Assessment of Discrepancies Between Follow-up Infarct Volume and 90-Day Outcomes Among Patients With Ischemic Stroke Who Received Endovascular Therapy
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SUBMITTER: Ganesh A
PROVIDER: S-EPMC8571657 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:ImportanceThe positive treatment effect of endovascular therapy (EVT) is assumed to be caused by the preservation of brain tissue. It remains unclear to what extent the treatment-related reduction in follow-up infarct volume (FIV) explains the improved functional outcome after EVT in patients with acute ischemic stroke.ObjectiveTo study whether FIV mediates the relationship between EVT and functional outcome in patients with acute ischemic stroke.Design, setting, and participantsPatient data from 7 randomized multicenter trials were pooled. These trials were conducted between December 2010 and April 2015 and included 1764 patients randomly assigned to receive either EVT or standard care (control). Follow-up infarct volume was assessed on computed tomography or magnetic resonance imaging after stroke onset. Mediation analysis was performed to examine the potential causal chain in which FIV may mediate the relationship between EVT and functional outcome. A total of 1690 patients met the inclusion criteria. Twenty-five additional patients were excluded, resulting in a total of 1665 patients, including 821 (49.3%) in the EVT group and 844 (50.7%) in the control group. Data were analyzed from January to June 2017.Main outcome and measureThe 90-day functional outcome via the modified Rankin Scale (mRS).ResultsAmong 1665 patients, the median (interquartile range [IQR]) age was 68 (57-76) years, and 781 (46.9%) were female. The median (IQR) time to FIV measurement was 30 (24-237) hours. The median (IQR) FIV was 41 (14-120) mL. Patients in the EVT group had significantly smaller FIVs compared with patients in the control group (median [IQR] FIV, 33 [11-99] vs 51 [18-134] mL; P = .007) and lower mRS scores at 90 days (median [IQR] score, 3 [1-4] vs 4 [2-5]). Follow-up infarct volume was a predictor of functional outcome (adjusted common odds ratio, 0.46; 95% CI, 0.39-0.54; P < .001). Follow-up infarct volume partially mediated the relationship between treatment type with mRS score, as EVT was still significantly associated with functional outcome after adjustment for FIV (adjusted common odds ratio, 2.22; 95% CI, 1.52-3.21; P < .001). Treatment-reduced FIV explained 12% (95% CI, 1-19) of the relationship between EVT and functional outcome.Conclusions and relevanceIn this analysis, follow-up infarct volume predicted functional outcome; however, a reduced infarct volume after treatment with EVT only explained 12% of the treatment benefit. Follow-up infarct volume as measured on computed tomography and magnetic resonance imaging is not a valid proxy for estimating treatment effect in phase II and III trials of acute ischemic stroke.
| S-EPMC6439953 | biostudies-literature
Project description:OBJECTIVE:The putative mechanism for the favourable effect of endovascular treatment (EVT) on functional outcome after acute ischaemic stroke is preventing follow-up infarct volume (FIV) progression. We aimed to assess to what extent difference in FIV explains the effect of EVT on functional outcome in a randomised trial of EVT versus no EVT (MR CLEAN). METHODS:FIV was assessed on non-contrast CT scan 5-7 days after stroke. Functional outcome was the score on the modified Rankin Scale at 3 months. We tested the causal pathway from intervention, via FIV to functional outcome with a mediation model, using linear and ordinal regression, adjusted for relevant baseline covariates, including stroke severity. Explained effect was assessed by taking the ratio of the log odds ratios of treatment with and without adjustment for FIV. RESULTS:Of the 500 patients included in MR CLEAN, 60 died and four patients underwent hemicraniectomy before FIV was assessed, leaving 436 patients for analysis. Patients in the intervention group had better functional outcomes (adjusted common odds ratio (acOR) 2.30 (95% CI 1.62-3.26) than controls and smaller FIV (median 53 vs. 81 ml) (difference 28 ml; 95% CI 13-41). Smaller FIV was associated with better outcome (acOR per 10 ml 0.60, 95% CI 0.52-0.68). After adjustment for FIV the effect of intervention on functional outcome decreased but remained substantial (acOR 2.05, 95% CI 1.44-2.91). This implies that preventing FIV progression explains 14% (95% CI 0-34) of the beneficial effect of EVT on outcome. CONCLUSION:The effect of EVT on FIV explains only part of the treatment effect on functional outcome. KEY POINTS:• Endovascular treatment in acute ischaemic stroke patients prevents progression of follow-up infarct volume on non-contrast CT at 5-7 days. • Follow-up infarct volume was related to functional outcome, but only explained a modest part of the effect of intervention on functional outcome. • A large proportion of treatment effect on functional outcome remains unexplained, suggesting FIV alone cannot be used as an early surrogate imaging marker of functional outcome.
