Endovascular Intervention For Acute Stroke Research Articles

Early Stent Patency After Endovascular Therapy for Tandem or Isolated Carotid Steno-Occlusive Disease

Early Stent Patency After Endovascular Therapy for Tandem or Isolated Carotid Steno-Occlusive Disease

Rural-urban differences in functional outcomes after acute stroke therapy within the stroke belt

IntroductionThe Southeastern United States (US) has the highest stroke mortality rate in the country. A high proportion of its population lives in rural areas. Rural patients with stroke have worse outcomes than their urban counterparts. We compared 90-day modified Rankin Score (mRS) between patients living in urban versus rural areas who received endovascular intervention for acute stroke. MethodsWe performed a retrospective analysis of patients who received acute stroke therapy at a comprehensive stroke center in the Southeastern US from 2014 to 2018. Individuals were classified as rural or urban dwellers based on 2010 Rural-Urban Commuting Area Codes. Stepwise logistic regression models were performed using clinical and demographic characteristics to compare good (mRS 0–1) vs poor (mRS 2–6) functional outcomes between urban and rural patients. Results232 patients were included (185 urban and 47 rural). Urban and rural groups had similar composition of age, gender, and proportion of African-Americans. Mean baseline NIH stroke scale was higher in rural patients (17.0 vs 14.8 respectively, p-value=0.03.). Our model for poor functional outcome at 90-days revealed only older age as a significant risk factor (OR 0.97, 95% CI 0.95–0.99). ConclusionsOur study found that for patients receiving acute therapy for ischemic stroke, there were no significant differences in functional outcome between urban versus rural patients. Only older age predicted poor functional outcome at 90 days. Our study demonstrates that patients from rural areas may not have worse mortality rates or poor outcomes and can recover similarly to those from urban areas.

Development of a machine learning-based real-time location system to streamline acute endovascular intervention in acute stroke: a proof-of-concept study

BackgroundDelivery of acute stroke endovascular intervention can be challenging because it requires complex coordination of patient and staff across many different locations. In this proof-of-concept paper we (a) examine whether...

Combined Use of X-ray Angiography and Intraprocedural MRI Enables Tissue-based Decision Making Regarding Revascularization during Acute Ischemic Stroke Intervention.

Background For patients with acute ischemic stroke undergoing endovascular mechanical thrombectomy with x-ray angiography, the use of adjuncts to maintain vessel patency, such as stents or antiplatelet medications, can increase risk of periprocedural complications. Criteria for using these adjuncts are not well defined. Purpose To evaluate use of MRI to guide critical decision making by using a combined biplane x-ray neuroangiography 3.0-T MRI suite during acute ischemic stroke intervention. Materials and Methods This retrospective observational study evaluated consecutive patients undergoing endovascular intervention for acute ischemic stroke between July 2019 and May 2020 who underwent either angiography with MRI or angiography alone. Cerebral tissue viability was assessed by using MRI as the reference standard. For statistical analysis, Fisher exact test and Student t test were used to compare groups. Results Of 47 patients undergoing acute stroke intervention, 12 patients (median age, 69 years; interquartile range, 60-77 years; nine men) underwent x-ray angiography with MRI whereas the remaining 35 patients (median age, 80 years; interquartile range, 68-86 years; 22 men) underwent angiography alone. MRI results influenced clinical decision making in one of three ways: whether or not to perform initial or additional mechanical thrombectomy, whether or not to place an intracranial stent, and administration of antithrombotic or blood pressure medications. In this initial experience, decision making during endovascular acute stroke intervention in the combined angiography-MRI suite was better informed at MRI, such that therapy was guided in real time by the viability of the at-risk cerebral tissue. Conclusion Integrating intraprocedural 3.0-T MRI into acute ischemic stroke treatment was feasible and guided decisions of whether or not to continue thrombectomy, to place stents, or to administer antithrombotic medication or provide blood pressure medications. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Lev and Leslie-Mazwi in this issue.

