Acute Large Artery Occlusion Research Articles

Reperfusion combined with intraarterial administration of resveratrol-loaded nanoparticles improved cerebral ischemia–reperfusion injury in rats

Endovascular thrombectomy (EVT) has been recommended as the first line therapy for large artery occlusion (LAO) stroke. However, abrupt recovery of blood flow induces oxidative stress which breaks down the blood–brain barrier (BBB), activates apoptosis and inhibits neurogenesis. Supplement of exogenous antioxidants to relieve the injuries related to oxidative stress is a rational treatment combined to EVT for acute LAO therapy. Resveratrol (RES), an antioxidant, was encapsulated into polymeric nanoparticles (RES-NPs). In transient middle cerebral artery occlusion (tMCAO) rats, intraarterial administration of RES-NPs demonstrated significant protection against cerebral ischemia/reperfusion (I/R) injuries. RES-NPs attenuated the oxidative stress induced by I/R, prevented brain edema, protected neurons from undergoing apoptosis, and contributed to neurogenesis through enhanced expression of brain-derived neurotrophic factor (BDNF). These results suggested that intra-arterial infusion of RES-NPs in conjunction with EVT could be a potential strategy for the LAO stroke therapy.

Abstract TP29: Endovascular Thrombectomy in In-Hospital Stroke Patients

Background and Purpose: Outcome of in-hospital stroke (IHS) patients is reported to be poor because of having other diseases as malignancy, cardiac, kidney and pulmonary diseases. IHS accounts for 5% of all ischemic strokes. Recent endovascular thrombectomy (EVT) can dramatically improve the clinical outcome of acute large artery occlusion(LVO) patients. However, it is not clear whether EVT can improve the outcome of HIS patients with LVO. Methods: Our prospective stroke registry between 2014 and 2019 were retrospectively reviewed. Among them, we enrolled acute stroke patients with LVO treated with EVT. We classified two group; IHS group; had IHS patients and outside hospital onset stroke (OHS) group; stroke onset was outside of our hospital and were directly admitted to our hospital. We compared clinical background and patient outcome at 3 months between two groups. Favorable outcome was identified as mRS 0-2 at 3 months. Results: Among 225 EVT patients((age 79 years [68-83], male 140 [62%], NIHSS score 15 [8-21]), 27 and 198 patients were classified to the IHS group and OHS group, respectively. Age, gender, initial NIHSS score was similar between IHS and OHS group (P=0.891, 1.000, and 0.146). ICA occlusion tended to be infrequent in the IHS group (11% vs. 26%, P=0.098), while distal MCA occlusion tended to be frequent (41% vs. 25%, P=0.107). Successful reperfusion was achieved in 82% in the IHS group and in 84% in the OHS group (P=0.780). Favorable outcome at 3 months was similar between two groups (39% in the IHS group and 51% in the OHS group, P=0.457). Conclusion: Patient outcome at 3 months in IHS patients with LVO was similar to OHS patients. In hospital stroke patients with LVO, EVT should improve the patient outcome as well as OHS patients. Thus, EVT in HIS patients with LVO should be performed without hesitation.

Postoperative hyperglycemia predicts symptomatic intracranial hemorrhage after endovascular treatment in patients with acute anterior circulation large artery occlusion

IntroductionAcute phase hyperglycemia is independently associated with an increased risk of death and symptomatic intracranial hemorrhage (sICH) in stroke patients treated with intravenous thrombolysis. Whether postoperative hyperglycemia is an independent predictor of sICH after endovascular therapy remains unknown. Here, we assessed whether hyperglycemia after endovascular therapy can predict sICH. MethodsConsecutive acute ischemic stroke patients who were treated with mechanical thrombectomy with or without subsequent stent implantation were analyzed. The primary outcome was the occurrence of sICH within the first 7 days after endovascular treatment. The second outcome was other forms of hemorrhagic transformation (HT), including parenchymal hematoma (PH) and parenchymal hematoma type 2 (PH-2). ResultsOne hundred and fifty-six patients were included. Fifteen patients (9.62%) developed sICH after endovascular therapy. After adjusting for potential confounding factors, postoperative glucose values were independently associated with sICH after endovascular therapy. Furthermore, adding postoperative glucose values to conventional risk factors led to a substantial reclassification for sICH following endovascular therapy (net reclassification improvement = 28.1%; p = .014). Moreover, postoperative glucose values were found to be risk factors for PH-2. ConclusionsWe found that postoperative glucose values might be an independent risk factor for sICH in patients with anterior circulation large vessel occlusion who are treated with mechanical thrombectomy. Adding postoperative glucose values to conventional risk factors could improve risk stratification for sICH following endovascular therapy.

