Mechanical Thrombectomy In Patients Research Articles

Rescue Therapy for Failed Mechanical Thrombectomy in Acute Ischemic Stroke: A Pooled Analysis of the Society of Vascular and Interventional Neurology Registry.

We aimed to evaluate the association between rescue therapy (RT) and functional outcomes compared to medical management (MM) in patients presenting after failed mechanical thrombectomy (MT). This cross-sectional study utilized prospectively collected and maintained data from the Society of Vascular and Interventional Neurology Registry, spanning from 2011 to 2021. The cohort comprised patients with large vessel occlusions (LVOs) with failed MT. The primary outcome was the shift in the degree of disability, as gauged by the modified Rankin Scale (mRS) at 90 days. Additional outcomes included functional independence (90-day mRS score of 0-2), symptomatic intracranial hemorrhage (sICH), and 90-day mortality. Of a total of 7,018 patients, 958 presented failed MT and were included in the analysis. The RT group comprised 407 (42.4%) patients, and the MM group consisted of 551 (57.5%) patients. After adjusting for confounders, the RT group showed a favorable shift in the overall 90-day mRS distribution (adjusted common odds ratio = 1.79, 95% confidence interval [CI] = 1.32-2.45, p < 0.001) and higher rates of functional independence (RT: 28.8% vs MM: 15.7%, adjusted odds ratio [aOR] = 1.93, 95% CI = 1.21-3.07, p = 0.005) compared to the MM group. RT also showed lower rates of sICH (RT: 3.8% vs MM: 9.1%, aOR = 0.52, 95% CI = 0.28-0.97, p = 0.039) and 90-day mortality (RT: 33.4% vs MM: 45.5%, aOR = 0.61, 95% CI = 0.42-0.89, p = 0.009). Our findings advocate for the utilization of RT as a potential treatment strategy for cases of LVO resistant to first-line MT techniques. Prospective studies are warranted to validate these observations and optimize the endovascular approach for failed MT patients. ANN NEUROL 2024;96:343-355.

Mechanical thrombectomy in patients with acute ischemic stroke in the USA before and after time window expansion

BackgroundIn 2018, the time window for mechanical thrombectomy eligibility in patients with acute ischemic stroke increased from within 6 hours to within 24 hours of symptom onset. The purpose of...

Paradigm Shift of Interventional Strategies and Outcomes for Acute Limb Ischemia Post-Pandemic.

We performed a large-scale comparison of patients treated for acute limb ischemia (ALI) in the pre-COVID (2017-2019) and COVID (2020-2022) eras to evaluate changes in interventional strategies and compare factors associated with adverse outcomes. We sought to characterize patient outcomes in an evolving ALI treatment algorithm in response to pandemic-associated presentation delays and rapid technological advancements in mechanical thrombectomy (MT). Using the TriNetX global research network, we conducted a multicenter query across 80 health care organizations (HCOs) spanning 4 countries for patients treated for ALI. Propensity score matching was performed to account for comorbidities. Risk of adverse outcomes within 30 days was calculated for each era, including re-intervention (RI30), major/minor amputation, and death. Patients were then stratified by initial intervention: open revascularization (OR), MT, or catheter-directed thrombolysis and adjunctive endovascular procedures alone (CDT/EP). Risk of adverse outcomes was compared between treatment groups of the same era. After propensity score matching, the pre-COVID era and COVID era cohorts included 7344 patients each. COVID era patients experienced a statistically significant higher risk of 30-day mortality (RR=1.211, p=0.027). Mechanical thrombectomy interventions were performed more frequently in the COVID era (RR=1.314, p<0.0001). Comparing outcomes between treatment groups, MT patients required RI30 more than OR patients (pre-COVID: RR=2.074, p=0.006; COVID: RR=1.600, p=0.025). Open revascularization patients had higher 30-day mortality (pre-COVID: RR=2.368, p<0.0001; COVID: RR=2.013, p<0.0001) and major amputations (pre-COVID: RR=2.432, p<0.0001; COVID: RR=2.176, p<0.0001) than CDT/EP. Pre-COVID CDT/EP patients were at higher risk for RI30 (RR=1.449, p=0.005) and minor amputations (RR=1.500, p=0.010) than OR. The MT group had higher major amputation rates than CDT/EP (pre-COVID: RR=2.043, p=0.019; COVID: RR=1.914, p=0.007). COVID-era MT patients had greater 30-day mortality (RR=1.706, p=0.031) and RI30 (RR=1.544, p=0.029) than CDT/EP. Significant shifts toward an MT-based approach have been observed in the last 3 years. Although MT required more RI30 than OR, there was no associated consequence of mortality and limb salvage. The increased mortality seen among COVID-era patients could be explained by delayed presentation, as well as poorly understood pro-thrombogenic or pro-inflammatory mechanisms related to the first waves of COVID. More research is necessary to determine an optimal treatment algorithm. Comorbid risk factors and severity of ischemia must be carefully considered before selecting an interventional strategy to prevent adverse outcomes and maximize limb salvage. Open revascularization strategies are associated with increased mortality and limb loss compared to less-invasive thrombolytic therapy alone. Mechanical thrombectomy (MT)-based approaches have been increasingly used in the last 3 years. Patients receiving MT are more likely to require reintervention within 30 days.

