Neurointerventional Advances in 2022

Abstract

HomeStroke: Vascular and Interventional NeurologyVol. 3, No. 1Neurointerventional Advances in 2022 Open AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessEditorialPDF/EPUBNeurointerventional Advances in 2022 Sunil A. Sheth, MD and Ashutosh P. Jadhav, MD, PhD Sunil A. ShethSunil A. Sheth *Correspondence to: Sunil A. Sheth, MD, Department of Neurology, UTHealth McGovern Medical School, 6431 Fannin St, MSB 7.210, Houston, TX 77030. E‐mail: E-mail Address: [email protected] https://orcid.org/0000-0003-0602-8509 , Associate Professor, Department of Neurology, UTHealth McGovern Medical School, Houston, , TX, , USA Search for more papers by this author and Ashutosh P. JadhavAshutosh P. Jadhav , Associate Professor of Neurology and Neurosurgery, , Barrow Neurological Institute, , Phoenix, , AZ, Search for more papers by this author Originally published3 Jan 2023https://doi.org/10.1161/SVIN.122.000720Stroke: Vascular and Interventional Neurology. 2023;3:e000720As Stroke: Vascular and Interventional Neurology (S:VIN) completes its first full year, we recap several key highlights published in the field of vascular and interventional neurology. Many results anticipated from the inaugural Editor's column last year did in fact come to fruition. The field continues to move forward quickly, and trial enrollment, completion, and publication remained at a consistent and rapid pace in 2022.Results from 2 key basilar thrombectomy trials dominated discussions at the European Stroke Organization conference prior to their ultimate publication in the New England Journal of Medicine.1, 2 Whereas previous studies had shown unexpectedly disappointing results, possibly due to cross‐over and patient selection biases – 2 trials from Chinese cohorts addressed these key issues. The ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion) trial randomized 340 patients with basilar artery occlusion and a National Institutes of Health Stroke Scale of 10 or above who presented within 12 hours from onset in a 2:1 ratio to thrombectomy or medical care.2 The absolute difference in good outcomes (modified Rankin Scale [mRS] 0–3) was greater by 23% in patients treated with endovascular therapy (EVT), with reduced rates of mortality (adjusted risk ratio 0.66). The BAOCHE (Basilar Artery Occlusion Chinese Endovascular) trial randomized 217 patients between 6 and 24 hours of symptom onset and was halted early at a prespecified interim analysis after clear benefit of EVT over medical treatment was demonstrated.1 Absolute improvement in BAOCHE was similar to the ATTENTION trial with an approximately 2‐fold benefit: 46% in the EVT arm achieved a mRS 0–3, versus 24% in the best medical management arm, although improvement in mortality was not seen in this study. Both trials also provided granular data on rates of procedural complications (e.g., arterial dissection and vessel perforations): approximately 11% in ATTENTION and 14% in BAOCHE.2 Rates of symptomatic hemorrhage were 5% and 6%, respectively. The functional benefit noted therefore outweighed the risk of complication both numerically as well as in terms of clinical significance.Another high‐profile study, the CHOICE (Intraarterial Alteplase versus Placebo after Mechanical Thrombectomy) trial, explored a new territory of stroke physiology and interventional treatment.3 This trial initially began as a study of adjunctive intraarterial thrombolysis in patients with substantial but incomplete reperfusion (Thrombolysis in Cerebral Infarction 2b [TICI 2b]) after EVT for large vessel occlusion acute ischemic stroke. Due to challenges imposed by COVID including enrollment difficulty, the study pivoted to a distinct but related question. The study allowed for inclusion of patients with Thrombolysis in Cerebral Infarction 2c/3 (TICI 2c/3) revascularization after EVT and in doing so, asked the question of whether intraarterial thrombolysis even after reperfusion may be beneficial – that is, is there a neuroprotective benefit beyond opening the proximal occlusion. In their randomized, multicenter, blinded cohort of 121 patients, a greater proportion achieved excellent outcomes with intra‐arterial alteplase infused in the intracranial vasculature after EVT (59% versus 40%, mRS 0–1, alteplase versus placebo). Importantly, no symptomatic hemorrhages were reported in the alteplase group, whereas this rate in the placebo group was similar to those seen in other conventional EVT trials (∼4%).4 These results, which imply that adjunctive thrombolysis may not only improve clinical outcome, also support the concept of microcirculatory dysfunction following