BackgroundThe first pass effect has been shown to improve clinical outcomes in patients with middle cerebral artery (MCA) M1 occlusions.ObjectiveTo determine the rates of first pass effect in MCA M1 occlusions and determine if proximal or distal location of occlusion modified clinical outcomes.MethodsPatients with recanalized MCA M1 occlusions who underwent endovascular thrombectomy (EVT) were reviewed to determine the effect of first pass effect (FPE) and location of occlusion on clinical outcomes. MCA occlusions were classified as proximal if they included the first two thirds of the MCA and involved the lenticulostriate vessels, or distal if they did not.ResultsWe included 261 patients of which 27% achieved FPE. Of the cohort, there were 91 (35%) proximal MCA occlusions and 170 (65%) distal MCA occlusions. Baseline demographics and treatment time metrics were comparable across both groups. There was a trend toward good clinical outcome in patients with or without a FPE (60 vs. 46%; p = 0.06), however a higher rate of excellent clinical outcome was noted in patients with FPE (46 vs. 30%; p = 0.02). When compared by location, patients with distal MCA occlusions had a higher rate of excellent clinical outcome (40 vs. 25%; p = 0.02). Multivariable analysis showed that distal MCA occlusion was the strongest predictor of an excellent clinical outcome and first pass effect.ConclusionPatients with MCA M1 occlusions with FPE have a higher rate of excellent clinical outcomes compared to those who did not. Location of MCA occlusion appears to modify rates of first pass effect and excellent clinical outcomes.
Introduction: Hematoma expansion (HE) is a known prognostic indicator of spontaneous intracerebral hemorrhage (sICH). Although several scores exist for prediction of HE, universal adoption has been limited due to their lack of sensitivity and specificity. As machine learning (ML) algorithms have shown promise in the stroke field, here we examine the predictive accuracy of several ML algorithms for HE in sICH patients. Methods: We retrospectively analyzed demographic, clinical data, and radiographic signs of patients with sICH in our 2-hospital database. A total of 61 clinical, imaging, and treatment variables were included in the study. Nine ML models were applied: Adaptive Boost (AdaBoost), Bernoulli Naïve Bayes (BNB), Decision Tree (DT), Gaussian Naïve Bayes (GNB), Logistic Regression (LR), Multi-Layer Perceptron (MLP), Multinomial Naïve Bayes models (MNB), Random Forest (RF), and Extreme Gradient Boosting (XGBoost). All models were trained to predict HE. Model accuracy was assessed using the area under characteristic curve (AUC). Results: Of the 301 patients with sICH, 63 developed HE (21.93%). Of the 9 models studied, MLP had the highest AUC score (0.93±0.042), followed by XGBoost (0.80±0.06). All models demonstrated moderate to high predictive accuracy (AUC 0.64-0.93) for HE. The top predictors in MLP were Baseline NIHSS score, HDL, aPPT, time from last known well to ER, initial hematoma volume, and island sign. MLP had moderate sensitivity of 0.46±0.17 and high specificity of 0.99±0.02. GNB, however, showed the highest sensitivity at 0.86±0.06 and a moderate specificity of 0.65±0.07. Five of the 9 models ranked time last known well to ER presentation as a predictor of HE. Conclusion: In our study, we found all ML models applied had moderate to high predictive accuracy for prediction of HE in sICH, with MLP having the highest accuracy of all models. Future studies examining the use of these algorithms are warranted.
Introduction Recent randomized clinical trials have demonstrated that endovascular therapy for basilar artery occlusion is safe and effective. However, many people still have poor outcomes despite treatment. The aim of this study was to identify the predictors of good functional outcome in posterior circulation strokes after mechanical thrombectomy from the Trevo Stent‐Retriever Acute Stroke TRACK and the North American Solitaire Stent Retriever Acute Stroke (NASA) registries. Methods Patient‐level data from the TRACK and NASA registries were pooled and patients with posterior circulation stroke were included in the analysis. Patients were dichotomized into those with 90‐day good functional outcome (mRS≤2) and poor functional outcome (mRS>2). Baseline and procedural data were compared between the two cohorts. Multivariate logistic regression was then performed to identify predictors of functional outcome. P‐value < 0.05 was considered significant. Results Out of 119 posterior stroke patients (99 BA, 16 VA, and 4 PCA), a total of 110 patients had mRS data available on follow‐up. Good functional outcome was observed in 44 patients (37%). Patients with mRS≤2 were less likely to have hypertension (61.4% versus 83.3%, p = 0.01), dyslipidemia (38.6% versus 62.1%, p = 0.016), and diabetes (18.2% versus 36.4%, p = 0.040). Patients with mRS≤2 had a lower mean baseline NIHSS (15.2±9.95 versus 22.6±9.50, p< .001). Time to puncture, utilization of BGC, general anesthesia use, number of passes, and successful recanalization (TICI≥ 2B) were not significantly different between the two cohorts. On multivariate analysis, higher baseline NIHSS was associated with worse functional outcome (OR:0.91, CI:0.87‐0.96, P< .001). Use of IV tPA was associated with higher odds of achieving good functional outcomes (OR:2.82, CI:1.06‐7.51, P:0.038). Conclusions In this pooled analysis of the NASA and TRACK Registries, posterior circulation patients achieving good outcome were more likely to have a lower baseline NIHSS and less comorbidities. Use of IV‐tPA and lower baseline NIHSS were independent predictors of functional outcome.
