Risultati per: Circulation

Stroke, Volume 55, Issue Suppl_1, Page AWP205-AWP205, February 1, 2024. Introduction:Recent randomized control trials suggested that mechanical thrombectomy (MT) was associated with good functional outcomes after acute ischemic stroke (AIS) due to large vessel occlusion (LVO) in patients presenting with low Alberta Stroke Program Early CT Score (ASPECTS) (defined as ASPECTS 2-5). The aim of this study is to develop and validate a stroke prediction tool for outcome in MT for AIS patients with low ASPECTS using data from an ongoing international multicenter registry, the Stroke Thrombectomy and Aneurysm Registry (STAR).Methods:236 AIS patients with low ASPECTS caused by LVO who undertook MT between January 2010 and December 2022 were retrospectively investigated. Univariate and multivariate logistic regression results were used to screen model predictors and construct nomograms of 90-day modified Rankin Scale scores (mRS) 0-3. The performance of the model was detected by using receiver operating characteristic analysis. The bootstrap resampling method was considered internal validation of the model.Results:Age (< 70 years), premorbid status (mRS 0), National Institutes of Health Stroke Scale (NIHSS) (< 20), and recanalization status after the MT (modified Thrombolysis in Cerebral Ischemia [mTICU] ≥2b) were related to 90-day mRS 0-3. Predictive score was calculated by adding 1 point for age (< 70 years), premorbid status (mRS 0), and NIHSS < 20 and 3 points for a mTICI ≥2b (ranging 0-6). 90-day mRS 0-3 was observed in 0% of patients with a score of 0 or 1, 6.3% with a score of 2, 17.7% with a score of 3, 22.2% with a score of 4, 45.7% with a score of 5, and 73.7% with a score of 6. The score showed relatively high performance in predicting 90-day mRS0-3 (area under the curve: 0.79 [95% CI 0.73-0.79] and 0.78 [95% CI 0.78-0.78] for derivation and validation cohorts, respectively).Conclusions:This study indicates the STAR score can be calculated with baseline and periprocedural characteristics to predict the 90-day outcome after MT in AIS patients with low ASPECTS.

Stroke, Volume 55, Issue Suppl_1, Page ATP119-ATP119, February 1, 2024. Introduction:“Stroke code” activation is a uniform process to summon healthcare stakeholders to orchestrate the rapid sequential steps for urgent management in patients with possible stroke. Acute dizziness, a common emergency department (ED) presentation, frequently leads to stroke code activation; however, cancellation rates remain high and process improvement strategies are warranted.Methods:We analyzed stroke identification accuracy, cancellation rates, and clinical characteristics in patients presenting with an acute vestibular syndrome to inform process improvement strategies for stroke code activation. We developed an ED triage diagnostic algorithm termed, “Dizzy-7”, based on evidence incorporating key history and physical examination elements derived in patients with acute posterior circulation ischemia. Subsequent analyses were performed on algorithmic utilization and its ability to predict stroke.Results:1599 patients presented with acute dizziness over a 4-month period (2022-2023). Stroke code activation occurred in nearly one in four (366/1599) these presentations. 20% (319/1599) were ultimately diagnosed with stroke and of these, 49% (319/366) were identified following stroke code activation. The Dizzy-7 algorithm was used infrequently (4%) among all acute dizziness presentations. Of the 65 cases that incorporated the algorithm, 16 resultant stroke code activations occurred with 1 confirmed diagnosis (6%). We analyzed stroke alert cancellation and found an increased frequency in cancellation for those without use of the protocol at 22% (77/350) compared to those who did use it at 6% (1/16).Discussion:Accurate and reliable identification of acute ischemic stroke among patients presenting with acute dizziness remains complex. Implementation of a triage diagnostic algorithm based on contemporary evidence was infrequently implemented. Process improvement efforts targeted at greater algorithmic use, interprofessional collaboration, and education may improve stroke code utilization efficiency. Although based on limited sample size, a trend towards reduced stroke code cancellation rates were seen throughout the pilot Dizzy-7 algorithm use.

