Safety Of Mechanical Thrombectomy Research Articles

Outcomes of mechanical thrombectomy in anticoagulated patients with acute distal and medium vessel stroke.

Stroke remains a major health concern globally, with oral anticoagulants widely prescribed for stroke prevention. The efficacy and safety of mechanical thrombectomy (MT) in anticoagulated patients with distal medium vessel occlusions (DMVO) are not well understood. This retrospective analysis involved 1282 acute ischemic stroke (AIS) patients who underwent MT in 37 centers across North America, Asia, and Europe from September 2017 to July 2023. Data on demographics, clinical presentation, treatment specifics, and outcomes were collected. The primary outcomes were functional outcomes at 90 days post-MT, measured by modified Rankin Scale (mRS) scores. Secondary outcomes included reperfusion rates, mortality, and hemorrhagic complications. Of the patients, 223 (34%) were on anticoagulation therapy. Anticoagulated patients were older (median age 78 vs 74 years; p < 0.001) and had a higher prevalence of atrial fibrillation (77% vs 26%; p < 0.001). Their baseline National Institutes of Health Stroke Scale (NIHSS) scores were also higher (median 12 vs 9; p = 0.002). Before propensity score matching (PSM), anticoagulated patients had similar rates of favorable 90-day outcomes (mRS 0-1: 30% vs 37%, p = 0.1; mRS 0-2: 47% vs 50%, p = 0.41) but higher mortality (26% vs 17%, p = 0.008). After PSM, there were no significant differences in outcomes between the two groups. Anticoagulated patients undergoing MT for AIS due to DMVO did not show significant differences in 90-day mRS outcomes, reperfusion, or hemorrhage compared to non-anticoagulated patients after adjustment for covariates.

Is time really brain in stroke therapy?: A meta-analysis of mechanical thrombectomy up to 155h post ictus.

Mechanicalthrombectomy (MT) has been established as the gold standard of treatment for patients with Acute Ischemic Stroke (AIS) who present up to 6h after the onset of the stroke. Recently, the DEFUSE-3 and DAWN trials established the safety of starting the MT procedure up to 16 and 24h after the patient was last seen well, respectively. The purpose of this study is to assess the safety and functional effects of thrombectomy in individuals with AIS detected at a late stage (> 24h). PubMed, Web of Science, Embase, and Cochrane databases were thoroughly searched for research on MT in patients in the extremely late time window after AIS. The primary outcomes were symptomatic cerebral hemorrhage, 90-day mortality, Thrombolysis in Cerebral Infarction (TICI) 2b-3, and Modified Rankin Scale (mRS) 0-2. Our study included fifteen studies involving a total of 1,221 patients who presented with AIS and an extended time window. The primary outcome of interest was the favorable functional outcome, mRS 0-2 at 90days. The pooled proportion for this outcome was 45% (95% confidence interval 34-58%). Other outcomes included the TICI 2b or 3 (successful recanalization), which was reported in 12 studies and had a 79% incidence in the study population (95% CI 68-87%). Complications included: symptomatic intracranial hemorrhage (sICH), which revealed an incidence of 7% in the study population (95% CI 5-10%); and 90-day mortality, which reported a 27% incidence (95% CI 24-31%). In addition, we conducted a comparative analysis between endovascular treatment and standard medical therapy. Our meta-analysis provides evidence that supports the need of further randomized and prospective clinical trials to better assess the effectiveness and safety of MT in these patients.

Outcomes of mechanical thrombectomy in patients with acute ischemic stroke and thrombocytopenia: systematic review and meta-analysis.

Mechanical Thrombectomy (MT) has improved outcomes in acute ischemic stroke (AIS) due to Large Vessel Obstruction (LVO). However, there is limited data on the safety and outcomes of MT in AIS patients with thrombocytopenia. This study aims to assess the efficacy and safety of MT in this population. Following the PRISMA guidelines, a comprehensive systematic review was conducted using PubMed, Embase, Web of Science, and Scopus. Studies meeting inclusion criteria underwent rigorous risk of bias assessment using the ROBINS-I tool. We compared outcomes between patients with and without thrombocytopenia undergoing MT. Using the R software version 4.3.1, meta-analyses were conducted employing random-effect models. This meta-analysis encompassed data from 5 studies. Thrombocytopenic AIS patients who underwent MT (n = 974) exhibited lower rates of functional independence (OR 0.83, 95% CI 0.71-0.98; p = 0.030) compared to patients with normal platelet counts (n = 2036). In addition, the thrombocytopenic group experienced higher mortality as compared to the group with normal platelet counts (OR 1.76, 95% CI 1.26-2.45; p < 0.001). Rates of sICH were found to be similar between groups (OR 1.20, 95% CI 0.74-1.93; p = 0.456), as were rates of successful recanalization (OR 0.94, 95% CI 0.47-1.87; p = 0.863). Lastly, no significant differences were observed in procedure times between thrombocytopenic and non-thrombocytopenic groups. As compared to patients without thrombocytopenia, thrombocytopenic AIS patients undergoing MT displayed lower functional independence and higher mortality rates, with no significant differences in sICH or successful recanalization.

