TICI 2b Research Articles

Sex-specific differences in presentations and determinants of outcomes after endovascular thrombectomy for large vessel occlusion stroke.

Sex-specific differences in ischemic stroke outcomes are prevalent. We sought to investigate sex differences in the determinants of reperfusion and functional outcomes after endovascular thrombectomy (EVT) for emergent large vessel occlusion ischemic stroke (ELVO). Patients presenting to a single referral center with an anterior circulation ELVO that underwent EVT from 2011 to 2019 were included in this retrospective analysis. Sex differences in history, presentation, adequate reperfusion (TICI 2b-3), and 90-day good outcome [delta modified Rankin Scale (mRS) ≤ 2 from pre-stroke] were examined. Multivariable logistic regression analyses were performed to assess sex-specific associations with outcomes. Three hundred and eighty-one consecutive ELVO patients were identified. Women (N = 193) were older (75 vs 64years, p < 0.0001), had more pre-stroke disability (17% vs 9%, p = 0.032), more atrial fibrillation (41% vs 30%, p = 0.033), but less carotid atherosclerosis (8% vs 16%, p = 0.027). Rates of TICI 2b-3 and good outcome were similar between sexes. Carotid atherosclerosis (OR 0.315, 95% CI 0.130, 0.762) and dissection (OR 0.124, 95% CI 0.027, 0.569) independently decreased the odds of TICI 2b-3 among men but not women. Older age, more severe stroke, and not achieving TICI 2b-3 independently decreased the odds of good outcome among both sexes, while prior stroke (OR 0.258, 95% CI 0.083, 0.797) and hemorrhagic transformation (OR 0.111, 0.021, 0.592) were determinants exclusive to men. In a real-world analysis of ELVO stroke patients treated with EVT, we found that despite advanced age and more pre-stroke disability, women have comparable reperfusion rates and functional outcomes compared to men. Sex-specific determinants of reperfusion and functional outcome were identified that require further study.

Bigger is Still Better: A Step Forward in Reperfusion With React 71.

While multiple new larger-bore aspiration catheters have been introduced for stroke thrombectomy, sizeable cohort outcome studies are lacking along with meaningful comparative studies to evaluate whether they represent a clinically relevant improvement compared to predecessors. To evaluate comparative angiographic and clinical outcomes between an 071 and 068 aspiration catheter. The authors reviewed an institutional thrombectomy database extracting the first 150 consecutive cases utilizing React 71 (Medtronic, Dublin, Ireland) with a comparison of background/demographic, procedural, angiographic, and clinical outcome variables to a cohort of patients treated with our previously most frequently utilized 0.068-inch aspiration catheter. In our React 71 cohort, successful reperfusion (thrombolysis in cerebral infarction [TICI] 2b-3) was achieved in 95% of cases. In comparison to a prior cohort of 96 patients treated with a 0.068-inch catheter, there was no statistically significant difference in rates of successful reperfusion (TICI 2b-3), initial disposition, and 90-d outcome. However, the frequency of single pass cases was significantly higher in the React 71 cohort (47%vs 35%, P=.019 on multivariate analysis) along with the rate of TICI 2c-3 reperfusion after the first pass (26%vs 14%, P=.019 on multivariate analysis), and final TICI 2c-3 reperfusion (39%vs 28%, P=.04 on multivariate analysis). While rates of TICI 2b-3 reperfusion and clinical outcome results were similar, our study suggests that a newer, larger bore aspiration catheter may be associated with a greater frequency of single pass cases and higher quality reperfusion, judged as TICI 2c-3 frequency after the first and final pass.

