Endovascular Mechanical Thrombectomy Research Articles

A clinical and computed tomography-based nomogram to predict the outcome in patients with anterior circulation large vessel occlusion after endovascular mechanical thrombectomy.

To explore the positive predictors of the clinical outcome in acute ischemic stroke (AIS) patients with anterior circulation large vessel occlusion (ACLVO) after endovascular mechanical thrombectomy (EMT) at a 90-day follow-up, and to establish a nomogram model to predict the clinical outcome. AIS patients with ACLVO detected by multimodal Computed Tomography imaging who underwent EMT were collected. Patients were divided into the favorable and the unfavorable groups according to the 90-day modified Rankin Scale (mRS) score. Univariate and multivariate analyses were performed to investigate predictors of the favorable outcome (mRS of 0-2). A nomogram model for predicting the clinical outcome after EMT was drawn, and the receiver operating characteristic (ROC) curve was used to evaluate its predictive value. Totally 105 patients including 65 patients in the favorable group and 40 in the unfavorable group were enrolled. Multivariate logistic regression analysis showed that admission National Institute of Health Stroke scale (NIHSS) score [0.858 (95% CI 0.778-0.947)], ACLVO at M2 [20.023 (95% CI 2.204-181.907)] and infarct core (IC) volume [0.943 (95% CI 0.917-0.969)] was positively correlated with favorable outcome. The accuracy of the nomogram model in predicting the outcome was 0.923 (95% CI 0.870-0.976), with a cutoff value of 119.6 points. The area under the ROC curve was 0.848 (95% CI 0.780-0.917; sensitivity, 79.7%; specificity, 90.0%). A low Admission NIHSS score, ACLVO at M2, and a small IC volume were positive predictors for favorable outcome. The nomogram model may well predict the outcome in AIS patients with ACLVO after EMT.

Electrocardiographic Changes after Endovascular Mechanical Thrombectomy in a Patient with Pulmonary Embolism-A Case Report and Literature Review.

Background: Pulmonary embolism (PE) is a common disease with an annual incidence of about 1/1000 persons. About every sixth patient dies within the first 30 days after diagnosis. The electrocardiogram (ECG) is one of the first diagnostic tests performed, and is able to confirm the suspicion of PE with typical electrocardiographic signs. Some ECG signs and their regression are also prognostically relevant. Endovascular mechanical thrombectomy is one option for PE treatment, and aims to relieve right heart strain immediately. The first studies on endovascular mechanical thrombectomy using a dedicated device (FlowTriever System, Inari Medical, Irvine, CA, USA) yielded promising results. Methods: In the following, we report the case of a 66-year-old male patient who presented with New York Heart Association III dyspnea in our emergency department. Among typical clinical and laboratory results, he displayed very impressive electrocardiographic and radiological findings at the time of PE diagnosis. Results: After endovascular mechanical thrombectomy, the patient's complaints and pulmonary hemodynamics improved remarkably. In contrast, the ECG worsened paradoxically 18 h after intervention. Nevertheless, control echocardiography 4 days after the intervention no longer showed any signs of right heart strain, and dyspnea had disappeared completely. At a 4-month follow-up visit, the patient presented as completely symptom-free with a high quality of life. His ECG and echocardiography were normal and excluded recurrent right heart strain. Conclusions: Overall, the patient benefitted remarkably from endovascular mechanical thrombectomy, resulting in an almost complete resolution of electrocardiographic PE signs at the 4-month follow-up after exhibiting multiple typical electrocardiographic PE signs at time of diagnosis and initial electrocardiographic worsening 18 h post successful intervention.

Nationwide Incidence and Trends in Central Retinal Arterial Occlusion Management: A 5000-Patient Analysis.