The prognostic value of ASPECTS in specific regions following mechanical thrombectomy in patients with acute ischemic stroke from large-vessel occlusion.

The aim of this study is to investigate the relationship between the volume of specific regional infarction and the prognosis of patients who undergo mechanical thrombectomy (MT) for acute large vessel occlusion. In this study, we collected the clinical and imaging features of patients with unilateral acute anterior circulation ischemic stroke from January 2021 to June 2023 in the Second Affiliated Hospital of Nanchang University. All patients underwent CT perfusion and non-contrast CT scan before MT. The ASPECTS was assessed based on imaging data, and artificial intelligence was used to obtain the percentage of infarction in each of the 10 regions of ASPECTS. According to the modified Rankin Scale, the patients were divided into the good prognosis group and poor prognosis group at the 90-day follow-up. Various indicators in the two groups were compared. Multivariable logistic regression was used to assess the risk factors for poor prognosis. The relationship between core infarction volume and the probability of poor prognosis was plotted to analyze the trend of poor prognosis with changes in the proportion of infarction volume. Finally, a receiver operating characteristic curve was constructed to analyze the predictive ability on poor prognosis. A total of 91 patients were included, with 58 patients having a good prognosis (mRS ≤ 2) and 33 patients having a poor prognosis (mRS ≥ 3). Multivariate analysis showed that NIHSS score and core infarction involving the internal capsule and M6 region were independent risk factors for poor prognosis. According to the linear correlation, a higher ratio of core infarction volume in the internal capsule or M6 region was linked to an increased risk of a poor prognosis. However, the non-linear analysis revealed that the prognostic impact of core infarction volume was significant when the ratio was greater than 69.7%. The ROC curve indicated that the combination of NIHSS score, infarct location, and the ratio of infarct volume has an AUC of 0.87, with a sensitivity of 84.8% and a specificity of 84.5%. It is important to examine the location and volume of the infarct in the internal capsule and M6 when deciding whether to do a MT.

Observation of Efficacy of rt-PA Thrombolysis Combined with Solitaire AB Stent Mechanical Thrombectomy in Patients with Acute Ischemic Stroke: A Retrospective Analysis

Objective: To observe and analyze the efficacy of recombinant tissue-plasminogen activator (rt-PA) thrombolysis combined with Solitaire AB stent mechanical thrombectomy in patients with acute ischemic stroke. Methods: Clinical efficacy, neurological function, oxidative stress response, adverse reactions, and quality of life were compared between the two groups. Results: Lower NIHSS scores were observed among patients who received treatment within 2 hours after stroke onset when compared with those in a timeframe of 2-6 hours, suggesting better neurological function recovery of the patients with early intervention and thus emphasizing the importance of early treatment for patients with stroke onset. Clinical efficacy in the combination group was significantly higher than in the control group (P < 0.05). After treatment, Paraoxonase-1 (PON-1) levels were higher, while lipoprotein-associated phospholipase A2 (Lp-PLA2) and Serum Amyloid A (SAA) levels were lower in the combination group compared to the control group (P < 0.05). The incidence of adverse reactions was significantly lower in the combination group (P < 0.05). At discharge, we observed significantly more patients with good recovery in the combination group when compared to the control group (P < 0.05), suggesting better quality of life of the patients, while this statistical significance was no longer observable at 90 days after discharge (P > 0.05). Conclusion: For acute ischemic stroke patients, rt-PA thrombolysis combined with Solitaire AB stent mechanical thrombectomy treatment is effective. It promotes neurological function recovery, improves vascular stenosis, reduces inflammation and adverse reactions, and enhances quality of life, showing promising clinical applications.

Incidence, Risk Factors, and Clinical Implications of Subarachnoid Hyperdensities on Flat-Panel Detector CT following Mechanical Thrombectomy in Patients with Anterior Circulation Acute Ischemic Stroke.

