Ido R. van den Wijngaard

Impact of Collateral Status Evaluated by Dynamic Computed Tomographic Angiography on Clinical Outcome in Patients With Ischemic Stroke

Background and Purpose— Status of collateral circulation is a strong predictor of outcome after acute ischemic stroke. Our aim was to compare the predictive value of strategies for collateral blood flow assessment with dynamic computed tomographic angiography (CTA) and conventional single-phase CT angiography. Methods— Patients with a proximal middle cerebral artery occlusion underwent noncontrast CT, single-phase CTA and whole brain CT perfusion/dynamic CTA within 9 hours after stroke onset. We defined poor outcome as a score on the modified Rankin Scale score of ≥3. The association between collateral score and clinical outcome at 3 months was analyzed with Poisson regression. The prognostic value of collateral scoring with dynamic CTA and single-phase CTA in addition to age, stroke severity, and noncontrast CT was assessed with logistic regression and summarized with the area under the curve. Results— Seventy patients were included, with a mean age of 68 years. We observed an increased risk of poor outcome in patients with poor collaterals on single-phase CTA (risk ratio, 1.8; 95% confidence interval, 1.0–3.1) and on dynamic CTA (risk ratio, 2.0; 95% confidence interval, 1.5–2.7). The prediction of poor clinical outcome by means of collateral adjustment was better with dynamic CTA (area under the curve, 0.84; likelihood ratio test P<0.01) than by single-phase CTA (area under the curve, 0.80; likelihood ratio test P=0.33). Conclusions— Collateral assessment with dynamic CTA better predicts clinical outcome at 3 months than single-phase conventional CTA. Clinical Trial Registration— URL: http://www.trialregister.nl/trialreg. Unique identifier: NTR1804. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00880113.

Intra-Arterial Treatment in a Child with Embolic Stroke Due to Atrial Myxoma

Arterial ischaemic stroke is an important cause of morbidity in children. Timely diagnosis is necessary for acute stroke treatment but can be challenging in clinical practice. Due to a paucity of data there are no specific recommendations regarding the use of mechanical thrombectomy devices in current paediatric stroke guidelines. A 14-year-old boy presented with a severe acute left hemisphere stroke due to a proximal middle cerebral artery occlusion caused by emboli from an atrial myxoma. No clinical improvement was seen after administration of intravenous thrombolysis. Subsequent mechanical thrombectomy with a second-generation stent-based thrombectomy device resulted in successful recanalization and clinical improvement. To our knowledge, this is the first report of mechanical thrombectomy in a child with acute embolic stroke caused by atrial myxoma.

Cortical Venous Filling on Dynamic Computed Tomographic Angiography A Novel Predictor of Clinical Outcome in Patients With Acute Middle Cerebral Artery Stroke

Background and Purpose— Venous flow in the downstream territory of an occluded artery may influence patient prognosis after ischemic stroke. Our aim was to study cortical venous filling (CVF) in a time-resolved manner with dynamic computed tomographic angiography and to assess the relationship with clinical outcome. Methods— Patients with a proximal middle cerebral artery occlusion underwent noncontrast CT and whole-brain CT perfusion/dynamic CT angiography within 9 hours after stroke-onset. We defined poor outcome as a modified Rankin Scale score of ≥3. Association between the extent and velocity of CVF and poor outcome at 3 months was analyzed with Poisson-regression. Prognostic value of optimal CVF (maximum opacification of cortical veins) in addition to age, stroke severity, treatment, Alberta Stroke Program Early CT score, cerebral blood flow, and collateral status was assessed with logistic regression and summarized with the area under the curve. Results— Eighty-eight patients were included, with a mean age of 67 years. By combining the extent and velocity of optimal CVF, we observed a decreased risk of poor outcome in patients with good and fast optimal CVF, risk ratio of 0.5 (95% confidence interval, 0.3–0.7). Extent and velocity of optimal CVF had additional prognostic value (area under the curve, 0.88; 95% confidence interval, 0.77–0.98; P<0.02) compared with a model without CVF information. Conclusions— The combination of extent and velocity of optimal CVF, as assessed with dynamic CT angiography, is useful to identify patients with acute middle cerebral artery stroke at higher risk of poor clinical outcome at 3-month follow-up. Clinical Trial Registration— URL: http://www.trialregister.nl/trialreg and http://www.clinicaltrials.gov. Unique identifier: NTR1804 and NCT00880113, respectively.

Treatment and imaging of intracranial atherosclerotic stenosis: current perspectives and future directions

Intracranial atherosclerosis is a common cause of stroke worldwide. It results in ischemic stroke due to different mechanisms including artery‐to‐artery embolism, in situ thrombo‐occlusion, occlusion of perforating arteries, and hemodynamic failure. In this review, we present an overview of current treatment and imaging modalities in intracranial atherosclerotic stenosis.

