Eloquence-based reperfusion scoring and its ability to predict post-thrombectomy disability and functional status

Abstract

Background

Angiographic reperfusion after endovascular thrombectomy in acute ischemic stroke is commonly graded using volume-based reperfusion scores such as the modified thrombolysis in cerebral infarct score. The location of non-reperfused regions is not included in modified thrombolysis in cerebral infarct score. We studied the predictive ability of an eloquence-based reperfusion score.

Methods

Consecutive cases of endovascular thrombectomy for anterior circulation strokes performed between January 2018 and April 2020 were included. Digital subtraction angiograms were reviewed by two blinded neurointerventionalist operators. Incomplete reperfusion was further classified by lobar regions lacking reperfusion to create various cohorts. Outcomes were graded four to seven days post-procedure with the National Institute of Health Stroke Scale (NIHSS) and 90 days post-procedure with the modified Rankin Scale.

Results

One hundred patients were identified. Via multivariate analysis, we found that frontal lobe non-reperfusion (mean difference (MD) = −1.60, p = 0.002) and occipital lobe non-reperfusion (MD = −1.68, p = 0.001) were associated with worse mental status improvement while left-sided stroke (MD = 2.02, p < 0.001) featured better improvement post-thrombectomy. Occipital lobe non-reperfusion (MD = −0.734, p = 0.009) was associated with the worse improvement of visual fields. The non-reperfusion of the frontal lobe was associated with a 1.732-worse NIHSS hemibody strength score (95% confidence interval (95%CI) = −3.39 to −0.072, p = 0.041). Worse improvement in NIHSS scores was found to be associated with frontal lobe non-reperfusion (MD = −5.34, 95%CI = −9.52 to −1.18, p = 0.013) and occipital lobe non-reperfusion (MD = −6.35, 95%CI = −10.4 to −2.31, p = 0.002). Odds of achieving modified Rankin Scale of 0–2 at 90 days were decreased with frontal lobe non-reperfusion (odds ratio (OR) = 0.279, 95%CI = 0.090–0.869, p = 0.028) and left laterality (OR = 0.376, 95%CI = 0.153–0.922, p = 0.033).

Conclusions

Eloquence-based reperfusion assessment is an important predictor for functional outcomes after thrombectomy.

Keywords

Angiography disability eloquence reperfusion thrombectomy

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References

Rha

Saver

. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke 2007; 38: 967–973.

Zaidat

Yoo

Khatri

, et al. Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke 2013; 44: 2650–2663.

Liebeskind

Bracard

Guillemin

, et al. eTICI reperfusion: defining success in endovascular stroke therapy. J Neurointerv Surg 2019; 11: 433–438.

Tomsick

Broderick

Carrozella

, et al. Revascularization results in the interventional management of stroke II trial. Am J Neuroradiol 2008; 29: 582–587.

Phan

Saleh

Dmytriw

, et al. Influence of ASPECTS and endovascular thrombectomy in acute ischemic stroke: a meta-analysis. J Neurointerv Surg 2019; 11: 664–669.

Raychev

Saber

Saver

, et al. Impact of eloquent motor cortex-tissue reperfusion beyond the traditional thrombolysis in cerebral infarction (TICI) scoring after thrombectomy. J Neurointerv Surg 2020; https://doi.org/10.1136/neurintsurg-2020-016834.

Gibo

Carver

Rhoton

Jr , et al. Microsurgical anatomy of the middle cerebral artery. J Neurosurg 1981; 54: 151–169.

Shapiro

Raz

Nossek

, et al. Neuroanatomy of the middle cerebral artery: implications for thrombectomy. J Neurointerv Surg 2020; 12: 768–773.

Cheng

Forkert

Zavaglia

, et al. Influence of stroke infarct location on functional outcome measured by the modified rankin scale. Stroke 2014; 45: 1695–1702.

10.

Etherton

Rost

. Infarct topography and functional outcomes. J Cereb Blood Flow Metab 2018; 38: 1517–1532.

11.

Phan

Demchuk

Srikanth

, et al. Proof of concept study: relating infarct location to stroke disability in the NINDS rt-PA trial. Cerebrovasc Dis 2013; 35: 560–565.

12.

Bath

Lees

Schellinger

, et al. Statistical analysis of the primary outcome in acute stroke trials. Stroke 2012; 43: 1171–1178.

