Thrombectomy For Acute Ischemic Stroke Research Articles

Variation in Vessel Size and Angiographic Outcomes Following Stent‐Retriever Thrombectomy in Acute Ischemic Stroke: STRATIS Registry

Background Mechanical thrombectomy is established for large‐vessel occlusions in acute ischemic stroke, but the potential role in distal vessel occlusions of medium arteries is less well established. Such medium or distal arterial segments have not been assessed with respect to thrombectomy devices used during endovascular therapy. We conducted an analysis of arterial size, segmental anatomy, and stent‐retriever device performance with respect to vessel size during thrombectomy. Methods The STRATIS registry angiography core laboratory adjudicated the exact location of the occlusion, proximal, and distal device deployment, relationship to arterial bifurcations, and anatomic nomenclature. Arterial diameters were measured at all these sites. Statistical analyses examined the relationship between vessel and stent size, and arterial recanalization using expanded Thrombolysis in Cerebral Infarction reperfusion score. Results Overall, 665 patients with stroke were included following thrombectomy using various Solitaire device sizes, including Solitaire 4×40, Solitaire 6×30, Solitaire 4×20, Solitaire 6×20, and Solitaire 4×15. Arterial diameter at the occlusion site was a median of 2.17 mm (interquartile range [IQR], 1.88–2.60 mm) in the distal M1, 1.67 mm (IQR, 1.47–2.06 mm) in the proximal M2 middle cerebral artery, 1.50 mm (IQR, 1.15–1.61 mm) in the distal M2 middle cerebral artery, 1.24 mm (IQR, 1.11–1.24 mm) in the M3 middle cerebral artery, and 1.88 mm (IQR, 1.49–1.94 mm) in the P1 posterior cerebral artery. Expanded Thrombolysis in Cerebral Infarction 2b to 3 reperfusion was achieved in all M3 or P1 segment occlusions. The rate of first‐pass recanalization was significantly higher in patients with medium (0.75–2 mm) versus large (>2 mm) vessel occlusion (69.5% versus 57.1%; P = 0.003). Conclusion Considerable overlap was noted between arterial sizes at occlusion sites carrying different segmental arterial nomenclature or vessel names. Substantial reperfusion may be achieved with currently available mechanical thrombectomy devices in medium arteries.

Abstract WP210: Intensive vs. Conventional Blood Pressure Management After Thrombectomy for Acute Ischemic Stroke: Systemic Review and Meta-Analysis of Randomized Controlled Trials

Background: Optimal Blood pressure management after thrombectomy for acute ischemic stroke and its association with clinical outcomes remains unclear. We performed this study to compare clinical outcomes between intensive systolic blood pressure (SBP) control (<120-140mmHg) and conventional SBP control (< 180mmHg). Methods: In September 2023, this registered systematic review (CRD42023464176) was performed using multiple databases for the following keywords: stroke, thrombectomy, and Blood Pressure from 2010 to present. Randomized control studies were included if they had the reported the outcome for adults aged >18 who underwent successful thrombectomy (defined as mTICI 2b or higher) for acute ischemic stroke. The primary outcome of interest was the rate of functional independence, defined as a modified Rankin scale of 0-2 at 90 days. The secondary outcomes of interest included rates of mortality, and symptomatic intracranial hemorrhage (sICH). For all outcome events, corresponding odds ratios (OR) and 95% confidence intervals (CI) were calculated using a random-effects meta-analysis model. Results: Four studies comprising 1497 patients were included. Compared to conventional SBP control, intensive SBP control was associated with lower rates of functional independence (OR 0.67, 95% CI 0.51- 0.88 p=0.0). There were comparable rates of sICH (OR 1.12, 95% CI 0.75-1.67; p = 0.56) and mortality (OR 1.21, 95% CI 0.90-1.64; p = 0.19) between intensive and conventional SBP control groups. Conclusions: Our findings suggest that intensive blood pressure control does not improve clinical outcomes. More robust data is needed to draw definite conclusions.

