Endovascular Therapy For Acute Stroke Research Articles

Longitudinal changes in the US emergency department use of advanced neuroimaging in the mechanical thrombectomy era.

To describe ED neuroimaging trends across the time-period spanning the early adoption of endovascular therapy for acute stroke (2013-2018). We performed a retrospective, cross-sectional study of ED visits using the 2013-2018 National Emergency Department Sample, a 20% sample of ED encounters in the United States. Neuroimaging use was determined by Common Procedural Terminology (CPT) code for non-contrast head CT (NCCT), CT angiography head (CTA), CT perfusion (CTP), and MRI brain (MRI) in non-admitted ED patients. Data was analyzed according to sampling weights and imaging rates were calculated per 100,000 ED visits. Multivariate logistic regression analysis was performed to identify hospital-level factors associated with imaging utilization. Study population comprised 571,935,906 weighted adult ED encounters. Image utilization increased between 2013 and 2018 for all modalities studied, although more pronounced in CTA (80.24/100,000 ED visits to 448.26/100,000 ED visits (p < 0.001)) and CTP (1.75/100,000 ED visits to 28.04/100,000 ED visits p < 0.001)). Regression analysis revealed that teaching hospitals were associated with higher odds of high CTA utilization (OR 1.88 for 2018, p < 0.05), while low-volume EDs and public hospitals showed the reverse (OR 0.39 in 2018, p < 0.05). We identified substantial increases in overall neuroimaging use in a national sample of non-admitted emergency department encounters between 2013 and 2018 with variability in utilization according to both patient and hospital properties. Further investigation into the appropriateness of this imaging is required to ensure that access to acute stroke treatment is balanced against the timing and cost of over-imaging.

Development of a new scale for self-reported procedural patient comfort during endovascular therapy for acute stroke.

In stroke patients with acute large vessel occlusion, endovascular therapy (EVT) may be performed with or without sedation. Our aim is to describe self-reported intraprocedural comfort in patients undergoing EVT depending on sedation type. We performed a prospective observational single-center study of patients undergoing EVT. Patients were systematically interviewed on the day following intervention using a structured questionnaire addressing five domains (nausea/vomiting, pain of any kind, physical discomfort, emotional discomfort, and medical team interaction). Each domain scored 0 to 2 points for a maximum total of 10 points (a higher score indicating greater discomfort). In addition, satisfaction with procedural comfort was rated on a visual analog scale (VAS), and patients reported whether they would have preferred more, less, or the same amount of sedation. Patients who underwent EVT without sedation (local anesthesia, LA) were compared to those who received procedural sedation (conscious sedation, CS). Seventy-seven questionnaires were completed: 37 (48%) patients underwent EVT with CS while 40 (52%) were treated under LA. Median scores on the self-reported discomfort scale (1[0-2] vs 1[0-2], p = 0.70) and mean scores on VAS (76 ± 25 vs 81 ± 24, p = 0.37) were similar between the CS and the LA group. The proportion of patients who were satisfied with the adopted sedation strategy was similar between groups. EVT without prior sedation seems to be well tolerated. Systematic self-evaluation of patient comfort appears feasible and may become integrated into routine clinical care. Patient-oriented outcomes should be included in future trials of sedation during thrombectomy.

Early neurological changes following endovascular therapy for acute stroke due to intracranial atherosclerotic disease