Flat-panel detector CT immediately after mechanical thrombectomy can detect complications, including early hemorrhagic transformation and subarachnoid hyperdensities. The clinical significance of subarachnoid hyperdensities in patients undergoing mechanical thrombectomy remains unclear. We studied 223 patients who underwent mechanical thrombectomy for anterior circulation stroke who had flat-panel detector CT performed immediately after the procedure and had follow-up imaging within 24 hours. Subarachnoid hyperdensity severity was categorized into 5 grades (subarachnoid hyperdensities, 0: absent to subarachnoid hyperdensities, IV: extensive). Baseline and procedural characteristics as well as outcome measures were analyzed using group comparisons and multivariable logistic regression analyses. Overall, 100/223 (45%) patients showed subarachnoid hyperdensities on immediate postinterventional flat-panel detector CT. The factors associated with an increased subarachnoid hyperdensity risk were the following: medium-vessel occlusion or distal-vessel occlusion compared with a large-vessel occlusion, a more distal device position, a higher number of device passes, a larger volume of contrast applied, worse final reperfusion expanded TICI, and after receiving IV thrombolysis. The occurrence of subarachnoid hyperdensity grades II-IV was independently associated with worse functional outcomes (adjusted OR for mRS, 3-6: 2.2; 95% CI 1.1-4.3), whereas patients with subarachnoid hyperdensity grade I had outcomes similar to those in patients without subarachnoid hyperdensities. Our study identified risk factors for subarachnoid hyperdensities, most of which reflect increasingly challenging procedures or more peripheral recanalization attempts. The presence of subarachnoid hyperdensity grades II-IV was associated with poorer outcomes, suggesting the need for personalized strategies to reduce its incidence and severity or potentially improve recovery after subarachnoid hyperdensities.

Factors associated with decreasing diffusion-weighted imaging-positive area volume after mechanical thrombectomy in patients with large early ischemic changes.

This study aimed to evaluate the factors associated with decreasing diffusion-weighted imaging (DWI) positive areas in patients with large early ischemic changes after mechanical thrombectomy (MT). This retrospective single-center clinical study was conducted between January 2013 and December 2022. We included consecutive patients who underwent MT for acute large-vessel occlusion of the anterior circulation with low pretreatment DWI-Alberta Stroke Program Early Computed Tomography Scores (ASPECTS) (0-5), effective recanalization [thrombolysis in cerebral infarction (TICI) 2b or TICI3], and magnetic resonance imaging (MRI) acquired before and after MT. We measured the DWI-positive area volume before and after MT. The primary endpoint was the after/before-MT DWI-positive area-volume ratio. In total, 28 patients were included in this study. Eight patients (29%) had an after/before-MT DWI-positive area-volume ratio of <1. The median mean apparent diffusion coefficient (ADC) levels of the DWI-positive areas in the groups with a ratio of <1 or >1 were 717 × 10⁶ mm2/s and 637 × 106 mm2/s, respectively (p = 0.011). Multivariate logistic regression analysis showed that ADC level (OR, 1.020 [95% confidence intervals (CIs), 1.001-1.040]; p = 0.040) was an independent predictor of a decreased DWI-positive area after MT. There was a negative correlation between the mean ADC level and the after/before-MT DWI-positive area-volume ratio (p < 0.001, |ρ| = 0.650), and the mean pretreatment ADC cutoff level was 649 × 106 mm2/s (area under the curve (AUC) = 0.806) for predicting a volume ratio of <1. The mean ADC level before-MT correlated with the after/before-MT DWI-positive area-volume ratio. A mean pretreatment ADC cutoff level of 649 × 106 mm2/s predicted a decreased DWI-positive area after MT.

Low blood flow ratio is associated with hemorrhagic transformation secondary to mechanical thrombectomy in patients with acute ischemic stroke