Endovascular Acute Stroke Intervention - Tandem OCclusion Trial

Endovascular Acute Stroke Intervention - Tandem OCclusion Trial

A randomized pilot study of patients with tandem carotid lesions undergoing thrombectomy

Background and purposeThe optimal management of patients with tandem lesions (TL), or cervical internal carotid artery (c-ICA) steno-occlusive pathology and ipsilateral intracranial occlusion, who are undergoing endovascular thrombectomy (EVT) remains unknown. We sought to establish the feasibility of a trial designed to address this question. Materials and methodsThe Endovascular Acute Stroke Intervention (EASI) study was a single-centre randomized trial comparing EVT to medical therapy for large-vessel occlusion stroke. Patients with TL receiving EVT were randomly allocated to acute c-ICA stenting or no stenting. The primary outcome was the proportion of patients with a modified Rankin Scale (mRS) score of 0–2 at 90 days. Safety outcomes were symptomatic intracranial hemorrhage (sICH) at 24hours and mortality at 90 days. ResultsOf 301 patients included in EASI between 2013 and 2018, 24 (8.0%) with TL were randomly allocated to acute stenting (n=13) or no stenting (n=11). Baseline characteristics were balanced. Eight (61.5%; 95% CI 35.5%–82.3%) and 7 (63.6%; 95% CI 35.4%–84.9%) patients, respectively, had a favorable outcome (mRS 0–2; P=1.0). One non-stented patient had a symptomatic intracerebral hemorrhage. ConclusionsThis pilot trial of patients with TL undergoing EVT suggests that a sufficiently powered larger TL trial comparing acute c-ICA stenting to no stenting is feasible. Clinical Trial RegistrationURL: http://www.clinicaltrials.gov. Unique identifier: NCT02157532.

A randomized pragmatic care trial on endovascular acute stroke interventions (EASI): criticisms, responses, and ethics of integrating research and clinical care

BackgroundThe Endovascular Acute Stroke Intervention (EASI) trial was conceived as a pragmatic care trial, designed to integrate trial methods with clinical practice. Reporting the EASI experience was met with objections and criticisms during peer review concerning both scientific and ethical issues. Our goal is to discuss these criticisms in order to promote the pragmatic approach of care trials in outcome-based medical care.MethodsThe comments and criticisms of 11 reviewers from 5 journals were collected and analyzed. The EASI protocol was also compared to the protocols of seven thrombectomy trials using the pragmatic-explanatory continuum indicator summary (PRECIS).ResultsMain criticisms of EASI concerned selection criteria that were judged to be too vague and too inclusive, brain and vascular imaging methods that were not sufficiently prescribed by protocol, lack of blinding of outcome assessment, and lack of power. EASI was at the pragmatic end of the spectrum of thrombectomy trials.ConclusionThe pragmatic care trial methodology is not currently well-established. More work needs to be done to integrate scientific methods and ethical care in the best medical interest of current patients.

Mechanical Thrombectomy for Acute Ischemic Stroke: Weight of the Evidence

In 2015, several high-profile acute stroke trials were published that demonstrated the value of endovascular acute stroke intervention. Now, researchers have performed a systematic analysis of trials evaluating mechanical thrombectomy between 5 and 12 hours after onset of acute ischemic stroke. For this analysis, thrombectomy devices had to be used in the trials (as opposed to intra-arterial thrombolysis alone), 90-day follow-up was …

Reliability of Detection of Intracranial Hemorrhage After Endovascular Intervention for Acute Stroke (P1.200)

Reliability of Detection of Intracranial Hemorrhage After Endovascular Intervention for Acute Stroke (P1.200)

Abstract TP12: Safety of Endovascular Intervention for Acute Stroke in Patients on Anticoagulation

Background and Purpose: Current guidelines recommend against IV tPA use in patients on warfarin with INR > 1.7, recent use of novel oral anticoagulants (NOACs), or current therapeutic parenteral anticoagulation. These patients are sometimes considered for endovascular thrombolysis, however there is limited data on the safety of this approach. We sought to assess the safety of endovascular intervention in these patients. Methods: We performed a multicenter retrospective study to identify consecutive patients undergoing endovascular intervention for acute ischemic stroke while on therapeutic anticoagulation (defined as warfarin use with INR > 1.7, heparin with elevated PTT, or recent LMWH or NOAC use). The primary outcome measure was symptomatic ICH (sICH) using the NINDS definition. We compared the observed rate of sICH to risk-adjusted published historical control rates of sICH after IV tPA using weighted averages of the Hemorrhage after Thrombolysis (HAT) and Multicenter Stroke Survey (MSS) prediction scores. Results: Of 82 cases, mean age was 73 ± 15 years, 46% were female, and median NIHSS was 19 (IQR 14-22). Anticoagulation consisted of warfarin (n=43, mean INR 2.3), IV heparin (n=19), NOACs (n=17), and LMWH (n=3). Any ICH on follow-up CT was present in 26 (32%) patients, and sICH in 7 (8.5%, 95% CI 4.2-16.6) patients. All 7 sICH occurred in patients on warfarin. Severe systemic bleeding occurred in 1 patient. At discharge, 10% subjects returned home, 44% went to an acute rehabilitation facility, 27% to a nursing facility, and 19% had died. Predicted sICH rate for the cohort based on HAT and MSS scoring was 12% and 7% respectively. Conclusions: Endovascular intervention in subjects on therapeutic anticoagulation appears reasonably safe, with a sICH rate similar to patients not on anticoagulation receiving IV tPA.