Stroke, Volume 55, Issue Suppl_1, Page AWP192-AWP192, February 1, 2024. Introduction:Despite comparable outcomes for different frontline techniques in mechanical thrombectomy (MT) for acute ischemic stroke (AIS), there are sparse data regarding if and when to switch techniques if the first pass is unsuccessful. We aimed to investigate the impact of converting from one MT technique to another on the second MT attempt for AIS among patients with large vessel occlusion (LVO).Methods:This was a retrospective observational study using data from the large multicenter international Stroke Thrombectomy and Aneurysm Registry (STAR). Data from 29 stroke centers for 10,229 AIS patients treated with MT for LVO between January 2010 and December 2022 was investigated. The primary outcome measure was successful recanalization defined as modified Thrombolysis in Cerebral Ischemia (mTICI) score of 2b or higher. 90-day modified Rankin score (mRS) 0-2, mortality and symptomatic hemorrhage were used as secondary outcomes. Clinical and technical outcomes after the second MT attempt were compared between those with or without technique conversion.Results:Among 10,229 AIS patients, 1,797 AIS patients with LVO failed first pass recanalization and were included in this retrospective analysis. 927 patients were female (52%) and median (interquartile range) age was 72 (61-81) years. Converting to alternative techniques following a first failed attempt was more likely to be associated with successful recanalization at the second attempt (adjusted odds ratio 2.30, 95% CI: 1.37-3.86, P = 0.002) and 90-day good clinical outcome (adjusted odds ratio 2.10, 95% CI: 1.15-3.85, P = 0.02) after multivariate adjustment.Conclusions:This study demonstrates better clinical and technical outcomes with conversion of MT technique for the second attempt in AIS patients with LVO who failed first pass recanalization.

Stroke, Volume 55, Issue Suppl_1, Page ATP252-ATP252, February 1, 2024. Objective:Forward head posturing (FHP) has been associated with chronic anatomic vertebral artery disturbances possibly leading to posterior circulation ischemia. The data supporting FHP as a true risk factor of posterior circulation stroke has not been well established. We aim to study if patients with severe cervical myalgias and FHP have an increased risk of posterior circulation stroke.Methods:We identified all adult patients with posterior circulation stroke and diagnosis of cervical myalgia at Loyola University Medical Center from January 2018 to January 2023. Information on demographics and comorbidities were also collected. We then identified matched pair case-controls (based on age and gender) with non-stroke cervical myalgia patients in the same 5-year period. We compared the relevant comorbidities, C2 tilt angle, and C2-C7 tilt angle of patients to their matched controls to for statistical difference.Results:76 patients (38 cases and 38 controls) with an average age of 64 years, including 38 (50%) females met our inclusion criteria. The average C2 tilt of cases was 22.9 degrees compared to 17.7 degrees in controls, and the average C2-C7 tilt of cases was 18.9 degrees in cases compared 10.5 degrees in controls. There were no significant differences between relevant comorbidities (including hypertension, hyperlipidemia, diabetes, atrial fibrillation, hyper-coagulopathy, or body mass index) of cases and controls. There was a significant difference of 5.2 degrees higher C2 tilt and 8.1 degrees higher C2-C7 tilt in cases compared to controls respectively (p-value = 0.03).Conclusion:In this single-center retrospective analysis, we found that after controlling for age, gender, and comorbidities, patients with posterior circulation stroke were more likely to have significantly higher C2 and C2-C7 cervical tilt (worse FHP based on radiographic standards) compared to their matched control counterparts.

Stroke, Volume 55, Issue Suppl_1, Page ATP132-ATP132, February 1, 2024. Objective:CT-perfusion (CTP) has revolutionised stroke care by improving diagnostic accuracy and expanding eligibility to acute therapies. Software packages utilise various mathematical techniques to transform raw perfusion data into measures of infarct core and ischaemic penumbra. These techniques have been derived from studies of anterior-circulation stroke and not yet validated in posterior circulation stroke (PCS). We examined the optimal CTP thresholds for acute PCS.Methods:Data were analysed from 331-patients diagnosed with a PCS enrolled in the International-stroke-perfusion-registry (INSPIRE). Twenty-seven-patients with baseline multimodal-CT with occlusion of a large posterior-circulation (PC) artery and follow up diffusion-weighted-MRI at 24-48 hours were included. CTP parametric maps were generated using five different post-processing methods. Receiver-operating-curve analysis was used to determine the optimal perfusion parameter and thresholds.Results:Partial deconvolution was the optimal post-processing method for characterisation of ischaemic penumbra and infarct core. Mean transit time (MTT) at a threshold of >165% and >195% most accurately defined ischaemic core (AUC=0.73) and penumbra (AUC=0.78) respectively. Post-processing technique influenced accuracy of core (AUC range=0.54-0.73) and penumbra (AUC range=0.72-0.79) estimates. MTT was consistently the most accurate parameter at distinguishing core and penumbra across all post-processing methods.Conclusion:CTP has significant diagnostic utility in PCS. Accuracy of CTP varies considerably by post-processing method. The underlying post-processing technique employed by individual software packages should be considered when interpreting the accuracy of ischemic core and penumbra estimates.

