Patients with low Alberta Stroke Program Early CT Score (ASPECTS) but good collaterals benefit from endovascular recanalization

Broocks, Gabriel; Kniep, Helge; Schramm, Peter; Hanning, Uta; Flottmann, Fabian; Faizy, Tobias D.; Schönfeld, Michael; Meyer, Lukas; Schön, Gerhard; Aulmann, Linda F.; Machner, Björn; Royl, Georg; Fiehler, Jens; Kemmling, André

doi:10.1136/neurintsurg-2019-015308

Cited by 68 publications

(53 citation statements)

References 33 publications

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“…On the contrary, the baseline ASPECTS between the two groups in our study were comparable (p ¼ 0.545), suggesting that there might be additional factors which should be considered: clot burden, thrombus length/composition, and presence of collaterals. 19,20 A late M1 division was associated with atherosclerotic disease as the main cause of AIS with a higher rate of tandem occlusion or stenosis (15% vs. 5.7%, p ¼ 0.060). As such, no impact on angiographic or clinical outcome was found.…”

Section: Discussionmentioning

confidence: 99%

Impact of early division of the middle cerebral artery on outcome following mechanical thrombectomy

Styczen

Maus

Hesse³

et al. 2020

Interv Neuroradiol

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Background Mechanical thrombectomy has become the standard care for acute ischemic stroke caused by large vessel occlusion. However, complete reperfusion cannot be achieved in all cases, and several factors influencing the results of mechanical thrombectomy have been investigated. Among others, a tortuous anatomy is associated with lower rates of complete reperfusion. We aimed to investigate whether an early division of the middle cerebral artery has an impact on reperfusion results in mechanical thrombectomy. Methods Retrospective review of consecutive patients with M1 occlusion treated endovascularly between January 2016 and December 2019 at three tertiary care centers. The study group was dichotomized based on the length of the M1 segment. Early division of the middle cerebral artery was defined as a maximum length of 10 mm of the M1 segment. Primary endpoints were first-pass mTICI scores of 3, ≥2c, and ≥2b. Secondary endpoints contained final reperfusion, number of device-passes, time interval from groin puncture to reperfusion, rate of postinterventional symptomatic intracranial hemorrhage, and frequency of emboli of new territory. Results Among 284 included patients, 70 presented with an early division of the M1 segment (25%). Reperfusion results did not differ significantly between early and late division of M1. A higher rate of symptomatic intracranial hemorrhage was found in the group with an early M1 division treated with aspiration only (14.3% vs. 0%; p = 0.013). Patients with late M1 division had a significantly higher rate of large artery sclerosis (19.2% vs. 8.6%, p = 0.039). Conclusion The anatomic variant of an early division of the middle cerebral artery was not a predictor for incomplete reperfusion.

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Section: Discussionmentioning

confidence: 99%

Impact of early division of the middle cerebral artery on outcome following mechanical thrombectomy

Styczen

Maus

Hesse³

et al. 2020

Interv Neuroradiol

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“…One hundred and twenty-nine patients with a CS of 0-2 were included (CS 0=37; CS 1=50; CS 2=42). The mean (SD) age of these patients was 73 (12), and the median NIHSS was 18 (IQR: [15][16][17][18][19][20]. Admission imaging was performed after a median time of 3 hours after symptom onset (IQR: 2-4).…”

Section: Resultsmentioning

confidence: 99%

“…12 The results of this study emphasise that patients with poor intracranial collaterals, who are often excluded in stroke trials, may still benefit from thrombectomy, with improved clinical outcome. 19 Although the effect of vessel recanalisation on oedema formation has already been discussed, the exact mechanisms of this phenomenon remain uncertain. Factors such as age or blood glucose concentration have been discussed as important mediators of oedema formation, but the potential role of collaterals has not yet been described.…”