Background and purposeA significant decrease of cerebral blood flow (CBF) is a risk factor for hemorrhagic transformation (HT) in acute ischemic stroke (AIS). This study aimed to ascertain whether the ratio of different CBF thresholds derived from computed tomography perfusion (CTP) is an independent risk factor for HT after mechanical thrombectomy (MT). MethodsA retrospective single center cohort study was conducted on patients with AIS undergoing MT at the First Affiliated Hospital of Wenzhou Medical University from August 2018 to December 2023. The perfusion parameters before thrombectomy were obtained according to CTP automatic processing software. The low blood flow ratio (LFR) was defined as the ratio of brain volume with relative CBF <20 % over volume with relative CBF <30 %. HT was evaluated on the follow-up CT images. Binary logistic regression was used to analyze the correlation between parameters that differ between the two groups with regards to HT occurrence. The predictive efficacy was assessed utilizing the receiver operating characteristic curve. ResultsIn total, 243 patients met the inclusion criteria. During the follow-up, 46.5 % of the patients (113/243) developed HT. Compared with the Non-HT group, the HT group had a higher LFR (0.47 (0.34–0.65) vs. 0.32 (0.07–0.56); P < 0.001). According to the binary logistic regression analysis, the LFR (aOR: 6.737; 95 % CI: 1.994–22.758; P = 0.002), Hypertension history (aOR: 2.231; 95 % CI: 1.201–4.142; P = 0.011), plasma FIB levels before MT (aOR: 0.641; 95 % CI: 0.456–0.902; P = 0.011), and the mismatch ratio (aOR: 0.990; 95 % CI: 0.980–0.999; P = 0.030) were independently associated with HT secondary to MT. The area under the curve of the regression model for predicting HT was 0.741. ConclusionLFR, a ratio quantified via CTP, demonstrates potential as an independent risk factor of HT secondary to MT.

Data Extraction from Free-Text Reports on Mechanical Thrombectomy in Acute Ischemic Stroke Using ChatGPT: A Retrospective Analysis.

Background Procedural details of mechanical thrombectomy in patients with ischemic stroke are important predictors of clinical outcome and are collected for prospective studies or national stroke registries. To date, these data are collected manually by human readers, a labor-intensive task that is prone to errors. Purpose To evaluate the use of the large language models (LLMs) GPT-4 and GPT-3.5 to extract data from neuroradiology reports on mechanical thrombectomy in patients with ischemic stroke. Materials and Methods This retrospective study included consecutive reports from patients with ischemic stroke who underwent mechanical thrombectomy between November 2022 and September 2023 at institution 1 and between September 2016 and December 2019 at institution 2. A set of 20 reports was used to optimize the prompt, and the ability of the LLMs to extract procedural data from the reports was compared using the McNemar test. Data manually extracted by an interventional neuroradiologist served as the reference standard. Results A total of 100 internal reports from 100 patients (mean age, 74.7 years ± 13.2 [SD]; 53 female) and 30 external reports from 30 patients (mean age, 72.7 years ± 13.5; 18 male) were included. All reports were successfully processed by GPT-4 and GPT-3.5. Of 2800 data entries, 2631 (94.0% [95% CI: 93.0, 94.8]; range per category, 61%-100%) data points were correctly extracted by GPT-4 without the need for further postprocessing. With 1788 of 2800 correct data entries, GPT-3.5 produced fewer correct data entries than did GPT-4 (63.9% [95% CI: 62.0, 65.6]; range per category, 14%-99%; P < .001). For the external reports, GPT-4 extracted 760 of 840 (90.5% [95% CI: 88.3, 92.4]) correct data entries, while GPT-3.5 extracted 539 of 840 (64.2% [95% CI: 60.8, 67.4]; P < .001). Conclusion Compared with GPT-3.5, GPT-4 more frequently extracted correct procedural data from free-text reports on mechanical thrombectomy performed in patients with ischemic stroke. © RSNA, 2024 Supplemental material is available for this article.

General anesthesia versus conscious sedation in mechanical thrombectomy for patients with acute ischemic stroke: systematic review and meta-analysis.

After recently published randomized clinical trials, the choice of the best anesthetic procedure for mechanical thrombectomy (MT) in acute ischemic stroke (AIS) due to large vessel occlusion (LVO) is not definite. To compare the efficacy and safety of general anesthesia (GA) versus conscious sedation (CS) in patients with AIS who underwent MT, explicitly focusing on procedural and clinical outcomes and the incidence of adverse events. PubMed, Embase, and Cochrane were systematically searched for randomized controlled trials (RCTs) comparing GA versus CS in patients who underwent MT due to LVO-AIS. Odds ratios (ORs) were calculated for binary outcomes, with 95% confidence intervals (CIs). Random effects models were used for all outcomes. Heterogeneity was assessed with I2 statistics. Eight RCTs (1,300 patients) were included, of whom 650 (50%) underwent GA. Recanalization success was significantly higher in the GA group (OR 1.68; 95% CI 1.26-2.24; p < 0.04) than in CS. No significant difference between groups were found for good functional recovery (OR 1.13; IC 95% 0.76-1.67; p = 0.56), incidence of pneumonia (OR 1.23; IC 95% 0.56- 2,69; p = 0.61), three-month mortality (OR 0.99; IC 95% 0.73-1.34; p = 0.95), or cerebral hemorrhage (OR 0.97; IC 95% 0.68-1.38; p = 0.88). Despite the increase in recanalization success rates in the GA group, GA and CS show similar rates of good functional recovery, three-month mortality, incidence of pneumonia, and cerebral hemorrhage in patients undergoing MT.