| S-EPMC6302877 | biostudies-other
Project description:Background and purposeCerebral infarct volume as observed in follow-up CT is an important radiologic outcome measure of the effectiveness of treatment of patients with acute ischemic stroke. However, manual measurement of CIV is time-consuming and operator-dependent. The purpose of this study was to develop and evaluate a robust automated measurement of the CIV.Materials and methodsThe CIV in early follow-up CT images of 34 consecutive patients with acute ischemic stroke was segmented with an automated intensity-based region-growing algorithm, which includes partial volume effect correction near the skull, midline determination, and ventricle and hemorrhage exclusion. Two observers manually delineated the CIV. Interobserver variability of the manual assessments and the accuracy of the automated method were evaluated by using the Pearson correlation, Bland-Altman analysis, and Dice coefficients. The accuracy was defined as the correlation with the manual assessment as a reference standard.ResultsThe Pearson correlation for the automated method compared with the reference standard was similar to the manual correlation (R = 0.98). The accuracy of the automated method was excellent with a mean difference of 0.5 mL with limits of agreement of -38.0-39.1 mL, which were more consistent than the interobserver variability of the 2 observers (-40.9-44.1 mL). However, the Dice coefficients were higher for the manual delineation.ConclusionsThe automated method showed a strong correlation and accuracy with the manual reference measurement. This approach has the potential to become the standard in assessing the infarct volume as a secondary outcome measure for evaluating the effectiveness of treatment.
| S-EPMC8051473 | biostudies-literature
Project description:BACKGROUND:endovascular therapy (ET) is the standard of care for anterior circulation acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). The role of adjunctive intravenous thrombolysis (IVT) in these patients remains unclear. The present study aims to investigate whether IVT followed by ET (CoT, combined therapy) provides additional benefits over direct ET for anterior circulation AIS with LVO. METHODS:we achieved a single center retrospective study of patients with AIS caused by anterior circulation LVO, referred to our center between January 2014 and January 2017 and treated with ET. Functional recovery (modified Rankin at 3-months follow-up), recanalization rate (thrombolysis in cerebral infarction [TICI] score) and time, early follow-up brain CT scan infarct volume (EFIV) (for recanalized patients only), symptomatic intracerebral hemorrhage (sICH) and 3-month mortality were the outcomes of interests. Independent predictors of the outcomes were explored with multivariable logistic regression. RESULTS:145 subjects were included in the study, of whom 70 underwent direct ET and 75 were treated with CoT. Functional independence at 3-months was more frequent in CoT subjects compared to patients who received direct ET (mRS score 0-1: 48.5% vs 18.6%; P?<?0.001. mRS score 0-2: 67.1% vs 37.3%; P?<?0.001); CoT patients had also higher first-pass success rate (62.7% vs 38.6%, P?<?0.05), higher recanalization rate (84.3% vs 65.3%; P?=?0.009) and, in recanalized subjects, smaller EFIV (16.4?ml vs 62.3?ml; P?=?0.003). Mortality and intracranial bleeding did not differ between the two groups. In multivariable regression analysis, low baseline NIHSS score (P?<?0.05), vessel recanalization (P?=?0.05) and CoT (P?=?0.03) were independent predictors of favorable outcome at three months. CONCLUSIONS:CoT appears more effective than ET alone for anterior circulation AIS with LVO, with similar safety profile.
| S-EPMC6540520 | biostudies-literature
Project description:Background and purposeCollateral blood flow is an important prognostic marker in the acute stroke situation but approaches for assessment vary widely. Our aim was to compare strategies of collateral blood flow assessment in dynamic and conventional CTA in their ability to predict the follow-up infarction volume.Materials and methodsWe retrospectively included all patients with an M1 occlusion from an existing cohort of 1912 consecutive patients who underwent initial multimodal stroke CT and follow-up MR imaging or nonenhanced CT. Collateralization was assessed in both conventional CT angiography and dynamic CT angiography by using 3 different collateral grading scores and segmentation of the volume of hypoattenuation. Arterial, arteriovenous, and venous phases were reconstructed for dynamic CT angiography, and all collateral scores and the volume of hypoattenuation were individually assessed for all phases. Different grading systems were compared by using the Bayesian information criterion calculated for multivariate regression analyses (Bayesian information criterion difference = 2-6, "positive"; Bayesian information criterion difference = 6-10, "strong"; Bayesian information criterion difference = >10, "very strong").ResultsOne hundred thirty-six patients (mean age, 70.4 years; male sex, 41.2%) were included. In the multivariate analysis, models containing the volume of hypoattenuation showed a significantly better model fit than models containing any of the 3 collateral grading scores in conventional CT angiography (Bayesian information criterion difference = >10) and dynamic CT angiography (Bayesian information criterion difference = >10). All grading systems showed the best model fit in the arteriovenous phase. For the volume of hypoattenuation, model fit was significantly higher for models containing the volume of hypoattenuation as assessed in the arteriovenous phase of dynamic CT angiography compared with the venous phase (Bayesian information criterion difference = 6.2) and the arterial phase of dynamic CT angiography (Bayesian information criterion difference = >10) and in comparison with conventional CT angiography (Bayesian information criterion difference = >10).ConclusionsThe use of dynamic CT angiography within the arteriovenous phase by using quantification of the volume of hypoattenuation is the superior technique for assessment of collateralization among the tested approaches.