2019 Update of the Korean Clinical Practice Guidelines of Stroke for Endovascular Recanalization Therapy in Patients with Acute Ischemic Stroke.

Endovascular recanalization therapy (ERT) has been a standard of care for patients with acute ischemic stroke due to large artery occlusion (LAO) within 6 hours after onset, since five landmark ERT trials conducted by 2015 demonstrated its clinical benefit. Recently, two randomized clinical trials demonstrated that ERT, even in the late time window of up to 16 hours or 24 hours after last known normal time, improved the outcome of patients who had a target mismatch, defined as either clinical-core mismatch or perfusion-core mismatch, which prompted the update of national guidelines in several countries. Accordingly, to provide evidence-based and up-to-date recommendations for ERT in patients with acute LAO in Korea, the Clinical Practice Guidelines Committee of the Korean Stroke Society decided to revise the previous Korean Clinical Practice Guidelines of Stroke for ERT. For this update, the members of the writing group were appointed by the Korean Stroke Society and the Korean Society of Interventional Neuroradiology. After thoroughly reviewing the updated evidence from two recent trials and relevant literature, the writing members revised recommendations, for which formal consensus was achieved by convening an expert panel composed of 45 experts from the participating academic societies. The current guidelines are intended to help healthcare providers, patients, and their caregivers make well-informed decisions and to improve the quality of care regarding ERT. The ultimate decision for ERT in a particular patient must be made in light of circumstances specific to that patient.

2019 Update of the Korean Clinical Practice Guidelines of Stroke for Endovascular Recanalization Therapy in Patients with Acute Ischemic Stroke

Endovascular recanalization therapy (ERT) has been a standard of care for patients with acute ischemic stroke due to large artery occlusion (LAO) within 6 hours after onset, since five landmark ERT trials conducted by 2015 demonstrated its clinical benefit. Recently, two randomized clinical trials demonstrated that ERT, even in the late time window of up to 16 hours or 24 hours after last known normal time, improved the outcome of patients who had a target mismatch, defined as either clinical-core mismatch or perfusion-core mismatch, which prompted the update of national guidelines in several countries. Accordingly, to provide evidence-based and up-to-date recommendations for ERT in patients with acute LAO in Korea, the Clinical Practice Guidelines Committee of the Korean Stroke Society decided to revise the previous Korean Clinical Practice Guidelines of Stroke for ERT. For this update, the members of the writing group were appointed by the Korean Stroke Society and the Korean Society of Interventional Neuroradiology. After thoroughly reviewing the updated evidence from two recent trials and relevant literature, the writing members revised recommendations, for which formal consensus was achieved by convening an expert panel composed of 45 experts from the participating academic societies. The current guidelines are intended to help healthcare providers, patients, and their caregivers make well-informed decisions and to improve the quality of care regarding ERT. The ultimate decision for ERT in a particular patient must be made in light of circumstances specific to that patient.

Metallic Hyperdensity Sign on Noncontrast CT Immediately after Mechanical Thrombectomy Predicts Parenchymal Hemorrhage in Patients with Acute Large-Artery Occlusion.

Parenchymal hemorrhage is a severe complication following mechanical recanalization in patients with acute ischemic stroke with large-vessel occlusion. This study aimed to assess whether the metallic hyperdensity sign on noncontrast CT performed immediately after mechanical thrombectomy can predict parenchymal hemorrhage at 24 hours. We included consecutive patients with acute ischemic stroke with large-vessel occlusion who underwent noncontrast CT immediately after mechanical thrombectomy between January 2014 and September 2018. The metallic hyperdensity sign was defined as a nonpetechial intracerebral hyperdense lesion (diameter, ≥1 cm) in the basal ganglia and a maximum CT density of >90 HU. The sensitivity, specificity, and positive and negative predictive values of the metallic hyperdensity sign in predicting parenchymal hemorrhage were calculated. A total of 198 patients were included. The metallic hyperdensity sign was found in 59 (29.7%) patients, and 51 (25.7%) patients had parenchymal hemorrhage at 24 hours. Patients with the metallic hyperdensity sign are more likely to have parenchymal hemorrhage than those without it (76.3% versus 4.3%, P < .001). The sensitivity, specificity, positive predictive value, and negative predictive value of the metallic hyperdensity sign in predicting parenchymal hemorrhage were 88.2%, 90.5%, 76.3%, and 95.7%, respectively. The presence of the metallic hyperdensity sign on noncontrast CT performed immediately after mechanical thrombectomy in patients with large-vessel occlusion could predict the occurrence of parenchymal hemorrhage at 24 hours, which might be helpful in postinterventional management within 24 hours after mechanical thrombectomy.

