Complete Recanalization Research Articles

Possible Occurrence of Delayed Leukoencephalopathy Following Acute Ischemic Stroke With Large‐Vessel Occlusion

Background Typically detected at least 14 days after acute ischemic stroke onset, delayed leukoencephalopathy (DL) involves diffuse hyperintensities restricted to white matter on fluid‐attenuated inversion recovery accompanied mostly by partial diffusion‐weighted image hyperintensities. DL cases, which are rarely reported, have occurred after large‐vessel occlusion (LVO). Herein, we aim to elucidate the incidence and factors associated with DL. Methods Our study covers consecutive ischemic strokes involving: (1) onset‐to‐door time within 7 days and (2) available scans from at least a second magnetic resonance imaging procedure at least 14 days after onset. First, we examined the incidence of DL generally and whether LVO could be a risk factor for DL in ischemic strokes generally, and second, we examined the incidence and risk factors associated with DL in patients with LVO. Results We screened 1857 consecutive patients with ischemic stroke and selected 792 general patients—573 (72%) men, median age 67 years—and 183 patients with LVO—128 (70%) men, median age 67 years. DL was detected in 2.3% of the general patients and 9.2% of the patients with LVO ischemic stroke. LVO was strongly associated with DL (odds ratio [OR], 69.1 [95 CI, 9.06–526]; P <0.001). Among patients with LVO, DL‐associated factors were age/10 years (OR, 1.76 [95% CI, 1.13–2.75]; P =0.012), low‐density lipoprotein cholesterol/10 mg/dL (OR, 0.863 [95% CI, 0.745–1.00]; P =0.049), complete recanalization (OR, not calculable; P <0.001), and endovascular therapy (OR, 17.4 [95% CI, 4.44–68.5]; P <0.001). Conclusion DL might not be rare following LVO. We speculate that certain risk factors and their combinations are key in the development of DL.

Abstract 127: Delayed Thrombectomy In A Patient With Recurrent MCA Strokes

Introduction Prior research has demonstrated mechanical thrombectomy (MT) to be a safe and effective treatment for stroke patients with a large vessel occlusion (LVO).1 However, MT has generally only been studied in a time window of less than 24 hours.2 To the best of the authors' knowledge, this case report is the first publication of a MT done months after the initial stroke event, in a patient with recurrent strokes and an evolving occlusion visualized in the middle cerebral artery (MCA). Methods The patient is a 55‐year‐old man with a past medical history of a left‐sided MCA stroke 2 months prior to current admission with multiple transient ischemic attacks (TIAs) on dual antiplatelet therapy (DAPT), with no persistent residual deficits. His first stroke was preceded by about 1 week of intermittent confusion and right arm tingling. MRI at the time showed an acute embolic infarct in left MCA territory, and a CTA showed a sub‐occlusive thrombus vs. atherosclerotic plaque in the superior branch of the left MCA. He was discharged on DAPT, but his prior symptoms began to recur on a weekly basis, lasting for a few minutes each time. The patient eventually presented on this admission to the ED with persistent dysarthria and word finding difficulties. Within 4 hours, his exam improved to an NIHSS of 0. An MRI without contrast showed a new acute punctate infarct in the posterior left lateral temporal cortex. CT angiogram showed a persistent left M2 occlusion which was confirmed by the diagnostic cerebral angiogram. CT Perfusion also showed a large penumbra in the same region. The decision was made to perform MT, and complete recanalization was achieved. On 2‐month follow‐up, the patient continues to report no new symptoms since the time of MT. Results The patient’s positive outcome thus far at 60 day follow up indicates that MT can prove safe and efficacious even in significantly delayed time windows. This also shows that the decision to proceed with MT ought not to depend on time interval and degree of collaterals alone, but also on the pattern of symptoms the patient is exhibiting. The recurrent TIAs and strokes our patient was having indicates that, although collaterals had formed in response to his sub‐occlusive thrombus in the MCA, they were still unable to provide full compensation for this lost blood flow, leading to the patient’s intermittent symptoms. Conclusion This report demonstrates that MT can be safely and effectively utilized even in significantly delayed time windows in patients with recurrent TIAs or strokes.

Abstract 130: Endovascular Therapy for Cerebral Venous Sinus Thrombosis: A Systematic Review of 267 patients

Introduction Cerebral venous sinus thrombosis (CVST) is a rare form of stroke that usually affects young females especially during pregnancy and the postpartum period. Several risk factors can contribute to the development of cerebral venous sinus thrombosis including hypercoagulable states, dehydration, infections, head or neck injuries, cancer, and some rheumatological diseases (1). The symptoms of cerebral venous sinus thrombosis can vary depending on the location and extent of the clot. Common signs and symptoms may include severe headaches, visual disturbances, seizures, focal neurological deficits, altered mental status, and in severe cases, coma. The initial treatment for CVST is systemic anticoagulation (2‐3). However, endovascular treatment (EVT) of CVST is typically reserved for cases associated with significant thrombus burden and lack of clinical improvement or worsening of symptoms despite systemic anticoagulation therapy without current conclusive evidence of its benefit. The aim of this study is to evaluate the evidence of EVT in patients with CVST. Methods A systemic literature search was conducted via PubMed to identify relevant studies. Only studies with sample sizes larger than 10 were included. We excluded small case series, meta‐analyses, systematic reviews, and studies that lack the main outcomes of interest. Our main outcomes included functional outcome defined as modified Rankin Scale score (mRS 0‐3), mortality, new or expanded ICH and recanalization rates. Results We finally included 10 studies (4‐13) in our qualitative synthesis. Only one study was a small, randomized clinical trial while the rest were observational studies. In our included studies, 267 patients underwent EVT for CVST. Among them, the median age was ranging from 12 to 75 and 162 (60 %) of patients were females. Patients were followed up for a mean ranging from 3 to 12 months. Recanalization was observed in 161 patients, out of which 111 were complete recanalization (68.9%) and 50 were partial recanalization (31.1%). Good functional outcome defined as mRS 0‐3 was achieved in a total of 181 patients. Additionally, 26 (9.7%) patients had a new onset or expanded ICH while 26 patients had died (9.7%). Conclusion EVT for CVST was associated with improved clinical outcomes with acceptable safety profile in severe cases. There is a lack of evidence from large randomized clinical trials so more prospective studies are needed to confirm these results.

