Thrombectomy For Ischemic Stroke Research Articles

Decoding Molecular Mechanisms Underlying Outcomes After Ischemic Stroke Thrombectomy by RNA Sequencing of Retrieved Clots.

Transcriptomic profiling has emerged as a powerful tool for exploring the molecular landscape of ischemic stroke clots and providing insights into the pathophysiological mechanisms underlying stroke progression and recovery. In this study, we aimed to investigate the relationship between stroke clot transcriptomes and stroke thrombectomy outcome, as measured by early neurological improvement (ENI) 30 (i.e., a 30% reduction in NIHSS at 24 h post-thrombectomy). We hypothesized that there exist distinct clot gene expression patterns between good and poor neurological outcomes. Transcriptomic analysis of 32 stroke clots retrieved by mechanical thrombectomy was conducted. Transcriptome data of these clots were analyzed to identify differentially expressed genes (DEGs), defined as those with a log(fold-change) ≥ 1.5 and q < 0.05 between samples with good and poor early neurological outcomes. Gene ontology and bioinformatics analyses were performed on genes with p < 0.01 to identify enriched biological processes and Ingenuity Pathway Analysis canonical pathways. Moreover, AUC analysis assessed the predictive power of DEGs for 90-day function outcome (mRS ≤ 2) and cellular composition of clot was predicted using CIBERSORT. We also assessed whether differential enrichment of immune cell types could indicate patient survival. A total of 41 DEGs were identified. Bioinformatics showed that enriched biological processes and pathways emphasized the chronic immune response and matrix metalloproteinase inhibition. Moreover, 25 of the DEGs were found to be significant predictors of 90-day mRS. These genes were indicative of monocytes enrichment and neutrophil depletion in patients with poorer outcomes. Our study revealed a distinct gene expression pattern and dysregulated biological pathways associated with ENI. This expression pattern was also predictive of long-term outcome, suggesting a biological link between those ENIs and 90-day mRS.

Outcomes of endovascular thrombectomy for ischaemic stroke among nonagenarians with and without pre-existing dependency

BackgroundOur aim was to compare the outcomes of treatment with endovascular thrombectomy for pre-stroke dependent versus pre-stroke independent among the very elderly ≥90 years. MethodsA retrospective cohort study was performed on 106 patients ≥90 years who underwent endovascular thrombectomy for ischaemic stroke in Western Australia between June 2016 and September 2021. Patient, stroke and procedural details along with inpatient progress and outcome at 90 days were recorded. Patients were divided into Group A (pre-stroke modified Rankin Scale 0-2) and Group B (pre-stroke modified Rankin Scale >2). Primary outcome measure was functional status at 90 days post-stroke, with favourable clinical outcome defined as a 90-day mRS category equal to the patients’ respective pre-stroke mRS category. Secondary outcome measures include successful reperfusion, symptomatic intracranial haemorrhage, hospital length-of-stay, change in accommodation to an aged care facility, and mortality during admission, at 90 days and one year. Results61 patients were allocated to Group A and 45 to Group B. There was none with pre-stroke mRS 5. Group B had more pre-existing cognitive impairment, aged care facility residents, higher median age and lower Alberta Stroke Program Early CT Score. For primary outcome measure, 38 % of patients in Group A and 49 % in Group B achieved a favourable clinical outcome. The difference was not significant (p=0.3408). For secondary outcome measures, Group B had a significantly higher 90-day mortality rate at 47 % versus 24 % in Group A (p=0.03). All other secondary outcome measures were similar between the two groups. These include the rate of successful reperfusion and symptomatic intracranial haemorrhage, hospital length-of-stay, new transition into an aged care facility, inpatient mortality rate and 1-year mortality rate. ConclusionWhen treated with endovascular thrombectomy for ischaemic stroke, nonagenarians with pre-existing dependency achieved a rate of favourable functional outcome comparable with their independent peers, although they also had higher 90-day mortality rate.

Early technique switch following failed passes during mechanical thrombectomy for ischemic stroke: should the approach change and when?

BackgroundFast and complete reperfusion in endovascular therapy (EVT) for ischemic stroke leads to superior clinical outcomes. The effect of changing the technical approach following initially unsuccessful passes remains undetermined.ObjectiveTo evaluate...