BackgroundEndovascular therapy (EVT) reduces functional disability in patients with acute large vessel occlusion (LVO). However, the early neurological change after EVT may be limited in patients with intracranial atherosclerotic disease (ICAD). MethodsWe analyzed the Japanese Registry of NeuroEndovascular Therapy (JR-NET) 4 which was a retrospective, nationwide, multicenter registry of patients with LVO between 2015 and 2019. We compared the early neurological change, efficacy and safety of EVT for acute LVO in ICAD and other etiologies. The primary outcome was NIHSS improvement ≥10 points, and secondary outcome were NIHSS worsening ≥4 points 7 days after EVT, effective reperfusion rate, 30-day functional outcomes, and safety outcomes. ResultsAmong the 6710 enrolled patients, 610 (9.1%) had ICAD. The ICAD group was younger (mean 72.0 vs. 75.8 years) and predominantly male (63.4% vs. 56.0%), had lower NIHSS scores before EVT (median 16 vs. 18), and underwent percutaneous transluminal angioplasty and stenting more frequently (43.0% vs. 4.4%, 12.3% vs. 4.4%). In the ICAD group, NIHSS improvement was significantly lower (adjusted odds ratio (aOR) [95% confidence interval (95%CI)] 0.52 [0.41–0.65]), NIHSS worsening was significantly higher (aOR [95%CI] 1.76 [1.31–2.34]), and effective reperfusion was significantly lower (aOR [95%CI] 0.47 [0.36–0.60]). Fewer patients with ICAD had modified Rankin scale 0–2 at 30 days (aOR [95%CI] 0.60 [0.47–0.77]). The risk of acute reocclusion was more prominent in the ICAD group (aOR [95%CI] 4.03 [1.98–8.21]). ConclusionsImprovement in neurological severity after EVT was lower in patients with LVO and ICAD.

Patients' perceptions on outcomes after mechanical thrombectomy in acute ischemic stroke.

The modified Rankin Scale (mRS) is a clinician-reported scale that measures the degree of disability in patients who suffered a stroke. Patients' perception of a meaningful recovery from severe stroke, expected value of a stroke intervention, and the effect of disparities are largely unknown. We conducted a survey of patients, their family members, and accompanying visitors to understand their personal preferences and expectations for acute strokes potentially eligible for acute endovascular intervention using a hypothetical scenario of a severe stroke in a standardized questionnaire. Of 164 survey respondents, 65 (39.6%) were the patient involved, 93 (56.7%) were a family member, and six (3.7%) were accompanied visitors (friends, other). Minimally acceptable disability after a stroke intervention was considered as mRS 2 by 42 respondents (25.6%), as mRS 3 by 79 (48.2%), and as mRS 4 by 43 (26.2%) respondents. Race was associated with different views on this question (p < 0.001; Hispanic and Black patients being more likely to accept disability than Caucasian and Asian patients), while sex (p = 0.333) and age (p = 0.560) were not. Sixty-three respondents (38.4%) viewed minimally acceptable probability of improvement with an intervention as over 50%, 57 (34.8%) as 10-50%, and 44 (26.8%) as less than 10%. A wide range of acceptable outcomes were reported regardless of gender or age. However, race was associated with different acceptable outcome. This is an important finding to demonstrate because of the persistent racial and ethnic disparities in the utilization of endovascular therapy for acute stroke in the United States.

Cost-effectiveness of endovascular therapy for acute stroke with a large ischemic region in Japan: impact of the Alberta Stroke Program Early CT Score on cost-effectiveness

BackgroundAlthough randomized clinical trials (RCTs) demonstrated short-term benefits of endovascular therapy (EVT) for acute ischemic stroke (AIS) with a large ischemic region, little is known about the long-term cost-effectiveness or...

Endovascular therapy for acute stroke with a large infarct core: A systematic review and meta-analysis