Stroke, Volume 55, Issue Suppl_1, Page ATP141-ATP141, February 1, 2024. Background:Computerized tomography perfusion (CTP) imaging serves as a valuable modality for the assessment of individuals with a large vessel anterior circulation stroke. Current literature proposes that employing CTP imaging in patients within the initial time frame of less than 8 hours, may lead to an overestimation of the projected infarct core, specifically when utilizing cerebral blood flow (CBF) less than 30%. The hypoperfusion intensity ratio (HIR) may result in overestimation. We sought to further investigate the interplay of CTP parameters in patients presenting within 8 hours of symptom onset of stroke, to assess the accuracy of core infarct estimation.Methods:A retrospective cohort study analyzing patients with large vessel anterior occlusion (LVAO) who underwent CTP and mechanical thrombectomy within 24 hours of symptom onset between January 2017 to December 2022. RAPID software estimates the infarct core using CBF

Stroke, Volume 55, Issue Suppl_1, Page ATP133-ATP133, February 1, 2024. Purpose:Clot Burden Score (CBS) is a semiquantitative measure of thrombus extent on CTA for proximal anterior circulation strokes whose relationship with perfusion metrics has not been fully explored. CBS has potential added value during stroke triage if perfusion imaging is not available or suboptimal. We aimed to investigate if CBS is (1) correlated to perfusion estimates of infarct core volume, hypoperfusion volume, or collateral status, and (2) a predictor of final infarct extent without reperfusion therapy.Methods:Retrospective analysis included consecutive patients (1) arriving

Stroke, Volume 55, Issue Suppl_1, Page ATP130-ATP130, February 1, 2024. Background/Purpose:Fast progressors (FP) of infarct growth in anterior circulation large vessel occlusions (LVO) may be prevalent in the =70mL of overall hypoperfusion present; and as “FP100” with IGR >16.7mL/h (which would result in an ICV >100mL by 6h)andhad >=100mL of overall hypoperfusion present.Results:108 patients were included with median (IQR) age of 75.5 (67-85), NIHSS of 20 (12-24), onset time of 2h (1.5-4), median ICV of 11mL (0-40), hypoperfusion volume of 122mL (70-164), and mismatch volume of 86.5mL (58-130). The sites of LVO were ICA 12 (11.1%), M1 73 (67.6%), and both 23 (21.3%). Median IGR for the cohort was 3.8mL/h (0-16.4). 31 FP70 were found (28.7%, 95% CI: 19.5-40.7%) with median IGR of 31.3mL/h (16.8-42). 14 of these (45.2%, 95% CI: 24.7-75.8%) already had ICV >70mL upon arrival, with median of 100mL (86-156) and 8 of 14 also showed mismatch ratio 100mL upon arrival, with median of 138mL (101-172) and 5 of 8 also showed mismatch ratio

Stroke, Volume 55, Issue Suppl_1, Page ATMP96-ATMP96, February 1, 2024. Background:Endovascular thrombectomy (EVT) has established efficacy across a wide range of patient age, radiological findings, and clinical features. However, EVT may be less effective in extreme scenarios (e.g., large established infarction in later treatment windows), where there are currently limited data.Methods:A heterogeneous, multinational observational cohort (CLEAR registry) of consecutive adult patients ≥18 years old who underwent EVT for acute occlusion (2014-2022) of the internal carotid or proximal middle cerebral (M1 or M2) arteries was queried (n=64 sites). A high-fidelity model for predicting good functional outcome at 90 days (return to pre-stroke modified Rankin Scale [mRS] or mRS 0-2 after EVT) was developed using a binary, multivariable logit model with adaptive double lasso adjustment, which was validated using 5-fold cross validation and 1000 bootstrap sampling for confidence intervals.Results:At the time of the analysis, we evaluated 2953 patients from the registry treated with EVT, of which 1855 (63%) had complete covariate data for inclusion. The median National Institutes of Health Stroke Scale (NIHSS) score was 15 (IQR 9-20), with 14.0% having a pre-stroke mRS >2, 8.3% having a NIHSS

