Benchmarking the Extent and Speed of Reperfusion: First Pass TICI 2c-3 Is a Preferred Endovascular Reperfusion Endpoint

Isquèmia cerebral; Trombectomia mecànica; ReperfusióIsquemia cerebral; Trombectomía mecánica; ReperfusiónBrain ischaemia; Mechanical thrombectomy; ReperfusionBackground and Purpose: End-of-procedure substantial reperfusion [modified Treatment in Cerebral Ischemia (mTICI) 2b-3], the leading endpoint for thrombectomy studies, has several limitations including a ceiling effect, with recent achieved rates of ~90%. We aimed to identify a more optimal definition of angiographic success along two dimensions: (1) the extent of tissue reperfusion, and (2) the speed of revascularization. Methods: Core-lab adjudicated TICI scores for the first three passes of EmboTrap and the final all-procedures result were analyzed in the ARISE II multicenter study. The clinical impact of extent of reperfusion and speed of reperfusion (first-pass vs. later-pass) were evaluated. Clinical outcomes included 90-day functional independence [modified Rankin Scale (mRS) 0–2], 90-day freedom-from-disability (mRS 0–1), and dramatic early improvement [24-h National Institutes of Health Stroke Scale (NIHSS) improvement ≥ 8 points]. Results: Among 161 ARISE II subjects with ICA or MCA M1 occlusions, reperfusion results at procedure end showed substantial reperfusion in 149 (92.5%), excellent reperfusion in 121 (75.2%), and complete reperfusion in 79 (49.1%). Reperfusion rates on first pass were substantial in 81 (50.3%), excellent reperfusion in 62 (38.5%), and complete reperfusion in 44 (27.3%). First-pass excellent reperfusion (first-pass TICI 2c-3) had the greatest nominal predictive value for 90-day mRS 0–2 (sensitivity 58.5%, specificity 68.6%). There was a progressive worsening of outcomes with each additional pass required to achieve TICI 2c-3. Conclusions: First-pass excellent reperfusion (TICI 2c-3), reflecting rapid achievement of extensive reperfusion, is the technical revascularization endpoint that best predicted functional independence in this international multicenter trial and is an attractive candidate for a lead angiographic endpoint for future trials.Cerenovus sponsored the ARISE II study, and provided support for open access to this article

Benchmarking the Extent and Speed of Reperfusion: First Pass TICI 2c-3 Is a Preferred Endovascular Reperfusion Endpoint.

Background and Purpose: End-of-procedure substantial reperfusion [modified Treatment in Cerebral Ischemia (mTICI) 2b-3], the leading endpoint for thrombectomy studies, has several limitations including a ceiling effect, with recent achieved rates of ~90%. We aimed to identify a more optimal definition of angiographic success along two dimensions: (1) the extent of tissue reperfusion, and (2) the speed of revascularization. Methods: Core-lab adjudicated TICI scores for the first three passes of EmboTrap and the final all-procedures result were analyzed in the ARISE II multicenter study. The clinical impact of extent of reperfusion and speed of reperfusion (first-pass vs. later-pass) were evaluated. Clinical outcomes included 90-day functional independence [modified Rankin Scale (mRS) 0-2], 90-day freedom-from-disability (mRS 0-1), and dramatic early improvement [24-h National Institutes of Health Stroke Scale (NIHSS) improvement ≥ 8 points]. Results: Among 161 ARISE II subjects with ICA or MCA M1 occlusions, reperfusion results at procedure end showed substantial reperfusion in 149 (92.5%), excellent reperfusion in 121 (75.2%), and complete reperfusion in 79 (49.1%). Reperfusion rates on first pass were substantial in 81 (50.3%), excellent reperfusion in 62 (38.5%), and complete reperfusion in 44 (27.3%). First-pass excellent reperfusion (first-pass TICI 2c-3) had the greatest nominal predictive value for 90-day mRS 0-2 (sensitivity 58.5%, specificity 68.6%). There was a progressive worsening of outcomes with each additional pass required to achieve TICI 2c-3. Conclusions: First-pass excellent reperfusion (TICI 2c-3), reflecting rapid achievement of extensive reperfusion, is the technical revascularization endpoint that best predicted functional independence in this international multicenter trial and is an attractive candidate for a lead angiographic endpoint for future trials. Clinical Trial Registration: http://www.clinicaltrials.gov, identifier NCT02488915

