Thrombectomy In Acute Stroke Patients Research Articles

Outcomes of mechanical thrombectomy in acute stroke patients with atrial fibrillation detected after stroke versus known atrial fibrillation

We aim to compare the outcomes in patients with atrial fibrillation detected after stroke (AFDAS) and their counterparts with known AF (KAF) presenting with large vessel occlusion (LVO) treated with mechanical thrombectomy (MT). This observational, prospective study included consecutive patients with acute LVO ischemic stroke of the anterior circulation with AFDAS, KAF and without AF. The primary study outcome was functional independence at 90 days after stroke. The secondary study outcomes were variation of the NIHSS score at 24 h, rate of successful reperfusion, death at 90 days and rate of immediate complications post-procedure. Overall, our cohort included 518 patients with acute ischemic stroke and LVO treated with MT, with 289 (56.8%) without a diagnosis of AF; 107 (21%) with AFDAS; 122 (22.2%) with KAF. There was no significant difference in terms of functional independence at 90 days after stroke between the three groups. Regarding the secondary study outcome, the rate of symptomatic intracranial haemorrhage (sICH) and/or parenchymal hematoma (PH) were significantly higher in the group of patients without AF (respectively, P = 0.030 and < 0.010). Logistic regression analysis showed that the subtypes of AF were not statistically significantly associated with functional independence at 90 days after stroke and with the likelihood of any ICH. Our results suggest that the subtypes of AF are not associated with clinical and safety outcomes of MT in patients with acute stroke and LVO. Further studies are needed to confirm our findings.

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

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

Piecing Arterial Branching Pattern Together from Non-Contrast and Angiographic Brain Computed Tomography before Endovascular Thrombectomy for Acute Ischemic Stroke.

Predicting the unseen arterial course and branching pattern distal to vessel occlusion is crucial for endovascular thrombectomy in acute stroke patients. We investigated whether a comprehensive interpretation of NCT and CTA would enhance arterial course prediction more than either NCT or CTA interpretation alone. Among 150 patients who achieved post-thrombectomy TICI grades ≥ IIb for anterior circulation occlusions, we assessed visualization grade on both NCT and CTA by five scales at the thrombosed and the distal-to-thrombus segment, using DSA as the reference standard. The visualization grades were compared and related to various subgroups. The mean visualization grade of the distal-to-thrombus segment on NCT was significantly larger than that of CTA (mean ± SD, 3.62 ± 0.87 versus 3.31 ± 1.20; p < 0.05). On CTA, visualization grade of distal-to-thrombus segment in the good collateral flow subgroup was higher than that in the poor collateral flow subgroup (mean ± SD, 4.01 ± 0.93 versus 2.56 ± 0.99; p < 0.001). After the comprehensive interpretation of NCT and CTA, seventeen cases (11%) showed visualization grade of distal-to-thrombus segment upgrading. Tracing arterial course and piecing branching patterns together in distal-to-occlusion of stroke patients was feasible on the routine pre-interventional NCT and CTA, which may provide timely guidance during thrombectomy.

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

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

Cost-effectiveness of endovascular thrombectomy in acute stroke patients with large ischemic core

BackgroundEvidence has shown that endovascular thrombectomy (EVT) treatment improves clinical outcomes. Yet, its benefit remains uncertain in patients with large established infarcts as defined by ASPECTS (Alberta Stroke Program Early...

Investigating Outcomes Post-Endovascular Thrombectomy in Acute Stroke Patients With Cancer.