Abstract TP36: Predictors and Associated Outcomes of Subarachnoid Hemorrhage Following Endovascular Treatment for Acute Ischemic Stroke

Introduction: The rates of occurrence, predictors, and associated outcomes of subarachnoid hemorrhage (SAH) following endovascular treatment are not well studied. Methods: We retrospectively analyzed data from the Interventional Management of Stroke Trial (IMS III). This prospective trial randomized patients to intravenous (IV) rt-PA alone versus IV rt-PA followed by endovascular intervention. All patients underwent computed tomography (CT) at 24 hours post randomization. The scans were assessed by independent reviewers at a core laboratory for the presence, location, and type of intracranial hemorrhage.The primary outcome assessment was by modified Rankin Scale (mRS) score at 3 months. Results: Thirty four out of 434 (7.8%) patients who received endovascular treatment suffered SAH at 24 hours. There were 19 men (55.9%), and 19 patients were older than 70 years.In univariate analysis only pre-existing ischemic heart disease was identified as a predictor of SAH (p=0.03) while patient age was borderline significant (p=0.055). Three-monthmRS score was available for 24/34 patients with SAH and for 318/400 among the other patients. There was no difference in mortality (12.5% vs. 4.1%, p=0.167) or favorable outcome defined as mRS =<2 (41.7% vs. 53.5%, p=0.366). Conclusions: SAH following endovascular intervention for acute stroke is more common among patients with history of ischemic heart disease. It does not impact on functional outcome or mortality at 3 months.

Endovascular interventions for acute stroke: past practice and current research

The way clinical care and research are currently conceived is entangled in multiple problems. While the problems are universal, nowhere were they more painfully experienced than in the acute care of patients with severe stroke. While we are celebrating that we now possess evidence that patients can benefit from endovascular interventions, we should not miss the opportunity to review the difficult path that led to this point and reflect on how it could be improved. A narrative review of the past and current status of care and research in endovascular treatment of acute stroke may serve to expose the problems and potential solutions. For more than 25 years, rescue endovascular interventions were offered to selected patients using a vast array of drugs and devices not designed for that purpose with little success, at least in the early years.1 Occasionally, a Lazarus experience (spectacular recovery associated with recanalization) would fuel enough enthusiasm to go on for another long run of failures. We have always been aware that the occasional miracle could not justify a full-scale campaign for the massive resources required to staff centers with expert personnel, streamlined patient transportation, not to mention the generous budget needed for such high-technology care. Clinical research thus focused on intravenous (IV) therapy, a simpler approach which can be delivered locally.2 Following the positive National Institute of Neurological Disorders and Stroke (NINDS) study, subsequent research endeavors were largely devoted to neuroprotective agents promoted by the pharmaceutical industry. Meanwhile, increasingly effective endovascular tools became available, but regulatory agencies never required proof of clinical benefit (angiographic demonstration that vessels can be recanalized would typically suffice) to authorize the sale of ever more expensive devices. Intra-arterial (IA) therapy thus did not have the financial impetus to rigorously assess patient outcomes. Until recently, in the presence of large …

Abstract W MP7: Good Outcomes After Endovascular Therapy For Ischemic Stroke In Octogenarians Are Consistently Present If Final Infarct Volume Is Less Than 20 Cubic Centimeters

