Perfusion imaging and clinical outcome in acute ischemic stroke with large core

More proof YOU NEED TO HAVE THE CORRECT STROKE. With nothing to be done by your doctor you will continue to lose 1.9 million neurons per minute. Ask your doctor why they have not contacted researchers to solve this problem. Are they OK with leaving some stroke survivors behind? Or is this ok because this person will not survive and thus your doctor has left no survivor behind?

 

Perfusion imaging and clinical outcome in acute ischemic stroke with large core

Pierre Seners PhD, Catherine Oppenheim PhD, Guillaume Turc PhD, Jean-François Albucher, Adrien Guenego, Nicolas Raposo PhD, Soren Christensen PhD, Lionel Calvière, Alain Viguier … See all authors

First published: 03 July 2021

https://doi.org/10.1002/ana.26152

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1002/ana.26152.

Abstract

Objective

Mechanical thrombectomy (MT) is not recommended for acute stroke with large vessel occlusion (LVO) and a large volume of irreversibly injured tissue (“core”). Perfusion imaging may identify a subset of patients with large core who benefit from MT.

Methods

We compared two cohorts of LVO-related patients with large core (>50 ml on diffusion-weighted-imaging or CT-perfusion using RAPID), available perfusion imaging, and treated within 6 hrs from onset by either MT + Best Medical Management (BMM) in one prospective study, or BMM alone in the pre-MT era from a prospective registry. Primary outcome was 90-day modified Rankin Scale≤2. We searched for an interaction between treatment group and amount of penumbra as estimated by the mismatch ratio (MMRatio = critical hypoperfusion/core volume).

Results

Overall, 107 patients were included (56 MT + BMM + 51 BMM): Mean age was 68 ± 15 yrs, median core volume 99 ml (IQR: 72–131) and MMRatio 1.4 (IQR: 1.0–1.9). Baseline clinical and radiological variables were similar between the 2 groups, except for a higher intravenous thrombolysis rate in the BMM group. The MMRatio strongly modified the clinical outcome following MT (P_interaction < 0.001 for continuous MMRatio); MT was associated with a higher rate of good outcome in patients with, but not in those without, MMRatio>1.2 (adjusted OR [95%CI] = 6.8 [1.7–27.0] vs. 0.7 [0.1–6.2], respectively). Similar findings were present for MMRatio≥1.8 in the subgroup with core≥70 ml. Parenchymal hemorrhage on follow-up imaging was more frequent in the MT + BMM group regardless of the MMRatio.

Interpretation

Perfusion imaging may help select which patients with large core should be considered for MT. Randomized studies are warranted.

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Endovascular reperfusion outcomes in patients with a stroke and low ASPECTS is highly dependent on baseline infarct volumes

More proof YOU NEED TO HAVE THE CORRECT STROKE. With nothing to be done by your doctor you will continue to lose 1.9 million neurons per minute. Ask your doctor why they have not contacted researchers to solve this problem. Are they OK with leaving some stroke survivors behind?

Endovascular reperfusion outcomes in patients with a stroke and low ASPECTS is highly dependent on baseline infarct volumes</a>

1. http://orcid.org/0000-0003-1601-5912Mehdi Bouslama1,
2. Clara M Barreira2,
3. Diogo C Haussen2,
4. http://orcid.org/0000-0002-9152-0882Gabriel Martins Rodrigues1,
5. Leonardo Pisani3,
6. Michael R Frankel1,
7. Raul G Nogueira4

1. Correspondence to Dr Raul G Nogueira, Department of Neurology and Interventional Neuroradiology, Emory University, Atlanta, GA 30303, USA; rnoguei@emory.edu

Abstract

Background Patients with large vessel occlusion stroke (LVOS) and a low Alberta Stroke Program Early CT Score (ASPECTS) are often not offered endovascular therapy (ET) as they are thought to have a poor prognosis.

Objective To compare the outcomes of patients with low and high ASPECTS undergoing ET based on baseline infarct volumes.

Methods Review of a prospectively collected endovascular database at a tertiary care center between September 2010 and March 2020. All patients with anterior circulation LVOS and interpretable baseline CT perfusion (CTP) were included. Subjects were divided into groups with low ASPECTS (0–5) and high ASPECTS (6-10) and subsequently into limited and large CTP-core volumes (cerebral blood flow 30% >70 cc). The primary outcome measure was the difference in rates of 90-day good outcome as defined by a modified Rankin Scale (mRS) score of 0 to 2 across groups.