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 > 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 < 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 WP154: Factors Associated With Prolonged Length of Intensive Unit Stay Following Mechanical Thrombectomy for Acute Ischemic Stroke

Objective and Background: The objective of the study was to investigate factors affecting the length of stay (LOS) in the intensive care unit (ICU) following mechanical thrombectomy (MT) for acute ischemic stroke. Methods: We identified patients undergoing MT from a prospective registry at a comprehensive stroke center between January 2021 and June 2023. ICU stay for more than 48 hours was defined as prolonged ICU stay. Results: Out of 363 patients, 41.6% (n=151) required a prolonged ICU stay. Prolonged ICU stay were more likely to have higher baseline median NIHSS score (19 vs. 14%, p < 0.0001), posterior circulation stroke (12.6% vs. 5.7%, p = 0.0200), intubation for the procedure (86.7% vs. 69.3%, p = 0.0001), complications including pneumonia (18.5% vs. 6.1%, p = 0.0002), deep vein thrombosis (7.3 vs. 2.3, p = 0.0242), urinary tract infection (12.6% vs. 6.1%, p = 0.0326), and symptomatic intracerebral hemorrhage (7.3% vs. 1.9%, p = 0.0109). Patients receiving thrombolysis prior to thrombectomy were less likely to have a prolonged LOS (27.8% vs. 41.7%, p = 0.0086). Independent predictors for prolonged ICU LOC included higher NIHSS (odds ratio [OR] 2.7, p = 0.0002), intubation prior to the procedure (OR 2.7, p = 0.0002), not receiving IV thrombolysis (OR 2.3, p = 0.0069), thrombolysis in cerebral infarction (TICI) score ≥ 2B (OR 0.458, p = 0.0754), composite ICU complications (OR 2.4, p = 0.0027), and symptomatic intracranial hemorrhage (OR 5.2, p = 0.0157). Conclusions: Almost one-third of the acute ischemic stroke patients required a prolonged ICU stay following MT. A better understanding of the factors associated with prolonged ICU stay may assist in appropriate allocation of resources.

Abstract WP119: Magnetic Resonance Imaging versus Computed Tomography Before Mechanical Thrombectomy for Acute Ischemic Stroke

Introduction: Magnetic resonance imaging (MRI) and computed tomography (CT) is useful for the evaluation of the ischemic core and penumbra. The indication for mechanical thrombectomy (MT) for acute ischemic stroke is determined by either or both imaging modalities. The selection of initial imaging modality is differed by the institute, and it is uncertain which imaging modality is superior before MT. In this study, we compared the clinical outcomes after MT by imaging modality in the K-NET registry (Kanagawa intravenous and endovascular treatment of acute ischemic stroke registry). Methods: The K-NET registry is a Japanese multicenter prospective registry study of patients treated with Intravenous thrombolysis with recombinant tissue plasminogen activator, endovascular treatment, or both for acute ischemic stroke. The present study is based on patients' data in the K-NET registry between January 2018 and June 2021. The inclusion criteria for the current analysis were as follows: (1) pre-modified Rankin score (mRS) 0-2; (2) patients transferred directly to primary stroke centers; (3) treated with MT; and (4) performed only CT or MRI for diagnosis of acute ischemic stroke before MT. The patients who performed both CT and MRI at admission were excluded. Unbalanced cohorts with a nonrandom distribution of patients were accounted for by using propensity score matching. Results: 2348 patients were enrolled in the registry during the period, and 753 patients were eligible for inclusion criteria. 498 (249 matched pairs) were included after propensity score-matched analysis. The baseline characteristics were well-balanced between the two groups. There was no difference in the final mTICI grade between the two groups. The time from image to puncture in the MRI group was significantly shorter than the CT group (52min versus 38min), and the time from image to recanalization was also significantly shorter in the MRI group (108min versus 88.5min). The rate of functional independence (90 days mRS 0-2) was higher in the MRI group versus the CT group (54.4% versus 43.8%, p=0.017). Conclusions: The selection of MRI before MT was associated with a shorter time from image to puncture and recanalization and a favorable outcome compared with CT.

