Emergent Large Vessel Occlusion Research Articles

Association between age and outcomes following thrombectomy for anterior circulation emergent large vessel occlusion is determined by degree of recanalisation

BackgroundOlder patients undergoing thrombectomy for emergent large vessel occlusion have worse outcomes. However, complete or near-complete reperfusion (modified Thrombolysis in Cerebral Ischemia (mTICI) score of 2 c/3) is associated with...

Ultra-early IV tPA for emergent large vessel occlusion strokes improves clinical outcomes (P4.236)

Ultra-early IV tPA for emergent large vessel occlusion strokes improves clinical outcomes (P4.236)

An Emergent Large Vessel Occlusion Screening Protocol for Acute Stroke: A Quality Improvement Initiative.

Nurses play an integral role in triaging stroke patients. The purpose of this quality improvement initiative was to determine the efficacy of using an emergent large vessel occlusion (ELVO) screening protocol in the emergency department by nursing staff to improve identification of eligible patients as compared with current practice, improving time to endovascular treatment. Retrospective chart review was used to identify 76 patients admitted to a large urban stroke center. Of these, 36 presented during a 4-month period before the implementation of the Stroke Vision, Aphasia, Neglect (Stroke VAN) tool for assessing ELVO risk; 40 patients were admitted during the 4 months after implementation of Stroke VAN. The mean door-to-computed tomography angiography scan times were reduced from 119 to 49 minutes (P < .0001) for all patients and reduced from 77 to 27 minutes in a subset of VAN-positive patients. Implementation of the VAN screening tool to assess for ELVO was associated with decreased door-to-computed tomography angiography times and more rapid identification of endovascular eligible patients with ischemic stroke.

An Emergent Large Vessel Occlusion Screening Protocol for Acute Stroke: A Quality Improvement Initiative.

An Emergent Large Vessel Occlusion Screening Protocol for Acute Stroke: A Quality Improvement Initiative.

Comparative safety and efficacy of combined IVT and MT with direct MT in large vessel occlusion.

In this multicenter study, we sought to evaluate comparative safety and efficacy of combined IV thrombolysis (IVT) and mechanical thrombectomy (MT) vs direct MT in emergent large vessel occlusion (ELVO) patients. Consecutive ELVO patients treated with MT at 6 high-volume endovascular centers were evaluated. Standard safety and efficacy outcomes (successful reperfusion [modified Thrombolysis in Cerebral Infarction IIb/III], functional independence [FI] [modified Rankin Scale (mRS) score of 0-2 at 3 months], favorable functional outcome [mRS of 0-1 at 3 months], functional improvement [mRS shift by 1-point decrease in mRS score]) were compared between patients who underwent combined IVT and MT vs MT alone. Additional propensity score-matched analyses were performed. A total of 292 and 277 patients were treated with combination therapy and direct MT, respectively. The combination therapy group had greater functional improvement (p = 0.037) at 3 months. After propensity score matching, 104 patients in the direct MT group were matched to 208 patients in the combination therapy group. IVT pretreatment was independently (p < 0.05) associated with higher odds of FI (odds ratio [OR] 1.75; 95% confidence interval [CI] 1.02-2.99) and functional improvement (common OR 1.64; 95% CI 1.05-2.56). Combination therapy was independently (p < 0.05) related to lower likelihood of 3-month mortality (0.50; 95% CI 0.26-0.96). This observational study provides preliminary evidence that IVT pretreatment may improve outcomes in ELVO patients treated with MT. The question of the potential effect of IVT on ELVO patients treated with MT should be addressed with a randomized controlled trial. This study provides Class III evidence that for stroke patients with emergent large vessel occlusion, combined IVT and MT is superior to direct MT in improving functional outcomes.

The VITAL study and overall pooled analysis with the VIPS non-invasive stroke detection device

IntroductionEffective triage of patients with emergent large vessel occlusion (ELVO) to endovascular therapy capable centers may decrease time to treatment and improve outcome for these patients. Here we performed a...