Central retinal artery occlusion (CRAO) is a rare and visually debilitating vascular condition characterized by sudden and severe vision loss. CRAO is a compelling target for intravenous alteplase (tPA) and endovascular mechanical thrombectomy (MT) due to pathophysiological similarities with acute ischemic stroke; however, the utility of these interventions in CRAO remains dubious due to limited sample sizes and potential risks. To assess usage and outcomes of tPA and MT in CRAO, we queried the National Inpatient Sample database using International Classification of Disease, Ninth and Tenth edition for patients with CRAO and acute ischemic stroke between 2010 and 2019. Our cohort of 5009 CRAO patients were younger with higher rates of obesity, hypertension, long-term anticoagulant use, and tobacco use compared to acute ischemic stroke patients. CRAO patients had lower rates of tPA administration (3.41% vs 6.21%) and endovascular MT (0.38% vs 1.31%) but fewer complications, including deep vein thrombosis, pneumonia, urinary tract infection, acute kidney injury, and acute myocardial infarction (all P < 0.01). CRAO patients had lower rates of poor functional outcome (31.74% vs 58.1%) and in-hospital mortality (1.2% vs 5.64%), but higher rates of profound blindness (9.24% vs 0.58%). A multivariate regression showed no relationship between tPA and MT and profound blindness, although the limited sample size of patients receiving interventions may have contributed to this apparent insignificance. Further investigation of larger patient cohorts and alternative treatment modalities could provide valuable insights for revascularization therapies in CRAO to optimize visual restoration and clinical outcomes.

Endovascular Thrombectomy in Patients With Preexisting Disability: A Review

Endovascular mechanical thrombectomy (EVT) drastically reduces disability after acute ischemic stroke due to large‐vessel occlusion, but only a small proportion of patients with stroke are eligible for this powerful treatment. Several ongoing studies are aiming to expand the indications for EVT to further reduce disability after acute ischemic stroke for a larger proportion of patients suffering from large‐vessel occlusion stroke. Patients with preexisting disability, comprising ≈30% of all patients with acute ischemic stroke, were universally excluded from the landmark clinical trials that established EVT efficacy. These patients disproportionally suffer from accumulated disability after stroke, with substantial societal and economic impact. Further, there is significant heterogeneity in current practice of EVT among patients with preexisting disability. Establishing evidence‐based acute stroke treatments for this population is a priority. In this narrative review, we summarize the current literature regarding EVT in patients with preexisting disability. While doing so, we highlight key concepts regarding statistical analysis and discuss opportunities and challenges for future studies focusing on this vulnerable population.

COMPUTED TOMOGRAPHY PERFUSION IN ACUTE STROKE ASSESSMENT.

Traditionally, non-contrast computed tomography (CT) alone was used in the initial assessment of acute ischaemic stroke patients mainly to exclude haemorrhage or alternative pathology. Late-window (beyond 6 hours) and recent large-volume endovascular mechanical thrombectomy (MT) trials integrated CT Perfusion (CTP) imaging to guide MT and/or intravenous thrombolysis (IVT) decision-making in stroke patients. In current clinical practice, many patients are being excluded from reperfusion therapy due to a lack of data from urgent investigations to assess cerebral vasculature and perfusion. Here, we explore the potential benefits of CTP incorporated into the initial CT protocol assessment of stroke patients.

Orbital Inflammation Prompted by Endovascular Mechanical Thrombectomy

Orbital Inflammation Prompted by Endovascular Mechanical Thrombectomy

Outcomes of Acute Ischemic Stroke Among Patients with Renal Cell Carcinoma: A Nationwide Analysis

IntroductionRenal cell carcinoma (RCC) has been associated with an increased risk for acute ischemic stroke (AIS). As individuals with cancer who experience AIS tend to face higher mortality rates compared to AIS patients without cancer, recognizing the implications of RCC in AIS is crucial for identifying high-risk patients for major complications and directing management strategies. ObjectiveTo examine risk factors, interventions, and outcomes for patients with AIS stratified by their RCC diagnosis. MethodsThe National Inpatient Sample (NIS) database was queried for the period 2010-2019 using International Classification of Disease 10th Edition (ICD-10) codes for acute ischemic stroke and renal malignancies. We assessed demographic information, comorbidities, and clinical interventions between patients presenting with AIS, with and without renal malignancies. A logistic regression model was employed to further examine mortality outcomes. ResultsAmong 1,609,817 patients identified with AIS, 2,068 (0.12%) had a concomitant diagnosis of RCC. AIS patients with RCC were older (72.09 yrs. vs. 70.9 yrs., p < 0.01), more often white (72.05% vs. 68.16%, p < 0.01), and had similar stroke severity scores. RCC patients received less tissue plasminogen activator (tPA; 4.98% vs. 6.2%, p = 0.02) but underwent endovascular mechanical thrombectomy (MT) at similar rates. RCC patients had more complications (p < 0.01) as well as longer hospital stays (8.19 days vs. 5.98 days, p < 0.01), and higher rates of mortality (11.27% vs. 5.63%, p < 0.01), when compared to their non-RCC counterparts. Propensity score-adjusted analysis largely confirmed these findings, with RCC being positively associated with in-hospital mortality (OR: 1.373, p < 0.01) and longer stays (OR: 2.591, p < 0.01). ConclusionIn addition to describing the demographics and clinical course of AIS patients diagnosed with RCC, our study underscores the substantial impact of RCC on AIS outcomes. Despite experiencing strokes of similar severity, AIS patients diagnosed with RCC are at a heightened risk of complications, including thromboembolic events and infections, leading to elevated in-hospital mortality rates and prolonged hospital stays.