Abstract 197: Mechanical Thrombectomy Of Basilar Artery Occlusion On A Hypoplastic Vertebrobasilar Circulation

Introduction Basilar artery occlusion (BAO) is one of the most severe acute ischemic strokes which carries high mortality and morbidity risk. Mechanical thrombectomy (MT) has been used as a promising treatment for BAO. However, the vertebral‐basilar anatomy is more challenging for MT compared to the anterior circulation due to several congenital variants such as hypoplastic vertebral artery, fenestration on the vertebrobasilar junction, or chronic asymptomatic occlusions of vertebral arteries, and tortuous subclavian arteries and vertebral arteries (VAs). Here, we described a BAO case with hypoplastic vertebrobasilar arteries, which was successfully treated with thrombectomy using the direct aspiration technique. Methods Electronic Medical Records review of a patient with acute basilar artery occlusion stroke. Results 55‐year‐old healthy gentleman presented to ER with acute onset with confusion, dysarthria, left‐sided weakness, and right facial droop. Initial NIHSS was 12. CT angiography (CTA) head and neck showed basilar artery was occluded in the distal one third segment. Because of the right fetal posterior cerebral artery and prominent left posterior communicating artery, his bilateral VAs and basilar artery were underdeveloped. The left VA appeared to be slightly bigger than the right one. After the patient received IV tPA, he was taken for mechanical thrombectomy. A Ballast catheter was placed in the left subclavian artery near the left VA origin. The conventional angiography showed the left VA was 2.8 mm and proximal basilar was about 2.1 mm. The Zoom 35 aspiration catheter was then used for mechanical thrombectomy. A complete basilar recanalization was achieved on the first pass. The patient improved after the MT. His NIHSS on discharge was 0. Conclusion The benefits of MT on BAO remain unknown despite several clinical trials. One of the reasons is due to more challenged vascular anatomy compared to anterior circulation. Underdevelopment of unilateral VA was commonly seen in posterior circulation ischemic strokes. But the underdevelopment of bilateral VAs with basilar arteries in BAO cases was rare and more difficult to treat. The Zoom 35 aspiration catheter provided a great advantage for this case with its smaller outer diameter, good navigation ability, and great aspiration efficacy. Our experience suggested a direct aspiration first pass technique (ADAPT) has an advantage on BAO, especially in the congenitally underdeveloped vertebrobasilar arteries.

Abstract 116: Reversal of Acute Ocular Ischemic Syndrome Following Rescue Carotid Revascularization: A Case Report

Introduction Ocular ischemic syndrome (OIS) is a rare, vision‐threatening condition resulting from severe carotid artery disease secondary to severe atherosclerosis or arteritis. Common clinical features include acute/subacute to gradual vision loss, ocular pain, amaurosis fugax, photophobia and diplopia. We are presenting a case of acute ocular ischemic syndrome secondary to acute re‐occlusion of the right internal carotid artery (RICA) post Carotid Endarterectomy (CEA), that reversed with carotid revascularization. Methods Case Summary: 59‐year‐old male with history of T2DM, hyperlipidemia, tobacco use presented to an outside hospital with complaints of dizziness, blurry vision, left upper extremity weakness and multiple falls with head trauma. Exam revealed left lower quadrantanopia, mild left arm weakness and left hemineglect. Computed Tomography (CT) Head showed scattered right middle cerebral artery (MCA) territory infarcts. CT Angiography (CTA) revealed ulcerated plaque with a small focus of thrombus intraluminally in the RICA. Subsequently, the patient was initiated on heparin infusion and underwent CEA. On postoperative day (POD) 2, the patient experienced severe stabbing right eye pain with reduced visual acuity and worsening of left arm weakness. Imaging revealed complete occlusion of the right common carotid artery (RCCA). Perfusion imaging did not reveal a core or a penumbra. Given acute loss of vision likely secondary to ocular ischemic syndrome, decision was taken to proceed with rescue stenting. Using a transfemoral approach, an 8‐French balloon guide catheter was advanced into the proximal RCCA. A primary suction thrombectomy was performed under proximal flow arrest. After achieving a complete recanalization in one pass, we started the patient on cangrelor 30 mcg/kg intravenous bolus followed by 4 mcg/kg/min infusion. Post bolus, we placed a tandem closed‐cell carotid stent measuring 8x36mm & 10x37mm. The patient reported immediate relief of ocular pain, vision and weakness following the procedure. He transitioned from cangrelor infusion to ticagrelor 90 mg twice daily and aspirin 81 mg daily. On post‐stenting day 7, the patient experienced acute onset headache, and imaging revealed re‐occlusion of the entire carotid artery sparing only the ophthalmic segment of the RICA which now filled retrograde via anterior communicating artery (AcoA) from the contralateral carotid artery. However, his visual acuity remained unchanged and reported no ocular pain. At one month follow‐up the patient remains symptom‐free. Results Discussion: Incidence of OIS is estimated to be 7.5 cases per million every year. Carotid artery atherosclerosis is the most common etiology. Majority of OIS (∼90%) present with gradual vision loss and approximately 40% present with ocular pain. Gradual vision loss is predominantly related to chronic ocular hypoperfusion and resultant iris neovascularization and glaucoma. In this case, patient suffered acute vision loss secondary to acute ICA occlusion following CEA. Emergent carotid revascularization resulted in restoration of vision and resolution of ocular pain. Conclusion Our main goal is to emphasize the importance of rescue stenting to address symptoms of aOIS. Immediately post‐stenting, there was remarkable improvement in ocular pain and visual acuity. Although, the carotid re‐occluded within seven days post‐stenting, we hypothesize that gradual re‐occlusion while on DAPT provided enough time recruit and preserve collaterals into the right ophthalmic artery via retrograde flow into the ophthalmic segment of RICA from the contralateral carotid artery via the AcoA which was subsequently confirmed on imaging.