Streamlined triage and transfer protocols improve door-to-puncture time for endovascular thrombectomy in acute ischemic stroke

ObjectiveShorter time from symptom onset to treatment is associated with improved outcomes in patients who undergo mechanical thrombectomy for treatment of acute ischemic stroke due to emergent large vessel occlusion. In this work, we detail pre-thrombectomy process improvements in a multi-hospital network and report the effect on door-to-puncture time in patients undergoing mechanical thrombectomy. Patients and MethodsA streamlined workflow was adopted to minimize door-to-puncture time. Key features of this workflow included rapid and concurrent clinical and radiological evaluation with point-of-care image interpretation, pre-transfer IV thrombolysis and CTA for transferred patients, immediate transport to the angiography suite potentially before neurointerventional radiology team arrival, and minimalist room setup. Door-to-puncture time was measured prospectively and analyzed retrospectively for 78 consecutive patients treated between January 2015 and December 2015. Statistical analysis was performed using the F-test on individual coefficients of a linear regression model. ResultsFrom quarter 1 to quarter 4, the number of thrombectomies performed increased by 173% (11 patients to 30 patients, p = 0.002), and there was a significant increase in the proportion of transferred patients that underwent pre-transfer CTA (p = 0.04). During this interval, overall median door-to-puncture time decreased by 74% (147 min to 39 min, p < 0.001); this decrease was greatest in transferred patients with pre-transfer CTA (81% decrease, 129 min to 25 min, p < 0.001) and smallest in patients presenting directly to the emergency department (52% decrease, 167 min to 87 min, p < 0.001). ConclusionSimple workflow improvements to streamline in-hospital triage and perform critical workup at transferring hospitals can produce reductions in door-to-puncture time.

Magnetic resonance-guided, high-intensity focused ultrasound sonolysis: potential applications for stroke.

Stroke is one of the leading causes of death worldwide and a significant source of long-term morbidity. Unfortunately, a substantial number of stroke patients either are ineligible or do not significantly benefit from contemporary medical and interventional therapies. To address this void, investigators recently made technological advances to render transcranial MR-guided, high-intensity focused ultrasound (MRg-HIFU) sonolysis a potential therapeutic option for both acute ischemic stroke (AIS)-as an alternative for patients with emergent large-vessel occlusion (ELVO) who are ineligible for endovascular mechanical thrombectomy (EMT) or as salvage therapy for patients in whom EMT fails-and intracerebral hemorrhage (ICH)-as a neoadjuvant means of clot lysis prior to surgical evacuation. Herein, the authors review the technological principles behind MRg-HIFU sonolysis, its results in in vitro and in vivo stroke models, and its potential clinical applications. As a noninvasive transcranial technique that affords rapid clot lysis, MRg-HIFU thrombolysis may develop into a therapeutic option for patients with AIS or ICH. However, additional studies of transcranial MRg-HIFU are necessary to ascertain the merit of this treatment approach for thrombolysis in both AIS and ICH, as well as its technical limitations and risks.

Abstract TP122: Validation of the Vision Aphasia Neglect (VAN) Screening Tool for Clinical Diagnosis of Emergent Large Vessel Occlusion

