BACKGROUND AND PURPOSE:Treatment strategies in acute ischemic stroke aim to curtail ischemic progression. Emerging paradigms propose patient subselection using imaging biomarkers derived from CT, CTA, and CT perfusion. We evaluated the performance of a fully-automated computational tool, hypothesizing enhancements compared with qualitative approaches. The correlation between imaging variables and clinical outcomes in a cohort of patients with acute ischemic stroke is reported.
We evaluated the utility of left atrial volume index (LAVI) and markers of coagulation and hemostatic activation (MOCHA) in cryptogenic stroke (CS) patients to identify those more likely to have subsequent diagnosis of atrial fibrillation (AF), malignancy or recurrent stroke during follow-up.Consecutive CS patients who met embolic stroke of undetermined source (ESUS) who underwent transthoracic echocardiography and outpatient cardiac monitoring following stroke were identified from the Emory cardiac registry. In a subset of consecutive patients, d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex and fibrin monomer (MOCHA panel) were obtained ≥2 weeks post-stroke and repeated ≥4 weeks later if abnormal; abnormal MOCHA panel was defined as ≥2 elevated markers which did not normalize when repeated. We assessed the predictive abilities of LAVI and the MOCHA panel to identify patients with subsequent diagnosis of AF, malignancy, recurrent stroke or the composite outcome during follow-up.Of 94 CS patients (mean age 64 ± 15 years, 54% female, 63% non-white, mean follow-up 1.4 ± 0.8 years) who underwent prolonged cardiac monitoring, 15 (16%) had new AF. Severe LA enlargement (vs normal) was associated with AF (P < .06). In 42 CS patients with MOCHA panel testing (mean follow-up 1.1 ± 0.6 years), 14 (33%) had the composite outcome and all had abnormal MOCHA. ROC analysis showed LAVI and abnormal MOCHA together outperformed either test alone with good predictive ability for the composite outcome (AUC 0.84).We report the novel use of the MOCHA panel in CS patients to identify a subgroup of patients more likely to have occult AF, occult malignancy or recurrent stroke during follow-up. A normal MOCHA panel identified a subgroup of CS patients at low risk for recurrent stroke on antiplatelet therapy. Further study is warranted to evaluate whether the combination of an elevated LAVI and abnormal MOCHA panel identifies a subgroup of CS patients who may benefit from early anticoagulation for secondary stroke prevention.
Introduction:
Endovascular therapy is the standard of care for the treatment of proximal large vessel occlusion strokes (LVOS). Its safety and efficacy in the treatment of distal intracranial occlusions has not been well studied.
Methods:
We retrospectively reviewed a prospectively collected endovascular database (September 2010-December 2015, n=898) for all patients with distal intracranial occlusions treated with endovascular therapy. Distal occlusions were defined as any occlusion of the anterior cerebral artery (ACA), any occlusion of the posterior cerebral artery (PCA), or any occlusion at or distal to the middle cerebral artery (MCA)-M3 opercular segment.
Results:
Distal occlusions were treated in 70 patients. The mean age was 66+/-14 and 57% of the patients were male. Thirty-one (44%) of the patients received IV-tPA. The median pre-procedure NIHSS was 19 (IQR, 13-23). The distal occlusion was the primary treatment location in 54 patients and in 16 patients the distal occlusion was treated as a rescue strategy after successful treatment of a proximal LVOS. The locations of the primary cases were MCA-M3 (n=21), ACA with a concomitant MCA-M1 or MCA-M2 (n=16), ACA alone (n=9), PCA (n=6), and ACA with a concomitant MCA-M3 (n=2). The locations of the rescue cases were MCA-M3 (n=8), ACA (n=7), and both MCA-M3 and ACA (n=1). The most common treatment modalities employed were intra-arterial tPA (n=37, 52%), small (3mm) stent-retrievers (n=24, 33%), and thromboaspiration (n=30, 42%). Near or complete reperfusion (mTICI 2b-3) was achieved in 56 cases (80%). Overall, there were 5 (7%) cases of any parenchymal hematoma (PH). However, two of the PHs were in patients with both a MCA-M1 and an ACA occlusion, and both of these hemorrhages were in the MCA territory. Thus only 3 PHs (4.3%) occurred in the territory of the treated distal occlusion with two of these patients also receiving IV tPA. At 90 days, 24 patients (40%) had a mRS of 0-2 and 13 (21%) had died.
Conclusions:
Distal intracranial occlusions can be treated safely and successfully with endovascular therapy. Although promising our results need to be corroborated by larger prospective controlled studies.
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