Abstract TP195: Impact of Intracranial Atherosclerotic Disease on Thrombectomy Outcomes in Acute Cerebral Infarction With Large Vessel Occlusion

Introduction: In acute cerebral infarction with Large Vessel Occlusion (LVO), Intracranial Atherosclerotic Disease (ICAD) often causes vascular occlusion. Previous studies have noted that ICAD-related LVOs, compared to embolic occlusions, have longer procedural times and lower successful reperfusion rates. However, clinical outcomes remain similar. This study compares post-thrombectomy outcomes in both groups, matched by initial NIHSS scores. Method: From October 2017 to March 2023, we studied LVO cases undergoing thrombectomy for acute ischemic stroke. Our primary focus was on evaluating thrombectomy outcomes within two distinct groups— ICAD-related LVO group (ICAD group) and Embolic LVO group (Embolic group)—matched based on preoperative NIHSS scores. ICAD group was defined as persistent occlusion or residual stenosis at the initial occlusion site. Patient outcomes at 3 months were assessed using modified Rankin Scale (mRS) scores, defining devastating outcomes as mRS 5-6. Successful recanalization was defined as Thrombolysis in Cerebral Ischemia score ≥2b. Logistic regression identified factors independently associated with devastating outcomes. Result: Analyzing 2407 cases, we extracted matched pairs (33 each) adjusted by NIHSS. ICAD group had lower atrial fibrillation frequency, lower BNP levels, more M1 occlusions, and fewer M2 occlusions compared to the Embolic group. In treatment outcomes, ICAD group had lower successful recanalization (82% vs 43%, P =0.001), higher reocclusion rates (0% vs 21%, P =0.005), and longer puncture-to-reperfusion time (median 51 vs 88 minutes, P <0.001). Devastating outcomes were higher in ICAD group (15% vs 39%, P =0.027). Multivariate analysis showed ICAD's independent association with devastating outcomes (Odds ratio, 6.54; 95% CI, 1.56-27.4; P =0.010) along with age, NIHSS, and tPA absence. Conclusion: In thrombectomy-treated LVO patients, matching based on admission NIHSS scores revealed significantly higher devastating outcomes in the ICAD group when compared to the Embolic group.

Abstract 158: Rescue Strategy for Failed Mechanical Thrombectomy in Acute Ischemic Stroke: An Analysis of the SVIN Registry

Background: Mechanical thrombectomy (MT) fails to achieve successful reperfusion in up to 20% of large vessel occlusions (LVOs). Rescue strategies (RS) have shown promise in multicenter studies and meta-analyses. We aimed to evaluate the association between RS with functional outcomes compared to medical management (MM) in patients who underwent failed MT. Methods: This is a cross-sectional study using prospectively collected data from the Society of Vascular and Interventional Neurology (SVIN) Registry from 2018 to 2021. We included all adult patients with anterior circulation LVOs who experienced a failed MT (mTICI 0-2a after multiple attempts to clot retrieval) at the 14 participating centers. The patients were divided into two groups: those who received RS (including balloon angioplasty alone, intracranial stenting with or without balloon angioplasty) and those who only received MM. The primary outcome was the shift in the degree of disability, as measured by the mRS at 90 days. Additional outcomes included functional independence (90-day mRS score of 0-2), sICH, and mortality at 90 days. Results: A total of 642 patients were included in the analysis. The RS group consisted of 294 (45.8%) patients, while the MM group comprised 348 (54.2%) patients. A mTICI score of 2b-3 was achieved in 242/293 (82.6%) patients in the RS group. After adjusting for confounders, the RS group showed a favorable shift in the overall 90-day mRS distribution (acOR=1.97, 95%CI 1.36-2.85, p =<0.001) and higher rates of functional independence (RS: 30.7% vs. MM: 12%, aOR=2.39, 95%CI 1.34-4.26, p =0.003) ( Figure ) compared to the MM group. RS also showed lower rates of sICH (RS: 2.7% vs. MM: 9%, aOR=0.32, 95%CI 0.14-0.71, p =0.005) and 90-day mortality (RS: 29.5% vs. MM: 49.7%, aOR=0.49, 95%CI 0.33-0.74, p =<0.001). Conclusion: Our findings support the use of RS as a potential alternative for stroke patients with failed MT. Further prospective studies are needed to validate these observations.