Abstract P505: Prediction of Infarct Volume at the 24 Hours After Late Window Presentation With Perfusion Imaging in Patients With Anterior Circulation Large Vessel Occlusion

Introduction: We sought to evaluate the accuracy of perfusion-weighted imaging (PWI) in late presenting patients for estimating the infarct volume at 24 hours after presentation. Methods: This is a secondary analysis of DEFUSE 3, which included stroke patients with anterior circulation occlusion within 6-16 hours of last known normal. The primary outcome is the final infarct volume on a 24-hour MRI scan (volume of DWI positive tissue), adjusted for the baseline infarct volume. We censored 3 patients with 24-hour follow-up MRI infarct volumes &gt;300 mL, which we considered non-physiologic for a hemispheric stroke. The primary predictors are the baseline volume of Tmax &gt;6s, Tmax &gt;10s, and hypoperfusion intensity ratio (HIR: Tmax10/Tmax6) on CT/MR perfusion at hospital admission. We stratified the cohort into 4 categories (untreated, TICI 0-2a, TICI 2b, and TICI3) and fit linear regression models to each of our predictors. Results: We included 147 patients, of which 69 were untreated, 17 had TICI 0-2a, 46 had TICI 2b, and 15 had TICI 3. In untreated patients, both HIR and Tmax10 volume were predictive of adjusted 24-hour follow-up infarct volume (Table). In treated patients, there were no consistent relationships between the perfusion imaging variables and adjusted final infarct volume (Table). Conclusion: For patients with late window anterior circulation large vessel occlusion stroke, HIR and Tmax10 volume appear to be reliable predictors of subsequent infarct volume in untreated patients. For patients treated with thrombectomy, further research is warranted to better understand the more complex relationship between baseline perfusion imaging and the 24 hour, and beyond, infarct volume.

Abstract 31: Penumbra Consumption Rates Based on T Max Delay and Reperfusion Status: A Post-Hoc Analysis of the Defuse-3 Trial

Introduction: In patients with acute large vessel occlusion, the definition of penumbral tissue based on T max delay perfusion imaging is not well established in relation to late-window endovascular thrombectomy (EVT). In this study, we sought to evaluate penumbra consumption rates for T max delays in patients treated between 6 and 16 hours from last known normal. Methods: This is a secondary analysis of the DEFUSE-3 trial, which included patients with an acute ischemic stroke due to anterior circulation occlusion within 6-16 hours of last known normal. The primary outcome is percentage penumbra consumption defined as (24 hour infarct volume-core infarct volume)/(Tmax volume-baseline core volume). We stratified the cohort into 4 categories (untreated, TICI 0-2a, TICI 2b, and TICI3) and calculated penumbral consumption rates. Results: We included 143 patients, of which 66 were untreated, 16 had TICI 0-2a, 46 had TICI 2b, and 15 had TICI 3. In untreated patients, a median (IQR) of 48% (21% - 85%) of penumbral tissue was consumed based on Tmax6 as opposed to 160.6% (51% - 455.2%) of penumbral tissue based on Tmax10. On the contrary, in patients achieving TICI 3 reperfusion, a median (IQR) of 5.3% (1.1% - 14.6%) of penumbral tissue was consumed based on Tmax6 and 25.7% (3.2% - 72.1%) of penumbral tissue based on Tmax10. Conclusion: Contrary to prior studies, we show that at least 75% of penumbral tissue with Tmax &gt; 10 sec delay can be salvaged with successful reperfusion and new generation devices. In untreated patients, since infarct expansion can occur beyond 24 hours, future studies with delayed brain imaging are needed to determine the optimal T max delay threshold that defines penumbral tissue in patients with proximal anterior circulation large vessel occlusion.

Abstract P482: Outcome of Endovascular Thrombectomy for Ultra-Long Aeromedical Transfers: The Experience of 1 Hub and 11 Spoke Sites Covering More Than 1.8 Million Km 2

