Effect of stroke thrombolysis predicted by distal vessel occlusion detection

Kunz, Wolfgang G.; Fabritius, Matthias P.; Sommer, Wieland H.; Höhne, Christopher; Scheffler, Pierre; Rotkopf, Lukas T.; Fendler, Wolfgang P.; Sabel, Bastian O.; Meinel, Felix G.; Dorn, Franziska; Ertl‐Wagner, Birgit; Reiser, Maximilian; Thierfelder, Kolja M.

doi:10.1212/wnl.0000000000005519

Cited by 7 publications

(6 citation statements)

References 37 publications

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“…Findings in the test cohort have not been published before. Data in all 121 patients from the validation cohort have been previously reported in separate studies (15)(16)(17)(18). Although the latter studies focused on CT perfusion postprocessing and diaschisis phenomena at CT perfusion imaging in acute ischemic stroke, our study was designed to correlate CT perfusion data and automated cerebral x-ray attenuation measurements at noncontrast CT.…”

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confidence: 99%

Attenuation Changes in ASPECTS Regions: A Surrogate for CT Perfusion–based Ischemic Core in Acute Ischemic Stroke

Reidler¹,

Thierfelder²,

Rotkopf³

et al. 2019

Radiology

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ndovascular thrombectomy (EVT) provides a substantial clinical benefit as late as 24 hours after symptom onset in selected patients with stroke, as shown by the DAWN and DEFUSE 3 trials (1,2). Patient selection was largely based on the ischemic core size as determined at CT perfusion imaging or MRI. Hence, the 2018 American Stroke Association guidelines implemented a Level IA recommendation for the use of advanced imaging in this context (3). However, from a global perspective, only 53% of stroke centers routinely apply these advanced imaging recommendations (4). This represents an obstacle for an immediate real-world application of these important results and creates a demand for surrogate imaging parameters, which facilitate guideline-based clinical decision making. Moreover, the use of only noncontrast CT and CT angiography instead of CT perfusion imaging for decision making could lead to a time savings of up to 15 minutes (5).The Alberta Stroke Program Early CT Score (AS-PECTS) at noncontrast CT (6) is the largest common denominator among all stroke centers and was applied in the randomized thrombectomy trials of 2015 for this reason (7). However, visual ASPECTS assessment faces issues of interrater and intrarater variability, thereby causing insecurity among clinicians and neuroradiologists (8) because changes in x-ray attenuation can be very subtle and are easily missed by radiologists (9). This subjectivity may be avoided by automated and standardized algorithms of AS-PECTS assessment (10).In contrast to the subjective ASPECTS rating, the measurement of x-ray attenuation in Hounsfield unit (HU) values in brain parenchyma at noncontrast CT represents an interval-scaled parameter independent of any observer interpretation. Changes in x-ray attenuation in acute ischemic stroke reflect the water uptake of the ischemic brain

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confidence: 99%

Attenuation Changes in ASPECTS Regions: A Surrogate for CT Perfusion–based Ischemic Core in Acute Ischemic Stroke

Reidler¹,

Thierfelder²,

Rotkopf³

et al. 2019

Radiology

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“… 22 Future IVT studies, by excluding patients with AIS caused by an M2 occlusion because of expanding EVT eligibility, will have difficulty showing positive results, as much of the benefit shown in previous IVT trials may be attributed to high rates of successful recanalization of M2 occlusions. 23 , 24 An example of averted EVT after IVT in a patient presenting with NIHSS score of 20 due to an underlying M2 MCA occlusion is presented in Figure 1 . A second important point is that despite a high-volume cut-off at 70 ml of infarcted tissue, most patients had an extremely low ischemic core volume (<4 ml), raising doubts on the validity of the positive results for AIS patients with larger ischemic cores.…”

Section: Ivt After 45 H From Last Seen Wellmentioning

confidence: 99%

“…For patients presenting to a nonthrombectomy center with ischemic stroke of 4.5–9 h duration (known onset) with CT or MRI perfusion core/penumbra mismatch and who are eligible for mechanical thrombectomy, six of nine group members suggested IVT before EVT (expert consensus statement). 24 …”

Section: Bridging Therapy In Wus and After 45 H From Lswmentioning

confidence: 99%

“…For patients presenting to a nonthrombectomy center with ischemic stroke of 4.5-9 h duration (known onset) with CT or MRI perfusion core/penumbra mismatch and who are eligible for mechanical thrombectomy, six of nine group members suggested IVT before EVT (expert consensus statement). 24 Individual patient characteristics may also play a role. From the safety perspective, clinicians could opt for direct EVT and skip IVT in LVO patients with large core, especially in the concomitance of risk factors for hemorrhagic transformation as presented in Table 1.…”

Section: Studymentioning

confidence: 99%

“…(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24) h, WUS) Ischemic core <21 ml and NIHSS ⩾ 10 (age ⩾ 80) or Ischemic core <31 ml and NIHSS ⩾ 10 (age < 80) or Ischemic core <51 ml and NIHSS ⩾ 20 (age < 80) DWI or CTP Assessment with Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention with Trevo study; DWI, diffusion-weighted imaging; EVT, endovascular therapy; FLAIR, fluid-attenuated inversion recovery; IQR, interquartile range; IVT, intravenous thrombolysis; LSW, last seen well; LVO, large vessel occlusion; MCA, middle cerebral artery; NIHSS, National Institutes of Health Stroke Scale; RCT, randomized controlled trial; WUS, wake-up stroke.…”

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confidence: 99%

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Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach

Magoufis

Safouris

Guy

et al. 2021

Ther Adv Neurol Disord

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Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.

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Differential Benefit of Collaterals for Stroke Patients Treated with Thrombolysis or Supportive Care

et al. 2019

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Effect of stroke thrombolysis predicted by distal vessel occlusion detection

Abstract: In stroke patients with negative CTA, distal vessel occlusions as detected by waveletCTA are an independent predictor of a favorable response to IVT.

Cited by 7 publications

References 37 publications

Attenuation Changes in ASPECTS Regions: A Surrogate for CT Perfusion–based Ischemic Core in Acute Ischemic Stroke

Attenuation Changes in ASPECTS Regions: A Surrogate for CT Perfusion–based Ischemic Core in Acute Ischemic Stroke

Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach

Differential Benefit of Collaterals for Stroke Patients Treated with Thrombolysis or Supportive Care

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