First-pass Reperfusion Research Articles

Economic and Efficient: Introducing the Bifurcation-Invisible Sign in Endovascular Thrombectomy for Middle Cerebral Artery Occlusions.

Introduction Selecting thrombectomy techniques for acute ischemic stroke (AIS) due to large vessel occlusion (LVO) significantly affects outcomes and costs. This study introduces the Bifurcation-Invisible (BI) sign identified on initial microcatheter angiogram in acute middle cerebral artery occlusions before endovascular thrombectomy. We aimed to evaluate whether this sign is associated with better angiographic outcomes using contact aspiration (CA) versus stent retriever (SR). Methods In this study, we reviewed 285 cases of acute M1-segment middle cerebral artery (M1-MCA) occlusions treated with stent retriever (SR) or contact aspiration (CA). Angiographic success was evaluated using modified Thrombolysis In Cerebral Infarction (mTICI) scores after the first attempt, clinical outcomes by 90-day modified Rankin Scale (mRS) scores, and procedural costs were analyzed. Categorical variables were analyzed using χ2 or Fisher's exact test, and continuous variables using Student's t-test or Mann-Whitney U test. Subgroup multivariate logistic analysis and interaction tests were conducted, with post-hoc analysis applying Bonferroni correction. Results BI-positive patients treated with CA had higher first-pass reperfusion rates (mTICI 2b-3: 64.0% vs. 41.3%, p = 0.005; Bonferroni-corrected p = 0.030) and 19.8% lower device costs (p < 0.05) than those treated with SR. BI-positive CA patients had higher first-pass reperfusion rates (mTICI 2b-3: 64.0% vs. 32.1%; p < 0.001; Bonferroni-corrected p = 0.002) and a 39.9% reduction in device costs (p < 0.05) than BI-negative patients. The interaction tests showed significant interactions between the presence of BI and contact aspiration for first-pass reperfusion rates (p = 0.007) and device costs (p ˂ 0.001). Conclusion The BI sign, a refined version of the BSO sign identified via microcatheter angiography, could guide the selection of contact aspiration, improving recanalization rates and reducing costs in MCA occlusions.

The Effect of Systemic Inflammatory Response on Mechanical Thrombectomy is Partly Mediated by Pre-thrombectomy Cerebral Edema in Acute Stroke Patients.

To explore the effect of baseline Systemic Inflammatory Response reflected by platelet-to-lymphocyte ratio (PLR) and pre-thrombectomy cerebral edema reflected by Net Water Uptake (NWU) on futile recanalization in patients with Acute Ischemic Stroke (AIS) after successful thrombectomy, and to investigate the potential mediating role of baseline cerebral edema. 134 Patients with anterior circulation ischemic stroke receiving successful thrombectomy were retrospectively studied. Their demographic and clinical characteristics were collected at admission, and the NWU was quantitatively calculated based on baseline computed tomography (CT). The predictive value of PLR for futile recanalization and the relationship between PLR, NWU, and futile recanalization using mediation analysis were explored. Patients were followed up for 90 days and were divided into a futile recanalization group and a favorable prognosis group [90-day modified Rankin Scale score of 0-2]. High baseline PLR, NWU, no first-pass reperfusion, and large baseline ischemic core volume were independent predictors of futile recanalization after successful thrombectomy in patients with AIS. Mediation analysis results indicate that PLR may partially mediate the occurrence of futile recanalization through NWU. Baseline PLR and NWU were independent predictors of futile recanalization, and higher PLR and NWU values were associated with a higher likelihood of futile recanalization. The findings suggest that early cerebral edema reflected by a high NWU value may be a mediator of PLR-affecting prognosis.

Endovascular thrombectomy first-pass reperfusion and ancillary device placement

BackgroundRecent randomized trials have demonstrated the efficacy of mechanical thrombectomy in treating acute ischemic stroke, however, further research is required to optimize this technique. We aimed to evaluate the impact...

Comparison of 4 mm-sized and 3 mm-sized Stent Retrievers in Mechanical Thrombectomy for M2 Occlusion.