A Study of Efficacy and Outcomes of Two Techniques of Mechanical Thrombectomy in Acute Ischemic Stroke

Abstract Background Endovascular mechanical thrombectomy (A Direct Aspiration First Pass Technique [ADAPT] and Solitaire stent retrieval techniques) as an emergency reperfusion therapy in acute ischemic stroke patients avoids secondary brain insult and thereby prevents permanent neurological deficits. As studies comparing the two thrombectomy procedures are scarce, we evaluated their efficacy. Methods In this prospective observational study done at Manipal Hospitals Bangalore, 75 patients were separated into two groups based on the final reperfusion technique employed: ADAPT group with 39 patients who underwent contact aspiration technique and Solitaire group with 36 patients who underwent stent retrieval thrombectomy. The rate of successful reperfusion (modified treatment in cerebral infarction scores [mTICI]); functional outcomes (modified Rankin scale [mRS] and National Institutes of Health Stroke Scale [NIHSS]) at 24 hours, 1 month and 3 months postintervention; and the adverse events were compared between the two groups. Results Successful reperfusion was significantly higher in the ADAPT group. Mean NIHSS and mRS scores reduced significantly postintervention for both groups, but was greater for the ADAPT group, while mortality and other adverse events were significantly greater in the solitaire group. Conclusion Mechanical thrombectomy is an effective reperfusion therapy for acute ischemic stroke patients. Comparing the two techniques revealed better outcomes for ADAPT, than stent retrieval technique.

Abstract WP60: On vs. Off-Hours Arrival to Groin Time: Identifying Gaps in a Comprehensive Stroke Center

Introduction: Timeliness of treatment for patients with acute ischemic stroke (AIS) directly correlates with outcomes. The most current AHA guidelines standard of care for patients having a large vessel occlusion (LVO) stroke is endovascular mechanical thrombectomy (MT). Earlier treatment is associated with better outcomes at 90 days. Parallel processing is paramount when executing an expedited transition from the emergency department (ED) to the MT suite. At a large academic comprehensive stroke center (CSC), as we receive a high volume of direct ED cases, we examined whether there was a difference in daytime vs. off-hour LVO cases. Methods: The MT database maintained by the CSC was queried for all cases from July 2022- July 2023. Inclusion criteria included all AIS with LVO and receiving MT that were transported by EMS directly to the CSC ED. Data was further stratified by time of day and day of the week. Cases were designated as day if they arrived Monday through Friday between 7am-5pm. Cases were considered night/weekend if they arrived 5pm-7am or anytime Saturday or Sunday. Times between groups were compared with t-test. Results: There were a total of 37 cases in the day group and 43 cases in the night/weekend group. Patients arriving during the day had a median arrival-to-groin time of 89 minutes and a mean of 93 minutes. The night/weekend group had a median of 116 minutes and a mean of 125 minutes, and the difference was statistically significant (p=0.0009). Upon further analysis, mean ED arrival to suite time was significantly longer for night/weekends, 105 vs. 76 minutes, p=0.008, but mean suite to groin puncture time was not significantly different, 18 vs. 16 minutes, p=0.24. Conclusion: There is a statistically significant difference in arrival to suite/groin times between the day and night/weekend groups, therefore putting patients with LVO arriving off hours at higher risk for poor outcomes. Historically some cardiac cath labs have utilized nursing bridge teams to help with parallel processing, and we theorize that using such a team to facilitate preparation of the patient and suite, we can reduce treatment times for off-hour’s ED MT cases and potentially improve outcomes.

