Mechanical Thrombectomy For Acute Stroke Research Articles

Abstract WP133: Phase MRI Clot Characteristic and Radiologic Thrombectomy Outcomes in Acute Ischemic Stroke

Background: Magnetic Resonance (MR) susceptibility weighted imaging (SWI) sequences produce filtered Phase images where blood products demonstrate signal intensities opposite to calcifications. Though susceptibility Vessel Sign (SVS) on pre-interventional MRI has been reported as an indicator of outcome following thrombectomy, the association of Phase MR imaging with thrombectomy outcomes is not previously studied. Methods: In this retrospective cohort study of consecutive acute large vessel occlusion strokes with Phase MR imaging prior to thrombectomy, we evaluated the correlation between clot features on pre-interventional MR imaging with radiographic outcomes following thrombectomy. The clot characteristics included the presence of SVS and its geometrical features on both Phase and GRE sequenced MRIs and thrombus extension. Results: A total of 57 patients were included in this analysis (mean age: 65.04 ± 15.8, 33% Female, mean NIHSS: 13.0 (7.5, 19.5), 33% M1 occlusion), among which 52 (91%) patients had positive SVS on phase-sequence MRI. Successful recanalization was achieved in 91% and successful first pass recanalization was observed in 46%. In univariate analysis, baseline demographics and clinical characteristics including age, sex, and comorbidities were not associated with successful recanalization. Homogeneity of Phase-SVS was significantly associated with the first pass successful recanalization (Odds ratio (OR) 1.81; Confidence interval (CI) [1.14-2.88], p: 0.006). Conclusion: Our study suggests MRI Phase-SVS clot homogeneity as a novel predictor of first pass successful recanalization following mechanical thrombectomy in acute stroke.

Abstract WMP50: Disparities of Interhospital Transfer for Mechanical Thrombectomy in Acute Stroke in US

Introduction: A large proportion of mechanical thrombectomies (MT) in acute stroke include patients transferred from an outside hospital to thrombectomy capable centers. However, patient characteristics associated with the odds of transfer is unknown. We explored the US national claims database to explore predictors of interfacility transfer in MT hospitalizations using a nationally representative sample. Methods: National Inpatient Sample database was retrospectively explored from 2016 to 2020 for stroke hospitalizations with EVT. The primary outcome was transfer status from the presenting emergency department of MT-capable hospital. Multivariable logistic regression models with multiple robustness checks were performed to determine patient characteristics with the odds of transfer. Results: This study included 100,865 patients with MT, of whom 32,685 patients (32.4%) were transferred (median [IQR] age, 71 [60-81] years; 16775 women [51.2%]; 23090 White individuals [74.9%]; 3715 Black individuals [12.1%]; 1875 Hispanic individuals [6.1%]; 895 Asian individuals [2.9%]). White race, higher baseline NIHSS, hospital size and status (urban teaching vs rural), and hospital location were independent predictors of interfacility transfer for MT. Conclusion: Nearly one in 3 MTs in the US is performed in patients presenting following transfer from another acute care hospital. Analysis of population level data utilizing the National Inpatient Sample database shows disparities in the transfer of patients with minority backgrounds (Black, Hispanic, Asian) for MT. Urban teaching centers, larger hospitals, higher baseline NIHSS, and hospital location (northeast and midwest) were more likely to receive Interhospital MT transfers regardless of race.

Abstract 050: Intraarterial cooling combined with mechanical thrombectomy in acute stroke patients: systematic review and meta‐analysis