Differences in outcome between left-sided and right-sided mechanical thrombectomy for acute ischemic stroke: A systematic review and meta-analysis.

Mechanical thrombectomy (MT) is a safe and effective treatment option for acute ischemic stroke due to large vessel occlusion. To investigate differences in outcomes between patients receiving left-sided and right-sided MT, we performed a systematic review and meta-analysis. A systematic literature review was performed using Embase, PubMed, Scopus, and Web of Science databases. Additional literature was searched for manually. Studies reporting safety and efficacy metrics for MT were included. Data regarding the modified Rankin scale (mRS), thrombolysis in cerebral infarction (TICI), symptomatic intracranial hemorrhage (sICH), and 90-day mortality were included. A random-effects model was used to calculate pooled odds ratios (ORs), mean differences (MDs), and 95% confidence intervals (CIs). The literature search yielded 13 reports consisting of 19 studies ranging from 98 to 5590 patients. Patients presenting with left-sided stroke had a National Institutes of health stroke scale score 2.89 greater than patients presenting with right-sided stroke (MD = 2.89; 95% CI = 2.09-3.68; P-value < 0.001). There were no differences between left-sided and right-sided MT patients for mRS 0-2 (OR = 0.94; 95% CI = 0.85-1.04; P-value = 0.224), TICI 2b-3 (OR = 1.05; 95% CI = 0.88-1.25; P-value = 0.598), sICH (OR = 0.83; 95% CI = 0.61-1.14; P-value = 0.255), or 90-day mortality (OR = 1.06; 95% CI = 0.84-1.33; P-value = 0.610). There does not appear to be a difference in outcomes for patients undergoing left-sided or right-sided thrombectomy.

Outcomes of Mechanical Thrombectomy in Patients With Neurological Disorders: A National Inpatient Sample Database Analysis.

Mechanical thrombectomy (MT) has changed the standard of care for patients presenting with acute ischemic stroke (AIS). The window of treatment has significantly increased the number of patients who would benefit from intervention and operators may be confronted with patients harboring preexistent neurological disorders. Still, the epidemiology of patients with AIS and neurological disorders has not been established. This is a retrospective study,which utilizes data from the National Inpatient Sample (NIS) between 2012 and 2016. Patients with the major neurological comorbidities in the study were included: Alzheimer's dementia (AD), Parkinson's disease (PD), amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), and myasthenia gravis (MG). These patients were divided into groups and analyzed based on discharged home status, length of hospital stay (LOS), and inpatient mortality. These outcomes were also compared between patients who underwent MT versus those who did not. In this study, 460,070 patients with AIS were identified and included. MT was performed less often when the patient had a neurological diagnosis compared to those without aneurological disease (p<0.0001). However, patients with AIS whohave underlying neurological disorders such as AD, PD, and MShave shown similar outcomes after MT to those who do not have these disorders. Patients with preexisting neurological disorders were less likely to undergo MT. Further studies are required to elucidate the implications of having a neurological disorder in the setting of an AIS.

Abstract 141: Physician Transfer versus Patient Transfer for Mechanical Thrombectomy in Patients With Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Background: Physician transfer has been explored as an alternate option to patient transfer for the expedient performance of mechanical thrombectomy in acute ischemic stroke patients. Methods: We conducted a systematic review to identify studies that evaluate the effect of physician transfer in patients with acute ischemic stroke who undergo mechanical thrombectomy. Data were extracted from relevant studies found through a search of PubMed, Scopus, and Web of Science until March 2023. A statistical pooling with random-effects meta-analysis was performed to examine the odds of reduced time interval between stroke onset and recanalization, functional independence, mortality, and time from stroke onset to recanalization with physician transfer against no patient transfer. Results: A total of 12 studies (11 nonrandomized observational studies, and 1 non-randomized controlled trial) were included. Physician transfer significantly reduced the time interval between stroke onset and recanalization with a pooled standardized mean difference estimate of -0.60 (95% CI [-1.17, -0.04], p = 0.035, 8 studies involving 1419 patients, and with high between-study heterogeneity in the estimates (I 2 =91.7%). The odds for functional independence at 90 days were significantly higher (OR 1.29, 95% CI 1.00-1.66, p = 0.046, 7 studies involving 1222 patients) with physician transfer with low between-study heterogeneity (I 2 =0%). Physician transfer was associated with higher odds of near complete or complete angiographic recanalization (OR 1.18, 95%CI 0.89-1.57, p = 0.25, I 2 =2.8%, 11 studies, 1856 subjects). Conclusions: We found a significant reduction in the mean time interval between symptom onset and recanalization associated with physician transfer with increased odds for functional independence at 90 days among patients undergoing mechanical thrombectomy.

