Endovascular Thrombectomy Group Research Articles

Endovascular Thrombectomy Versus Intravenous Alteplase For Distal Medium Vessel Occlusions: A Propensity Score‐Matched Analysis

BACKGROUND The benefits of endovascular thrombectomy (EVT) for distal medium vessel occlusions (DMVOs) are not well established. This study aimed to determine the superiority of EVT over intravenous tissue‐type plasminogen activator (IV tPA) in the treatment of DMVOs. METHODS This study analyzed data from the Kanagawa Intravenous and Endovascular Treatment of Acute Ischemic Stroke Registry, a prospective, multicenter, observational registry of acute ischemic stroke patients treated with EVT or IV tPA. The study evaluated patients with acute DMVOs who were treated with EVT and/or IV tPA. DMVOs was defined as occlusions in M2–M3 segment of the middle cerebral artery, anterior cerebral artery, or posterior cerebral artery. The analysis included primary DMVOs and excluded secondary DMVOs, such as distal embolism after recanalization of proximal vessel occlusion. Propensity score‐matched analysis was conducted to compare the outcomes between EVT and IV tPA alone. A good outcome was defined as a modified Rankin Scale score 0–2 or no worsening at 90 days. An excellent outcome was defined as an modified Rankin Scale score 0–1. RESULTS The study included 1148 patients with DMVOs, of whom 816 were treated with EVT and 332 were IV tPA alone. Before propensity score matching, the incidence of good and excellent outcomes was significantly lower in EVT group (good outcomes: EVT 50.3% versus IV tPA 68.0%; P < 0.01; excellent outcomes: 39.8% versus 59.8%; P < 0.001). After propensity score matching, there were no significant differences between EVT and IV tPA groups in good outcomes (EVT 57.8% versus IV tPA 61.3%; P = 0.51), excellent outcomes (46.6% versus 55.0%; P = 0.17), all cerebral hemorrhage (11.6% versus 12.7%; P = 0.74), and symptomatic hemorrhage (2.9% versus 0.6%; P = 0.13). Subarachnoid hemorrhage was more frequent in EVT group (14.5% versus IV tPA 0%). CONCLUSION The benefits of EVT for acute DMVOs were similar to IV tPA alone. Randomized multicenter trials are warranted to establish the superiority of EVT over IV tPA alone for DMVOs.

Endovascular thrombectomy for ischemic stroke with large infarct, short- and long-term outcomes: a meta-analysis of 6 randomised control trials.

Endovascular Thrombectomy (EVT) as first-line treatment of patients with large core ischemic infarct is a subject of debate. A systematic literature search was conducted in four electronic databases for randomized control trials (RCTs) comparing EVT to best medical treatment (BMT) for large core infarcts (ASPECTS ≤ 5). Relevant studies were added after screening for titles, abstracts, and complete text. Meta-analysis was performed. The continuous outcomes were analyzed using the standardized mean difference (SMD) and 95% CI, while the binary outcomes were analyzed using the risk ratio (RR) and 95% confidence interval (CI). A funnel plot was used to visually evaluate publication bias, and if feasible, Egger's test was used to validate. We included 1918 patients from six RCTs that compared EVT plus BMT and BMT alone in patients with large core infarct due to large vessel occlusion in the anterior circulation. There were 946 patients in the EVT group and 972 patients in the BMT group. The one-year outcomes are available for 314 patients in the EVT group and 292 patents in the BMT group from two RCTs. EVT group had statistically significant higher rate of 90-day mRS 0-1 (RR = 3.1, P-value < 0.0001), mRS 0-2 (RR = 2.64, P-value < 0.0001), mRS 0-3 (RR = 1.80, P-value < 0.0001), lower 90-day mean mRS score (SMD = -0.29, P-value < 0.0001), lower 90-day mortality rate (RR = 0.85, P-value = 0.015), and greater early neurological improvement (RR = 2.16, P-value < 0.00001) compared to the BMT group. However, the rates of symptomatic intracerebral hemorrhage (sICH) (RR = 1.76, P-value = 0.01) and any ICH (RR = 2.18, P-value < 0.00001) were higher in EVT group. Our finding showed that EVT plus BMT led to in an absolute improvement of 5%, 12%, and 16% in 90-day mRS 0-1, 0-2, and 0-3, respectively. In addition, patients in EVT plus BMT group had a 3% increased probability of experiencing sICH and were 32% more susceptible to any ICH. Moreover, the one-year mRS 0-2 (RR = 2.16, P-value < 0.00001) and mRS 0-3 (RR = 1.80, P-value < 0.0001) was significantly favor the EVT plus BMT over BMT alone. Although, the one-year mortality rate was not significantly differed between two groups (RR = 0.91, P-value = 0.31). There was no statistically significant difference observed between the EVT plus BMT group and the BMT group concerning new stroke, decompressive craniectomy, and serious adverse events. Combined data from six RCTs shows that EVT plus BMT provides significantly better short- and long-term functional outcomes with minimal increase in symptomatic hemorrhage over BMT in patient with large core infarcts.

Clinical Observation of Infarct Volume ≥150mL in Endovascular Thrombectomy Treatment.

