BACKGROUND AND PURPOSE:The advent of modern neuroendovascular techniques has highlighted the need for a simple, effective, and reliable brain arteriovenous malformation endovascular grading scale. A novel scale of this type has recently been described. It incorporates the number of feeding arteries, eloquence, and the presence of an arteriovenous fistula component. Our aim is to assess the validity of this grading scale.
Introduction/purposeThere is no standard imaging approach for EVT patient selection. CT remains the most widely used modality for stroke evaluation. Ischemic change on non-contrast CT (NCCT) quantified using ASPECTS has been demonstrated to predict clinical response to EVT. To date, definitive studies evaluating the impact of CTA source image (CTA-SI) pre-treatment ASPECTS (pre-ASPECTS) on outcomes following EVT are lacking. START was a prospective, multicenter study to evaluate the influence of pre-treatment core infarct size in patients undergoing endovascular stroke therapy using the Penumbra System.Materials and MethodsThe imaging method was at each center's discretion and included NCCT, CTA-SI, CT perfusion, or MRI diffusion imaging. This study focused on the preliminary CTA-SI results. Results are reported from an interim analysis of the START trial data as adjudicated by a central Core Laboratory. Graded in a blinded fashion, ASPECTS was analyzed according to the a priori classification (0–4, 5–7, 8–10), as well as using the entire scale. Clinical outcomes were dichotomized as 90-day modified Rankin Scale scores of 0–2 (good) vs 3–6. Univariate and multivariate analyses were performed to determine predictors of outcome.ResultsOf the 147 patients enrolled, 77 met study criteria for this interim analysis. The mean age was 66.0±14.1 years; median NIHSS was 19 (14–24). Target vessel occlusions were in the ICA (22.1%), MCA (75.3%), and other (2.6%). The median pre-ASPECTS on CTA-SI was 6 (4–7). There were 20 (26%) patients with scores of 0–4, 43 (55.8%) with 5–7, 14 (18.2%) with 8–10. The rate of TIMI 2–3 revascularization was 85.3% (64/75). The median time from groin puncture to aspiration discontinuation was 71.5 (40–108) min. 37 (48.1%) patients achieved a good 90-day outcome. 22 (28.6%) died. Four (5.2%) patients suffered from symptomatic hemorrhage, and 11 (14.3%) suffered from asymptomatic hemorrhage. Higher pre-ASPECTS on CTA-SI was significantly associated with good outcomes (median 6 (IQR 5–7) vs 5 (IQR 3–7), p<0.05). The rate of good outcomes was 20.0% for ASPECTS 0–4, 55.8% for 5–7, and 64.3% for 8–10 (p=0.08). Adjusting for age and NIHSS and comparing ASPECTS 0–4 with 5–10, pre-ASPECTS 5–10 was an independent predictor of good outcome (OR 6.8, p=0.006). In ROC analysis, ASPECTS >4 was the optimal threshold for identifying good outcomes (89% sensitivity, 38% specificity). Other univariate predictors of good outcome were lower age (p=0.01), lower NIHSS (p=0.04), revascularization time (p<0.0001), and shorter time from groin puncture to aspiration cessation (p=0.0004).ConclusionHigher pre-treatment ASPECTS on CTA source images are associated with better outcomes following EVT. Comparative studies with NCCT ASPECTS are required to evaluate relative accuracy for patient selection.Competing interestsD Frei: None. A Yoo: None. D Heck: None. F Hellinger II: None. V McCollom: None. D Fiorella: None. A Turk III: None. T Malisch: None. O Zaidat: None. M Alexander: None. T Devlin: None. E Levy: None. Q Shah: Non...
PurposeThe importance of early reperfusion to functional recovery after mechanical thrombectomy is well established. Factors contributing to the delay of endovascular therapies remain unclear. Data was analyzed to evaluate the cause (s) for delaying the start of IA intervention in the Penumbra trials.MethodsA pooled analysis of 1028 patients was conducted from the prospective and retrospective Penumbra trials (Pivotal N = 124, PICS N = 261, START N = 133, POST N = 108, RetroSTART N = 191, Speed 054 N = 71). All obtained treatment at <8 h from stroke symptom onset. Included patients were either refractory or ineligible to IV rtPA, had a NIHSS score of 8 or greater, and were in the anterior and posterior circulations.The univariate relationships between the outcomes and predictor variables were calculated using Spearman’s rank correlation for continuous variables and Wilcoxon rank sums for two-group variables. Predictors of hours from arrival to procedure start with a univariate significance of p < 0.20 were included in the multivariate model. The final multivariate logistic regression model of hours from arrival to procedure start was determined using a standard stepwise selection method. The level of significance was set at p < 0.05.ResultsAmong the 1028 patients pooled, 742 met study criteria. Mean age was 66 ± 15 and 53% were female. The median admission NIHSS score was 18 (IQR 13–21) and 49% were administered IV-tPA prior to mechanical thrombectomy. Baseline ASPECTS of 0–4, 5–7, 8–10 was 9.5%, 34.5% and 56%, respectively. The median time from symptom onset to hospital arrival was 128 (IQR 63–210) minutes. The median time from hospital arrival to procedure start was 121 (79–165) minutes.In the univariate analysis, age, gender, target vessel location, baseline NIHSS, IV-tPA prior to IAT, and general anesthesia were not associated with longer arrival to puncture times. The strongest predictors of arrival time to puncture were transfer patient status (p < 0.0001) and onset to arrival (p < 0.0001). Furthermore, transfer patients on average took longer to arrival the hospital, but were treated quicker. However, transfer patients still had a longer overall time from symptom onset to start of procedure. In the multivariate model, a transfer patient’s time from door to procedure was lower by 26 min (p < 0.0001), while every hour increase in onset to arrival time, reduced time to procedure by 18 min (p < 0.0001).ConclusionIn this pooled analysis, transferred patients had a lower door to puncture time, but overall greater total time from onset to puncture longer than direct admit. Even with direct admission patients, as onset to arrival time increased, door to puncture times decreased. Our findings suggest that there is a need to conduct an intensive review of in-hospital triaging procedures for endovascular therapy.DisclosuresA. Yoo: 2; C; NIH, Penumbra, Inc., Remedy Pharmaceuticals. R. Gupta: None. B. Mehta: None. H. Buell: 5; C; Penumbra, Inc. K. Adamski: 5; C; Penumbra, Inc. S. Hak: 5; C; Penumbra, Inc. S. Kuo: 5; C; ...
microangioscope embedded in a 0.0165' microcatheter. In human cadaveric experiments, that the microangioscope is compatible with the human intracranial vasculature beyond the Circle of Willis (eg. navigation into and visualization of the M2 origin). In in vivo swine model experiments, the microangioscope has adequate resolution and illumination to identify and differentiate between various intravascular pathologies (eg. red thrombus versus white thrombus). With flow arrest and irrigation, mechanical thrombectomy (both with stent retriever and direct aspiration), coil embolization, stent deployment, and balloon angioplasty were precisely performed under direct visualization with the microangioscope. After deployment, the microangioscope enables direct inspection of devices, providing complementary information to standard angiography. Imaging quality, illumination, and flexibility of the microangioscope progressively improved through modifications to the image bundle. Based on these results, the microangioscope is compatible with the human distal cerebrovasculature; it also provides adequate direct visualization for neurointerventions.
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