ObjectiveIn this meta-analysis, we aimed to investigate the efficacy and safety of endovascular treatment (EVT) for acute ischemic stroke (AIS) patients with large core infarct. MethodsThree online databases of Web of Science, PubMed and Scopus were systematically searched. Original studies which evaluated AIS participants with large core infarction who underwent EVT were included. R statistical software was used for statistical analyses. Effect sizes were presented with odds ratios (ORs) with their 95% confidence intervals (CIs). The effect sizes were pooled using random effects modeling. ResultsIncluding 47 studies and 15,173 patients, this meta-analysis showed that compared with medical management (MM), EVT was significantly associated with decreased odds of mortality (0.67, 95% CI: 0.51–0.87) and increased odds of favorable outcomes, including a modified Rankin Scale of 0–3 (2.36, 95% CI: 1.69–3.291) and of 0–2 (3.54, 95% CI: 1.96–6.4) in 90 days and remarkable improvement in National Institutes of Health Stroke Scale within 48 h after the procedure (3.6, 95% CI:1.32–9.79). Besides, there was a higher chance of intracranial hemorrhage (ICH) development (1.88, 95% CI: 1.32–2.68) but not symptomatic ICH (1.34, 95% CI: 0.78–2.31) in those who underwent EVT. ConclusionOur study suggests that EVT might be an effective and relatively safe treatment option for the treatment of AIS patients with large vessel occlusion who have large core infarcts, although more large-scale trials are needed to consolidate the results and to make inclusion criteria and the patient selection process clearer.

Single-step Optimization in Triaging Large Vessel Occlusion Strokes: Identifying Factors to Improve Door-to-groin Time for Endovascular Therapy.

Although acute stroke endovascular therapy (EVT) has dramatically improved outcomes in acute ischemic stroke (AIS) patients with large vessel occlusions (LVO), access to EVT-capable centers remains limited, particularly in rural areas. Therefore, it is essential to optimize triage systems for EVT-eligible patients. One strategy may be the use of a telestroke network that typically consists of multiple spoke sites that receive a consultation to determine appropriateness of patient transfer to an EVT-capable hub site. Standardization of AIS protocols may be necessary to achieve target door-to-groin (DTG) times of less than 60 minutes in EVT-eligible patients upon hub arrival. Specifically, the decision to obtain vascular imaging at the transferring hub site vs delaying until arrival at the hub is controversial. The purpose of this study was to identify factors associated with reduced DTG time in LVO-AIS patients. We performed a retrospective chart review for all patients treated over a 3.5-year period at our home hub institution. Patients were classified as telestroke transfers, non-telestroke transfers, and direct-to-hub presentations. We recorded demographic information, DTG time, reperfusion status, length of stay (LOS), functional status at discharge, seven-day mortality, and the site where vascular imaging- computed tomography angiography (CTA)-was obtained. We performed binary logistic regression to identify factors associated with DTG <60 minutes. In the sample of EVT-eligible patients (n = 383), CTA was performed at the spoke site prior to transfer to the hub institution in 53% of cases. Further, 59% of telestroke transfer cases received a CTA prior to transfer compared to only 40% of non-telestroke transfers (59 vs 40%, P = 0.01). A Door-to-groin time <60 minutes was achieved in 67% of transfer patients who received pre-transfer CTA compared to only 22% of transfer patients who received CTA upon hub arrival and 17% of patients who presented directly to the hub. Ultimately, transfer patients who received CTA prior to transfer were 7.2 times more likely to have a DTG <60 minutes compared to those who did not (OR 7.2, 95% confidence interval 3.5-14.7; P < 0.001). Pre-transfer computed tomography angiography was the only significant predictor of achieving target door-to-groin times of less than 60 minutes. Because DTG time has been well established as a predictor of clinical outcomes, including pre-transfer CTA in a standardized acute ischemic stroke protocol may prove beneficial. Our findings also illustrate the need to optimize direct-to-hub stroke alerts and telestroke relationships to minimize workflow disruptions, which became more apparent during the pandemic.

Role of Brain Imaging in the Prediction of Intracerebral Hemorrhage Following Endovascular Therapy for Acute Stroke.