A stent retriever (SR) is widely used in mechanical thrombectomy (MT) for M2 segment occlusion. However, the suitable size of SR in M2 occlusion remains unclear. Therefore, we aimed to compare 4 mm-sized SR with 3 mm-sized SR in M2 occlusion. Patients who underwent MT with SR for M2 occlusion were dichotomized into 4×20 mm SR and 3×20 mm SR groups. Then, 1:1 propensity score matching was performed. The M2 segment was divided into proximal and distal segments according to the occlusion site. Subgroup analysis was then performed for each cohort. A total of 111 patients were enrolled, with 4×20 mm SR and 3×20 mm SR applied in 72 (64.9%) and 39 (35.1%) cases, respectively. In propensity score matching, mean number of stent passages for reperfusion was significantly lower in the 4×20 mm SR group than in the 3×20 mm SR group (1.5 ± 0.8 vs. 2.1 ± 1.1; p = 0.004). First-pass reperfusion (FPR) was more highly achieved in the 4×20 mm SR group than in the 3×20 mm SR group (52.6% vs. 42.1%; p = 0.007). In both proximal and distal occlusion cohorts, the 4 mm SR group showed lower mean number of SR passage (p = 0.004 and p = 0.003, respectively) and higher FPR rate than the 3 mm SR group (p = 0.003 and p = 0.007, respectively). In MT for M2 occlusion, 4×20 mm SR enables an effective procedure with lesser SR passage for reperfusion and a higher rate of FPR than 3×20 mm SR.

Stent Retriever Deployment Tracing Susceptibility Vessel Sign in the M2 Branch Predicts the Effective First-Pass Reperfusion in Thrombectomy for M1 Occlusion

Successful first-pass reperfusion is associated with better functional outcomes after mechanical thrombectomy (MT) for acute ischemic stroke, but its treatment strategies remain unclear. We retrospectively recruited patients who underwent MT for M1 occlusion between December 2020 and May 2023 at our institution. The locations of susceptibility vessel sign (SVS) on magnetic resonance imaging were classified into M1 only, M1 to single M2 branch, or M1 to both M2 branches. Patients were included in the SVS tracing group when the stent retriever of the first pass covered the entire SVS length. Successful reperfusion was defined as a modified Thrombolysis in Cerebral Infarction scale 2b-3. Any intracranial hemorrhage detected at 24-hour postoperatively was included as a hemorrhagic complication. The SVS was detected in M1 only, M1 to single M2 branch, and M1 to both M2 branches in 8, 22, and 4 patients, respectively. Among the 34 patients, 27 were included in the SVS-tracing group. Successful first-pass reperfusion was significantly more frequent in the SVS-tracing group compared with the non-SVS tracing group (odds ratio (OR), 14.4; 95% confidence interval (95%CI), 2.0-101; P = 0.007). The procedural time was significantly reduced in the SVS tracing group (median, 29 [interquartile range, 22-49] min vs. 63 [43-106] min; P = 0.043). There was a trend towards less frequent hemorrhagic complications in the SVS tracing group (OR, 0.17; 95%CI, 0.029-1.0; P = 0.052). This study provides a thrombus imaging-based MT strategy to efficiently achieve first-pass reperfusion in M1 occlusion.

Value of Automatically Derived Full Thrombus Characteristics: An Explorative Study of Their Associations with Outcomes in Ischemic Stroke Patients.

(1) Background: For acute ischemic strokes caused by large vessel occlusion, manually assessed thrombus volume and perviousness have been associated with treatment outcomes. However, the manual assessment of these characteristics is time-consuming and subject to inter-observer bias. Alternatively, a recently introduced fully automated deep learning-based algorithm can be used to consistently estimate full thrombus characteristics. Here, we exploratively assess the value of these novel biomarkers in terms of their association with stroke outcomes. (2) Methods: We studied two applications of automated full thrombus characterization as follows: one in a randomized trial, MR CLEAN-NO IV (n = 314), and another in a Dutch nationwide registry, MR CLEAN Registry (n = 1839). We used an automatic pipeline to determine the thrombus volume, perviousness, density, and heterogeneity. We assessed their relationship with the functional outcome defined as the modified Rankin Scale (mRS) at 90 days and two technical success measures as follows: successful final reperfusion, which is defined as an eTICI score of 2b-3, and successful first-pass reperfusion (FPS). (3) Results: Higher perviousness was significantly related to a better mRS in both MR CLEAN-NO IV and the MR CLEAN Registry. A lower thrombus volume and lower heterogeneity were only significantly related to better mRS scores in the MR CLEAN Registry. Only lower thrombus heterogeneity was significantly related to technical success; it was significantly related to a higher chance of FPS in the MR CLEAN-NO IV trial (OR = 0.55, 95% CI: 0.31-0.98) and successful reperfusion in the MR CLEAN Registry (OR = 0.88, 95% CI: 0.78-0.99). (4) Conclusions: Thrombus characteristics derived from automatic entire thrombus segmentations are significantly related to stroke outcomes.