13.

Saver

. Optimal end points for acute stroke therapy trials: best ways to measure treatment effects of drugs and devices. Stroke 2011; 42: 2356–2362.

14.

Panni

Michelozzi

Blanc

, et al. The role of infarct location in patients with DWI-ASPECTS 0–5 acute stroke treated with thrombectomy. Neurology 2020; 95: e3344–e3354.

15.

Seyedsaadat

Neuhaus

Pederson

, et al. Location-specific ASPECTS paradigm in acute ischemic stroke: a systematic review and meta-analysis. Am J Neuroradiol 2020; 41: 2020–2026.

16.

Rosso

Blanc

, et al. Impact of infarct location on functional outcome following endovascular therapy for stroke. J Neurol Neurosurg Psychiatr 2019; 90: 313–319.

17.

Haranhalli

Mbabuike

Grewal

, et al. Topographic correlation of infarct area on CT perfusion with functional outcome in acute ischemic stroke. J Neurosurg 2019; 132: 33–41.

18.

Regenhardt

Etherton

Das

, et al. White matter acute infarct volume after thrombectomy for anterior circulation large vessel occlusion stroke is associated with long term outcomes. J Stroke Cerebrovasc Dis2020; 30: 105567.

19.

Kleine

Kaesmacher

Wiestler

, et al. Tissue-selective salvage of the white matter by successful endovascular stroke therapy. Stroke 2017; 48: 2776–2783.

20.

Dacosta-Aguayo

Graña

Fernández-Andújar

, et al. Structural integrity of the contralesional hemisphere predicts cognitive impairment in ischemic stroke at three months. PLoS One 2014; 9: e86119.

21.

Spiotta

Vargas

Hawk

, et al. Impact of the ASPECT scores and distribution on outcome among patients undergoing thrombectomy for acute ischemic stroke. J Neurointerv Surg 2015; 7: 551–558.

22.

Boers

AMM

Jansen

IGH

Brown

, et al. Mediation of the relationship between endovascular therapy and functional outcome by follow-up infarct volume in patients with acute ischemic stroke. JAMA Neurol 2019; 76: 194–202.

23.

Tian

Parsons

Levi

, et al. Influence of occlusion site and baseline ischemic core on outcome in patients with ischemic stroke. Neurology 2019; 92: e2626–e2643.

24.

Olive-Gadea

Martins

Boned

, et al. Baseline ASPECTS and e-ASPECTS correlation with infarct volume and functional outcome in patients undergoing mechanical thrombectomy. J Neuroimaging2019; 29: 198–202.

25.

Denes

Semenza

Stoppa

, et al. Unilateral spatial neglect and recovery from hemiplegia: a follow-up study. Brain 1982; 105: 543–552.

26.

Kalra

Smith

Crome

. Stroke in patients aged over 75 years: outcome and predictors. Postgrad Med J 1993; 69: 33–36.

27.

Goto

Okuda

Ito

, et al. Locomotion outcome in hemiplegic patients with middle cerebral artery infarction: the difference between right- and left-sided lesions. J Stroke Cerebrovasc Dis 2009; 18: 60–67.

28.

Paolucci

Antonucci

Pratesi

, et al. Functional outcome in stroke inpatient rehabilitation: predicting no, low and high response patients. Cerebrovasc Dis 1998; 8: 228–234.

29.

Yoo

Romero

Hakimelahi

, et al. Predictors of functional outcome vary by the hemisphere of involvement in major ischemic stroke treated with intra-arterial therapy: a retrospective cohort study. BMC Neurol 2010; 25: 1186.

30.

Foerch

Misselwitz

Sitzer

, et al. Difference in recognition of right and left hemispheric stroke. Lancet 2005; 366: 392–393.

31.

Prasetya

Ramos

Epema

, et al. qTICI: quantitative assessment of brain tissue reperfusion on digital subtraction angiograms of acute ischemic stroke patients. Int J Stroke2021; 16: 207–216.

32.

Bhurwani

MMS

Snyder

Waqas

, et al. Use of biplane quantitative angiographic imaging with ensemble neural networks to assess reperfusion status during mechanical thrombectomy. Proc SPIE Int Soc Opt Eng 2021; 11597.