Abstract 81: Radial versus Femoral Access for Mechanical Thrombectomy in Patients With Large Vessel Occlusion: A Randomized Clinical Trial

Introduction: Femoral artery is the most used access for mechanical thrombectomy (MT) in stroke patients with a large vessel occlusion. Routine radial access has been proposed as an alternative following cardiology guidelines although its safety and efficacy remain controversial. Hypothesis: Radial access for MT is non-inferior to femoral access in terms of final recanalization. Methods: The study was an investigator-initiated, single-center, evaluator-blinded randomized clinical trial. Stroke patients undergoing MT, with femoral artery patency and radial artery diameter ≥2.5mm were randomly assigned (1:1) to either radial (60 patients) or femoral access (60 patients). The primary binary outcome was successful recanalization (final eTICI score 2b-3) assigned by blinded evaluators. In the per protocol analysis, patients with allocated access failure were considered non-recanalized. We established a non-inferiority margin of -13.2%, considering an acceptable reduction of 15% in the expected recanalization rates. Results: From September 2021 to July 2023, 120 patients were randomly assigned and 114 (57 radial access, 57 femoral access) with confirmed intracranial occlusion on initial angiogram were included in the primary analysis. In the intention to treat analysis, successful recanalization was achieved in 48/57 (84.2%) patients assigned to femoral access and in 54/57(94.7%) patients assigned to radial (adjusted risk difference 3.36%, 95% CI –6.47% to 13%; p&lt;0.001). The lower limit of one-sided 95% CI was –4.8%, which did not cross our predefined margin of -13.2%. Median time from angiography suite arrival to first pass (femoral: 30 (IQR 25-37) minutes versus radial: 41 (IQR 33-62) minutes, p&lt;0.001) and from suite arrival to recanalization (femoral: 42 (IQR 28-74) versus radial: 59.5 (IQR 44-81) minutes, p&lt;0.050) were longer after radial access. Both groups presented one severe access complication and there was no difference in the rate of allocated access failure: radial 6 (10.5%) radial Vs femoral 5 (8.8%) (p=0.751). Conclusion: Among patients who underwent MT, radial access was non-inferior to femoral access in terms of final recanalization. Procedural delays may favor femoral access as default first approach.

Abstract TP282: Impact of Interhospital Transfer on Patients Undergoing Endovascular Thrombectomy for Acute Ischemic Stroke From a Comprehensive Stroke Center

Objective: This study aims to evaluate how interhospital transfers impact the correlation between functional outcomes, mortality, reperfusion rates, and workflow time metrics in patients undergoing endovascular thrombectomy (EVT) for acute ischemic stroke caused by large vessel occlusion (LVO). Background: This analysis is based on a prospective database encompassing consecutive patients who underwent EVT for LVO between January 2021 and June 2023 at a comprehensive stroke center (CSC). Main Outcome Measures: The primary outcome measures assessed include the rate of favorable 90-day functional outcomes (modified Rankin Scale 0-2), successful reperfusion (Thrombolysis in Cerebral Infarction scale grade 2b or 3), symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. Additionally, essential workflow time metric milestones were analyzed. Results: Out of 363 patients, 172 (47.4%) were transferred from other hospitals. The transferred patients were relatively younger than those who presented directly (66.5 ± 15.6 vs. 70.6 ± 14.5). No significant differences were observed in baseline characteristics, including gender, National Institutes of Health Stroke Scale score, and the rate of intravenous thrombolysis, between the transferred and direct presentation groups (all p &gt; 0.05). The time of symptom onset to groin puncture time was significantly higher for the transfer group (703.6 min vs. 394.5 min, p &lt; 0.0001), while comparable figures were noted for groin puncture to reperfusion time (43.9 min vs. 45.1 min, p = 0.7071) and ICU length of stay (70.8 hours vs. 59.3 hours, p = 0.7071) between the two cohorts. Similar rates were also seen for successful reperfusion (p = 0.2348), sICH (p = 0.4933), favorable 90-day functional outcomes (p = 0.9457), mortality (p = 0.8534), and composite complications during hospitalization (p = 0.5779). Conclusion: Although we observed significantly longer time intervals from symptom onset to initiation of mechanical thrombectomy in patients transferred from outside facilities, there were no adverse consequences on patient outcomes.