Abstract 13065: Comparative Efficacy of Endovascular Mechanical Thrombectomy With and Without Intravenous Thrombolysis in Acute Ischemic Stroke: A Meta-Analysis of Randomized Trials

Background: Current guidelines states that intravenous tissue plasminogen activator (tPA) should be administered to eligible acute ischemic stroke (AIS) patients even if endovascular mechanical thrombectomy (EMT) is being considered. However, there is still uncertainty regarding the superiority of EMT with tPA over direct EMT. Aim: This meta-analysis seeks to provide a comprehensive evaluation of the comparative effectiveness of EMT with and without tPA in treating AIS. Methods: We performed a systematic literature search using PubMed, EMBASE, Cochrane, Web of Science, and clincialtrials.gov. Relevant articles from inception until April 10th, 2023, were scrutinized. The primary outcome of interest was functional independence assessed by the modified Rankin Score between 0-2 at 90 days. Secondary outcomes included all-cause mortality within 90 days, successful recanalization defined as extended thrombolysis in cerebral infarction score of 2b to 3, and safety outcome, i.e., the occurrence of symptomatic intracranial hemorrhage (sICH). Results: Our analysis included 6 RCTs involving 2334 patients. The pooled analysis of the primary outcome revealed no significant difference between EMT with tPA and direct EMT [OR, 1.08 (95% CI, 0.87-1.34), p=0.41]. All-cause mortality [OR, 0.93 (95% CI, 0.74-1.16), p=0.42] and sICH [OR, 1.22 (95% CI, 0.91-1.62), p=0.14] also did not significantly differ between the two groups. However, the results for successful recanalization [OR, 1.35 (95% CI, 1.01-1.80), p=0.04] indicate that patients who underwent EMT with tPA had a 35% significantly higher likelihood of achieving successful recanalization. Conclusion: Our meta-analysis found no significant difference in functional outcome, all-cause mortality, or sICH between EMT with tPA and direct EMT. However, EMT with tPA was associated with a higher likelihood of successful recanalization, suggesting its potential benefit in improving recanalization rates in AIS.

Aristotle‐Only Direct Aspiration First‐Pass Technique (AO‐ADAPT) for Endovascular Mechanical Thrombectomy: A Technical Series of a Novel Technique Demonstrating Safety and Efficacy

Background The introduction of soft, large‐profile microwires has improved aspiration catheter delivery for intracranial large‐vessel occlusions. The Aristotle‐only direct aspiration first‐pass technique (AO‐ADAPT) uses the Aristotle 24 microwire to deliver a large‐bore aspiration catheter to the target occlusion without a microcatheter. We characterized rates of technical success achieved using this technique for mechanical aspiration thrombectomy. Methods A retrospective review of prospectively collected thrombectomy databases at 4 academic institutions identified patients undergoing procedures in which AO‐ADAPT was used. Patient demographics, clinical considerations, technical details, and radiographic outcomes were collected. Rates of successful aspiration catheter delivery without adjunctive devices and of successful reperfusion (Thrombolysis in Cerebral Infarction≥2B) were collected. Results Forty‐five patients met inclusion criteria (mean age 72.2±13.2 years, 62.2% female; 71.1% M1 occlusions). With a first‐line AO‐ADAPT approach, 42/45 (93.3%) patients achieved Thrombolysis in Cerebral Infarction≥2B reperfusion, with first‐pass recanalization in 26/45 (57.8%). We delivered the aspiration catheter to the target occlusion without adjunctive device in 35/45 (77.8%) patients. Of these, 29 (82.9%) underwent successful contact aspiration. This entire cohort (64.4% of the population) achieved Thrombolysis in Cerebral Infarction≥2B, with a mean time to reperfusion of 16 minutes and a first‐pass recanalization rate of 66%. Of the 16 patients who did not achieve successful AO‐ADAPT reperfusion, 6 needed a microcatheter for aspiration catheter delivery but underwent successful contact aspiration, 6 achieved microcatheter‐free delivery but needed a stentriever for final recanalization, and 4 required both microcatheter for delivery and stentriever for final recanalization. No intracranial vascular complications occurred during the procedures; 1 patient (2.2%) experienced symptomatic intracranial hemorrhage secondary to reperfusion injury. Conclusion The AO‐ADAPT approach to mechanical thrombectomy safely and effectively achieved reperfusion for patients with large‐vessel occlusions, with first‐pass success and successful recanalization rates comparable with other techniques. For most cases in this series, this technique obviated the need for a microcatheter and/or stentriever.

