Early prediction of malignant infarction may guide treatment decisions. For patients who received endovascular treatment, the risk of malignant infarction is unknown and risk factors are unrevealed.
The objective of this study is to estimate the incidence of malignant infarction after endovascular treatment in patients with an occlusion of the anterior circulation, to identify independent risk factors, and to establish a model for prediction.
We analyzed patients who received endovascular treatment for a large vessel occlusion in the anterior circulation within 6.5 h after symptom onset, included in the Dutch MR CLEAN Registry between March 2014 and June 2016. We compared patients with and without malignant infarction. Candidate predictors were incorporated in a multivariable binary logistic regression model. The final prediction model was established using backward elimination. Discrimination and calibration were evaluated with the area under the receiver operating characteristic curve (AUROC) and the Hosmer-Lemeshow test.
Of 1445 patients, 82 (6%) developed malignant infarction. Independent predictors were lower age, higher National Institutes of Health Stroke Scale (NIHSS), lower alberta stroke program early CT score (ASPECTS), internal carotid artery occlusion, lower collateral score, longer times from onset to groin puncture, and unsuccessful reperfusion. The AUROC of a prediction model combining these features was 0.83 (95% confidence interval (CI): 0.79–0.88) and the Hosmer-Lemeshow test indicated appropriate calibration (P = 0.937).
The risk of malignant infarction after endovascular treatment started within 6.5 h of stroke onset is approximately 6%. Successful reperfusion decreases the risk. A prediction model combining easily retrievable measures of age, ASPECTS, collateral status, and reperfusion shows good discrimination between patients who will develop malignant infarction and those who will not.
Triage for suspected acute stroke has two main options: (1) transport to the closest primary stroke center (PSC) and then to the nearest comprehensive stroke center (CSC) (Drip-and-Ship) or (2) transport the patient to the nearest CSC, bypassing a closer PSC (mothership). The purpose was to evaluate the effectiveness of drip-and-ship versus mothership models for acute stroke patients.
A Markov decision-analytic model was constructed. All model parameters were derived from recent medical literature. Our target population was adult patient with sudden onset of acute stroke within 8 h of onset over a one-year horizon. The primary outcome was quantified in terms of quality-adjusted-life-years (QALYs).
The base case scenario show that the drip-and-ship strategy has a slightly higher expected health benefit, 0.591 QALY, as compared to 0.586 QALY in the mothership strategy when the time to PSC is 30 min and to CSC is 65 min, although the difference in health benefit becomes minimal as the time to PSC increases towards 60 min. Multiple sensitivity analyses show that when both PSC and CSC are far from place of onset (>1.5 h away), drip-and-ship becomes the better strategy. Mothership strategy is favored by smaller difference between distances to PSC and CSC, shorter transfer time from PSC to CSC, and longer delay in reperfusion in CSC for transferred patients. Drip-and-ship is favored by the reverse.
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.
Introduction
The DAWN trial demonstrated the effectiveness of late endovascular treatment (EVT) in acute ischemic stroke (AIS) patients selected on the basis of a clinical-core mismatch. We explored in a real-world sample of EVT patients if a clinical-ASPECTS (Alberta Stroke Program Early CT Score) mismatch was associated with an outcome benefit after late EVT.
Methods
We retrospectively analysed all consecutive AIS patients admitted 6-24 hours after last proof of good health in two stroke centres, with initial National Institutes of Health Stroke Scale (NIHSS) ≥10 and an internal carotid artery or M1 occlusion. We defined clinical-ASPECTS mismatch as NIHSS≥10 and ASPECTS≥7, or NIHSS≥20 and ASPECTS≥5. We assessed the interaction between clinical-ASPECTS mismatch positive and negative patients and late EVT, using ordinal shift analysis of the 3-month modified Rankin Scale and adjusting for multiple confounders.