Effect of Hyperglycemia at Presentation on Outcomes in Acute Large Artery Occlusion Patients Treated With Solitaire Stent Thrombectomy.

Background: Sporadic data showed hyperglycemia at presentation is associated with poor outcomes in patients with acute ischemic stroke (AIS) under mechanical thrombectomy (MT) treatment.Objective: This study aims to evaluate the relationship of admission hyperglycemia and outcomes in patients treated with solitaire stent thrombectomy.Methods: This multicenter prospective study registered patients with AIS due to anterior circulation large vessel occlusion (LVO) suitable for MT with Solitaire stent retriever. We analyzed the influence of admission hyperglycemia (≥7.8 mmol/L) and serum glucose on functional independence which is defined as modified Rankin Scale score (mRS) of 0–2, symptomatic intracranial hemorrhage (sICH) and several outcomes of interest using univariable and multiple logistic regression analysis.Results: This study involved 17 stroke centers across China and consecutively recruited 149 patients. Patients with hyperglycemia at presentation less frequently exhibited a functional independence at 3 months than patients without hyperglycemia (22.2 vs. 66.4%; odds ratio 0.75, 95% confidence interval 0.61–0.92; P = 0.005). Higher glucose levels were correlated with worse outcome (per 1 mmol/L increase in glucose: odds ratio for mRS score 0–2 at 3 months 0.17, 95% confidence interval 0.06–0.45; P < 0.001) at 3 months and sICH (per 1 mmol/L increase in glucose: odds ratio for sICH was 8.2, 95% confidence interval 1.13–29.57; P < 0.001) after thrombectomy.Conclusions: Higher admission serum glucose and hyperglycemia were independently correlated with lower functional independence at 3 months in patients treated with Solitaire stent thrombectomy of anterior circulation LVO. Higher admission serum glucose was also associated with sICH after thrombectomy.

Abstract 107: Rescue Tirofiban in Mechanical Thrombectomy for Acute Cerebral Large Artery Occlusion: A Multicenter Prospective Registry Study

Background and Purpose: Preferred rescue treatment has not yet been recommended for recanalization refractory stroke patients during mechanical thrombectomy (MT). We aim to evaluate the safety and efficacy of rescue tirofiban in acute ischemic stroke(AIS) patients undergoing MT. Methods: We derived data from the ANGEL study, a multi-centric, prospective registry study that included MT patients owing to proximal large-artery occlusionfrom June 2015 to December 2017. Patients in this study were dichotomized into tirofiban and non-tirofiban group according to whether rescue tirofiban was performed during and after MT. Safety (symptomatic intracerebral hemorrhage [sICH], ICH and thrombus distalization) and efficacy outcomes (artery recanalization and functional outcomes at 3-month follow-up) were compared between groups. Results: We included 662 patients from the entire 917 patients in the Registry. Among them, there were 230 in tirofiban group and 432 in non-tirofiban group, and 47 (7.1%) patients suffered sICH and 102 (15.4%) suffered ICH within post-MT 24 hours; 33 (5.0%) experienced thrombus distalization; 289 (43.7%) achieved functional independence and 135 (20.4%) died after three-month follow-up. No significant differences of safety outcomes on sICH, ICH thrombus distalization and efficacy outcomes on artery recanalization and long-term functional independence were found between tirofiban and non-tirofiban groupeither for the entire cohort, anterior circulation stroke(ACS) patients or posterior circulation stroke(PCS) patients (p&gt;0.05 for all groups). Yet, rescue tirofiban was significantly correlated with long-term mortality reduction for PCS patients (adjusted hazard ratio 0.35 [0.14-0.92], p=0.03). Conclusion: Rescue tirofiban during and after MT was not associated with increased risk of safety outcomes on sICH, ICH and thrombus distalization for AIS patients, and was correlated with long-term mortality reduction for PCS.