Currently most acute ischemic stroke patients presenting with a large vessel occlusion are treated with endovascular therapy (EVT), which results in high rates of successful recanalization. Despite this success, more than half of EVT-treated patients are significantly disabled 3 months later partly due to the occurrence of post-EVT intracerebral hemorrhage. Predicting post-EVT intracerebral hemorrhage is important for individualizing treatment strategies in clinical practice (eg, safe initiation of early antithrombotic therapies), as well as in selecting the optimal candidates for clinical trials that aim to reduce this deleterious outcome. Emerging data suggest that brain and vascular imaging biomarkers may be particularly relevant since they provide insights into the ongoing acute stroke pathophysiology. In this review/perspective, we summarize the accumulating literature on the role of cerebrovascular imaging biomarkers in predicting post-EVT-associated intracerebral hemorrhage. We focus on imaging acquired before EVT, during the EVT procedure, and in the early post-EVT time frames when new therapeutic therapies could be tested. Accounting for the complex pathophysiology of post-EVT-associated intracerebral hemorrhage, this review may provide some guidance for future prospective observational or therapeutic studies.

Trial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct

BackgroundThe role of endovascular therapy for acute stroke with a large infarction has not been extensively studied in differing populations.MethodsWe conducted a multicenter, prospective, open-label, randomized trial in China involving patients with acute large-vessel occlusion in the anterior circulation and an Alberta Stroke Program Early Computed Tomography Score of 3 to 5 (range, 0 to 10, with lower values indicating larger infarction) or an infarct-core volume of 70 to 100 ml. Patients were randomly assigned in a 1:1 ratio within 24 hours from the time they were last known to be well to undergo endovascular therapy and receive medical management or to receive medical management alone. The primary outcome was the score on the modified Rankin scale at 90 days (scores range from 0 to 6, with higher scores indicating greater disability), and the primary objective was to determine whether a shift in the distribution of the scores on the modified Rankin scale at 90 days had occurred between the two groups. Secondary outcomes included scores of 0 to 2 and 0 to 3 on the modified Rankin scale. The primary safety outcome was symptomatic intracranial hemorrhage within 48 hours after randomization.ResultsA total of 456 patients were enrolled; 231 were assigned to the endovascular-therapy group and 225 to the medical-management group. Approximately 28% of the patients in both groups received intravenous thrombolysis. The trial was stopped early owing to the efficacy of endovascular therapy after the second interim analysis. At 90 days, a shift in the distribution of scores on the modified Rankin scale toward better outcomes was observed in favor of endovascular therapy over medical management alone (generalized odds ratio, 1.37; 95% confidence interval, 1.11 to 1.69; P=0.004). Symptomatic intracranial hemorrhage occurred in 14 of 230 patients (6.1%) in the endovascular-therapy group and in 6 of 225 patients (2.7%) in the medical-management group; any intracranial hemorrhage occurred in 113 (49.1%) and 39 (17.3%), respectively. Results for the secondary outcomes generally supported those of the primary analysis.ConclusionsIn a trial conducted in China, patients with large cerebral infarctions had better outcomes with endovascular therapy administered within 24 hours than with medical management alone but had more intracranial hemorrhages. (Funded by Covidien Healthcare International Trading [Shanghai] and others; ANGEL-ASPECT ClinicalTrials.gov number, NCT04551664.)

Post-ischemic hyperemia following endovascular therapy for acute stroke is associated with lesion growth

A substantial proportion of acute stroke patients fail to recover following successful endovascular therapy (EVT) and injury to the brain and vasculature secondary to reperfusion may be a contributor. Acute stroke patients were included with: i) large vessel occlusion of the anterior circulation, ii) successful recanalization, and iii) evaluable MRI early after EVT. Presence of hyperemia on MRI perfusion was assessed by consensus using a modified ASPECTS. Three different approaches were used to quantify relative cerebral blood flow (rCBF). Sixty-seven patients with median age of 66 [59–76], 57% female, met inclusion criteria. Hyperemia was present in 35/67 (52%) patients early post-EVT, in 32/65 (49%) patients at 24 hours, and in 19/48 (40%) patients at 5 days. There were no differences in incomplete reperfusion, HT, PH-2, HARM, severe HARM or symptomatic ICH rates between those with and without early post-EVT hyperemia. A strong association (R2 = 0.81, p < 0.001) was found between early post-EVT hyperemia (p = 0.027) and DWI volume at 24 hours after adjusting for DWI volume at 2 hours (p < 0.001) and incomplete reperfusion at 24 hours (p = 0.001). Early hyperemia is a potential marker for cerebrovascular injury and may help select patients for adjunctive therapy to prevent edema, reperfusion injury, and lesion growth.