Abstract 128: Endovascular Thrombectomy for Severe Cerebral Venous Thrombosis: A Comprehensive Meta‐analysis Assessing Safety and Efficacy

Introduction Cerebral sinus venous thrombosis (CSVT) has traditionally been treated medically with systemic anticoagulation. Recent advances in endovascular therapy (EVT) may represent an alternative treatment to medical therapy for CSVT. We conducted a systematic review and meta‐analysis to evaluate the use of EVT for CSVT. Methods We conducted a systematic literature review using PubMed, Embase, Scopus, and Web of Science. We included studies that reported outcomes following EVT for CSVT. The primary outcome of interest was rate of modified Rankin Scale (mRS) 0‐2. Secondary outcomes of interest were rates of complete, partial, and failed recanalization, mortality, and new or expansion of hematoma. We calculated pooled rates (%) and their corresponding 95% confidence intervals (CI). Results Thirty‐eight studies with 682 patients were included. Rate of mRS 0‐2 was 82.6% (95% CI, 75.3%‐88.0%). Rate of complete recanalization was 60.9% (95% CI, 49.1%‐71.5%), rate of partial recanalization was 34.2% (95% CI, 24.1%‐45.9%), and rate of failed recanalization was 5.4% (95% CI, 3.1%‐9.2%). Rate of mortality was 6.7% (95% CI, 4.1%‐10.8%) and rate of new or expansion of hematoma was 5.1% (2.9%‐8.8%). Conclusion In this systematic review and meta‐analysis, EVT for CSVT was associated with favorable rates of mRS 0‐2 and recanalization. Furthermore, EVT was associated with a promising safety profile. Future prospective, comparative studies are warranted to assess EVT for CSVT.

Abstract 213: Successful Mechanical Thrombectomy in Acute Stroke With Pre‐interventional Thrombolysis‐Induced Intracerebral Hemorrhage: Case Report

Introduction Intravenous thrombolytics (IVT) and mechanical thrombectomy (MT) have become the standards of care for treating patients with large vessel occlusion (LVO) acute ischemic strokes (AIS) [1‐4}. Intracerebral hemorrhage (ICH) is a main complication of IVT, with prevalence reported around 3.2% in a large multicentered meta‐analysis [2,6]. However, limited data remains about the safety and efficacy for patients to undergo MT with IVT associated pre‐interventional ICH as no randomized control trials or standard of care guidelines are available [2,4,5,7]. Methods NA Results 56‐yo male with history of alcohol abuse presented via EMS as a stroke alert with acute onset right hemiplegia, global aphasia, right facial droop, and leftward gaze preference two hours prior to arrival. RACE 10+ with NIHSS 24. No known history antiplatelet or anticoagulation use. Computerized Tomography (CT) Brain scan showed left middle cerebral artery (MCA) hyperdense sign with left insular cortical ribboning. CT angiography (CTA) showed near occlusive stenosis of the left carotid bulb with an acute thrombus within Supraclinoid Internal Carotid Artery (ICA) extending into the Left MCA and origin of Left Anterior Cerebral Artery (ACA). Patient was emergently administered IV‐tissue Plasminogen Activator (IV‐tPA) and taken for endovascular thrombectomy. During initial angiogram, after crossing the stenotic cervical bulb, the left Supraclinoid ICA and MCA occlusions were visualized. There was longitudinal partially occlusive thrombus extending from the M1 into the M2 divisions. No opacification of the inferior M2 branch was visualized, with perfusion deficit over the temporal, parietal and frontal regions. Additionally, extravasation of contrast was seen within the left basal ganglia region, concerning for hemorrhagic transformation from IV‐tPA. Reversal of IV‐tPA was initiated, and patient was given cryoprecipitate, platelets, and tranexamic acid. Decision to undergo MT was made secondary to severity of debilitating neurologic symptoms, age, and large perfusion deficit observed. He underwent single pass complete recanalization, TICI 2C using Stent retriever and aspiration. Left ICA stenting was not completed secondary to hemorrhagic transformation. Repeat CT Brain confirmed moderate left frontal lobe hemorrhage with vasogenic edema and 3mm left‐to‐right midline shift. No neurosurgical intervention required. Magnetic resonance imaging (MRI) Brain showed left cerebral hematoma with mass effect, acute infarct within left caudate nucleus, and minimal posterior cortical restricted diffusion without hemorrhagic conversion. Patient was monitored for 1 week with serial brain imaging. Patient was discharged on Aspirin 81 mg daily to inpatient rehabilitation with NIHSS 21, mRS 4 (0 prestroke). Today, in rehab he ambulates with walker with moderate expressive aphasia and right upper extremity weakness. Plan to follow‐up 2‐month post‐hospitalization for left ICA stenting. Conclusion While pre‐interventional IVT‐associated ICH in AIS with LVO are rare, few cases have been shown to have positive neurological outcomes [2,5,7]. We demonstrate a unique case of early identification of reperfusion hemorrhage on fluoroscopy with prompt reversal initiated. The decision to continue with MT based on downstream occlusion of basal ganglia hemorrhage not at further risk of expansion from reperfusion. The patient did well on follow‐up imaging despite the hemorrhage. Further randomized control clinical trials are required to establish best care guidelines, safety, and efficacy.