Background and Purpose: Octogenarians are thought to have uniformly poor outcomes following endovascular therapy for stroke. We sought to verify whether this contention hold true when low final infarct volumes (FIV) are achieved following endovascular reperfusion. Methods: Retrospective analysis of an acute stroke endovascular database. Inclusion criteria: age ≥ 80, anterior circulation large vessel occlusion stroke, available outcomes and post procedural MRI allowing for FIV analysis. Results: A total of 1298 patients were identified of which 192 (15%) were octogenarians. Of those 95 with available brain MRI and follow up data were included. Baseline: Median age: 83, female: 67%, median admission NIHSS: 16.4, and median time to treatment: 4.7 hours. Occlusion location: M1 in 71 (73%), M2 in 7 (7%), ICA terminus in 17 (17%), and tandem occlusions in 9 (8.8%) of cases. Atrial fibrillation was found in 57% of cases. Median ASPECTS: 9. Successful recanalization rate (TICI 2b, 3) was achieved in 74%, with a favorable outcome (mRS 0-2) in 23 patients (24%). Median FIV was 38.4 cc (mean 72.2 cc). In patients with favorable outcome, median FIV was 15 cc (interquartile range- IQR 2.4 to 24.5 cc), versus 55.8 cc (IQR 21.1 to 120.5 cc), p=0.0007 in patients with poor outcomes. In 31 patients (32.5%), the FIV was < 20 cc, and of those patients 14 (45%) had a favorable outcome, while only 9 (14%) of patients with FIV > 20 cc achieved favorable outcome, p=0.001. Mean ASPECTS in patients with FIV of < 20 cc was 9.23, versus 8.38 with FIV > 20 cc, p=0.0013. In multivariate analysis, predictors of good outcome included FIV of < 20 cc (odds ratio (OR) 6.6, 95% CI 1.4-27.1), successful recanalization (OR 15.9, 95% CI 1.4 to 1.9), but not age, admission NIHSS, time to treatment or occlusion location. Conclusions: Final infarct volumes of < 20 cc after endovascular acute stroke intervention in octogenarians are associated nearly half of the times with good outcomes while larger final infarcts rarely result in good outcomes. Different baseline infarct thresholds may be necessary when selecting octogenarians vs younger stroke patients for endovascular therapy.

Abstract 119: Serial Analysis of Perfusion Angiography in Endovascular Intervention for Acute Stroke With Proximal Middle Cerebral Artery Occlusion

Background: Perfusion imaging is often used to predict tissue fate during acute stroke in clinical practice and in research trials. During endovascular interventions, conventional angiography provides perfusion information at the actual time of reperfusion therapy yet scoring reperfusion remains operator-dependent and limited by scale properties. Here, a quantitative analysis was conducted to evaluate serial changes in perfusion during treatment. Methods: Angiography was analyzed from 118 acute MCA occlusion cases with attempted endovascular reperfusion at UPMC or UCLA. Parametric maps for MTT, TTP, Tmax, CBV, and CBF were extracted with perfusion angiography software (PerfAngio) from angiograms acquired at the time of treatment. Delta maps were created representing the serial change in perfusion parameters across treatment. Region of interest analysis (ROI) performed on the MCA distribution quantified the average change in perfusion. Results: Delta maps allowed for spatial characterization of the change in perfusion that occurs as a consequence of endovascular therapy as shown in the figure. ROI analysis performed for the first 35 cases demonstrated a wide variance in perfusion change ranging from 52% decrease in CBF to 476% increase in CBF. Conclusions: Serial changes extracted using perfusion angiography provide a quantitative, continuous measure of tissue reperfusion resulting from an endovascular therapy. Such perfusion data are more spatially informative and may be more amenable to statistical analysis than the standard categorical scale of reperfusion (TICI) following endovascular intervention.

Abstract WP11: Decreased Intraprocedural End Tidal Carbon Dioxide Is Associated With Unfavorable Functional Outcome After Endovascular Intervention For Acute Ischemic Stroke

Introduction: Patientsundergoing endovascular intervention for acute stroke may have better outcomeswhen managed with conscious sedation (CS) instead of general anesthesia (GA). Previous investigations have not elucidated aclear mechanism for this observation. Hypothesis: Wehypothesize that decreased intraprocedural blood pressure and decreased end tidal CO2 would be associated with worsened functional outcomes at 90 days. Methods: Consecutive patients undergoing stroke interventions between August 2007 and December 2010 were identified from a prospective database. Clinical data was then extracted by retrospective chart review. Outcomes were stratified according to 90 day modified Rankin Scale (mRS), with scores of 0-3 designated as favorable and 4-6 as unfavorable. Variables significantly associated with outcome in univariate analysis were also examined in multivariate analysis, controlling for well-established predictors of functional outcome: age, medical comorbidities, TICI score, and NIH stroke scale score. Results: Of the 106 patients identified, 86 had complete medical and anesthetic records and could be included in the study. None of the measured parameters, including the absolute BP, the absolute decrease in BP, and the relative decrease in BP were associated with functional outcome at 90 days. On the other hand, end tidal carbon dioxide (ETCO2) at 60 min and 90 min was significantly associated with outcome in both univariate and multivariate analysis, controlling for other well-established predictors of functional outcome. Conclusion: Intraprocedural hypocapnia was associated with unfavorable functional outcomes at 3 months, whereas intraprocedural blood pressure was not related to functional outcome. This finding suggests that intraprocedural hypocapnia, rather than the hemodynamic effects of anesthesia, may account for the differences in outcome between GA and CS patients.