Whether patients with infarct volume ≥150mL could benefit from endovascular thrombectomy (EVT) remains unclear. Patients (n=104) with anterior circulation Alberta Stroke Program Early Computed Tomography Score <6 were screened for infarct volume ≥150mL using the Pullicino formula × (1-22%). The following were compared with the baseline at 90 days: the modified Rankin scale score (mRS) ≤3, mortality rate, symptomatic intracranial hemorrhage and any intracranial hemorrhage within 48 hours, and modified Thrombolysis in Cerebral Infarction (mTICI) ≥2b between the EVT and drug therapy (DT) groups. In patients with infarct volumes ≥150mL, mRS≤3 at 90 days was higher in the EVT group than in the DT group [adjusted odds risk (aOR), 5.52; 95% CI: 1.10-28.24, P=0.04), and mTICI ≥2b at 82.8%. Intracranial hemorrhage within 48 hours occurred in 7 (24.1%) patients in the EVT group and 5 (14.7%) in the DT group (aOR, 0.75; 95% CI: 0.16-3.46; P=0.71). Older age (aOR, 0.94; 95% CI: 0.90-0.99, P=0.01), EVT treatment (aOR, 4.51; 95% CI: 1.60-12.78, P=0.01), and infarct volume ≥150mL (aOR, 0.11; 95% CI: 0.04-0.31, P<0.01) were significantly associated with patient prognosis. Patients with infarct volume ≥150mL who received EVT had a higher proportion of mRS≤3 compared with those who received DT. However, there was no statistically significant difference in intracranial hemorrhage and death between the groups. EVT, smaller infarct volume, and younger age were associated with a good prognosis. The findings require large sample data verification.

Comparing Outcomes of Thrombectomy Versus Intravenous Thrombolysis Based on Middle Cerebral Artery M2 Occlusion Features.

Current evidence provides limited support for the superiority of endovascular thrombectomy (EVT) in patients with M2 segment middle cerebral artery occlusion. We aim to investigate whether imaging features of M2 segment occlusion impact the effectiveness of EVT. We conducted a retrospective cohort study from January 2017 to January 2022, drawing data from the CASE II registry (Computer-Based Online Database of Acute Stroke Patients for Stroke Management Quality Evaluation), which specifically documented patients with acute ischemic stroke presenting with M2 segment occlusion undergoing reperfusion therapy. Patients were stratified into the intravenous thrombolysis (IVT) group (IVT alone) and EVT group (IVT plus EVT or EVT alone). The primary outcome was a modified Rankin Scale score 0 to 2 at 90 days. Secondary outcomes included additional thresholds and distribution of modified Rankin Scale scores, 24-hour recanalization, early neurological deterioration, and relevant complications during hospitalization. Safety outcomes encompassed intracranial hemorrhagic events at 24 hours and mortality at 90 days. Binary logistic regression analyses with propensity score matching were used. Subgroup analyses were performed based on the anatomic site of occlusion, including right versus left, proximal versus distal, dominant/co-dominant versus nondominant, single versus double/triple branch(es), and anterior versus central/posterior branch. Among 734 patients (43.3% were females; median age, 73 years) with M2 segment occlusion, 342 (46.6%) were in the EVT group. Propensity score matching analysis revealed no statistical difference in the primary outcome (odds ratio, 0.860 [95% CI, 0.611-1.209]; P=0.385) between the EVT group and IVT group. However, EVT was associated with a higher incidence of subarachnoid hemorrhage (odds ratio, 6.655 [95% CI, 1.487-29.788]; P=0.004) and pneumonia (odds ratio, 2.015 [95% CI, 1.364-2.977]; P<0.001). Subgroup analyses indicated that patients in the IVT group achieved better outcomes when presenting with right, distal, or nondominant branch occlusion (Pall interaction<0.05). Our study showed similar efficiency of EVT versus IVT alone in acute M2 segment middle cerebral artery occlusion. This suggested that only specific patient subpopulations might have a potentially higher benefit of EVT over IVT alone. URL: https://clinicaltrials.gov; Unique identifier: NCT04487340.

Expanding the Treatable Imaging Profile in Patients With Large Ischemic Stroke: Subanalysis From a Randomized Clinical Trial.

We aimed to examine the boundary of the ischemic core volume in patients undergoing endovascular thrombectomy (EVT) versus those receiving medical management to determine the minimum optimal size for favorable treatment outcomes. This is a prespecified substudy of the RESCUE-Japan LIMIT (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism-Japan Large Ischemic Core Trial). Patients with large vessel occlusion were enrolled between November 2018 and September 2021 with a National Institutes of Health Stroke Scale score of at least 6 on admission and an Alberta Stroke Program Early Computed Tomography Score value of 3 to 5. We investigated the correlation between optimal quantified ischemic core volume, assessed solely using magnetic resonance diffusion-weighted imaging, and functional outcomes (modified Rankin Scale score, 0-3) at 90 days by predictive marginal plots. Final infarct volume and safety outcomes (symptomatic intracerebral hemorrhage and mortality) were also assessed. Of the 203 cases, 168 patients (85 in the EVT group versus 83 in the medical management group) were included. The median (interquartile range) core volume was 94 (65-160) mL in patients with EVT and 115 (71-141) mL in the medical management group (P=0.72). The predictive marginal probabilities of the 2 groups intersected at 128 mL for estimating functional outcomes. Symptomatic intracerebral hemorrhage and mortality within 90 days had overlay margins through all core volumes in both groups. The median final infarct volume (interquartile range) was smaller in the EVT group (142 [80-223] mL versus 211 [123-289] mL in the medical management group; P<0.001). In this prespecified analysis of a randomized clinical trial involving patients with large ischemic strokes, patients with an estimated core volume of up to 128 mL on diffusion-weighted imaging benefit from EVT. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03702413.