Efficacy and safety of mechanical thrombectomy in the posterior cerebral circulation—a single center study

Mechanical thrombectomy (MT) is the current standard treatment for strokes in the anterior cerebral circulation (AMT) and has recently been proven to be beneficial in the posterior circulation strokes (PMT). Our study aims to evaluate parameters for favorable outcomes in PMT-patients and to compare the clinical characteristics of individuals who received AMT and PMT. For this purpose, we confronted AMT and PMT-receipients and performed a multivariate regression analysis to assess the influence of factors on favorable outcomes in the study group and in the AMT and PMT subgroups. When analysing 623 MT-patients, those who received PMT had significantly lower admission National Institutes of Health Stroke Scale (NIHSS) scores (9 vs. 13; p < 0.001) and 24 h post-MT (7 vs. 12; p = 0.006). Key parameters influencing the favorable outcomes of PMT at discharge and at 90th day include: NIHSS scores (OR: 0.865, 95% CI: 0.813–0.893, and OR: 0.900, 95% CI: 0.861–0.925), MT time (OR: 0.993, 95% CI: 0.987–0.998 and OR: 0.993, 95% CI: 0.990–0.997), and leukocytosis (OR: 0.961, 95% CI: 0.928–0.988 and OR: 0.974, 95% CI: 0.957–0.998). Different clinical profiles exist between AMT and PMT-recipients, with the neurological status post-MT being decisive for the prognosis. Several factors play an important role in predicting outcome, especially in the PMT group.

Mechanical Thrombectomy for All LVO – Is It Feasible? – Recent Evidence to Expand the Current Stroke Guidelines

Mechanical thrombectomy (MT) has established its role as a standard care of acute ischemic stroke due to large vessel occlusion (LVO). Current early stroke management guidelines have defined certain selection criteria for LVO patients undergoing MT to achieve the most benefit. However, it is still uncertain if some other LVO patients who do not meet these criteria can also benefit from MT. In this review, we research the latest evidence on efficacy and safety of MT for LVO in various unique stroke populations, such as advanced age, pre-stroke disability, LVO with minor stroke, large infarct volume, poor mismatch profile, very late time window, posterior circulation LVO and distal medium-sized vessel occlusions. By comparing the benefits and risks of MT with best medical management only, we may develop further subgroup-specific criteria to expand our capacity to best treat these unique LVO populations.

The Efficacy and Safety of Mechanical Thrombectomy in Posterior Circulation Large Vessel Occlusion as Compared to Anterior Circulation Large Vessel Occlusion: A Systematic Review.

Mechanical thrombectomy (MT) has been established as a standard of care for patients with stroke due to anterior circulation large vessel occlusion (AC-LVO). Due to a lack of robust evidence for the effectiveness of mechanical thrombectomy, intravenous thrombolysis (IVT) is still the only approved first-line acute reperfusion strategy for posterior circulation large vessel occlusion (PC-LVO). This systematic review analyzes and reports on the effectiveness and safety of MT in PC-LVO. A literature review was performed to identify all studies of patients with acute ischemic stroke due to PC-LVO who underwent MT with second-generation devices (stent retrievers and/or aspiration devices) that were reported between January 2017 and January 2023. The primary outcome was functional independence at 90 days, defined as a modified Rankin (mRS) score of ≤2. Secondary outcomes were successful recanalization (modified treatment in cerebral infarction score (mTICI) 2b/3), symptomatic intracerebral hemorrhage (sICH), and mortality at 90 days post-procedure. We looked at 13 studies with a total of 30,407 participants in four meta-analyses and 5951 participants in nine observational studies. In most studies, patients in the PC-LVO group were male and younger than the AC-LVO group. Higher baseline National Institutes of Health Stroke Scale (NIHSS) score, lower rates of IVT, longer onset-to-groin puncture time, lower likelihood of sICH, higher 90-day mortality rates, and higher futile recanalization rates were frequently observed in the PC-LVO group with a large discrepancy in the likelihood of functional independence at 90 days with majority studies showing comparable rates. Hence, in patients with acute ischemic stroke caused by the PC-LVO, successful reperfusion can be achieved via MT, though at the cost of higher mortality rates. Such futile recanalization can be avoided with the refinement of procedures through technical improvements, skills training, and recognition of reliable predictors associated with it, which might help increase the efficacy of MT in PC-LVO. Additionally, future large-scale RCTs comparing patient selection and interventional strategies to avoid futile interventions are also needed.

