Displaying One Session

Scientific Communications
Session Type
Scientific Communications
Room
Hall L3
Date
07.11.2020, Saturday
Session Time
08:30 AM - 10:00 AM

TREATMENT EFFECT OF MECHANICAL THROMBECTOMY IS CONSISTENT ACROSS AGE AND ASPECTS GROUPS: RESULTS FROM THE HERMES COLLABORATION.

Session Type
Scientific Communications
Date
07.11.2020, Saturday
Session Time
08:30 AM - 10:00 AM
Room
Hall L3
Lecture Time
08:30 AM - 08:40 AM

Abstract

Group Name

HERMES collaborators

Background And Aims

Age and Alberta Stroke Program Early CT Score (ASPECTS) are both strong predictors of outcome in acute ischemic stroke, and they are often assumed to interact with each other: young patients with low ASPECTS are commonly treated with endovascular therapy (EVT), while in elderly patients, physicians tend to refrain from EVT. This sub-analysis from the HERMES collaboration aimed to evaluate the benefit of EVT in different ASPECTS groups across the entire age spectrum and to determine a possible interaction effect of age and ASPECTS.

Methods

Binary logistic regression with adjustment for patient baseline characteristics was performed for treatment and control arm patients separately to predict good functional outcome, defined as modified Rankin Score (mRS) 0-2, with age, ASPECTS and an age-ASPECTS interaction term as predictor variables. EVT treatment effect (common odds ratios for a one-point shift on the mRS scale compared to the control arm) as a function of age was predicted for different ASPECTS groups.

Results

No significant interaction was observed between age and ASPECTS (EVT arm: padj=0.37, control arm: padj=0.77). Although there were slight differences in EVT treatment effect between ASPECTS groups, and 95% confidence intervals included zero, we failed to determine an ASPECTS group that did not benefit from EVT (figure).

Conclusions

EVT seemed to be beneficial across all age and ASPECTS groups in our analysis, and there was no interaction effect of age and ASPECTS. These findings suggest low ASPECTS patients may potentially benefit from EVT, irrespective of their age.

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“FLYING INTERVENTION TEAM”: A NOVEL HEALTH CARE SYSTEM FOR ENDOVASCULAR TREATMENT IN ACUTE ISCHEMIC STROKE IN RURAL AREAS

Session Type
Scientific Communications
Date
07.11.2020, Saturday
Session Time
08:30 AM - 10:00 AM
Room
Hall L3
Lecture Time
08:40 AM - 08:50 AM

Abstract

Background And Aims

In rural areas of South-East-Bavaria a novel health care concept was implemented to reduce time delays to endovascular treatment (EVT) in stroke patients with large vessel occlusion: After telemedicine-based identification of EVT candidates in primary stroke centers (PSC), a flying intervention team (neuroradiologist and angiography assistant) (FIT) is flown from two comprehensive stroke centers (CSC) by an exclusive project helicopter to PSC to perform EVT onsite. Patients remain at local stroke unit for further treatment.

Methods

Between 2018-02-01 and 2019-10-24 FIT was deployed on 26 predefined weeks/year between 8am-10pm in 13 participating PSC. During remaining weeks EVT candidates were transferred to CSC by emergency medical service. Data collection included baseline characteristics, time delays, recanalisation rate, safety parameters (periprocedural and in-hospital complications) and modified Rankin Scale after 3 months. Patients treated by FIT are compared to patients transferred to CSC.

Results

Data presentation will include analyses of time delay from decision for EVT to groin puncture, time delay from symptom onset to recanalization, recanalization rate, rate of symptomatic intracerebral hemorrhage, mortality and functional independence after 3 months comparing both groups.

Conclusions

Our results will show whether time delays can be significantly reduced by FIT deployment and whether this novel health care system should be considered as a potential solution to optimize treatment of EVT candidates in rural areas.

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ENDOVASCULAR TREATMENT FOR IN-HOSPITAL STROKES IN THE MR CLEAN REGISTRY

Session Type
Scientific Communications
Date
07.11.2020, Saturday
Session Time
08:30 AM - 10:00 AM
Room
Hall L3
Lecture Time
08:50 AM - 09:00 AM

Abstract

Group Name

MR CLEAN Registry Investigators

Background And Aims

Patients with in-hospital stroke (IHS) who receive endovascular treatment (EVT) might have a different logistic workflow and a worse functional outcome compared with patients who have stroke onset outside a hospital (OHS). We studied the effect of IHS on workflow, clinical, radiological and safety endpoints of EVT.

