BackgroundPresently accepted criteria for ELVO intervention rely on time from last seen well (LSW) following conformation of LVO diagnosis and favorable baseline imaging. Many patients however present outside established treatment windows or with unknown LSW, and thus, represent a population of great relevance. Here we present in hospital and 90 day outcomes of a large patient cohort, many treated at extended LSW, after MRI assessment.PopulationELVO patients with isolated occlusion of the carotid terminus or M1 segment, baseline mRS ≤2, age ≥18, and no MRI contraindication.MethodsRegression analysis with primary outcome 90d mRS ≤2 and secondary outcomes in-hospital mortality, 90d mortality, 24 hour and discharge stroke severity (NIHSS).ResultsFrom a stroke intervention dataset representing n=80 ELVO patients treated with thrombectomy between 12/25/2014 and 8/14/2016, n=40 cases were identified meeting inclusion criteria. Median patient age was 69, baseline NIHSS was 17.5, and mean CT ASPECTS was 8.78. 15/40 (37.5%) received IV tPA and the median presenting DWI core volume was 15 mL (IQR: 5.0–33.7). Median time to femoral access was 418 min (IQR: 281–936). TICI ≥2B recanalization success was 85%. No patient had PH2 intracranial hemorrhage, 1 had PH1, 3 HT1, and 2 SAH, none requiring additional intervention.90d mRS ≤2 was 20%, in-hospital mortality was 12.5%, 90d mortality was 30%. All patients with 90d mRS ≤2 also had TICI ≥2B recanalization. Many patients (20/40) showed early response to therapy as defined by improvement in NIHSS≥4, an effect that was more likely with TICI ≥2B recanalization (OR 2.53 [95CI: 1.663–3.876]), and equally likely with femoral access before or after 6 hours LSW (OR 1.403 [95CI: 0.782–2.516]). The strongest predictor of 90d mRS ≤2 was baseline MRI core volume (b=−0.364, p=0.013). A similar and more robust effect was observed with discharge NIHSS (b=0.256, p<0.001). Time to femoral access showed a weak interaction with 90 day outcome and discharge NIHSS although a few patients treated at very early time LSW (<3 hour) showed excellent early response to therapy.ConclusionMRI selected ELVO patients represented in this cohort showed favorable response to therapy even at extended time from LSW. Although a few patients treated <3 hours LSW showed excellent response to therapy, MRI core volume was a better predictor of both in hospital and 90 day outcomes than time.Abstract E-031 Table 1 Logistic Regression Analysis 90d mRS ≤2 95 CI for B B Sig Lower Upper Age (yr) −0.088 0.014 −10.6 0.256 Baseline NIHSS 0.050 0.313 −5.54 13.7 Time to Fem Access (min) 0.001 0.013 −0.202 0.130 Baseline DWI Core (mL) −0.364 0.013 −35.3 0.040 Abstract E-031 Table 2 Linear Regression Analysis Discharge NIHSS 95 CI for B B Sig Lower Upper Age (yr) 0.227 0.003 0.110 0.358 TICI≥2B −12.2 0.008 −21.6 −4.8 Time to Fem Acc (min) −0.001 0.182 −0.001 0.007 Baseline DWI Core (mL) 0.256 0.001 0.118 0.369 Disclosures B. Cristiano: None. K. Cicilioni: None. M. Pond: None. J. Lee: None. P. Promod: None. U. Oyoyo,...
BackgroundIsolated occlusion of the MCA M2 segment may result in significant motor or speech symptoms and is often amenable to mechanical thrombectomy. Although isolated M2 occlusions are not uncommon they are unrepresented in recent large randomized controlled trials, and therefore, represent a population of great interest. Here we show significant response to therapy among a cohort of M2 occlusion patients, many treated at extended time LSW after MRI assessment.PopulationELVO patients with isolated occlusion of the right or left MCA M2 segment, baseline NIHSS speech score ≥1, baseline mRS ≤2, age ≥18, and no MRI contraindication.MethodsRetrospective cohort analysis with primary outcome discharge NIHSS speech score and secondary outcome NIHSS speech score improvement.ResultsFrom an institutional stroke intervention dataset representing n=80 ELVO patients treated with thrombectomy between 12/25/2014 and 8/14/2016, n=8 cases were identified meeting inclusion criteria. Median age was 66, median baseline NIHSS was 9 (range: 6–21), and mean CT ASPECTS was 9.25. 3/8 (37.5%) received IV tPA, median time LSW to femoral access was 216 min (IQR: 330–534), and median baseline DWI volume was 6 mL (IQR: 5–18). 7/8 patients studied (87.5%) showed at least one-point improvement in NIHSS speech score at discharge with 6/8 (75%) either insignificant or mild aphasia at discharge. 2/8 patients had time to femoral access ≤6 hour LSW, both had mild aphasia that was resolved at discharge. 4/5 patients presenting beyond 6 hour LSW had insignificant or mild aphasia at discharge, a response rate of 80% and not statistically different from the early presenting group (OR: 1.5 [95CI: 0.82–2.64]).ConclusionMRI selected ELVO patients with isolated M2 occlusion and significant aphasia represented in this cohort showed excellent response to therapy at extended time LSW.Abstract P-011 Table 1 Isolated M2 Occlusion Patients Presenting With Aphasia Case LSW to Fem Access (min) Baseline MRI Core (mL) Bas NIHSS Speech Score 24 hour Speech Score (NIHSS) Aphasia Severity Discharge 90 d mRS 1 467 6 1 -- None -- 2 150 15 1 1 None 3 3 425 5 2 2 Mild 2 4 600 6 3 2 Moderate 4 5 435 5 2 0 None -- 6 956 20 3 3 Moderate 1 7 425 0 3 0 None Dead 8 235 20 2 -- Mild Dead Dash indicates not recorded or unobtainableDisclosures B. Cristiano: None. K. Cicilioni: None. M. Pond: None. J. Lee: None. P. Promod: None. U. Oyoyo: None. J. Jacobson: None.