Abstract WP50: Histopathologic Analysis of Retrieved Thrombi in Acute Ischemic Stroke Patients With Cancer

Introduction: The procoagulant state in cancer increases the thrombotic risk and underlying cancer could affect treatment strategies and outcomes in stroke patients. Therefore, it is important to detect cancer as a cause of stroke. However, the histopathologic characteristics of retrieved thrombi in cancer patients remain understudied. Aims: The aims of this study were to assess the histopathological difference between the thrombi in cancer patients and in non-cancer patients. Methods: We studied consecutive patients with acute large-vessel occlusion treated with endovascular therapy between October 2010 and December 2016 from our single-center registry. We histopathologically investigated retrieved thrombi using staining with hematoxylin and eosin and Masson’s trichrome. We observed the existence of organization and the ratios of erythrocyte and fibrin/platelet components, using a lattice composed of 10х10 squares. Results: Of 180 patients studied, 17 cases (8 women, 76.5±11.5 years old) had cancer and 163 cases (69 women, 74.1±11.2 years old) did not. There were no significant differences in basic clinical characteristics and cardiovascular risk factors including atrial fibrillation between the two groups. Cancer-related cases had higher proportions of fibrin/platelets (56.6±27.4% vs. 40.1±23.9%, p&lt;0.01), less proportions of erythrocytes (42.1±28.3% vs. 57.5±25.1%, p=0.02) and higher serum D-dimer levels (5.9 ± 8.2 vs. 2.4 ± 4.3, p&lt;0.01) than non-cancer cases. The ROC analysis showed the cut-off ratio of fibrin/platelet components related to cancer was 55.7% with a sensitivity of 74.8%, specificity 58.8%, and AUC value 0.67(95% CI: 0.533–0.813), the cut-off ratio of erythrocyte components was 44.7% with a sensitivity of 71.2%, specificity 58.9%, and AUC value 0.66(95% CI: 0.514–0.797). Conclusion: Cancer-associated acute large artery occlusion was relatively due to emboli with the fibrin/platelet rich component.

Clinical Outcomes of Valvular versus Nonvalvular Atrial Fibrillation in Acute Anterior Circulation Occlusive Stroke Undergoing Endovascular Treatment

BackgroundThrombectomy is the first choice for cardioembolism due to atrial fibrillation (AF), however, whether valvular AF and nonvalvular AF had different safety and functional outcomes has not been reported yet. We aimed to investigate the differences between patients with valvular AF and patients with nonvalvular AF on safety and functional outcomes in acute large artery occlusion undergoing thrombectomy. MethodsValvular AF refers to patients with mitral stenosis or artificial heart valves and valve repair. Rate of symptomatic intracerebral hemorrhage [sICH], modified Rankin Scale Score (mRS), and death at 90 days were compared between valvular AF and nonvalvular AF groups. Univariate and multivariable logistic regression was performed to identify the predictors for unfavorable functional outcome (mRS 3-6). Results18.8% (51/271) of AF were valvular AF. The valvular AF group had significantly higher proportion of mRS 0-2 (49% [25/51] versus 33.3% [73/219], P = .04) and less death (21.6% [11/51] versus 38.4% [84/219], P = .02) comparing with nonvalvular AF group. The rates of sICH between both groups were nonsignificantly different (21.5% [47/219] for nonvalvular AF versus 13.7% [7/51] for valvular AF, P = .46). Valvular AF was not an independent predictor for unfavorable functional outcome (odds ratio .67, 95% confidence interval: .24-1.84) with age, collateral flow, chronic heart failure, NIHSS at admission, recanalization status, glucose at admission, occlusion site, ASPECTS, and ICH as covariates. ConclusionsValvular AF and nonvalvular AF have similar safety and functional outcomes in patients with acute anterior circulation large artery occlusion undergoing thrombectomy.

Prognosis of Acute Intracranial Atherosclerosis-Related Occlusion after Endovascular Treatment.