Background: Local endovascular services for acute stroke in rural and remote regions remain a significant challenge despite higher rates of stroke in these regions. Aim: We present time metrics, logistical, safety and outcome data on large vessel occlusion (LVO) patients receiving endovascular thrombectomy (EVT) that were aeromedically transferred from rural and remote “spoke” sites to the Gold Coast University Hospital (GCUH) “hub”. Methods: This is a retrospective observational study utilizing prospectively collected stroke database from December 2018 to March 2020. Aeromedical transfers from ten rural and remote Queensland sites and one northern New South Wales site were included, covering more than 1.853 million km 2 catchment. Results: 20 out of 26 transferred patients underwent EVT over this period. Mean distance was 1380.5 km, median time of ictus to re-canalization was 928 minutes and TICI 2b-3 was achieved in 90% of the patients. One out of 20 patients (5%) had symptomatic ICH (sICH), and 9 out of 20 (45%) achieved functional independence (mRS 0-2) at 90 days; similar to the recent pivotal trials. Conclusions: Our 12-center network experience confirms real world reproducibility of trial results including ultra-long transfers and supports such transfers at other centers worldwide.

Abstract P519: Higher Number of Thrombectomy Passes Significantly Increases Risk of Mass Effect, Poor Functional Outcome, and Mortality

Background: Endovascular treatment (EVT) is a widely proven method to treat patients diagnosed with intracranial large vessel occlusion (LVO). Through this method of treatment, it has been hypothesized that a lower number of thrombectomy passes is an indicator of higher rates of modified Thrombolysis in Cerebral Infarction 2b-3 (mTICI) and favorable outcomes defined as modified Rankin Scale 0-2 (mRS). Methods: Through the utilization of a prospectively collected endovascular database between 2012-2020, variables such as demographics, co-morbid conditions, intracerebral hemorrhage, mass effect, mortality rate, and good/poor outcomes in regard to mTICI score and mRS assessment at discharge were examined. The outcomes between patients receiving EVT who were treated with &lt; 3 thrombectomy passes or ≥ 3 passes were compared. Results: Out of 454 patients treated with mechanical thrombectomy of qualifying intracranial internal carotid artery or middle cerebral artery occlusion, site of occlusion (internal carotid artery, M1 and M2), a total of 372 (81.9%) were treated with &lt; 3 thrombectomy passes (average age 70.34 ± 13.75 years, 46.0% women), and 82 (18.1%) were treated with ≥ 3 thrombectomy passes (average age 70.30 ± 13.72 years, 48.8% women). Significantly higher rates of mass effect (p=0.043), mRS score 3-6 (p=0.029), and mortality (p=0.025) were noted in patients treated with ≥ 3 thrombectomy passes. Further analysis revealed that patients presenting 6-24 hours from symptom onset had significantly lessened chance of effective recanalization (TICI 2B-3; p=0.021). Conclusion: A higher number of thrombectomy passes, characterized as ≥ 3 passes in this study, was associated with significantly worsened patient outcome in regard to functional outcome, and mortality. Further research is required to determine whether the number of thrombectomy passes is an accurate indicator of treatment outcome and whether delayed presentation time increases risk of poor outcome.

Abstract P524: Impact of Intra-Procedural Workflow and Time Metrics of Establishing Fast Reperfusion on Clinical Outcomes in the ESCAPE-NA1 Trial

Background: Time from imaging to establishing reperfusion is a major influencer of clinical outcomes and over the years thrombectomy techniques have evolved rapidly. This has led to improvements in achieving fast and complete reperfusion. We analyzed the impact of various intra-procedural techniques and tools on the speed of reperfusion and correlated procedural duration with probability of achieving good clinical outcomes. Methods: We analyzed intra-procedural time metrics and examined factors leading to delays during EVT. The relationship between outcome (mRS Scale) and procedural time from arterial puncture to time of achieving mTICI 2b-3 First Reperfusion (FRE) was modeled using logistic regression. Results: The various procedural time metrics are summarized in Figure 1. Every 10-minute increase in FRE time reduced the probability of achieving functional independence(90-day modified Rankin Scale 0-2) by 6.7% (P=0.021, adjusted). The medianFRE timewas 25min (IQR 17-39) and was significantly longer in patients with tandem occlusions(median 34min, p 0.0005). General anesthesia vs procedural sedation vs no sedation use did not significantly alter the FRE time (p = 0.1453). The use of BGC (54.2%) was nominally longer FRE (median 26min “IQR 18-38” vs 23ming, “IQR 16-38”; p 0.095)while the use of contact aspiration (n=213) vs retrievable stents (n=676) as the first approach was associated with a shorter FRE time (21min “IQR 14-35” vs 26 min “IQR18-40”, p =0.001). Conclusions: Puncture to first reperfusion time is a significant predictor of clinical outcome in theESCAPE-NA1 trial. Various procedural and anatomical factors influence this timemetric. Figure: Intra-Procedural workflow time metrics expressed in medians and 90th percentiles. The cumulative times are calculated for each major milestone in the procedure for upto three attempts. First reperfusion duration where TICI 2b was achieved is shown in comparison to other procedural time metrics.