Abstract 249: In‐silico Versus In‐Vitro Evaluation of a New Stent‐Retriever Design: A Novel Approach to Pre‐clinical Development

Introduction In‐vitro evaluation (analysis in a bench top flow model) is the gold standard and a regulatory requirement for pre‐clinical investigation of devices being developed for endovascular thrombectomy (EVT). In‐silico evaluation (computer simulated analysis in a virtual stroke model) has the potential to test and optimize large number of stent‐retriever design variations in a relatively time and cost‐effective manner. Further, new design concepts can be tested across multiple anatomical scenarios. We aim to validate the utility of in‐silico evaluation when compared with in‐vitro evaluation for the SuperNova Stent‐retriever. Methods In‐silico analysis was performed using a virtual thrombectomy model, built using data from a fine‐grained finite‐element model, to estimate the probability of successful recanalization and emboli in new/distal territory. Neurovascular anatomy of the virtual model was built based on digital subtraction angiography of an in‐vitro model (Sim Agility, Mentice, Inc). Gravity Medical Technology’s SuperNova Stent‐retriever was the device under investigation‐ physical device for in‐vitro analysis and virtual replica for in‐silico analysis (built using finite element analysis incorporating various physical metrics of the stent‐retriever). Experiments performed for in‐vitro analysis were replicated for in‐silico analysis. Multiple thrombectomy scenarios were defined and validation analysis was performed. Data was analyzed using SPSS 23 (IBM, Armonk, NY) Results We defined multiple thrombectomy scenarios including 1 cm red blood clot in M1 artery, 2 cm bifurcation M1‐M2 red blood clot (Y‐shaped clot), 1 cm white blood clot in M1 artery, and 1 cm white blood clot in superior M2 artery. The figure below demonstrates a pictorial representation of the first scenario‐ 1 cm red blood clot in M1 artery followed by mechanical thrombectomy simulation using the SuperNova stent‐retriever. Per our in‐vitro analysis (10 thrombectomy experiments), the rate of first pass effect and the rate of complete recanalization after a maximum of 3 passes using SuperNova stent‐retriever was 50% and 90%, respectively. Complete data from in‐silico analysis is being generated and will be presented at the conference. Preliminary data suggests high degree of concordance. Conclusion In‐silico analysis has the potential to improve and expedite pre‐clinical thrombectomy device development. Further studies are required to better understand the scope and potential of this technology.

Mechanical thrombectomy with a new intermediate balloon catheter combining the BGC and DAC features: Initial clinical experience with the iNedit device.

The iNedit balloon distal access catheter is a novel thrombectomy device. It has an inner diameter of 0.058″, proximal outer diameter of 2.13 mm, and distal outer diameter of 1.67mm. It is compatible with a 0.088″ guide catheter and includes a balloon located 5 cm from the catheter tip, enabling proximal flow restriction and combined therapy with stent retrievers. We investigate the appraisal of the use, safety, and efficacy of the iNedit catheter in the first-in-human study. In the preliminary cases that demanded training on the product previous to a multicentric study, prospective data were collected on 22 consecutive patients treated with the iNedit catheter to perform thrombectomy for acute ischemic stroke due to large vessel occlusion within 24 h. The outcome measures consisted of several evaluations of user experience rated on a 5-point scale ranging from 1 (bad) to 5 (excellent), as well as assessments of procedural safety outcomes such as artery perforation and arterial occlusion, procedural efficacy outcomes including first-pass effect (Thrombolysis In Cerebral Infarction [TICI] 2c/3) and final recanalization (TICI 2b/3), and clinical efficacy outcomes such as a 3-month 0-2 modified Rankin Scale (mRS). The mean age was 72 ± 12 years old; median National Institute Health Stroke Scale was 17 (11-19). Sites of primary occlusion were: 2 internal carotid artery, 12 M1-MCA, 7 M2-MCA, and one P1. Median score evaluation of the appraisal of use was 4- IQR [4-5]. The median number of passes was 1 [IQR 1-2]. First pass complete recanalization rate was 50% and the final recanalization rate was 94.45%. No artery perforation and arterial occlusion. Good functional outcome mRS 0-2 was achieved in 50% of patients. In this initial clinical experience, iNedit device achieved a high rate of first-pass effect and final recanalization rate with no safety concerns, thus favoring a high percentage of good clinical outcomes.

Impact of Balloon Guide Catheters in Elderly Patients Treated with Mechanical Thrombectomy: Insights from the ROSSETTI Registry.

