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Arrarte Terreros N, Stolp J, Bruggeman AAE, Swijnenburg ISJ, Lopes RR, van Meenen LCC, Groot AED, Kappelhof M, Coutinho JM, Roos YBWEM, Emmer BJ, Beenen LFM, Dippel DWJ, van Zwam WH, van Bavel E, Marquering HA, Majoie CBLM. Thrombus Imaging Characteristics to Predict Early Recanalization in Anterior Circulation Large Vessel Occlusion Stroke. J Cardiovasc Dev Dis 2024; 11:107. [PMID: 38667725 PMCID: PMC11050543 DOI: 10.3390/jcdd11040107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 03/23/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
The early management of transferred patients with a large vessel occlusion (LVO) stroke could be improved by identifying patients who are likely to recanalize early. We aim to predict early recanalization based on patient clinical and thrombus imaging characteristics. We included 81 transferred anterior-circulation LVO patients with an early recanalization, defined as the resolution of the LVO or the migration to a distal location not reachable with endovascular treatment upon repeated radiological imaging. We compared their clinical and imaging characteristics with all (322) transferred patients with a persistent LVO in the MR CLEAN Registry. We measured distance from carotid terminus to thrombus (DT), thrombus length, density, and perviousness on baseline CT images. We built logistic regression models to predict early recanalization. We validated the predictive ability by computing the median area-under-the-curve (AUC) of the receiver operating characteristics curve for 100 5-fold cross-validations. The administration of intravenous thrombolysis (IVT), longer transfer times, more distal occlusions, and shorter, pervious, less dense thrombi were characteristic of early recanalization. After backward elimination, IVT administration, DT and thrombus density remained in the multivariable model, with an AUC of 0.77 (IQR 0.72-0.83). Baseline thrombus imaging characteristics are valuable in predicting early recanalization and can potentially be used to optimize repeated imaging workflow.
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Affiliation(s)
- Nerea Arrarte Terreros
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Jeffrey Stolp
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Agnetha A. E. Bruggeman
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Isabella S. J. Swijnenburg
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Ricardo R. Lopes
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Laura C. C. van Meenen
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Adrien E. D. Groot
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Manon Kappelhof
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Jonathan M. Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Yvo B. W. E. M. Roos
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Bart J. Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Ludo F. M. Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | | | - Wim H. van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, 6229 HX Maastricht, The Netherlands;
| | - Ed van Bavel
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
| | - Henk A. Marquering
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Charles B. L. M. Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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Che B, Kusuma Y, Bush S, Dowling R, Williams C, Houlihan C, Mitchell PJ, Yan B. Neurological Improvement by One-Thirds Is Associated With Early Recanalization in Stroke With Large Vessel Occlusion. Stroke 2024; 55:569-575. [PMID: 38323425 DOI: 10.1161/strokeaha.123.045504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 01/12/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND A proportion of large vessel occlusion strokes demonstrate early recanalization, obviating the initial intention to proceed to endovascular thrombectomy. Neurological improvement is a possible surrogate marker for reperfusion. We aimed to determine the optimal threshold of neurological improvement, as defined by the National Institutes of Health Stroke Scale (NIHSS), which best associates with early recanalization. METHODS We retrospectively analyzed consecutive patients with large vessel occlusion transferred from primary stroke centers to a tertiary comprehensive stroke center in Melbourne, Australia, for possible endovascular thrombectomy from January 2018 to December 2022. Absolute and percentage changes in NIHSS between transfer, as well as other definitions of neurological improvement, were compared using receiver operating characteristic curve analysis for association with recanalization as defined by the absence of occlusion in the internal carotid artery, middle cerebral artery (M1 or M2 segments), or basilar artery on repeat vascular imaging. RESULTS Six hundred and fifty-four transferred patients with large vessel occlusion were included in the analysis: mean age was 68.8±14.0 years, 301 (46.0%) were women, and 338 (52%) received intravenous thrombolytics. The proportion of extracranial internal carotid artery, intracranial internal carotid artery, M1, proximal M2, and basilar artery occlusion was 18.8%, 13.6%, 48.3%, 15.0%, and 4.3%, respectively, on initial computed tomography angiogram. Median NIHSSprimary stroke center and NIHSScomprehensive stroke center scores were 15 (interquartile range, 9-18) and 13 (interquartile range, 8-19), respectively. Early recanalization occurred in 82 (13%) patients. NIHSS reduction of ≥33% was the best tradeoff between sensitivity (64%) and specificity (83%) for identifying recanalization. NIHSS reduction of ≥33% had the highest discriminative ability to predict recanalization (area under the curve, 0.735) in comparison with other definitions of neurological improvement. CONCLUSIONS One-third neurological improvement between the primary hospital and tertiary center was the best predictor of early recanalization.