Efficacy, safety, and predictors for functional outcomes of mechanical thrombectomy in patients aged over 90 years with acute ischemic stroke and literature review

BackgroundNo evidence supports the efficacy and safety of mechanical thrombectomy (MT) in patients aged ≥ 90 years with acute ischemic stroke (AIS). This study clarifies the efficacy, safety, and predictors of MTs in patients aged ≥ 90 years by investigating our results and reviewing previous studies. MethodsWe retrospectively investigated data from 80 consecutive patients who underwent MT at our hospital between 2018 and 2021. We analyzed outcomes using the modified Thrombolysis in the Cerebral Infarction (mTICI) scale and modified Rankin Scale (mRS). Functional outcomes were investigated at 90 days or discharge. ResultsWe obtained functional outcomes mRS ≤ 3 patients in 41.6%. The mortality rate was 16.6%. The rate of successful recanalization was 75%. Comparison mRS ≤ 3 and mRS ≥ 4 at 90 days or discharge showed statistical significance in the National Institute of Health Stroke Scale, the location of occluded vessels, and mTICI ≥ 2b at the first pass. Univariable logistic regression analysis indicated that the Alberta Stroke Program Early Computed Tomography Score was a predictor of mRS ≤ 3. ConclusionsThe efficacy is lower than that of patients aged < 90; however, MT is effective even in patients aged ≥ 90 years. The safety of MT in patients aged ≥ 90 years was similar to that in those aged < 90 years. Neuro-interventionalists should consider predictors and take the best strategies to achieve successful recanalization in patients aged ≥ 90 years with AIS.

Stroke with large vessel occlusion in the posterior circulation: IV thrombolysis plus thrombectomy versus IV thrombolysis alone.

Efficacy and safety of mechanical thrombectomy (MT) for stroke with posterior circulation large vessel occlusion (LVO) is still under debate. We aimed to compare the outcomes of stroke patients with posterior circulation LVO treated with intravenous thrombolysis (IVT) (< 4.5h after symptom onset) plus MT < 6h after symptom onset with those treated with IVT alone (< 4.5h after symptom onset). Patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) and in the Italian centers included in the SITS-ISTR were analysed. We identified 409 IRETAS patients treated with IVT plus MT and 384 SITS-ISTR patients treated with IVT alone. IVT plus MT was significantly associated with higher rate of sICH (ECASS II) compared with IVT alone (3.1 vs 1.9%; OR 3.984, 95% CI 1.014-15.815), while the two treatments did not differ significantly in 3-month mRS score ≤ 3 (64.3 vs 74.1%; OR 0.829, 95% CI 0.524-1.311). In 389 patients with isolated basilar artery (BA) occlusion, IVT plus MT was significantly associated with higher rate of any ICH compared with IVT alone (9.4 vs 7.4%; OR 4.131, 95% CI 1.215-14.040), while two treatments did not differ significantly in 3-month mRS score ≤ 3 and sICH per ECASS II definition. IVT plus MT was significantly associated with higher rate mRS score ≤ 2 (69.1 vs 52.1%; OR 2.692, 95% CI 1.064-6.811) and lower rate of death (13.8 vs 27.1%; OR 0.299, 95% CI 0.095-0.942) in patients with distal-segment BA occlusion, while two treatments did not differ significantly in 3-month mRS score ≤ 3 and sICH per ECASS II definition. IVT plus MT was significantly associated with lower rate of mRS score ≤ 3 (37.1 vs 53.3%; OR 0.137, 0.009-0.987), mRS score ≤ 1 (22.9 vs 53.3%; OR 0.066, 95% CI 0.006-0.764), mRS score ≤ 2 (34.3 vs 53.3%; OR 0.102, 95% CI 0.011-0.935), and higher rate of death (51.4 vs 40%; OR 16.244, 1.395-89.209) in patients with proximal-segment BA occlusion. Compared with IVT alone, IVT plus MT was significantly associated with higher rate of sICH per ECASS II definition in patients with stroke and posterior circulation LVO, while two treatment groups did not differ significantly in 3-month mRS score ≤ 3. IVT plus MT was associated with lower rate of mRS score ≤ 3 compared with IVT alone in patients with proximal-segment BA occlusion, whereas no significant difference was found between the two treatments in primary endpoints in patients isolated BA occlusion and in the other subgroups based on site occlusion.