Several nonrandomized studies have demonstrated the effectiveness of balloon guide catheters in treating patients with anterior circulation large-vessel occlusion. However, their impact on the elderly populations has been underreported. We aimed to analyze the effect of balloon guide catheters in a cohort of elderly patients (80 years of age or older) with anterior circulation large-vessel occlusion. Consecutive patients from June 2019 to June 2022 were collected from the ROSSETTI Registry. Demographic and clinical data, angiographic endovascular technique, and clinical outcome were compared between balloon guide catheter and non-balloon guide catheter groups. We studied the association between balloon guide catheters and the rate of complete recanalization after a single first-pass effect modified TICI 2c-3, as well as their association with functional independence at 3 months. A total of 808 patients were included during this period, 465 (57.5%) of whom were treated with balloon guide catheters. Patients treated with balloon guide catheters were older, had more neurologic severity at admission and lower baseline ASPECTS, and were less likely to receive IV fibrinolytics. No differences were observed in terms of the modified first-pass effect between groups (45.8 versus 39.9%, P = .096). In the multivariable regression analysis, balloon guide catheter use was not independently associated with a modified first-pass effect or the final modified TICI 2c-3, or with functional independence at 3 months. In our study, balloon guide catheter use during endovascular treatment of anterior circulation large-vessel occlusion in elderly patients did not predict the first-pass effect, near-complete final recanalization, or functional independence at 3 months. Further studies, including randomized clinical trials, are needed to confirm these results.

Anticoagulation for the treatment of septic cerebral venous sinus thrombosis in the setting of pediatric sinogenic and otogenic intracranial infections.

Septic cerebral venous sinus thrombosis (CVST) is a recognized complication of pediatric sinogenic and otogenic intracranial infections. The optimal treatment paradigm remains controversial. Proponents of anticoagulation highlight its role in preventing thrombus propagation and promoting recanalization, while others cite the risk of hemorrhagic complications, especially after a neurosurgical procedure for an epidural abscess or subdural empyema. Here, the authors investigated the diagnosis, management, and outcomes of pediatric patients with sinogenic or otogenic intracranial infections and a septic CVST. All patients 21 years of age or younger, who presented with an intracranial infection in the setting of sinusitis or otitis media and who underwent neurosurgical treatment at Connecticut Children's, Rady Children's Hospital-San Diego, or Ann and Robert H. Lurie Children's Hospital of Chicago from March 2015 to March 2023, were retrospectively reviewed. Demographic, clinical, and radiological data were systematically collated. Ninety-six patients were treated for sinusitis-related and/or otitis media-related intracranial infections during the study period, 15 (15.6%) of whom were diagnosed with a CVST. Of the 60 patients who presented prior to the COVID-19 pandemic, 6 (10.0%) were diagnosed with a septic CVST, whereas of the 36 who presented during the COVID-19 pandemic, 9 (25.0%) had a septic CVST (p = 0.050). The superior sagittal sinus was involved in 12 (80.0%) patients and the transverse and/or sigmoid sinuses in 4 (26.7%). Only 1 (6.7%) patient had a fully occlusive thrombus. Of the 15 patients with a septic CVST, 11 (73.3%) were initiated on anticoagulation at a median interval of 4 (IQR 3-5) days from the most recent neurosurgical procedure. Five (45.5%) patients who underwent anticoagulation demonstrated complete recanalization on follow-up imaging, and 4 (36.4%) had partial recanalization. Three (75.0%) patients who did not undergo anticoagulation demonstrated complete recanalization, and 1 (25.0%) had partial recanalization. None of the patients treated with anticoagulation experienced hemorrhagic complications. Septic CVST is frequently identified among pediatric patients undergoing neurosurgical intervention for sinogenic and/or otogenic intracranial infections and may have become more prevalent during the COVID-19 pandemic. Anticoagulation can be used safely in the acute postoperative period if administered cautiously, in a monitored setting, and with interval cross-sectional imaging. However, some patients exhibit excellent outcomes without anticoagulation, and further studies are needed to identify those who may benefit the most from anticoagulation.

Comparison of the efficacy and safety between rivaroxaban and dabigatran in the treatment of acute portal vein thrombosis in cirrhosis

BackgroundNew oral anticoagulants (NOACs) have been becoming prevalent in recent years and are increasingly used in the treatment of port vein thrombosis. The difference of the efficacy and safety between rivaroxaban and dabigatran remains unclear in the treatment of cirrhotic patients with acute portal vein thrombosis (PVT).MethodsThis retrospective study included all consecutive cirrhotic patients with acute portal vein thrombosis in our institute from January 2020 to December 2021. The patients received oral anticoagulation with rivaroxaban or dabigatran. The demographic, clinical, and imaging data of patients were collected. The diagnosis of acute PVT was confirmed by imaging examinations. The severity of liver cirrhosis was assessed using Child–Pugh score and Model for End-Stage Liver Disease (MELD) score. Outcomes included recanalization (complete, partial, and persistent occlusion), liver function, bleedings, and survival. The log-rank test was used to compare Kaplan–Meier distributions of time-to-event outcomes. The Cox proportional hazards model was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs).ResultsA total of 94 patients were included, 52 patients (55%) received rivaroxaban and 42 (45%) with dabigatran. The complete and partial recanalization of PVT was observed in 41 patients. There was no significant difference in complete recanalization, partial recanalization, and persistent occlusion between the two groups. With multivariate analysis, D-dimer (HR 1.165, 95% CI 1.036–1.311, p = 0.011) was independent predictors of complete recanalization. The Child–Pugh score (p = 0.001) was significantly improved in both two groups after anticoagulation, respectively. However, there was no difference between the two groups. The probability of survival was 94%, 95% in the rivaroxaban and dabigatran groups (log-rank p = 0.830). Major bleedings were reported in 3 patients (6%) in rivaroxaban group and 1 patient (2%) in dabigatran group (p = 0.646). Six patients (12%) in rivaroxaban group experienced minor bleeding, and five (12%) from dabigatran group (p = 0.691).ConclusionsThe efficacy and safety were comparable between rivaroxaban and dabigatran in the treatment of cirrhotic patients with acute portal vein thrombosis. And D-dimer can contribute to the prediction of PVT recanalization in cirrhotic patients.