| S-EPMC8013068 | biostudies-literature
Project description:ObjectivesSmall subcortical infarcts (SSI) frequently coexist with brain white matter hyperintensity (WMH) lesions. We sought to determine whether preexisting WMH burden relates to SSI volume, SSI etiology, and 90-day functional outcome.Materials and methodsWe retrospectively studied 80 consecutive patients with acute SSI. Infarct volume was determined on diffusion weighted imaging, and WMH burden was graded on fluid-attenuated inversion recovery sequences according to the Fazekas scale. SSI etiology was categorized as small vessel disease (SVD) vs non-SVD related. Multivariable linear and logistic regression models were constructed to determine whether WMH burden was independently associated with the SSI volume and a poor 90-day outcome (modified Rankin scale [mRS] score >2), respectively.ResultsIn unadjusted analyses, patients with non-SVD-related SSI were older (P=.002) and more frequently had multiple infarcts (P<.001) than patients with SVD-related SSI. In the fully adjusted model, WMH severity (Coefficient 0.07; 95%-CI 0.029-0.117; P=.002) but not SSI etiology (P>.1) was independently associated with the SSI volume. On multivariable logistic regression, worse WMH (OR 2.28; 95%-CI 1.04-4.99; P=.040), SSI etiology (OR 9.20; 95%-CI 1.04-81.39; P=.046), preadmission mRS (OR 8.96; 95%-CI 2.65-30.27; P<.001), and SSI volume (OR 1.98; 95%-CI 1.14-3.44; P=.016) were associated with a poor 90-day outcome.ConclusionsGreater WMH burden is independently associated with a larger SSI volume and a worse 90-day outcome.
| S-EPMC5332524 | biostudies-literature
Project description:Patients who have large cerebral infarctions may not be good candidates for endovascular treatment. Various methods for determining infarct volume have been used in clinical studies. We evaluated the effectiveness of several methods for measuring infarct volume, especially regarding futile outcomes despite endovascular treatment.Patients with acute ischemic stroke in unilateral anterior circulation territory who were treated with intra-arterial thrombectomy were included. For assessing infarct volume, the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) scoring system was applied to images obtained by noncontrast computed tomography (NCCT), postcontrast CT (PCCT), and diffusion-weighted imaging (DWI). DWI stroke volume was semiquantitatively measured with the manually outlined hyperintense lesion. Infarct core volume was calculated with a threshold apparent diffusion coefficient value of 600?×?10?mm/s. Intraclass correlation coefficients (ICC) were estimated to assess inter-reader reliability for ASPECTS scoring and DWI stroke volume. Receiver operating characteristic (ROC) curve analyses, and univariable and multivariable comparative analyses, were performed with each evaluation method to predict futile outcome (modified Rankin Scale score 5-6).The mean age of the included 79 patients was 65.1?±?15.7 years. Among them, 55 (69.6%) patients demonstrated successful reperfusion after intra-arterial thrombectomy, but 34 (43.0%) patients had futile outcomes. Inter-reader agreement was excellent for measurement of the DWI stroke volume (ICC, 0.973), DWI ASPECTS (0.940), and PCCT ASPECTS (0.859), but was moderate for NCCT ASPECTS (0.694). Regarding prediction of futile outcomes, area under ROC curve was 0.551 on NCCT ASPECTS and it was significantly smaller than that in PCCT ASPECTS (area under ROC 0.651, P?=?0.030), DWI ASPECTS (0.733, P?=?0.003), DWI stroke volume (0.702, P?=?0.022), and infarct core volume (0.702, P?=?0.021). Besides old age and high National Institutes of Health Stroke Scale score on admission, MRI parameters such as DWI ASPECTS and infarct core volume indicating large volumes were independently associated with futile outcomes in multivariable analyses.DWI ASPECTS can be a good parameter predicting futility, which is easily measured and has high prediction power.