Introduction Mechanical thrombectomy (MT) plays an important role in the treatment of intracranial large vessel occlusion (LVO) with recanalization success rate of 60%‐95%. Although the restoration of blood flow can ensue excess generation of reactive oxygen species (ROS) and inflammation which leads to cellular damage known as reperfusion injury. Recent studies have shown promising neuroprotection by reducing body temperature with the mechanism of limiting ROS and immune cells’ response. Although systemic hypothermia is associated with several adverse events and limited hypothermia affecting the specific ischemic brain tissue. Intra‐arterial cooling (IAC) combined with mechanical thrombectomy is a novel method for localized cooling. Methods Embase, and Web of Science were screened for English‐language papers including case reports/series, cohort studies and clinical trials. Studies were reviewed by 2 independent reviewers for inclusion criteria as patients with the age of >18 years old who had LVO and underwent mechanical thrombectomy combined with cold Saline infusion during mechanical thrombectomy (before or after recanalization). Statistical analyses were performed using R software version R‐4.3, P Value of <0.05 was considered significant. Results Four studies were included from initial 1177 studies, including 204 cases with MT combined with IAC (intra‐arterial 4°C saline infusion before or after recanalization) and 219 control with MT. Patients with MT+IAC had lower final infarct volume (MD=25, 95%CI [‐34.02, ‐15.98], P <0.0001), and better modified Rankin scale (mRS) after 90 days (RR=1.42, 95%CI [1.14, 1.77, P= 0.0015). There was no significant difference between MT+IAC and IAC group regarding deterioration of NIHSS in 24 hours(RR=1.09, 95%CI [0.42, 1.3, P=0.287), recanalization at 24 hours (RR=1.03, 95%CI [0.93, 1.14], P= 0.622), vascular spasm in 10 minutes (RR=2.90, , 95%CI [0.78, 10.80], P= 0.111), symptomatic intracranial hemorrhage (RR=0.78, 95%CI [0.48, 1.27], P= 0.322), coagulation abnormality (RR=0.94, , 95%CI [0.35, 2.54], P= 0.902), pneumonia (RR=1.09, 95%CI [0.79, 1.50], P= 0.585), and mortality in 90 days (RR=0.78, 95%CI [0.51, 1.20], P= 0.265). Conclusion Preliminary data is showing Intraarterial cooling combined with mechanical thrombectomy in acute stroke is a feasible and safe method for localized brain tissue cooling to prevent reperfusion injury and maximize long term outcome of MT.

Abstract 213: Successful Mechanical Thrombectomy in Acute Stroke With Pre‐interventional Thrombolysis‐Induced Intracerebral Hemorrhage: Case Report

Introduction Intravenous thrombolytics (IVT) and mechanical thrombectomy (MT) have become the standards of care for treating patients with large vessel occlusion (LVO) acute ischemic strokes (AIS) [1‐4}. Intracerebral hemorrhage (ICH) is a main complication of IVT, with prevalence reported around 3.2% in a large multicentered meta‐analysis [2,6]. However, limited data remains about the safety and efficacy for patients to undergo MT with IVT associated pre‐interventional ICH as no randomized control trials or standard of care guidelines are available [2,4,5,7]. Methods NA Results 56‐yo male with history of alcohol abuse presented via EMS as a stroke alert with acute onset right hemiplegia, global aphasia, right facial droop, and leftward gaze preference two hours prior to arrival. RACE 10+ with NIHSS 24. No known history antiplatelet or anticoagulation use. Computerized Tomography (CT) Brain scan showed left middle cerebral artery (MCA) hyperdense sign with left insular cortical ribboning. CT angiography (CTA) showed near occlusive stenosis of the left carotid bulb with an acute thrombus within Supraclinoid Internal Carotid Artery (ICA) extending into the Left MCA and origin of Left Anterior Cerebral Artery (ACA). Patient was emergently administered IV‐tissue Plasminogen Activator (IV‐tPA) and taken for endovascular thrombectomy. During initial angiogram, after crossing the stenotic cervical bulb, the left Supraclinoid ICA and MCA occlusions were visualized. There was longitudinal partially occlusive thrombus extending from the M1 into the M2 divisions. No opacification of the inferior M2 branch was visualized, with perfusion deficit over the temporal, parietal and frontal regions. Additionally, extravasation of contrast was seen within the left basal ganglia region, concerning for hemorrhagic transformation from IV‐tPA. Reversal of IV‐tPA was initiated, and patient was given cryoprecipitate, platelets, and tranexamic acid. Decision to undergo MT was made secondary to severity of debilitating neurologic symptoms, age, and large perfusion deficit observed. He underwent single pass complete recanalization, TICI 2C using Stent retriever and aspiration. Left ICA stenting was not completed secondary to hemorrhagic transformation. Repeat CT Brain confirmed moderate left frontal lobe hemorrhage with vasogenic edema and 3mm left‐to‐right midline shift. No neurosurgical intervention required. Magnetic resonance imaging (MRI) Brain showed left cerebral hematoma with mass effect, acute infarct within left caudate nucleus, and minimal posterior cortical restricted diffusion without hemorrhagic conversion. Patient was monitored for 1 week with serial brain imaging. Patient was discharged on Aspirin 81 mg daily to inpatient rehabilitation with NIHSS 21, mRS 4 (0 prestroke). Today, in rehab he ambulates with walker with moderate expressive aphasia and right upper extremity weakness. Plan to follow‐up 2‐month post‐hospitalization for left ICA stenting. Conclusion While pre‐interventional IVT‐associated ICH in AIS with LVO are rare, few cases have been shown to have positive neurological outcomes [2,5,7]. We demonstrate a unique case of early identification of reperfusion hemorrhage on fluoroscopy with prompt reversal initiated. The decision to continue with MT based on downstream occlusion of basal ganglia hemorrhage not at further risk of expansion from reperfusion. The patient did well on follow‐up imaging despite the hemorrhage. Further randomized control clinical trials are required to establish best care guidelines, safety, and efficacy.