Abstract 152: Endovascular Therapy versus Medical Management for Acute Ischemic Stroke With Large Infarct: A Time-Benefit Relationship Analysis

Objective: Recent randomized trials demonstrated the benefit of endovascular thrombectomy for acute ischemic stroke with large infarct. We aimed to characterize the effect of time to treatment on the benefit of endovascular therapy compared to medical management among patients with acute large ischemic stroke. Methods: Analysis the Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients with a Large Infarct Core trial (ANGEL-ASPECT), which was a multicenter, randomized trial at 46 comprehensive stroke centers in China from August 2020 to October 2022. Onset to arterial puncture time (OPT) associated with outcomes of endovascular therapy were analyzed as a category and continuous variable. The primary outcome was favorable outcome (modified Rankin scale 0-3) at 90 days. Secondary outcomes included degree of disability (modified Rankin scale range), symptomatic intracranial hemorrhage, any intracranial hemorrhage, and mortality. Results: Among 455 eligible patients, the median age was 68 years, and median Alberta Stroke Program Early Computed Tomography Score was 3 (interquartile range 3-4). Compared with medical management alone, endovascular therapy plus medical management was associated with higher rates of favorable outcome with OPT within 6 hours (44.4% vs 29.9%, adjusted odds ratio[aOR] 2.78 [95% confidence interval [CI] 1.22-6.32]), 6-12 hours (45.7% vs 29.6%, aOR 2.39 [95% CI 1.21-4.71]), but not in OPT beyond 12 hours (51.6% vs 41.4%, aOR 2.05 [95% CI, 0.88-4.77]). The benefit in favorable outcome became nonsignificant after OPT of 13 hours and 22 minutes. In three OPT intervals, the odds of better disability outcome with endovascular therapy plus medical management than medical management alone were observed; the rates of symptomatic intracranial hemorrhage and mortality were similar, though the rates of any intracranial hemorrhage increased. Conclusion: In patients with large cerebral infarction, endovascular therapy plus medical management was efficacious in improving functional outcomes with acceptable safety in a broad time window of 0 to 24 hours, but greater benefit was observed with earlier treatment. A pooled analysis with larger sample size is needed.

Abstract TP188: Diving MCA and First-Pass Reperfusion: A Subgroup Analysis of the Arise II Study

Introduction: Tortuosity of Internal carotid artery impact on achieving first pass in mechanical thrombectomy has been previously described. Here, we investigate the association of middle cerebral artery(MCA) tortuosity on radiographic and functional outcome. Methods: The Analysis of Revascularization in Ischemic Stroke with EmboTrap II was utilized to identify patients with anterior circulation stroke. MCA tortuosity was calculated using Inflection Count Metric(ICM) by two blinded readers to angiographical/clinical outcomes. The total cohort was trichotomized into 3 groups (A, B, C) based on M1 tortuosity tertiles. The primary efficacy end point was achievement of modified Thrombolysis in Cerebral Ischemia (mTICI) reperfusion scores of ≥2b on first pass. Good functional outcomes was defined as mRS0-2 on 90-day followup. Baseline and procedural data were compared between groups. Results: A total of 200 with known MCA tortuosity were identified. Patients within group A were significantly older (P<0.05) . Group C patient were more likely to have renal disease and atrial fibrillation (P<0.05). There was no differences in terms of NIHSS score at presentation nor ASPECT score between groups. Achieving first-pass success was more likely in group A (60.6%) vs 47% and 38.2%, P=0.033 for groups B and C, respectively. Likewise, the rate of mTICI≥2c was higher in group A (54.5%) vs 36.4% and 26.5%, p=0.003. Achieving mRS0-2 was more likely in group A (76.6%) vs 73.4% and 49.3%, p=0.001. There were no differences in distal emboli, or symptomatic intracranial hemorrhage. Findings of first-pass and angiographic outcomes were consistent with standard tortuosity scoring system. Conclusion: Patients with higher MCA tortuosity are less likely to have successful reperfusion and good functional outcome post mechanical thrombectomy for acute ischemic stroke.