Objective: Numerous screening tools have emerged in an effort to identify patients with emergent large vessel occlusion (ELVO) for mechanical thrombectomy (MT). The vision, aphasia, and neglect (VAN) screening tool was designed as a quick evaluation of cortical function to predict ELVO and was shown to be effective when used in the emergency room in predicting ELVO with a 100% sensitivity and 90% specificity in the pilot study of 62 patients. The objective of this study was to evaluate the VAN tool as applied to a large patient population and assess its ability to predict ELVO. Methods: Emergency visits that resulted in diagnosis of stroke or received thrombolysis for stroke in a community hospital over 18 months were reviewed. The VAN tool was applied, using components of initial NIHSS to identify changes in vision, language, or attention coupled with weakness. Patients were also screened for NIHSS ≥6. These two indices were evaluated for ability to predict ELVO and then candidacy for MT based on guideline criteria for MT. Results: Of 617 patient cases reviewed, 159 (25.9%) were VAN positive while 233 (37.9%) had an NIHSS ≥6. Sixty-four (64) patients (10.4%) had ELVO. The VAN score had a sensitivity of 61% and a specificity of 76.8% for predicting ELVO, while an NIHSS value ≥6 had a sensitivity of 71.7% and a specificity of 63.6%. Of 38 VAN positive patients with ELVO, only 18 met all current guideline criteria for MT, representing only 11% of all VAN positive patients. Of 43 patients with an NIHSS ≥6 who had ELVO, 19 met criteria for MT, 8.2% of all NIHSS ≥6 patients. Only 19 of 617 stroke patient cases reviewed 19 had ELVO eligible for MT (3.1%). Discussion: This study demonstrates that in a much larger population than that of the pilot study, the VAN screening tool for ELVO has a lower sensitivity and specificity than believed. Barring limitations, this population is ten times as large as the pilot study and shows that ELVO as well as ELVO meeting criteria for MT among VAN positive patients are less common than previously predicted by the VAN tool. Continued work needs to analyze and compare ELVO screening tools for predicting ELVO, and guidelines for MT need to adapt in a rapidly evolving field, especially with this and other studies suggesting an even larger population could benefit from MT.

Abstract WP64: Ultra-early Treatment With IV tPA for Large Artery Occlusion Improves Recanalization Rates and Clinical Outcomes

Introduction: Emergent large vessel occlusions (ELVO) cause approximately 45% of ischemic strokes and are associated with poor outcomes. With the advent of intra-arterial therapy (IAT), the role of IV tPA for treatment of ELVO stroke has been questioned. We hypothesized that ultra-early treatment with IV tPA for ELVO stroke improves recanalization rates and clinical outcomes. Methods: Retrospective chart review was performed of patients who received IV tPA for ELVO stroke and were treated at our institution between January 2013 and December 2016. We compared patients treated with IV tPA within 60 minutes of being last known well (LKW) with patients treated beyond 60 minutes in regards to (1) recanalization, defined as complete reconstitution of blood flow on arterial imaging, (2) early neurological improvement, defined as National Institute of Health Stroke Scale (NIHSS) of ≤ 1 or decline by ≥ 5 points at 24 hour post-IV tPA, (3) 90 day functional status measured by modified Rankin Scale (mRS), and (4) mortality at 90 days. Results: Of 201 patients with ELVO ischemic stroke, 158 patients had adequate post-IV tPA arterial imaging. 25 patients were treated within 60 minutes of LKW, while the remaining 133 patients were treated beyond 60 minutes. Groups did not differ in regards to age, gender, cardiovascular risk factors, NIHSS on presentation, baseline mRS, or occlusion location. The percentage of patients who underwent IAT for persistent occlusion did not differ between the two groups. Recanalization of arterial occlusion following IV tPA without IAT, early neurological improvement, survival, and good clinical outcome were more frequent in patients who received IV tPA within 60 minutes of LKW. Conclusion: Our data suggest that ultra-early IV tPA administration for ELVO stroke increases the chance of recanalization and leads to improved clinical outcomes. Prospective studies are needed to verify our findings.

Abstract TP239: Initial Results From a Community Emergency Medical System Based Bypass Protocol Using Rapid Arterial Occlusion Scale to Screen for Emergent Large Vessel Occlusion