Abstract 122: Mechanical Thrombectomy for Acute Stroke in the Elderly: A Single‐Center Case Series in the Philippines

Introduction Mechanical thrombectomy (MT) has become the standard of care for acute ischemic stroke (AIS) caused by large‐vessel occlusion. However, the extent of its benefits in elderly populations remains uncertain, as most landmark trials on MT have focused on younger individuals. This single‐center case series aims to shed light on the advantages and disadvantages of MT in higher age groups, particularly within the context of low‐ or middle‐income countries. Methods Between January 2018 and June 2023, we conducted a chart review of five patients aged ≥80 years who underwent MT for stroke. The study analyzed the patients' premorbid comorbidities, time to treatment, revascularization rates, procedural complications, mortality, and 90‐day modified Rankin Scale (mRS) scores. Results The five cases included individuals aged between 81 and 94 years. Among them, two had mild baseline disability (mRS score 0‐1), and three had moderate baseline disability (mRS score 2‐4). Upon admission, the National Institutes of Health Stroke Scale (NIHSS) scores ranged from 14 to 24. Three of the patients received pre‐thrombectomy intravenous thrombolysis with Alteplase and subsequently underwent MT within 4 to 7 hours of symptom onset. Successful recanalization (TICI score 2b‐3) was achieved in all five patients. However, two patients developed symptomatic intracranial hemorrhage post‐thrombectomy, and one of them succumbed to the complication. Three out of the four discharged patients attained favorable clinical outcomes with a 90‐day mRS score of 0‐2 or equivalent to their prestroke disability. Conclusion Our case series suggests that elderly individuals can potentially achieve favorable functional outcomes after MT. Nevertheless, this potential is influenced by stroke severity and the success of the treatment. As the elderly population, including octogenarians, nonagenarians, and centenarians, is expected to grow in the future, cautious patient selection should be exercised when considering thrombectomy in this age group. Further research comparing endovascular and conventional treatments in the elderly is imperative to inform better clinical decisions.

What is aChallenging Clot? : ADELPHI Consensus Statement from the CLOTS 7.0 Summit.

Predicting achallenging clot when performing mechanical thrombectomy in acute stroke can be difficult. One reason for this difficulty is alack of agreement on how to precisely define these clots. We explored the opinions of stroke thrombectomy and clot research experts regarding challenging clots, defined as difficult to recanalize clots by endovascular approaches, and clot/patient features that may be indicative of such clots. Amodified DELPHI technique was used before and during the CLOTS 7.0 Summit, which included experts in thrombectomy and clot research from different specialties. The first round included open-ended questions and the second and final rounds each consisted of 30closed-ended questions, 29on various clinical and clot features, and 1on number of passes before switching techniques. Consensus was defined as agreement ≥ 50%. Features with consensus and rated ≥ 3out of 4on the certainty scale were included in the definition of achallenging clot. Three DELPHI rounds were performed. Panelists achieved consensus on 16/30 questions, of which 8were rated 3or 4on the certainty scale, namely white-colored clots (mean certainty score3.1), calcified clots under histology(3.7) and imaging(3.7), stiff clots(3.0), sticky/adherent clots(3.1), hard clots(3.1), difficult to pass clots(3.1) and clots that are resistant to pulling(3.0). Most panelists considered switching endovascular treatment (EVT) techniques after 2-3 unsuccessful attempts. This DELPHI consensus identified 8distinct features of achallenging clot. The varying degree of certainty amongst the panelists emphasizes the need for more pragmatic studies to enable accurate apriori identification of such occlusions prior to EVT.