Background and PurposeLittle is known about prognosis after endovascular therapy (EVT) for acute large artery occlusion (LAO) caused by underlying intracranial atherosclerotic stenosis (ICAS). Therefore, we investigated the prognosis following EVT according to the underlying etiology of LAO. MethodsPatients from the Acute Stroke due to Intracranial Atherosclerotic occlusion and Neurointervention-Korean Retrospective (ASIAN KR) registry (n=720) were included if their occlusion was in the intracranial anterior circulation and their onset-to-puncture time was <24 hours. Occlusion was classified according to etiology as follows: no significant stenosis after recanalization (Embolic group), and fixed significant focal stenosis in the occlusion site with flow impairment or re-occlusion observed during EVT (ICAS group). Patients were excluded when significant extracranial carotid lesions existed, and when the intracranial occlusion was intractable to EVT so that the etiology was undetermined. The effect of angiographic etiologic classification on outcomes was evaluated using multivariable analysis that was adjusted for potential confounders. ResultsAmong eligible patients (n=520), 421 and 99 were classified in the Embolic and ICAS groups, respectively. Patients in the Embolic and ICAS groups had similar successful reperfusion rates with EVT (79.6% vs. 76.8%, P=0.537) and 3-month functional independence (54.5% vs. 45.5%, P=0.104). In multivariable analysis, ICAS-related occlusion (odds ratio, 0.495; 95% confidence interval, 0.269 to 0.913; P=0.024) showed poorer 3-month functional independence compared to embolic occlusion. ConclusionsAfter EVT, patients with acute ICAS-related occlusion have relatively poor functional outcomes compared to those with embolic occlusion. Novel strategies need to be developed to improve EVT outcomes for ICAS occlusion.

The Processing Time for Recanalization and Size of Ischemic Lesions on DWI is Related With Complete Reperfusion After Mechanical Thrombectomy

Recent studies demonstrated that modified thrombolysis in cerebral infarction (TICI) 3 reperfusion have better functional outcomes than modified TICI 2b after mechanical thrombectomy in acute ischemic stroke with large vessel occlusion. The purpose of this study was to determine significant factors to forecast the presence of complete reperfusion after mechanical thrombectomy based on multimodal magnetic resonance imaging (MRI). We investigated 96 consecutive patients with acute large intracranial artery occlusion of anterior circulation who based on multimodal MRI. Also, we compared clinical and radiologic parameters between patients with modified TICI 3 and those with modified TICI 0-2b. Among 96 eligible subjects received mechanical thrombectomy, 39 patients (40.6%) showed complete reperfusion and 57 partial or nonreperfusion (mTICI 2b-26, mTICI 2a-9, mTICI 1-8, and mTICI 0-14) after mechanical thrombectomy. Patients with mTICI 3 had significantly smaller initial Diffusion weighted images (DWI) lesion volume (P < .01) and much shorter time interval from onset to reperfusion (P < .01) than those patients with mTICI (0-2b). In multivariate analysis, smaller initial DWI volume (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.23-2.57; P < .01) and faster reperfusion time (OR, 1.07; 95% CI 1.01-1.14; P = .015) had an independence significance for complete reperfusion after mechanical thrombectomy. In this study, the ischemic lesion volume on DWI and faster processing time are critical factor to predict the state of complete reperfusion after mechanical thrombectomy.

Safety and Optimal Neuroprotection of neu2000 in acute Ischemic stroke with reCanalization: study protocol for a randomized, double-blinded, placebo-controlled, phase-II trial

BackgroundThe potential of neuroprotective agents should be revisited in the era of endovascular thrombectomy (EVT) for acute large-artery occlusion because their preclinical effects have been optimized for ischemia and reperfusion injury. Neu2000, a derivative of sulfasalazine, is a multi-target neuroprotectant. It selectively blocks N-methyl-D-aspartate receptors and scavenges for free radicals. This trial aimed to determine whether neuroprotectant administration before EVT is safe and leads to a more favorable outcome.MethodsThis trial is a phase-II, multicenter, three-arm, randomized, double-blinded, placebo-controlled, blinded-endpoint drug trial that enrolled participants aged ≥ 19 years undergoing an EVT attempt less than 8 h from symptom onset, with baseline National Institutes of Health Stroke Scale (NIHSS) score ≥ 8, Alberta Stroke Program Early CT score ≥ 6, evidence of large-artery occlusion, and at least moderate collaterals on computed tomography angiography. EVT-attempted patients are randomized into control, low-dose (2.75 g), and high-dose (5.25 g) Neu2000KWL over 5 days. Seventy participants per group are enrolled for 90% power, assuming that the treatment group has a 28.4% higher proportion of participants with functional independence than the placebo group. The primary outcome, based on intention-to-treat criteria is the improvement of modified Rankin Scale (mRS) scores at 3 months using a dichotomized model. Safety outcomes include symptomatic intracranial hemorrhage within 5 days. Secondary outcomes are distributional change of mRS, mean differences in NIHSS score, proportion of NIHSS score 0–2, and Barthel Index > 90 at 1 and 4 weeks, and 3 months.DiscussionThe trial results may provide information on new therapeutic options as multi-target neuroprotection might mitigate reperfusion injury in patients with acute ischemic stroke before EVT.Trial registrationClinicalTrials.gov, ID: NCT02831088. Registered on 13 July 2016.

