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Endovascular Therapy for Ischemic Stroke
Ramana M R Appireddy,Andrew M Demchuk,Mayank Goyal,Bijoy K Menon,Muneer Eesa,Philip Choi,Michael D. Hill 대한신경과학회 2015 Journal of Clinical Neurology Vol.11 No.1
The utility of intravenous tissue plasminogen activator (IV t-PA) in improving the clinical outcomes after acute ischemic stroke has been well demonstrated in past clinical trials. Thoughmultiple initial small series of endovascular stroke therapy had shown good outcomes as compared to IV t-PA, a similar beneficial effect had not been translated in multiple randomizedclinical trials of endovascular stroke therapy. Over the same time, there have been parallel advances in imaging technology and better understanding and utility of the imaging in therapy ofacute stroke. In this review, we will discuss the evolution of endovascular stroke therapy followed by a discussion of the key factors that have to be considered during endovascular stroketherapy and directions for future endovascular stroke trials.
Jin Soo Lee,Andrew M. Demchuk 대한뇌졸중학회 2015 Journal of stroke Vol.17 No.3
Recently, several prospective randomized control trials regarding endovascular treatment for patients with intracranial large artery occlusions causing acute ischemic stroke have been successfully reported. Effort to minimize time delays to endovascular treatment, patient selection and the use of retrievable stent were important factors for the success of these trials. The inclusion and exclusion criteria for each of these trials did include differences in imaging protocols. In this review, we focus on the importance of baseline non-invasive angiography prior to deciding endovascular treatment. Then imaging protocols are described for each trial according to measurement of infarct volume and collateral grading.
Sun-Uk Lee,홍지만,김선용,방오영,Andrew M. Demchuk,이진수 대한뇌졸중학회 2016 Journal of stroke Vol.18 No.2
Background and Purpose The outcomes of acute internal carotid artery (ICA) terminus occlusions are poor. We classified ICA terminus occlusions into 2 groups according to the occlusion pattern of the circle of Willis and hypothesized that clinical outcomes would significantly differ between them. Methods Consecutive patients with acute ICA terminus occlusions evaluated by baseline computed tomographic angiography were enrolled. We investigated the occlusion patterns in the circle of Willis, retrospectively classified patients into simple ICA terminus occlusion (STO; with good Willisian collaterals from neighboring cerebral circulation) and complex ICA terminus occlusion (CTO; with one or more of A2 anterior cerebral artery, fetal posterior cerebral artery occlusion, or hypoplastic/absent contralateral A1; or with poor collaterals from anterior communicating artery) groups, and compared their baseline characteristics and outcomes. Results The STO group (n=58) showed smaller infarct volumes at 72 hours than the CTO group (n=34) (median, 81 mL [interquartile range, 38-192] vs. 414 mL [193-540], P<0.001) and more favorable outcomes (3-month modified Rankin Scale 0-3, 44.8% vs. 8.8%, P<0.001; 3-month mortality, 24.1% vs. 67.6%, P<0.001). In multivariable analyses, STO remained an independent predictor for favorable outcomes (odds ratio 6.1, P=0.010). Conclusions Favorable outcomes in STO group suggested that the outcomes of acute ICA terminus occlusions depend on Willisian collateral status. Documenting the subtypes on computed tomographic angiography would help predict patient outcome.
Distinctive patterns on CT angiography characterize acute internal carotid artery occlusion subtypes
Hong, Ji Man,Lee, Sung Eun,Lee, Seong-Joon,Lee, Jin Soo,Demchuk, Andrew M. The Authors. Published by Wolters Kluwer Health, I 2017 Medicine Vol.96 No.5
<P>Our study indicates that acute ICA occlusion can be subtyped into cervical, cavernous, and terminus. Distinctive findings on initial CTA can help differentiate ICA-occlusion subtypes with specific characteristics.</P>
Wu Qiu,Hulin Kuang,Johanna M. Ospel,Michael D. Hill,Andrew M. Demchuk,Mayank Goyal,Bijoy K. Menon 대한뇌졸중학회 2021 Journal of stroke Vol.23 No.2
Background and Purpose Multiphase computed tomographic angiography (mCTA) provides time variant images of pial vasculature supplying brain in patients with acute ischemic stroke (AIS). To develop a machine learning (ML) technique to predict tissue perfusion and infarction from mCTA source images. Methods 284 patients with AIS were included from the Precise and Rapid assessment of collaterals using multi-phase CTA in the triage of patients with acute ischemic stroke for Intra-artery Therapy (Prove-IT) study. All patients had non-contrast computed tomography, mCTA, and computed tomographic perfusion (CTP) at baseline and follow-up magnetic resonance imaging/noncontrast- enhanced computed tomography. Of the 284 patient images, 140 patient images were randomly selected to train and validate three ML models to predict a pre-defined Tmax thresholded perfusion abnormality, core and penumbra on CTP. The remaining 144 patient images were used to test the ML models. The predicted perfusion, core and penumbra lesions from ML models were compared to CTP perfusion lesion and to follow-up infarct using Bland-Altman plots, concordance correlation coefficient (CCC), intra-class correlation coefficient (ICC), and Dice similarity coefficient. Results Mean difference between the mCTA predicted perfusion volume and CTP perfusion volume was 4.6 mL (limit of agreement [LoA], –53 to 62.1 mL; P=0.56; CCC 0.63 [95% confidence interval [CI], 0.53 to 0.71; P<0.01], ICC 0.68 [95% CI, 0.58 to 0.78; P<0.001]). Mean difference between the mCTA predicted infarct and follow-up infarct in the 100 patients with acute reperfusion (modified thrombolysis in cerebral infarction [mTICI] 2b/2c/3) was 21.7 mL, while it was 3.4 mL in the 44 patients not achieving reperfusion (mTICI 0/1). Amongst reperfused subjects, CCC was 0.4 (95% CI, 0.15 to 0.55; P<0.01) and ICC was 0.42 (95% CI, 0.18 to 0.50; P<0.01); in non-reperfused subjects CCC was 0.52 (95% CI, 0.20 to 0.60; P<0.001) and ICC was 0.60 (95% CI, 0.37 to 0.76; P<0.001). No difference was observed between the mCTA and CTP predicted infarct volume in the test cohort (P=0.67). Conclusions A ML based mCTA model is able to predict brain tissue perfusion abnormality and follow-up infarction, comparable to CTP.