Neurointerventional Advances in 2022

Neurointerventional Advances in 2022

Endovascular Therapy for Acute Stroke: New Evidence and Indications.

Endovascular therapy (EVT) has revolutionized the treatment of acute ischemic stroke. In the past few years, endovascular treatment indications have expanded to include patients being treated in the extended window, with large ischemic core infarction, basilar artery occlusion (BAO) thrombectomy, as demonstrated by several randomized clinical trials. Intravenous thrombolysis (IVT) bridging to mechanical thrombectomy has also been studied via several randomized clinical trials, with the overall results indicating that IVT should not be skipped in patients who are candidates for both IVT and EVT. Simplification of neuroimaging protocols in the extended window to permit non-contrast CT, CTA collaterals have also expanded access to mechanical thrombectomy, particularly in regions across the world where access to advanced imaging may not be available. Ongoing study of areas to develop include rescue stenting in patients with failed thrombectomy, medium vessel occlusion thrombectomy, and carotid tandem occlusions. In this narrative review, we summarize recent trials and key data in the treatment of patients with large ischemic core infarct, simplification of neuroimaging protocols for the treatment of patients presenting in the late window, bridging thrombolysis, and BAO EVT evidence. We also summarize areas of ongoing study including medium and distal vessel occlusion.

EE408 Economic Evaluation of Endovascular Therapy for Acute Stroke With a Large Ischemic Region in China

The beneficial effects of endovascular therapy compared with medical-care alone to treat acute stroke with a large ischemic region have been shown in randomized controlled trial. The aim of this study was to compare the cost-effectiveness of endovascular therapy compared with the established medical-care for the treatment of acute stroke with a large ischemic region in China.

Endovascular Therapy vs Medical Management for Patients With Acute Stroke With Medium Vessel Occlusion in the Anterior Circulation

Randomized clinical trials have shown the efficacy of endovascular therapy (EVT) for acute large vessel occlusion strokes. The benefit of EVT in acute stroke with distal, medium vessel occlusion (DMVO) remains unclear. To examine the efficacy and safety outcomes associated with EVT in patients with primary DMVO stroke when compared with a control cohort treated with medical management (MM) alone. This multicenter, retrospective cohort study pooled data from patients who had an acute stroke and a primary anterior circulation emergency DMVO, defined as any segment of the anterior cerebral artery (ACA) or distal middle cerebral artery, between January 1, 2015, and December 31, 2019. Those with a concomitant proximal occlusion were excluded. Outcomes were compared between the 2 treatment groups using propensity score methods. Data analysis was performed from March to June 2021. Patients were divided into EVT and MM groups. Main efficacy outcomes included 3-month functional independence (modified Rankin Scale [mRS] scores, 0-2) and 3-month excellent outcome (mRS scores, 0-1). Safety outcomes included 3-month mortality and symptomatic intracranial hemorrhage. A total of 286 patients with DMVO were evaluated, including 156 treated with EVT (mean [SD] age, 66.7 [13.7] years; 90 men [57.6%]; median National Institute of Health Stroke Scale [NIHSS] score, 13.5 [IQR, 8.5-18.5]; intravenous tissue plasminogen activator [IV tPA] use, 75 [49.7%]; ACA involvement, 49 [31.4%]) and 130 treated with medical management (mean [SD] age, 69.8 [14.9] years; 62 men [47.7%]; median NIHSS score, 7.0 [IQR, 4.0-14.0], IV tPA use, 58 [44.6%]; ACA involvement, 31 [24.0%]). There was no difference in the unadjusted rate of 3-month functional independence in the EVT vs MM groups (151 [51.7%] vs 124 [50.0%]; P = .78), excellent outcome (151 [38.4%] vs 123 [31.7%]; P = .25), or mortality (139 [18.7%] vs 106 [11.3%]; P = .15). The rate of symptomatic intracranial hemorrhage was similar in the EVT vs MM groups (weighted: 4.0% vs 3.1%; P = .90). In inverse probability of treatment weighting propensity analyses, there was no significant difference between groups for functional independence (adjusted odds ratio [aOR], 1.36; 95% CI, 0.84-2.19; P = .20) or mortality (aOR, 1.24; 95% CI, 0.63-2.43; P = .53), whereas the EVT group had higher odds of an excellent outcome (mRS scores, 0-1) at 3 months (aOR, 1.71; 95% CI, 1.02-2.87; P = .04). The findings of this multicenter cohort study suggest that EVT may be considered for selected patients with ACA or distal middle cerebral artery strokes. Further larger randomized investigation regarding the risk-benefit ratio for DMVO treatment is indicated.