Stroke, Volume 55, Issue Suppl_1, Page ATP259-ATP259, February 1, 2024. Background and Purpose:Right-to-left shunt (RLS) is one of the potential embolic sources in embolic stroke of undetermined source (ESUS), but the eligibility of conducting shunt study to detect RLS in ESUS is still unknown. To reveal clinical features associated with RLS in ESUS, we aimed to compare clinical features including transthoracic echocardiography findings and imaging findings with and without RLS in ESUS.Methods:Consecutive ischemic stroke patients in a comprehensive stroke center were screened between April 2013 and April 2023. Inclusion criteria were: 1) who fulfilled the ESUS criteria based on NAVIGATE-ESUS trial, 2) who underwent transesophageal echocardiogram, and 3) admitted 7 days from the onset. We compared clinical features, including transthoracic echocardiography findings and imaging findings such as lesion characteristics (size, cortical or subcortical, and anterior or posterior), between ESUS patients with RLS (RLS-ESUS) and without RLS (non RLS-ESUS).Results:We screened 2,304 consecutive ischemic stroke patients, including 225 ESUS patients (166 [74%] male, median age 64 years old). Of all, 76 patients had RLS (59 [78%] male, median age 62 years old, Figure A). RLS-ESUS showed higher frequency of anterior circulation lesion (RLS-ESUS vs. non RLS-ESUS; 84% vs. 71%, p = 0.035), slower early mitral inflow velocity (E) (51.6 vs. 54.9 cm/s, p = 0.021). In multivariable analysis, E (OR 0.83, 95%CI0.70-0.99, p = 0.037) and anterior circulation lesion (OR 2.23, 95%CI 1.08-4.62, p = 0.036) were independently associated with RLS-ESUS (Figure B).Conclusions:In ESUS patients, slower early mitral inflow velocity and lesion in anterior circulation was associated with RLS, suggesting shunt study should be conducted to reveal RLS in such patients.

Stroke, Volume 55, Issue Suppl_1, Page ATP175-ATP175, February 1, 2024. Background:Older patients with acute stroke due to anterior circulation large vessel occlusion (ACLVO) experience worse clinical outcomes. Fast progressors typically present early with high stroke severity and larger ischemic core volumes. However, the relationship between aging and early infarct growth rate is unknown. We examined the association between older age, baseline ischemic core volumes and fast or slow infarct growth during ACLVO.Methods:Retrospective study of patients with acute ICA or MCA occlusion across two academic centers in 2014-2019. Patients were included if they had baseline CTP or MRI within 24 hours after estimated stroke onset. Infarct growth rate (IGR) was calculated as ischemic core volume (ml) / stroke onset to imaging time (h). Fast or Slow progressor status was defined by IGR ≥ or < 10 ml/h. Univariate comparisons were made across age tertiles. Multivariable linear and logistic regression analysis examined the association of age tertile with ischemic core volume and slow progressor status adjusting for sex, vascular co-morbidities and NIHSS.Results:We included 312 patients (57% female; age tertiles [T1-T3]: 33—66, 67—81, and 82—102). Older age was associated with decreasing ischemic core volume (median [range] ml: T1, 29 [0-253]; T2, 12 [0-406]; T3, 6 [0-244]; p

Stroke, Volume 55, Issue Suppl_1, Page ATP246-ATP246, February 1, 2024. Background/Purpose:Fibrinolytic activity in blood plasma displays a circadian rhythm with a drop in the morning hours that may predispose to acute thrombotic events. The Clot Burden Score (CBS) is a semiquantitative measure on CT angiography (CTA) of thrombus extent in proximal anterior circulation strokes that has been correlated with functional outcome. Higher clot burden has also been shown to have lower recanalization rates with intravenous thrombolytics. We aimed to investigate whether CBS is a parameter that displays circadian variability.Methods:We performed a retrospective analysis on consecutive stroke patients presenting 0.107.Conclusion:CBS as a measure of thrombus extent in proximal anterior circulation strokes on CTA appears to show circadian variability, with lower scores (higher clot burden) during MORNING onset (6:00-11:59) than the EVENING (18:00-23:59). This may have implications for future studies of chronotherapeutic protocols.