Introduction: Although mechanical thrombectomy (MT) is the standard of care for patients with acute ischemic stroke due to emergent large vessel occlusion (ELVO), few patients remain eligible for MT due to pre-hospital delays and presentation to non-MT capable hospitals. Emergence of in field screening tools have allowed EMS to reliably identify patients with likely ELVO, thus facilitating their direct triage to MT capable hospitals for prompt thrombectomy. Methods: In collaboration with the Peninsulas EMS Council (PEMS), we implemented a community based pilot program in the Hampton Roads region of Southeastern Virginia to identify patients with ELVO by utilizing the Rapid Arterial oCclusion Evaluation (RACE) scale, a validated in field screening tool. Under this protocol, since March 1 st , 2017, patients with a RACE score of ≥ 5, presenting within 6 hours of last known well would be transported directly to a Comprehensive Stroke Center (CSC) rather than a Primary Stroke Center (PSC), provided the bypass does not prolong the trip by more than 15 minutes. We present the initial results of this study including iv tPA and MT treatment rates, time metrics, and patient outcomes, in comparison to the pre-RACE protocol data. Results: Between March 1 st and June 30 th , 2017, of the 75 brain attacks received in our CSC, 45 patients were screened using the RACE scale by the EMS. 30 patients scored ≥ 5 on the RACE scale (RACE +) and 21 of those bypassed PSCs on their way. RACE + patients had a higher median NIHSS (16 vs. 6, p &lt; .0 5 ), and ischemic strokes (70% vs. 58%), compared to the non-RACE + patients in the preceding 4 months. Improved time metrics (median) were observed for symptom onset to arrival (54 min vs. 81 min), arrival to CT (8.5 min vs. 12 min, p &lt; .05), DTN (36 min vs. 47 min), DTG (94 min vs. 105 min), and arrival to recanalization with MT (142 min vs. 185 min). IV tPA (27% vs. 11%) and MT treatments rates (33% vs. 11%) with TICI ≥ 2b (90% vs. 77%) were higher in the RACE + patients compared to the non-RACE + cohort. Conslusion: Our pilot program employing RACE as an in field screening tool for ELVO and using it to bypass PSCs in favor of CSCs is feasible in the community setting, and demonstrates improved metrics in key domains known to be associated with better outcomes for these patients.

Abstract 145: Thrombus Composition is Associated With Endothelial Injury and Stroke Etiology in Patients Undergoing Mechanical Thrombectomy for Emergent Large Vessel Occlusion

Introduction: High rates of recanalization of Emergent Large Vessel Occlusion (ELVO) provide an opportunity to examine retrieved thrombi. We studied device and endothelial (ET) interactions to evaluate ET injury and the relationship between thrombi and Acute Ischemic Stroke (AIS) mechanism. Methods: Prospective registry examining immunohistochemical characteristics of retrieved thrombi in ELVO patients. Thrombi were categorized histopathologically and ET injury quantified by CD34 staining and immunohistochemistry, ELISA and reverse transcribed quantitative PCR to detect ET components. ET mRNA expression of CD31 was quantified from thrombi RNA. Plasma at the thrombectomy site was tested for ET derived biomarkers: microparticles (MPs), soluble Intercellular Cell Adhesion Molecule-1 (sICAM1) and soluble Thrombomodulin (sTM). Statistical analysis was performed with unpaired student’s t-tests and chi-square tests. Results: Twenty-five patients (age 68±3 , NIHSS 16±2, 48% female) were enrolled. The most common sites of occlusion were the MCA (9) and ICA (7). Eighty eight % of patients required three or less attempts at recanalization and 71 % achieved TICI 2b or 3. Histopathology demonstrated fibrin rich (5), erythrocytic (2), layered (7), and serpentine (11) thrombi and four were CD 34 positive. Levels of plasma biomarkers were: sTM 2.2±0.4 (&lt;0.6-10.2ng/ml), MPs 101.4±18.4 (1.33-221nM), and sICAM1 160.0±19.8 (&lt;15-406.1ng/ml). Patients with &gt; 3 revascularization attempts had higher levels of sTM (5.5±0.4 vs 1.7±0.2, p&lt;0.0002), sICAM (261.2±79.2 vs. 146.3±20.3, p&lt;0.03), and CD31CT (27.7±0.8 vs 25.5±0.3, p &lt; 0.03). Patients with PH 1 or 2 ICH had higher levels of microparticles than those without ICH or with HI 1 or 2 (203±19 vs 92±19, p&lt;0.05). Patients with cardioembolic stroke had higher sTM (2.8±0.8 vs. 1.3±0.3, p&lt;0.05) and sICAM1 levels (186±32 vs. 115±29, p&lt;0.05) than those with carotid or intracerebral atherosclerosis. Conclusions: ET markers can be detected in the retrieved thrombi and plasma milieu of ELVO patients. ET markers relate to increasing number of attempts at thrombectomy indicating ET disruption. sTM and sICAM are more common in patients with cardioembolic stroke and may serve as thrombus associated markers of AIS mechanism.