| S-EPMC5008586 | biostudies-literature
Project description:ObjectiveOur study aimed to compare symptoms day by day for non-hospitalized individuals testing positive and negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).MethodsIn total, 210 positive-test and 630 negative-test healthcare workers in the Central Denmark Region were followed for up to 90 days after testing, between April and June, 2020. Their daily reported COVID-19-related symptoms were compared graphically and by logistic regression.ResultsThirty per cent of the positive-test and close to 0% of the negative-test participants reported a reduced sense of taste and smell during all 90 days (adjusted odds ratio [aOR] 86.07, 95% CI 22.86-323). Dyspnea was reported by an initial 20% of positive-test participants, declining to 5% after 30 days, without ever reaching the level of the negative-test participants (aOR 6.88, 95% CI 2.41-19.63). Cough, headache, sore throat, muscle pain, and fever were temporarily more prevalent among the positive-test participants; after 30 days, no increases were seen. Women and older participants were more susceptible to long-lasting COVID-19 symptoms.ConclusionThe prevalence of long-lasting reduced sense of taste and smell is highly increased in mild COVID-19 patients. This pattern is also seen for dyspnea at a low level, but not for cough, sore throat, headache, muscle pain, or fever.
| S-EPMC8133825 | biostudies-literature
Project description:Background Patients aged ?90 were excluded or under-represented in past thrombectomy trials; thus, uncertainty remains whether treatment benefits can be expected regardless of age. This study investigates outcome and safety of thrombectomy in nonagenarians to improve decision making in a real-world setting. Methods and Results All currently available data of patients aged ?90 enrolled in the GSR-ET (German Stroke Registry-Endovascular Treatment) were combined with a smaller cohort from 3 tertiary stroke centers. Baseline characteristics, procedural (Thrombolysis in Cerebral Infarction scale) and functional outcomes (modified Rankin Scale; mRS), as well as complications (symptomatic intracranial hemorrhage, serious adverse events; SAEs) were analyzed. Good functional outcome was defined as mRS ?3 at 90-days. 203 patients with anterior circulation stroke and prestroke mRS ?3 were included. The rate of successful recanalization (Thrombolysis in Cerebral Infarction scale ?2b) was 75.9% (154/203). Good functional outcome (mRS ?3) was observed in 21.6% (41 of 193) at 90-days. In-hospital mortality was 27.1% (55 of 203) and increased significantly at 90 days to 48.9% (93 of 190; P<0.001). Symptomatic intracranial hemorrhage occurred in 3% (6 of 203) of patients. Logistic regression analysis identified Alberta Stroke Program Early CT Score (adjusted odds ratio, 1.93; 95% CI, 1.01-3.70; P=0.046) and initial National Institute of Health Stroke Scale (adjusted odds ratio, 0.85; 95% CI, 0.76-0.97; P=0.014) as independent predictors for good outcome. Patients with successful recanalization had a significant (P=0.001) shift of mRS distribution with higher rates of good functional outcomes (23.8% [34 of 143] versus 14.9% [7 of 47]) and lower mortality at 90-days (46.8% [67 of 143] versus 55.3% [26 of 47]). Conclusions Despite high mortality and less frequent favorable outcome, our data suggest that thrombectomy is still effective and safe for nonagenarians. Decision making for thrombectomy in patients aged ?90 should be based on a case-by-case basis with regard to initial National Institute of Health Stroke Scale and Alberta Stroke Program Early CT Score.
| S-EPMC7335589 | biostudies-literature
Project description:There is increasing interest in defining stroke lesion volume thresholds to predict poststroke outcome. However, there is a paucity of data on factors that impact the association between critical infarct thresholds volume and outcome. We sought to determine whether lesion thresholds best predicting outcome depend on the degree of preexisting white matter hyperintensity (WMH) lesion burden.Magnetic resonance imaging infarct volumes were quantified in 414 consecutive patients with anterior circulation ischemic strokes evaluated between January 2014 and December 2014. The WMH lesion volume was graded according to the Fazekas scale and dichotomized to absent to mild versus moderate to severe. Receiver operator characteristics curves were calculated to determine the infarct volume threshold best predicting the 90-day outcome. Multivariable logistic regression was used to determine whether the critical lesion thresholds independently predicted a favorable 90-day outcome after adjusting for pertinent confounders.The infarct volumes thresholds predicting the 90-day outcome for the entire cohort (standard thresholds) were ?29.5 mL (modified Rankin scale [mRS] 0-1), ?29.9 mL (mRS 0-2), and ?34.1 mL (mRS 0-3). For patients with absent-to-mild WMH lesion burden, WMH-adjusted critical infarct thresholds were significantly greater than the standard infarct thresholds. In the fully adjusted multivariable regression models, the WMH-adjusted infarct thresholds correctly predicted the outcome to a similar degree as the standard thresholds.In this proof-of-concept study, the WMH lesion burden impacted the critical outcome-predicting infarct thresholds. If confirmed, using a WMH-adjusted infarct threshold could allow defining patients that have a favorable outcome despite having relatively large infarct volumes.
| S-EPMC5039097 | biostudies-other