Automated Detection and Location Specification of Large Vessel Occlusion on Computed Tomography Angiography in Acute Ischemic Stroke

Background Fast and accurate detection of large vessel occlusions (LVOs) is crucial in selection of patients with acute ischemic stroke for endovascular treatment. We assessed accuracy of an automated LVO detection algorithm with LVO localization feature. Methods Consecutive patients who underwent computed tomography angiography in 2 centers between January 2018 and September 2019 and between June and November 2020 for suspected anterior circulation LVO were retrospectively included. Reference standard for presence and site of an anterior circulation LVO (intracranial internal carotid artery, M1, or M2 segments of the middle cerebral artery) was established by consensus of 2 independent neuroradiologist readings. All computed tomography angiographies were processed by StrokeViewer‐LVO, Nicolab. Accuracy of this algorithm with LVO localization feature was assessed. Results In total, computed tomography angiographies of 364 patients with suspected anterior circulation LVO were analyzed (mean age 67±15 years; 185 male patients). A total of 180 patients (49%) had an LVO (intracranial internal carotid artery [n=49 (27%)], M1 [n=91 (51%)], and M2 [n=40 (22%)]). Sensitivity and specificity for LVO detection were, respectively, 91% (95% CI, 86%–95%) and 87% (95% CI, 81%–91%). NPV and PPV were, respectively, 91% (95% CI, 86%–94%) and 87% (95% CI, 82%–91%). Accuracy of the LVO localization feature was 95%. Median upload‐to‐notification time was 04:31 (interquartile range, 04:21–05:50) minutes. Conclusions The automated LVO detection algorithm evaluated in this study, rapidly and accurately detected anterior circulation LVOs with high accuracy of the LVO localization feature. Therefore, it is a suitable screening tool to support and speed up diagnosis of stroke

Collateral capacity assessment : Robustness and interobserver agreement of two grading scales and agreement with quantitative scoring

Background and purpose: Intracranial collateral capacity is conducive to imply parenchymal perfusion of affected territory after acute vessel occlusion. The Tan collateral score is commonly used to assess the intracranial collateral capacity; however, this score is coarsely grained and interobserver agreement is low, which reduces prognostic value and clinical utility. We introduce and evaluate an alternative extended Tan score based on the conventional Tan scale and assess the agreement with a quantitative score. Methods: We included 100 consecutive patients with a proven acute single large vessel occlusion of the proximal anterior circulation. Collaterals were graded with the conventional and extended Tan score and an automated quantitative score. The extended Tan score is a finer 6‑scale manual score based on the conventional 4‑point Tan scale. The quantitative score is calculated by an automatic software package (StrokeViewer). Interobserver agreement of the manual scores was assessed with the weighted kappa. The Spearman correlation coefficient was calculated to determine the agreement between the manual and automated collateral scores. Results: The interobserver agreement was higher for the extended score than for the conventional score with a weighted kappa of 0.70 and 0.65, respectively. For the extended and conventional score, the Spearman correlation coefficient for the agreement with the automated score was 0.78 and 0.76, respectively. Conclusion: Because of the good interobserver agreement and good agreement with quantitative assessment, the extended collateral score is a strong candidate to improve prognostic value of collateral assessment and implementation in clinical practice

Abstract 200: ICA Lesion Etiology does not affect the Outcomes after Endovascular Treatment of Acute Tandem LVO