Cancer is a common comorbidity in patients with acute ischemic stroke (AIS). Randomized controlled trials that established endovascular thrombectomy (EVT) as the standard of care for large vessel occlusion generally excluded patients with cancer. As such, the clinical benefits of endovascular thrombectomy in the cancer population are currently poorly established. We examine clinical outcomes of patients with cancer who underwent EVT using a large inpatient database, the National Inpatient Sample (NIS). The NIS was queried for AIS admission between 2016 and 2019, and patients with cancer were identified. Baseline demographics, comorbidities, reperfusion therapies, and outcomes were compared between patients with AIS with and without cancer. For patients who underwent EVT, propensity score matching was used to study primary outcomes such as risk of intracranial hemorrhage, hospital length of stay, and discharge disposition. During the study period, 2,677,200 patients were hospitalized with AIS, 228,800 (8.5%) of whom had a diagnosis of cancer. A total of 132,210 patients underwent EVT, of which 8,935 (6.8%) had cancer. Over 20% of patients with cancer who underwent EVT had a favorable outcome of a routine discharge home without services. On adjusted propensity score analysis, patients with cancer who underwent EVT had similar rates of intracranial hemorrhage (OR 1.03, CI 0.79-1.33, p = 0.90) and odds of a discharge home, with a significantly higher rate of prolonged hospitalization greater than 10 days (OR 1.34, CI 1.07-1.68, p = 0.01). Compared with patients without cancer, patients with metastatic cancer who underwent EVT also had similar rates of intracranial hemorrhage (OR 1.03, CI 0.64-1.67, p = 1.00) and likelihood of routine discharge (OR 0.83, CI 0.51-1.35, p = 0.54) but higher rates of in-hospital mortality (OR 2.72, CI 1.52-4.90, p < 0.01). Our findings show that in contemporary medical practice, patients with acute stroke with comorbid cancer or metastatic cancer who undergo endovascular thrombectomy have similar rates of intracranial hemorrhage and favorable discharges as patients without cancer. This suggests that patients with AIS who meet the criteria for reperfusion therapy may be considered in the setting of a comorbid cancer diagnosis.

P.113 Time metrics and clinical outcomes of thrombectomy in acute stroke patients before and after implementation of COVID-19 infection protocols in six Canadian stroke centres

Background: The coronavirus disease 2019 (COVID-19) pandemic has led the implementation of institutional infection control protocols. This study will determine the effects of these protocols on outcomes of acute ischemic stroke (AIS) patients treated with endovascular therapy (EVT). Methods: Uninterrupted time series analysis of the impact of COVID-19 safety protocols on AIS patients undergoing EVT. We analyze data from prospectively collected quality improvement databases at 6 centers from March 11, 2019 to March 10, 2021. The primary outcome is 90-day modified Rankin Score (mRS). The secondary outcomes are angiographic time metrics. Results: Preliminary analysis of one stroke center included 214 EVT patients (n=150 pre-pandemic). Baseline characteristics were comparable between the two periods. Time metrics “last seen normal to puncture” (305.7 vs 407.2 min; p=0.05) and “hospital arrival to puncture” (80.4 vs 121.2 min; p=0.04) were significantly longer during pandemic compared to pre-pandemic. We found no significant difference in 90-day mRS (2.0 vs 2.2; p=0.506) or successful EVT rate (89.6% vs 90%; p=0.93). Conclusions: Our results indicate an increase in key time metrics of EVT in AIS during pandemic, likely related to infection control measures. Despite the delays, we found no difference in clinical outcomes between the two periods.

Efficacy of the MRA-Based Road Mapping of the Para-Aortic Access Route before Mechanical Thrombectomy in Patients with Acute Ischemic Stroke

Introduction: The aim of this study was to clarify whether magnetic resonance angiography (MRA)-based road mapping of the para-aortic transfemoral access route can reduce the procedural time of mechanical thrombectomy in patients with acute ischemic stroke. We further investigated the role of pre-procedural MRA-based road mapping in optimal initial catheter selection for rapid mechanical thrombectomy. Materials and Methods: We retrospectively reviewed 57 consecutive patients with acute ischemic stroke who underwent mechanical thrombectomy at our hospital between April 2018 and May 2021. Twenty-nine patients underwent MRA-based road mapping to visualize the para-aortic access route, whereas 28 patients only underwent routine head magnetic resonance imaging/angiography without MRA-based road mapping before neuro-interventional procedures. We then compared the basic procedural times required for mechanical thrombectomy, such as the time from femoral artery puncture to recanalization (“puncture to recanalization time”) and the time from the admission to recanalization (“door to recanalization time”), between the groups. Results: MRA-based road mapping significantly reduced the “puncture to recanalization time” (52.0 min vs. 70.0 min; p = 0.019) and the “door to recanalization time” (146 min vs. 183 min; p = 0.013). Conclusion: MRA-based road mapping of the para-aortic access route is useful to reduce the procedural time of mechanical thrombectomy in acute stroke patients, possibly by enabling optimal initial catheter selection during the procedure.

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

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

TAB-TICI Score: Successful Recanalization Score After Endovascular Thrombectomy in Acute Stroke.