Methods

We included patients from the MR CLEAN registry, treated with EVT for acute stroke with anterior circulation large vessel occlusion between March 2014 and November 2017. Primary endpoint was time of first neurological assessment to groin puncture time (AGT). Secondary outcomes were score on the 90-day modified Rankin Scale (mRS) and symptomatic intracranial hemorrhage. After imputation for missing data we used a random effects model with random intercepts by treating center and analyzed endpoints using regression models adjusting for confounders.

Results

3087 patients were included and 312 (10%) had IHS. AGT was 26 minutes longer while onset-to-groin puncture time was 30 minutes shorter due to much faster onset-to-assessment time in IHS patients. mRS was worse for IHS patients although this was mostly due to imbalances in baseline characteristics (acOR 0.83 [95%CI:0.66–1.06]). There were no differences in occurrence of symptomatic intracranial hemorrhage (aOR 1.09 [95%CI:0.66–1.82])

Conclusions

Patients with IHS treated with EVT have a slower in-hospital workflow and, mostly due to baseline differences, worse functional outcome. However overall time to treatment is faster and EVT safety was similar to OHS patients. There is room for improvement in management and logistics of in-hospital stroke.

Trial Registration Number

Not applicable

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IMPACT OF INTERHOSPITAL TRANSFER VERSUS DIRECT ADMISSION ON OUTCOMES OF THROMBECTOMY FOR LARGE VESSEL OCCLUSION ACUTE ISCHEMIC STROKE PATIENTS, AN ANALYSIS OF THE COMPLETE REGISTRY

Session Type
Scientific Communications
Date
07.11.2020, Saturday
Session Time
08:30 AM - 10:00 AM
Room
Hall L3
Lecture Time
09:00 AM - 09:10 AM

Abstract

Group Name

on behalf of the COMPLETE Study Investigators

Background And Aims

Efficacy of thrombectomy treatment in large vessel occlusion acute ischemic stroke (LVO-AIS) patients is time dependent. Interhospital transfers (versus direct admission) to thrombectomy capable centers may cause treatment delays and lead to worse outcomes.

Methods

COMPLETE was a global prospective multicenter registry that enrolled LVO-AIS patients with planned frontline thrombectomy with Penumbra System (PS) per site routine practice. Endpoints included core-lab adjudicated post-procedure angiographic revascularization (mTICI ≥ 2b), 90-day functional outcome (mRS 0-2), and 90-day all-cause mortality. Time metrics and outcome differences between transfer and direct patients are compared.

Results

At 42 sites across North America and Europe, 650 patients (341 transfer, 309 direct) were enrolled. For transfer compared to direct cases respectively: median age was 70.0 and 71.0, median ASPECTS was 8.0 and 8.0, median PC-ASPECTS was 8.0 and 8.0, IV-tPA was given pre-procedure in 51.0% and 47.2% of cases, median onset-to-puncture time was 340 mins and 190 mins (p<0.001), median puncture-to-revascularization time was 27mins and 27mins, successful revascularization rate post-procedure was 90.3% and 87.2%, 90-day mRS 0-2 was 50.2% and 61.9% (p=0.004), 90-day mortality was 18.2% and 14.7%, and incidence of symptomatic ICH as 24 hours was 3.5% and 3.6%, and median length-of-stay was 8 and 7 days (p=0.091). Data collection and core lab review are ongoing.

Conclusions

In the COMPLETE registry, direct admission was associated with significantly shorter onset-to-puncture times, and higher rates of good clinical outcome. Additional research should focus on LVO-AIS detection to facilitate direct routing of patients to an appropriate treatment center.

Trial Registration Number

NCT03464565

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THE VALUE OF COLLATERAL CIRCULATION ADDED TO CLINICAL-IMAGING MISMATCH FOR THE SELECCION OF MCA STROKE PATIENTS UNDERGOING MECHANICAL THROMBECTOMY IN SHORT AND EXTENDED THERAPEUTIC WINDOWS.

Session Type
Scientific Communications
Date
07.11.2020, Saturday
Session Time
08:30 AM - 10:00 AM
Room
Hall L3
Lecture Time
09:10 AM - 09:20 AM

Abstract

Group Name

on behalf of the NORDICTUS Stroke Study Group

Background And Aims

Clinical-imaging mismatch (CIMM) (NIHSS >=6 & ASPECTS >= 6) has been recently proposed to select stroke patients for endovascular treatment (ET), even in extended (> 6h) therapeutic windows, and regardless of the state of collateral circulation (CC). We compared the prognosis of patients with CIMM treated within 6 h and beyond this time, and evaluated whether the evaluation of CC may improve the selection of patients using this imaging protocol.