Abstract 203: Predicting Outcomes After Mechanical Thrombectomy: Early vs Delayed Neurological Improvement in the SELECT Database

Introduction Understanding of patient benefit and improvement following mechanical thrombectomy in ischemic stroke has made tremendous strides in recent years, however clinicians still struggle to accurately predict patient outcomes and long‐term neurological functioning following large vessel occlusion and endovascular therapy. These limitations are further complicated by a highly variable time course of improvement following intervention that spans from minutes to months. Prior literature has shown that successful reperfusion is associated with better outcomes even in the absence of early improvement. Delayed neurological improvement may be the result of microvasculature effects and inflammatory changes, and is likely multifactorial. Improved understanding of predictors of early versus delayed neurological improvement in this population may help inform goals of care, aid in clinical decision making, and manage patient and family expectations. Methods Patient data from the SELECT database was retrospectively analyzed. The SELECT study was a prospective, non‐randomized, multicenter cohort study that enrolled patients with acute ischemic stroke due to anterior circulation large vessel occlusion at nine US centers between 1/2016 and 2/2018, with patients falling into either the mechanical thrombectomy or medical management arm. Only patients in the mechanical thrombectomy arm (n=149) were included in this analysis. Possible predictors of early vs late neurological improvement were segregated into pre‐procedure (age, NIHSS at baseline, IV thrombolytic therapy, transfer status, occlusion location, ischemic core, ischemic penumbra, hypoperfusion intensity ratio, successful reperfusion, type of anesthesia, time from last known well to puncture, time from puncture to reperfusion) and post‐procedure (NIHSS at 24‐hour follow‐up, ASPECTS on follow‐up imaging, ASPECTS point loss from baseline, infarct volume on follow‐up imaging, infarct growth from baseline ischemic core, neurological worsening, midline shift, hemorrhagic transformation and type). Backwards stepwise regression was used to identify significant predictors of early and delayed improvement. Results Pre‐procedure predictors of early neurological improvement (defined as mRS 0‐2 at discharge) were age (p=0.001), NIHSS score (p=0.002), ischemic core volume (p=0.001), transfer status (p=0.019), and successful reperfusion (defined as mTICI 2b or better, p=0.001). Post‐procedure predictor of early neurological improvement was NIHSS score at 24 hours (p&lt;0.001). Pre‐procedure predictor of delayed neurological improvement (defined as mRS 0‐2 at 90 days among those who did not achieve early neurological improvement) was ischemic core volume (p=0.003). Post‐procedure predictors of delayed neurological improvement were final infarct volume (p=0.012), change in ASPECTS on follow‐up imaging (p=0.001), and growth in infarct size (p=0.030). Pre‐procedure predictors of early excellent outcome (defined as mRS 0‐1 at discharge) were age (p=0.001), NIHSS score (p&lt;0.001), successful reperfusion (p=0.001), ischemic core volume (p=0.004), and infarct growth rate (p=0.034). Pre‐procedure predictor of delayed excellent outcome (defined as mRS 0‐1 at 90 days among those who did not achieve early excellent outcome) was NIHSS score (p=0.002). Additionally, midline shift of 5mm or more at 24 hours was associated with poor outcome at 90 days. Conclusion Several demographic, imaging, and clinical factors were found to correlate with either early or delayed neurological improvement. Further investigation may help delineate how these predictors can be utilized to inform clinical decisions and discussions regarding stroke patients receiving mechanical thrombectomy.

Abstract 274: Mechanical Thrombectomy for Ischemic Stroke in Elderly Population

Introduction Stroke is a leading cause of mortality and morbidity worldwide and the risk increases with age. Mechanical thrombectomy (MT) in eligible patients is proven to improve outcomes and is ow standard of care for acute ischemic stroke. Clinical trials evaluating MT often exclude patients older than 80 and available scientific evidence supporting MT in elderly is limited and varied. Purpose of this systematic review is to examine current literature on efficacy and outcomes of MT in octogenarian and nonagenarian stroke patients. Methods A literature search was conducted using PubMed and Scopus from 2013‐2023. All studies that included patients 80 yrs and older with acute ischemic stroke who underwent MT and provided 90‐day clinical outcomes and rates of complications were reviewed. Results Review identified 25 publications and the median age of study populations ranged from 82 to 93.3 years with proportion of female patients higher in all studies. Success rate of MT ranged from 66.7% to 97%. Symptomatic intracranial hemorrhage was the common complication ranging from 3% to 28%. The 90‐day mortality rate ranged from 7% to 70%. No differences were noted between octogenarians and nonagenarians. Conclusion MT in elderly patients had high reperfusion rates indicating procedural success, and variable clinical outcomes with wide range of complication and mortality rates. Factors influencing MT outcomes in elderly are discussed and the need for randomized control trials providing the highest level of scientific evidence for MT in this population is emphasized.