Splanchnic vein thrombosis associated with SARS-CoV-2 infection: A VALDIG case–control study

Whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is a risk factor for splanchnic vein thrombosis (SVT) is unknown. This study aims to assess the impact of SARS-CoV-2 infection on the presentation and prognosis of recent SVT and to identify specific characteristics of SARS-CoV-2-associated SVT. This is a retrospective study collecting health-related data of 27 patients presenting with recent SVT in the context of SARS-CoV-2 infection in 12 Vascular Liver Disease Group (VALDIG) centres and in comparison with 494 patients with recent SVT before the SARS-CoV-2 pandemic. Twenty-one patients with SARS-CoV-2 had portal vein thrombosis with or without thrombosis of another splanchnic vein, two had superior mesenteric vein thrombosis, one had splenic vein thrombosis, and three had hepatic vein thrombosis. Diagnosis of SVT was made 10 days (95% CI 0-24 days) after the diagnosis of SARS-CoV-2 infection. Fever (52 vs. 15%; p <0.001) and respiratory symptoms (44 vs. 0%; p <0.001) were more frequent, and median lymphocyte count was lower (1.1×103/mm3vs. 1.6×103/mm3; p= 0.043) in patients with infection than in those without SARS-CoV-2 infection. A prothrombotic condition was identified in 44 and 52% of patients with and without SARS-CoV-2 infection, respectively (p= 0.5). All patients with SARS-CoV-2 received anticoagulation therapy. During a median follow-up of 250 days, three SARS-CoV-2-infected patients (11%) required intestinal resection for infarction 1 to 3 months after diagnosis of SVT compared with 13 (2.6%) controls (p= 0.044). Partial or complete recanalisation of the thrombosed splanchnic vein was performed in 33% of patients with SARS-CoV-2. SARS-CoV-2 infection can be associated with recent SVT. Intestinal infarction leading to intestinal resection might be more frequent in patients with SARS-CoV-2. SARS-CoV-2 infection can be associated with recent SVT. SVT occurring during SARS-CoV-2 infection is characterised by a higher frequency of respiratory symptoms and a lower lymphocyte count. Intestinal infarction leading to intestinal resection appears to occur more frequently in patients with SARS-CoV-2.

Early haemodynamic predictors of poor functional outcomes in patients with acute ischaemic stroke receiving endovascular therapy: a single-centre retrospective study in China.

Changes in cerebral haemodynamics following endovascular therapy (EVT) for large-vessel occlusion stroke may affect the outcomes of patients with acute ischaemic stroke (AIS); however, evidence supporting this belief is limited. This study aims to identify the early haemodynamic predictors of poor outcomes in patients with AIS caused by anterior circulation large-artery occlusion after undergoing EVT and to evaluate the usefulness of these indicators in predicting functional outcomes at 90 days. This retrospective study was conducted at a single academic hospital, using prospectively collected data. We enrolled adult patients with acute anterior circulation stroke who underwent EVT. Transcranial colour-coded sonography (TCCS) examinations of the recanalised and contralateral middle cerebral artery (MCA) were performed within 12 h after undergoing EVT. Haemodynamic indicators were analysed to determine their association with poor functional outcomes (modified Rankin Scale: 3-6) 90 days after stroke. Receiver operating characteristic (ROC) curves were used to evaluate the usefulness of haemodynamic indicators in predicting functional outcomes. In total, 108 patients (median age: 66 years; 69.4% males) were enrolled in this study. Complete recanalization was achieved in 93 patients (86.1%); however, 60 patients (55.6%) had a poor 90-day outcome. The peak systolic velocity (PSV) ratio, adjusted PSV ratio, mean flow velocity (MFV) ratio, and adjusted MFV ratio of the MCA were significantly higher in patients with poor prognosis than in patients with good prognosis (p<0.02). A multivariate logistic regression analysis showed that higher PSV ratio, adjusted PSV ratio, MFV ratio, and adjusted MFV ratio were independently associated with a poor 90-day outcomes (adjusted odds ratio: 1.11-1.48 for every 0.1 increase; p<0.03). Furthermore, adding the adjusted MFV ratio significantly improved the prediction ability of the basic model for the 90-day poor functional outcome using the ROC analysis, the areas under ROC curves increased from 0.75 to 0.85 (p=0.013). Early TCCS examination may help in predicting poor functional outcomes at 90 days in patients with AIS who underwent EVT. Moreover, combining novel TCCS indicators (adjusted MFV ratio) with conventional parameters improved the prediction ability of the base model.

Effect of race/ethnicity on arterial recanalization following intravenous thrombolysis in acute ischemic stroke patients

IntroductionSeveral reports have identified that clinical outcomes such as death or disability in acute ischemic stroke (AIS) patients following intravenous (IV) tissue plasminogen activator (tPA) treatment can vary according to race and ethnicities. We determined the effect of race/ethnicity on rates of arterial recanalization in AIS patients with large vessel occlusion (LVO) after IV tPA. MethodsWe analyzed 234 patients with LVO detected on computed tomographic angiography (CTA) who received IV tPA and subsequently underwent angiography for potential thrombectomy. The primary occlusion sites on CTA and digital subtracted angiography (DSA) were compared and a score was given to the level of recanalization with values ranging from 1 (complete recanalization), 2 (partial recanalization), or 3 (no recanalization).The effect of race/ethnicity were assessed for predicting vessel recanalization using the covariates of age, gender, time since stroke onset, tPA dose received, NIHSS (National Institute of Health Stroke Scale) score at baseline, and location of the occlusion, using logistic regression analysis. ResultsFive patients (2.1%) were Hispanic or Latino, 8 (3.4%) Asian, 24 (10.3%) African American, and 197 (84.2%) White. A total of 50% had a distal ICA/proximal M1 occlusion, 20% distal M1 occlusion, and 16% single M2 occlusion. At the primary occlusion site, 44 (18.8%) had complete recanalization on post IV tPA angiogram, 17 (7.3%) had partial recanalization, and 165 (70.5%) had no recanalization. We did not find any association between race/ethnicity and vessel recanalization post IV tPA (Nonwhite combined [OR=1.49, p=0.351]; Asian [OR=1.460, p=0.650]; African American [OR=1.508, p=0.415]; White [OR=0.672, p=0.351]; ethnicity (Hispanic or Latino) [OR= 1.008, p=0.374]); Occlusion location (OR=0.189, p<0.001). Final TICI scores and mRS at 90 days were similar among the different groups. ConclusionApproximately 19% of patients had complete recanalization after IV tPA, but race and ethnicity did not seem to have an effect on arterial recanalization. Arterial recanalization was only affected by location of occlusion.