ischemia and reperfusion as a key factor driving clinical response and complications after EVT. At present, despite tremendous advances in our ability to reopen occluded vessels, with TICI 2b/3 rates routinely exceeding 90%, many patients still fail to achieve functional independence; the rate of mRS 0–2 at 90 days was 27% in the HERMES consortium.4 The CHOICE trial suggests a new therapeutic target, namelypharmaceutical interventions to address micro‐circulatory dysfunction and maximize distal capillary flow. In the coming years, we anticipate an increase in potential neuroprotectants, novel lytics, and possibly even therapeutic devices targeting this mechanism.With regards to thrombolysis, the ACT (Alteplase Compared to Tenecteplase) trial provided one of the largest and most pragmatic assessments of tenecteplase versus alteplase in patients with arterial ischemic stroke presenting with 4.5 hours of symptom onset.5 A total of 1600 patients were enrolled, and rates of excellent outcome (mRS 0–1) at 90 days were nearly identical (36.9% tenecteplase versus 34.8% alteplase), as were rates of 24‐hour symptomatic hemorrhage (3.4% tenecteplase versus 3.2% alteplase) and mortality (15.3% tenecteplase versus 15.4% alteplase).5 For those in favor of switching from alteplase to tenecteplase due to practical conveniences, this trial provided just that impetus. This trial also confirmed the preferred dose of tenecteplase: 0.25 mg/kg to a maximum of 25 mg, a moving target in recent trials.Several important secondary stroke prevention studies were also published this past year. The CHANCE 2 (Clopidogrel in High‐Risk Patients With Acute Non‐Disabling Cerebrovascular Events) trial offered a potential look at how precision medicine may play a role in pharmaceutical selections. The study evaluated 6412 patients and found that in those carrying the CYP2C19 loss of function allele, ticagrelor was a superior option for stroke prevention after minor stroke or transient ischemic attack, relative to clopidogrel.6 More routine testing for this variant is pending. The ACTION CVT (Anticoagulation in the Treatment of Cerebral Venous Thrombosis) study advanced data on management of cerebral venous sinus thrombosis.7 In one of the largest cohorts for this disease, the authors studied whether direct oral anticoagulants perform comparably to warfarin. They found rates of hemorrhage 4 per 100 patient‐years across the entire cohort, and that direct oral anticoagulant use resulted in comparable rates of recanalization on follow up imaging, with lower rates of major hemorrhage.Projecting ahead to 2023, there are many results to look forward to. Foremost amongst them are the findings of the “large core” thrombectomy trials. One such study has recently been published, RESCUE‐Japan LIMIT (Randomized Controlled Trial of Endovascular Therapy for Acute Large Vessel Occlusion with Large Ischemic Core).8 The investigators used magnetic resonance imaging as the predominant imaging modality to screen patients and found that those with ASPECTS 3–5 had greater rates of mRS 0–3 at 90 days with EVT relative to medical management (relative risk 2.43 [1.35–4.37]). Because of some unique methodologic details in this study, including the heavy use of magnetic resonance imaging and the slightly lower alteplase dose (0.6 mg/kg), the other ongoing large core trials (including TESLA [Thrombectomy for Emergent Salvage of Large Anterior Circulation Ischemic Stroke] trial, LASTE [Large Stroke Therapy Evaluation], and SELECT2 [Randomized Controlled Trial to Optimize Patient's Selection for Endovascular Treatment in Acute Ischemic Stroke] ) have continued their enrollment, and their results are anticipated early in 2023. Progress in other frontiers also continues, with the first endovascular brain computer interface implanted in a US patient in 2022.9 The next year will likely see more of these devices implanted, continuing to propel this field forward. Endovascular embolization for subdural hematoma is gaining traction in clinical practice – the EMBOLISE (Embolization of the Middle Meningeal Artery with ONYX Liquid Embolic System for Subacute and Chronic Subdural Hematoma) and STEM (The SQUID Trial for the Embolization of the Middle Meningeal Artery for Treatment of Chronic Subdural Hematoma) trials have enrolled rapidly and will shed much‐needed outcomes data on a procedure that has gained rapid popularity.10, 11 Finally, progress in device development continues. The latest round of studies includes ultra‐large bore aspiration catheters, stent‐retrievers with allegedly more effective and safe designs, and novel approaches toward aspiration. In an era where the