Neighbourhood deprivation, distance to nearest comprehensive stroke centre and access to endovascular thrombectomy for ischemic stroke: a population-based study.

Endovascular thrombectomy (EVT) has revolutionized ischemic stroke care. We aimed to assess whether neighbourhood socioeconomic status is predictive of access to EVT after receipt of alteplase for ischemic stroke among patients living in Alberta, Canada, and whether this relation is mediated by the distance a person lives to the nearest comprehensive stroke centre (CSC). We performed a retrospective study including all people older than 18 years living in Alberta who were admitted to hospital with an ischemic stroke and who received intravenous alteplase treatment between Jan. 1, 2017, and Dec. 31, 2019. Data were obtained through administrative data sets. The primary outcome was treatment with EVT. We assigned neighbourhood deprivation quintile based on the Material and Social Deprivation Index. We used logistic regression modelling to assess for a relation between deprivation and treatment with EVT. We adjusted for age, sex, stroke severity and distance to the nearest CSC. We calculated the average causal mediation effect of distance to the nearest CSC on the relation between neighbourhood deprivation level and treatment with EVT. The study cohort consisted of 1335 patients, of whom 181 (13.6%) had missing data and were excluded from the main regression analysis. Endovascular thrombectomy was performed or attempted in 314 patients (23.5%). In the primary model, patients from the most deprived neighbourhoods were less likely than those from less deprived neighbourhoods to have received EVT (adjusted odds ratio 0.43, 95% confidence interval 0.24 to 0.77). Neighbourhood deprivation level was not significantly associated with EVT when distance to the nearest CSC was included as a covariate. Mediation analysis suggested that 48% of the total effect that neighbourhood deprivation level had on the odds of receiving EVT was attributable to the distance a person lived from the nearest CSC. The results suggest that people from more deprived neighbourhoods in Alberta were less likely to be treated with EVT than those from less deprived neighbourhoods. Improving access to EVT for people living in remote locations may improve the equitable distribution of this treatment.

Evaluation of effectiveness and safety of the multizone NeVaTM stent retriever for mechanical thrombectomy in ischemic stroke

PurposeThis study aimed to evaluate the effectiveness and safety of the NeVaTM stent retriever as first- and second-line device for mechanical thrombectomy in acute ischemic stroke.MethodsIn this retrospective single-center study, all consecutive patients that underwent mechanical thrombectomy with NeVaTM stent retriever as first- or second-line device due to intracranial vessel occlusion with acute ischemic stroke between March and November 2022 were included.ResultsThirty-nine patients (m=18, f=21) with a mean age of 69.9 ± 13.3 years were treated with the NeVaTM stent retriever. NeVaTM stent retriever was used as first-line device in 24 (61.5%) of patients and in 15 (38.5%) as second-line device. First-pass rate (≥mTICI 2c) of NeVaTM stent retriever was both 66.7% when used as first- or second-line device. Final recanalization rate including rescue strategies was 92.3% for ≥mTICI2c and 94.9% for ≥mTICI2b. No device-related minor or major adverse events were observed. A hemorrhage was detected in 33.3% of patients at 24h post-thrombectomy dual-energy CT, of which none was classified as symptomatic intracerebral hemorrhage. NIHSS and mRS improved significantly at discharge compared to admission (p<0.05).ConclusionThe NeVaTM stent retriever has a high effectivity and good safety profile as first- and second-line device for mechanical thrombectomy in acute ischemic stroke.

Conscious sedation by sedation-trained interventionalists versus anesthesia providers in patients with acute ischemic stroke undergoing endovascular thrombectomy: A propensity score-matched analysis.