Endovascular Therapy for Acute Stroke with a Large Ischemic Region

BackgroundEndovascular therapy for acute ischemic stroke is generally avoided when the infarction is large, but the effect of endovascular therapy with medical care as compared with medical care alone for large strokes has not been well studied.MethodsWe conducted a multicenter, open-label, randomized clinical trial in Japan involving patients with occlusion of large cerebral vessels and sizable strokes on imaging, as indicated by an Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) value of 3 to 5 (on a scale from 0 to 10, with lower values indicating larger infarction). Patients were randomly assigned in a 1:1 ratio to receive endovascular therapy with medical care or medical care alone within 6 hours after they were last known to be well or within 24 hours if there was no early change on fluid-attenuated inversion recovery images. Alteplase (0.6 mg per kilogram of body weight) was used when appropriate in both groups. The primary outcome was a modified Rankin scale score of 0 to 3 (on a scale from 0 to 6, with higher scores indicating greater disability) at 90 days. Secondary outcomes included a shift across the range of modified Rankin scale scores toward a better outcome at 90 days and an improvement of at least 8 points in the National Institutes of Health Stroke Scale (NIHSS) score (range, 0 to 42, with higher scores indicating greater deficit) at 48 hours.ResultsA total of 203 patients underwent randomization; 101 patients were assigned to the endovascular-therapy group and 102 to the medical-care group. Approximately 27% of patients in each group received alteplase. The percentage of patients with a modified Rankin scale score of 0 to 3 at 90 days was 31.0% in the endovascular-therapy group and 12.7% in the medical-care group (relative risk, 2.43; 95% confidence interval [CI], 1.35 to 4.37; P=0.002). The ordinal shift across the range of modified Rankin scale scores generally favored endovascular therapy. An improvement of at least 8 points on the NIHSS score at 48 hours was observed in 31.0% of the patients in the endovascular-therapy group and 8.8% of those in the medical-care group (relative risk, 3.51; 95% CI, 1.76 to 7.00), and any intracranial hemorrhage occurred in 58.0% and 31.4%, respectively (P<0.001).ConclusionsIn a trial conducted in Japan, patients with large cerebral infarctions had better functional outcomes with endovascular therapy than with medical care alone but had more intracranial hemorrhages. (Funded by Mihara Cerebrovascular Disorder Research Promotion Fund and the Japanese Society for Neuroendovascular Therapy; RESCUE-Japan LIMIT ClinicalTrials.gov number, NCT03702413.)

