The capillary index score: rethinking the acute ischemic stroke treatment algorithm. Results from the Borgess Medical Center Acute Ischemic Stroke Registry

Al-Ali, Firas; Jefferson, Anne; Barrow, Tom; Cree, T.; Louis, Susan; Kim, Luke; Major, Kevin; Németh, Dániel; Smoker, Sandy; Walker, Sarah

doi:10.1136/neurintsurg-2011-010146

Cited by 33 publications

(47 citation statements)

References 17 publications

(14 reference statements)

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“…Reperfusion results were reported by using the modified TICI score and were defined as ranging from no reperfusion (TICI 0) to complete reperfusion (TICI 3), including partial reperfusion (TICI 2) [14]. Collateral arterial supply was assessed using the capillary index score (CIS) [15], and patients were dichotomized into favourable and unfavourable collateral flow groups (CIS 2 or 3 and CIS 0-1, respectively). Peri-procedural complications were also noted.…”

Section: Methodsmentioning

confidence: 99%

Is Reperfusion Useful in Ischaemic Stroke Patients Presenting with a Low National Institutes of Health Stroke Scale and a Proximal Large Vessel Occlusion of the Anterior Circulation?

et al. 2017

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Background: In population-based studies, patients presenting with minor or mild stroke symptoms represent about two-thirds of stroke patients, and almost one-third of these patients are unable to ambulate independently at the time of discharge. Although mechanical thrombectomy (MT) has become the standard of care for acute ischaemic stroke with proximal large vessel occlusion (LVO) in the anterior circulation, the management of patients harbouring proximal occlusion and minor-to-mild stroke symptoms has not yet been determined by recent trials. The purpose of this study was to evaluate the impact of reperfusion on clinical outcome in low National Institutes of Health Stroke Scale (NIHSS) patients treated with MT. Methods: We analysed 138 consecutive patients with acute LVO of the anterior circulation (middle cerebral artery M1 or M2 segment, internal carotid artery or tandem occlusion) with NIHSS <8, having undergone MT in 3 different centres. Reperfusion was graded using the modified thrombolysis in cerebral infarction (TICI) score and 3 grades were defined, ranging from failed or poor reperfusion (TICI 0, 1, 2A) to complete reperfusion (TICI 3). The primary clinical endpoint was an excellent outcome defined as a modified Rankin score (mRs) 0-1 at 3-months. The impact of reperfusion grade was assessed in univariate and multivariate analyses. The secondary endpoints included favourable functional outcome (90-day mRS 0-2), death and safety concerns. Results: Successful reperfusion was achieved in 81.2% of patients (TICI 2B, n = 47; TICI 3, n = 65). Excellent outcome (mRs 0-1) was achieved in 69 patients (65.0%) and favourable outcome (mRs ≤2) in 108 (78.3%). Death occurred in 7 (5.1%). Excellent outcome increased with reperfusion grades, with a rate of 34.6% in patients with failed/poor reperfusion, 61.7% in patients with TICI 2B reperfusion, and 78.5% in patients with TICI 3 reperfusion (p < 0.001). In multivariate analysis adjusted for patient characteristics associated with excellent outcome, the reperfusion grade remained significantly associated with an increase in excellent outcome; the OR (95% CI) was 3.09 (1.06-9.03) for TICI 2B and 6.66 (2.27-19.48) for TICI 3, using the failed/poor reperfusion grade as reference. Similar results were found regarding favourable outcome (90-day mRs 0-2) or overall mRS distribution (shift analysis). Conclusion: Successful reperfusion is strongly associated with better functional outcome among patients with proximal LVO in the anterior circulation and minor-to-mild stroke symptoms. Randomized controlled studies are mandatory to assess the benefit of MT compared with optimal medical management in this subset of patients.