Does the Ischemic Core Really Matter? An Updated Systematic Review and Meta‐Analysis of Large Core Trials After TESLA, TENSION, and LASTE

Background The available evidence supporting the use of endovascular thrombectomy (EVT) in acute ischemic stroke patients with large core has increased with the recent release of the Thrombectomy for Emergent Salvage of Large Anterior Circulation Ischemic Stroke (TESLA), Efficacy and Safety of Thrombectomy In Stroke with Extended Lesion and Extended Time Window (TENSION), and Large Stroke Therapy Evaluation (LASTE) trials, providing critical information on additional subgroups not included in initial trials. We aimed to study the efficacy and safety of EVT in patients with acute ischemic stroke with large core and stratify by several subgroups including core infarct at presentation, using a comprehensive meta‐analysis of aggregate data. Methods We executed a systematic search to identify randomized controlled trials that compared EVT to medical management (MM) for the treatment of patients with acute ischemic stroke with large core, defined as Alberta Stroke Program Early CT [Computed Tomography] Score ≤5 on noncontrast CT and/or estimated ischemic core ≥50 mL on CT‐perfusion/MR diffusion. The primary outcome was the shift analysis in the 90‐day modified Rankin scale (mRS) score. Secondary outcomes included functional independence (mRS score 0–2), independent ambulation (mRS score 0–3), 90‐day mortality, and symptomatic intracranial hemorrhage. Pooled odds ratios were calculated for shift mRS score through the random‐effects meta‐analyses, and risk ratios (RRs) were used for the other outcomes, comparing EVT with MM alone. Results Out of 3402 titles and abstracts screened, 6 randomized controlled trials with 1886 patients were included. The EVT group had a higher shift toward a lower mRS than MM alone (odds ratio [OR], 1.49 [95% CI, 1.24–1.79]). Furthermore, the use of EVT was associated with higher rates of functional independence (19.5% versus 7.5%, RR, 2.49 [95% CI, 1.92–3.24]), independent ambulation (36.5% versus 19.9%, RR, 1.91 [95% CI, 1.51–2.43]), and symptomatic intracranial hemorrhage (5.5% versus 3.2%, RR, 1.73 [95% CI, 1.01–2.95]) compared with MM. There was no difference between the 2 groups regarding mortality (31.5% versus 36.8%, RR, 0.86 [95% CI, 0.72–1.02]). Importantly, EVT was consistently associated with a shift toward a lower mRS score in both Alberta Stroke Program Early CT Score 3–5 (OR, 1.60 [95% CI, 1.10–2.32]) and Alberta Stroke Program Early CT Score 0–2 (OR, 1.45 [95% CI, 1.17–1.80]) when compared with MM alone. Conclusion Our results confirm the efficacy of EVT for acute ischemic stroke with large core and suggest a consistent benefit across all Alberta Stroke Program Early CT Score categories. These results represent an important shift in the current large vessel occlusion selection paradigm that currently considers core as an effect modifier for EVT selection.

Efficacy of Endovascular Thrombectomy in Acute Basilar Artery Occlusion with Low PC-ASPECTS: A Nationwide Prospective Registry-Based Study.

We evaluated the efficacy of endovascular thrombectomy (EVT) on the functional outcome of patients with acute basilar artery occlusion and low posterior circulation acute stroke prognosis early computed tomography score (PC-ASPECTS). We identified patients with acute ischemic stroke due to basilar artery occlusion and PC-ASPECTS of 6 or less, presenting within 24 h between August 2008 and April 2022. The primary outcome was a favorable functional outcome, defined as a modified Rankin Scale (mRS) score of 0-3 at 90 days. The secondary outcomes included an mRS score of 0-2, a favorable shift in the ordinal mRS scale, the occurrence of symptomatic intracranial hemorrhage (sICH), and mortality at 90 days. We compared the outcome of patients treated with EVT and those without EVT, using the inverse probability of treatment weighting methods. Out of 566 patients, 55.5% received EVT. In the EVT group, 106 (33.8%) achieved favorable outcomes, compared to 56 patients (22.2%) in the conservative group. EVT significantly increased the likelihood of achieving a favorable outcome compared to conservative treatment (relative risk [RR] 1.39, 95% confidence interval [CI], 1.11-1.74, p = 0.004). EVT was associated with a favorable shift in the mRS (RR 1.85, 95% CI, 1.49-2.29, p < 0.001) and reduced mortality without an increase in the risk of sICH. It did not have an impact on achieving an mRS score of 0-2. Patients with acute basilar artery occlusion and a PC-ASPECTS of 6 or less might benefit from EVT without an increasing sICH. ANN NEUROL 2024;95:788-799.