Results
The included 337 patients had a median age of 73 years (IQR=61-82), admission NIHSS of 18 (15-22) and baseline ASPECTS of 7 (5-9). Out of 196 (58.2%) patients showing clinical-ASPECTS mismatch, 146 (74.5%) underwent late EVT. Among 141 (41.8%) mismatch negative patients, late EVT was performed in 72 (51.1%) patients. In the adjusted analysis, late EVT was significantly associated with a better outcome in the presence of clinical-ASPECTS mismatch (adjusted Odd Ratio, aOR=2.83; 95% confidence interval, CI: 1.48-5.58) but not in its absence (aOR=1.32; 95%CI: 0.61-2.84). The p-value for the interaction term between clinical-ASPECTS mismatch and late EVT was 0.073.
Conclusions
In our retrospective two-site analysis, late EVT seemed effective in the presence of a clinical-ASPECTS mismatch, but not in its absence. If confirmed in randomized trials, this finding could support the use of an ASPECTS-based selection for late EVT decisions, obviating the need for advanced imaging.
Establishing an endovascular therapy (EVT) program at a cardiology cath lab could be done with a minimal learning curve if operators had prior experience with carotid stenting, one tertiary university hospital reported.
The program, started in 2012 with the addition of an experienced interventional radiologist as lead operator, had stroke patients achieve good clinical outcomes at 90 days in 47.9% of cases.
Importantly, the distribution in modified Rankin Scale (mRS) scores stayed stable every year through 2019, according to Jakub Sulenko, MD, PhD, of Charles University and University Hospital Kralovske Vinohrady in Prague, Czech Republic, and colleagues in the PRAGUE-16 group.
"When a catheter-based thrombectomy program was initiated in an experienced cardiac cath lab in close cooperation between cardiologists, neurologists, and radiologists, outcomes were comparable to those of neuroradiology centers," Sulenko and colleagues concluded in JACC: Cardiovascular Interventions.
"These results are even more astonishing as PRAGUE-16, in contrast to the randomized trials, also included patients with ischemia in the posterior circulation in their analysis," commented Marius Hornung, MD, and Horst Sievert, MD, both of the CardioVascular Center Frankfurt.
"By caring for patients with MI, the physicians involved are comfortable working in critical situations and under mental and physical pressure. We are currently at a time when many experienced cardiologists are also trained in performing carotid artery interventions. Therefore, they are experienced in accessing the supra-aortic arteries," Hornung and Sievert said in an accompanying editorial.
The Prague cath lab operated every day and at all hours treating acute MIs before it started taking in acute ischemic stroke patients.
EVT complication rates included 5.7% symptomatic intracerebral hemorrhage and 1.8% embolization in a new vascular territory.
"These findings support the potential role of interventional cardiac cath labs in the treatment of acute stroke in regions where this therapy is not readily available due to the lack of neurointerventionalists," Sulenko's group said, citing a smaller, similar experience previously reported from a Pennsylvania center.
At the beginning of the Prague EVT program, two cardiologists with experience in carotid artery stenting (one with 42 procedures, the other with >100) were selected to perform around 30 mechanical thrombectomies under supervision of the newly arrived interventional radiologist. Subsequently, the cardiologists were able to perform thrombectomies without supervision.
A neurologist always decided which patients got stroke thrombectomy based on clinical symptoms and CT angiography.
"To be able to guarantee optimized stroke therapy as soon as possible, disputes over competence among the individual medical societies involved must be ended, and interdisciplinary teams must be created to be able to offer the best possible treatment for each patient," according to Hornung and Sievert.
"Diagnostics, patient selection, and follow-up care must remain the core competencies and tasks of neurology. Appropriately trained and experienced physicians, regardless of their specialties, should perform acute stroke interventions and endovascular thrombectomy," they urged.
The Prague experience included 333 patients with a large vessel occlusion stroke from 2012 to 2019.
Number of EVTs increased from four in 2012 to 82 in 2019. Patients were older over time, from an average of 60 to 72.
Some evidence for a learning curve was observed, as the rate of successful recanalization (TICI grade 2b/3) improved over time from a low of 60% in 2013 to a high of 84% in 2019 (P=0.047). Overall, operators achieved TICI 2b/3 in 79.3% of patients.