Mechanical Thrombectomy Treatment More than 16 h after Last Known Well for Patients with Large Vessel Occlusion

Introduction: Mechanical thrombectomy (MT) has been reported to be effective within 24 h after last known well (LKW) by the DAWN (DWI or CTP Assessment with Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention with Trevo) trial and within 16 h after LKW by the DEFUSE-3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3) trial. However, there have been few reports of MT more than 16 h after LKW, and the efficacy and safety of MT more than 24 h after LKW have not yet been demonstrated. We evaluated the efficacy and safety of MT more than 16 h after LKW. Methods: Using data from the Nippon Medical School Hospital MT registry from April 2011 to August 2022, consecutive patients with anterior circulation large vessel occlusion (LVO) and prehospital modified Rankin scale (mRS) scores of 0–3 were enrolled. Patients were classified into the following three groups: early group (LKW <6 h), middle group (LKW 6–16 h), and late group (LKW >16 h). The clinical characteristics and outcomes were compared among these three groups. Results: Among 778 patients in the MT registry, 624 were enrolled. The early group included 432 patients, the middle group included 123 patients, and the late group included 69 patients. The patients had a median age of 77 years (interquartile range, 68–83), and 359 were male (57.5%). The median prehospital mRS score was 1 (interquartile range, 1–1), median National Institutes of Health Stroke Scale score on admission was 17 (interquartile range, 10–23), and median Alberta Stroke Program Early CT Score was 10 (interquartile range, 8–10). Regarding safety and efficacy, the proportions of cases with successful reperfusion (modified Thrombolysis in Cerebral Infarction score of 2b–3; 85.4% vs. 92.7% vs. 88.7%; p = 0.47), symptomatic intracranial haemorrhage (6.4% vs. 5.7% vs. 7.2%; p = 0.99), mRS score ≤3 at 90 days (52.0% vs. 60.2% vs. 44.9%; p = 0.11), and mRS score of 6 at 90 days (11.3% vs. 10.6 vs. 8.7%; p = 0.37) were not significantly different between the three groups. Conclusion: Patients who received MT more than 16 h after LKW experienced the same safety and efficacy as those who received MT at 0–16 h after LKW. MT more than 16 h after LKW may be safe and effective for stroke patients with LVO.

Safety of Mechanical Thrombectomy in Patients on Antiplatelet/Anticoagulation

Mechanical thrombectomy (MT) is performed in patients who are already on anticoagulation (AC)/antiplatelet therapy (AP). However, data are insufficient regarding MT's safety and efficacy profiles in these patients. Investigate the outcome of stroke patients already on anticoagulation/antiplatelet receiving MT. We included consecutive acute ischemic stroke patients treated with MT for 10years (2012-2022) in a comprehensive stroke center. Baseline variables, efficacy (recanalization [Thrombolysis in Cerebral Infraction]≥2b), good functional outcome (modified Ranking Scale ≤ 2 at 3months), and safety (symptomatic intracranial hemorrhage [sICH], mortality rates) were evaluated. Additionally, we conducted a subgroup analysis of patients with prior single-AP versus DAPT. Six hundred forty-six patients were included (54.5% women, median age 71years), 84 (13%) were on AC, 196 (30.3%) on AP, and 366 (56.7%) in the control group. The AC and AP groups were older and had more comorbidities. sICH occurred in 7.3% of cases. There was no significant difference in sICH incidence across the groups. The AC group had a lower rate of intravenous thrombolysis (15.9%; P < 0.001), a higher rate of sICH (11.9% vs. AP 7.7% and control 6%; P= 0.172), and higher mortality at discharge (17.9% vs. AP 8.7% and control 10.4%; P= 0.07). However, the groups had similar functional outcomes and mortality rates at 3months. Successful recanalization was achieved in 92.7% and was similar across groups. Multivariable logistic regression and the subgroup analysis (single-AP vs. dual AP) did not reveal statistically significant associations. MT in patients with prior anticoagulation and AP presenting with acute ischemic strokeis feasible, effective, and safe.