Background and Purpose: Successful reperfusion therapy is supposed to be comprehensive and validated beyond the grade of recanalization. This study aimed to develop a novel scoring system for defining the successful recanalization after endovascular thrombectomy.Methods: We analyzed the data of consecutive acute stroke patients who were eligible to undergo reperfusion therapy within 24 h of onset and who underwent mechanical thrombectomy using a nationwide multicenter stroke registry. A new score was produced using the predictors which were directly linked to the procedure to evaluate the performance of the thrombectomy procedure.Results: In total, 446 patients in the training population and 222 patients in the validation population were analyzed. From the potential components of the score, four items were selected: Emergency Room-to-puncture time (T), adjuvant devices used (A), procedural intracranial bleeding (B), and post-thrombectomy reperfusion status [Thrombolysis in Cerebral Infarction (TICI)]. Using these items, the TAB-TICI score was developed, which showed good performance in terms of discriminating early neurological aggravation [AUC 0.73, 95% confidence interval (CI) 0.67–0.78, P < 0.01] and favorable outcomes (AUC 0.69, 95% CI 0.64–0.75, P < 0.01) in the training population. The stability of the TAB-TICI score was confirmed by external validation and sensitivity analyses. The TAB-TICI score and its derived grade of successful recanalization were significantly associated with the volume of thrombectomy cases at each site and in each admission year.Conclusion: The TAB-TICI score is a valid and easy-to-use tool to more comprehensively define successful recanalization after endovascular thrombectomy in acute stroke patients with large vessel occlusion.

Analysis of microRNA signatures in ischemic stroke thrombus

BackgroundWe investigated the microRNA expression pattern from thrombus retrieved by mechanical thrombectomy in acute stroke patients to understand the stroke mechanism.MethodsThis study included acute ischemic stroke patients who had undergone...

Association Between Blood Pressure Variability and Short-Term Outcome After Intra-arterial Thrombectomy in Acute Stroke Patients With Large-Vessel Occlusion.

The optimal range of blood pressure variability (BPV) for acute stroke patients with large-vessel occlusion (LVO) remains unclear. This study investigated the association between BPV from admission through the first 24 h after intra-arterial thrombectomy (IAT) and short-term outcome in LVO patients. We retrospectively analyzed 257 consecutive patients with LVO stroke who were treated with IAT. BP values were recorded at 2-h intervals from admission through the first 24 h after IAT. BPV, as reflected by pulse pressure variability (PPV), was determined based on standard deviation (SD), coefficient of variation (CV), successive variation (SV), and the difference between maximum and minimum blood pressure (ΔBP; systolic BP minus diastolic BP). The association between BPV and clinical outcome (Modified Rankin Scale score at 90 days) was analyzed by multivariate logistic regression analysis. Of the 257 included patients, 70 had a good outcome at 3 months. PPV from admission through the first 24 h after IAT was independently associated in a graded manner with poor outcome [multivariable-adjusted odds ratios (95% confidence interval) for the highest of PPV were 43.0 (8.7–212.8) for SD, 40.3 (9.8–165.0) for CV, 55.0 (11.2–271.2) for SV, and 40.1 (8.0–201.9) for ΔBP]. The area under the receiver operating characteristic curve (95% confidence interval) of the PPV parameters were 0.924 (0.882–0.965) for SD, 0.886 (0.835–0.938) for CV, 0.932 (0.891–0.973) for SV, and 0.892 (0.845–0.939) for ΔBP, and the Youden index values were 0.740, 0.633, 0.759, and 0.756, respectively. In summary, BPV from admission through the first 24 h after IAT was independently associated with poor outcome at 3 months in patients with LVO, with greater variability corresponding to a stronger association. Thus, PPV may be a clinically useful predictor of functional prognosis in LVO patients treated with IAT.

Current status of aspiration thrombectomy for acute stroke patients in China: data from ANGEL-ACT Registry.

