies that reported core laboratory-read and operator angiographic outcomes after mechanical thrombectomy for ischemic stroke. Furthermore, study-defined successful recanalization data were collected. RESULTS Eight studies were included with 4797 patients, 51.2% of whom were male. Four thousand, four hundred and thirty-one patients had core readings, and 4211 had operator readings. Study-defined successful recanalization was significantly higher for operator (84%, 3543/4211) examinations than for core laboratory-read (78.4%, 3476/4431) examinations (p<0.001; OR=1.462, 95% CI 1.175 to 1.819). The modified Thrombolysis in Cerebral Infarction (mTICI) scale score of ≥2 b was higher for operator (85%, 3341/3929) examinations than for core laboratory-read (78.6%, 3107/3952) examinations (p<0.001; OR=1.349, 95% CI 1.071 to 1.701). mTICI 3 was significantly higher for operator (54.6%, 1000/1832) examinations than for core laboratory-read (39.9%, 731/1832) examinations (p<0.001; OR=1.823, 95% CI 1.598 to 2.081). CONCLUSION Operator angiographic reads are statistically significantly higher than core laboratory-read readings following stroke thrombectomy, especially for complete recanalization. These differences should be considered when interpreting reports of angiographic outcomes after thrombectomy.
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Affiliation(s)
| | | | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Daniel M Heiferman
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | | | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Regenhardt RW, Awad A, Kraft AW, Rosenthal JA, Dmytriw AA, Vranic JE, Bonkhoff AK, Bretzner M, Etherton MR, Hirsch JA, Rabinov JD, Singhal AB, Rost NS, Stapleton CJ, Leslie-Mazwi TM, Patel AB. Characterizing reasons for stroke thrombectomy ineligibility among potential candidates transferred in a hub-and-spoke network. STROKE (HOBOKEN, N.J.) 2022; 2:e000282. [PMID: 36187724 PMCID: PMC9524427 DOI: 10.1161/svin.121.000282] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Background Access to endovascular thrombectomy (EVT) is relatively limited. Hub-and-spoke networks seek to transfer appropriate large vessel occlusion (LVO) candidates to EVT-capable hubs. However, some patients are ineligible upon hub arrival, and factors that drive transfer inefficiencies are not well described. We sought to quantify EVT transfer efficiency and identify reasons for EVT ineligibility. Methods Consecutive EVT candidates presenting to 25 spokes from 2018-2020 with pre-transfer CTA-defined LVO and ASPECTS ≥6 were identified from a prospectively maintained database. Outcomes of interest included hub EVT, reasons for EVT ineligibility, and 90-day modified Rankin Scale (mRS) ≤2. Results Among 258 patients, the median age was 70 years (IQR 60-81); 50% were female. 56% were ineligible for EVT after hub arrival. Cited reasons were large established infarct (49%), mild symptoms (33%), recanalization (6%), distal occlusion (5%), sub-occlusive lesion (3%), and goals of care (3%). Late window patients [last known well (LKW) >6 hours] were more likely to be ineligible (67% vs 43%, P<0.0001). EVT ineligible patients were older (73 vs 68 years, p=0.04), had lower NIHSS (10 vs 16, p<0.0001), longer LKW-hub arrival time (8.4 vs 4.6 hours, p<0.0001), longer spoke Telestroke consult-hub arrival time (2.8 vs 2.2 hours, p<0.0001), and received less intravenous thrombolysis (32% vs 45%, p=0.04) compared to eligible patients. EVT ineligibility independently reduced the odds of 90-day mRS≤2 (aOR=0.26, 95%CI=0.12,0.56; p=0.001) when controlling for age, NIHSS, and LKW-hub arrival time. Conclusions Among patients transferred for EVT, there are multiple reasons for ineligibility upon hub arrival, with most excluded for infarct growth and mild symptoms. Understanding factors that drive transfer inefficiencies is important to improve EVT access and outcomes.