Mechanical Thrombectomy Versus Combined Thrombectomy and Intravenous Thrombolysis in Tandem Lesions (S24.003)

Mechanical Thrombectomy Versus Combined Thrombectomy and Intravenous Thrombolysis in Tandem Lesions (S24.003)

Abstract Number: LBA6 Mechanical Thrombectomy for Basilar Artery Occlusion: Systematic Review and Meta‐analysis of Randomized Controlled Trials

Introduction Acute ischemic stroke (AIS) caused by basilar artery occlusion (BAO) is known to be associated with high rates of mortality and lifelong disability. In the past few years, two clinical trials (the BEST and the BASICS trials) investigated the benefits and safety of mechanical thrombectomy (MT) for BAO and did not provide evidence to support the efficacy of MT in BAO patients. Given the recent positive results from the ATTENTION and the BAOCHE clinical trials, we conducted this meta‐analysis to provide updated collective evidence regarding the benefits of MT in patients with BAO. Methods We searched for eligible papers till June 1st, 2021, in five databases: PubMed, Web of Science, Scopus, and Embase databases using keywords and/or medical subject (MeSH) terms. We included all randomized controlled trials (RCTs) with no restrictions on publication date, data, or language of the included studies to avoid missing any relevant papers. All data were analyzed using R software. We computed the pooled risk ratios (RRs) and their corresponding 95% confidence intervals (CI), using a random‐effect model or fixed‐effect model depending on heterogeneity among the included studies. Heterogeneity was assessed with Q statistics and the I2 test considering it significant with I2 value &gt; 50% or P‐value &lt; 0.05. Results Four trials were included in this meta‐analysis, namely the BEST, the BASICS, the BAOCHE, and the ATTENTION trials. The four trials recruited a total of 988 patients. The MT group achieved a significantly higher rate of modified Rankin scale (mRS) score of 0–3 was as compared to the best medical treatment (BMT) one (RR = 1.54; 95% CI = 1.16‐2.04; P‐value = 0.002). Similarly, the mRS 0–2 rate was significantly higher in the MT group as compared to the BMT group (RR = 1.79; 95% CI = 1.09‐2.95; P‐value = 0.022). Nevertheless, heterogeneity was noticed amongst the included studies. Moreover, there was a significant reduction in the 90‐day mortality in the MT group as compared to the BMT group (RR = 0.76; 95% CI = 0.65‐0.89; P‐value = 0.002). On the other hand, there was a significantly higher rate of symptomatic intracerebral hemorrhage (sICH) in the MT group compared to the BMT group (RR = 7.48; 95% CI = 2.27‐24.61; P‐value&lt; 0.001). There with no heterogeneity observed in both outcomes of mortality and sICH. Noted that there were no significant differences in overall parenchymal hemorrhage (PH) and type I PH rates, yet type II PH was more prevalent in the MT group compared to the BMT one (RR = 5.53; 95% CI = 1.47‐20.84; P‐value = 0.011). Conclusions The current evidence favors MT for basilar artery occlusions over the conservative approach in terms of achieving higher rates of good functional outcomes and decreasing mortality rates. Further large‐scale trials of different populations are needed to corroborate these results and also to ensure generalizability.

Abstract Number: LBA23 Endovascular treatment of large vessel occlusion stroke caused by infective endocarditis

Introduction Infective endocarditis (IE) often presents as an acute ischemic stroke (AIS) secondary to a thromboembolic event leading to large vessel occlusion (LVO). These patients are at significant risk for intracerebral hemorrhage when given intravenous thrombolytics (IT) and are therefore better candidates for mechanical thrombectomy (MT). Current reports in the literature are divided on the safety of MT in this setting and no randomized control studies exist. With the advent of modern thrombectomy devices, we believe MT might be safe in this patient population. Methods Here we report a patient with IE who presented with LVO stroke (MCA syndrome) and underwent MT leading to first‐pass Thrombolysis inCerebral Infarction (TICI) score of 3 revascularization. In addition to presenting our case, we did a comprehensive review of the current literature on this topic. Results A thirty‐year‐old female with a history of cocaine abuse presented with acute onset left hemiplegia, dysarthria, and rightward gaze deviation. NIHSS was 19 and she presented 90 minutes from her last known well time . Computed Tomography (CT) head and CT perfusion imaging demonstrated a large MCA distribution stroke, an AlbertaStrokeProgram Early CT Score (ASPECTS) of 10, with significant perfusion mismatch of right MCA territory. CT angiography (CTA) confirmed a proximal large vessel occlusion (LVO) at the proximal M1. On initial assessment, the patient was febrile with a temperature of 40 degrees Celsius with a high clinical suspicion for IE; therefore, intravenous thrombolytic was not administered. MT was performed with one pull of stent retrieval under aspiration led to a successful opening of the vessel with TICI score of 3. Positive cocaine on urine toxicology was noted as well as, two sets of gram‐positive blood cultures which later resulted in Staph Aureus, oxacillin susceptible, unremarkable transthoracic echo, but with TEE demonstrating vegetative thickening within atrial aspects of both anterior andposterior mitral valve leaflets(Figure1). On hospital day two, magnetic resonance imaging of the brain shows small acute infarct with no bleed. The patient underwent a mitral valve replacement on hospital day nine. The patient was discharged to rehabilitation facilities with an NIHSS of two for mild left facial droop and mild left arm weakness; her degree of disability was measured as a modified Rankin Scale (mRS) one at 3 months. Conclusions In case IE is suspected, giving IV tPA (tissue‐type plasminogen activator) is contraindicated as it increases the chance of hemorrhagic complications and when LVO is confirmed in the setting of AIS, MT might be safe and effective to be considered .