Abstract 83: Successful Recanalization With Intravenous Thrombolysis Preceding Mechanical Thrombectomy in Large Vessel Occlusions: A Systematic Review and Meta-Analysis

Introduction: Although current guidelines advocate pretreatment with intravenous thrombolysis (IVT) in all eligible patients with emergent large vessel occlusion (ELVO) prior to mechanical thrombectomy (MT), there are observational data questioning the efficacy of IVT pretreatment in patients with ELVO. One of the main arguments in favour of IVT pretreatment is the potential for tPA-induced successful recanalization (SR) before the onset of endovascular procedure averting the need for MT. Methods: We performed a systematic review in MEDLINE and SCOPUS databases for randomized clinical trials (RCTs) and observational cohorts providing rates of SR with IVT in patients with ELVO before the initiation of MT. We also performed subgroup analyses according to study type (RCTs or observational) and according to the inclusion per-protocol of patients with tandem (intracranial/extracranial) occlusions. Results: We identified 10 eligible studies (7 RCTs &amp; 3 observational cohorts), including 1227 ELVO patients (median NIHSS score: 17). SR following IVT and before MT was documented in 9% (95%CI: 5%-14%; I 2 =85.4%) of ELVO patients, with no significant (p=0.263) differences among RCTs and observational cohorts (Figure). Higher tPA-induced SR rates were identified in studies reporting exclusion of patients with tandem occlusions compared to the rest (15%, 95%CI: 6%-26% vs 5%, 95%CI: 2%-9%; p for subgroup difference=0.052). Conclusions: Pretreatment with IVT in ELVO patients eligible for MT results in SR in almost one out of ten cases, negating the need for additional endovascular reperfusion. Tandem occlusions appear to be the least responsive to IVT pretreatment.

Abstract TP48: Fluid-Attenuated Inversion Recovery Hyperintense Vessel Predicts Pre- and Post-Recanalization Infarct Lesion

Background and Purpose: In patients with emergent large vessel occlusion (ELVO), fluid-attenuated inversion recovery (FLAIR) hyperintense vessel (FHV) has been linked to cerebral hypoperfusion. However, the association between FHV and infarction lesion after successful recanalization by endovascular thrombectomy (ET) remains unknown. In this study, we investigated the relationship baseline FHV and baseline or post-ET diffusion weighted imaging (DWI) positive lesions. Methods: From April 2012 to August 2016, fifty-nine patients were received ET for ELVO of the anterior circulation. We included twenty-five patients of them who obtained successful (Thrombolysis In Cerebral Infarction score 2b/3) recanalization of ICA or M1 occlusion. All patients had DWI before and after ET and FLAIR before ET. Infarct lesions and FHV were evaluated in seven cortical lesions which divided according to cortical area of Alberta Stroke Program Early CT (ASPECT) scoring (I, M1-M6). The association between baseline or post-ET DWI positive and baseline FHV was analyzed in each one hundred seventy-five lesions. Results: DWI positive lesions were present in 65/171 (37%) and 108/175 (62%) lesions on baseline and post-ET DWI, respectively. FHV was present in 89/175 (51%) lesions on baseline FLAIR. Baseline DWI positive lesion was significantly higher at FHV positive lesion than FHV negative lesion (FHV (+) vs. FHV (-): 56% vs. 17%, p&lt;0.0001). In one-hundred ten baseline DWI negative lesions, FHV positive lesion was likely to become post-ET DWI positive than FHV negative lesion (FHV (+) vs. FHV (-): 51% vs. 32%, p=0.052). In patients who obtained successful recanalization within 6 hours from onset, post-ET DWI positive lesion was significantly higher at FHV positive lesion than FHV negative lesion (FHV (+) vs. FHV (-): 55% vs. 29%, p=0.0234). Conclusion: Baseline FHV positive lesions have already been infarcted before ET and likely to become infarction after successful recanalization compared to FHV negative lesion. Because FHV positive lesion became infarct despite early successful recanalization, FHV seemed to suggest severe hypoperfusion.