Abstract TP188: Diving MCA and First-Pass Reperfusion: A Subgroup Analysis of the Arise II Study

Introduction: Tortuosity of Internal carotid artery impact on achieving first pass in mechanical thrombectomy has been previously described. Here, we investigate the association of middle cerebral artery(MCA) tortuosity on radiographic and functional outcome. Methods: The Analysis of Revascularization in Ischemic Stroke with EmboTrap II was utilized to identify patients with anterior circulation stroke. MCA tortuosity was calculated using Inflection Count Metric(ICM) by two blinded readers to angiographical/clinical outcomes. The total cohort was trichotomized into 3 groups (A, B, C) based on M1 tortuosity tertiles. The primary efficacy end point was achievement of modified Thrombolysis in Cerebral Ischemia (mTICI) reperfusion scores of ≥2b on first pass. Good functional outcomes was defined as mRS0-2 on 90-day followup. Baseline and procedural data were compared between groups. Results: A total of 200 with known MCA tortuosity were identified. Patients within group A were significantly older (P&lt;0.05) . Group C patient were more likely to have renal disease and atrial fibrillation (P&lt;0.05). There was no differences in terms of NIHSS score at presentation nor ASPECT score between groups. Achieving first-pass success was more likely in group A (60.6%) vs 47% and 38.2%, P=0.033 for groups B and C, respectively. Likewise, the rate of mTICI≥2c was higher in group A (54.5%) vs 36.4% and 26.5%, p=0.003. Achieving mRS0-2 was more likely in group A (76.6%) vs 73.4% and 49.3%, p=0.001. There were no differences in distal emboli, or symptomatic intracranial hemorrhage. Findings of first-pass and angiographic outcomes were consistent with standard tortuosity scoring system. Conclusion: Patients with higher MCA tortuosity are less likely to have successful reperfusion and good functional outcome post mechanical thrombectomy for acute ischemic stroke.

Evaluation of effectiveness and safety of the large-format pRESET 6-50 thrombectomy stent-retriever in the endovascular treatment of ischemic stroke: real-world experiences from two tertiary comprehensive stroke centers.

Mechanical thrombectomy (MT) has become the standard treatment for acute ischemic stroke (AIS) with large vessel occlusion (LVO). First-pass (FP) reperfusion of the occluded vessel and fewer passes with stent retrievers show improvement in functional outcomes in stroke patients, while higher numbers of passes are associated with higher complication rates and worse outcomes. Studies indicate that a larger size of the stent-retriever is associated with a higher rate of first-pass reperfusion and improved clinical outcomes. In this retrospective study, we investigated the clinical performance of a recently developed and one of the largest stent-retrievers available in the treatment of LVO (pRESET 6-50, phenox GmbH, Bochum). All consecutive patients with ischemic stroke due to proximal large vessel occlusion treated with MT using the pRESET 6-50 stent-retriever in two tertiary stroke centers between 09/2021 and 07/2022 were included in this study. The reperfusion rate after MT was quantified by the modified thrombolysis in cerebral infarction (mTICI) score, and functional neurological outcome was evaluated with the National Institutes of Health Stroke Scale (NIHSS) score and the major early neurological recovery (mENR) rate after 24 h. Successful FP reperfusion was defined as mTICI ≥ 2b. Successful and complete reperfusion were defined as mTICI ≥ 2b and mTICI ≥ 2c, respectively. In total, 98 patients (52 men and 46 women) with a median age of 75 (range 25-95 years) were included. A total of 70 (72%) patients presented with an occlusion of the middle cerebral artery (MCA) in the M1 segment, 6 (6%) patients with an occlusion of the M2 segment, 17 (17%) patients with an occlusion of the internal carotid artery (ICA), and 5 (5%) patients with an occlusion of the obstructed basilar artery (BA). Successful FP reperfusion was achieved in 58 patients (62%). Successful and complete reperfusion were achieved in 95 (97%) and 82 (83%) patients, respectively. The median National Institutes of Health Stroke Scale (NIHSS) in all treated patients improved from 17 to 7.5. Major early neurological recovery (mENR) was observed in 34 patients (35.1%). MT with the pRESET 6-50 stent-retriever achieves high successful first-pass and final reperfusion rates in patients with AIS and LVO. The results of this study support the thesis to use large-format stent-retriever in proximal vessel occlusion MT whenever feasible in order to improve high FP and final reperfusion rate, which are known predictors of good clinical outcome.