The appropriate choice of perioperative sedation during endovascular thrombectomy for ischemic stroke is unknown. Few studies have evaluated the role of nursing-administered conscious sedation supervised by a trained interventionalist. To compare the safety and efficacy of endovascular thrombectomy for ischemic stroke performed with nursing-administered conscious sedation supervised by a trained interventionalist with monitored anesthesia care supervised by an anesthesiologist. A retrospective review of a prospectively collected stroke registry was performed. The primary outcome was functional independence at 90 days, defined as a modified Rankin score of 0-2. Propensity score matching was performed to control for known confounders including patient comorbidities, access type, and direct-to-suite transfers. A total of 355 patients underwent endovascular thrombectomy for large vessel occlusion between 2018 and 2022. Thirty five patients were excluded as they arrived at the endovascular suite intubated. Three hundred and twenty patients were included in our study, 155 who underwent endovascular thrombectomy with nursing-administered conscious sedation and 165 who underwent endovascular thrombectomy with monitored anesthesia care. After propensity score matching, there were 111 patients in each group. There was no difference in modified Rankin score 0-2 at 90 days (26.1% vs 35.1%, p = 0.190). Patients undergoing monitored anesthesia care received significantly more vasoactive medications (23.4% vs 49.5%, p < 0.001) and had a lower intraoperative minimum systolic blood pressure (134 vs 123 mmHg, p < 0.046). There was no difference in procedural efficacy, safety, intubation rates, and postoperative complications. Perioperative sedation with nursing-administered conscious sedation may be safe and effective in patients undergoing endovascular thrombectomy for ischemic stroke.

Edema Reduction versus Penumbra Salvage- Investigating Treatment Effects of Mechanical Thrombectomy in Ischemic Stroke.

Mechanical thrombectomy (MT) is of benefit to patients with ischemic stroke; however, the effect of recanalization on lesion pathophysiology is not yet well understood. The aim of this study was to quantitatively assess how the effect of vessel recanalization on clinical outcome is mediated by edema reduction versus penumbra salvage. Consecutive analysis of anterior circulation ischemic stroke patients triaged by multimodal-CT undergoing MT. Edema reduction was defined using the difference of quantitative net water uptake (NWU) determined on baseline and follow-up CT (∆NWU). Penumbra salvage volume (PSV) was defined as the difference between admission penumbra and net infarct growth volumes to follow-up. Mediation analyses were performed with vessel recanalization as independent variable (mTICI≥2b), and ∆NWU/PSV as mediator variables. Modified Rankin Scale (mRS) scores at 90 days served as endpoint. 321/422 included patients (76%) achieved successful recanalization. The median ∆NWU was 6.8% (IQR:3.9-10.4) and the median PSV was 66ml (IQR:8-124). ∆NWU, PSV, and recanalization were significantly associated with functional outcome in logistic regression analysis. ∆NWU and PSV partially mediated the relationship between recanalization with outcome. 66% of the relationship between recanalization and functional outcome could be explained by treatment-induced edema reduction while 22% was mediated by PSV (p<0.0001). Compared to penumbra salvage, edema reduction was a stronger mediator of the effect of recanalization on functional outcome. Given the current trials on adjuvant neuroprotectants also targeting ischemic edema formation, combining reperfusion with antiedematous neuroprotectants may have synergistic effects resulting in better outcomes in patients with ischemic stroke. This article is protected by copyright. All rights reserved.

Peri-procedural decrease in hemoglobin following mechanical thrombectomy for ischemic stroke.

Peri-procedural blood loss and hemodilution occur in patients undergoing mechanical thrombectomy (MT) for ischemic stroke; however, its relationships with thrombectomy passes, procedure times, and clinical outcomes are unknown. Consecutive patients undergoing MT for anterior circulation large-vessel occlusion ischemic strokes were identified at a Comprehensive Stroke Center. Clinical information, modified treatment in cerebral ischemia (mTICI) scores, and modified Rankin Scores (mRS) at 90 days were prospectively collected from 2012 to 2021. Hemoglobin measurements before and after MTs were collected retrospectively via chart review, and changes were quantified. Patients with new-onset severe anemia (defined as post-MT hemoglobin less than 10g/dL) were identified. Modified Rankin scale (mRS) at 90 days was used to measure clinical outcomes. Four-hundred and forty-five patients were identified. Hemoglobin decreased 1.27 ± 1.05 g/dL after MT on average. Greater number of thrombectomy passes and longer procedure times were associated with larger decreases in hemoglobin (p < 0.001 and p = 0.002, respectively). 11.5% (51 of 445) of patients had new-onset severe anemia, and this incidence was significantly higher with more thrombectomy passes (6.4% for one pass, 11.9% for two passes, and 17.4% for three or more passes; p = 0.010). In multivariable analyses, new-onset severe anemia was associated with significantly higher odds of 90-day poor outcomes (mRS 3-6, OR 2.70 [95%CI 1.12-6.51], p = 0.027) and death (OR 2.73 [95%CI 1.06-7.04], p = 0.037) compared to mild post-MT anemia. More thrombectomy passes and longer procedure times were significantly associated with larger peri-procedural decreases in hemoglobin. Patients with new-onset hemoglobin less than 10 g/dL are at risk of poor outcomes.