Value of Whole Brain Computed Tomography Perfusion for Predicting Outcome after TIA or Minor Ischemic Stroke

INTRODUCTION About 15% of patients with transient ischemic attack (TIA) or minor ischemic stroke have functional impairment after 3 months. We studied the role of whole brain computed tomography perfusion (WB-CTP) in the emergency diagnosis of TIA or minor stroke in predicting disability at 3 months. METHODS We included patients with ongoing symptoms of a TIA or minor stroke with a National Institutes of Health Stroke Scale (NIHSS) score less than 4 who were evaluated with noncontrast CT (NCCT), CT angiography (CTA), and WB-CTP within 24 hours of symptom onset. Patients treated with thrombolysis or a premorbid modified Rankin Scale (mRS) score greater than 1 were excluded. The association between clinical or imaging features and disability (mRS score ≥2) at 3 months was analyzed with Poisson regression. Potential additional prognostic value of WB-CTP was assessed with logistic regression. RESULTS We included 115 patients in 2012 to 2013. Median age was 68 years, and 66% were men. At 3 months, 20 patients (17%) were disabled. NIHSS score on admission (relative risk [RR], 3.6; 95% confidence interval [CI], 1.4-9.3), female sex (RR, 2.4; 95% CI, 1.1-5.3), early ischemic changes on NCCT (RR, 5.0; 95% CI, 2.6-9.9), extracranial or intracranial vessel stenosis ≥50% on CTA (RR, 3.0; 95% CI, 1.4-6.4), and perfusion abnormalities on WB-CTP (RR, 11.4; 95% CI, 4.6-28.2) were associated with disability at 3 months. In multivariable analysis, the relation between perfusion abnormalities and poor outcome remained essentially the same. WB-CTP showed prognostic value in addition to proved clinical and imaging predictors of disability. CONCLUSIONS WB-CTP is useful to identify patients with TIA or minor ischemic stroke at high risk of functional impairment at 3-month follow-up.

Time to Endovascular Treatment and Outcome in Acute Ischemic Stroke: MR CLEAN Registry Results

Background: Randomized, clinical trials in selected acute ischemic stroke patients reported that for every hour delay of endovascular treatment (EVT), chances of functional independence diminish by up to 3.4%. These findings may not be fully generalizable to clinical practice because of strict in- and exclusion criteria in these trials. Therefore, we aim to assess the association of time to EVT with functional outcome in current, everyday clinical practice. Methods: The MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) is an ongoing, prospective, observational study in all centers that perform EVT in The Netherlands. Data were analyzed from patients treated between March 2014 and June 2016. In the primary analysis we assessed the association of time from stroke onset to start of EVT and time from stroke onset to successful reperfusion with functional outcome (measured with the modified Rankin Scale), by means of ordinal logistic regression. Results: We analyzed 1488 patients with acute ischemic stroke who underwent EVT. An increased time to start of EVT was associated with worse functional outcome (adjusted common odds ratio, 0.83 per hour; 95% confidence interval, 0.77–0.89) and a 2.2% increase in mortality. Every hour increase from stroke onset to EVT start resulted in a 5.3% decreased probability of functional independence (modified Rankin Scale, 0–2). In the 742 patients with successful reperfusion, every hour increase from stroke onset to reperfusion was associated with a 7.7% decreased probability of functional independence. Conclusions: Time to EVT for acute ischemic stroke in current clinical practice is strongly associated with functional outcome. Our data suggest that this association might be even stronger than previously suggested in reports on more selected patient populations from randomized, controlled trials. These findings emphasize that functional outcome of EVT patients can be greatly improved by shortening onset to treatment times.

Importance of Reperfusion Status after Intra-Arterial Thrombectomy for Prediction of Outcome in Anterior Circulation Large Vessel Stroke

Background: Reperfusion status after intra-arterial thrombectomy (IAT) is a critical predictor of functional outcome after acute ischemic stroke. However, most prognostic models have not included a detailed assessment of reperfusion status after IAT. Objective: The aim of this work was to assess the association between successful reperfusion and clinical outcome. Methods: Clinical, radiological, and procedural variables of patients treated with IAT were extracted from our prospective stroke registry. The association with functional outcome using the modified Rankin Scale (mRS) after 3 months was assessed using multivariable logistic regression. An extension of the modified TICI score, eTICI, was used to classify reperfusion status. The prognostic value of reperfusion status after IAT in addition to age, stroke severity, imaging characteristics, treatment with intravenous thrombolysis, and time from symptom onset to the end of IAT was assessed with logistic regression and summarized with receiver operating characteristic curves. Results: In total, 119 patients were included (mean age 66 years). In multivariable analysis, age >80 years (OR 6.8, 95% CI 1.2–39.8), NIHSS at presentation >15 (OR 7.3, 95% CI 2.3–23.5), and incomplete reperfusion status (eTICI score <2C; OR 10.3, 95% CI 3.5–30.6) were the strongest predictors of a poor outcome (mRS 3–6). Adding reperfusion status to the model improved the prognostic accuracy (AUC 0.88, 95% CI 0.91–0.94). Our results indicate a large difference between using an eTICI cutoff of ≥2C versus ≥2B: a cutoff ≥2C improved the predictive value for a good clinical outcome (2C: positive predictive value, PPV, 0.78; 2B: PPV 0.32). Conclusion: Our results promote using reperfusion status for assessing prognosis in ischemic stroke patients treated with IAT. A model using eTICI ≥2C had greater PPV than eTICI ≥2B and could improve prognostic accuracy.