Motor Strength Grade and Collateralization on Admission as Predictors of Outcome after Endovascular Intervention in Acute Stroke (P04.052)

Objective: To determine if admission medical research council(MRC) motor strength grade and presence of vascular collateralization are predictors of outcome after endovascular intervention(EI) for acute stroke. Background Large vessel ischemia constitute 30-50% of all cerebrovascular events and EI are gaining importance in the management. There are few clinical indicators of poor outcome like NIH stroke scale, age, extent of territory, infarct volume among others. Design/Methods: Retrospective analysis of 62 patients who underwent EI (MERCI,penumbra,alligator,balloon angioplasty,stents or combination of these procedures) with or without concurrent t-PA for acute stroke from 2007-2011. All patients had head and neck CTA with perfusion and EI. Admission MRC motor grade and collateralization on CTA were independent variables. Modified collateral flow(CS) grading 0-3 for absent, ≤50%,>50% but Results: Median age=75; median motor grade=2,with an interquartile range0-3. 53% were discharged to acute rehab or home(good outcome). SNF placement was 16%(intermediate outcome). Hospice disposition and death was 30%(poor outcome). In the poor outcome category,100% had MRC grade 0-1. The motor grade was significantly associated with death/SNF;as well as worse functional outcome(p Conclusions: This preliminary data suggest Motor grade assessment serve as a robust predictor of outcome after acute stroke intervention. Limitations:Severe neglect,intubated/sedated patients,and previous stroke.Modified collateral flow score grading needs revision as there is a disparity between different grades especially grade 1 & 2. For example person with minimal collaterals (eg: 5%)is in the same category of CS 1 as the person with 49% collaterals, which has a huge bearing on clinical outcome. Disclosure: Dr. Hedna has nothing to disclose. Dr. Favilla has nothing to disclose. Dr. Patel has nothing to disclose. Dr. Khaku has nothing to disclose. Dr. Stead has nothing to disclose. Dr. Gottipati has nothing to disclose. Dr. Gottipati has nothing to disclose. Dr. Waters has nothing to disclose.

Endovascular intervention for acute stroke due to infective endocarditis

The overall incidence of neurological complications due to infective endocarditis is as high as 40%, with embolic infarcts more common than hemorrhagic strokes. The standard of care for typical strokes does not apply to infective endocarditis because there is a substantial risk of hemorrhage with thrombolysis. In the last decade there have been multiple case reports of intravenous and intraarterial thrombolysis with successful outcomes for acute strokes with related infective endocarditis, but successful endovascular interventions for acute strokes associated with infective endocarditis are rarely reported. To the authors' knowledge, this report is the first case in the literature to use a mechanical retrieval device in successful vegetation retrieval in an infective endocarditis acute stroke. Although an interventional approach for treatment of acute stroke related to infective endocarditis is a promising option, it is controversial and a cautious clinical decision should be made on a case-by-case basis. The authors conclude that this approach can be tested in a case series with matched controls, because this condition is rare and a randomized clinical trial is not a realistic option.

Temporary Endovascular Bypass

The goal of mechanical thrombolysis is to re-establish blood flow to a completely occluded artery in patients who fail intravenous thrombolytic therapy or who are outside the therapeutic window. We present our single-institution experience with the use of temporary, partial deployment of a self-expanding intracranial stent as a rescue technique for the treatment of acute stroke. The use of the Enterprise stent represents an off-label use of a humanitarian device exemption device. We performed a retrospective review of a prospective database of acute stroke patients treated with intra-arterial techniques at the Thomas Jefferson University Comprehensive Stroke Center from July 2009 to July 2010. Seven patients were included, and we obtained a 100% recanalization rate to Thrombolysis in Myocardial Infarction grade 2 and 3 with a 28% asymptomatic hemorrhagic transformation. No device-related complications were encountered. Temporary, partial deployment of a self-expanding intracranial stent as a rescue procedure is feasible, effective, and safe in the setting of endovascular intervention for acute stroke, although our experience is limited. This technique was used only as a rescue procedure when more established procedures failed.