Priorities for Advancements in Neuroimaging in the Diagnostic Workup of Acute Stroke.

STAIR XII (12th Stroke Treatment Academy Industry Roundtable) included a workshop to discuss the priorities for advancements in neuroimaging in the diagnostic workup of acute ischemic stroke. The workshop brought together representatives from academia, industry, and government. The participants identified 10 critical areas of priority for the advancement of acute stroke imaging. These include enhancing imaging capabilities at primary and comprehensive stroke centers, refining the analysis and characterization of clots, establishing imaging criteria that can predict the response to reperfusion, optimizing the Thrombolysis in Cerebral Infarction scale, predicting first-pass reperfusion outcomes, improving imaging techniques post-reperfusion therapy, detecting early ischemia on noncontrast computed tomography, enhancing cone beam computed tomography, advancing mobile stroke units, and leveraging high-resolution vessel wall imaging to gain deeper insights into pathology. Imaging in acute ischemic stroke treatment has advanced significantly, but important challenges remain that need to be addressed. A combined effort from academic investigators, industry, and regulators is needed to improve imaging technologies and, ultimately, patient outcomes.

Time to Reperfusion Is Not Associated With Functional Outcomes in First‐Pass Reperfusion: Analysis of the STRATIS Registry

Background Time is considered a fundamental driver of treatment success in ischemic stroke reperfusion therapy. First‐pass reperfusion (FPR) is associated with improved outcomes. We explored the association between time to reperfusion, FPR, and functional outcomes in an analysis of the STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) registry data. Methods Registry patients with anterior circulation stroke, treated with endovascular thrombectomy and achieving complete or near‐complete expanded Thrombolysis in Cerebral Infarction scale (eTICI) 2c/3 reperfusion per core laboratory assessment were included. FPR was considered eTICI 2c/3 reperfusion in a single device pass. Patients undergoing multipass reperfusion required ≥2 device passes to achieve the same, total, or near‐total reperfusion (eTICI 2c/3). Logistic regression was used to model functional independence, defined as a modified Rankin scale score of 0 to 2 at 3 months, as a function of time to reperfusion, comparing FPR and multipass reperfusion patient populations. Results Of the 984 patients in the STRATIS registry, 563 patients achieved eTICI 2c/3 reperfusion of anterior circulation large‐vessel occlusions and were eligible for inclusion in the analysis. In patients undergoing multipass reperfusion (n=186), increased time to treatment was associated with a decreased likelihood of a good clinical outcome. Odds ratio for every 60‐minute delay to treatment: 0.71 (95% CI, 0.55–0.90; P =0.005). However, in patients undergoing FPR (n=377), no association between increased time to treatment and good clinical outcomes was observed (odds ratio for every 60‐minute delay to treatment, 0.93 [95% CI, 0.79–1.09]; P =0.347). Conclusion First‐pass reperfusion may compensate for the effects of delays to reperfusion on functional outcomes in ischemic stroke.

Intra-arterial tenecteplase during thrombectomy for acute stroke (BRETIS-TNK II): rationale and design

BackgroundOur recent pilot study suggests intra-arterial tenecteplase (TNK) during the first pass of endovascular treatment (EVT) seems safe, may increase first-pass reperfusion and good outcome in acute ischaemic stroke (AIS)...

Intra-arterial tenecteplase is safe and may improve the first-pass recanalization for acute ischemic stroke with large-artery atherosclerosis: the BRETIS-TNK trial.