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Affiliation(s)
- Robert W Regenhardt
- Neurosurgery, Massachusetts General Hospital
- Neurology, Massachusetts General Hospital
| | - Amine Awad
- Neurology, Massachusetts General Hospital
| | | | | | - Adam A Dmytriw
- Neurosurgery, Massachusetts General Hospital
- Radiology, Massachusetts General Hospital
| | - Justin E Vranic
- Neurosurgery, Massachusetts General Hospital
- Radiology, Massachusetts General Hospital
| | | | | | | | | | - James D Rabinov
- Neurosurgery, Massachusetts General Hospital
- Radiology, Massachusetts General Hospital
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11
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de Havenon A, Elhorany M, Boulouis G, Naggara O, Darcourt J, Clarençon F, Richard S, Marnat G, Bourcier R, Sibon I, Arquizan C, Dargazanli C, Maïer B, Seners P, Lapergue B, Consoli A, Eugene F, Vannier S, Caroff J, Denier C, Boulanger M, Gauberti M, Rouchaud A, Macian F, Rosso C, Turc G, Ozkul-Wermester O, Papagiannaki C, Albucher JF, Le Bras A, Evain S, Wolff V, Pop R, Timsit S, Gentric JC, Bourdain F, Veunac L, Fahed R, Finitsis SN, Gory B. Thrombectomy in basilar artery occlusions: impact of number of passes and futile reperfusion. J Neurointerv Surg 2022; 15:422-427. [PMID: 35450929 DOI: 10.1136/neurintsurg-2022-018715] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/05/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND The number of mechanical thrombectomy (MT) passes is strongly associated with angiographic reperfusion as well as clinical outcomes in patients with anterior circulation ischemic stroke. However, these associations have not been analyzed in patients with basilar artery occlusion (BAO). We investigated the influence of the number of MT passes on the degree of reperfusion and clinical outcomes, and compared outcome after ≤3 passes versus >3 passes. METHODS We used data from the prospective multicentric Endovascular Treatment in Ischemic Stroke (ETIS) Registry at 18 sites in France. Patients with BAO treated with MT were included. The primary outcome was a favorable outcome, defined as a modified Rankin Scale score of 0-3 at 90 days. We fit mixed multiple regression models, with center as a random effect. RESULTS We included 275 patients. Successful recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) 2b-3) was achieved in 88.4%, and 41.8% had a favorable outcome. The odds ratio for favorable outcome with each pass above 1 was 0.41 (95% CI 0.23 to 0.73) and for recanalization (mTICI 2b-3) it was 0.70 (95% CI 0.57 to 0.87). In patients with ≤3 passes, the rate of favorable outcome in recanalized versus non-recanalized patients was 50.5% versus 10.0% (p=0.001), while in those with >3 passes it was 16.7% versus 15.2% (p=0.901). CONCLUSIONS We found that BAO patients had a significant relationship between the number of MT passes and both recanalization and favorable functional outcome. We further found that the benefit of recanalization in BAO patients was significant only when recanalization was achieved within three passes, encouraging at least three passes before stopping the procedure.
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Affiliation(s)
- Adam de Havenon
- Department of Neurology, Yale University, New Haven, Connecticut, USA
| | - Mahmoud Elhorany
- Interventional Neuroradiology, Hopital Universitaire Pitie Salpetriere, Paris, France
| | | | | | | | - Frédéric Clarençon
- Sorbonne Université, Paris, France.,Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Sébastien Richard
- Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
| | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | | | | | | | - Cyril Dargazanli
- Neuroradiology, Centre Hospitalier Regional Universitaire de Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Benjamin Maïer
- Neuroradiology, Adolphe de Rothschild Ophthalmological Foundation Department of Interventional Neuroradiology, Paris, Île-de-France, France
| | - Pierre Seners
- Adolphe de Rothschild Ophthalmological Foundation Department of Interventional Neuroradiology, Paris, Île-de-France, France
| | - Bertrand Lapergue
- Versailles Saint-Quentin-en-Yvelines University, Versailles, Île-de-France, France
| | - Arturo Consoli
- Diagnostic and Interventional Neuroradiology, Hospital Foch, Suresnes, France.,Interventional Neurovascular Unit, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
| | | | | | - Jildaz Caroff
- Department of Interventional Neuroradiology - NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | | | | | | | - Aymeric Rouchaud
- Interventional Neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges, France.,Univ. Limoges, CNRS, XLIM, UMR 7252, Limoges, France
| | | | - Charlotte Rosso
- Urgences Cérébro-Vasculaires, Pitié-Salpétrière Hospital, Paris, France
| | - Guillaume Turc
- Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France
| | | | | | | | - Anthony Le Bras
- Department of Radiology, CH Bretagne Atlantique, Vannes, France.,CHU Rennes Service de radiologie et d'imagerie médicale, Rennes, France
