Validation of the extended thrombolysis in cerebral infarction score in a real world cohort

Behme, Daniel; Tsogkas, Ioannis; Colla, Ruben; Gera, Roland Gerard; Schregel, Katharina; Hesse, Amélie Carolina; Maier, Ilko; Liman, Jan; Liebeskind, David S; Psychogios, Marios‐Nikos

doi:10.1371/journal.pone.0210334

Cited by 25 publications

(20 citation statements)

References 19 publications

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“…Multiple randomized trials have demonstrated the benefit of mechanical thrombectomy (MT) for acute ischemic stroke due to large vessel occlusion (LVO) [1,2]. Clinical outcome after MT can be improved by an increasing degree of reperfusion evaluated by the expanded thrombolysis in cerebral infarction (eTICI) scale [3,4]. Accordingly, complete reperfusion (TICI 3) is leading to a markedly better outcome with the highest rate of excellent functional outcome (mRS ≤ 1) [5,6].…”

Section: Introductionmentioning

confidence: 99%

Sub-angiographic peripheral emboli in high resolution DWI after endovascular recanalization

et al. 2020

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Background and aim To analyze the incidence of peripheral emboli after successful mechanical thrombectomy (MT) of intracranial large vessel occlusions (LVO). Methods We performed a prospective analysis of patients with intracranial LVO who underwent successful MT and received a 1.5 T MRI including diffusion-weighted imaging (DWI) in standard-and high-resolution as well as susceptibility-weighted imaging (SWI) on the day following the intervention. Reperfusion grade was assessed on post-thrombectomy digital subtraction angiography (DSA) using the expanded thrombolysis in cerebral infarction (eTICI) scale. Punctuate DWI lesions distal to the DWI core lesion were classified as peripheral emboli. DWI lesions outside the primary affected vascular territory were classified as emboli into new territories. Additionally, SWI and post-thrombectomy DSA were analyzed and correlated to findings on DWI. Results Twenty-eight patients undergoing successful MT met the inclusion criteria. In 26/28 patients (93%), a total of 324 embolic lesions were detected in DWI representing 2.1% of the cumulated ischemic core volume. 151 peripheral emboli were detected in standard-resolution DWI, 173 additional emboli were uncovered in high-resolution DWI. Eight out of nine patients with an eTICI 3 reperfusion had embolic lesions (29 DWI lesions). 9.6% (31/324) of peripheral emboli were observed in vascular territories not affected by the LVO. SWI lesions were observed in close proximity to 10.2% (33/324) of DWI lesions. Conclusions Peripheral emboli are frequent after MT even after complete reperfusion. These emboli occur rather in the vascular territory of the occluded vessel than in other territories. A large proportion of peripheral emboli is only detected by high-resolution DWI.

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Section: Introductionmentioning

confidence: 99%

Sub-angiographic peripheral emboli in high resolution DWI after endovascular recanalization

et al. 2020

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“…Since 2015, the use of intra-arterial thrombectomythe mechanical removal of a clot via a stenthas become the standard of care for patients with acute ischaemic stroke caused by large vessel occlusion [4,5]. Despite this, many patients do not recover full perfusion in their tissue downstream of the recanalized vessel [6]. This observation, commonly known as the "no-reflow" or "no-reperfusion" phenomenon, has been documented in numerous studies involving both animals and humans [7][8][9][10][11][12].…”

Section: Introductionmentioning

confidence: 99%

Modelling the impact of clot fragmentation on the microcirculation after thrombectomy