Abstract 212: Percutaneous Carotid access in Mechanical Thrombectomy ‐ a safe alternative to transfemoral approach

Introduction Emergent percutaneous carotid artery MER approach for acute ischemic large vessel strokes are rare given the risk of complications and seldom reported. Methods 75‐year‐old left‐handed functional male (mRs:0) with past medical history of HTN, HLD presented to ED after being found on the floor by his family with slurred speech, new onset right sided weakness, with a last known well of 17 hours. NIHSS on arrival was 14 for expressive aphasia, right visual field defect, right facial weakness, significant dysarthria, right hemiparesis, and sensory defect. CT Head demonstrated left MCA territory early ischemic changes. CTA head/neck demonstrated left M1 occlusion with large penumbra. Perfusion data demonstrated no area of core infarct with area of ischemic penumbra in the left MCA territory involving the left frontal, temporal and parietal lobes measuring 161 ml. ASPECT score 5‐6. The patient was deemed a candidate for mechanical endovascular thrombectomy (MER). The procedure was initiated via ultrasound‐guided right common femoral access. After multiple attempts using a wide range of techniques and wire/catheter combinations in order to establish left intracranial access and given extreme angulation/tortuosity/elongation in the proximal left common carotid artery, it was decided to proceed with the catheter position in the left common carotid or the left internal carotid artery that would allow for subsequent catheterization of the intracranial circulation for MER. Results Near complete revascularization with minimal distal thrombus material beyond endovascular reach corresponding to a TICI 2C degree of revascularization was achieved. Closure of the femoral puncture site was performed using an Angio seal femoral closure device. Surgical closure of the puncture site was performed by vascular surgery. The patient was eventually discharged to short term acute rehabilitation and continues to follow up outpatient with the Stroke clinic. Conclusion Older patients with ischemic stroke commonly have tortuous vessels or peripheral vascular disease. As a result, they may greatly benefit from emergent direct carotid access, as the trans‐femoral approach often poses challenges in accessing the thrombus. For patients with complex and unfavorable vascular anatomy for mechanical endo‐vascularization, direct percutaneous carotid puncture can be advantageous, effectively reducing the aforementioned difficulties. When opting for such an approach it is vital to factor in the aortic arch appearance and its branches.

Abstract 047: Solumbra ‘PINCHING’ technique for medium vessel occlusions (MeVOs): A Single Center Experience

Introduction Various techniques have been evolved and used by different operators for mechanical thrombectomies for improved procedural performance, lower intraoperative times and better recanalization rates The widely used, isolated stent‐retriever and contact aspiration technique for medium vessel occlusions (MeVOs) carries a high risk for clot fragmentation, spasm and distal migration. The stent–aspiration (Solumbra) technique uses a large bore aspiration catheter with a stent retriever device for potential synergistic effects. However, its use is limited in distal thrombectomies. Hereby, we assess the efficacy and safety of solumbra ‘Pinching’ technique by using a smaller profile aspiration catheter for MeVO thrombectomy. Methods We retrospectively analyzed our prospective institutional database for medium vessel occlusions (M2, M3 MCA/ A2, A3 ACA/ P2 PCA) who underwent endovascular mechanical thrombectomy using stent retriever or aspiration or combined (solumbra) technique. The technique involves deploying a stent retriever through microcatheter and large bore aspiration catheter like ACE 68 (Penumbra, Inc.), followed by both microcatheter and aspiration removal, clot localization and blind navigation of a correctly sized lower profile (3MAX or 4MAX, Penumbra, Inc.) aspiration catheter over stent bare wire to “pinch” the primal end of the clot. Besides various demographic parameters, we collected final recanalization rates with first pass effect [using modified Thrombolysis in Cerebral Infarction (TICI) score]. All the intra‐procedural complications (haemorrhage, vasospasm) were analysed. Clinical outcome was analysed using modified ranking score (mRS) on 7th day post procedure/ discharge(whichever is earlier) and at 90 days. Results Total 26 MeVOs were successfully treated in twenty‐five patients with solumbra ‘Pinching’ technique since January 2022 (Male: female 16:7, mean age 58.6 years, mean NIHSS 9.1). Majority of the procedures were done for primary MeVOs and 72% consisted of M2 MCA occlusions. Whether to use a 3MAX or 4MAX aspiration catheter was determined by eyeballing the appropriate calibre for target vessels. Final first pass mTICI 2c/3 recanalization was achieved in 24 patients (88%). Minor Intra‐procedural complications were observed in 13 patients. Favorable modified ranking score (mRS 0‐2) was achieved in approximately 80% patients at the end of 7 days/discharge and 14 out of 16 follow up patients achieved good clinical outcome at 90 days Conclusion Solumbra ‘Pinching’ technique, using a low profile aspiration catheter like 3 MAX or 4 MAX (Penumbra, Inc.) with a stent retriever, can be effectively used in management of acute ischaemic stroke secondary to a MeVOs with significantly enhancing the first‐pass recanalization with lesser risk of intimal injury, dissection and secondary embolization.