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

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

Higher Serum E-Selectin Levels Associated with Malignant Brain Edema after Endovascular Thrombectomy for Ischemic Stroke: A Pilot Study.

Background and Purpose: Little is known about the effect of soluble adhesion molecules on malignant brain edema (MBE) after endovascular thrombectomy (EVT). This study aimed to explore the association between serum concentrations of E-selectin and the risk of MBE in patients who received EVT. Methods: Patients with a large vessel occlusion stroke in the anterior circulation who underwent EVT were prospectively recruited. Serum soluble E-selectin concentrations were measured after admission for all patients. MBE was defined as a midline shift of ≥5 mm on follow-up imaging within 72 h after surgery. Multivariate logistic regression analyses were performed to determine the association between E-selectin levels and the risk of MBE. Results: Among the 261 included patients (mean age, 69.7 ± 12.3 years; 166 males), 59 (22.6%) developed MBE. Increasing circulating E-selectin levels were associated with an increased risk of MBE after multivariable adjustment (odds ratios [OR], highest vs. lowest quartile: 3.593; 95% confidence interval [CI], 1.178-10.956; p = 0.025). We further observed a significantly positive association between E-selectin and MBE (per 1-standard deviation increase; OR, 1.988; 95% CI, 1.379-2.866, p = 0.001) when the E-selectin levels were analyzed as a continuous variable. Furthermore, the restricted cubic spline demonstrated a linear correlation between serum E-selectin levels and the risk of MBE (p < 0.001 for linearity). Conclusions: In this prospective study, circulating levels of E-selectin were associated with an increased risk of MBE after EVT. Further mechanistic studies are warranted to elucidate the pathophysiology underlying this association.

Predictors for hemorrhagic transformation and cerebral edema in stroke patients with first-pass complete recanalization.

Predictors of radiological complications attributable to reperfusion injury remain unknown when baseline setting is optimal for endovascular treatment and procedural setting is the best in stroke patients with large vessel occlusion (LVO). To identify clinical and radiological/procedural predictors for hemorrhagic transformation (HT) and cerebral edema (CED) at 24 hr in patients obtaining complete recanalization in one pass of thrombectomy for ischemic stroke ⩽ 6 h from symptom onset with intra-cranial anterior circulation LVO and ASPECTS ⩾ 6. We conducted a cohort study on prospectively collected data from 1400 patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. HT was reported in 248 (18%) patients and early CED was reported in 260 (19.2%) patients. In the logistic regression model including predictors from a first model with clinical variables and from a second model with radiological/procedural variables, diabetes mellitus (odds ratio (OR) = 1.832, 95% confidence interval (CI) = 1.201-2.795), higher National Institutes of Health Stroke Scale (NIHSS) (OR = 1.076, 95% CI = 1.044-1.110), lower Alberta Stroke Program Early CT (ASPECTS) (OR = 0.815, 95% CI = 0.694-0.957), and longer onset-to-groin time (OR = 1.005, 95% CI = 1.002-1.007) were predictors of HT, whereas general anesthesia was inversely associated with HT (OR = 0.540, 95% CI = 0.355-0.820). Higher NIHSS (OR = 1.049, 95% CI = 1.021-1.077), lower ASPECTS (OR = 0.700, 95% CI = 0.613-0.801), intravenous thrombolysis (OR = 1.464, 95% CI = 1.061-2.020), longer onset-to-groin time (OR = 1.002, 95% CI = 1.001-1.005), and longer procedure time (OR = 1.009, 95% CI = 1.004-1.015) were predictors of early CED. After repeating a fourth logistic regression model including also good collaterals, the same variables remained predictors for HT and/or early CED, except diabetes mellitus and thrombolysis, while good collaterals were inversely associated with early CED (OR = 0.385, 95% CI = 0.248-0.599). Higher NIHSS, lower ASPECTS, and longer onset-to-groin time were predictors for both HT and early CED. General anesthesia and good collaterals were inversely associated with HT and early CED, respectively. Longer procedure time was predictor of early CED.