Systemic inflammatory response syndrome deteriorates the outcomes of mechanical thrombectomy in acute stroke (P14-5.031)

<h3>Objective:</h3> In this retrospective research, we investigated the association of the systemic inflammatory response syndrome and its impact on the outcomes of mechanical thrombectomy in acute stroke. <h3>Background:</h3> Systemic inflammatory response syndrome (SIRS) has been associated with poor outcomes after acute ischemic stroke (AIS). The primary goal of this study was to determine whether SIRS status on admission correlated with functional outcomes in AIS treated with mechanical thrombectomy (MT). <h3>Design/Methods:</h3> Consecutive patients from September 2015 to April 2019 were retrospectively reviewed for SIRS on admission. SIRS was defined as the presence of ≥2 of the following: temperature &lt; 36 °C or &gt; 38 °C, heart rate &gt; 90, respiratory rate &gt; 20, and white blood cell count &lt;4000/mm or &gt; 12,000 mm. <h3>Results:</h3> Of 202 patients, 188 met inclusion criteria. 49 patients (26%) had evidence of SIRS. Neither basic patient demographics nor standard stroke risk factors predicted the development of SIRS. However, presentation with SIRS was correlated with higher rates of death (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.2–5.5) as well as lower rates of favorable functional outcomes at discharge (OR, 0.09; 95% CI, 0.02–0.40) and 3-month follow up (OR 0.12; 95% CI 0.03–0.43). These results remained significant even after adjustment for age, sex, baseline NIHSS, recanalization status, and prior co-morbidities. <h3>Conclusions:</h3> In our sample population, SIRS was associated with worse outcomes and higher rates of mortality in AIS patients treated with MT. Recognition of key risk factors can provide better prognostication and possible future therapeutic targets. <b>Disclosure:</b> Dr. Jafari has nothing to disclose. Mr. Katlowitz has nothing to disclose. Dr. De la Garza has nothing to disclose. Dr. Sellers has nothing to disclose. Shawn Moore, MD has nothing to disclose. Dr. Hall has nothing to disclose. Aaron Desai, MD, MBBS has nothing to disclose. Vikramjeet Singh has nothing to disclose. Rahul Damani has nothing to disclose.

Dual-Energy Computed Tomography in Stroke Imaging

ObjectiveTo assess if a new dual-energy computed tomography (DECT) technique enables an improved visualization of ischemic brain tissue after mechanical thrombectomy in acute stroke patients.Material and MethodsThe DECT head scans with a new sequential technique (TwinSpiral DECT) were performed in 41 patients with ischemic stroke after endovascular thrombectomy and were retrospectively included. Standard mixed and virtual non-contrast (VNC) images were reconstructed. Infarct visibility and image noise were assessed qualitatively by two readers using a 4-point Likert scale. Quantitative Hounsfield units (HU) were used to assess density differences of ischemic brain tissue versus healthy tissue on the non-affected contralateral hemisphere.ResultsInfarct visibility was significantly better in VNC compared to mixed images for both readers R1 (VNC: median 1 (range 1–3), mixed: median 2 (range 1–4), p < 0.05) and R2 (VNC: median 2 (range 1–3), mixed: 2 (range 1–4), p < 0.05). Qualitative image noise was significantly higher in VNC compared to mixed images for both readers R1 (VNC: median 3, mixed: 2) and R2 (VNC: median 2, mixed: 1, p < 0.05, each). Mean HU were significantly different between the infarcted tissue and the reference healthy brain tissue on the contralateral hemisphere in VNC (infarct 24 ± 3) and mixed images (infarct 33 ± 5, p < 0.05, each). The mean HU difference between ischemia and reference in VNC images (mean 8 ± 3) was significantly higher (p < 0.05) compared to the mean HU difference in mixed images (mean 5 ± 4).ConclusionTwinSpiral DECT allows an improved qualitative and quantitative visualization of ischemic brain tissue in ischemic stroke patients after endovascular treatment.

Correlation between Thrombus Perviousness and Distal Embolization during Mechanical Thrombectomy in Acute Stroke.