Is telestroke more effective than conventional treatment for acute ischemic stroke? A systematic review and meta-analysis of patient outcomes and thrombolysis rates.

Telestroke systems operate through remote communication, providing distant stroke evaluation through expert healthcare providers. The aim of this study was to assess whether the implementation of a telestroke system influenced stroke treatment outcomes in acute ischemic stroke (AIS) patients compared with conventional in-person treatment. The study group evaluated multiple studies from electronic databases, comparing telemedicine (TM) and non-telemedicine (NTM) AIS patients between 1999 and 2022. We aimed to evaluate baseline characteristics, critical treatment times, and clinical outcomes. A total of 12,540 AIS patients were included in our study with 7936 (63.9%) thrombolyzed patients. Of the thrombolyzed patients, 4150 (51.7%) were treated with TM, while 3873 (48.3%) were not. The mean age of TM and NTM cohorts was 70.45 ± 4.68 and 70.42 ± 4.63, respectively (p > 0.05). Mean National Institute of Health Stroke Scale scores were comparable, with the TM group reporting a non-significantly higher mean (11.89 ± 3.29.6 vs. 11.13 ± 3.65, p > 0.05). No significant difference in outcomes was found for symptoms onset-to-intravenous tissue plasminogen activator (ivtPA) times (144.09 ± 18.87 vs. 147.18 ± 25.97, p = 0.632) and door-to-needle times (73.03 ± 20.04 vs. 65.91 ± 25.96, p = 0.321). Modified Rankin scale scores (0-2) were evaluated, and no significant difference was detected between cohorts (odds ratio (OR): 1.06, 95% confidence interval (CI): 0.89-1.29, p = 0.500). Outcomes did not indicate any significance between both cohorts for 90-day mortality (OR: 1.16, 95% CI: 0.94-1.43, p = 0.17) or symptomatic intracranial hemorrhage (OR: 0.99, 95% CI: 0.73-1.34, p = 0.93). Results between groups were also non-significant when analyzing the rate of thrombolysis with ivtPA (30.86%± 30.7 vs. 20.5%± 18.6, p = 0.372) and endovascular mechanical thrombectomy (11.8%± 11.7 vs. 18.7%± 18.9, p = 0.508). The use of telestroke in the treatment of AIS patients is safe with minimal non-significant differences in long-term outcomes and rates of thrombolysis compared with face-to-face treatment. Further studies comparing the different methods of TM are needed to assess the efficacy of TM in stroke treatment.

Intracarotid Infusion of Redox-Active Manganese Porphyrin, MnTnBuOE-2-PyP5+, following Reperfusion Improves Long-Term, 28-Day Post-Stroke Outcomes in Rats.

Endovascular mechanical thrombectomy, combined with a tissue plasminogen activator (t-PA), is efficacious as a standard care for qualifying ischemic stroke patients. However, > 50% of thrombectomy patients still have poor outcomes. Manganese porphyrins, commonly known as mimics of superoxide dismutases, are potent redox-active catalytic compounds that decrease oxidative/nitrosative stress and in turn decrease inflammatory responses, mitigating therefore the secondary injury of the ischemic brain. This study investigates the effect of intracarotid MnTnBuOE-2-PyP5+ (BMX-001) administration on long-term, 28-day post-stroke recovery in a clinically relevant setting. The 90 min of transient middle cerebral artery occlusion was performed in young, aged, male, female, and spontaneous hypertension rats. All physiological parameters, including blood pressure, blood gas, glucose, and temperature, were well controlled during ischemia. Either BMX-001 or a vehicle solution was infused through the carotid artery immediately after the removal of filament, mimicking endovascular thrombectomy, and was followed by 7 days of subcutaneous injection. Neurologic deficits and infarct volume were assessed at 28 days in a blinded manner. The effects of BMX-001 on the carotid arterial wall and blood-brain barrier permeability and its interaction with t-PA were assessed in normal rats. There were no intra-group differences in physiological variables. BMX-001-treated stroke rats regained body weight earlier, performed better in behavioral tests, and had smaller brain infarct size compared to the vehicle-treated group. No vascular wall damage and blood-brain barrier permeability changes were detected after the BMX-001 infusion. There was no drug interaction between BMX-001 and t-PA. Intracarotid BMX-001 infusion was safe, and it significantly improved stroke outcomes in rats. These findings indicate that BMX-001 is a candidate drug as an adjunct treatment for thrombectomy procedure to further improve the neurologic outcomes of thrombectomy patients. This study warrants further clinical investigation of BMX-001 as a new stroke therapy.