Thrombectomy for M2 Occlusions: Predictors of Successful and Futile Recanalization.

Patient-specific factors associated with successful recanalization in mechanical thrombectomy (MT) have been evaluated for acute ischemic stroke with large vessel occlusion. However, MT for M2 occlusions is still a matter of debate, and predictors of successful and futile recanalization have not been assessed in detail. We sought to identify predictors of recanalization success in patients with M2 occlusions undergoing MT based on large-scale clinical data. All patients prospectively enrolled in the German Stroke Registry (May, 2015 to December, 2021) were screened (N=13 082). Inclusion criteria for the complete case analysis were isolated M2 occlusions. Standard descriptive statistics and multivariable logistic regression analysis were used to identify factors associated with successful recanalization (Thrombolysis in Cerebral Infarction [TICI]≥2b), complete recanalization (TICI=3) and futile recanalization (TICI≥2b with 90-day modified Rankin Scale [mRS] score >2). One thousand two hundred ninety-four patients were included, thereof 439 (33.9%) with TICI=2b and 643 (49.7%) with TICI=3. Five hundred sixty-nine (44%) patients had good functional outcome (90-day mRS score ≤2). In multivariable logistic regression, general anesthesia (adjusted odds ratio [aOR], 1.47 [95% CI, 1.05-2.09]; P<0.05) was associated with higher probability of TICI≥2b while intraprocedural change from local to general anesthesia (aOR, 0.49 [0.26-0.95]; P<0.05) and higher pre-mRS (aOR, 0.75 [0.67-0.85]; P<0.001) lowered probability of successful recanalization. Futile recanalization was associated with higher age (aOR, 1.05 [1.04-1.07]; P<0.001), higher prestroke mRS (aOR, 3.12 [2.49-3.91]; P<0.001), higher NIHSS at admission (aOR, 1.11 [1.08-1.14]; P<0.001), diabetes (aOR, 1.96 [1.38-2.8]; P<0.001), higher number of passes (aOR, 1.29 [1.14-1.46]; P<0.001), and adverse events (aOR, 1.82 [1.2-2.74]; P<0.01). Higher Alberta Stroke Program Early CT Score (aOR, 0.85 [0.76-0.94]; P<0.01) and IV thrombolysis (aOR, 0.71 [0.52-0.97]; P<0.05) reduced risk of futile recanalization. In patients with M2 occlusions, successful recanalization was significantly associated with general anesthesia and low prestroke mRS, while intraprocedural change from conscious sedation to general anesthesia increased risk of unsuccessful recanalization, presumably caused by difficult anatomy and movement of patients in these cases. Futile recanalization was associated with severe prestroke mRS, comorbidity diabetes, number of passes and adverse events during treatment. IV thrombolysis reduced the risk of futile recanalization.

Endovascular treatment of acute basilar artery occlusion: A systematic review and meta-analysis of first-line stent retriever versus direct aspiration.

The best choice between first-line aspiration and stent retriever for acute basilar artery occlusion remains controversial. This study aims to perform a systematic review and meta-analysis comparing the stent retriever and direct aspiration about reported recanalization rates and periprocedural complications. PubMed, Embase, Web of Science, Cochrane, and Clinical Trials were searched for the studies evaluating the efficacy and safety of first-line aspiration versus stent retriever for acute basilar artery occlusion. A standard software program (Stata Corporation) was used for end-point analyses. Statistical significance was defined as a p-value less than .05. A total of 11 studies were involved in the current study, including 1014 patients. Regarding postoperative recanalization, the pooled analysis identified a significant difference in successful recanalization (odds ratio [OR]=1.642; 95% confidence interval (95% CI): 1.099-2.453; p=.015) and complete recanalization (OR=3.525; 95% CI: 1.306-2.872; p=.001) between the two groups in favor of the first-line aspiration. Concerning the complications, the first-line aspiration could achieve a lower rate of total complication (OR=.359; 95% CI: .229-.563; p<.001) and hemorrhagic complication (OR=.446, 95% CI: .259-.769; p=.004) than stent retriever. No significant difference was observed in postoperative mortality (OR=.966; p=.880), subarachnoid hematoma (OR=.171; p=.094), and parenchymal hematoma (OR=.799; p=.720). In addition, the pooled results revealed a significant difference in procedure duration between the two groups in favor of aspiration (WMD=-27.630, 95% CI: -50.958 to -4.302; p=.020). However, there was no significant difference in favorable outcome (OR=1.149; p=.352) and rescue therapy (OR=1.440; p=.409) between the two groups. Given that the first-line aspiration was associated with a higher rate of postoperative recanalization, a lower risk of postoperative complication, and a faster duration of the procedure, these findings support the aspiration may be more secure than a stent retriever.