Abstract 1122‐000210: Cangrelor to Prevent Intraluminal Thrombosis in Endovascular Therapy for Acute Stroke: Single Center Case Series

Introduction : Intraluminal thrombosis after endovascular therapy (EVT) is a peri‐procedural complication that carries a high burden of morbidity and mortality. The use of anti‐thrombotic therapies during EVT remains an evolving field. Recent surveys suggest the glycoprotein IIb/IIIa inhibitor, tirofiban, is often used during EVT. However, the increased intracranial hemorrhage risk and the medication’s long half‐life pose significant challenges to management. Cangrelor, an intravenous and reversible P2Y12 inhibitor, was first approved by FDA in 2015 for use in patients with coronary artery disease undergoing percutaneous intervention. Its rapid onset and offset are beneficial as an anti‐thrombotic during EVT. Our case series aim to characterize the safety and efficacy of cangrelor use in our institution and contribute towards its growing body of data. Methods : Chart review was conducted for patients that required endovascular therapy for acute stroke and received intravenous cangrelor at our center between January 2019 to December 2020. We included patients that underwent both extracranial and intracranial stent placement, as well as patients who suffered from intraluminal thromboses intra‐procedurally. Variables of interest included lesion pathophysiology, peri‐procedural complications including intraluminal re‐occlusion and intracranial hemorrhage, TICI score post‐procedurally, vessel patency and MRS on post‐hospitalization followup. Results : Nine patients received intravenous cangrelor during endovascular therapy. Mean age was 50 (range 41–67 years old), 3/9 patients were male. Seven patients (77.8%) had ischemic stroke, of whom five exhibited tandem intracranial occlusions and three required intraprocedural stent deployment. 3/7 patients received IV TPA prior to EVT. Interestingly, one patient had a previously placed Precise stent for acute internal carotid thrombus, briefly placed on eptifibatide (180mcg/kg), suffered from stent re‐occlusion on POD1 and required repeat thrombectomy with cangrelor intra‐procedurally; stent patency was maintained for the rest of her hospital course. One patient received balloon angioplasty of supraclinoid internal carotid artery. The remaining two patients required cangrelor for visualized intraluminal platelet aggregates during the EVT. Two patients presented with aneurysmal subarachnoid hemorrhage, one treated with flow diversion stent and the other requiring stenting for prolapsed aneurysm coiling. Dosing of cangrelor bolus and infusion varied. Six patients were bolused with 15 mcg/kg, while three patients received 7.5 mcg/kg. Infusion rates range from 0.5 to 4 mcg/kg/minute with all nine patients reaching therapeutic range P2Y12 levels on post‐procedural testing. Cangrelor infusion was transitioned to oral antiplatelet on post‐operative day 4 on average. In all nine patients, vessel and stent patency was maintained intra‐procedurally with cangrelor. Subsequent vascular imaging during hospitalization demonstrated no intraluminal thrombosis. One patient experienced intracranial hemorrhage, however they received intraprocedural eptifibatide (180mcg/kg) and cangrelor infusion (15 mcg/kg bolus, 2 mcg/kg/min) for their extensive clot burden and triple stent placement. Five patients attended three‐month post‐hospitalization followups. Their median MRS was 2 and all followup vessel imaging demonstrated patent vessels. Conclusions : Our case series demonstrate the promising efficacy of cangrelor in patients undergoing emergent endovascular therapy to prevent intraluminal thrombosis. Further studies with larger sample sizes can elucidate the optimal dose of cangrelor, length of treatment before oral transition, and compare its efficacy to eptifibatide.

Impact of Prior Antiplatelet Therapy on Outcomes After Endovascular Therapy for Acute Stroke: Endovascular Treatment in Ischemic Stroke Registry Results.