field of vascular and interventional neurology is rapidly evolving, S:VIN is poised at the frontline to report and disseminate developments that continue to improve clinical practice and patient outcomes.Sources of FundingDr. Sheth reports funding from the NIH (5R01 NS121154).DisclosuresThe authors report no disclosures relevant to the manuscript.AcknowledgmentsDr. Sheth reports grant support from the NIH (5R01 NS121154).Footnotes*Correspondence to: Sunil A. Sheth, MD, Department of Neurology, UTHealth McGovern Medical School, 6431 Fannin St, MSB 7.210, Houston, TX 77030. E‐mail: [email protected]harvard.eduThe opinions expressed in this article are not necessarily those of the American Heart Association or the Society of Vascular and Interventional Neurology.This manuscript was sent to Dr. Andrei V. Alexandrov, Guest Editor, for review by expert referees, editorial decision, and final disposition.References1 Jovin TG, Li C, Wu L, Wu C, Chen J, Jiang C, Shi Z, Gao Z, Song C, Chen W, et al. Trial of thrombectomy 6 to 24 hours after stroke due to basilar‐artery occlusion. New Engl J Med. 2022; 387:1373‐1384.Google Scholar2 Tao C, Nogueira RG, Zhu Y, Sun J, Han H, Yuan G, Wen C, Zhou P, Chen W, Zeng G, et al. Trial of endovascular treatment of acute basilar‐artery occlusion. New Engl J Med. 2022; 387:1361‐1372.Google Scholar3 Renú A, Millán M, Román LS, Blasco J, Martí‐Fàbregas J, Terceño M, Amaro S, Serena J, Urra X, Laredo C, et al. Effect of intra‐arterial alteplase vs placebo following successful thrombectomy on functional outcomes in patients with large vessel occlusion acute ischemic stroke. JAMA. 2022; 327:826‐835.CrossrefGoogle Scholar4 Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, Dávalos A, Majoie CB, van der Lugt A, de Miquel MA, et al. Endovascular thrombectomy after large‐vessel ischaemic stroke: a meta‐analysis of individual patient data from five randomised trials. Lancet. 2016; 387:1723‐1731. http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=26898852&retmode=ref&cmd=prlinksCrossrefMedlineGoogle Scholar5 Menon BK, Buck BH, Singh N, Deschaintre Y, Almekhlafi MA, Coutts SB, Thirunavukkarasu S, Khosravani H, Appireddy R, Moreau F, et al. Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (AcT): a pragmatic, multicentre, open‐label, registry‐linked, randomised, controlled, non‐inferiority trial. Lancet. 2022; 400:161‐169.CrossrefGoogle Scholar6 Wang Y, Meng X, Wang A, Xie X, Pan Y, Johnston SC, Li H, Bath PM, Dong Q, Xu A, et al. Ticagrelor versus clopidogrel in CYP2C19 loss‐of‐function carriers with Stroke or TIA. New Engl J Med. 2021; 385:2520‐2530.CrossrefMedlineGoogle Scholar7 Yaghi S, Shu L, Bakradze E, Salehi Omran S, Giles JA, Amar JY, Henninger N, Elnazeir M, Liberman AL, Moncrieffe K, et al. Direct oral anticoagulants versus warfarin in the treatment of cerebral venous thrombosis (ACTION‐CVT): a multicenter international study. Stroke. 2021; 53:728‐738.Google Scholar8 Yoshimura S, Sakai N, Yamagami H, Uchida K, Beppu M, Toyoda K, Matsumaru Y, Matsumoto Y, Kimura K, Takeuchi M, et al. Endovascular therapy for acute stroke with a large ischemic region. New Engl J Med. 2022; 386:1303‐1313.CrossrefGoogle Scholar9 Brain‐Computer Interface Startup Implants First Device in US Patient | Mount Sinai – New York [Internet]. [cited November 29, 2022]. Accessed November 28, 2022. https://www.mountsinai.org/about/newsroom/2022/braincomputer‐interface‐startup‐implants‐first‐device‐in‐us‐patientGoogle Scholar10 Medtronic Neurovascular Clinical Affairs. A Study of the Embolization of the Middle Meningeal Artery With ONYXTM Liquid Embolic System In the Treatment of Subacute and Chronic Subdural HEmatoma (EMBOLISE) [Internet]. clinicaltrials.gov; 2022 [cited November 28, 2022]. Accessed November 28, 2022. https://clinicaltrials.gov/ct2/show/NCT04402632Google Scholar11 Balt USA . The SQUID Trial for the Embolization of the Middle Meningeal Artery for Treatment of Chronic Subdural Hematoma (STEM) [Internet]. clinicaltrials.gov; 2022 [cited November 28, 2022]. Accessed November 28, 2022. https://clinicaltrials.gov/ct2/show/NCT04410146Google Scholar Previous Back to top Next FiguresReferencesRelatedDetails January 2023Vol 3, Issue 1Article InformationMetrics © 2023 The Authors. Published on behalf of the American Heart Association, Inc., and the Society of Vascular and Interventional Neurology by Wiley Periodicals LLC.This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.https://doi.org/10.1161/SVIN.122.000720 Manuscript receivedDecember 4, 2022Manuscript acceptedDecember 8, 2022Originally publishedJanuary 3, 2023 KeywordsEditorialsacute strokethrombectomystrokereviewimagingPDF download