Abstract WP292: Changing Landscape of Stroke Systems of Care: Increase in Inter Hospital Transfer in the United States

Purpose: Interhospital transfer is necessary to facilitate endovascular therapy (EVT) for patients with emergent large vessel occlusion (ELVO) who present to nonendovascular centers. We hypothesized that interhospital transfer would accelerate following 2014 pivotal randomized controlled trials (RCTs) demonstrating benefits of EVT. Methods: We analyzed trend of interhospital transfer for EVT using Get With The Guideline (GWTG)-Stroke from January 2012 to September 2016. Analyses of transfer-in trend for the hospitals consistently providing EVT were restricted to hospitals with &gt;1 EVT/quarter in last 4 study quarters (250 sites). We analyzed trend of interhospital transfer for all ischemic stroke (IS) patients and following subgroup: NIHSS ≥6 and arrival to the EVT-providing hospital within 7 hours of last known well. Results: During the study period 31425 patients received EVT. Transfer-in EVT cases increased from 334 to 912 from Q3 2014 to Q3 2016 (p&lt;0.001 for change in linear trend, Figure 1A). Interhospital transfer for EVT is common (44% in Q3 2016) and increasing proportion of IS patients are arriving to EVT-providing hospitals as transfers, especially among the subgroup of NIHSS ≥6 and arrival to the EVT-providing hospital within 7 hours of last known well (Figure 1B). Since RCT announcement, transfer-in patients receive EVT at a significantly higher rate (5.2% in Q3 2014 vs. 10.8% in Q3 2016, Figure 1C). Hospitals with a higher % transfer-in EVT (comparing top quartile to bottom quartile) were more likely to have more beds and be in an urban location, with comprehensive stroke center certification and higher annual EVT volumes. Conclusions: Interhospital transfer of IS patients has accelerated markedly in the past two years, highlighting the need to develop protocols and quality metrics to ensure efficient systems of care for this subset of patients.

Abstract TP13: Predicting Outcomes After Successful Endovascular Thrombectomy: Damage Control

Introduction: Endovascular Therapy (ET) has become the new standard of care for treating acute ischemic stroke (AIS) patients with Emergent Large Vessel Occlusion (ELVO). There are numerous tools that predict outcomes of ischemic stroke patients including those given IV tPA, however, there are no published tools for predicting outcomes after ET. Methods: From January 2015-March 2017, 109 AIS patients received ET. Patients with unsuccessful ET (TICI 0-2a) or with incomplete 90 day follow-up data were excluded, leaving 42 for final analysis. Primary outcome was defined as MRS at 90 days (good outcome MRS &lt;=3, bad outcome MRS &gt;3). Of the variables analyzed, 90 day outcomes correlated with age, diabetes, thrombolytic use, onset to groin time, and NIHSS scores. Numerical values were assigned to each variable based on OR analysis and the resulting score (range 0-8) was plotted against 90 day MRS and ROC analysis defined a cutoff value. Results: The relative score for each non-binary variable was approximated based on the corresponding OR identified during ROC analysis. Using the DamAGE cONTrol scoring tool (figure 1), a cut off of 4 points yielded Sn 0.82, Sp 0.95, p &lt;0.001, &amp; AUC 0.94 . Conclusion: DamAGE cONTrol represents a novel scoring tool which uses pre-intervention characteristics to predict outcome after successful ET. This type of tool may facilitate more informed discussions regarding the value of performing ET, as well as control unnecessary transfers.