| | - Sarah Evain
- Department of Neurology, Centre Hospitalier Bretagne Atlantique, Vannes, Bretagne, France
| | - Valerie Wolff
- Stroke Unit, Strasbourg University Hospitals, Strasbourg, France
| | - Raoul Pop
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France.,Interventional Radiology, Institut de Chirurgie Guidée par l'Image, Strasbourg, France
| | - Serge Timsit
- Department of Neurology, CHU Brest, Brest, France
| | | | | | - Louis Veunac
- Department of Radiology, Centre Hospitalier de la Cote Basque, Bayonne, Aquitaine, France
| | - Robert Fahed
- Medicine - Neurology, Ottawa Hospital, Ottawa, Ontario, Canada.,Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - Stephanos Nikolaos Finitsis
- Radiology, Centre Hospitalier de L'Universite de Montreal, Montreal, Québec, Canada.,Radiology, Centre Hospitalier de L'Universite de Montreal, Montreal, Québec, Canada
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, Lorraine, France
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12
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Minchell E, Rumbach A, Finch E. The effects of endovascular clot retrieval and thrombolysis on dysphagia in an Australian quaternary hospital: A retrospective review. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2022; 57:128-137. [PMID: 34767286 DOI: 10.1111/1460-6984.12681] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 09/20/2021] [Accepted: 10/04/2021] [Indexed: 06/13/2023]
Abstract
UNLABELLED Dysphagia (impaired swallowing) is known to contribute to decreased quality of life, and increased length of hospital stay and mortality post-stroke. Despite the advancements in stroke treatment with the introduction of thrombolysis and endovascular clot retrieval (ECR), patients continue to present with high rates of dysphagia. Speech and language therapists and stroke teams should consider the presence of haemorrhagic transformation, success of reperfusion and presence of communication deficits as risk factors for dysphagia post-ECR and/or thrombolysis. PURPOSE To establish incidence rates and patterns of dysphagia following the administration of reperfusion therapies in acute ischaemic stroke management. METHOD A retrospective review of 193 patients admitted with acute ischaemic stroke to a quaternary stroke unit in Australia over a three year period was completed. Clinical information extracted included demographics, type (thrombolysis and/or endovascular clot retrieval) and success of reperfusion therapy, and the progression of dysphagia and related factors. RESULTS Over half of all patients treated with reperfusion therapies presented with dysphagia on initial assessment by speech-language pathology (SLP). The type of reperfusion therapy administered was not significantly correlated with the presence of dysphagia. Dysphagia on initial assessment was significantly correlated with the presence of aphasia on initial assessment, the presence of haemorrhagic transformation, and the success of reperfusion. Increased rates of enteral feeding were also found in this study compared to figures reported in literature. CONCLUSION This study identified ongoing high rates of dysphagia amongst this patient population regardless of treatment type, demonstrating the need for ongoing SLP management post stroke. Further research is required in this area to develop an evidence-base for SLPs and the wider medical team and to inform clinical practice guidelines. WHAT THIS PAPER ADDS What is already known on the subject Stroke is one of the leading causes of disability and death internationally. Dysphagia (impaired swallowing), a common sequalae of stroke, is known to contribute to decreased quality of life, increased length of hospital stay and mortality. With advancements in technology, treatments for acute ischaemic stroke (endovascular clot retrieval and thrombolysis) are increasing in popularity. However, limited research exists exploring the impact of these therapies on dysphagia. What this paper adds Despite the advancements in stroke treatment, patients continue to present with high rates of dysphagia. Dysphagia following thrombolysis and/or ECR was found to be significantly correlated to the presence of aphasia, haemorrhagic transformation, and the success of reperfusion (regardless of treatment type). Additionally, increased rates of enteral feeding were found amongst this patient population compared to figures reported in the literature for patients following traditional stroke management. Clinical implications of this study Speech-language pathologists and the wider medical team should consider dysphagia as an ongoing consequence of stroke following reperfusion therapies, with consideration for success of reperfusion and adverse outcomes i.e., haemorrhagic transformation. Further research is required to provide an evidence-base and specific guidelines for the management of dysphagia post reperfusion therapies, including use of enteral feeding.