The Role of Mechanical Thrombectomy for Acute Massive Pulmonary Embolism in a Patient With Unilateral Lung Transplant and Atrial Septal Defect.

The risk of thromboembolic disease is high in patients with lung transplantation and is associated with significant morbidity and mortality with single healthy transplanted lung. We present a case involving successful endovascular management of life-threatening acute massive pulmonary embolism (PE) in a patient with single lung transplant and atrial septal defect (ASD). A 65-year-old man with a history of interstitial lung disease status post single left orthotopic lung transplant in 2012 presented with acute massive PE and clot burden in the pulmonary arteries of the transplanted left lung. Severe right heart dysfunction, hemodynamic instability, and requirement for vasopressors persisted post systemic thrombolytic therapy. As a result, the patient underwent successful endovascular mechanical thrombectomy with immediate improvement in oxygen saturation and hemodynamic status. The procedure was performed without adverse outcomes or paradoxical embolization despite the presence of ASD. The right heart dysfunction resolved, the patient was extubated the next day, and was discharged to home 2 days post procedure. Endovascular mechanical thrombectomy was safely used to treat acute massive PE in a single transplanted lung in the presence of ASD. Endovascular mechanical thrombectomy could be safely utilized to treat patients with lung transplant and acute massive or submassive pulmonary embolism. However, safely of mechanical thrombectomy should be determined in case-based scenarios and based on time interval from transplantation to when the thrombectomy is required.

The effect of distal aspiration catheter position on collateral flow in mechanical thrombectomy - an in vitro study.

Endovascular mechanical thrombectomy for ischaemic stroke is one of the most effective treatments. Despite the devices and techniques that have been developed, thrombi are not always successfully retrieved. The incidence of futile reperfusion after successful clot retrieval also remains a major concern. We hypothesise that simply placing an aspiration catheter in the system compromises collateral flow which may have an impact on functional outcomes. An in vitro study was conducted using a physical pulsatile flow model designed in glass to mimic the anterior cerebral circulation with middle cerebral artery M1 segment occlusion. A 5Fr aspiration catheter was positioned at the supra-clinoid internal carotid (SC-ICA), carotid terminus (T-ICA) and M1. For each catheter position, the flow rate through the model's anterior cerebral (ACA) and posterior communicating (PCOM) arteries was measured (no aspiration applied). Our results showed significant mean percentage flow reductions in the ACA and PCOM with the catheter positioned at the SC-ICA (PCOM 59.14% ± 0.93, ACA 59.52% ± 0.82, p < 0.001), T-ICA (PCOM 81.54% ± 0.55, ACA 85.65% ± 1.54) and M1 (PCOM 75.79% ± 0.98, ACA 84.20% ± 0.43) (Mann-Whitney U Test, p < 0.001). These results indicate a significant reduction in collateral flow following the insertion of a wide bore catheter in an in vitro model. In a clinical setting, this could have an impact on patient outcome, particularly in prolonged procedures and those requiring several passes to achieve recanalisation.

AutoML accurately predicts endovascular mechanical thrombectomy in acute large vessel ischemic stroke.