Introduction Tandem lesions (TLs) are present in up to 15% of patients with stroke due to acute large vessel occlusions.(1) Nevertheless, published research on endovascular treatment outcomes in this population is scarce. Although TLs are most commonly of atherosclerotic etiology, some patients present with dissection of the ICA.(2, 3) In this study, we compared the clinical outcomes of TL patients with the two etiologies. Methods A retrospective analysis was performed on a multicenter cohort of patients with TLs who underwent endovascular treatment. The patients were categorized into two groups according to the etiology of the ICA lesion: atherosclerosis and dissection. Patients were matched by baseline characteristics. Clinical outcomes, including recanalization success, functional independence and hemorrhagic events were assessed with multivariable analyses. Results Of 691 patients from the database, 526 met the inclusion criteria of this study. 467 (88.8%) patients presented with atherosclerosis of the ICA, and 59 (11.2%) patients presented dissection. Univariable differences were found in median age (69 y. [IQR 61 ‐ 76] vs. 52 y. [IQR 44 ‐ 63], p<.001), rates of hypertension (74.5% vs. 52.5%, p<0.001), hyperlipidemia (49.2% vs. 27.1%, p=.001), diabetes (29.8% vs. 15.3%, p=.019), and prior antiplatelets use (36.8% vs. 22.8%, p=.037). After matching and adjusting for confounders, we did not find differences between both groups for the main outcomes: Successful reperfusion (89.1% vs. 79.7%, aOR 0.46, 95% CI 0.20 – 1.08, p=.074), mRS 0‐2 at 90 days (47.5% vs. 47.4%, aOR 0.80, 95% CI 0.44 – 1.48, p=.381), and sICH (4.3% vs. 6.8%, aOR 0.96, 95% CI 0.17 – 5.58, p=0.965). Similarly, no differences were found for the secondary outcomes: Excellent recanalization (51.1% vs. 40.7%, aOR 0.86, 95% CI 0.46 – 1.60, p=.632), early neurological improvement (41% vs. 36.2%, aOR 0.76, 95% CI 0.40 – 1.43, p=.392), parenchymal hematoma type 2 (7.8% vs. 8.5%, aOR 0.59, 95% CI 0.17 – 2.03, p=.400), mortality at 90 days (17.4% vs. 14%, aOR 1.17, 95% CI 0.49 – 2.81, p=.726), and intrahospital mortality (9.6% vs. 8.6%, aOR 0.91, 95% CI 0.31 – 2.62, p=.859). Conclusion In our cohort, patients with lesions of atherosclerotic etiology achieved higher rates of successful and excellent recanalization, but the effect disappeared when matching the groups and adjusting for confounders. The results of this study show that the etiology of the ICA lesion does not affect the clinical outcomes of endovascular treatment in tandem lesions

Abstract WP188: Differences in Outcomes Due to Anesthesia Management During Endovascular Treatment of Patients With Acute Ischemic Stroke Due to Tandem Lesions

Abstract only Background: Endovascular therapy (EVT) has been reported to be safe and effective for acute ischemic stroke (AIS) patients with tandem lesions (TLs). However, the optimal anesthetic management during EVT for TL patients is unknown. We aimed to assess the impact of anesthesia modality on clinical outcomes in AIS patients with TLs. Methods: Patient level data were pooled from 16 centers for anterior circulation TLs from 2015-2020. Patients were divided into general anesthesia (GA) and procedural sedation (PS). Multivariable logistic regression was used to assess the association of outcomes including modified Rankin Score (mRS) 0-2, ordinal shift is mRS, symptomatic intracranial hemorrhage (sICH), successful reperfusion (mTICI score ≥2b), excellent reperfusion (mTICI 3), first pass effect (FPE), early neurological recovery (ENI), door to skin puncture and reperfusion, and 90-day mortality. Results: Among 691 patients, 595 (GA:230 [38.7%] and PS:365 [61.3%]) were included in the final analysis. Patients treated with GA had lower odds of mRS 0-2 (36.6% vs. 52.5%, aOR: 0.56, 95% CI: 0.38-0.84, p =0.005) and favorable shift in 90 days mRS (aOR: 0.71, 95% CI: 0.51-0.99, p =0.041) when compared to PS. No differences were noted for sICH (3.9% vs. 4.7%, aOR: 0.66, 95% CI: 0.26-1.66, p =0.38), successful reperfusion (89.1% vs 86.5%, aOR: 1.59, CI: 0.87-2.89, p=0.13), excellent reperfusion (48.5% vs 50.3%, aOR: 0.85, CI: 0.56-1.30, p=0.462), FPE (53.6% vs 63.4%, aOR: 0.67, CI 0.45-1.0, p=0.05), ENI (38.9% vs 38.8%, aOR: 0.70, CI: 0.44-1.12, p=0.138), mortality at 90 days (20.3% vs 16.3%, aOR: 0.74, CI: 0.29-1.87, p=0.525), door to skin puncture (80 [46-117.5] mins vs 54 [21-100], p=0.607) and skin puncture to reperfusion (59 [39.5-85.5] mins vs 54 [38-81], p=0.836). Conclusions: In patients with AIS with TLs treated with EVT, GA was associated with lower odds of functional independence without a significant increased risk of sICH, mortality, or treatment delays