Predictive Factors of First-Pass Effect in Patients Who Underwent Successful Endovascular Thrombectomy for Emergent Large Vessel Occlusion.

The primary treatment goal of current endovascular thrombectomy (EVT) for emergent large-vessel occlusion (ELVO) is complete recanalization after a single maneuver, referred to as the 'first-pass effect' (FPE). Hence, we aimed to identify the predictive factors of FPE and assess its effect on clinical outcomes in patients with ELVO of the anterior circulation. Among the 129 patients who participated, 110 eligible patients with proximal ELVO (intracranial internal carotid artery and proximal middle cerebral artery) who achieved successful recanalization after EVT were retrospectively reviewed. A comparative analysis between patients who achieved FPE and all others (defined as a non-FPE group) was performed regarding baseline characteristics, clinical variables, and clinical outcomes. Multivariate logistic regression analyses were subsequently conducted for potential predictive factors with p<0.10 in the univariate analysis to determine the independent predictive factors of FPE. FPE was achieved in 31 of the 110 patients (28.2%). The FPE group had a significantly higher level of functional independence at 90 days than did the non-FPE group (80.6% vs. 50.6%, p=0.002). Pretreatment intravenous thrombolysis (IVT) (odds ratio [OR], 3.179; 95% confidence interval [CI], 1.025-9.861; p=0.045), door-to-puncture (DTP) interval (OR, 0.959; 95% CI, 0.932-0.987; p=0.004), and the use of balloon guiding catheter (BGC) (OR, 3.591; 95% CI, 1.231-10.469; p=0.019) were independent predictive factors of FPE. In conclusion, pretreatment IVT, use of BGC, and a shorter DTP interval were positively associated with FPE, increasing the chance of acquiring better clinical outcomes.

Mechanical thrombectomy with intra-arterial thrombolysis versus mechanical thrombectomy alone in patients with acute ischemic stroke: A systematic review and meta-analysis.

There is conflicting evidence as to whether intra-arterial thrombolysis (IAT) adds benefit in patients with acute stroke who undergo mechanical thrombectomy (MT). We conducted a systematic review to identify studies that evaluate IAT in patients with acute stroke who undergo MT. Data were extracted from relevant studies found through a search of PubMed, Scopus, and Web of Science until February 2023. Statistical pooling with random effects meta-analysis was undertaken to evaluate odds of functional independence, mortality, and near-complete or complete angiographic recanalization with IAT compared to no IAT. A total of 18 studies were included (3 matched, 14 unmatched, and 1 randomized). The odds ratio (OR) for functional independence (modified Rankin Scale: 0-2) at 90 days was 1.14 (95% confidence interval (CI): 0.95-1.37, p = 0.17, 16 studies involving 7572 patients) with IAT with moderate between-study heterogeneity (I2 = 38.1%). The OR for functional independence with IAT was 1.28 (95% CI: 0.92-1.78, p = 0.15) in studies that were either matched or randomized and 1.24 (95% CI: 0.97-1.58, p = 0.08) in studies with the highest quality score. IAT was associated with higher odds of near-complete or complete angiographic recanalization (OR: 1.65, 95% CI: 1.03-2.65, p = 0.04) in studies that were either matched or of randomized comparisons. Although the odds of functional independence appeared to be higher with IAT and MT compared with MT alone, none of the results were statistically significant. A prominent effect of the design and quality of the studies was observed on the association between IAT and functional independence at 90 days.

Predictors for hemorrhagic transformation and cerebral edema in stroke patients with first-pass complete recanalization.

Predictors of radiological complications attributable to reperfusion injury remain unknown when baseline setting is optimal for endovascular treatment and procedural setting is the best in stroke patients with large vessel occlusion (LVO). To identify clinical and radiological/procedural predictors for hemorrhagic transformation (HT) and cerebral edema (CED) at 24 hr in patients obtaining complete recanalization in one pass of thrombectomy for ischemic stroke ⩽ 6 h from symptom onset with intra-cranial anterior circulation LVO and ASPECTS ⩾ 6. We conducted a cohort study on prospectively collected data from 1400 patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. HT was reported in 248 (18%) patients and early CED was reported in 260 (19.2%) patients. In the logistic regression model including predictors from a first model with clinical variables and from a second model with radiological/procedural variables, diabetes mellitus (odds ratio (OR) = 1.832, 95% confidence interval (CI) = 1.201-2.795), higher National Institutes of Health Stroke Scale (NIHSS) (OR = 1.076, 95% CI = 1.044-1.110), lower Alberta Stroke Program Early CT (ASPECTS) (OR = 0.815, 95% CI = 0.694-0.957), and longer onset-to-groin time (OR = 1.005, 95% CI = 1.002-1.007) were predictors of HT, whereas general anesthesia was inversely associated with HT (OR = 0.540, 95% CI = 0.355-0.820). Higher NIHSS (OR = 1.049, 95% CI = 1.021-1.077), lower ASPECTS (OR = 0.700, 95% CI = 0.613-0.801), intravenous thrombolysis (OR = 1.464, 95% CI = 1.061-2.020), longer onset-to-groin time (OR = 1.002, 95% CI = 1.001-1.005), and longer procedure time (OR = 1.009, 95% CI = 1.004-1.015) were predictors of early CED. After repeating a fourth logistic regression model including also good collaterals, the same variables remained predictors for HT and/or early CED, except diabetes mellitus and thrombolysis, while good collaterals were inversely associated with early CED (OR = 0.385, 95% CI = 0.248-0.599). Higher NIHSS, lower ASPECTS, and longer onset-to-groin time were predictors for both HT and early CED. General anesthesia and good collaterals were inversely associated with HT and early CED, respectively. Longer procedure time was predictor of early CED.