Thrombus permeability has been related to clot composition and treatment outcomes in stroke patients undergoing reperfusion therapies. The aim of this study was to evaluate whether thrombus perviousness, evaluated by multiphase computed tomography angiography (mCTA), is associated with distal embolization risk. We interrogated our dataset of acute ischemic stroke (AIS) patients involving the M1 segment of the middle cerebral artery (MCA) who had undergone mechanical thrombectomy, and we calculated thrombus average attenuation measurement (dHU) on non-contrast CT (NCCT) and clot perviousness on mCTA. dHU was calculated as the difference between the thrombus HU average value (tHU) and the HU average value on the contralateral side (cHU), while perviousness was calculated as the difference in mean clot density on mCTA and NCCT both in arterial (Perviousness pre-post-1) and delayed (Perviousness pre-post 2) phases. A total of 100 patients (53 females (53%), mean age 72.74 [± 2.31]) with M1 occlusion were available for analysis. Perviousness, calculated between baseline and arterial phase of mCTA (Perviousness pre-post1), was lower in patients with distal embolization (p = 0.05), revealing an association between reduced perviousness and distal embolization risk. Logistic regression showed that thrombus perviousness calculated on the arterial phase of mCTA (OR, 0.66; 95% CI, 0.44-0.99] (p = 0.04)) and the contact aspiration technique (OR, 0.39; 95% CI, 0.15-1.02] (p = 0.05)) were protecting factors against distal embolization. Our study showed an association between reduced perviousness and distal embolization, suggesting that perviousness evaluation may be a useful neuroimaging biomarker in predicting distal embolization risk during mechanical thrombectomy.

Mechanical Thrombectomy in Acute Stroke Patients with Moderate to Severe Pre-Stroke Disability.

Background and Purpose Studies on mechanical thrombectomy (MT) in acute ischemic stroke (AIS) patients with preexisting disability are limited. We aimed to compare the outcomes of MT versus best medical treatment (BMT) in these patients. Methods In the nationwide Austrian registry and Swiss monocentric registry, we identified 462 AIS patients with pre-stroke disability (modified Rankin Scale [mRS] score ≥3) and acute large vessel occlusion. The primary outcome was returning to pre-stroke mRS or better at 3 months. Secondary outcomes were early neurological improvement (National Institutes of Health Stroke Scale score improvement ≥8 at 24 to 48 hours), 3-month mortality, and symptomatic intracerebral hemorrhage (sICH). Multivariable regression models and propensity score matching (PSM) were used for statistical analyses. Results Compared with the BMT group (n=175), the MT group (n=175) had younger age, more severe strokes, and lower pre-stroke mRS, but similar proportion of receiving intravenous thrombolysis. MT was associated with higher odds of returning to baseline mRS or better at 3 months (adjusted odds ratio [aOR], 2.5; 95% confidence interval [CI], 1.39 to 4.47), early neurological improvement (aOR, 2.62; 95% CI, 1.41 to 4.88), and lower risk of 3-month mortality (aOR, 0.29; 95% CI, 0.18 to 0.49). PSM analysis showed similar findings. MT was not associated with an increased risk of sICH (4.0% vs. 2.1% in all patients; 4.2% vs. 2.4% in the PSM cohort). Conclusions MT in patients with pre-stroke mRS ≥3 might improve the 3-month outcomes and short-term neurological impairment, suggesting that pre-stroke disability alone should not be a reason to withhold MT, but that individual case-by-case decisions may be more appropriate.

Combining machine learning with radiomics features in predicting outcomes after mechanical thrombectomy in patients with acute ischemic stroke

Background and ObjectiveSome patients with mechanical thrombectomy will have a poor prognosis. This study establishes a model for predicting the prognosis after mechanical thrombectomy in acute stroke based on diffusion-weighted imaging (DWI) omics characteristics. MethodsA total of 260 stroke patients receiving mechanical thrombectomy in our hospital were randomly divided into a training set (n = 182) and a test set (n = 78) in a 7:3 ratio. The regions of interest (ROI) of the imaging features of the DWI infarct area were extracted, and the minimum absolute contraction and selection operator regression model were used to screen the best radiomics features. A support vector machine classifier established the prediction model of the prognosis after mechanical thrombectomy of acute stroke based on the selected features. The prediction efficiency of the model was evaluated by the receiver operating characteristic (ROC) curve. ResultsA total of 1936 radiomic features were extracted, and six features highly correlated with prognosis were screened after dimensionality reduction. Based on the DWI model, the ROC analysis showed that the area under the curve (AUC) for correct prediction in the training and test sets was 0.945 and 0.920, respectively. ConclusionThe model based on the characteristics of radiomics and machine learning has high predictive efficiency for the prognosis of acute stroke after mechanical thrombectomy, which can be used to guide personalized clinical treatment.