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Affiliation(s)
- Bizhong Che
- Melbourne Brain Centre (B.C., Y.K., C.W., B.Y.), Royal Melbourne Hospital, The University of Melbourne, Australia
| | - Yohanna Kusuma
- Melbourne Brain Centre (B.C., Y.K., C.W., B.Y.), Royal Melbourne Hospital, The University of Melbourne, Australia
| | - Steven Bush
- Department of Radiology (S.B., R.D., C.W., C.H., P.J.M., B.Y.), Royal Melbourne Hospital, The University of Melbourne, Australia
| | - Richard Dowling
- Department of Radiology (S.B., R.D., C.W., C.H., P.J.M., B.Y.), Royal Melbourne Hospital, The University of Melbourne, Australia
| | - Cameron Williams
- Melbourne Brain Centre (B.C., Y.K., C.W., B.Y.), Royal Melbourne Hospital, The University of Melbourne, Australia
- Department of Radiology (S.B., R.D., C.W., C.H., P.J.M., B.Y.), Royal Melbourne Hospital, The University of Melbourne, Australia
| | - Conor Houlihan
- Department of Radiology (S.B., R.D., C.W., C.H., P.J.M., B.Y.), Royal Melbourne Hospital, The University of Melbourne, Australia
| | - Peter J Mitchell
- Department of Radiology (S.B., R.D., C.W., C.H., P.J.M., B.Y.), Royal Melbourne Hospital, The University of Melbourne, Australia
| | - Bernard Yan
- Melbourne Brain Centre (B.C., Y.K., C.W., B.Y.), Royal Melbourne Hospital, The University of Melbourne, Australia
- Department of Radiology (S.B., R.D., C.W., C.H., P.J.M., B.Y.), Royal Melbourne Hospital, The University of Melbourne, Australia
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Pallesen LP, Winzer S, Hartmann C, Kuhn M, Gerber JC, Theilen H, Hädrich K, Siepmann T, Barlinn K, Rahmig J, Linn J, Barlinn J, Puetz V. Team Prenotification Reduces Procedure Times for Patients With Acute Ischemic Stroke Due to Large Vessel Occlusion Who Are Transferred for Endovascular Therapy. Front Neurol 2022; 12:787161. [PMID: 35046884 PMCID: PMC8761669 DOI: 10.3389/fneur.2021.787161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/29/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The clinical benefit from endovascular therapy (EVT) for patients with acute ischemic stroke is time-dependent. We tested the hypothesis that team prenotification results in faster procedure times prior to initiation of EVT. Methods: We analyzed data from our prospective database (01/2016–02/2018) including all patients with acute ischemic stroke who were evaluated for EVT at our comprehensive stroke center. We established a standardized algorithm (EVT-Call) in 06/2017 to prenotify team members (interventional neuroradiologist, neurologist, anesthesiologist, CT and angiography technicians) about patient transfer from remote hospitals for evaluation of EVT, and team members were present in the emergency department at the expected patient arrival time. We calculated door-to-image, image-to-groin and door-to-groin times for patients who were transferred to our center for evaluation of EVT, and analyzed changes before (–EVT-Call) and after (+EVT-Call) implementation of the EVT-Call. Results: Among 494 patients in our database, 328 patients were transferred from remote hospitals for evaluation of EVT (208 -EVT-Call and 120 +EVT-Call, median [IQR] age 75 years [65–81], NIHSS score 17 [12–22], 49.1% female). Of these, 177 patients (54%) underwent EVT after repeated imaging at our center (111/208 [53%) -EVT-Call, 66/120 [55%] +EVT-Call). Median (IQR) door-to-image time (18 min [14–22] vs. 10 min [7–13]; p < 0.001), image-to-groin time (54 min [43.5–69.25] vs. 47 min [38.3–58.75]; p = 0.042) and door-to-groin time (74 min [58–86.5] vs. 60 min [49.3–71]; p < 0.001) were reduced after implementation of the EVT-Call. Conclusions: Team prenotification results in faster patient assessment and initiation of EVT in patients with acute ischemic stroke. Its impact on functional outcome needs to be determined.
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Affiliation(s)
- Lars-Peder Pallesen
- Department of Neurology, Dresden NeuroVascular Center, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Simon Winzer
- Department of Neurology, Dresden NeuroVascular Center, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Christian Hartmann
- Department of Neurology, Dresden NeuroVascular Center, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Matthias Kuhn
- Carl Gustav Carus Faculty of Medicine, Institute for Medical Informatics and Biometry, Technische Universität Dresden, Dresden, Germany
| | - Johannes C Gerber
- Institute of Neuroradiology, Dresden Neurovascular Center, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Hermann Theilen
- Department of Anesthesiology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Kevin Hädrich
- Institute of Neuroradiology, Dresden Neurovascular Center, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Timo Siepmann
- Department of Neurology, Dresden NeuroVascular Center, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, Dresden NeuroVascular Center, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Jan Rahmig
- Department of Neurology, Dresden NeuroVascular Center, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Jennifer Linn
- Institute of Neuroradiology, Dresden Neurovascular Center, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Jessica Barlinn
- Department of Neurology, Dresden NeuroVascular Center, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Volker Puetz
- Department of Neurology, Dresden NeuroVascular Center, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
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