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Affiliation(s)
- Ellie Minchell
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
- Centre for Functioning and Health Research, Metro South Health, Brisbane, QLD, Australia
- Speech Pathology Department, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, QLD, Australia
| | - Anna Rumbach
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Emma Finch
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, Australia
- Centre for Functioning and Health Research, Metro South Health, Brisbane, QLD, Australia
- Speech Pathology Department, Princess Alexandra Hospital, Metro South Health, Brisbane, QLD, Australia
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13
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Nielsen M, Waldmann M, Frölich AM, Flottmann F, Hristova E, Bendszus M, Seker F, Fiehler J, Sentker T, Werner R. Deep Learning-Based Automated Thrombolysis in Cerebral Infarction Scoring: A Timely Proof-of-Principle Study. Stroke 2021; 52:3497-3504. [PMID: 34496622 DOI: 10.1161/strokeaha.120.033807] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background and Purpose Mechanical thrombectomy is an established procedure for treatment of acute ischemic stroke. Mechanical thrombectomy success is commonly assessed by the Thrombolysis in Cerebral Infarction (TICI) score, assigned by visual inspection of X-ray digital subtraction angiography data. However, expert-based TICI scoring is highly observer-dependent. This represents a major obstacle for mechanical thrombectomy outcome comparison in, for instance, multicentric clinical studies. Focusing on occlusions of the M1 segment of the middle cerebral artery, the present study aimed to develop a deep learning (DL) solution to automated and, therefore, objective TICI scoring, to evaluate the agreement of DL- and expert-based scoring, and to compare corresponding numbers to published scoring variability of clinical experts. Methods The study comprises 2 independent datasets. For DL system training and initial evaluation, an in-house dataset of 491 digital subtraction angiography series and modified TICI scores of 236 patients with M1 occlusions was collected. To test the model generalization capability, an independent external dataset with 95 digital subtraction angiography series was analyzed. Characteristics of the DL system were modeling TICI scoring as ordinal regression, explicit consideration of the temporal image information, integration of physiological knowledge, and modeling of inherent TICI scoring uncertainties. Results For the in-house dataset, the DL system yields Cohen’s kappa, overall accuracy, and specific agreement values of 0.61, 71%, and 63% to 84%, respectively, compared with the gold standard: the expert rating. Values slightly drop to 0.52/64%/43% to 87% when the model is, without changes, applied to the external dataset. After model updating, they increase to 0.65/74%/60% to 90%. Literature Cohen’s kappa values for expert-based TICI scoring agreement are in the order of 0.6. Conclusions The agreement of DL- and expert-based modified TICI scores in the range of published interobserver variability of clinical experts highlights the potential of the proposed DL solution to automated TICI scoring.
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Affiliation(s)
- Maximilian Nielsen
- Department of Computational Neuroscience (M.N., T.S., R.W.), University Medical Center-Hamburg-Eppendorf, Germany.,Center for Biomedical Artificial Intelligence (bAIome) (M.N., T.S., R.W.), University Medical Center-Hamburg-Eppendorf, Germany
| | - Moritz Waldmann
- Department of Diagnostic and Interventional Neuroradiology (M.W., A.M.F., F.F., J.F.), University Medical Center-Hamburg-Eppendorf, Germany
| | - Andreas M Frölich
- Department of Diagnostic and Interventional Neuroradiology (M.W., A.M.F., F.F., J.F.), University Medical Center-Hamburg-Eppendorf, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology (M.W., A.M.F., F.F., J.F.), University Medical Center-Hamburg-Eppendorf, Germany
| | | | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Germany (M.B., F.S.)