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Section: Methodsmentioning

confidence: 99%

Is Reperfusion Useful in Ischaemic Stroke Patients Presenting with a Low National Institutes of Health Stroke Scale and a Proximal Large Vessel Occlusion of the Anterior Circulation?

et al. 2017

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“…Several recent imaging studies serially analyzing recanalization and reperfusion in ischemic stroke patients report that, on average, 26% of successfully recanalized patients with thrombolytics do not show reperfusion (Dalkara and Arsava, 2012). Clinical trials have repeatedly demonstrated that a good outcome was better correlated with reperfusion than recanalization in stroke patients treated with tPA or interventional methods (Al-Ali et al, 2012;De Silva et al, 2009;Soares et al, 2010). The reperfusion injury also enhances the BBB permeability, predisposing to intraparenchymal hemorrhage and brain swelling in about 6% of patients receiving i.v.…”

Section: -Microvascular Injury After Recanalization Therapies For Smentioning

confidence: 94%

Cerebral microvascular pericytes and neurogliovascular signaling in health and disease

2015

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“…Therefore, therapeutic approaches aiming at reducing microvascular obstruction might improve the success rate of recanalization therapies. 4 Among many other factors, incomplete reperfusion at the microcirculatory level might be one of the reasons for this discrepancy. Despite the well-established nature of IMR in experimental models of cerebral ischemia, the incidence and relevance of this phenomenon in the clinical setting has not been analyzed systematically.…”

Section: Can We Improve the Stroke Outcome After Thrombolysis?mentioning

confidence: 99%

“…[1][2][3] There is also a not wellrecognized potential drawback associated with recanalization therapies, which is characterized by incomplete restoration of the microcirculatory flow in some parts of the ischemic tissue after reopening of the occluded blood vessel; the so-called 'no-reflow phenomenon'. [4][5][6][7] This phenomenon enjoyed considerable scientific interest after its first description in the 1970s; [8][9][10] later, it lost its popularity because of the claims that it might be an experimental artifact, [11][12][13][14] in addition to the concerns that it might be an epiphenomenon of the established tissue injury. 9,10 However, substantial experimental data accumulating since the past decades [15][16][17][18][19][20] and the recent clinical evidence suggesting that tissue reperfusion (restoration of microcirculatory blood flow) is a better predictor of outcome after thrombolysis than recanalization (reopening of the occluded artery) 21,22 necessitate that this phenomenon should be reevaluated.…”

mentioning

confidence: 99%

Can Restoring Incomplete Microcirculatory Reperfusion Improve Stroke Outcome after Thrombolysis?

Dalkara

Arsava

2012

J Cereb Blood Flow Metab

198

182

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Substantial experimental data and recent clinical evidence suggesting that tissue reperfusion is a better predictor of outcome after thrombolysis than recanalization necessitate that patency of microcirculation after recanalization should be reevaluated. If indeed microcirculatory blood flow cannot be sufficiently reinstituted despite complete recanalization as commonly observed in coronary circulation, it may be one of the factors contributing to low efficacy of thrombolysis in stroke. Although microvascular no-reflow is considered an irreversible process that prevents tissue recovery from injury, emerging evidence suggests that it might be reversed with pharmacological agents administered early during recanalization. Therefore, therapeutic approaches aiming at reducing microvascular obstructions may improve success rate of recanalization therapies. Importantly, promoting oxygen delivery to the tissue, where entrapped erythrocytes cannot circulate in capillaries, with ongoing serum flow may improve survival of the underreperfused tissue. Altogether, these developments bring about the exciting possibility that benefit of reperfusion therapies can be further improved by restoring microcirculatory function because survival in the penumbra critically depends on adequate blood supply. Here, we review the available evidence suggesting presence of an ‘incomplete microcirculatory reperfusion’ (IMR) after focal cerebral ischemia and discuss potential means that may help investigate IMR in stroke patients after recanalization therapies despite technical limitations.

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The capillary index score: rethinking the acute ischemic stroke treatment algorithm. Results from the Borgess Medical Center Acute Ischemic Stroke Registry

Abstract: Favorable CIS and recanalization were strong predictors of a good outcome. By using this new index as an adjunct to other criteria, the CIS may improve patient selection and help break the 50% barrier.

Cited by 33 publications

References 17 publications

Is Reperfusion Useful in Ischaemic Stroke Patients Presenting with a Low National Institutes of Health Stroke Scale and a Proximal Large Vessel Occlusion of the Anterior Circulation?

Is Reperfusion Useful in Ischaemic Stroke Patients Presenting with a Low National Institutes of Health Stroke Scale and a Proximal Large Vessel Occlusion of the Anterior Circulation?

Cerebral microvascular pericytes and neurogliovascular signaling in health and disease

Can Restoring Incomplete Microcirculatory Reperfusion Improve Stroke Outcome after Thrombolysis?

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