Endovascular Thrombectomy for Large-Vessel Occlusion Strokes with Preexisting Intracranial Aneurysms.

This study aimed to investigate the safety of endovascular thrombectomy in acute ischemic stroke with preexisting intracranial aneurysms. Patients with acute ischemic stroke due to large-artery occlusion combined with intracranial aneurysms, who received endovascular treatment, were analyzed retrospectively, and the procedure-related data were recorded. Among the 124 patients who suffered acute large-artery occlusion and received endovascular recanalization therapy, intracranial aneurysms were found in seven patients (5.6%). All the seven patients achieved successful recanalization, except one patient who suffered subarachnoid hemorrhage due to the rupture of aneurysm during the procedure. The prevalence of preexisting cerebral aneurysms in patients with acute ischemic stroke is high, leading to a procedure-related rupture risk. Endovascular treatment devices must be used carefully in these patients, especially when the aneurysms are located within the area where the procedure is performed.

Slow Collateral Flow Is Associated with Thrombus Extension in Patients with Acute Large-Artery Occlusion.

It is still poorly understood about the dynamic changes of the thrombus after intravenous thrombolysis and how the remaining thrombus affects clinical outcome in human stroke. Collateral flow was assumed to help to deliver endo/exogenous tissue-type plasminogen activator to the clot. We aimed to analyze the impact of collateral flow on the dynamic changes of the thrombus in patients with acute large-artery occlusion who received intravenous thrombolysis. We reviewed consecutive patients with acute ischemic stroke with M1 segment or distal internal carotid artery occlusion who underwent multimodal MR imaging or CT perfusion before and 24 hours after intravenous thrombolysis without recanalization. Patients were divided into 3 groups (thrombus extension, shortening, and no change) according to thrombus-length change between baseline and 24 hours. Collateral flow was measured with arrival time delay and the collateral scoring system. Poor outcome was defined as a 3-month modified Rankin Scale score of ≥3. Among 51 patients, 18 (35.3%) had thrombus extension, 14 (27%) had thrombus shortening, and 19 (37.3%) had thrombus without change. Arrival time delay was independently associated with thrombus extension (OR = 1.499; 95% CI, 1.053-2.135; P = .025). Similarly, the collateral score on the peak artery phase was independently associated with thrombus extension (OR = 0.456; 95% CI, 0.211-0.984; P = .045), whereas baseline National Institutes of Health Stroke Scale score (OR = 0.768; 95% CI, 0.614-0.961; P = .021) and baseline thrombus length (OR = 1.193; 95% CI, 1.021-1.394; P = .026) were associated with thrombus shortening. All patients with thrombus extension had poor outcomes. Slow collateral flow was related to thrombus extension in patients with large-artery occlusion without recanalization after intravenous thrombolysis.