Abstract P480: Impact of Intravenous Thrombolysis on Reperfusion Status in Stroke Thrombectomy

Introduction: It remains unclear whether use of intravenous thrombolysis (IVT) with intravenous tissue plasminogen activator (tPA) provides additional benefit to patients with emergent large vessel occlusion (ELVO) stroke undergoing mechanical thrombectomy (MT). We sought to determine the impact of IVT on procedure time, number of passes, and successful reperfusion (SR) during MT. Method: We retrospectively analyzed all patients who underwent anterior circulation mechanical thrombectomy for treatment of ELVO stroke at our institution from April 2012 to November 2019. Univariate and multivariate logistic regression analyzes were used to determine independent predictors of poor functional outcome at 90 days,and independent predictors of &gt;2 thrombectomy passes in patients with successful revascularization (SR: TICI 2B, 2C and 3). Results: A total of 400 patients were eligible for analysis. 189 patients received IVT before thrombectomy. Last known well time-to-endovascular therapy was shorter in the IVT group (290.0 min vs 452.75 min; P=&lt;0.001). The IVT group had a trend towards better outcomes at 90 days (mRS 0—2: 44% vs 35%; P=0.076). The number of passes and revascularization status did not significantly differ between IVT and non-IVT patients. The number of patients with any intracranial hemorrhage was higher in the IVT group than non- IVT group [10% vs 4%; p=0.038].Multivariate logistic regression demonstrated ICA occlusion site was an independent predictors of &gt;2 passes relative to M1 occlusion in patients with successful revascularization. Multivariate logistic regression revealed that age (OR 1.05, 95% CI 1.03-1.07; p&lt;0.001), NIHSS (OR 1.11, 95% CI 1.06-1.17; p&lt;0.001), ≥3 thrombectomy passes (OR 2.47, 95% CI 1.23-5.00; p=0.011) and intracranial hemorrhage (OR 5.50, 95% CI 1.45-20.84; p=0.012)were independently associated with an increased odds of poor outcome. TICI 2C/3 was associated with reduced odds of poor outcome (OR 0.16, 95% CI 0.07-0.35; p&lt;0,001). Conclusion: IVT pretreatment did not increase rates of SR and did not shorten MT procedure time nor number of passes needed to achieve SR during MT in our patient population. Randomized controlled trials are required for further evaluation of the impact of IVT on reperfusion status during MT.

Abstract 32: Residual Perfusion Deficit is Common Post Successful EVT and is Associated With Worse Clinical Outcome