Endovascular treatment of acute ischemic stroke patients with tandem lesions: antegrade versus retrograde approach

OBJECTIVE The optimal technique for treating tandem lesions (TLs) with endovascular therapy is debatable. The authors evaluated the functional, safety, and procedural outcomes of different approaches in a multicenter study. METHODS Anterior circulation TL patients treated from January 2015 to December 2020 were divided on the basis of antegrade versus retrograde approach and included. The evaluated outcomes were favorable modified Rankin Scale (mRS) score (mRS score 0–2) at 3 months, ordinal shift in mRS score, successful recanalization, excellent recanalization, first-pass effect (FPE), time from groin puncture to successful recanalization, symptomatic intracranial hemorrhage (sICH), and 90-day mortality. RESULTS Among 691 patients treated at 16 centers, 286 patients (174 antegrade and 112 retrograde approach patients) with acute stenting were included in the final analysis. There were no significant differences in mRS score 0–2 at 90 days (52.2% vs 50.0%, adjusted odds ratio [aOR] 0.83, 95% CI 0.42–1.56, p = 0.54), favorable shift in 90-day mRS score (aOR 1.03, 95% CI 0.66–1.29, p = 0.11), sICH (4.0% vs 4.5%, aOR 0.64, 95% CI 0.24–1.51, p = 0.45), successful recanalization (89.4% vs 93%, aOR 0.49, 95% CI 0.19–1.28, p = 0.19), excellent recanalization (51.4% vs 58.9%, aOR 0.59, 95% CI 0.40–1.07, p = 0.09), FPE (58.3% vs 69.7%, aOR 0.62, 95% CI 0.44–1.15, p = 0.21), and mortality at 90 days (16.6% vs 14.0%, aOR 0.94, 95% CI 0.35–2.44, p = 0.81) between the groups. The median (interquartile range) groin puncture to recanalization time was significantly longer in the antegrade group (59 [43–90] minutes vs 49 [35–73] minutes, p = 0.036). CONCLUSIONS The retrograde approach was associated with faster recanalization times with a similar functional and safety profile when compared with the antegrade approach in patients with acute ischemic stroke with TL

Safety Outcomes of Antiplatelet Therapy During Endovascular Treatment of Tandem Lesions in Acute Ischemic Stroke Patients

Risk of hemorrhage remains with antiplatelet medications required with carotid stenting during endovascular therapy (EVT) for tandem lesion (TLs). We evaluated the safety of antiplatelet regimens in EVT of TLs. This multicenter study included anterior circulation TL patients from 2015 to 2020, stratified by periprocedural EVT antiplatelet strategy: (1) no antiplatelets, (2) single oral, (3) dual oral, and (4) intravenous IV (in combination with single or dual oral). Primary outcome was symptomatic intracranial hemorrhage (sICH). Secondary outcomes were any hemorrhage, favorable functional status (mRS 0-2) at 90 days, successful reperfusion (mTICI score ≥ 2b), in-stent thrombosis, and mortality at 90 days. Of the total 691 patients, 595 were included in the final analysis. One hundred and nineteen (20%) received no antiplatelets, 134 (22.5%) received single oral, 152 (25.5%) dual oral, and 196 (31.9%) IV combination. No significant association was found for sICH (ref: no antiplatelet: 5.7%; single:4.2%; aOR 0.64, CI 0.20-2.06, p = 0.45, dual:1.9%; aOR 0.35, CI 0.09-1.43, p = 0.15, IV combination: 6.1%; aOR 1.05, CI 0.39-2.85, p = 0.92). No association was found for parenchymal or petechial hemorrhage. Odds of successful reperfusion were significantly higher with dual oral (aOR 5.85, CI 2.12-16.14, p = 0.001) and IV combination (aOR 2.35, CI 1.07-5.18, p = 0.035) compared with no antiplatelets. Odds of excellent reperfusion (mTICI 2c/3) were significantly higher for cangrelor (aOR 4.41; CI 1.2-16.28; p = 0.026). No differences were noted for mRS 0-2 at 90 days, in-stent thrombosis, and mortality rates. Administration of dual oral and IV (in combination with single or dual oral) antiplatelets during EVT was associated with significantly increased odds of successful reperfusion without an increased rate of symptomatic hemorrhage or mortality in patients with anterior circulation TLs