Endovascular Thrombectomy for Large Ischemic Stroke Across Ischemic Injury and Penumbra Profiles

Whether endovascular thrombectomy (EVT) efficacy for patients with acute ischemic stroke and large cores varies depending on the extent of ischemic injury is uncertain. To describe the relationship between imaging estimates of irreversibly injured brain (core) and at-risk regions (mismatch) and clinical outcomes and EVT treatment effect. An exploratory analysis of the SELECT2 trial, which randomized 352 adults (18-85 years) with acute ischemic stroke due to occlusion of the internal carotid or middle cerebral artery (M1 segment) and large ischemic core to EVT vs medical management (MM), across 31 global centers between October 2019 and September 2022. EVT vs MM. Primary outcome was functional outcome-90-day mRS score (0, no symptoms, to 6, death) assessed by adjusted generalized OR (aGenOR; values >1 represent more favorable outcomes). Benefit of EVT vs MM was assessed across levels of ischemic injury defined by noncontrast CT using ASPECTS score and by the volume of brain with severely reduced blood flow on CT perfusion or restricted diffusion on MRI. Among 352 patients randomized, 336 were analyzed (median age, 67 years; 139 [41.4%] female); of these, 168 (50%) were randomized to EVT, and 2 additional crossover MM patients received EVT. In an ordinal analysis of mRS at 90 days, EVT improved functional outcomes compared with MM within ASPECTS categories of 3 (aGenOR, 1.71 [95% CI, 1.04-2.81]), 4 (aGenOR, 2.01 [95% CI, 1.19-3.40]), and 5 (aGenOR, 1.85 [95% CI, 1.22-2.79]). Across strata for CT perfusion/MRI ischemic core volumes, aGenOR for EVT vs MM was 1.63 (95% CI, 1.23-2.16) for volumes ≥70 mL, 1.41 (95% CI, 0.99-2.02) for ≥100 mL, and 1.47 (95% CI, 0.84-2.56) for ≥150 mL. In the EVT group, outcomes worsened as ASPECTS decreased (aGenOR, 0.91 [95% CI, 0.82-1.00] per 1-point decrease) and as CT perfusion/MRI ischemic core volume increased (aGenOR, 0.92 [95% CI, 0.89-0.95] per 10-mL increase). No heterogeneity of EVT treatment effect was observed with or without mismatch, although few patients without mismatch were enrolled. In this exploratory analysis of a randomized clinical trial of patients with extensive ischemic stroke, EVT improved clinical outcomes across a wide spectrum of infarct volumes, although enrollment of patients with minimal penumbra volume was low. In EVT-treated patients, clinical outcomes worsened as presenting ischemic injury estimates increased. ClinicalTrials.gov Identifier: NCT03876457.

Endovascular thrombectomy for posterior cerebral artery strokes in the national inpatient sample (EaT PeCANpIeS) study.

Posterior cerebral arteries with acute ischemic strokes (PCA-AISs) comprise around 2% of all acute ischemic strokes and may result in significant long-term deficits. Current guidance regarding endovascular thrombectomy (EVT) for PCA-AIS is insufficient as no published randomized trials exist. An analysis of the National Inpatient Sample database compared medical management versus EVT for PCA-AIS. Propensity score matching was applied to adjust for nonrandomization. The study included 19,655 patients. Before matching, the EVT cohort had significantly higher National Institutes of Health Stroke Scale (NIHSS) (10.21 vs. 4.67, p < 0.001), had lower rates of favorable functional outcomes, functional independence, and higher rates of intracranial hemorrhage (ICH) and inpatient mortality. After matching, no differences in functional outcomes were identified, but revealed a higher proportion of ICH in the EVT group (17.45% vs. 8.98%, p < 0.001). However, NIHSS subgroup analysis identified improved functional outcomes associated with the EVT group who presented with an NIHSS between 10 and 19 both in terms of rates of favorable functional outcomes (35.56% vs. 12.09%, p < 0.001) and rates of functional independence (26.67% vs. 9.34%, p < 0.01). On further investigation, the clinical benefit, in the NIHSS 10-19 subgroup, was driven by patients receiving EVT in combination with intravenous thrombolysis (IVT). This analysis shows that current national practices utilize EVT for more severe PCA strokes. Clinical benefit was only detected in patients with moderate stroke severity (NIHSS 10-19) who were treated with combined EVT and IVT. Further work is needed to investigate the features of PCA-AIS that might benefit from EVT the most.

Does Endovascular Thrombectomy(ET) plus tirofiban benefit stroke patients: A systematic review and meta-analysis

BackgroundIschemic stroke is the second leading cause of death worldwide. Endovascular thrombectomy (ET) has been shown to prevent disability in a proportion of patients. The use of tirofiban in patients undergoing ET after acute stroke has resulted in improved patient function and reduced mortality to some extent. In this systematic review and meta-analysis of the current period, an overview of the most recent studies on the potential efficacy of using tirofiban to help acute stroke patients improve function and reduce mortality was provided. MethodsIn this meta-analysis, we explore the safety and efficacy of ET combined with tirofiban in patients with acute stroke. We searched the PubMed, EMBASE, Web of Science, and The Cochrane Library database from the construction of the library to the present relevant RCTs/non-RCTs. The following key words were used for finding relevant studies from the databases“tirofiban”“thrombectomy”“ Stroke”“ balloon angioplasty”“stenting”. ResultsTotal of 14 trials with 4366 individuals enrolled were included in the Meta-analysis including 2732(62.6) who received ET alone and 1634(37.4 %) who received tirofiban plus ET. The primary outcome of 90-day functional independence (modified Rankin scale (mRS) score≤2) was 42.2 % (1043/2473) in the ET alone group vs. 46.2 % (684/1480) in the tirofiban with ET group (risk ratio (RR), 1.10 [95 % CI, 1.02-1.18]; P=0.02),mortality at 90 days (RR, 0.86 [95 % CI, 0.76–0.98]; P = 0.02). There is no significant between-group differences were found in excellent outcome (mRS score ≤1) (RR, 1.08 [95 % CI, 0.95–1.23]; P = 0.22), symptomatic intracranial hemorrhage (RR, 1.11 [95 % CI, 0.92–1.34]; P = 0.27). ConclusionsThese findings suggest that the use of ET combined with tirofiban in patients with acute stroke is safe and has the potential to reduce mortality and improve functional independence at 90 days.