Methods

Retropective analysis from the multicenter ET prospective registry of the NORDICTUS Spanish stroke research network. Patients with MCA occlusion with CIMM at admission and outcome at 3 months were selected. CC was evaluated in the baseline CTA. Clinical characteristics, neuroimaging, ET variables and evolution of patients treated within 6h and beyond this time were compared. Good outcome was considered good when mRS was 2.

Results

868 patients were included, 747 (86%) treated within 6 hours and 121 (14%) between 6-24h. Patients treated beyond 6 hours had longer onset-neuroimaging and onset-recanalization times (p<0.000). No other differences were found between the two groups. Good prognosis was, however, less frequent in patients treated beyond 6 hours (48 % vs. 35%,p=0.008). The addition CC to NIHSS and ASPECTS increased good prognosis. In patients treated beyond 6h good prognosis became similar to patients treated 6h only with CC was added to the selection (50% and 48%, respectively; p=0.117).

Conclusions

When using a single imaging protocol (CT & CTA) for ET selection, the evaluation of CC should be considered, especially in patients treated beyond 6 hours.

Trial Registration Number

Not applicable

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ENDOVASCULAR THROMBECTOMY IN YOUNG PATIENTS WITH ACUTE ISCHEMIC STROKE

Session Type
Scientific Communications
Date
07.11.2020, Saturday
Session Time
08:30 AM - 10:00 AM
Room
Hall L3
Lecture Time
09:20 AM - 09:30 AM

Abstract

Group Name

MR CLEAN Registry Investigators

Background And Aims

Ischemic stroke due to large vessel occlusions in young patients is uncommon, and outcome data of these patients are scarce. We assessed clinical and radiological outcomes of young patients (<50 years) after endovascular thrombectomy (EVT).

Methods

We used data (March 2014 – Nov 2017) from the MR CLEAN Registry, a nationwide, prospective cohort study of patients treated with EVT in the Netherlands. We compared young patients (<50 years old) with older patients (≥50). Outcomes included mRS 0-2 after 90 days, eTICI score, symptomatic intracranial hemorrhage (sICH), and stroke causes. We used multiple logistic regression analyses and adjusted for potential confounders.

Results

We included 3288 patients, of whom 324 (10%) were <50 (median age 43, 47% male) and 2964 were ≥50 years (median age 73, 52% male). Young patients had lower NIHSS (14 vs. 16, p<0.001) and lower systolic blood pressure at baseline (136 mmHg vs. 151 mmHg, p<0.001) than older patients. Clinical outcome was better in young patients (mRS 0-2: 64% vs. 41%, aOR 2.15 95%CI 1.63–2.85), with lower mortality (6% vs. 30%, aOR 0.17 95%CI 0.11–0.28). Proportion eTICI 2b-3 did not differ between groups (64% vs. 61%, p=0.47). Young patients less frequently had sICH (3% vs. 6% (p=0.05, aOR 0.52 95%CI 0.27-0.99) and more frequently an underlying carotid dissection (11% vs. 3%, p<0.001).

Conclusions

EVT for acute ischemic stroke is rare in young patients. The underlying pathology is more often carotid dissection and young patients have a higher chance of remaining independent after EVT.

Trial Registration Number

Not applicable

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BENEFIT OF ENDOVASCULAR THERAPY FOR ACUTE STROKE WITH LARGE ISCHEMIC CORE

Session Type
Scientific Communications
Date
07.11.2020, Saturday
Session Time
08:30 AM - 10:00 AM
Room
Hall L3
Lecture Time
09:30 AM - 09:40 AM

Abstract

Background And Aims

We aimed to evaluate outcomes of endovascular therapy (EVT) for acute stroke with ischemic core volume (ICV) >70 mL, which was reported as a predictor of unfavorable outcomes no matter when or whether reperfusion is achieved.

Methods

Consecutive anterior circulation stroke patients with ICV >70 mL and <300 mL were retrospectively included between March 2014 and December 2019. To adjust selection bias with EVT, we developed a propensity score (PS)-matched cohort. Outcomes included mRS score 0–2 at 3 months, symptomatic intracranial hemorrhage (sICH), and mortality. Covariates for multivariable adjustment were ICV.

Results

Among 158 patients (88 females [55.7%], median age 81 [interquartile range (IQR), 72–86] years; median NIHSS score 23 [IQR, 19–28]; median ICV 123 [IQR, 88–174] ml; 47 cases with EVT), we matched 37 patients with EVT and 37 patients with medical management (MM) alone using PS. The baseline variables were balanced between the groups (age, P=0.41; NIHSS score, P=0.42; ICV, median 94 [IQR, 82–108] mL for the EVT group and 95 [83–108] mL for the MM group, P=0.63). In the post matching analysis adjusted for age, sex, premorbid mRS, and ICV, the EVT group showed a higher proportion of mRS 0–2 at 3 months (37.8% vs. 5.4%; adjusted odds ratio, 8.8 [95% CI, 1.58–49.9]). The EVT group less frequently had parenchymal hematoma (10.8% vs. 24.3%, P=0.13) and had lower mortality (10.8% vs. 24.3%, P=0.13) than the MM group.

graph_evt_psmatching_0111.jpglarge core_flow chart_0112.jpg

Conclusions

Compared with medical treatment, EVT would be associated with better functioning outcomes, less frequent sICH, and lower mortality in large core stroke.