Clinical prediction of thrombectomy eligibility: A systematic review and 4-item decision tree

Background A clinical large anterior vessel occlusion (LAVO)-prediction scale could reduce treatment delays by allocating intra-arterial thrombectomy (IAT)-eligible patients directly to a comprehensive stroke center. Aim To subtract, validate and compare existing LAVO-prediction scales, and develop a straightforward decision support tool to assess IAT-eligibility. Methods We performed a systematic literature search to identify LAVO-prediction scales. Performance was compared in a prospective, multicenter validation cohort of the Dutch acute Stroke study (DUST) by calculating area under the receiver operating curves (AUROC). With group lasso regression analysis, we constructed a prediction model, incorporating patient characteristics next to National Institutes of Health Stroke Scale (NIHSS) items. Finally, we developed a decision tree algorithm based on dichotomized NIHSS items. Results We identified seven LAVO-prediction scales. From DUST, 1316 patients (35.8% LAVO-rate) from 14 centers were available for validation. FAST-ED and RACE had the highest AUROC (both >0.81, p < 0.01 for comparison with other scales). Group lasso analysis revealed a LAVO-prediction model containing seven NIHSS items (AUROC 0.84). With the GACE (Gaze, facial Asymmetry, level of Consciousness, Extinction/inattention) decision tree, LAVO is predicted (AUROC 0.76) for 61% of patients with assessment of only two dichotomized NIHSS items, and for all patients with four items. Conclusion External validation of seven LAVO-prediction scales showed AUROCs between 0.75 and 0.83. Most scales, however, appear too complex for Emergency Medical Services use with prehospital validation generally lacking. GACE is the first LAVO-prediction scale using a simple decision tree as such increasing feasibility, while maintaining high accuracy. Prehospital prospective validation is planned.

Absence of Cortical Vein Opacification is Associated with Lack of Intra-arterial Therapy Benefit in Stroke

Purpose To assess the degree of cortical vein opacification in patients with internal carotid artery or middle cerebral artery (MCA) stroke and to evaluate the relationship with treatment benefit from intra-arterial therapy (IAT). Materials and Methods Written informed consent was obtained from all patients in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands. From the trials database, all patients (recruited from December 2010 until March 2014) with baseline computed tomographic (CT) angiograms were retrospectively included. Enhancement of the vein of Labbé, sphenoparietal sinus, and superficial middle cerebral vein was graded by one neuroradiologist, as follows: 0, not visible; 1, moderate opacification; and 2, full opacification. The sum for the ipsilateral hemisphere was calculated, resulting in the cortical vein opacification score (COVES) (range, 0-6). Primary outcome was the modified Rankin Scale score at 90 days. Association with treatment according to full cortical vein score and different dichotomized cutoff points was estimated with ordinal logistic regression. Interobserver agreement was assessed by two separate observers who reviewed 100 studies each. Results In total, 397 patients were analyzed. Interaction of the cortical vein score with treatment was significant (P = .044) when dichotomized COVES was 0 versus more than 0. The adjusted odds ratio for shift toward better functional outcome was 1.0 (95% confidence interval [CI]: 0.5, 2.0) for a COVES of 0 (n = 123) and 2.2 (95% CI: 1.6, 4.1) for a COVES greater than 0 (n = 274). The multirater κ value was 0.73. Conclusion In this study, patients with acute middle cerebral artery stroke with absence of cortical vein opacification in the affected hemisphere (COVES = 0) appeared to have no benefit from IAT, whereas patients with venous opacification (COVES >0) were shown to benefit from IAT.

Successful mechanical thrombectomy in a comatose patient with cerebral venous sinus thrombosis: A case report

Cerebral venous sinus thrombosis is a rare cause of stroke, which is routinely treated with systemic heparin. Unfavourable outcome is often seen in severe cases. Therefore alternative treatment methods should be explored in these patients. Due to the risk of haemorrhagic complications, treatment without administration of thrombolytics is of particular interest. This report presents a case of successful mechanical thrombectomy, without the use of thrombolytics, in a comatose patient with cerebral venous sinus thrombosis.