Abstract TP205: Intracranial Stenting With Mechanical Thrombectomy in Acute Ischemic Stroke in the United States

Background and Purpose: Large vessel occlusion secondary to intracranial atherosclerotic disease (ICAD-LVO) has an estimated prevalence of 10-30%. Registry-based reports from high volume centers indicate that about 4-7% of mechanical thrombectomy (MT) due to LVO are accompanied with intracranial rescue stenting in the US, yet the trend and utilization of rescue stenting in US is unknown. Methods: Analysis of US National Inpatient Sample of strokes with mechanical thrombectomy with or without concomitant intracranial stenting from October 1st, 2016, to December 31st, 2020, was performed. Patient- and hospital-level characteristics were analyzed. Outcomes included favorable disposition (discharged to home) and in-hospital mortality. Results: Among 68,975 of stroke MT with recorded NIHSS during the study period (51.1% women; mean age, 69.1 [SD, 14.6] years; mean NIHSS score of 15.1 [SD, 7.7]), 1,635 (2.3%) underwent concomitant intracranial stenting (44% women; mean age, 64.8 [SD, 13.7] years; mean NIHSS score of 13.8 [SD, 8.1]). Characteristics associated with intracranial stent utilization were male sex, history of diabetes, hypertension, or chronic kidney disease, absence of atrial fibrillation or CHF, and southern US region. Favorable outcome was achieved in 23.6% of MT with stenting versus 32.3% without stenting (P<0.001). In-hospital mortality occurred in 17.1% of MTs with stenting versus 10.5% without stenting (P<0.001). In multivariable analysis among MTs with concomitant intracranial stenting, favorable outcome was associated with lower presenting NIHSS (OR, 0.91 [95% CI, 0.87-0.95], P<0.001), and absence of DM (OR, 0.41 [95% CI, 0.20-0.85], P<0.01). In-hospital mortality was associated with male sex (OR, 3.08 [95% CI, 1.38-6.87], P=0.005) and concomitant IV lytic administration (OR, 2.45 [95% CI, 1.01-5.96], P=0.02). Conclusions: In US practice, less than 3/100 MT’s are performed with concomitant intracranial stenting which is well below the prevalence of failed thrombectomy rates due to underlying ICAD-LVO. Further studies are needed to improve outcomes in this subset of patients.

Safety Profile of Intra-Arterial Tirofiban as a Rescue Therapy during Mechanical Thrombectomy in Acute Ischemic Stroke

Abstract Purpose This article studies the safety profile and role of intra-arterial (IA) tirofiban as a rescue therapy in acute ischemic stroke (AIS) patients undergoing mechanical thrombectomy. Methods This is a retrospective observational study conducted among AIS patients with large vessel occlusion (LVO) eligible for endovascular revascularization and in whom IA tirofiban is given as rescue therapy. If the target vessel shows reocclusion following initial recanalization, flow limiting or significant residual stenosis after thrombectomy, or requires balloon angioplasty or stenting, IA tirofiban at a dose of 0.4 μg/kg/min was administered through the microcatheter in the target vessel followed by intravenous infusion of 0.1 μg/kg/min. The primary safety measure of the study was the incidence of symptomatic hemorrhage. Results The total number of patients in the study group was 82, 36 were in the tirofiban group and 46 were in the non-tirofiban group. Immediate successful reperfusion was achieved in 31 patients (86.1%) and 41 patients (89%) in the tirofiban and non-tirofiban groups, respectively. Note that 19.4 and 25% of patients in the tirofiban group required adjunct techniques of angioplasty and stenting, respectively. Also, 2.7% patient in the tirofiban group had a symptomatic hemorrhage, while 8.7% in the non-tirofiban group had symptomatic intracranial hemorrhage. On multinomial logistic regression, history of transient ischemic attack, truncal occlusion and watershed infarct pattern predicted the usage of IA tirofiban during mechanical thrombectomy. Conclusion Usage of IA tirofiban with or without adjunct techniques as a rescue therapy during mechanical thrombectomy in LVO improved recanalization rates without increasing the risk of symptomatic hemorrhage.