Section: Discussionmentioning

confidence: 99%

Effect of thrombectomy on oedema progression and clinical outcome in patients with a poor collateral profile

et al. 2020

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Background and purposeThe impact of the cerebral collateral circulation on lesion progression and clinical outcome in ischaemic stroke is well established. Moreover, collateral status modifies the effect of endovascular treatment and was therefore used to select patients for therapy in prior trials. The purpose of this study was to quantify the effect of vessel recanalisation on lesion pathophysiology and clinical outcome in patients with a poor collateral profile.Materials and methods129 patients who had an ischaemic stroke with large vessel occlusion in the anterior circulation and a collateral score (CS) of 0–2 were included. Collateral profile was defined using an established 5-point scoring system in CT angiography. Lesion progression was determined using quantitative lesion water uptake measurements on admission and follow-up CT (FCT), and clinical outcome was assessed using modified Rankin Scale (mRS) scores after 90 days.ResultsOedema formation in FCT was significantly lower in patients with vessel recanalisation compared with patients with persistent vessel occlusion (mean 19.5%, 95% CI: 17% to 22% vs mean 27%, 95% CI: 25% to 29%; p<0.0001). In a multivariable linear regression analysis, vessel recanalisation was significantly associated with oedema formation in FCT (ß=−7.31, SD=0.015, p<0.0001), adjusted for CS, age and Alberta Stroke Program Early CT Score (ASPECTS). Functional outcome was significantly better in patients following successful recanalisation (mRS at day 90: 4.5, IQR: 2–6 vs 5, IQR: 5–6, p<0.001).ConclusionAlthough poor collaterals are known to be associated with poor outcome, endovascular recanalisation was still associated with significant oedema reduction and comparably better outcome in this patient group. Patients with poor collaterals should not generally be excluded from thrombectomy.

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“…In this background, there is considerable interest and debate on the impact of collaterals on clinical outcomes after EVT in patients with low ASPECTS score . A recent study by Broocks et al demonstrated that pre-treatment collateral status could be used as a selection criterion for EVT treatment in low ASPECTS patients (Broocks et al, 2020). Authors found that in patients with ASPECTS of ≤5, patients could still benefit from EVT if good collaterals are present as good collaterals were directly associated with attenuated oedema formation with improved clinical outcome (Broocks et al, 2020).…”

Section: Collateral Assessment With Static and Dynamic Gradingmentioning

confidence: 99%

“…A recent study by Broocks et al demonstrated that pre-treatment collateral status could be used as a selection criterion for EVT treatment in low ASPECTS patients (Broocks et al, 2020). Authors found that in patients with ASPECTS of ≤5, patients could still benefit from EVT if good collaterals are present as good collaterals were directly associated with attenuated oedema formation with improved clinical outcome (Broocks et al, 2020). Given the small sample size in this study, future prospective studies on the relatively larger dataset are required to validate these findings and identify the optimal EVT eligibility criterion in lower ASPECTS patients.…”

Section: Collateral Assessment With Static and Dynamic Gradingmentioning

confidence: 99%

Cerebral collaterals in acute ischaemia: Implications for acute ischaemic stroke patients receiving reperfusion therapy

Ravindran

Killingsworth

Bhaskar

2020

Eur J of Neuroscience

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The cerebral collaterals play an important role in penumbral tissue sustenance after an acute ischaemic stroke. Recent studies have demonstrated the potential role of collaterals in the selection of acute ischaemic stroke patients eligible for reperfusion therapy. However, the understanding of the significance and evidence around the role of collateral status in predicting outcomes in acute ischaemic stroke patients treated with reperfusion therapy is still unclear. Moreover, the use of pre-treatment collaterals in patient selection and prognosis is relatively underappreciated in clinical settings. A focused review of the literature was performed on the various methods of collateral evaluation and the role of collateral status in acute ischaemic stroke patients receiving reperfusion therapy. We discuss the methods of evaluating pre-treatment collaterals in clinical settings. The patient selection based on collateral status as well as the prognostic and therapeutic value of collaterals in acute ischaemic stroke, in settings of intravenous thrombolysis or endovascular therapy alone, and bridge therapy, are summarized. Recommendations for future research and possible pharmacological intervention strategies aimed at collateral enhancement are also discussed. Collaterals may play an important role in identifying acute ischaemic stroke patients who are likely to benefit from endovascular treatment in an extended time window. Future neuroscientific efforts to better improve our understanding of the role of collaterals in | 1239 VISHNI RAVINDRAN et Al.

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Patients with low Alberta Stroke Program Early CT Score (ASPECTS) but good collaterals benefit from endovascular recanalization

Cited by 68 publications

References 33 publications

Impact of early division of the middle cerebral artery on outcome following mechanical thrombectomy

Impact of early division of the middle cerebral artery on outcome following mechanical thrombectomy

Effect of thrombectomy on oedema progression and clinical outcome in patients with a poor collateral profile

Cerebral collaterals in acute ischaemia: Implications for acute ischaemic stroke patients receiving reperfusion therapy

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