Abstract TP199: Prominent Laterality of the Posterior Cerebral Artery on MR Angiography Before Mechanical Thrombectomy in Patients With the Middle Cerebral Artery Occlusion Predicts Long-Term Functional Outcome

Background and Purpose: Well-developed collateral flow is reported to be associated with a reduction of infarct volume, successful reperfusion, and better functional outcome in acute ischemic stroke (AIS). Relatively increased visualization of posterior cerebral artery (PCA) ipsilateral to the ischemic lesion on MR angiography (MRA), a sign of prominent PCA laterality (PCAL), represents the development of collateral flow from PCA to middle cerebral artery (MCA) territory. However, the prognostic value of PCAL on functional outcome in AIS patients having MCA occlusion and undergoing mechanical thrombectomy, is not well known. Methods: We retrospectively reviewed initial MRA scans of pre-morbidly independent patients treated with mechanical thrombectomy for M1-segment occlusion from September 2017 to May 2022. PCAL was defined as better visualization of ipsilateral PCA, compared to contralateral PCA, by one or more segments on MRA. We divided patients into two groups, those presenting PCAL and not, and compared the background characteristics, in-hospital management, and functional outcome between the two groups. Factors associated with favorable outcome (mRS score 0-2) at 3 months after onset were assessed using multivariate logistic regression analysis. Results: In total, 172 patients (76 female [44%], median age 77 [IQR 74.5-78.0] years, median NIHSS score 16 [15-18]) were included. Of these, 86 patients (50%) presented PCAL on initial MRA. There is no significant difference between the two groups in age, sex, major vascular risk factors, NIHSS on admission, DWI-ASPECTS, onset-to-recanalization time (OTR), and preclinical modified Rankin scale. Multivariate logistic regression analysis showed an adjusted odds ratio of 2.11 for a favorable outcome in patients with PCAL (95% CI: 0.986 to 4.53, P=0.054). When focused on the cases with OTR &gt;6 hours (n=53), PCAL was independently associated with favorable outcome (OR 5.77, 95% CI: 1.28 to 26.0, P=0.022). Conclusion: PCAL on initial MRA in patients with M1-segment occlusion predicts favorable long-term functional outcome after mechanical thrombectomy, especially in the case taking longer time from onset to recanalization.

Abstract WP211: Mechanical Thrombectomy in Patients With Mild Thrombocytopenia is Safe and Effective; a Systematic Review and Meta-Analysis

Background: MT is a effective treatment for AIS patients with LVO, but MT on TP patients is risky due to lack of data and potential hemorrhage. Methods: Our review followed the PRISMA guidelines for systematic review and meta-analysis. We defined thrombocytopenia as platelet count ≤150х109/L, with further sub-classification into two groups: 1) Mild TP (Platelet count 100,000 - 149,000x109/L); 2) Moderate/severe TP (platelet count &lt;100х109/L). A favorable outcome was 90-day functional independence (mRS) ≤ 2). Unfavorable outcomes were mortality at 90 days and (sICH). Results: Compared to patients with normal platelets, patients with TP had no significant difference in outcomes (mRS &gt;2) at 90 days (RR 0.80 [95% CI: 0.69 - 0.94] p = 0.006). Further analysis based on sub-groups, the difference in mRS score was not statistically significant in patients with mild TP group (RR 0.84 [95% CI: 0.70 - 1.00] p = 0.05) and moderate/severe TP group (RR 0.71 [95% CI: 0.48 - 1.06] p = 0.09) when compared to patients with normal platelets. However Mortality was found to be higher in the TP group (RR 1.95 [95% CI: 1.62 - 2.36] p &lt; 0.00001), with similar trends of increased mortality in the mild and severe TP group (RR 1.88 [ 95% CI: 1.34 - 2.63] p = 0.0002 and RR 2.07 [95% CI: 1.46 - 2.92] p &lt; 0.0001). There was an overall slight increase in the incidence of sICH in the TP group (Relative Risk [RR] 2.47 [95% CI: 1.51 - 4.05], p = 0.0003) compared to patients with normal platelet counts, however subgroup demonstrated no significant higher risk in the mild thrombocytopenia group (RR 2.34 [95% CI: 1.24 - 4.40], p = 0.008) Conclusions: Mechanical thrombectomy for LVO in patients with mild thrombocytopenia is safe and does not increase the risk of sICH or worse outcomes. However, caution is advised in cases of moderate to severe thrombocytopenia, as there is a slightly higher risk of sICH and mortality. Nonetheless, we recommend thrombectomy for LVO patients with thrombocytopenia.

