Understanding Delays in MRI-based Selection of Large Vessel Occlusion Stroke Patients for Endovascular Thrombectomy

Regenhardt, Robert W; Nolan, Neal M.; Rosenthal, Joseph; McIntyre, Joyce; Bretzner, Martin; Bonkhoff, Anna K.; Snider, Samuel B.; Das, Alvin S; Alotaibi, Naif M.; Vranic, Justin E; Dmytriw, Adam A.; Stapleton, Christopher J.; Rost, Natalia S.; Leslie‐Mazwi, Thabele M

doi:10.1007/s00062-022-01165-y

Cited by 8 publications

(3 citation statements)

References 38 publications

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“…Neuroimaging is a core element of modern acute stroke management ( Lövblad et al, 2015 ; Regenhardt et al, 2022b ). It has been unparalleled in its capacity to derive detailed lesion characteristics.…”

Section: Introductionmentioning

confidence: 99%

Deep profiling of multiple ischemic lesions in a large, multi-center cohort: Frequency, spatial distribution, and associations to clinical characteristics

et al. 2022

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Background purposeA substantial number of patients with acute ischemic stroke (AIS) experience multiple acute lesions (MAL). We here aimed to scrutinize MAL in a large radiologically deep-phenotyped cohort.Materials and methodsAnalyses relied upon imaging and clinical data from the international MRI-GENIE study. Imaging data comprised both Fluid-attenuated inversion recovery (FLAIR) for white matter hyperintensity (WMH) burden estimation and diffusion-weighted imaging (DWI) sequences for the assessment of acute stroke lesions. The initial step featured the systematic evaluation of occurrences of MAL within one and several vascular supply territories. Associations between MAL and important imaging and clinical characteristics were subsequently determined. The interaction effect between single and multiple lesion status and lesion volume was estimated by means of Bayesian hierarchical regression modeling for both stroke severity and functional outcome.ResultsWe analyzed 2,466 patients (age = 63.4 ± 14.8, 39% women), 49.7% of which presented with a single lesion. Another 37.4% experienced MAL in a single vascular territory, while 12.9% featured lesions in multiple vascular territories. Within most territories, MAL occurred as frequently as single lesions (ratio ∼1:1). Only the brainstem region comprised fewer patients with MAL (ratio 1:4). Patients with MAL presented with a significantly higher lesion volume and acute NIHSS (7.7 vs. 1.7 ml and 4 vs. 3, pFDR < 0.001). In contrast, patients with a single lesion were characterized by a significantly higher WMH burden (6.1 vs. 5.3 ml, pFDR = 0.048). Functional outcome did not differ significantly between patients with single versus multiple lesions. Bayesian analyses suggested that the association between lesion volume and stroke severity between single and multiple lesions was the same in case of anterior circulation stroke. In case of posterior circulation stroke, lesion volume was linked to a higher NIHSS only among those with MAL.ConclusionMultiple lesions, especially those within one vascular territory, occurred more frequently than previously reported. Overall, multiple lesions were distinctly linked to a higher acute stroke severity, a higher total DWI lesion volume and a lower WMH lesion volume. In posterior circulation stroke, lesion volume was linked to a higher stroke severity in multiple lesions only.

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Section: Introductionmentioning

confidence: 99%

Deep profiling of multiple ischemic lesions in a large, multi-center cohort: Frequency, spatial distribution, and associations to clinical characteristics

et al. 2022

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“…These ‘slow progressor’ patients may constitute a third or more of transferred patients. While they can be identified with advanced imaging such as diffusion MRI and CT perfusion (CTP) [ 9 – 11 ], these resources are not often available at community hospitals and underserved regions [ 12 – 14 ]. This is especially true for patients in the extended window or with unknown onset [ 15 ].…”

Section: Introductionmentioning

confidence: 99%

Symmetric collateral pattern on CTA predicts favorable outcomes after endovascular thrombectomy for large vessel occlusion stroke

