Clinical and radiological outcome after mechanical thrombectomy in acute ischemic stroke: What matters?

Purpose Cerebral hyperdensities can appear on head computed tomography (CT) images performed early after endovascular treatment (EVT) in patients with acute ischemic stroke and may be secondary to contrast staining or hemorrhagic transformation. The aim of this study was to determine how the high-density sign on CT affects mortality and clinical outcome and whether CT parameters predict hemorrhagic conversion or unfavorable outcome. Methods We retrospectively reviewed a database of patients who underwent EVT with mechanical thrombectomy for acute ischemic stroke over 7 years. Included were acute stroke patients with a CT examination within 24 h post-EVT with mechanical thrombectomy, demonstrating areas of hyperdensity. We evaluated morphologic characteristics of these lesions, location, CT Hounsfield units and largest area, as well as patient demographics, EVT methods and patient outcome. Results A total of 29 patients met the strict inclusion criteria. Complete recanalization was achieved in 58.6% (17/29). Seventeen (58.6%) cases of post-intervention cerebral hyperdensities were related to contrast staining and 12 (41.4%) cases to contrast staining and hemorrhage. Patient mortality was significantly higher in the hemorrhagic group (50.0% versus 5.9%, p = 0.003). The increased density on CT was associated with higher hemorrhagic risk (odds ratio 1.05, p = 0.036). Conclusion Patients with the high-density sign on CT images after mechanical thrombectomy for acute ischemic stroke demonstrated increased mortality and worse clinical outcome, primarily when these hyperdensities were related to hemorrhage. CT imaging parameters as higher density areas can help in the differentiation of hemorrhage from contrast staining.

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“…There are, however, diagnostic difficulties to accurately predict which patient will suffer from devastating consequences. 4–7…”

Section: Introductionmentioning

confidence: 99%

Value of high-density sign on CT images after mechanical thrombectomy for large vessel occlusion in predicting hemorrhage and unfavorable outcome

et al. 2020

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“…1 Hyperacute recanalization with mechanical thrombectomy has proven to be paramount for clinical outcome. 2 The Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times (ESCAPE) trial was designed to assess whether patients with acute ischemic stroke, who were selected on the basis of results of computed tomography (CT) and CT angiography (CTA), would benefit from rapid endovascular treatment involving contemporary endovascular techniques. 3 Demchuk et al demonstrated that use of multiphase CTA, fast and efficient workflow, and effective thrombectomy devices provided evidence of benefit of endovascular treatment in patients with moderate-to-severe ischemic stroke.…”

Section: Introductionmentioning

confidence: 99%

Beyond the collaterals: Additional value of multiphase CTA in acute ischemic stroke evaluation

et al. 2019

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Purpose Multiphase computed tomography angiography (MP-CTA) is an innovative imaging tool that can give those managing acute ischemic stroke temporal information on degree and extent of pial collateral arterial filling in the affected brain. We sought to estimate the incidence of false-positive or -negative evaluation of the carotid bifurcation or intracranial thrombus on single-phase CTA (SP-CTA) compared with MP-CTA. Material and methods A single-center, retrospective consecutive review was conducted of imaging and clinical records of 150 patients in two months who presented with neurological symptoms with a National Institutes of Health Stroke Scale score ≥ 2 and who received an MP-CTA as part of their investigative work-up. The cohort consisted of 52.3% male and 47.7% female patients. Median individual age was 68 years (interquartile range 60–79). Extracranial and intracranial vessel images of the initial early arterial phase were evaluated and compared with late arterial and early venous phase images. Results In the cohort of 150 patients, in three patients (2%) SP-CTA would have led to an incorrect diagnosis and management without MP-CTA–acquired source imaging. The three scenarios represented differentiating a carotid string sign from internal carotid artery occlusion, determining the appearance and extent of thrombus in carotid T-occlusion, and differentiating slow flow and contrast mixing-related artifacts from intraluminal thrombus. Conclusions In addition to improving assessment of collateral circulation in acute stroke patients, MP-CTA is also useful in assessing specific flow-related scenarios for which SP-CTA may give spurious results.

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“…Diagnostic workup in stroke patients is extremely time-critical. Therefore, an easily evaluable and reliable diagnostic tool for standardized noninvasive assessment of cerebral hemodynamics is all the more important [38,39]. While manual ROI determination on 4D-CTA is time-consuming depending on the clinician's experience, fv-CTA provides concentrated information on cerebral hemodynamics in a single composite 3-dimensional data set which is calculated automatically and mostly independently from the software's operator and can be easily interpreted [35].…”

Section: Discussionmentioning

confidence: 99%

Noninvasive Collateral Flow Velocity Imaging in Acute Ischemic Stroke: Intraindividual Comparison of 4D-CT Angiography with Digital Subtraction Angiography

Muehlen

Kloska

Gölitz

et al. 2019

Fortschr Röntgenstr

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Purpose The collateral status can be defined not only by its morphological extent but also by the velocity of collateral filling characterized by the relative filling time delay (rFTD). The aim of our study was to compare different methods of noninvasive visualization of rFTD derived from 4D-CT angiography (4D-CTA) with digital substraction angiography (DSA) and to investigate the correlation between functional and morphological collateral status on timing-invariant CTA. Materials and Methods 50 consecutive patients with acute occlusion in the M1 segment who underwent DSA for subsequent mechanical recanalization after multimodal CT were retrospectively analyzed. 4D-CTA data were used to assess the relative filling time delay between the A1 segment of the affected hemisphere and the sylvian branches distal to the occluded M1 segment using source images (4D-CTA-SI) and color-coded flow velocity visualization with prototype software (fv-CTA) in comparison to DSA. The morphological extent of collaterals was assessed on the basis of the Collateral Score (CS) on temporal maximum intensity projections (tMIP) derived from CT perfusion data. Results There was very good correlation of rFTD between fv-CTA and DSA (n = 50, r = 0.9, p < 0.05). Differences of absolute rFTD values were not significant. 4D-CTA-SI and DSA also showed good correlation (n = 50, r = 0.6, p < 0.05), but mean values of rFTD were significantly different (p < 0.05). rFTD derived from fvCTA and CS derived from timing-invariant CTA showed a negative association (R = – 0.5; P = 0.000). In patients with a favorable radiological outcome defined by a TICI score of 2b or 3, there was a significant negative correlation of CS and mRS at 3 months (R = – 0.4, P = 0.006). Conclusion Collateral status plays an important role in the outcome in stroke patients. rFTD derived from 4D-CTA is a suitable parameter for noninvasive imaging of collateral velocity, which correlates with the morphological extent of collaterals. Further studies are needed to define valid thresholds for rFTD and to evaluate the diagnostic and prognostic value. Key points: Citation Format

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Clinical and radiological outcome after mechanical thrombectomy in acute ischemic stroke: What matters?

Abstract: Fast and complete recanalization is essential to achieve a favorable radiological and functional outcome after mechanical thrombectomy in acute ischemic stroke. Age, CBS and collateral supply play a subordinate role.

Cited by 11 publications

References 27 publications

Value of high-density sign on CT images after mechanical thrombectomy for large vessel occlusion in predicting hemorrhage and unfavorable outcome

Value of high-density sign on CT images after mechanical thrombectomy for large vessel occlusion in predicting hemorrhage and unfavorable outcome

Beyond the collaterals: Additional value of multiphase CTA in acute ischemic stroke evaluation

Noninvasive Collateral Flow Velocity Imaging in Acute Ischemic Stroke: Intraindividual Comparison of 4D-CT Angiography with Digital Subtraction Angiography

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