Abstract 067: Outcomes for large vessel occlusion patients with severe baseline disability with and without endovascular thrombectomy

Introduction Patients with baseline disability account for one‐third of stroke presentations. However, there remains controversy in treatment selection for endovascular thrombectomy (EVT). We compared long‐term outcomes and likelihood of transitioning to comfort care for large vessel occlusion (LVO) patients with severe pre‐stroke disability treated with EVT versus medical management at a single center from 2017‐2020. Methods Individuals who presented with LVO were identified retrospectively from a prospectively maintained database. Severe baseline disability was defined as modified Rankin Scale (mRS) 3‐5. Delta mRS was defined as the difference between baseline and 90‐day mRS. Logistic and ordinal regressions were performed to evaluate the relationships between EVT and outcomes. A mixed‐methods analysis was performed to assess rates and reasons for transitions to comfort care. Results A total of 175/1008 (17%) were identified with severe baseline disability. The median age was 82 (IQR 70‐89), and 59% were female. Thirty‐two (18%) with severe baseline disability were treated with EVT. EVT was independently associated with improved delta mRS (B=‐1.048; 95%CI=‐1.777,‐0.318; p=0.005) accounting for age and NIHSS. However, EVT did not reduce the odds of transitioning to comfort care (aOR=0.794; 95%CI=0.347,1.818; p=0.585) accounting for age and NIHSS. Seventy‐six (43%) with severe baseline disability were transitioned to comfort care. Of the 99 not transitioned to comfort care, 18 were treated with EVT, and EVT was independently associated with improved delta mRS (B=‐2.794; 95%CI=‐4.002,‐1.586; p&lt;0.0001) accounting for age and NIHSS. The median time from presentation to comfort care was 2 days (IQR 1‐7) in the non‐EVT group, compared to 7 (IQR 4‐11) in the EVT group (H(1)=5.46, p=0.019). The primary reasons for comfort care were poor perceived prognosis and medical complications. Conclusion Among patients with severe baseline disability, EVT is associated with less post‐stroke accumulated disability without limiting transitions to comfort care. EVT may be compatible with goal‐concordant care and should not be routinely withheld on the basis of baseline disability alone.

Abstract 216: Endovascular Thrombectomy +/‐ Thrombolytics In Patients With Cocaine‐Related Acute Ischemic Stroke

Introduction The safety of thrombolytic therapy in patients with cocaine‐related acute ischemic strokes (AIS) has been investigated, but the safety of endovascular thrombectomy in cocaine‐related AIS remains unknown (1‐2). Here, we report preliminary descriptive data on endovascular thrombectomy with or without thrombolytics performed in cocaine‐related ischemic strokes at our institution. Methods A retrospective chart review was performed at our comprehensive stroke center from June 2020 to May 2022 to identify AIS patients with cocaine‐positive urine toxicology screens on admission. Baseline demographics, urine toxicology, National Institute of Health Stroke Scale (NIHSS) scores, neuroimaging, Trial of ORG 10127 in Acute Stroke Treatment (TOAST) criteria, location of stroke, home medications, comorbidities, medical management, and outcomes including modified Rankin Score (mRS) were reported. Results A total of 74 AIS patients were identified to be cocaine‐positive. Of these patients, 14 underwent endovascular thrombectomy (EVT). Only 3 of these 14 patients received intravenous thrombolytics. Including the EVT group, 8 out of 74 AIS patients received thrombolytics. The mean age was found to be 61 years with 86% being male. The most common locations of large vessel occlusion were the M2 branch of the right middle cerebral artery (MCA) (40%), the M2 branch of the left MCA (33%), the M1 branch of the right MCA (13%), left internal carotid artery (7%), and A1 branch of the anterior cerebral artery (7%). Based on TOAST criteria, 64% of strokes were large artery atherosclerosis, 29% cardioembolic, and 7% cryptogenic stroke. The mean initial NIHSS was 14. Average mRS on admission was found to be &lt; 1 and follow‐up mRS at 3 months was found to be 3. Conclusion Our data suggest that cocaine patients who underwent EVT on average had unfavorable functional outcomes defined as mRS &gt; 2, on follow‐up mRS at 3 months. This study highlights the importance of future larger studies to investigate endovascular thrombectomy +/‐ thrombolytics in cocaine‐related AIS.

Bridging therapy improves functional outcomes and reduces 90-day mortality compared with direct endovascular thrombectomy in patients with acute posterior ischemic stroke: a systematic review and meta-analysis.