The first-pass recanalization of endovascular treatment (EVT) is closely correlated with clinical outcome of patients with large vessel occlusion (LVO) stroke. The aim of the study was to explore whether intra-arterial tenecteplase (TNK) during the first pass of EVT can increase first-pass successful reperfusion and improve the neurological outcome in AIS-LVO patients. The BRETIS-TNK trial (ClinicalTrials.gov Identifier: NCT04202458) was a prospective, single-arm, single center study. Twenty-six eligible AIS-LVO patients with large-artery atherosclerosis etiology were consecutively enrolled from December 2019 to November 2021. Intra-arterial TNK (4 mg) after microcatheter navigation through the clot was administered, followed by TNK (0.4 mg/min) given continuously for 20 min after the first retrieval attempt of EVT without confirmation of the reperfusion status by DSA. The 50 control patients comprised of a historical cohort before the BRETIS-TNK trial (from March 2015 to November 2019). Successful reperfusion was defined as modified Thrombolysis In Cerebral Infarction (mTICI) ≥2b. The first-pass successful reperfusion rate was higher in the BRETIS-TNK vs. control group (53.8% vs. 36%, p = 0.14), and the difference became statistically significant after propensity score matching (53.8% vs. 23.1%, p = 0.03). There was no difference in symptomatic intracranial hemorrhage between the BRETIS-TNK and control groups (7.7% vs. 10.0%, p = 0.92). There was a trend toward higher proportion of functional independence at 90 days in the BRETIS-TNK comparing with the control group (50% vs. 32%, p = 0.11). This is the first study to report that intra-arterial TNK during the first pass of EVT seems safe and feasible in AIS-LVO patients.

Impact of width of susceptibility vessel sign on recanalization following endovascular therapy

Background and purposeWe aimed to investigate the relationship between arterial recanalization following endovascular therapy and the susceptibility vessel sign (SVS) length and width on susceptibility-weighted imaging. MethodsWe retrospectively evaluated consecutive patients with anterior circulation ischemic stroke who underwent magnetic resonance imaging preceded endovascular therapy, and measured the SVS length and width. Successful recanalization was defined as expanded thrombolysis in cerebral infarction grade of 2b to 3. Logistic regression analysis was executed to determine the independent predictors of successful recanalization and first-pass reperfusion (FPR) after endovascular therapy. ResultsAmong 100 patients, successful recanalization and FPR were observed in 77 and 34 patients, respectively. The median SVS length and width were 10.3 mm (interquartile range, 6.8–14.1 mm) and 4.2 mm (interquartile range, 3.1–5.2 mm), respectively. In multivariate logistic regression analysis, SVS width was associated with successful recanalization (odds ratio, 1.88; 95% confidence interval, 1.14–3.07; p = 0.005) and FPR (odds ratio, 1.38; 95% confidence interval, 1.01–1.89; p = 0.039). The optimal cutoff value for the SVS width to predict successful recanalization and FPR were 4.2 mm and 4.0 mm, respectively. ConclusionsLarger SVS width may predict successful recanalization and FPR following endovascular therapy.

Effect of Early Balloon Inflation of Balloon Guide Catheter in Mechanical Thrombectomy for Large Vessel Occlusion.

A balloon guide catheter (BGC) is widely used in mechanical thrombectomy (MT). However, the balloon inflation timing of BGC has not been clearly established. We evaluated whether balloon inflation timing of BGC affects the results of MT. Patients who underwent MT with BGC for anterior circulation occlusion were enrolled. Patients were dichotomized into early and late balloon inflation groups, according to the timing of BGC inflation. Angiographic and clinical outcomes were compared between the two groups. Multivariable analyses were performed to evaluate the predictive factors for first-pass reperfusion (FPR) and successful reperfusion (SR). Of 436 patients, the early balloon inflation group showed a shorter procedure time (21 min [11-37] vs. 29 min [14-46], P = 0.014), a higher rate of SR with aspiration only (64.0% vs. 55.4%, P=0.016), a lower aspiration catheter delivery failure rate (11.1% vs. 19.4%, P = 0.005), less frequent technique conversion (36.0% vs. 44.5%, P = 0.009), higher rate of FPR (58.2% vs. 50.2%, P = 0.011), and a lower rate of distal embolization (7.9% vs. 11.7%, P = 0.006), compared to the late balloon inflation group. In multivariate analysis, early balloon inflation was an independent predictor for FPR (odds ratio, OR 1.53, 95% confidence interval, CI 1.37-2.57; P = 0.011) and SR (OR 1.26, 95% CI 1.18-1.64; P = 0.018). Early balloon inflation of BGC enables an effective procedure than late balloon inflation. Early balloon inflation was associated with higher rates of FPR and SR.

Application of Balloon AngioplaSty with the dIstal protection of Stent Retriever (BASIS) technique for acute intracranial artery atherosclerosis-related occlusion.