Robinson, Thompson G.,Wang, Xia,Arima, Hisatomi,Bath, Philip M.,Billot, Laurent,Broderick, Joseph P.,Demchuk, Andrew M.,Donnan, Geoffery A.,Kim, Jong S.,Lavados, Pablo M.,Lee, Tsong-Hai,Lindley, Richa American Heart Association, Inc. 2017 Stroke Vol.48 No.7
<P>Conclusions-Low-dose alteplase may improve outcomes in thrombolysis-treated acute ischemic stroke patients on prior APT, but this requires further evaluation in a randomized controlled trial.</P>
Johanna M. Ospel,Ondrej Volny,Wu Qiu,Mohamed Najm,Moiz Hafeez,Sarah Abdalrahman,Enrico Fainardi,Marta Rubiera,Alexander Khaw,Jai J. Shankar,Michael D. Hill,Mohammed A. Almekhlafi,Andrew M. Demchuk,May 대한뇌졸중학회 2021 Journal of stroke Vol.23 No.3
Background and Purpose Various imaging paradigms are used for endovascular treatment (EVT) decision-making and outcome estimation in acute ischemic stroke (AIS). We aim to compare how these imaging paradigms perform for EVT patient selection and outcome estimation. Methods Prospective multi-center cohort study of patients with AIS symptoms with multi-phase computed tomography angiography (mCTA) and computed tomography perfusion (CTP) baseline imaging. mCTA-based EVT-eligibility was defined as presence of large vessel occlusion (LVO) and moderate-to-good collaterals on mCTA. CTP-based eligibility was defined as presence of LVO, ischemic core (defined on relative cerebral blood flow, absolute cerebral blood flow, and cerebral blood volume maps) <70 mL, mismatch-ratio >1.8, absolute mismatch >15 mL. EVT-eligibility and adjusted rates of good outcome (modified Rankin Scale 0–2) based on these imaging paradigms were compared. Results Of 289/464 patients with LVO, 263 (91%) were EVT-eligible by mCTA-criteria versus 63 (22%), 19 (7%) and 103 (36%) by rCBF, aCBF, and CBV-CTP-criteria. CTP and mCTA-criteria were discordant in 40% to 53%. Estimated outcomes were best in patients who met both mCTA and CTP eligibility-criteria and were treated with EVT (62% to 87% good outcome). Patients eligible for EVT by mCTA-criteria and not by CTP-criteria receiving EVT achieved good outcome rates of 53% to 57%. Few patients met CTP-criteria and not mCTA-criteria for EVT. Conclusions Simpler imaging selection criteria that rely on little else than detection of the occluded blood vessel may be more sensitive and less specific, thus resulting in more patients being offered EVT and arguably benefiting from it.
Lee, Jin Soo,Lee, Seong-Joon,Hong, Ji Man,Choi, Jin Wook,Hong, Jeong-Ho,Chang, Hyuk-Won,Kim, Chang-Hyun,Kim, Yong-Won,Kang, Dong-Hun,Kim, Yong-Sun,Ovbiagele, Bruce,Demchuk, Andrew M.,Hwang, Yang-Ha,So Korean Society of Interventional Neuroradiology 2018 Neurointervention Vol.13 No.1
<P><B>Background and Purpose</B></P><P>The purpose of the current study is to evaluate the influence of temporal patterns related to the availability of new endovascular treatment (EVT) devices on care processes and outcomes among patients with AIS.</P><P><B>Materials and Methods</B></P><P>We enrolled 720 consecutive patients (January 2011 to May 2016) in a retrospective registry, ASIAN KR, from three Korean hospitals, who received EVT for acute ischemic stroke (AIS) caused by cervicocephalic arterial occlusions. We performed period-to-period analyses based on stent retriever reimbursement and the availability of second-generation direct-aspiration devices (Period 1: January 2011–July 2014 vs. Period 2: August 2014–May 2016); time metrics and outcomes were compared when the onset-to-puncture time was <720 min among patients with EVT for intracranial occlusion.</P><P><B>Results</B></P><P>Period 2 had better post-EVT outcomes (3-month modified Rankin Scale 0–2 or equal to prestroke score, 48.3% vs. 60.2%, P=0.004), more successful reperfusion rates (modified Treatment In Cerebral Ischemia 2b–3, 74.2% vs. 82.2%, P=0.019), fewer subarachnoid hemorrhages (modified Fisher grade 3–4, 5.5% vs. 2.0%, P=0.034) and lower hemorrhagic transformation rates (any intracerebral hemorrhage, 35.3 vs. 22.7%, P=0.001) than Period 1. Compared to Period 1, Period 2 had a shorter door-to-puncture time (median 109 vs. 90 min, P<0.001), but longer onset-to-door time (129 vs. 143 min, P=0.057).</P><P><B>Conclusion</B></P><P>Recent temporal improvements in post-EVT AIS outcomes in Korea are likely due to a combination of enhanced hospital care processes and administration of newer thrombectomy devices.</P>