Does Tenecteplase Before Mechanical Thrombectomy Result in a Faster Revascularization as Compared to Alteplase? Observations From a Comprehensive Stroke Care Center in Southern India

Background The Indian data concerning the endovascular mechanical thrombectomy (MT) in acute ischemic strokes (AIS) with large vessel occlusion (LVO) is still scarce and evolving. Tenecteplase (TNK) has been recently approved for intravenous stroke thrombolysis prior to the MT. Methods This study is a single-center retrospective study. We performed data analysis of the AIS patients who consecutively presented during the study period with LVO and underwent thrombectomy. Procedural success was defined by the post-thrombectomy angiographic picture of grades 2b and 3 on modified Thrombolysis in Cerebral Infarction (mTICI) scale. Primary efficacy outcome was defined as an improvement of ≥4 points in National Institute of Health Stroke Scale (NIHSS) score at 24 h. Secondary efficacy outcome was based on modified Rankin Scale (mRS) score at 90 days. We also performed a comparative analysis of TNK and alteplase subgroups. Results Successful recanalization (mTICI 2b/3) was achieved in 65 (86.67%) patients. There was a significant mean difference between the NIHSS scores on admission and at 24 h ( P &lt; .001). Likewise, mRS score at 3 months also showed a significant mean difference as compared to baseline ( P &lt; .001). A faster recanalization was observed in those who were thrombolyzed with TNK, needed fewer number of passes, and if the procedure was performed under conscious sedation. Conclusion This study further strengthens the Indian data on efficacy and safety of MT in LVO ischemic strokes. Besides, whether the observation of TNK resulting in a faster revascularization is due to some factors unaccounted in our study, or an actual effect on thrombus due to a high fibrin specificity, needs to be tested further in larger randomized studies with matched sample sizes.

Endovascular Thrombectomy with or without Intravenous Thrombolysis for Anterior Circulation Large Vessel Occlusion in the Imperial College London Thrombectomy Registry.

Background and purpose. Mechanical thrombectomy (MT) is the standard of care for eligible patients with a large vessel occlusion (LVO) acute ischemic stroke. Among patients undergoing MT there has been uncertainty regarding the role of intravenous thrombolysis (IVT) and previous trials have yielded conflicting results regarding clinical outcomes. We aim to investigate clinical, reperfusion outcomes and safety of MT with or without IVT for ischemic stroke due to anterior circulation LVO. Materials and Methods. This observational, prospective, single-centre study included consecutive patients with acute LVO ischemic stroke of the anterior circulation. The primary outcomes were the rate of in-hospital mortality, symptomatic intracranial haemorrhage and functional independence (mRS 0-2 at 90 days). Results. We enrolled a total of 577 consecutive patients: 161 (27.9%) were treated with MT alone while 416 (72.1%) underwent IVT and MT. Patients with MT who were treated with IVT had lower rates of in-hospital mortality (p = 0.037), higher TICI reperfusion grades (p = 0.007), similar rates of symptomatic intracranial haemorrhage (p = 0.317) and a higher percentage of functional independence mRS (0-2) at 90 days (p = 0.022). Bridging IVT with MT compared to MT alone was independently associated with a favorable post-intervention TICI score (>2b) (OR, 1.716; 95% CI, 1.076-2.735, p = 0.023). Conclusions. Our findings suggest that combined treatment with MT and IVT is safe and results in increased reperfusion rates as compared to MT alone.