Patients' perceptions on outcomes after mechanical thrombectomy in acute ischemic stroke.

The modified Rankin Scale (mRS) is a clinician-reported scale that measures the degree of disability in patients who suffered a stroke. Patients' perception of a meaningful recovery from severe stroke, expected value of a stroke intervention, and the effect of disparities are largely unknown. We conducted a survey of patients, their family members, and accompanying visitors to understand their personal preferences and expectations for acute strokes potentially eligible for acute endovascular intervention using a hypothetical scenario of a severe stroke in a standardized questionnaire. Of 164 survey respondents, 65 (39.6%) were the patient involved, 93 (56.7%) were a family member, and six (3.7%) were accompanied visitors (friends, other). Minimally acceptable disability after a stroke intervention was considered as mRS 2 by 42 respondents (25.6%), as mRS 3 by 79 (48.2%), and as mRS 4 by 43 (26.2%) respondents. Race was associated with different views on this question (p < 0.001; Hispanic and Black patients being more likely to accept disability than Caucasian and Asian patients), while sex (p = 0.333) and age (p = 0.560) were not. Sixty-three respondents (38.4%) viewed minimally acceptable probability of improvement with an intervention as over 50%, 57 (34.8%) as 10-50%, and 44 (26.8%) as less than 10%. A wide range of acceptable outcomes were reported regardless of gender or age. However, race was associated with different acceptable outcome. This is an important finding to demonstrate because of the persistent racial and ethnic disparities in the utilization of endovascular therapy for acute stroke in the United States.

Safety and efficacy of adjunctive intra-arterial antithrombotic therapy during endovascular thrombectomy for acute ischemic stroke: a systematic review and meta-analysis

BackgroundHalf of patients who achieve successful recanalization following endovascular thrombectomy (EVT) for acute ischemic stroke experience poor functional outcome. We aim to investigate whether the use of adjunctive intra-arterial antithrombotic...

Effect of sarcopenia on mortality in acute stroke patients receiving endovascular treatment.

To investigate the effect of sarcopenia on mortality in patients with acute ischemic stroke caused by anterior circulation large artery occlusion who underwent endovascular treatment. Acute ischemic stroke patients (n = 194) treated with mechanical thrombectomy who underwent chest computed tomography between 2019 and 2022 (median age, 69 [interquartile range: 61-77], 95 females, 99 males) were evaluated retrospectively. The cross-sectional area and density of the pectoralis muscle [pectoralis muscle area (PMA) and pectoralis muscle density (PMD)] at the level of the aortic arch and the erector spinae muscle at the T12 level [erector spinae muscle area (ESMA) and erector spinae muscle density (ESMD)] were measured. The association between skeletal muscle parameters and mortality outcomes was investigated using the receiver operating characteristic (ROC) curve and multivariable logistic regression analyses. The 90-day mortality rate was 32% in the study population (n = 62). The ROC analysis revealed that ESMD [area under the curve (AUC): 0.765] and PMD (AUC: 0.759) performed best in the prediction of 90-day mortality. In the multivariable logistic regression analysis, PMD [odds ratio (OR): 0.896; 95% confidence interval (CI): 0.846-0.948; p < 0.001], ESMA (OR: 0.929; 95% CI: 0.878-0.983; p = 0.011), and ESMD (OR: 0.947; 95% CI: 0.913-0.983; p = 0.004), but not PMA, were independent risk factors for 90-day mortality. PMD, ESMA, and ESMD may be risk factors for 90-day mortality after mechanical thrombectomy for acute ischemic stroke.

Neuroprotection during Thrombectomy for Acute Ischemic Stroke: A Review of Future Therapies.