| | - Fatih Seker
- Department of Neuroradiology, Heidelberg University Hospital, Germany (M.B., F.S.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology (M.W., A.M.F., F.F., J.F.), University Medical Center-Hamburg-Eppendorf, Germany
| | - Thilo Sentker
- Department of Computational Neuroscience (M.N., T.S., R.W.), University Medical Center-Hamburg-Eppendorf, Germany.,Center for Biomedical Artificial Intelligence (bAIome) (M.N., T.S., R.W.), University Medical Center-Hamburg-Eppendorf, Germany
| | - Rene Werner
- Department of Computational Neuroscience (M.N., T.S., R.W.), University Medical Center-Hamburg-Eppendorf, Germany.,Center for Biomedical Artificial Intelligence (bAIome) (M.N., T.S., R.W.), University Medical Center-Hamburg-Eppendorf, Germany
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14
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Pressman E, Waqas M, Sands V, Siddiqui A, Snyder K, Davies J, Levy E, Ionita C, Guerrero W, Ren Z, Mokin M. Factors Associated With Decreased Accuracy of Modified Thrombolysis in Cerebral Infarct Scoring Among Neurointerventionalists During Thrombectomy. Stroke 2021; 52:e733-e738. [PMID: 34496615 DOI: 10.1161/strokeaha.120.033372] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose The modified Thrombolysis in Cerebral Infarct (mTICI) score is used to grade angiographic outcome after endovascular thrombectomy. We sought to identify factors that decrease the accuracy of intraprocedural mTICI. Methods We performed a 2-center retrospective cohort study comparing operator (n=6) mTICI scores to consensus scores from blinded adjudicators. Groups were also assessed by dichotomizing mTICI scores to 0–2a versus 2b–3. Results One hundred thirty endovascular thrombectomy procedures were included. Operators and adjudicators had a pairwise agreement in 96 cases (73.8%). Krippendorff α was 0.712. Multivariate analysis showed endovascular thrombectomy overnight (odds ratio [OR]=3.84 [95% CI, 1.22–12.1]), lacking frontal (OR, 5.66 [95 CI, 1.36–23.6]), or occipital (OR, 7.18 [95 CI, 2.12–24.3]) region reperfusion, and higher operator mTICI scores (OR, 2.16 [95 CI, 1.16–4.01]) were predictive of incorrectly scoring mTICI intraprocedurally. With dichotomized mTICI scores, increasing number of passes was associated with increased risk of operator error (OR, 1.93 [95 CI, 1.22–3.05]). Conclusions In our study, mTICI disagreement between operator and adjudicators was observed in 26.2% of cases. Interventions that took place between 22:30 and 4:00, featured frontal or occipital region nonperfusion, higher operator mTICI scores, and increased number of passes had higher odds of intraprocedural mTICI inaccuracy.
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Affiliation(s)
- Elliot Pressman
- Department of Neurosurgery, University of South Florida, Tampa (E.P., V.S., W.G., Z.R., M.M.)
| | - Muhammad Waqas
- Department of Neurosurgery, University at Buffalo, NY (M.W., A.S., K.S., J.D., E.L., C.I.)
| | - Victoria Sands
- Department of Neurosurgery, University of South Florida, Tampa (E.P., V.S., W.G., Z.R., M.M.)
| | - Adnan Siddiqui
- Department of Neurosurgery, University at Buffalo, NY (M.W., A.S., K.S., J.D., E.L., C.I.)
| | - Kenneth Snyder
- Department of Neurosurgery, University at Buffalo, NY (M.W., A.S., K.S., J.D., E.L., C.I.)
| | - Jason Davies
- Department of Neurosurgery, University at Buffalo, NY (M.W., A.S., K.S., J.D., E.L., C.I.)
| | - Elad Levy
- Department of Neurosurgery, University at Buffalo, NY (M.W., A.S., K.S., J.D., E.L., C.I.)
| | - Ciprian Ionita
- Department of Neurosurgery, University at Buffalo, NY (M.W., A.S., K.S., J.D., E.L., C.I.)
| | - Waldo Guerrero
- Department of Neurosurgery, University of South Florida, Tampa (E.P., V.S., W.G., Z.R., M.M.)
| | - Zeguang Ren
- Department of Neurosurgery, University of South Florida, Tampa (E.P., V.S., W.G., Z.R., M.M.)
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa (E.P., V.S., W.G., Z.R., M.M.)
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