Background and Aims:Although noninferior to stent retriever (SR) as first-line approach for endovascular treatment (EVT) of acute large vessel occlusion (LVO) stroke, little is known about the current status of direct aspiration (DA) as first-line thrombectomy in China. This analysis of a prospective, nationwide registry (ANGEL-ACT) aimed to investigate the prevalence and comparative effectiveness of DA-first thrombectomy in a real-world practice in China.Methods:All patients receiving thrombectomy were screened from a prospective cohort of LVO patients undergoing EVT at 111 hospitals in China between November 2017 and March 2019, and divided into two groups based upon which type of thrombectomy was attempted first (“DA-first” and “SR-first”). The following outcome measures were compared using logistic regression models with adjustment: successful recanalization after first-device alone and all procedures, use of rescue treatment, intracranial hemorrhage (ICH) within 24 h, and modified Rankin Scale (mRS) score at 90 days.Results:A total of 1225 patients, 102 (8.3%) in DA-first group and 1123 (91.7%) in SR-first group, were included. Patients receiving DA-first had less often successful recanalization after first-device alone [30.4 versus 66.4%; odds ratio (OR) = 0.23, 95% confidence interval (CI) = 0.15–0.37], more frequent rescue treatment (62.8 versus 27.0%; OR = 4.55, 95% CI = 2.92–7.08) and ICH (35.4 versus 22.1%; OR = 1.78, 95% CI = 1.12–2.83) than those receiving SR-first; however, no significant difference was found in successful recanalization after all procedures (84.3 versus 90.3%; p = 0.18) and 90-day mRS (median: 3 versus 3 points; p = 0.90) between both groups.Conclusion:This real-world registry suggested that DA-first thrombectomy for acute stroke patients lagged behind in China during the study period. Far fewer DA-first than SR-first thrombectomies were performed, and DA-first was associated with lower first-device recanalization, more frequently requiring rescue treatment, and increased ICH risk.Clinical Trial Registration:ClinicalTrials.gov, NCT03370939.

Incomplete or failed thrombectomy in acute stroke patients with Alberta Stroke Program Early Computed Tomography Score 0-5 - how harmful is trying?

It is currently unknown whether mechanical thrombectomy (MT) for ischaemic stroke patients with low initial Alberta Stroke Program Early Computed Tomography Score (ASPECTS) is clinically beneficial or even harmful. The purpose of this study was to investigate whether failed or incomplete MT in acute large vessel occlusion stroke with an initial ASPECTS≤5 is associated with worse clinical outcome compared to patients not undergoing MT. This observational cohort study included a consecutive sample of patients with anterior circulation stroke and initial ASPECTS≤5 admitted between March 2015 and August 2019. Failed recanalization was defined as Thrombolysis in Cerebral Infarction (TICI) score 0-2a, and incomplete recanalization as TICI 2b. Clinical outcome was assessed using the modified Rankin Scale (mRS) at 90 days defining very poor clinical outcome as mRS>4. One hundred and seventy patients were included. Ninety-nine patients underwent MT and 71 patients received best medical treatment only. Clinical outcome after failed or incomplete MT (TICI 0-2b) was significantly better compared to patients with medical treatment only (median mRS 5, interquartile range 4-6 vs 5-6, P=0.03). In multivariable logistic regression analysis, failed or incomplete MT (TICI 0-2b) showed a significantly reduced likelihood for very poor outcome (odds ratio 0.39, 95% confidence interval 0.19-0.83, P=0.01). Failed MT (TICI 0-2a) was not associated with a worse outcome compared to best medical treatment. Patients with failed or incomplete recanalization results (TICI 0-2b) showed a reduced likelihood for very poor outcome compared with those who did not receive MT. Evidence from randomized trials is needed to confirm that even failed or incomplete MT is not harmful in these patients.

Early repatriation post-thrombectomy: a model of care which maximises the capacity of a stroke network to treat patients with large vessel ischaemic stroke

Background and purposeHealthcare systems are challenged to provide access to thrombectomy in acute stroke patients. Either the “drip and ship” or “mothership” models result in increased numbers of patients in...

Abstract WP53: Safety and Efficacy of Mechanical Thrombectomy in Acute Stroke Patients on New Oral Anticoagulants