Background and purpose In acute ischemic stroke (AIS) patients, a diffusion-weighted imaging (DWI) Alberta Stroke Program Early Computed Tomography Score (ASPECTS) is correlated with infarct volume and is an independent factor of functional outcomes. Patients with pretreatment DWI-ASPECTS £6 were excluded or underrepresented in the recent randomized endovascular therapy (EVT) trials. Our aim was to assess the impact of recanalization in patients with pretreatment DWI-ASPECTS £6 treated with EVT. Methods We analyzed data collected between January 2012 and August 2015 in 2 prospective clinical registries of AIS patients treated with EVT. Every patient with a documented internal carotid artery or middle cerebral artery occlusion with pretreatment DWI-ASPECTS £6 was eligible for this study. The primary outcome was a favorable outcome defined by a modified Rankin Scale of 0 to 2 at 90 days. Results Two hundred eighteen patients were included. Among them, 145 (66%) had a good recanalization (TICI 2 b) at the end of EVT. There was no statistically difference in the baseline clinical characteristics between recanalised and nonrecanalised patients. Recanalized patients had an increased rate of favorable outcomes (38.7% vs 17.4%, p = 0.002) and a decreased rate of mortality at 3 months (22.5% vs 39.1%, p = 0.013) compared with non-recanalised patients. The symptomatic intracerebral hemorrhage rate was not different in the 2 groups (13% vs 14.1%, p = 0.83). Conclusion Patients with a pretreatment DWI-ASPECTS £6 may still benefit of EVT when a good recanalization is achieved. In particular, EVT-induced recanalization was associated with a reduced rate of mortality without increased risk of symptomatic intracerebral hemorrhage.
PurposeWith thrombectomy for anterior circulation large vessel occlusion (ACLVO) stroke, time to recanalization is considered important, but collateral status may be a greater driver of outcome than time. We tested the hypothesis that patients with ACLVO stroke who present with a small core infarct on DWI would show similar good outcomes after thrombectomy, regardless of time from onset.Materials and methodsA cohort of 49 patients treated with thrombectomy after MR selection for ACLVO stroke from 11/1/2012 until 5/15/2015 was retrospectively reviewed. Patients were selected for thrombectomy based on DWI screening with presentation core volume ≤100 age considered favorable. Patients were divided into early (n = 24) or extended (n = 25) treatment groups, with intention to treat ≤6 hours = early, and comparisons made with final infarct volume the primary outcome.ResultsBaseline characteristics were similar (early versus extended), including admission NIHSSS (IQR 13–19 versus 11–18). Recanalization ≥ TICI2B was 79% and 83% respectively. There was no significant difference in median final infarct volume (16 mL versus 22 mL, estimated difference +4 mL [95 CI: –13 – +19], p = 0.61) or median infarct growth (1 mL versus 5 mL, estimated difference 1.0 mL [95 CI: –7.0 – +10], p = 0.71). For decision to treat up to 20 hours after onset, time did not correlate with final infarct volume, Figure 1. Similar rates of complications and mortality were observed.Abstract P005 Figure 1Final core volume does not correlate with treatment decision time. Dashed line, t = 6 hours; open circle = successful recanalization, closed circle = failed recanalization; Spearman rank-order correlation, rs(46) = 0.085, p = 0.566ConclusionUsing MR selection, similar good outcomes after thrombectomy for ACLVO stroke may be achieved well beyond 6 hours.DisclosuresB. Cristiano: None. M. Pond: None. S. Basu: None. U. Oyoyo: None. J. Jacobson: 4; C; GeneLux.
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