Endovascular recanalization for intracranial atherosclerotic disease-related acute large artery occlusion in anterior circulation

Objective To evaluate the effect of endovascular recanalization on acute ischemic stroke with large artery occlusion (LAO) in anterior circulation due to intracranial atherosclerotic disease (ICAD). Methods We conducted a retrospective analysis about 49 cases of ICAD-related LAO undergoing endovascular treatment at Department of Neurointervention, People＇s Hospital of Henan Province from June 2014 to June 2016. Recanalization result was assessed by catheter angiography according to Thrombolysis in Cerebral Ischemia (TICI) scale and the neurological function 1 week post procedure was evaluated by NIHSS (National Institutes of Health Stroke Scale). The 90-day outcome was assessed based on the modified Rankin Scale (mRS). In-stent restenosis was evaluated by DSA at 6-month follow-up. Results Among the 49 cases ICAD-related LAO enrolled into this study, the mean time from puncture to recanalization was (78.4±29.0) minutes. The rate of successful intraoperative recanalization (TICI score of 2b-3)was 87.8% (43/49). Intraoperative embolization occurred in 5 patients. Among them, 1 patient underwent stent retrieval and 3 received intra-arterial tirofiban treatment resulting in recanalization in 2 cases. The CT scan at 24 h post surgery demonstrated intracerebral hemorrhage in 7 cases including 3 symptomatic cases. The mean NIHSS score (8.8±4.1) 1 week post procedure was significantly lower than that prior to operation (15.6±3.9). At 3-month follow-up, 6 deaths were reported. The mean mRS score was (2.9±1.7) and the rate of good outcome was 57.1% (28/49). DSA was conducted in 15 patients at 6 months post stent placement which reported 2 cases(13.3%) of intrastent restenosis. Conclusion Endovascular treatment seems beneficial for patients with ICAD-related LAO to achieve good recanalization and clinical outcome. Key words: Stroke; Atherosclerosis; Treatment outcome; Mechanical thrombectomy

Solumbra thrombectomy as intravascular recanalization for treatment of acute ischemic stroke due to large cerebral artery occlusion

Objective To investigate the feasibility, effectiveness, and technical superiority of Solumbra thrombectomy for treatment of acute large cerebral artery occlusion stroke. Methods 32 patients who had acute large cerebral artery occlusion stroke and received mechanical thrombectomy in TEDA Hospital of Tianjin between January 2013 and August 2016, were divided into two groups: stent group(with conventional stent-retrievers, n=21)and Solumbra group(with Solumbra thrombectomy, n=11). Clinical characteristics, variables correlated with operation, and clinical outcomes were compared and analyzed retrospectively. Results There were no differences in basic clinical and radiographic parameters between stent group versus Solumbra group(all P>0.05). Moreover, there were no differences between Solumbra group versus Stent group in rates of embolus to new territory(18.2% vs.28.6%, P=0.425), in times of thrombectomy(2.2±1.0 vs.2.4±1.3, P=0.657), in non-symptomatic intracranial hemorrhage(18.2% vs.14.3%, P=0.572), in symptomatic intracranial hemorrhage(18.2% vs.9.5%, P=0.427), in TICI 2b/3 revascularization(81.8% vs.81.0%, P=0.670), in puncture-to-reperfusion time[(66.4±39.0)min vs.(51.6±34.5)min, P=0.279], and in NIHSS at 7 days(11.6±7.7 vs.11.3±7.2, P=0.925). A modified Rankin Scale(mRS ≤2)is a variable of recovery of function and good clinical outcome at 90 days.The levels of mRS were similar(P=0.490)between Solumbra and stent groups, but there was a tendency to higher rate of good clinical outcome at 90 days in Solumbra group(63.6%, 7/11)than in stent group(47.6%, 10/21). Conclusions Solumbra thrombectomy as intravascular revascularization technique is an effective and safe strategy for endovascular recanalization of acute large cerebral artery occlusion stroke.Compared with conventional Stent-Retriever thrombectomy, Solumbra thrombectomy has a good clinical outcome tendency at 90 days after operation. Key words: Brain infarction; Solumbra technique

Feasibility of Permanent Stenting with Solitaire FR as a Rescue Treatment for the Reperfusion of Acute Intracranial Artery Occlusion.