It remains unclear whether bridging therapy can achieve better neurologic outcomes than direct endovascular thrombectomy (EVT) in patients with posterior ischemic stroke. We systematically searched PubMed, EMBASE, and Cochrane databases with posterior artery occlusion treated with bridging therapy vs. EVT. Efficacy was assessed based on functional independence at 90days and successful recanalization, whereas safety was assessed by mortality, rate of symptomatic intracranial hemorrhage (sICH), and occurrence of any hemorrhage. All data were analyzed with Review Manager software v5.3 and the risk of bias was determined using the Methodological Index for Non-randomized Studies. We included 17 studies with a total of 3278 patients (1211 in the bridging therapy group and 2067 in the EVT group). Patients in the bridging group had a better functional outcome at 90days, as evidenced by a higher proportion with a Modified Rankin Scale (mRS) score of 0-2 compared with the EVT group (odds ratio (OR) = 1.83, 95% confidence interval (CI): 1.54-2.19, P < 0.01), while no difference in mRS score of 0-3 (OR = 1.18, 95% CI: 0.96-1.45, P = 0.11). Patients in the bridging therapy group also had lower 90-day mortality rate (OR = 0.75, 95% CI: 0.59-0.95, P = 0.02). There were no significant differences between groups in rates of successful recanalization (OR = 0.96, 95% CI: 0.74-1.25, P = 0.77), sICH (OR = 1.27, 95% CI: 0.86-1.89, P = 0.24), and hemorrhage (OR = 1.22, 95% CI: 0.60-2.50, P = 0.58). Among patients with posterior ischemic stroke, bridging therapy may be superior to EVT in achieving a good functional outcome and lowering the mortality without increasing the risks of hemorrhage.

Endovascular thrombectomy for ischemic stroke with large core volume: An updated, post-TESLA systematic review and meta-analysis of the randomized trials.

Limited randomized controlled trials (RCTs) have been performed comparing endovascular thrombectomy (EVT) to medical therapy (MEDT) for acute ischemic stroke with extensive baseline ischemic injury (AIS-EBI). We conducted a systematic review and meta-analysis of RCTs reporting EVT for AIS-EBI. Using the Nested Knowledge AutoLit software, we conducted a systematic literature review from inception to 12 February 2023 within Web of Science, Embase, Scopus, and PubMed databases. Results of the TESLA trial were included on 10 June 2023. We included RCTs that compared EVT to MEDT for AIS with large ischemic core volume. The primary outcome of interest was a modified Rankin Score (mRS) 0-2. Secondary outcomes of interest included early neurological improvement (ENI), mRS 0-3, thrombolysis in cerebral infarction (TICI) 2b-3, symptomatic intracranial hemorrhage (sICH), and mortality. A random-effects model was used to calculate risk ratios (RRs) and their corresponding 95% confidence intervals (CIs). We included four RCTs with 1310 patients, 661 of whom underwent EVT and 649 of whom were treated with MEDT. EVT was associated with greater rates of mRS 0-2 (RR = 2.33, 95% CI = 1.75-3.09; P-value < 0.001), mRS 0-3 (RR = 1.68, 95% CI = 1.33-2.12; P-value < 0.001), and ENI (RR = 2.24, 95% CI = 1.55-3.24; P-value < 0.001). Rates of sICH (RR = 1.99, 95% CI = 1.07-3.69; P-value = 0.03) were greater in the EVT group. Mortality (RR = 0.98, 95% CI = 0.83-1.15; P-value = 0.79) was comparable between the EVT and MEDT groups. The rate of successful reperfusion in the EVT group was 79.9% (95% CI = 75.6-83.6). Although the rate of sICH was greater in the EVT group, EVT conferred a greater clinical benefit to MEDT for AIS-EBI based on available RCTs.

Endovascular Thrombectomy Versus Best Medical Management Beyond 24 Hours From Last Known Well in Acute Ischemic Stroke Due to Large Vessel Occlusion

Background The safety and efficacy of endovascular thrombectomy (EVT) in patients with acute ischemic stroke due to large vessel occlusion presenting beyond 24 hours from last known well (LKW) remains undetermined. Methods In this single center study, we identified patients with large vessel occlusion who were eligible for EVT based on noncontrast computed tomography (CT)/CT angiography (without CT perfusion or magnetic resonance imaging) using an Alberta Stroke Program Early CT Score of ≥5, National Institutes of Health Stroke Scale of ≥6, and presenting beyond 24 hours from LKW, between January 2018 and March 2022. During the study period, EVT service limitations meant patients eligible for EVT presenting outside service hours, routinely received best medical management (BMM). Functional and safety outcomes were compared between patients receiving EVT or BMM following multivariable adjustment for age, baseline stroke severity, Alberta Stroke Program Early CT Score, time from LKW, IV thrombolysis, and clot location. Results Among 35 patients presenting beyond 24 hours from LKW and eligible for EVT, 19 (54%) were treated with EVT and 16 (46%) with BMM. Alberta Stroke Program Early CT Score were similar across both groups (EVT: 7 [6.75–8] versus BMM: 7 [6–8]), but not the baseline National Institutes of Health Stroke Scale (EVT: 17 [11–19.5] versus BMM: 20 [9.75–26]). No significant difference was observed between the EVT and BMM groups in the symptomatic intracranial hemorrhage (5.3% versus 0%; P =0.28) or mortality (26.3% versus 37.5%; P =0.42) rates, respectively. The modified Rankin scale at 90 days (adjusted common odds ratio [OR], 1.94; [95% CI 0.42–8.87]; P =0.39) and functional independence rate, although numerically higher in the EVT group compared with the BMM group (modified Rankin scale≤2; 36.9% versus 18.8%; adjusted OR, 4.34; [95% CI 0.34–54.83]; P =0.25), were not significantly different. 94.7% of patients treated with EVT achieved successful reperfusion (modified thrombolysis in cerebral infarction 2b–3). Conclusion In routine clinical practice, EVT beyond 24 hours from LKW appears safe and feasible, when performed in patients with acute ischemic stroke who were deemed eligible for EVT by noncontrast CT /CT angiography alone. A large collaborative randomized trial assessing the efficacy of EVT beyond 24 hours is warranted. Our findings provide a basis for the sample size estimate for an adequately powered trial.