Abstract TP95: Intra-arterial Interleukin-1 alpha is Well Tolerated and Neuroprotective After Experimental Ischemic Stroke

Endovascular thrombectomy combined with t-PA is the current standard of care for emergent large vessel occlusion (ELVO) stroke. Unfortunately, despite rising recanalization rates, stroke remains the leading cause of long-term disability worldwide suggesting that additional therapies are needed. Severe stroke morbidity may be due, partially, to the acute and sustained inflammatory stroke response. Preclinical research has shown some promise with anti-inflammatory agents in limiting brain injury and improving functional outcome; however, the post-stroke inflammatory cascade appears to have both beneficial and deleterious effects making the translation of such anti-inflammatory approaches perilous. We aim to show that the inflammatory cytokine interleukin-1alpha (IL-1α) is well-tolerated, neuroprotective, and conveys functional benefit after ischemic stroke. 3-month-old C57/BL6 mice were subjected to MCAo and given IL-1α via IV injection or IA infusion upon recanalization. Mice were allowed to recover for 7 days before sacrifice. Brains were flash frozen for IHC and serum for high sensitivity ELISA. We noted that IV IL-1α (1 ng) is neuroprotective (as measured by cresyl violet stained infarct volumes) and significantly improved functional recovery in open field behavioral tests. When given IV, IL-1α showed transient hemodynamic side effects that are typical of IL-1α’s known physiologic functions (fever, sterile inflammation, etc.) These effects are short lived with systemic (IV) administration and IA IL-1α (0.1 ng) administration showed neuroprotection without the side effects seen with IV treatment. Additionally, we noted that IL-1α is directly neuroprotective of primary mouse cortical neurons exposed to oxygen and glucose deprivation conditions in vitro . IL-1α’s profound, direct neuroprotective effects and its functional benefit, make IL-1α an attractive target for future study in ischemic stroke.

Neuroendovascular management of emergent large vessel occlusion: update on the technical aspects and standards of practice by the Standards and Guidelines Committee of the Society of NeuroInterventional Surgery

Acute ischemic stroke (AIS) is the fifth leading cause of death, and remains the leading cause of disability in the USA.1 There are an estimated 680 000 new strokes per...

Mechanical Thrombectomy in Strokes with Large-Vessel Occlusion Beyond 6 Hours: A Pooled Analysis of Randomized Trials.

Background and PurposeMechanical thrombectomy with or without intravenous thrombolysis is indicated in the acute treatment of ischemic strokes caused by an emergent large-vessel occlusion (ELVO) within 6 hours from symptom onset. However, a significant proportion of patients are referred to comprehensive stroke centers beyond this therapeutic time window. This study performed a pooled analysis of data from trials in which mechanical thrombectomy was performed beyond 6 hours from symptom onset.MethodsWe searched for randomized controlled trials that compared mechanical thrombectomy with the best medical treatment beyond 6 hours for ischemic strokes due to ELVO and reported on between 1990 and April 2018. The intervention group comprised patients treated with mechanical thrombectomy. Statistical analysis was conducted while pooling data and analyzing fixed- or random-effects models as appropriate.ResultsFour trials involving 518 stroke patients met the eligibility criteria. There were 267 strokes treated with mechanical thrombectomy, with a median time of 10.8 hours between when the patient was last known to be well to randomization. We observed a significant difference between groups concerning the rate of functional independence at 90 days from stroke, with an absolute difference of 27.5% (odds ratio=3.33, 95% CI=1.81–6.12, p<0.001) and good recanalization (odds ratio=13.17, 95% CI=4.17–41.60, p<0.001) favoring the intervention group.ConclusionsThis meta-analysis confirms the efficacy of mechanical thrombectomy in selected ischemic stroke patients beyond 6 hours from symptom onset. The selection is mainly based on the limited core infarct detected by emergent assessment using neuroimaging techniques.

Antiplatelet pretreatment and outcomes following mechanical thrombectomy for emergent large vessel occlusion strokes

BackgroundFew data are available regarding the safety and efficacy of antiplatelet (APT) pretreatment in acute ischemic stroke (AIS) patients with emergent large vessel occlusions (ELVO) treated with mechanical thrombectomy (MT)....