The Solitaire FR can be used not only as a tool for mechanical thrombectomy but also as a detachable permanent stent. Our aim was to assess the feasibility and safety of permanent stent placement with the Solitaire FR compared with other self-expanding stents for intracranial artery recanalization for acute ischemic stroke. From January 2011 through January 2016, we retrospectively selected 2979 patients with acute ischemic stroke. Among them, 27 patients who underwent permanent stent placement (13 patients with the Solitaire FR [Solitaire group] and 14 patients with other self-expanding stents [other stent group]) were enrolled. The postprocedural modified TICI grade and angiographic and clinical outcomes were assessed. The safety and efficacy of permanent stent placement of the Solitaire FR for acute large-artery occlusion were evaluated. Stent placement was successful in all cases. Modified TICI 2b-3 reperfusion was noted in 84.6% of the Solitaire group and in 78.6% of the other stent group. Procedural time was significantly shorter in the Solitaire group than in the other stent group (P = .022). Shorter procedural time was correlated with favorable outcome (ρ = 0.46, P = .035). No significant differences were found in the modified TICI grade, NIHSS score, mRS, and hemorrhagic transformation rate between the 2 groups. The acute in-stent thrombosis rate at discharge was significantly lower when a glycoprotein IIb/IIIa inhibitor was injected during the procedure (P = .013). Permanent stent placement with the Solitaire FR compared with other self-expanding stents appears to be feasible and safe as a rescue tool for refractory intra-arterial therapy.

Thrombectomy accessibility after transfer from a primary stroke center: Analysis of a three-year prospective registry.

Background No comprehensive study exists about mechanical thrombectomy accessibility for patients admitted to a primary stroke center without onsite interventional neuroradiology service. Aims To evaluate mechanical thrombectomy accessibility within 6 h after transfer from a primary stroke center to a distant (156 km apart; 1.5 h by car) comprehensive stroke center. Methods Analysis of data collected in a three-year prospective registry on patients admitted to a primary stroke center within 4.5 h after symptom onset and selected for transfer to a comprehensive stroke center for mechanical thrombectomy. Eligible patients had confirmed proximal arterial occlusion and no large cerebral infarction on MRI images (DWI-ASPECTS ≥ 5). The rate of transfer, transfer without mechanical thrombectomy, mechanical thrombectomy, reperfusion (TICI score ≥ 2b-3), and the main relevant time measures were determined. Results Among the 385 patients selected for intravenous thrombolysis and/or potential mechanical thrombectomy, 211 were considered as transferrable for mechanical thrombectomy. The rate of transfer was 56.4% (n = 119/211), transfer without mechanical thrombectomy 56.3% (n = 67/119), mechanical thrombectomy 24.6% (n = 52/211), and reperfusion by MT (TICI score 2b/3) 18% (n = 38/211). The relevant median times (interquartile range) were: 130 min (62) for intravenous thrombolysis start to comprehensive stroke center door, 95 minutes (39) for primary stroke center door-out to comprehensive stroke center door-in, 191 min (44) for intravenous thrombolysis start to mechanical thrombectomy puncture, 354 min (107) for symptom onset to mechanical thrombectomy puncture and 417 min (124) for symptom onset to recanalization. Conclusions Our study suggests that transfer to a distant comprehensive stroke center is associated with reduced access to early mechanical thrombectomy in patients with acute ischemic stroke and large artery occlusion. These results could be translated to other high volume distant primary stroke center.

Special Endovascular Treatment for Acute Large Artery Occlusion Resulting From Atherosclerotic Disease.

Acute intracranial atherosclerotic disease (IAD)-related large artery occlusion (LAO) is typically refractory to mechanical thrombectomy. We evaluated the feasibility and safety of emergency balloon-assisted or stent-assisted angioplasty performed with tirofiban administration for acute IAD-related LAO. We identified, from among 55 consecutive patients who underwent endovascular treatment for LAO, 12 patients with acute IAD-related LAO who underwent balloon-assisted or stent-assisted angioplasty with (n= 3) or without passage of a stent retriever. The treatment included tirofiban administration. We obtained, from patients' clinical records, thrombolysis in cerebral infarction scores (to assess the extent of reperfusion), follow-up magnetic resonance angiography images (to assess patency of the responsive arteries), and 90-day modified Rankin (mRS) scores (to assess outcomes). Temporary blood flow and severe stenosis were observed angiographically in all 12 patients, either when the stent retriever was deployed or when a microcatheter was advanced through the site of occlusion. Persistent recanalization was achieved in all patients, and there was no operative complication or arterial reocclusion. All 8 patients with an occluded major artery in the anterior circulation had a good outcome, with an mRS score of ≤2. Two of the 4 patients with basilar artery occlusion had a good outcome, with an mRS score of ≤2. One patient (25%) died within 72 hours after procedure. Our data point to the safety and feasibility of emergency balloon-assisted or stent-assisted angioplasty performed with tirofiban administration and a single or no passage of the stent retriever for acute IAD-related LAO.