El-Bouri

MacGowan

Józsa

et al. 2020

Preprint

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Many ischaemic stroke patients who have a mechanical removal of their clot (thrombectomy) do not get reperfusion of tissue despite the thrombus being removed. One hypothesis for this ‘no-reperfusion’ phenomenon is micro-emboli fragmenting off the large clot during thrombectomy and occluding smaller blood vessels downstream of the clot location. This is impossible to observe in-vivo and so we here develop an in-silico model based on in-vitro experiments to model the effect of micro-emboli on brain tissue. Through in-vitro experiments we obtain, under a variety of clot consistencies and thrombectomy techniques, micro-emboli distributions post-thrombectomy. Blood flow through the microcirculation is modelled for statistically accurate voxels of brain microvasculature including penetrating arterioles and capillary beds. A novel micro-emboli algorithm, informed by the experimental data, is used to simulate the impact of micro-emboli successively entering the penetrating arterioles and the capillary bed. Scaled-up blood flow parameters – permeability and coupling coefficients – are calculated under various conditions. We find that capillary beds are more susceptible to occlusions than the penetrating arterioles with a 4x greater drop in permeability per volume of vessel occluded. Individual microvascular geometries determine robustness to micro-emboli. Hard clot fragmentation leads to larger micro-emboli and larger drops in blood flow for a given number of micro-emboli. Thrombectomy technique has a large impact on clot fragmentation and hence occlusions in the microvasculature. As such, in-silico modelling of mechanical thrombectomy predicts that clot specific factors, interventional technique, and microvascular geometry strongly influence reperfusion of the brain. Micro-emboli are likely contributory to the phenomenon of no-reperfusion following successful removal of a major clot.

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“…Safety endpoints will include symtomatic ICH at 24 hours specified according to the Heidelberg Bleeding Classification 11 -defined as a new ICH as detected by brain imaging after 24 hours of intervention associated with: ► ≥4 points worsening of total NIHSS score at the time of diagnosis compared with immediately before deterioration ► ≥2 point worsening in one NIHSS category ► Leading to intubation/hemicraniectomy/external ventricular drain placement or other major medical/surgical intervention ► Absence of alternative explanation for deterioration.…”

Section: Clinical Efficacymentioning

confidence: 99%

Embotrap Extraction & Clot Evaluation & Lesion Evaluation for NeuroThrombectomy (EXCELLENT) Registry design and methods

Siddiqui

Waqas

Brinjikji

et al. 2021

J NeuroIntervent Surg

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BackgroundRelationships between occlusive clot histopathology, baseline characteristics, imaging findings, revascularization rates, and clinical outcomes of stroke patients with large vessel occlusion (LVO) are not well understood. This study will assess the real-world experience on the efficacy and safety of using the EmboTrap device as the first approach in LVO patients and explore the associations between clot histological characteristics, imaging and clinical findings, revascularization rates, and clinical outcomes.MethodsProspective, global, multicenter, single-arm, imaging core laboratory, and clot analysis central laboratory observational registry. Adult patients (>18 years) with LVO, treated with EmboTrap as the first attempted device, will be eligible for study participation.ResultsUp to 1000 subjects at 50 international sites may be enrolled. Occlusive clots will be collected from at least 500 subjects. Independent central and imaging core laboratories will perform clot analysis and image adjudication. Statistical analysis will assess the association between imaging and clinical findings, clot characteristics, subject comorbidities, revascularization, and clinical outcomes. Study endpoints are functional independence (modified Rankin Scale score ≤2 at 90 days), expanded Thrombolysis In Cerebral Infarction (eTICI) score ≥2b50 rate, first-pass effect, number of passes, embolization into new territory, symptomatic intracranial hemorrhage, and 90-day mortality.ConclusionsThe EXCELLENT registry will provide reproducible effectiveness and safety data of EmboTrap for its use for mechanical thrombectomy. Additionally, the study will characterize the blood clots retrieved during mechanical thrombectomy with respect to their composition and histopathological analysis and potential correlations with clinical and imaging findings.Trial registration numberNCT03685578.

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Validation of the extended thrombolysis in cerebral infarction score in a real world cohort

Cited by 25 publications

References 19 publications

Sub-angiographic peripheral emboli in high resolution DWI after endovascular recanalization

Sub-angiographic peripheral emboli in high resolution DWI after endovascular recanalization

Modelling the impact of clot fragmentation on the microcirculation after thrombectomy

Embotrap Extraction & Clot Evaluation & Lesion Evaluation for NeuroThrombectomy (EXCELLENT) Registry design and methods

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