Mechanical Thrombectomy for Acute Ischemic Stroke in A Mekong Delta Medical University Hospital

Introduction: Mechanical thrombectomy has become more and more common in the treatment of acute cerebral ischemic stroke. We report our 3-year outcomes of mechanical thrombectomy for ischemic stroke.&#x0D; Method and subjects: A descriptive study was conducted cross-sectionally. Each patient with a National Institute of Health Stroke Scale (NIHSS) score of 10 or higher who presented to our hospital within eight hours of the onset of the first symptom would be considered. The mechanical thrombectomy procedure is performed with aspiration techniques or in combination with stent retrievers, with or without rescue angioplasty and stenting.&#x0D; Results: From January 1st, 2018, to December 31st, 2020 (36 months), a total of 53 patients were included. Forty-four (44) patients had thrombectomy only, and another 9 patients had thrombectomy with stenting. The total technical success rates were 47/53 (88.6%). The death rate was 15/53 (28.3%). There were 31/53 patients (58.4%) who had significant recovery in motor movement, language, and cognition within 2 months.&#x0D; Conclusion: Our revascularization rate of mechanical thrombectomy was 88.6% with 58.4% of patients showing improved outcomes.

Endovascular thrombectomy for ischemic stroke with large core volume: An updated, post-TESLA systematic review and meta-analysis of the randomized trials.

Limited randomized controlled trials (RCTs) have been performed comparing endovascular thrombectomy (EVT) to medical therapy (MEDT) for acute ischemic stroke with extensive baseline ischemic injury (AIS-EBI). We conducted a systematic review and meta-analysis of RCTs reporting EVT for AIS-EBI. Using the Nested Knowledge AutoLit software, we conducted a systematic literature review from inception to 12 February 2023 within Web of Science, Embase, Scopus, and PubMed databases. Results of the TESLA trial were included on 10 June 2023. We included RCTs that compared EVT to MEDT for AIS with large ischemic core volume. The primary outcome of interest was a modified Rankin Score (mRS) 0-2. Secondary outcomes of interest included early neurological improvement (ENI), mRS 0-3, thrombolysis in cerebral infarction (TICI) 2b-3, symptomatic intracranial hemorrhage (sICH), and mortality. A random-effects model was used to calculate risk ratios (RRs) and their corresponding 95% confidence intervals (CIs). We included four RCTs with 1310 patients, 661 of whom underwent EVT and 649 of whom were treated with MEDT. EVT was associated with greater rates of mRS 0-2 (RR = 2.33, 95% CI = 1.75-3.09; P-value < 0.001), mRS 0-3 (RR = 1.68, 95% CI = 1.33-2.12; P-value < 0.001), and ENI (RR = 2.24, 95% CI = 1.55-3.24; P-value < 0.001). Rates of sICH (RR = 1.99, 95% CI = 1.07-3.69; P-value = 0.03) were greater in the EVT group. Mortality (RR = 0.98, 95% CI = 0.83-1.15; P-value = 0.79) was comparable between the EVT and MEDT groups. The rate of successful reperfusion in the EVT group was 79.9% (95% CI = 75.6-83.6). Although the rate of sICH was greater in the EVT group, EVT conferred a greater clinical benefit to MEDT for AIS-EBI based on available RCTs.

Prediction of Occurrence of Cerebral Infarction After Successful Mechanical Thrombectomy for Ischemic Stroke in the Anterior Circulation by Arterial Spin Labeling

PurposeThe overall goal of our study is to create modified Alberta Stroke Program Early Computed Tomography Score (ASPECTS) determined by the findings on arterial spin labeling imaging (ASL) to predict the prognosis of patients with acute ischemic stroke after successful mechanical thrombectomy (MT). Prior to that, we examined predictive factors including the value of cerebral blood flow (CBF) measured by ASL for occurrence of cerebral infarction at the region of interest (ROI) used in the ASPECTS after successful MT.MethodsOf the 92 consecutive patients with acute ischemic stroke treated with MT at our institution between April 2013 and April 2021, a total of 26 patients who arrived within 8 h after stroke onset and underwent MT resulting in a thrombolysis in cerebral infarction score of 2B or 3 were analyzed. Magnetic resonance imaging, including diffusion-weighted imaging (DWI) and ASL, was performed on arrival and the day after MT. The asymmetry index (AI) of CBF by ASL (ASL-CBF) before MT was calculated for 11 regions of interest using the DWI-Alberta Stroke Program Early CT Score.ResultsOccurrence of infarction after successful MT for ischemic stroke in the anterior circulation can be expected when the formula 0.3211 × history of atrial fibrillation +0.0096 × the AI of ASL-CBF before MT (%) +0.0012 × the time from onset to reperfusion (min) yields a value below 1.0 or when the AI of ASL-CBF before MT is below 61.5%.ConclusionThe AI of ASL-CBF before MT or a combination of a history of atrial fibrillation, the AI of ASL-CBF before MT, and the time from onset to reperfusion can be used to predict the occurrence of infarction in patients arriving within 8 h after stroke onset in which reperfusion with MT was successful.