Mechanical Thrombectomy for Acute Stroke in a 2-Month-Old Patient and Review of the Literature in Infancy.

Mechanical thrombectomy (MT) in pediatric stroke is supported by studies in adults, but there is controversy regarding younger patients. The main growth of intracranial vessels occurs up to 2 years when there can be more difficulties in MT.Description of the MT performed in a 2-month-old patient-the youngest infant published to date. We also review the literature on MT for stroke in infants.A 2-month-old patient presented with an awakening stroke secondary to an occlusion of the M1 segment of the left middle cerebral artery. A successful MT was performed with an aspiration device without clinically significant complications. An etiological study was completed, and neuroimaging showed focal cerebral arteriopathy. The 3-month outcome was excellent: the pediatric modified Rankin score was 0.Including this case, MT for acute stroke has been reported in only 10 infants. MT was successful in 90%, mostly using adult conventional stent retrievers. There were complications only in patients with mechanical circulatory support (MCS) devices; three patients died due to hemorrhagic transformation after MT and one patient died due to recurrent ischemic stroke.MT seems effective and safe in infants similarly to other pediatric ages. In children under 2 years of age, the presence of comorbidities requiring MCS devices is the main factor underlying poor prognosis.

Imaging Indicators for Parenchymal Hemorrhage After Mechanical Thrombectomy in Acute Stroke

Background In patients with acute ischemic stroke with large vessel occlusion, the presence of hyperintense lesions on fluid‐attenuated inversion recovery (FLAIR‐positive) before mechanical thrombectomy (MT) and that of hyperdense lesions on noncontrast computed tomography (CT‐positive) after MT are associated with parenchymal hemorrhage, but the significance of these findings is unclear. Methods Patients with acute stroke with large vessel occlusion underwent magnetic resonance imaging, including diffusion‐weighted imaging and FLAIR, before MT. Noncontrast CT was obtained within 60 minutes after MT. The occurrence of parenchymal hemorrhage type 2 (PH2) was assessed on CT within 7 days after MT. FLAIR and CT‐positive were defined as a case with hyperintense and hyperdense lesions immediately before and after MT, respectively. Clinical and imaging factors associated with PH2 were evaluated by multivariate regression analysis. Results Enrolled were 412 patients (median age, 76 years; men, 58.3%; median National Institutes of Health Stroke Scale score, 16). The site of occlusion was the internal carotid artery (n=122, 29.6%), M1 (n=180, 43.7%), and M2 (n=96, 23.3%). FLAIR‐positive, CT‐positive, and PH2 were found in 149 (36.2%), 223 (54.1%), and 34 patients (8.3%), respectively. PH2 was significantly more frequent in CT‐positive than CT‐negative patients (14.3% versus 1.1%; P &lt;0.001), but not in FLAIR‐positive than FLAIR‐negative patients (10.7% versus 6.8%; P =0.193). Regardless of FLAIR status, PH2 was significantly more frequent in CT‐positive than CT‐negative patients (12.8% versus 0.8% [ P &lt;0.001] for FLAIR‐negative, and 16.7% versus 1.7% [ P =0.003] for FLAIR‐positive). Multivariate regression analysis demonstrated that CT‐positive was the only independent factor associated with PH2 (odds ratio, 12.699 [95% CI, 2.964–54.416]; P &lt;0.001). Sensitivity, specificity, positive predictive value, and negative predictive values of CT‐positive for predicting PH2 occurrence were 94.1%, 49.5%, 14.3%, and 98.9%, respectively. Conclusion In patients with acute ischemic stroke with large vessel occlusion, CT‐positive immediately after MT was strongly predictive of PH2, but no such relationship was found for FLAIR‐positive before MT.

Mechanical Thrombectomy for Acute Stroke in a 2-Month-Old Patient and Review of the Literature in Infancy

Mechanical thrombectomy (MT) in pediatric stroke is supported by studies in adults, but there is controversy regarding younger patients. The main growth of intracranial vessels occurs up to 2 years when there can be more difficulties in MT.Description of the MT performed in a 2-month-old patient-the youngest infant published to date. We also review the literature on MT for stroke in infants.A 2-month-old patient presented with an awakening stroke secondary to an occlusion of the M1 segment of the left middle cerebral artery. A successful MT was performed with an aspiration device without clinically significant complications. An etiological study was completed, and neuroimaging showed focal cerebral arteriopathy. The 3-month outcome was excellent: the pediatric modified Rankin score was 0.Including this case, MT for acute stroke has been reported in only 10 infants. MT was successful in 90%, mostly using adult conventional stent retrievers. There were complications only in patients with mechanical circulatory support (MCS) devices; three patients died due to hemorrhagic transformation after MT and one patient died due to recurrent ischemic stroke.MT seems effective and safe in infants similarly to other pediatric ages. In children under 2 years of age, the presence of comorbidities requiring MCS devices is the main factor underlying poor prognosis.