Abstract WMP89: Mechanical Thrombectomy For Distal Medium-vessel Occlusion Stroke: Systematic Review And Meta-analysis

Introduction: Definitive evidence about the role and effectiveness of mechanical thrombectomy (MT) in patients with distal medium-vessel occlusions (DMVOs) is limited. Objective: To determine the efficacy and safety of MT for DMVOs. Methods: A systematic search was performed until May 2022 in Scopus, Embase, Medline, Web of Science, and Cochrane. An additional cohort of 33 patients from our institutional experience was also included. Primary efficacy and safety outcomes were successful reperfusion (mTICI 2b-3) and sICH, respectively. Additional outcomes were the rate of complete reperfusion (mTICI 3), 90-day excellent and favorable functional outcome (defined as an mRS of 0-1 and 0-2, respectively), and 90-day mortality. We conducted meta-analyses using random-effects models and assessed the certainty of evidence using the GRADE approach. Statistical heterogeneity across studies was assessed with I 2 statistics. Results: A total of 24 studies with 1046 patients were included in our analysis. Successful and complete reperfusion rates were 89.8% (95% CI 83.7-93.7%; I 2 =0%; moderate-certainty evidence) and 47.2% (95% CI 32.3-62.5%; I 2 =75%; very low-certainty evidence), respectively. Favorable and excellent functional outcome rates were 59.1% (95% CI 48.4-68.9%; I 2 =73%; moderate-certainty evidence) and 43% (95% CI 32.9-53.7%; I 2 =68%; low-certainty evidence), respectively. Mortality and sICH rates were 12.4% (95% CI 9.3-16.5%; I 2 =16%; high-certainty evidence) and 5.5% (95% CI 3.5-8.5%; I 2 =23%; moderate-certainty evidence), respectively. Conclusion: This systematic review with meta-analysis found that MT for DMVO provides rates of successful reperfusion and sICH comparable to the evidence from MT for LVO stroke and M2 occlusions. Given the level of evidence of our results, further confirmation on well-designed RCTs is needed.

Abstract TP133: Efficacy Of Mechanical Thrombectomy For The Posterior Circulation Stroke

Background and Purpose: The efficacy of mechanical thrombectomy (MT) for posterior circulation large vessel occlusions has not been fully elucidated. We investigated the efficacy and safety of MT for posterior circulation stroke (PCS) compared with anterior circulation stroke (ACS). Methods: We analyzed 885 consecutive patients who underwent MT for acute ischemic stroke between January 2013 and December 2020 at six comprehensive stroke centers. The patients were divided into two groups; the PCS and ACS group. The procedural and clinical outcomes were compared between the groups. Results: A total of 767 patients (PCS group, 83; ACS group, 684), were analyzed. PCS patients were significantly younger (75 vs. 79, P = 0.008) and had a higher NIHSS score at baseline (23 vs 19, p=0.012) and longer door to puncture time (97 vs 73 min, p=0.009). The rate of male (67.0 vs 46.9% p&lt;0.001) and atherosclerotic brain infarction (22.8 vs 8.3% p&lt;0.001) were higher, comorbid atrial fibrillation (50.6 vs 64.4% p=0.022) was fewer in the PCA group. The rate of mTICI 3 recanalization at the first pass (40.9 vs 28.5% p=0.019) was significantly higher in the PCS group. However, the rates of final mTICI ≥ 2b recanalization (86.6 vs 83.8% p=0.491), symptomatic hemorrhagic complications, good clinical outcome at 90 days (34.3 vs 32.5% p=0.767), and mortality (22.3 vs 16% p=0.184) were similar in the groups. In the PCS group, the single use of a stent retriever for the first pass was associated with higher mortality rate compared with use of ADAPT or combined technique (38.6 vs 12.2% p=0.012). Conclusions: MT for PCS seemed to be beneficial, having similar complication, recanalization rate, and clinical outcomes with ACS.

Mechanical Thrombectomy for Pediatric Large Vessel Occlusions : ASystematic Review and Meta-analysis.

Acute intracranial large vessel occlusion (LVO) is an important cause of morbidity and mortality among children; however, unlike in adults, no clinical trial has investigated the benefit of mechanical thrombectomy (MT) in pediatric LVO. Thus, MT remains an off-label procedure for pediatric stroke. To investigate the efficacy and safety of MT in pediatric LVO. Asystematic literature search was conducted in Ovid MEDLINE, Ovid Embase, Scopus, Web of Science, and Cochrane Central Register of Clinical Trials databases. Studies reporting safety and efficacy outcomes for endovascular treatment of pediatric LVO were included. Data regarding recanalization, functional outcome, symptomatic intracranial hemorrhage (sICH), and mortality were extracted from the included studies. Functional outcome was assessed with the modified Rankin scale (mRS). Afixed or random-effects model was used to calculate pooled event rates and 95% confidence intervals (CI). In this study 11 studies comprising 215 patients were included. The successful recanalization rate was 90.3% (95% CI = 85.77-95.11%), and complete recanalization was achieved in 52.7% (95% CI = 45.09-61.62%) of the cases. The favorable (mRS = 0-2) and excellent (mRS = 0-1) outcome rates were 83.3% (95% CI = 73.54-94.50%) and 59.5% (95% CI = 44.24-80.06%), respectively. The overall sICH prevalence was 0.59% (95% CI = 0-3.30%) and mortality rate was 3.2% (95% CI = 0.55-7.38%). In our meta-analysis, MT demonstrated apromising safety and efficacy profile for pediatric patients, with consistently high efficacy outcomes and low complication rates. Our results support the utilization of MT in pediatric LVOs; however, prospective studies are still needed to further establish the role of pediatric MT as afirst-line treatment strategy.