Modified first pass effect (mFPE) of TICI 2B or greater is an independent predictor of clinical outcome in patients who undergo mechanical thrombectomy (MT). Location of the occlusion in the M1 segment may affect the mFPE and may influence clinical outcomes. A comparison of mFPE between occlusions of the proximal and distal (sparing lenticulostriate branches) M1 segments of the MCA has yet to be performed. We aim to examine the interaction between first pass effect and clinical outcomes in proximal versus distal M1 occlusions. We performed retrospective analysis of patients who underwent MT between 2014 and 2020. Patients were included if they were treated for M1 occlusion within 24 hours from last seen normal, and achieved successful recanalization (TICI2b or greater). Patients were excluded if they were not successfully recanalized, or if they had other intracranial or multifocal occlusions. A total of 264 patients were included in this analysis. Ninety two patients had proximal M1 occlusions and 172 had distal M1 occlusions. Patients with proximal M1 occlusions had higher NIHSS (median 18 vs. 16, p=0.003), lower ASPECTS (mean 8.5 vs 9, p=0.02), and were less likely to be females (44.6% vs. 62.8%, p=0.006). Modified first pass effect was achieved in 45.3% of distal M1 occlusions compared to 31.9% of proximal (p=0.047). Excellent clinical outcome, defined as mRS of 0-1 at 90 days was higher in distal occlusion group (38.8% vs. 24.7%, p=0.03). Additionally, the proximal occlusion group was more likely to experience any grade of hemorrhagic transformation (HT) (37.4 vs. 23.3, p=0.02). Other baseline characteristics and time metrics did not differ between the two groups. In a multivariate analysis of predictors of excellent outcome in the overall cohort, ASPECTS (OR=1.39, p = 0.026) and proximal occlusion site (OR=0.485, p=0.037) were the only two independent predictors. Therefore, mFPE was not a predictor of excellent outcome when adjusted for exact location of occlusion.
Introduction: First pass effect (FPE) defined as TICI 3 recanalization or greater is an independent predictor of clinical outcome in patients who undergo mechanical thrombectomy (MT). The first pass effect may be impacted by device-related factors, thrombus composition, or collateral circulation flow dynamics. In this study, we aim to examine the impact of first pass effect on clinical outcomes in patients with MCA M1 occlusions. Methods: A retrospective analysis of all patients with MCA M1 occlusion who underwent successful mechanical thrombectomy (TICI 2b or greater) between 2014-2020 at two thrombectomy stroke centers was performed. Location of occlusion was recorded as proximal MCA (involvement of the lenticulostriate vessels) or distal. Patients were excluded if they were not successfully recanalized or if they had multifocal intracranial occlusions. Patient characteristics, time metrics, procedural data, and 90 day clinical outcomes were collected. The primary outcome of interest was first pass effect, defined as TICI 3 after a single pass. Results: A total of 261 patients achieved successful recanalization of MCA occlusions in our cohort, with 70 (26.8%) patients achieving a first pass effect. Baseline demographics, rates of IV-tPA administration, and time metrics were similar between the FPE and non-FPE group. Proportion of proximal MCA and distal MCA occlusions were similar between groups as well (38.2% vs. 25.7%; p=0.08). Rates of excellent clinical outcomes were significantly higher in the FPE group compared to the non-FPE group (46.3% vs. 29.9%; p=0.02). In a multivariate analysis, proximal MCA occlusion was a significant predictor of first pass effect. Conclusion: First pass effect in middle cerebral artery M1 occlusions is a significant predictor of an excellent clinical outcome. Patients with a proximal MCA M1 occlusion are more likely to achieve a first pass effect compared to patients with a distal MCA occlusion.
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