Management strategies of unanticipated intracranial stenosis during mechanical thrombectomy for acute stroke: A survey of academic neurointerventionalists.

The optimal approach to the management of intracranial atherosclerotic disease (ICAD) at the time of mechanical thrombectomy (MT) for large vessel occlusion (LVO) remains controversial. The goal of this study is to characterize current practices concerning this challenging clinical situation in a survey of practicing neurointerventionalists. An electronic questionnaire was sent to a cross-section of North American academic neurointerventionalists using publicly available contact information and departmental websites. Prior to analysis, responses were anonymized and categorized by region. A total of 136/360 responses were recorded from the U.S. and Canada. The mean number of years of practicing as a neurointerventionalist among the respondents was 10.5 (± 6.2 years). ICAD was perceived as a causative factor during MT for LVO in 5-10% of thrombectomy cases. The most common first-line treatment approach for significant ICAD, assuming a TICI 2b or better reperfusion, was medical therapy (77.9% of respondents), followed by angioplasty + stent placement (8.8% of respondents). There were no significant differences in the first line treatment of ICAD in LVO between geographical regions (p = 0.815). The approach to underlying ICAD in LVO varies widely; however, the majority of neurointerventionalists prefer medical therapy with DAPT as a first-line treatment approach. The current survey highlights the need for studies that better define the optimal timing and modality of treatment, along with an evidence-based framework for balancing the risks associated with these treatment approaches.

Safety of Sheathless Transradial Balloon Guide Catheter Placement for Acute Stroke Thrombectomy

Transradial access has been described for mechanical thrombectomy in acute stroke, and proximal balloon occlusion has been shown to improve recanalization and outcomes. However, sheathed access requires a larger total catheter diameter at the access site. We aimed to characterize the safety of sheathless transradial balloon guide catheter use in acute stroke intervention. Consecutive patients who underwent sheathless right-sided transradial access for thrombectomy with a balloon guide catheter were identified in a prospectively collected dataset from 2019 to 2021. Demographics, procedure details, and short-term outcomes were collected and reported with descriptive statistics. A total of 48 patients (20 women) with a mean age of 72.3 years were identified. Of patients, 56.3% had occlusions in the left-sided circulation; 35 (72.9%) had M1 occlusions, 7 (14.6%) had M2 occlusions, and 6 (12.5%) had internal carotid artery occlusions. Tissue plasminogen activator was administered to 16 (33.3%) patients. Five (10.4%) patients underwent intraprocedural carotid stenting. The cohort had successful reperfusion after a median of 1 (interquartile range: 1, 2) pass. Median time from access to recanalization was 31 (interquartile range: 25, 53) minutes. A postprocedural Thrombolysis In Cerebral Infarction score of ≥2b was achieved in 46 (95.8%) patients. Five patients had wrist access site hematomas. All hematomas resolved with warm compresses, and no further intervention was required. Sheathless radial access using a balloon guide catheter may be safely performed for acute ischemic stroke with excellent radiographic outcomes. Further investigation is warranted to evaluate the comparative effectiveness of sheathless compared with sheathed transradial balloon guide access.

Abstract WP93: An Internet Of Things Based Real Time Location System With Machine Learning For Coordination Of Acute Stroke Endovascular Intervention: A Proof-of-concept Study