Trial Registration Number

Not applicable

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EXPLORING ENDOVASCULAR TREATMENT AFTER 6 HOURS: IMPLICATIONS OF VARYING TREATMENT EFFECTS BY TIME AND PENUMBRA STATUS

Session Type
Scientific Communications
Date
07.11.2020, Saturday
Session Time
08:30 AM - 10:00 AM
Room
Hall L3
Lecture Time
09:40 AM - 09:50 AM

Abstract

Background And Aims

Endovascular treatment (EVT) <6h has a robust positive effect on patient outcome in large vessel ischemic stroke. Surprisingly, given the importance of time, EVT has even larger effects after 6h of time last known well (LKW) using advanced imaging to select patients with preserved penumbra. We aim to study interaction between EVT and time and penumbra and hypothesize that the efficacy of EVT increases with time in patients with larger penumbra.

Methods

In all 182 patients enrolled in DEFUSE3 (large artery occlusion, 6-16 hours from time LKW, radiographic evidence of penumbra, defined as perfusion deficit volume minus core), we used logistic regression to predict good functional outcome (30 day mRS <= 2) logistic). Two key covariates were included: probability of good outcome (from MR PREDICTS model based on clinical, radiographic and demographic features) and 2-way interaction terms; penumbra multiplied by time from LKW, stratified by treatment.

Results

A time LKW-penumbra interaction was identified in patients without EVT (beta=-0.0002, p=0.02), but not for patients receiving EVT (beta=1e-7, p=0.98). In the EVT group, the probability of a good outcome increased with shorter time since LKW in patients with large penumbra but less in patients with small penumbra (Figure) All patients were predicted to benefit from EVT, but the magnitude varied with time LKW and penumbra.

mrs30daymarginsbytimequartilesimplifiedcropped.png

Conclusions

The combination of penumbra and time modifies the effect of EVT treatment in late time windows and may have implications for patient selection. Future work to inform the independent effects of penumbra and LKW time on benefit of EVT is needed.

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PREDICTORS OF INDEPENDENT OUTCOME OF THROMBECTOMY IN PATIENTS WITH LARGE BASELINE INFARCTS IN CLINICAL PRACTICE: A MULTICENTER ANALYSIS

Session Type
Scientific Communications
Date
07.11.2020, Saturday
Session Time
08:30 AM - 10:00 AM
Room
Hall L3
Lecture Time
09:50 AM - 10:00 AM

Abstract

Group Name

For the GSR-ET Investigators

Background And Aims

It remains unclear whether stroke patients with large vessel occlusion and low Alberta Stroke Program Early CT Score (ASPECTS) benefit from endovascular treatment (ET). We aimed to assess the outcome of ET and identify predictors of independent outcome in patients with an ASPECTS <6 treated by thrombectomy.

Methods

Data of consecutive patients from an industry-independent, multi-center, prospective registry (German Stroke Registry–Endovascular Treatment), who were treated by ET with different devices (June 2015-April 2018), were analyzed. Multivariate regression analysis identified predictors of independent outcome (modified Rankin Scale (mRS) score 0-2) and death 90 days after stroke in patients with a baseline ASPECTS <6.

Results

Of 1,700 patients included in the analysis, 152 (8.9%) had an ASPECTS <6 at baseline. Of these, 33 (21.6%) achieved independent outcome, 68 (44.7%) were dead at 90 days. L­­­ower age, lower baseline National Institutes of Health Stroke Scale (NIHSS) score, and successful recanalization (TICI 2b/3) predicted independent outcome. Successful recanalization showed the strongest association with independent outcome (OR 7.0, 95% CI 1.8-26.8). Pre-treatment parameters predicting independent outcome were age <70 years (sensitivity 0.79, specificity 0.69) and NIHSS <12 (0.57, 0.94). Higher age, a pre-stroke mRS score >1, and failed recanalization were predictors of death.

Conclusions

A considerable proportion of stroke patients with an ASPECTS <6 achieves independent outcome after ET, in particular younger patients with less severe strokes, given that successful recanalization is achieved. These findings may encourage considering ET in low ASPECTS patients in clinical practice until results from randomized trials are available.

Trial Registration Number

Not applicable

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