The Effect Of Hyperdense Artery Sign On Treatment Strategies And Clinical Prognosis In Acute Large Vessel Occlusion

The hyperdense artery sign(HAS)is an early sign of large vessel occlusion on non-enhanced CT.Patients with HAS are characterized by serious neurological deficits on admission,large cerebral infarcts and poor clinical prognosis.In addition,HAS and non-HAS patients can benefit from endovascular treatment(EVT),the effect of different EVT strategies on the successful recanalization and prognosis of HAS varies.The study will systematically explore the impact of HAS on standard medical treatment(SMT),EVT strategies,successful recanalization and functional prognosis in patients with acute posterior and anterior circulation vessel occlusion,and provide new insights for optimistic EVT strategies.Part Ⅰ: The Effect of Hyperdense Basilar Artery Sign on Treatment Strategies and Clinical Prognosis in Acute Basilar Artery OcclusionBackground and purpose: Acute basilar artery occlusion stroke have low morbidity and high mortality,and prior studies have found that patients with HAS due to large vessel occlusion were associated with severe neurological deficits.However,the findings of hyperdense basilar artery sign(HBAS)are very scarce.The proper treatment for patients with HBAS and the factors for clinical prognosis in patients with HBAS is still unclear.Thus,the aim of this study is to investigate the treatment strategies for patients with HBAS and the factors that influence the functional prognosis.Methods: Patients included in this study were from the Acute Basilar Artery Occlusion Stroke Endovascular Study(BASILAR),a multicenter participating registry study from January 2014 enrolment to May 2019 cut-off enrolment.Six of 829 patients with acute basilar artery occlusion had missing admission CT data and 823 patients were ultimately included in our analysis.HBAS was evaluated by two experienced neuroradiologists using a 5-grade scale based on non-enhanced CT.Patients were divided into HBAS positive and negative groups,and into direct treatment and bridging treatment groups.The primary outcome was the proportion of favorable outcome at 90 days,and secondary outcomes included successful recanalization,mortality within 90 days,symptomatic intracranial hemorrhage(s ICH)and the proportion of favorable outcome at 1 year follow-up.Results: 1.424 patients were observed HBAS on non-enhanced CT.Among HBAS patients,330(77.83%)was treated with EVT and 94(22.17%)was underwent standard medical treatment(SMT).Higher age,high NIHSS,and arterial fibrillation are frequent in patients with HBAS.2.During 90 days follow-up,106 patients(31.12%)had favorable outcome and 164(49.70%)died in patients with HBAS undergoing EVT,while 9 patients(9.57%)had favorable outcome and 65(69.15%)died in SMT group.In patients with HBAS,EVT was associated with favorable outcome [adjusted odds ratio(a OR),6.44;95% confidence interval(95% CI),2.61–15.87,P < 0.001] and mortality(a OR,0.42;95% CI,0.24–0.74,P=0.003).EVT also increased the rate of favorable outcome at 1 year(32.60% vs 14.77%,P=0.001)and reduced the rate of morality within 1 year(57.05% vs 81.82%,P<0.001).3.No significant differences were found in successful recanalization,number of attempts,s ICH and short-term neurological prognosis between HBAS positive and negative patients receiving EVT.Compared with negative HBAS group,low rate of favorable outcome(32.60% vs 39.38%,P = 0.08)at 1 year and high morality(57.05% vs 51.71%,P=0.19)within 1 year were observed in patients with HBAS.4.There was no statistically difference between bridging treatment and direct treatment in successful recanalization(79.85% vs 89.10%,P=0.89),s ICH(7.34% vs 7.81%,P>0.99),favorable outcome at 90 days(29.85% vs 32.70%,P=0.66),and mortality with 90 days(50.75% vs 49.43%,P=0.85).5.Low NIHSS,high pc-ASPECT and stent retriever were associated with successful recanalization in patients with HBAS.Age,NIHSS,pc-ASPECTS,collateral circulation,and successful recanalization were independent predictors of favorable outcome at 90-days in patients with HBAS underwent EVT.In addition,NIHSS score and pc-ASPECT score were effective factors of clinical outcomes in patients with HBAS at 1 year follow-up.Conclusions: Patients with HBAS can benefit from EVT.But no significant difference was founded in clinical prognosis between positive and negative HBAS group receiving EVT.Bridging treatment could not modify the clinical outcomes compared with direct treatment.Besides,in patients with HBAS,low NIHSS,high pc-ASPECT,and stent retriever were associated with successful recanalization,and NIHSS and pc-ASPECT were considered the predictors of favorable outcome at 90-days and 1 year.Part 2:The Effect of Hyperdense Artery Sign on Treatment Strategies and Clinical Prognosis in Anterior Circulation Large Vessel OcclusionBackground and Purpose: Bridging treatment is recommended as the main treatment for patient with ischemic stroke due to anterior circulation large vessel occlusion within 4.5 hours of onset.However,bridging treatment could increase the risk of thrombus escape and intracranial hemorrhage(ICH).HAS is an early sign of large vessel occlusion and often indicates a poor clinical prognosis.The thrombus burden scores is high in patients with HAS,which is associated with higher rate of thrombus fragment during the process of bridging treatment.Thus,the aim of our study was to compare the clinical prognosis between direct and bridging treatment and to provide evidence to support individualized treatment of patients with HAS.Methods: In our study,those patients came from effect of endovascular treatment alone vs intravenous alteplase plus endovascular treatment on functional independence in patients with acute ischemic stroke(DEVT),which enrolled 234 patients from 20 May 2018 to 2 May 2020.HAS was assessed by two experienced neuroradiologists using 5-grade scale based on patients’ non-enhanced CT.Patients were divided into negative and positive group according to HAS,and into bridging treatment and direct treatment group according to the use of intravenous thrombolysis before EVT.The primary outcome was the proportion of favorable outcome at 90 days,and secondary outcomes were successful recanalization,mortality within 90 days,and s ICH.Results: 1.Of the 234 patients,confirmed with acute large vessel occlusion within 4.5 hours,were enrolled in DEVT,74(31.62%)was observed with HAS.Among those patients with HAS,bridging treatment was performed in 38 patients(51.35%),and 36 patients(48.65%)received with direct treatment.In the multivariate analyses,HAS was associated with a favorable outcome at 90 days(a OR,2.01;95% CI,1.03–3.93,P=0.04).2.No significant difference was found in successful recanalization(87.88% vs 86.84%,P=0.90)and favorable outcome(52.78% vs 57.89%,P=0.66)between direct treatment and bridging treatment in patients with HAS.In subgroup analysis,patients with HAS and good collateral circulation who received with bridging treatment had higher rate of favorable outcome at 90 days compared with direct treatment(100% vs 55.56%,P=0.02).3.Onset to puncture time(a OR,0.98;95% CI,0.97–0.99,P=0.04)was an independent predictor of successful recanalization in patients with HAS.Age(a OR,0.94;95% CI,0.89–0.99,P=0.03),low NIHSS score(a OR,0.85;95% CI,0.74–0.98,P=0.03)and middle cerebral vessel occlusion(a OR,7.97;95% CI,1.56–40.64,P=0.01)were associated with favorable outcome at 90 days.Conclusions: There was no difference in clinical outcomes between direct and bridging treatment in patients with HAS.Interestingly,subgroup analysis suggested that patients with HAS could get benefits from bridging treatment if their collateral circulation was good.In addition,a short puncture to recanalization time was associated with successful recanalization.Age,NIHSS score,and middle cerebral artery occlusion were independent predictors of favorable outcome at 90 days in patients with HAS.