Stroke is a major cause of death and disability worldwide. Endovascular thrombectomy has been impactful in decreasing mortality. However, many clinical results continue to show suboptimal functional outcomes despite high recanalization rates. This gap in recanalization and symptomatic improvement suggests a need for adjunctive therapies in post-thrombectomy care. With greater insight into ischemia-reperfusion injury, recent preclinical testing of neuroprotective agents has shifted towards preventing oxidative stress through upregulation of antioxidants and downstream effectors, with positive results. Advances in multiple neuroprotective therapies, including uric acid, activated protein C, nerinetide, otaplimastat, imatinib, verapamil, butylphthalide, edaravone, nelonemdaz, ApTOLL, regional hypothermia, remote ischemic conditioning, normobaric oxygen, and especially nuclear factor erythroid 2-related factor 2, have promising evidence for improving stroke care. Sedation and blood pressure management in endovascular thrombectomy also play crucial roles in improved stroke outcomes. A hand-in-hand approach with both endovascular therapy and neuroprotection may be the key to targeting disability due to stroke.

Radially adjustable stent retriever for mechanical thrombectomy in acute ischemic stroke: Improved first-pass effect with rapid-inflation deflation technique.

Evidence for improved first-pass effect with the novel radially adjustable radio-opaque stent retriever Tigertriever is lacking. To compare improvement in first pass success with Tigertriever using two different techniques-rapid inflation deflation (RID) and suction thrombectomy (ST). Retrospective analysis of patients with acute ischemic stroke who underwent mechanical thrombectomy with Tigertriever at a single comprehensive stroke center. Thirty patients were included. Mean age was 72.8 years. Twelve patients (48%) experienced successful first passes with Tigertriever. Successful revascularization (modified thrombolysis in cerebral infarction (mTICI) 2b/3) was achieved in all (100%) patients who received RID or ST technique for thrombectomy. Good clinical outcome (modified Rankin score = 0-2) was noted in 40% (n = 10). Total mortality in the cohort was 8% (n = 2). RID and ST groups comprised of 10 and 15 patients, respectively. Five patients underwent MT with Tigertriever as a rescue device. No difference was noted in mean age (p = 0.27), gender (p = 0.29), location of occlusion (p = 0.46), and device used for first pass (p = 0.57). A 70% first-pass success rate in RID group and 37.5% in ST group was noticed (p = 0.06). Mean time from groin puncture to reperfusion (TICI 2b//3) was statistically similar (p = 0.29, RID: 19.9 min vs ST: 25 min). Both groups noted a 100% complete recanalization rate. The rate of mortality between the two groups were not statistically different (p = 0.46). The preliminary first-pass success rates of RID technique with Tigertriever compared to ST technique, are encouraging. Longitudinal studies with longer follow up are needed to elucidate the smaller learning curve with this device.

Evaluating outcome associations with race after mechanical thrombectomy: an analysis of the NVQI-QOD acute ischemic stroke registry

BackgroundMechanical thrombectomy has become the standard of care for acute ischemic stroke due to large vessel occlusions. Racial differences in outcomes after mechanical thrombectomy for acute ischemic stroke have not...

Blood Pressure Trajectories and Outcomes After Endovascular Thrombectomy for Acute Ischemic Stroke.

Data on systolic blood pressure (SBP) trajectories in the first 24 hours after endovascular thrombectomy (EVT) in acute ischemic stroke are limited. We sought to identify these trajectories and their relationship to outcomes. We combined individual-level data from 5 studies of patients with acute ischemic stroke who underwent EVT and had individual blood pressure values after the end of the procedure. We used group-based trajectory analysis to identify the number and shape of SBP trajectories post-EVT. We used mixed effects regression models to identify associations between trajectory groups and outcomes adjusting for potential confounders and reported the respective adjusted odds ratios (aORs) and common odds ratios. There were 2640 total patients with acute ischemic stroke included in the analysis. The most parsimonious model identified 4 distinct SBP trajectories, that is, general directional patterns after repeated SBP measurements: high, moderate-high, moderate, and low. Patients in the higher blood pressure trajectory groups were older, had a higher prevalence of vascular risk factors, presented with more severe stroke syndromes, and were less likely to achieve successful recanalization after the EVT. In the adjusted analyses, only patients in the high-SBP trajectory were found to have significantly higher odds of early neurological deterioration (aOR, 1.84 [95% CI, 1.20-2.82]), intracranial hemorrhage (aOR, 1.84 [95% CI, 1.31-2.59]), mortality (aOR, 1.75 [95% CI, 1.21-2.53), death or disability (aOR, 1.63 [95% CI, 1.15-2.31]), and worse functional outcomes (adjusted common odds ratio,1.92 [95% CI, 1.47-2.50]). Patients follow distinct SBP trajectories in the first 24 hours after an EVT. Persistently elevated SBP after the procedure is associated with unfavorable short-term and long-term outcomes.