The influence of prior antiplatelet therapy (APT) uses on the outcomes of patients with acute ischemic stroke treated with endovascular therapy is unclear. We compared procedural and clinical outcomes of endovascular therapy in patients on APT or not before stroke onset. We analyzed 2 groups from the ongoing prospective multicenter Endovascular Treatment in Ischemic Stroke registry in France: patients on prior APT (APT+) and patients without prior APT (APT-) treated by endovascular therapy, with and without intravenous thrombolysis. Multilevel mixed-effects logistic models including center as random effect were used to compare angiographic (rates of reperfusion at the end of procedure, procedural complications) and clinical (favorable and excellent outcome, 90-day all-cause mortality, and hemorrhagic complications) outcomes according to APT subgroups. Comparisons were adjusted for prespecified confounders (age, admission National Institutes of Health Stroke Scale score, Alberta Stroke Program Early CT Score, intravenous thrombolysis, and time from onset to puncture), as well as for meaningful baseline between-group differences. A total of 2939 patients were analyzed, of whom 877 (29.8%) were on prior APT. Patients with prior APT were older, had more frequent vascular risk factors, cardioembolic stroke mechanism, and prestroke disability. Rates of complete reperfusion (37.9% in the APT- group versus 42.7 % in the APT+ group; aOR, 1.09 [95% CI, 0.88-1.34]; P=0.41) and periprocedural complication (16.9% versus 13.3%; aOR, 0.90 [95% CI, 0.7-1.2]; P=0.66) did not differ between the two groups. Symptomatic intracerebral hemorrhage (aOR, 0.93 [95% CI, 0.63-1.37]; P=0.73), 3 months favorable clinical outcome (modified Rankin Scale score of 0-2; aOR, 0.98 [95% CI, 0.77-1.25]; P=0.89), and mortality (aOR, 0.95 [95% CI, 0.72-1.26]; P=0.76) at 90 days did not differ between the groups. Prior APT does not influence angiographic and functional outcomes following endovascular therapy and should not be taken into account for acute revascularization strategies.

Management of endovascular therapy for acute ischemic stroke amid the COVID-2019 pandemic: a multicenter survey in China

ABSTRACT Objectives: The impact of COVID-19 pandemic on endovascular therapy (EVT) for acute ischemic stroke in China is unknown. This study was aimed to verify the volume change of EVT for acute ischemic stroke affected by COVID-19 and its potential factors. Methods: This cross-sectional study was conducted via an online questionnaire survey in China. The questionnaire was mainly composed of descriptive information, volume change of EVT for acute ischemic stroke, and the protection status of medical staff. Results: A total of 103 stroke physicians in 28 provinces across China completed the survey questionnaire. A volume decline in EVT for acute stroke occurred in 93 (90.3%) hospitals after lockdown (23 January 2020). Nearly half of the hospitals (51/103, 49.5%) experienced a volume decline of EVT case more than 50% and 14 (13.6%) hospitals completely ceased offering EVT. Hospitals with decline >50% of EVT case had higher proportion of hospitals with a designated area for COVID-19 screening in the emergency room (44/51, 86.3% vs 34/52, 65.4%, p= 0.01) and medical staff in quarantine (19/51, 37.3% vs 7/52, 13.5%, p< 0.01), with lower proportion of hospitals with personal protective equipment protocol (41/51, 80.4% vs 49/52, 94.2%, p= 0.03) than hospitals with decline ≤50%. Conclusions: The volume of EVT for acute ischemic stroke severely declined after lockdown in China. Designating a specific area for COVID-19 screening, insufficient personal protection and understaffing may exacerbate the volume decline of EVT.

Response to Ganau et al letter ‘The continuous quest for a more tailored approach to anesthetic management of patients undergoing endovascular therapy for acute stroke’

We thank the authors1 for their interest in our article2 regarding anesthetic management during mechanical thrombectomy (MT). They make valid points regarding patient age, conversion rates to general anesthesia (GA)...

The continuous quest for a more tailored approach to anesthetic management of patients undergoing endovascular therapy for acute stroke

To the Editor We read with great interest the article by Pop et al 1 on a propensity score analysis comparing anesthetic management of patients undergoing endovascular therapy for acute...