Introduction: The delivery of mechanical thrombectomy in acute stroke can be challenging because it requires coordination between patient travel and multiple stroke team members across different locations in the hospital. A Real Time Location System (RTLS) can facilitate a streamlined workflow by determining a patient’s location, but the required infrastructure can be costly to set up. We investigated the feasibility of a machine learning based RTLS using an Internet Of Things (IOT) device prototype to coordinate acute stroke endovascular intervention. Methods: In this proof-of-concept study, study investigators programmed an IOT device to collect WiFi signals from different hospital zones relevant to the mechanical thrombectomy workflow. Different machine learning (ML) algorithms were trained on location labelled training WiFi signals to predict location. The accuracies of the different ML algorithms to predict unlabeled testing WiFi signals collected on a separate day were measured, in percentages. Results: The training and testing datasets contained 1,179 and 293 samples respectively, with 2,516 and 2,618 unique WiFi signals detected in each dataset. The trained neural network, random forest, support vector machine, K-nearest neighbors, decision tree and ensemble classifiers achieved accuracies of 96.6%, 96.2%, 97.3%, 97.3%, 83.6% and 97.3% on the testing dataset respectively. Additionally, the neural network model produced estimates of uncertainty, which were significantly associated with the correctness of predictions based on logistic regression analysis (p &lt; 0.001). Conclusions: An IOT based real time location system with machine learning can accurately predict locations within the hospital, demonstrating immense potential for the future applications of streamlining delivery of acute stroke endovascular intervention.

Transradial versus transfemoral access for acute stroke endovascular thrombectomy: a 4-year experience in a high-volume center.

To compare clinical outcomes and safety of transradial (TRA) versus transfemoral access (TFA) for endovascular mechanical thrombectomy in acute stroke patients. Retrospective analysis of 832 consecutive patients with acute stroke undergoing interventional thrombectomy using TRA (n = 64) or TFA (n = 768). Direct TFA failures occurred in 36 patients, 18 of which underwent crossover TFA to TRA, while direct TRA failures occurred in 2 patients having both crossovers to TFA. Successful catheterization was achieved in 96.8% (62/64) and 95.3% (732/768) of patients undergoing direct TRA and direct TFA, respectively, without significant differences. The median (IQR) catheterization time was 10 (8-16) min in the direct TRA group and 15 (10-20) in the direct TFA group (P < 0.001). This difference was also significant in the subgroup of anterior circulation strokes and in patients younger and older than 80years of age. The majority of procedures yielded thrombolysis in cerebral infarction grade 2b/2c/3 revascularization in patients undergoing direct TRA (88.5%) and direct TFA (90.8%), without statistically significant differences. The median (IQR) puncture to recanalization time was 37 (24-58) min for the direct TRA group and 42 (28-70) min for the direct TFA group. Significant differences in access site complications, symptomatic ICH, and mRS score 0-2 at 90days between both TRA and TFA accesses were not found. TRA is not inferior to TFA in the probability of catheterization, times of catheterization and revascularization, and other clinical outcomes for mechanical thrombectomy in acute stroke.

Mechanical Thrombectomy for Acute Stroke Due to Large-Vessel Occlusion Presenting With Mild Symptoms.

Purpose: To evaluate the safety and efficacy of mechanical thrombectomy (MT) for acute stroke due to large vessel occlusion (LVO), presenting with mild symptoms.Methods: A prospective cohort study of patients with mild ischemic stroke and LVO was conducted. Patients were divided into two groups: MT group or best medical management (MM) group. Propensity score matching (PSM) was conducted to reduce the confounding bias between the groups. The primary outcome was functional independence at 90 days. The safety outcome was symptomatic intracranial hemorrhage (sICH). Univariate and multivariate logistic regression analyses were used to identify the independent factors associated with outcomes.Results: Among the 105 included patients, 43 were in the MT group and 62 in the MM group. Forty-three pairs of patients were generated after PSM. There were no significant differences in sICH rates between two groups (p = 1.000). The MT group had a higher proportion of independent outcomes (83.7% MT vs. 67.4% MM; OR 2.483; 95% CI 0.886–6.959; p = 0.079) and excellent outcomes (76.7% MT vs. 51.2% MM; OR 3.150; 95% CI 1.247–7.954; p = 0.013) compared to the MM group, especially in patients with stroke of the anterior circulation (p < 0.05). Multivariate logistic regression analysis showed that small infarct core volume (p = 0.015) and MT treatment (p = 0.013) were independently associated with excellent outcomes.Conclusions: Our results suggest that MT in stroke patients, presenting with mild symptoms, due to acute LVO in the anterior circulation may be associated with satisfactory clinical outcomes.Clinical Trial Registration: ClinicalTrials.gov, identifier: NCT04526756.

Common Reasons for Not Performing Mechanical Thrombectomy in Acute Stroke

Endovascular thrombectomy (EVT) is a proven treatment for select patients with an acute ischemic stroke and large vessel occlusion (LVO). Although EVT