Admission systolic blood pressure and effect of endovascular treatment in patients with ischaemic stroke: an individual patient data meta-analysis

Current guidelines for ischaemic stroke treatment recommend a strict, but arbitrary, upper threshold of 185/110 mm Hg for blood pressure before endovascular thrombectomy. Nevertheless, whether admission blood pressure influences the effect of endovascular thrombectomy on outcome remains unknown. Our aim was to study the influence of admission systolic blood pressure (SBP) on functional outcome and on the effect of endovascular thrombectomy. We used individual patient data from seven randomised controlled trials (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT, PISTE, and THRACE) that randomly assigned patients with anterior circulation ischaemic stroke to endovascular thrombectomy (predominantly using stent retrievers) or standard medical therapy (control) between June 1, 2010, and April 30, 2015. We included all patients for whom SBP data were available at hospital admission. The primary outcome was functional outcome (modified Rankin Scale) at 90 days. We assessed the association of SBP with outcome in both the endovascular thrombectomy group and the control group using multilevel regression analysis and tested for non-linearity and for interaction between SBP and effect of endovascular thrombectomy, taking into account treatment with intravenous thrombolysis. We included 1753 patients (867 assigned to endovascular thrombectomy, 886 assigned to control) after excluding 11 patients for whom SBP data were missing. We found a non-linear association between SBP and functional outcome with an inflection point at 140 mm Hg (732 [42%] of 1753 patients had SBP <140 mm Hg and 1021 [58%] had SBP ≥140 mm Hg). Among patients with SBP of 140 mm Hg or higher, admission SBP was associated with worse functional outcome (adjusted common odds ratio [acOR] 0·86 per 10 mm Hg SBP increase; 95% CI 0·81-0·91). We found no association between SBP and functional outcome in patients with SBP less than 140 mm Hg (acOR 0·97 per 10 mm Hg SBP decrease, 95% CI 0·88-1·05). There was no significant interaction between SBP and effect of endovascular thrombectomy on functional outcome (p=0·96). In our meta-analysis, high admission SBP was associated with worse functional outcome after stroke, but SBP did not seem to negate the effect of endovascular thrombectomy. This finding suggests that admission SBP should not form the basis for decisions to withhold or delay endovascular thrombectomy for ischaemic stroke, but randomised trials are needed to further investigate this possibility. Medtronic.

Therapeutic strategies for acute basilar-artery occlusion

Therapeutic strategies for acute basilar-artery occlusion

Abstract Number ‐ 193: Endovascular Thrombectomy for Basilar Artery Occlusion: Systematic Review and Meta‐analysis

Introduction Basilar artery occlusion (BAO), accounting for approximately 1% of all ischemic strokes and 5–10% of all proximal intracranial occlusions, usually causes devastating neurologic sequelae, poor prognosis and even death [1‐2]. Endovascular thrombectomy (EVT) has been recommended for anterior circulation stroke with large vessel occlusion (LVO) [3‐6]. During the past decade, there has been emerging interests in whether EVT could provide similar overwhelming benefits in posterior circulation stroke, especially BAO [7‐8]. The goal of our study is to compare EVT with conservative medical treatment (CMT) about the efficacy and the safety in patients with BAO. Methods All relevant literature comparing the outcomes of EVT versus CMT in patients with BAO were recruited via PubMed, Embase and the Cochrane Library until April 2022. Random‐effects model was adopted to pool estimates regrading favorable/good functional outcome, symptomatic intracranial hemorrhage (sICH) and the mortality. The heterogeneity of outcomes was assessed using the Cochran Q test (reported as a Cochran Q p value) and I2 statistics. Results Of the eight studies, a total of 3733 patients with pure BAO were enrolled. EVT was conducted in 2573 patients, and the others received CMT. Compared with CMT group, EVT group with or without intravenous thrombolytic therapy achieved more favorable functional outcome (OR 1.26, 95% CI 1.03 to 1.55, I2 = 54%, p = 0.05; Figure 1A) in patients with BAO. Similar trend was also noted in the good functional outcome (OR 1.23, 95% CI 0.97 to 1.57, I2 = 63%, p = 0.02; Figure 1B). Even though EVT group tended to provoke more sICH (OR 2.91, 95% CI 1.38 to 6.18, I2 = 22%, p = 0.27; Figure 1C), it reduced the mortality (OR 0.81, 95% CI 0.70 to 0.93, I2 = 31%, p = 0.19; Figure 1D) in patients with BAO, originally a devastating condition. Conclusions Our study worked in concert with the recent climate in the endovascular era [9] that EVT in BAO provides superior functional outcomes and less mortality compared with CMT. Despite the tendency of developing sICH after reperfusion, EVT still brought a dawn to posterior circulation stroke. We are no more at our wits’ end with BAO and its grave prognosis. Furthermore, we still need more future randomized control trials [10] or large‐scale cohorts for conclusive evidence.