Results 1248 patients fit the inclusion criteria. 125 patients had low ASPECTS, of whom 16 (12.8%) had a large core (LC), whereas 1123 patients presented with high ASPECTS, including 29 (2.6%) patients with a LC. In the category with a low ASPECTS, there was a trend towards lower rates of functional independence (90-day modified Rankin Scale (mRS) score 0-2) in the LC group (18.8% vs 38.9%, p=0.12), which became significant after adjusting for potential confounders in multivariable analysis (aOR=0.12, 95% CI 0.016 to 0.912, p=0.04). Likewise, LC was associated with significantly lower rates of functional independence (31% vs 51.9%, p=0.03; aOR=0.293, 95% CI 0.095 to 0.909, p=0.04) among patients with high ASPECTS.

Conclusions Outcomes may vary significantly in the same ASPECTS category depending on infarct volume. Patients with ASPECTS ≤5 but baseline infarct volumes ≤70 cc may achieve independence in nearly 40% of the cases and thus should not be excluded from treatment.

http://dx.doi.org/10.1136/neurintsurg-2020-017184

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Footnotes

• Twitter @bouslamamd, @diogohaussen, @pisanileonardo

• MB and CMB contributed equally.

• Contributors Study design: MB, CMB, RGN. Data collection, analysis, and interpretation: MB, CMB, DCH, GMR, LP, MRF, RGN. Drafting the original manuscript: MB. Revising the work critically for important intellectual content: MB, CMB, DCH, GMR, LP, MRF, RGN. Final approval: MB, CMB, DCH, GMR, LP, MRF, RGN. Agreement to be accountable for all aspects of the work: MB, CMB, DCH, GMR, LP, MRF, RGN.

• Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

• Competing interests DCH reports consulting fees for advisory roles with Stryker, Cerenovus, Vesalio, and stock options with Viz-AI. MRF reports research funding from Nico Corp, Inc (ENRICH trial). RGN reports consulting fees for advisory roles with Anaconda, Biogen, Cerenovus, Genentech, Imperative Care, Medtronic, Phenox, Prolong Pharmaceuticals, Stryker Neurovascular, and stock options for advisory roles with Astrocyte, Brainomix, Cerebrotech, Ceretrieve, Corindus Vascular Robotics, Vesalio, Viz-AI, and Perfuze.

• Patient consent for publication Not required.

• Ethics approval ocal institutional review board (IRB)/Emory University IRB.

• Provenance and peer review Not commissioned; externally peer reviewed.

• Data availability statement Data are available upon reasonable request. The unpublished data from this dataset is held by Grady Memorial Hospital/Emory University and MB/RGN. Requests for data sharing would have to be discussed with them directly.

• Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

 

Safety and Costs of Stroke Unit Admission for Select Acute Intracerebral Hemorrhage Patients

Notice the word; 'SELECT'.  Once again you have to have the correct stroke. Rather than figuring out how ALL stroke survivors can get fully recovered our fucking lazy researchers take the easy route.  

Safety and Costs of Stroke Unit Admission for Select Acute Intracerebral Hemorrhage Patients

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Corey R. Fehnel, MD, MPH, Kimberly M. Glerum, BA, Linda C. Wendell, MD, ...

First Published June 2, 2017 Research Article

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Abstract

Background and Purpose:

There are limited data to guide intensive care unit (ICU) versus dedicated stroke unit (SU) admission for intracerebral hemorrhage (ICH) patients. We hypothesized select patients can be safely cared for in SU versus ICU at lower costs.

Methods:

We conducted a retrospective cohort study of consecutive patients with predefined minor ICH (≤20 cm³, supratentorial, no coagulopathy) receiving care in either an ICU or an SU. Multiple linear regression and inverse probability weighting were used to adjust for differences in patient characteristics and nonrandom ICU versus SU assignment. The primary outcome was poor functional status at discharge (modified Rankin score [mRS] ≥3). Secondary outcomes included complications, discharge disposition, hospital length of stay, and direct inpatient costs.

Results:

The study population included 104 patients (41 admitted to the ICU and 63 admitted to the SU). After controlling for differences in baseline characteristics, there were no differences in poor functional outcome at discharge (93% vs 85%, P = .26) or in mean mRS (2.9 vs 3.0, P = .73). Similarly, there were no differences in the rates of complications (6% vs 10%, P = .44), discharged dead or to a skilled nursing facility (8% vs 13%, P = .59), or direct patient costs (US$7100 vs US$6200, P = .33). Median length of stay was significantly longer in the ICU group (5 vs 4 days, P = .01).

Conclusions:

This study revealed a shorter length of stay but no large differences in functional outcome, safety, or cost among patients with minor ICH admitted to a dedicated SU compared to an ICU.