A study limitation was its single-center nature.
"The results of PRAGUE-16 show that experienced interventional cardiologists can perform endovascular stroke interventions and thrombectomy with a high degree of technical and clinical success after appropriate training and supervision," Hornung and Sievert maintained.
Only with a larger network of stroke interventionalists, they suggested, can clinicians stop "losing unnecessary time to patient transfer" or "continuing to offer only the second best therapy" to eligible stroke patients.
![author['full_name']](https://clf1.medpagetoday.com/media/images/author/nicoleLou_188.jpg)
Disclosures
The study was supported by Charles University
Sulzenko and co-authors disclosed no relevant relationships with industry.
Hornung and Sievert disclosed relevant relationships (institutional) with Abbott, Access Closure, AGA, Angiomed, Arstasis, Atritech, Atrium, Avinger, Bard, Boston Scientific, Bridgepoint, Cardiac Dimensions, CardioKinetix, CardioMEMS, Coherex, Contego, Cardiovascular Systems, EndoCross, Endotext, Epitek, Evalve, ev3, FlowCardia, Gore, Guidant, Guided Delivery Systems, InSeal Medical, Lumen Biomedical, Heart Leaflet Technologies, Kensey Nash, Kyoto Medical, Lifetech, Lutonix, Medinol, Medtronic, NDC, NMT Medical, Occlutech, Osprey, Ovalis, Pathway, PendraCare, Percardia, pfm Medical, Rox Medical, Sadra, Sorin, Spectranetics, Square One, Trireme, Trivascular, Velocimed, and Veryan.
Primary Source
JACC: Cardiovascular Interventions
Secondary Source
JACC: Cardiovascular Interventions
Source Reference: Hornung M and Sievert H "It is time to fight ischemic stroke the best possible way" JACC Cardiovasc Interv 2021; DOI: 10.1016/j.jcin.2021.02.017.
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.
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.
Introduction
The DAWN trial demonstrated the effectiveness of late endovascular treatment (EVT) in acute ischemic stroke (AIS) patients selected on the basis of a clinical-core mismatch. We explored in a real-world sample of EVT patients if a clinical-ASPECTS (Alberta Stroke Program Early CT Score) mismatch was associated with an outcome benefit after late EVT.
Methods
We retrospectively analysed all consecutive AIS patients admitted 6-24 hours after last proof of good health in two stroke centres, with initial National Institutes of Health Stroke Scale (NIHSS) ≥10 and an internal carotid artery or M1 occlusion. We defined clinical-ASPECTS mismatch as NIHSS≥10 and ASPECTS≥7, or NIHSS≥20 and ASPECTS≥5. We assessed the interaction between clinical-ASPECTS mismatch positive and negative patients and late EVT, using ordinal shift analysis of the 3-month modified Rankin Scale and adjusting for multiple confounders.
Results
The included 337 patients had a median age of 73 years (IQR=61-82), admission NIHSS of 18 (15-22) and baseline ASPECTS of 7 (5-9). Out of 196 (58.2%) patients showing clinical-ASPECTS mismatch, 146 (74.5%) underwent late EVT. Among 141 (41.8%) mismatch negative patients, late EVT was performed in 72 (51.1%) patients. In the adjusted analysis, late EVT was significantly associated with a better outcome in the presence of clinical-ASPECTS mismatch (adjusted Odd Ratio, aOR=2.83; 95% confidence interval, CI: 1.48-5.58) but not in its absence (aOR=1.32; 95%CI: 0.61-2.84). The p-value for the interaction term between clinical-ASPECTS mismatch and late EVT was 0.073.
Conclusions
In our retrospective two-site analysis, late EVT seemed effective in the presence of a clinical-ASPECTS mismatch, but not in its absence. If confirmed in randomized trials, this finding could support the use of an ASPECTS-based selection for late EVT decisions, obviating the need for advanced imaging.