Complete Recanalization in Mechanical Thrombectomy Is Associated with Favorable Functional Outcome for M2 Occlusions.

There are insufficient coherent reports on mechanical thrombectomy (MT) for occlusion of the second segment of the middle cerebral artery (M2 occlusion) in a real-world clinical setting. We evaluated the efficacy and safety of MT for M2 occlusions and compared the primary thrombectomy strategies (stent retriever, aspiration catheter, and combined technique) to analyze factors predicting good functional outcomes. We evaluated background factors, preprocedural factors, procedural factors, and procedural time for patients who underwent MT for M2 occlusions from our retrospective cohort. According to the modified Rankin Scale (mRS) score three months after MT, patients were divided into good (mRS ≤2) and poor (mRS ≥3) prognosis groups. A total of 29 patients (median age, 78 years; 11 [37.9%] females) were included in the study. In this cohort, rates of successful reperfusion, thrombolysis in cerebral infarction (TICI) 3, postprocedural hemorrhage (PPH), and symptomatic PPH were 82.8, 34.5, 31.0, and 0%, respectively. Good prognoses were achieved in 13 (45%) cases. A prognostic factor of MT for M2 occlusions is TICI 3 from multivariate analysis (OR, 11.7; 95% CI, 1.003-136; p = 0.0497). There was no statistically significant difference in the functional outcome three months after MT based on the choice of the primary thrombectomy strategy. MT for M2 occlusions is a reliable and relatively safe procedure. The presence of TICI 3 was a prognostic factor in this cohort. Future studies are warranted to investigate the optimal thrombectomy strategy for medium vessel occlusion.

Relevance of admission hyperglycaemia and diabetes mellitus to efficacy and safety of mechanical thrombectomy in stroke patients.

The relevance of diabetes mellitus (DM) to the efficacy of mechanical thrombectomy (MT) has been the subject of few studies and with only inconclusive results. This study aimed to evaluate the effect of DM and admission hyperglycaemia on the efficacy and safety of MT in stroke patients. This retrospective study analysis focused on the relevance of admission hyperglyacemia and DM to the functional status of patients treated with MT at the Upper Silesian Medical Centre of the Silesian Medical University in Katowice, Poland. 417 stroke patients (median age 70 years) were qualified for the study. There were 103 patients (24.70%) with DM. Admission hyperglycaemia ≥ 140 mg% was found in 91 patients (21.82%), of whom 69 were diagnosed with DM before or during hospitalisation. The parameters with the strongest effect on the functional status on days 7, 90 and 365 were: age, and neurological status according to the National Institutes of Health Stroke Scale (NIHSS) on the first day of ischaemic stroke before MT. The angiographic effect indirect after MT and patient functional status on days 7, 90 and 365 were comparable between the groups, regardless of the DM burden. The frequency of symptomatic intracranial bleeding 24 hours after MT was comparable between patients with and patients without DM (p = 0.092). Model based on parameters were age, NIHSS on the first day of ischaemic stroke, an when score in Thrombolysis In Cerebral Infarct (TICI) showed good predictive attributes for the functional status of patients in the acute period (day 7). Age, a lack of admission hyperglycaemia, and the neurological state on day 1 of ischaemic stroke (before MT) were the key parameters for a favourable outcome (≤ 2 points on the modified Rankin Scale, mRS) on day 90. Admission hyperglycaemia ≥ 140 mg/dL, regardless of the presence or absence of DM, had a negative effect on achieving a good functional status one week after stroke onset. Diabetes mellitus has a neutral effect on the angiographic and clinical outcomes of mechanical thrombectomy in stroke patients. It does not increase the risk of intracranial haemorrhage after instrumental therapy. It is admission hyperglycaemia, rather than diabetes mellitus, that is a predictor of poor functional status in patients treated with thrombectomy. According to our results, the patient's neurological status, age, and the outcome of thrombectomy are relevant to the functional status in the acute ischaemic stroke period.