Endovascular therapy (EVT) is complex in the context of intracranial atherosclerosis (ICAS)-related large vessel occlusion (LVO) and the re-occlusion rates are high due to residual stenosis, the procedure time is long and the optimal EVT technique is unclear. The Balloon AngioplaSty with the dIstal protection of Stent Retriever (BASIS) technique is a novel thrombectomy technique that allows emergent balloon angioplasty to be performed via the wire of the retrieval stent. Our study presents our initial experience with the BASIS technique in ICAS-related LVO and assesses its feasibility. In patients with ICAS-related LVO treated with BASIS, clinical and angiographic data were retrospectively analyzed. Angiographic data included first-pass reperfusion (PFR), the rate of residual stenosis, distal emboli, and re-occlusion post-procedure. The Extended Thrombolysis in Cerebral Infarction (eTICI) scale was used to assess reperfusion extent, and an eTICI score ≥2b was defined as successful perfusion. Clinical outcome was evaluated at 3 months (modified Rankin score [mRS]), and an mRS ≤ 2 was defined as a good clinical outcome. A total of seven patients with ICAS-related LVO were included, and the median age of the patients was 76 years. All patients achieved eTICI 3 reperfusion and FPR. The residual stenosis rate ranged from 5 to 10%. None of the patients had re-occlusion post-procedure. The median puncture-to-reperfusion time was 51 min. None of the patients had a symptomatic cerebral hemorrhage, re-occlusion, distal embolism, and dissection. Good clinical outcomes were observed in four patients (4/7, 57.1%), and 1 patient (1/7, 14.3%) died. The BASIS technique is feasible and safe for treating acute ICAS-related LVO.

First pass results of mechanical thrombectomy with two-drop zone NeVaTM device.

Occlusive thrombi in acute ischemic stroke can be in various types which limits the success of the thrombectomy. The NeVaTM (Vesalio, Nashville, Tennessee) thrombectomy device was originally designed for all types of clot. Our aim was to evaluate the efficacy and safety of the NeVaTM device for mechanical thrombectomy. Retrospective review of prospectively collected mechanical thrombectomy database revealed 145 patients who had fullfilled the inclusion criteria. The data collected includes clinical patient characteristics, procedural measures, timestamp at each stage, and patient outcome. IV thrombolytics application, pre and post-intervention imaging findings, device related adverse event and any type of intracranial hemorrhage were recorded. There was female pre-dominance (54.5%). Median presenting national institutes of health stroke scale (NIHSS) was 16 (IQR, 3-32). 88 MCA-m1 (60,6%), 43 ICA-tip (29,6%), 11 MCA-m2 (7,5%), 2 ACA (1,4%) and 1 basilar (0,7%) occlusions were underwent for mechanical thrombectomy. Median procedure time was 25 min (IQR, 7-136). First-pass reperfusion scores were mTICI 0-2a 22.7%, mTICI 2b 23.4%, mTICI 2c 17.9% and mTICI 3 35.9%. Mean number of pass was 1,84 ± 1,14. Final mTICI 2b-3 score was 97.9% and TICI2c-3 score was 87.6%. No device related adverse event occurred. The mean 24-h NIHSS score was 6 (IQR 0-33). In conclusion, the NeVa thrombectomy device offers a high rate of first-pass success along with favorable safety profile. Larger series and multi-center studies are needed for further investigation.

Predictors of first-pass reperfusion for mechanical thrombectomy in acute ischemic stroke

Background and objectiveRapid reperfusion of ischemic penumbra in patients with acute stroke is critical to neurological recovery. Achieving reperfusion after first-pass mechanical thrombectomy has been associated with improved patient outcomes. However, the predictors for obtaining first-pass reperfusion are not well known. MethodsA single-institution retrospective study of all patients who underwent mechanical thrombectomy at a tertiary care center from January 2010 until March 2019 was conducted to assess for predictors of first-pass reperfusion. ResultsA total of 257 patients were reviewed. Successful reperfusion was obtained in 63.4% of patients, and in 38% of patients on the first pass. On multivariate analysis, increasing door-to-puncture time was a negative predictor of FPR (OR 0.989, 95% CI = 0.980–0.997) and use of combined thrombectomy technique with stent-retriever and aspiration was a positive predictor of FPR compared to aspiration or stent-retriever alone (OR 4.441, 95% CI = 1.001–19.699). ConclusionsCombination therapy using stent-retriever and aspiration may increase the chance of obtaining FPR, whereas delays in starting the procedure after patient arrival may decrease the odds of FPR. Rapid thrombectomy initiation and procedural technique may play in optimizing rates of FPR and ultimately patient outcomes, however, randomized controlled trials assessing these variables are necessary to determine optimal treatment strategies.