Abstract TP198: Factors Associated With Need for Decompressive Hemicraniectomy After Mechanical Thrombectomy in Stroke Patients

Background: Mechanical thrombectomy (MT) has significantly reduced morbidity and mortality in acute ischemic stroke (AIS). This study aims to analyze the outcomes and factors associated with decompressive hemicraniectomy (DHC) in AIS patients who underwent MT. Methods: We retrospectively analyzed data from an ongoing, multicenter database to investigate AIS patients who underwent MT for ICA, M1, or M2 occlusion. We compared clinical and procedural variables between patients who underwent DHC and those who did not. Propensity score (PS) matching between the two groups was conducted using age, sex, admission NIHSS, occluded vessel, ASPECTS, time from symptoms onset to arterial puncture, intracranial hemorrhage (ICH), and symptomatic ICH (sICH). Results: Among the 3,135 MT patients who met our inclusion criteria, 113 underwent DHC. A 1:3 propensity matching yielded a well-matched cohort of 113 in the DHC group versus 339 in the non-DHC group. The DHC group had a significantly higher rate of successful recanalization (mTICI ≥ 2C) (175 [51.6%] versus 36 [31.9%], P &lt; 0.001) and a longer procedure duration, with a median of 30 minutes (IQR: 17-54) compared to 44 minutes (IQR: 25-78) in the non-DHC group (P = &lt;0.001). Further comparison of patients with low ASPECTS (≤ 5) who underwent DHC (n = 36) with those who did not (n = 99) showed no significant difference in successful recanalization rates (15 [41.7%] versus 43 [43.4%], P &gt; 0.90). However, procedure duration was significantly longer in the DHC group with a median of 29 minutes (IQR: 13-52), compared to 39 minutes (IQR: 27-86) in the non-DHC group (P = 0.02). Conclusions: Successful recanalization can help in preventing DHC in AIS patients with high ASPECTS, but not those with low ASPECTS. Procedure duration is independently related to DHC following MT, especially in low ASPECTS patients.

Application of a nomogram model for the prediction of 90-day poor outcomes following mechanical thrombectomy in patients with acute anterior circulation large-vessel occlusion.

The past decade has witnessed advancements in mechanical thrombectomy (MT) for acute large-vessel occlusions (LVOs). However, only approximately half of the patients with LVO undergoing MT show the best/independent 90-day favorable outcome. This study aimed to develop a nomogram for predicting 90-day poor outcomes in patients with LVO treated with MT. A total of 187 patients who received MT were retrospectively analyzed. Factors associated with 90-day poor outcomes (defined as mRS of 4-6) were determined by univariate and multivariate logistic regression analyzes. One best-fit nomogram was established to predict the risk of a 90-day poor outcome, and a concordance index was utilized to evaluate the performance of the model. Additionally, 145 patients from a single stroke center were retrospectively recruited as the validation cohort to test the newly established nomogram. The overall incidence of 90-day poor outcomes was 45.16%, affecting 84 of 186 patients in the training set. Moreover, five variables, namely, age (odds ratio [OR]: 1.049, 95% CI [1.016-1.083]; p = 0.003), glucose level (OR: 1.163, 95% CI [1.038-1.303]; p = 0.009), baseline National Institute of Health Stroke Scale (NIHSS) score (OR: 1.066, 95% CI [0.995-1.142]; p = 0.069), unsuccessful recanalization (defined as a TICI grade of 0 to 2a) (OR: 3.730, 95% CI [1.688-8.245]; p = 0.001), and early neurological deterioration (END, defined as an increase of ≥4 points between the baseline NIHSS score and the NIHSS score at 24 h after MT) (OR: 3.383, 95% CI [1.411-8.106]; p = 0.006), were included in the nomogram to predict the potential risk of poor outcomes at 90 days following MT in LVO patients, with a C-index of 0.763 (0.693-0.832) in the training set and 0.804 (0.719-0.889) in the validation set. The proposed nomogram provided clinical evidence for the effective control of these risk factors before or during the process of MT surgery in LVO patients.

Assessing the clinical reasoning of ChatGPT for mechanical thrombectomy in patients with stroke

BackgroundArtificial intelligence (AI) has become a promising tool in medicine. ChatGPT, a large language model AI Chatbot, shows promise in supporting clinical practice. We assess the potential of ChatGPT as...