PREDICTORS OF OUTCOMES IN ELDERLY ACUTE STROKE PATIENTS UNDERGOING ENDOVASCULAR THROMBECTOMY

Introduction: The aging population is one of the main reasons for the increase in stroke cases.The aim of this study was to evaluate the predictors of 3-month outcomes in patients aged ≥65 years who underwent mechanical thrombectomy for acute ischemic stroke and compare patients aged 65–79 years with those aged ≥80 years in terms of demographic characteristics, workflow, functional outcomes, and complication rates. Materials and Method: This retrospective cohort study included 169 consecutive patients aged ≥65 years who underwent mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion between April 2020 and May 2023. Results: Recanalization was successful for 148 (87.57%) patients.According to multivariable logistic regression analysis results, low (≤9) Alberta Stroke Program Early Computed Tomography score (odds ratio: 4.217, 95% confidence interval: 1.209–14.715, and p=0.024), high National Institutes of Health Stroke Scale score at 24th hour (odds ratio: 1.192, 95% confidence interval: 1.087–1.306, and p&lt;0.001), high Acute Physiology and Chronic Health Evaluation score (odds ratio: 1.127, 95% confidence interval: 1.016–1.250, and p=0.023), and intubation need (odds ratio: 15.055, 95% confidence interval: 2.087–108.612, and p=0.007) were independent predictors of poor outcome. Conclusion: The lack of significant differences in workflow, functional outcomes, and complications among patients ˃80 years of age indicates that MT is effective in this age group. Considering the aging population, identifying the predictors of 3-month outcomes after mechanical thrombectomy will help predict outcomes, better identify elderly patients who may benefit from the procedure, and guide treatment decisions. Keywords: Aged; Ischemic Stroke; Endovascular Procedures; Thrombectomy.

Technique for Recanalization of Sheath Introducer Occlusion due to Captured Thrombus during Mechanical Thrombectomy for Acute Ischemic Stroke: A Technical Note.

Mechanical thrombectomy (MT) is the gold standard treatment for acute ischemic stroke. During these interventions, a thrombus frequently obstructs a guiding catheter. The obstructed guiding catheter should be withdrawn before distal embolism occurs; however, albeit infrequently, the thrombus occludes even a sheath introducer (SI). While conventionally new SI placement is required for continuation of treatment, we propose a viable alternative for recanalization of the occluded SI, termed vacuum-assisted delivery of thrombus (VADT), with a clinical report of our cases. The usefulness of this technique was also evaluated in simulation experiments. The VADT procedure is as follows: 1) insert a peel-away sheath, originally attached to a balloon-guiding catheter (BGC), into the SI to continuously open the hemostatic valve; 2) advance the BGC into the peel-away sheath while applying mechanical aspiration; and 3) remove the peel-away sheath/BGC assembly slowly. In a simulation environment using an artificial thrombus, we repeated the VADT procedure five times and reproducibly achieved SI reopening within only 10-20 seconds. From March 2013 to September 2022, 204 patients were treated with MT at our stroke center and SI occlusion occurred in three patients (1.5%). These events occurred exclusively in patients with extracranial internal carotid artery occlusion. All three patients with SI occlusion underwent successfully thrombus extraction in the SI using the VADT on the first try. The results of clinical experience and simulation experiments strongly support VADT as a reliable option for recanalization of an occluded SI.