Stroke, Volume 55, Issue Suppl_1, Page A153-A153, February 1, 2024. Objective:To determine whether first pass effect (FPE) after mechanical thrombectomy (MT) for anterior circulation large vessel occlusion acute ischemic stroke (LVO-AIS) is modified by procedural time (PT).Methods:The Stroke Thrombectomy and Aneurysm Registry (STAR), a multi-center international dataset, was retrospectively analyzed for anterior circulation LVO-AIS treated by MT who achieved excellent reperfusion (TICI 2c/3). The primary outcome was good functional outcome as defined by a 90-day modified Rankin Scale (mRS) 0-2. The primary study exposure was first pass success (FPS, 1 pass vs ≥2 passes) and the secondary exposure was PT. Logistic regression models were fit-adjusted and marginal effects used to assess the interaction of PT (≤30 vs >30 minutes) and FPS, adjusting for potential confounders including time from last known well to start of MT.Results:A total of 1,310 patients had excellent reperfusion. These patients were divided into two cohorts based on PT: ≤30 minutes (777 patients, 59.3%) and > 30 minutes (533 patients, 40.7%). Good functional outcome was observed in 658 patients (50.2%). The interaction term between FPS and PT was significant (p=0.018). Individuals with FPS in ≤30 minutes had 11.5% higher adjusted predicted probability of good outcome compared with those who required ≥2 passes (58.2% vs. 46.7%, p=0.001). However, there was no significant difference in the adjusted predicted probability of good outcome based on FPS in individuals with PT >30 minutes (p=0.763). This relationship appeared identical in models with PT treated as a continuous variable.Conclusion:In a large, real-world, multi-national dataset, we find that FPE is importantly modified by PT. The added clinical benefit of FPE is lost in longer procedures ( >30 minutes). These data argue for a new metric for MT procedures, namely, FPE30, that better represents the ideal of fast, complete reperfusion with a single pass of a thrombectomy device.

Circulation, Volume 149, Issue 2, Page 155-159, January 9, 2024.

Stroke, Ahead of Print. BACKGROUND:The effectiveness of intravenous thrombolysis (IVT) before endovascular treatment (EVT) has been investigated in randomized trials and meta-analyses. These studies mainly concerned anterior circulation occlusions. We aimed to investigate clinical, technical, and safety outcomes of IVT before EVT in posterior circulation occlusions in a nationwide registry.METHODS:Patients were included from the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), a nationwide, prospective, multicenter registry of patients with acute ischemic stroke due to a large intracranial vessel occlusion receiving EVT between 2014 and 2019. All patients with a posterior circulation occlusion were included. Primary outcome was a shift toward better functional outcome on the modified Rankin Scale at 90 days. Secondary outcomes were favorable functional outcome (modified Rankin Scale scores, 0–3), occurrence of symptomatic intracranial hemorrhages, successful reperfusion (extended Thrombolysis in Cerebral Ischemia ≥2B), first-attempt successful reperfusion, and mortality at 90 days. Regression analyses with adjustments based on univariable analyses and literature were applied.RESULTS:A total of 248 patients were included, who received either IVT (n=125) or no IVT (n=123) before EVT. Results show no differences in a shift on the modified Rankin Scale (adjusted common odds ratio, 1.04 [95% CI, 0.61–1.76]). Although symptomatic intracranial hemorrhages occurred more often in the IVT group (4.8% versus 2.4%), regression analysis did not show a significant difference (adjusted odds ratio, 1.65 [95% CI, 0.33–8.35]). Successful reperfusion, favorable functional outcome, first-attempt successful reperfusion, and mortality did not differ between patients treated with and without IVT.CONCLUSIONS:We found no significant differences in clinical, technical, and safety outcomes between patients with a large vessel occlusion in the posterior circulation treated with or without IVT before EVT. Our results are in line with the literature on the anterior circulation.

Annals of Internal Medicine, Ahead of Print.