Abstract Number: LBA7 Outcomes of Endovascular Thrombectomy Versus Medical Treatment in Ischemic Strokes Secondary to Medium Vessel Occlusion

Introduction Acute ischemic stroke (AIS) from arterial occlusions are treated with emergent endovascular thrombectomy (EVT) when clinically appropriate. Clinical outcomes of EVT in medium vessel occlusion (MVO) compared to large vessel occlusion (LVO) have neither been well established nor compared to alternate medical management. Our aim was to evaluate outcomes of patients with AIS secondary to MVO undergoing EVT. Methods We conducted a retrospective chart review of patients presenting to our comprehensive stroke center with MVO‐associated AIS undergoing EVT or aggressive intra‐arterial thrombolytic treatment with concurrent administration of IV eptifibatide. We assessed occlusion site, NIHSS (presentation, 7 day or discharge, 3 months), modified Rankin Scale (baseline, 90‐day), and intracranial hemorrhage (ICH) rate. MVO was defined as occlusion of pure M2 middle cerebral artery without M1 segment involvement, anterior cerebral artery A1 segment or more distal, and posterior cerebral artery P1 segment or more distal. Mann‐Whitney U test, Fisher exact test statistic, and T‐test statistic were used for analysis. Social science statistics software was used for data analysis. Results From August 2020 to December 2021, out of 175 patients who underwent EVT, 50 had MVO (n = 33 M2 occlusion, n = 12 M3 occlusion, n = 1 for P1, P2, A1, A2, A3 each). Twelve subjects with MVO received aggressive medical management with concurrent IV eptifibatide. Subjects between arms were similar at baseline (median NIHSS 11 [95% CI 10.75, 14.32]; mean age 71.5 [95% CI 69.24, 73.77]; male 48.39% [n = 30]). The difference between initial NIHSS and discharge NIHSS was statistically significant in the EVT arm (Z‐Score = 4.03; p‐value &lt; .00001) but not in the medical arm (Z‐score = 1.96; p‐value 0.05). Hemorrhagic transformation occurred in 28% (n = 14) of EVT arm and 16.67% (n = 2) of medical arm. This was not statistically significant (Fisher value: 0.71). Median 90 day mRS was 1 (95% CI [0.89, 2.11]). The difference between 90 day mRS was not significantly different (Z‐score = ‐1.20; p‐value 0.23). Conclusions In our patient cohort, endovascular therapy was safe in medium vessel occlusion and may have more favorable clinical outcomes as illustrated by higher delta NIHSS in the endovascular thrombectomy group. Larger, prospective studies are needed to validate our results.

Abstract TMP86: Clinical Outcomes Of Endovascular Thrombectomy Versus Acute Medical Treatment In Acute Ischemic Strokes Secondary To Medium Vessel Occlusion

Introduction: Acute ischemic stroke (AIS) from arterial occlusions are treated with emergent endovascular thrombectomy (EVT) when clinically appropriate. Clinical outcomes of EVT in medium vessel occlusion (MVO) compared to large vessel occlusion (LVO) have neither been well established nor compared to alternate medical management. Our aim was to evaluate outcomes of patients with AIS secondary to MVO undergoing EVT. Methods: We conducted a retrospective chart review of patients presenting to with MVO-associated AIS undergoing EVT or aggressive intra-arterial thrombolytic treatment with concurrent administration of IV eptifibatide. We assessed occlusion site, NIHSS (presentation, 7 day or discharge, 3 months), mRS (baseline, 90-day), and intracranial hemorrhage (ICH) rate. MVO was defined as occlusion of pure M2 middle cerebral artery without M1 segment involvement, anterior cerebral artery A1 segment or more distal, and posterior cerebral artery P1 segment or more distal. Mann-Whitney U test, Fisher exact test statistic, and T-test statistic were used for analysis. Results: From August 2020 to December 2021, out of 175 patients who underwent EVT, 50 had MVO (n=33 M2 occlusion, n=12 M3 occlusion, n=1 for P1, P2, A1, A2, A3 each). Twelve subjects with MVO received aggressive medical management with concurrent IV eptifibatide. Subjects between arms were similar at baseline (median NIHSS 11 [95% CI 10.75, 14.32]; mean age 71.5 [95% CI 69.24, 73.77]; male 48.39% [n=30]). The difference between initial NIHSS and discharge NIHSS was statistically significant in the EVT arm (Z-Score=4.03; p-value &lt; .00001) but not in the medical arm (Z-score=1.96; p-value 0.05). Hemorrhagic transformation occurred in 28% (n=14) of EVT arm and 16.67% (n=2) of medical arm. This was not statistically significant (Fisher value: 0.71). Median 90 day mRS was 1 (95% CI [0.89, 2.11]). The difference between 90 day mRS was not significantly different (Z-score=-1.20; p-value 0.23). Conclusion: In our patient cohort, endovascular therapy was safe in medium vessel occlusion and may have more favorable clinical outcomes as illustrated by higher delta NIHSS in the endovascular thrombectomy group. Larger, prospective studies are needed to validate our results.