Automated machine learning or autoML has been widely deployed in various industries. However, their adoption in healthcare, especially in clinical settings is constrained due to a lack of clear understanding and explainability. The aim of this study is to utilize autoML for the prediction of functional outcomes in patients who underwent mechanical thrombectomy and compare it with traditional ML models with a focus on the explainability of the trained models. A total of 156 patients of acute ischemic stroke with Large Vessel Occlusion (LVO) who underwent mechanical thrombectomy within 24 h of stroke onset were included in the study. A total of 34 treatment variables including clinical, demographic, imaging, and procedure-related data were extracted. Various conventional machine learning models such as decision tree classifier, logistic regression, random forest, kNN, and SVM as well as various autoML models such as AutoGluon, MLJAR, Auto-Sklearn, TPOT, and H2O were used to predict the modified Rankin score (mRS) at the time of patient discharge and 3 months follow-up. The sensitivity, specificity, accuracy, and AUC for traditional ML and autoML models were compared. The autoML models outperformed the traditional ML models. For the prediction of mRS at discharge, the highest testing accuracy obtained by traditional ML models for the decision tree classifier was 74.11%, whereas for autoML which was obtained through AutoGluon, it showed an accuracy of 88.23%. Similarly, for mRS at 3 months, the highest testing accuracy of traditional ML was that of the SVM classifier at 76.5%, whereas that of autoML was 85.18% obtained through MLJAR. The 24-h ASPECTS score was the most important predictor for mRS at discharge whereas for prediction of mRS at 3 months, the most important factor was mRS at discharge. Automated machine learning models based on multiple treatment variables can predict the functional outcome in patients more accurately than traditional ML models. The ease of clinical coding and deployment can assist clinicians in the critical decision-making process. We have developed a demo application which can be accessed at https://mrs-score-calculator.onrender.com/.

Reperfusion Therapies in Acute Ischemic Stroke Beyond the Conventional Time Window: A Narrative Review.

Stroke is the second most common cause of death worldwide, with 50% of survivors experiencing long-term disability. For more than two decades, treatment with intravenous thrombolysis (IVT) and mechanical endovascular thrombectomy (MET), the only approved stroke reperfusion therapies, was restricted to patients within the 4.5-6 hour time window, respectively. Therefore, patients who presented with acute ischemic stroke (AIS) beyond the conventionaltime window were excluded from reperfusion treatment. This narrative review aims to review the scientific literature on the possibilities of reperfusion therapies for patients who present with an unknown time of stroke onset, and those with stroke onset beyond the conventional 4.5-6 hour time window. Beyond the conventional time window, the eligibility of patients for IVT or MET, the two main therapeutic procedures, is decided based on the concept of penumbral imaging. Penumbral imaging identifies patients with hypoperfused but viable brain tissue, who could benefit from reperfusion. On the other hand, clock-based DWI-fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) can detect stroke that has occurred within 4.5 hours in patients with an unknown time of onset, including patients who awaken with stroke. The introduction of penumbral imaging and MRI-based tissue clocking as imaging biomarkers for stroke has revolutionized stroke therapy, potentially allowing for personalized treatment of eligible stroke patients.

Single center experience using 3 mm trevo stent retrievers in medium vessel occlusion thrombectomy.

Endovascular mechanical thrombectomy has been shown to benefit select patients with acute ischemic stroke caused by medium vessel occlusion, aided by recent advancements in endovascular mechanical thrombectomy devices that facilitate navigation through narrower vasculature. In this study, we aim to evaluate the safety and efficacy of using the 3 mm Trevo NXT stent retriever (Stryker, Kalamazoo, MI) for endovascular mechanical thrombectomy in patients with acute ischemic stroke caused by medium vessel occlusion. From our single-center registry, we performed a retrospective review of all acute ischemic stroke patients from 2018 to 2022 who underwent endovascular mechanical thrombectomy for medium vessel occlusion with a 3 mm Trevo NXT. We examined efficacy outcomes (modified thrombolysis in cerebral infarction and puncture-to-revascularization time), clinical outcomes (National Institutes of Health Stroke Scale), and procedural complication rate. Between 2018 and 2022, 44 patients (52.2% female, mean age 71.1 years, median National Institutes of Health Stroke Scale of 15 [8-22.8]) met our inclusion criteria. The 3 mm Trevo NXT was used in the first pass in 56.9% of individuals, with 72.4% achieving successful recanalization (modified thrombolysis in cerebral infarction ≥ 2B). The 3 mm Trevo NXT was used as "rescue" after initial revascularization failure in 43.1% of individuals, achieving successful recanalization in 60.0% of passes. Acute complications were reported in 2.4% of cases. Median National Institutes of Health Stroke Scale at 24 h after intervention was 12 (4-20.8). Our results suggest that endovascular mechanical thrombectomy using the 3 mm Trevo NXT is a safe and effective treatment option for medium vessel occlusion. The utility of novel stent retrievers in the treatment of medium vessel occlusion should be further explored in future multicenter studies.