Regenhardt

Lev

et al. 2023

PLoS ONE

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Endovascular thrombectomy (EVT) has revolutionized large vessel occlusion (LVO) stroke management, but often requires advanced imaging. The collateral pattern on CT angiograms may be an alternative because a symmetric collateral pattern correlates with a slowly growing, small ischemic core. We tested the hypothesis that such patients will have favorable outcomes after EVT. Consecutive patients (n = 74) with anterior LVOs who underwent EVT were retrospectively analyzed. Inclusion criteria were available CTA and 90-day modified Rankin Scale (mRS). CTA collateral patterns were symmetric in 36%, malignant in 24%, or other in 39%. Median NIHSS was 11 for symmetric, 18 for malignant, and 19 for other (p = 0.02). Ninety-day mRS ≤2, indicating independent living, was achieved in 67% of symmetric, 17% of malignant, and 38% of other patterns (p = 0.003). A symmetric collateral pattern was a significant determinant of 90-day mRS ≤2 (aOR = 6.62, 95%CI = 2.24,19.53; p = 0.001) in a multivariable model that included age, NIHSS, baseline mRS, thrombolysis, LVO location, and successful reperfusion. We conclude that a symmetric collateral pattern predicts favorable outcomes after EVT for LVO stroke. Because the pattern also marks slow ischemic core growth, patients with symmetric collaterals may be suitable for transfer for thrombectomy. A malignant collateral pattern is associated with poor clinical outcomes.

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“…Neuroimaging, as a core element of modern acute stroke management, 2,3 has been unparalleled in its capacity to derive detailed lesion characteristics. Especially after the introduction of elaborate imaging modalities, such as diffusion-weighted imaging (DWI), it became possible to reliably disentangle the acute versus chronic, lacunar versus non-lacunar, and single versus multiple nature of ischemic lesions, to name just a few examples.…”

Section: Introductionmentioning

confidence: 99%

Deep profiling of multiple ischemic lesions in a large, multi-center cohort: Frequency, spatial distribution, and associations to clinical characteristics

Bonkhoff

Ullberg

Bretzner

et al. 2022

Preprint

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BackgroundA substantial number of patients with acute ischemic stroke (AIS) experience multiple acute lesions (MAL). However, the spatial distribution and clinical implications of such MAL are incompletely understood.MethodsAnalyses relied upon imaging and clinical data of patients with AIS from the international MRI-GENIE study. Initially, we systematically evaluated the occurrences of MAL within (i) one and, (ii) several vascular supply territories. Associations between the presence of MAL and important characteristics, such as DWI lesion volume, NIHSS-based acute stroke severity, and long-term functional outcome were subsequently determined. The interaction effect between single and multiple lesion status and DWI lesion volume was estimated by means of Bayesian regression modeling for stroke severity and functional outcome.ResultsWe analyzed 2,466 patients [age: 63.4±14.8, 39% women], 49.7% of which presented with single lesions. Another 37.4% experienced MAL in a single vascular territory, while 12.9% featured lesions in several territories. Within most territories (anterior, middle, and posterior cerebral artery, cerebellar), multiple lesions occurred as frequently as single lesions (ratio ∼1:1). Only the brainstem region comprised fewer patients with multiple lesions (ratio ∼1:4). Patients with MAL presented with a significantly higher DWI lesion volume and acute NIHSS (7.7ml vs. 1.7ml and 4 vs. 3, pFDR≤0.001). In contrast, patients with a single lesion were characterized by a significantly higher WMH burden (6.1ml versus 5.3ml, pFDR=0.048). Functional outcome did not differ significantly between patients with single versus multiple lesions. Bayesian analyses suggested that the association between DWI lesion volume and stroke severity between single and multiple lesions was the same in case of anterior circulation stroke. In the case of posterior circulation stroke, DWI lesion volume was linked to a higher acute NIHSS only among those with multiple lesions.ConclusionsMultiple lesions, especially those within one vascular territory, occurred more frequently than previously reported. Overall, multiple lesions were distinctly linked to a higher acute stroke severity, a higher DWI lesion volume and lower WMH lesion volume. In posterior circulation stroke, lesion volume was linked to a higher stroke severity in multiple lesions only.

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Understanding Delays in MRI-based Selection of Large Vessel Occlusion Stroke Patients for Endovascular Thrombectomy

Cited by 8 publications

References 38 publications

Deep profiling of multiple ischemic lesions in a large, multi-center cohort: Frequency, spatial distribution, and associations to clinical characteristics

Deep profiling of multiple ischemic lesions in a large, multi-center cohort: Frequency, spatial distribution, and associations to clinical characteristics

Symmetric collateral pattern on CTA predicts favorable outcomes after endovascular thrombectomy for large vessel occlusion stroke

Deep profiling of multiple ischemic lesions in a large, multi-center cohort: Frequency, spatial distribution, and associations to clinical characteristics

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