Association of thrombus density and endovascular treatment outcomes in patients with acute ischemic stroke due to M1 occlusions

PurposeWe aimed to study the association of non-contrast CT (NCCT) thrombus density with procedural and clinical outcomes in patients with acute ischemic stroke who underwent endovascular treatment (EVT). Since thrombus density is associated with thrombus location, we focused on M1 occlusions only.MethodsPatients with available thin-slice (< 2.5 mm) NCCT were included from a nationwide registry. Regression models were used to assess the relation between thrombus density (per Hounsfield unit [HU]) and the following outcomes. For reperfusion grade, adjusted common odds ratios (acOR) indicated a 1-step shift towards improved outcome per HU increase in thrombus density. For the binary outcomes of first-pass reperfusion (first-pass extended thrombolysis in cerebral infarction [eTICI] 2C-3, FPR), functional independence [90-day modified Rankin Scale (mRS) score of 0–2] and mortality), aORs were reported. Adjusted β coefficients (aβ) were reported for 24-h NIHSS and procedure duration in minutes. Outcome differences between first-line treatment devices (stent retriever versus aspiration) were assessed with interaction terms.ResultsIn 566 patients with M1 occlusions, thrombus density was not associated with reperfusion (acOR 1.01, 95% CI 0.99–1.02), FPR (aOR 1.01, 95% CI 0.99–1.03), mortality (aOR 0.98, 95% CI 0.95–1.00), 24-h NIHSS (aβ − 0.7%, 95% CI − 1.4–0.2), or procedure duration (aβ 0.27, 95% CI − 0.05–0.58). In multivariable analysis, thrombus density was associated with functional independence (aOR 1.02, 95% CI 1.00–1.05). No interaction was found between thrombus density and first-line treatment device for any outcome.ConclusionIn patients with M1 occlusions, thrombus density was not clearly associated with procedural and clinical outcomes after EVT.

Poor clinical outcome despite successful basilar occlusion recanalization in the early time window: incidence and predictors

BackgroundEndovascular treatment (EVT) for basilar artery occlusions (BAO) is associated with a higher rate of futile recanalization compared with anterior circulation procedures. We aimed to identify the incidence and predictors...

The association of transradial access and transfemoral access with procedural outcomes in acute ischemic stroke patients receiving endovascular thrombectomy: A meta-analysis

ObjectiveThere is an ongoing debate regarding the benefits of using transradial access (TRA) over transfemoral access (TFA) in endovascular therapies including endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) patients. This study sought to investigate the association of TRA and TFA with procedural success, access-site complications, first-pass reperfusion (FPR), puncture-to-recanalisation (PTR) time and hemorrhagic transformation (HT) by performing a meta-analysis. Materials and methodsPubMed, EMBASE and Scopus were searched. Studies with patients aged ≥ 18 years and head-to-head TRA vs TFA comparisons were included. Random-effects modeling was performed to obtain summary effects and forest plots were plotted to study the association of TFA with access site complications, FPR, HT, PTR time and procedural success. ResultsSix studies encompassing 945 patients (347 TRA and 598 TFA) were included in the meta-analysis. Meta-analysis revealed that in AIS patients receiving EVT, TRA was significantly associated with a decreased risk of access-site complications (RR 0.17, 95% CI 0.05 0.54; p = 0.003, z = −2.957) and HT (RR 0.07, 95% CI 0.02 0.27; p < 0.0001, z = −3.8841). However, TRA was not significantly associated with procedural success (RR 0.96, 95% CI 0.90 1.01; p = 0.141, z = −1.473), FPR (RR 0.91, 95% CI 0.79 1.05; p = 0.194, z = −1.299) and PTR time (SMD −0.14, 95% CI −0.42 −0.14; p = 0.323, z = −0.989). ConclusionOur meta-analysis demonstrated that TRA is a safe alternative to TFA, in AIS patients receiving EVT, with significantly decreased access-site complications and HT with TRA, albeit with comparable procedural success, FPR and PTR time to TFA. Data availability statementThe original contributions presented in the study are included in the article/Supplementary information, further inquiries can be directed to the corresponding author.