Safety and Efficacy of Baseline Antiplatelet Treatment in Patients Undergoing Mechanical Thrombectomy for Ischemic Stroke: Antiplatelets Before Mechanical Thrombectomy

PurposeTo investigate the safety and efficacy of baseline antiplatelet treatment in patients with acute ischemic stroke (AIS) undergoing mechanical thrombectomy (MT). Materials and MethodsBaseline use of antiplatelet medication before MT for (AIS) may provide benefit on reperfusion and clinical outcome but could also carry an increased risk of intracranial hemorrhage (ICH). All consecutive patients with AIS and treated with MT with and without intravenous thrombolysis (IVT) between January 2012 and December 2019 in all centers performing MT nationwide were reviewed. Data were prospectively collected in national registries (eg, SITS-TBY and RES-Q). Primary outcome was functional independence (modified Rankin Scale 0–2) at 3 months; secondary outcome was ICH. ResultsOf the 4,351 patients who underwent MT, 1,750 (40%) and 666 (15%) were excluded owing to missing data from the functional independence and ICH outcome cohorts, respectively. In the functional independence cohort (n = 2,601), 771 (30%) patients received antiplatelets before MT. Favorable outcome did not differ in any antiplatelet, aspirin, and clopidogrel groups when compared with that in the no-antiplatelet group: odds ratio (OR), 1.00 (95% CI, 0.84–1.20); OR, 1.05 (95% CI, 0.86–1.27); and OR, 0.88 (95% CI, 0.55–1.41), respectively. In the ICH cohort (n = 3,685), 1095 (30%) patients received antiplatelets before MT. The rates of ICH did not increase in any treatment options (any antiplatelet, aspirin, clopidogrel, and dual antiplatelet groups) when compared with those in the no-antiplatelet group: OR, 1.03 (95% CI, 0.87–1.21); OR, 0.99 (95% CI, 0.83–1.18); OR, 1.10 (95% CI, 0.82–1.47); and OR, 1.43 (95% CI, 0.87–2.33), respectively. ConclusionsAntiplatelet monotherapy before MT did not improve functional independence or increase the risk of ICH.

Mortality following mechanical thrombectomy for ischemic stroke in patients with COVID-19

ObjectivesMultiple prior studies have shown a relationship between COVID-19 and strokes; further, COVID-19 has been shown to influence both time-to-thrombectomy and overall thrombectomy rates. Using large-scale, recently released national data, we assessed the association between COVID-19 diagnosis and patient outcomes following mechanical thrombectomy. Materials and methodsPatients in this study were identified from the 2020 National Inpatient Sample. All patients with arterial strokes undergoing mechanical thrombectomy were identified using ICD-10 coding criteria. Patients were further stratified by COVID diagnosis (positive vs. negative). Other covariates, including patient/hospital demographics, disease severity, and comorbidities were collected. Multivariable analysis was used to determine the independent effect of COVID-19 on in-hospital mortality and unfavorable discharge. Results5078 patients were identified in this study; 166 (3.3%) were COVID-19 positive. COVID-19 patients had a significantly higher mortality rate (30.1% vs. 12.4%, p < 0.001). When controlling for patient/hospital characteristics, APR-DRG disease severity, and Elixhauser Comorbidity Index, COVID-19 was an independent predictor of increased mortality (OR 1.13, p = 0.002). COVID-19 was not significantly related to discharge disposition (p = 0.480). Older age and increased APR-DRG disease severity were also correlated with increase morality. ConclusionsOverall, this study indicates that COVID-19 is a predictor of mortality among mechanical thrombectomy. This finding is likely multifactorial but may be related to multisystem inflammation, hypercoagulability, and re-occlusion seen in COVID-19 patients. Further research would be needed to clarify these relationships.