Background: Limited data exists on the benefits of mechanical thrombectomy (MT) in acute ischemic stroke patients on new oral anticoagulants (NOAC). The aim of our study is to examine the safety and efficacy of MT in NOAC patients at our center. Methods: A retrospective review of our prospective MT database was performed for this study. Baseline characteristics, National Institutes of Health Stroke Scale (NIHSS) score, revascularization rate, symptomatic intracranial hemorrhage rate (sICH), and 90-day mortality and favorable outcomes were compared in MT patients on NOAC (MT-NOAC) versus those who were not on NOAC (MT). Results: From July 2012 to December 2018, 553 AIS patients underwent treatment with MT, with 36 patients on NOAC (6.5%). Median age was similar (73 versus 74), with 52.8% and 52.0% (p=0.8) female in the MT-NOAC and MT groups, respectively. Median baseline NIHSS score (17 IQR10-21 versus 17 IQR 12-21, p=0.75) and ASPECTS (9 IQR 8-9, p=0.80) were similar between the groups. Atrial fibrillation was more prevalent in the MT-NOAC group (80.6% versus 37.7%, p=&lt;0.0001). No difference was seen in occlusion site between the group, with M1 occlusions the most common site (44.4% versus 43.3%, p=0.9). Median onset to revascularization times did not differ between the cohorts (146 minutes versus 206, p=0.61). Successful revascularization (mTICI≥2b) was 87.5% and 81.8% in the MT NOAC and MT groups, respectively. Rates of symptomatic intracerebral hemorrhage per ECASS III criteria were similar between the two groups (5.5% versus 4.6%, p=0.68). No difference was seen in 90-day favorable outcomes (mRS 0-2) (48.3% versus 41.1%, p=0.44) or mortality (27.6% versus 27.1%, 0.95). Conclusion: MT in patients on NOAC appears to be safe and efficacious. As our study is limited by sample size, larger prospective studies are needed to understand the safety and efficacy of MT in AIS patients on NOAC.

Addressing a real-life problem: treatment with intravenous thrombolysis and mechanical thrombectomy in acute stroke patients with an extended time window beyond 4.5 h based on computed tomography perfusion imaging.

Acute ischemic stroke treatment with intravenous thrombolysis (IVT) is restricted to a time window of 4.5h after known or presumed onset. Recently, magnetic resonance imaging-guided treatment decision-making in wake-up stroke (WUS) was shown to be effective. The aim of this study was to determine the safety and outcome of IVT in patients with a time window beyond 4.5h selected by computed tomography perfusion (CTP) imaging. We analyzed all consecutive patients last seen well beyond 4.5h after stroke onset treated with IVT based on CTP between January 2015 and October 2018. CTP was visually assessed to estimate the mismatch between cerebral blood flow and cerebral blood volume maps. Early infarct signs were documented according to Alberta Stroke Program Early CT Score (ASPECTS). Safety data were obtained for mortality and symptomatic intracerebral hemorrhage (sICH). Follow-up was assessed with the modified Rankin Scale (mRS). A total of 70 patients fulfilled the inclusion criteria (mean age±SD 77.6±11.5years, 50.0% female). Median National Institutes of Health Stroke Scale score on admission was 8.0 [interquartile range (IQR), 4-14]. The most frequent reasons for an extended time window were WUS (60.0%) and delayed hospital admission (27.1%). Median time from last seen well to IVT was 11.4h. Median ASPECTS was 10 (IQR, 9-10) and CTP mismatch 90% (IQR, 80%-100%). A total of 24 patients (34.3%) underwent additional mechanical thrombectomy. sICH occurred in four patients (5.7%). At follow-up, 49.3% had an mRS score of 0-2 and 22.4% had an mRS score of 0-1. In patients presenting in an extended time window beyond 4.5h, IVT treatment with decision-making based on CTP might be a safe procedure. Further evaluation in clinical trials is needed.

Renal Impairment Is Associated with Intracerebral Hemorrhage after Mechanical Thrombectomy in Vertebrobasilar Stroke

Background and Purpose: Renal dysfunction (RD) is overall associated with unfavorable functional outcome and higher risk of mortality after acute ischemic stroke. Associations between RD and outcome in patients with acute vertebrobasilar stroke treated with thrombectomy have not been evaluated so far. Materials and Methods: Consecutive patients with vertebrobasilar stroke treated with mechanical thrombectomy between October 2010 and July 2017 at our center were analyzed. RD was defined as glomerular filtration rate (GFR) < 60 mL/min/1.73 m² at admission. Endpoints were (I) poor clinical outcome (modified Rankin Scale > 2) at 3 months, (II) 3-month mortality, and (III) intracerebral hemorrhage (ICH) after treatment. Results: Overall, 106 patients were included. Median age was 73.0 years (interquartile range 62.0–80.0), and RD was present in 20.8%. Multivariate analysis revealed that RD was associated with a higher risk for any ICH (OR 3.54; 95% CI 1.09–11.49; p = 0.035). Stroke severity at onset predicted poor clinical outcome (OR 1.08; 95% CI 1.03–1.14; p = 0.003). Neither low GFR nor any ICH, but stroke severity (OR 1.08; 95% CI 1.03–1.14; p = 0.002) and poor recanalization results (OR 11.38; 95% CI 2.01–64.41; p = 0.006) were associated with a higher risk for mortality. Conclusions: Patients with RD and acute vertebrobasilar stroke should be thoroughly monitored to prevent ICH after thrombectomy. Our results support performing mechanical thrombectomy in acute stroke patients with large vessel occlusions of the posterior circulation, irrespective of their renal function.