Outcomes After Endovascular Therapy With Procedural Sedation vs General Anesthesia in Patients With Acute Ischemic Stroke

General anesthesia and procedural sedation are common practice for mechanical thrombectomy in acute ischemic stroke. However, risks and benefits of each strategy are unclear. To determine whether general anesthesia or procedural sedation for anterior circulation large-vessel occlusion acute ischemic stroke thrombectomy are associated with a difference in periprocedural complications and 3-month functional outcome. This open-label, blinded end point randomized clinical trial was conducted between August 2017 and February 2020, with final follow-up in May 2020, at 10 centers in France. Adults with occlusion of the intracranial internal carotid artery and/or the proximal middle cerebral artery treated with thrombectomy were enrolled. Patients were assigned to receive general anesthesia with tracheal intubation (n = 135) or procedural sedation (n = 138). The prespecified primary composite outcome was functional independence (a score of 0 to 2 on the modified Rankin Scale, which ranges from 0 [no neurologic disability] to 6 [death]) at 90 days and absence of major periprocedural complications (procedure-related serious adverse events, pneumonia, myocardial infarction, cardiogenic acute pulmonary edema, or malignant stroke) at 7 days. Among 273 patients evaluable for the primary outcome in the modified intention-to-treat population, 142 (52.0%) were women, and the mean (SD) age was 71.6 (13.8) years. The primary outcome occurred in 38 of 135 patients (28.2%) assigned to general anesthesia and in 50 of 138 patients (36.2%) assigned to procedural sedation (absolute difference, 8.1 percentage points; 95% CI, -2.3 to 19.1; P = .15). At 90 days, the rate of patients achieving functional independence was 33.3% (45 of 135) with general anesthesia and 39.1% (54 of 138) with procedural sedation (relative risk, 1.18; 95% CI, 0.86-1.61; P = .32). The rate of patients without major periprocedural complications at 7 days was 65.9% (89 of 135) with general anesthesia and 67.4% (93 of 138) with procedural sedation (relative risk, 1.02; 95% CI, 0.86-1.21; P = .80). In patients treated with mechanical thrombectomy for anterior circulation acute ischemic stroke, general anesthesia and procedural sedation were associated with similar rates of functional independence and major periprocedural complications. ClinicalTrials.gov Identifier: NCT03229148.

Safety and Efficacy of MCA‐M2 Thrombectomy in Delayed Time Window: A Propensity Score Analysis From the STAR Registry

Background Mechanical thrombectomy of middle cerebral artery M2 segment occlusion of the middle cerebral artery has reported safety and efficacy in recent post‐hoc and observational studies. However, there is no known benefit of mechanical thrombectomy for patients with M2 segment occlusions in the delayed time window (&gt;6 hours). Methods The Stroke Thrombectomy and Aneurysm Registry (STAR) is a prospective, multicenter, nonrandomized observational study registry for acute ischemic stroke thrombectomy and aneurysm treatment. We analyzed all patients who underwent mechanical thrombectomy within the late time window (&gt;6 hours from symptom onset) involving isolated M2 occlusions. We used propensity score matching to select a comparison group of patients who underwent mechanical thrombectomy for M1 occlusion in the same time window. Results Of 1083 consecutive patients analyzed, propensity matching yielded 180 well matched M1 and M2 pairs. Baseline demographics were well balanced between the groups (M1 and M2). Alberta stroke program early CT score (7.6±1.7 versus 8.3±1.5; P &lt;0.001) was higher in the M2 group. There was a trend towards less complete recanalization (Thrombolysis in Cerebral Infarction 3) 46.1% versus 39.9% ( P =0.053) in the middle cerebral artery M2 segment cohort. However, successful recanalization (Thrombolysis in Cerebral Infarction 2b‐3) was better in middle cerebral artery M2 segment cohort (85% versus 90.5%; P =0.053). Postprocedural asymptomatic hemorrhage rates were similar (29.4% versus 27.8%; P =0.816), but symptomatic hemorrhage rates were higher in the M1 group (7.2% versus 2.2%; P =0.047). Rates of good clinical outcome (modified Rankin scale 0–2) were similar at final follow‐up (43.9% versus 46.7%; P =0.672). The overall mortality was also similar between the cohorts (12.8% versus 13.9%; P =0.877). Conclusion In our analysis of the Stroke Thrombectomy and Aneurysm Registry, M2 occlusions not only achieved similar rates of recanalization and good functional outcome compared with M1 occlusions in a delayed time window (6–24 hours from last normal) but also had less symptomatic intracranial hemorrhage.