Effects of mechanical thrombectomy for acute stroke patients with etiology of large artery atherosclerosis

AimsAtherosclerosis is more prevalent in Asian population. This distinct etiology of stroke might disadvantage Asian patients when applying.mechanical thrombectomy (MT). The purpose of this research was to evaluate the efficacy and safety of MT in a cohort of Chinese patients with acute ischemic stroke.due to large artery atherosclerosis (LAA). Methods and resultsA total of 649 patients treated with MT were included. Patients were classified according to etiology of stroke as LAA and cardioembolism ones. Successful revascularization was defined as modified Thrombolysis in Cerebral Infarction (mTICI) grade ≥ 2b. Favorable outcome was defined as modified Rankin Scale (mRS) score ≤ 2 at 90 days. Logistic regression was used to identify predictors for functional outcomes. The patients with stroke of LAA etiology had significantly higher rate of favorable functional outcome (50.2% vs 36.5%, p < .001) and good collateral (grade of ASITN/SIRI: 2–3) (58.8% versus 43.2%, p < .001), and lower median baseline National Institutes of Health Stroke Scale score (NIHSS) (15.6 versus 18.2, p < .001), compared to patients with stroke of cardioembolism etiology. There was no significant difference in the rate of successful postprocedural mTICI between groups (84.5% versus 83.2%, p = .671). Rates of symptomatic intracranial hemorrhage (20.0% versus 11.7%, p = .004) and mortality (31.8% versus 18.8%, p < .001) within 3 months were notably higher in the cardioembolism group than that in the LAA group. ConclusionMechanical thrombectomy may be more efficacious in treating acute ischemic stroke of LAA etiology than that of cardioembolism etiology.

Overview of evidence on emergency carotid stenting in patients with acute ischemic stroke due to tandem occlusions: a systematic review and meta-analysis.

Endovascular intracranial thrombectomy (IT) has established itself as the standard of care in treating large-vessel anterior circulation acute ischemic stroke (AIS). However, internal carotid artery (ICA) stenosis/occlusion hampers distal access and controversy about simultaneous emergency ICA stenting ensues. The purpose of this review was to evaluate the safety of emergency ICA stenting in combination with IT for AIS with tandem occlusions. To our knowledge this is the first meta-analysis to evaluate emergency ICA stenting in tandem occlusions, combining results from studies with a control group. A meta-analysis was conducted according to the recommendations of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. A total of 649 potentially relevant articles were initially selected. After reviewing at title or abstract level, 87 articles were read in full and 23 were included. These studies recruited 1000 patients, 220 submitted to IT with no emergency ICA stenting and 780 to IT and emergency ICA stenting. Successful revascularization (Thrombolysis in cerebral infarction scale [TICI] ≥2b) was achieved in 48.6-100%. Good outcome (modified Rankin scale [mRS] ≤2) ranged from 18.2-100%. Symptomatic intracranial hemorrhage (sICH) ranged from 0-45.7% (overall N.=168; 17.2%). Mortality at 90 days ranged from 0-45.4% (overall N.=114; 11.7%). Time to recanalization was significantly longer in the stenting group with an overall mean difference of 1.76 (95% CI: 1.59-1.93). In this meta-analysis time to recanalization was significantly longer in the emergency ICA stenting group. There was no benefit from emergency stenting in parameters such as successful revascularization (TICI≥2b), clinical outcome (mRS≤2) or 90-day mortality. Data on sICH were scarce. Emergency ICA stenting appears to increase time to revascularization and increase the risk of complications with no demonstrated clinical benefit. Furthermore, no prospective, randomized controlled trials demonstrating relative efficacy and safety of concomitant ICA stenting have been published to date. Additional studies must be undertaken to define the role of angioplasty and stenting of the extracranial carotid arteries in the early management of acute stroke in tandem occlusions. Until then, we recommend that ICA stenting concomitant to thrombectomy in acute stroke patients should be avoided.