Introduction: A significant portion of patients despite achieving successful recanalization following endovascular therapy (EVT) still have some residual perfusion deficit. The objective of this study was to identify the association of residual perfusion deficit with recanalization status and clot presence post EVT. Methods: Patients were included if they were evaluated at one of two comprehensive stroke centers from January 2015 through February 2018, had LVO of the anterior circulation, had baseline MRI pre EVT, and treated with EVT. Independent image reads by two separate readers blinded to target vessel, TICI score, and clinical outcome, evaluated the pre EVT, 2 hours, and 24 hours post EVT MRI for perfusion deficit and clot presence. The MTT and TTP maps post EVT were read separately for residual perfusion deficit, compared to the pre EVT perfusion deficit. Clot presence was read as susceptibility sign on GRE consistent with the vascular territory identified on the pre EVT PWI. Successful recanalization was defined as TICI 2b\3 in the IR suite. Early neurological improvement (ENI) was defined as a reduction of the admit NIHSS by ≥4 points or a score of 0-1 at 24 hours. Results: Fifty-eight patients were included with median age of 58 years, 55% female, 47% Black\African-American, median admit NIHSS of 19, 72% with M1 LVO, 69% treated with IV tPA, 79% achieved TICI of 2b\3, and 52% with ENI at 24 hours. All patients had a perfusion deficit pre EVT with 73% having a corresponding clot on GRE. Following EVT, 76% and 52% of patients had residual perfusion deficit at 2 and 24 hours post EVT, but only 24% and 13%, respectively, still had evidence of clot. For the 46 patients with successful recanalization, 41% still had some residual perfusion deficit at 24 hours, but only 9% still had clot, suggesting inadequate perfusion without a mechanical obstruction. The frequency of ENI at 24 hours was associated with complete reperfusion, 88% versus 46% (p=0.039) at 2 hours post EVT, and 76% versus 33% (p=0.002) at 24 hours post EVT. Conclusions: Residual perfusion deficit on post EVT MRI is common, even with successful recanalization, and is associated with poor outcome. Patients with residual perfusion deficit may benefit from early adjunctive therapy following EVT to improve outcome.

Abstract P361: Visualization of the Anterior Temporal Artery as a Predictor of Outcome in Middle Cerebral Artery Occlusion Patients Achieving Successful Recanalization After Interfacility Transfer

Introduction: Many non-thrombectomy centers lack Computerized Tomography Perfusion (CTP) capability. Anterior temporal artery (ATA) visualization on Computerized Tomography Angiography (CTA) has been previously associated with good outcomes in middle cerebral artery (MCA) occlusions, but not in the context of recanalization after interfacility transfer for thrombectomy. We hypothesized that independent functional outcome at 90 days would be greater for MCA occlusion patients initially presenting to non-thrombectomy centers with a visualized ATA on CTA who achieved TICI 2b or greater recanalization after transfer. Methods: We conducted a retrospective cohort study of patients transferred for mechanical thrombectomy. A neuroradiologist blinded to patient outcomes confirmed the MCA as the most proximal site of occlusion on CTA, and assessed for visualization of the ATA. TICI 2b or greater revascularization scores were confirmed by neurointerventionalists blinded to patient outcomes. Ninety-day mRS scores were obtained via telephone utilizing a structured questionnaire. Results: We identified a total of 107 MCA occlusion patients over a 3 ½ year period meeting our inclusion criteria. There were no significant differences in age, gender, race, comorbidities, median NIHSS, or time-to-revascularization variables between the ATA visualized (n=50) versus non-visualized (n=57) group, with the exception of significantly more wake-up strokes in the ATA visualized group (34.7% vs 16.1%, p=0.03). There was a non-significant trend for independent outcome (mRS ≤2) at 90 days for patients with ATA visualization compared to those for whom the ATA was not visualized on the CTA (63.8% vs 45.5%, p=0.06). Conclusion: For MCA occlusion patients initially presenting to non-thrombectomy centers achieving successful recanalization via mechanical thrombectomy, there is a strong trend for visualization of the anterior temporal artery on the CTA performed at the non-thrombectomy center as being a predictor of independent functional outcome. Especially for institutions without CTP capability, this association with ATA visualization should be further investigated as a predictor for good outcome after transfer for successful mechanical thrombectomy.

Abstract P474: Functional Outcomes and Regional Significance of Ischemic Lesions After Thrombectomy for Large Vessel Occlusion Stroke

Introduction: Endovascular thrombectomy (EVT) has revolutionized large vessel occlusion (LVO) stroke care. However, over half remain functionally disabled or die despite treatment. Understanding outcomes may influence EVT selection, novel therapies, and prognostication. We sought to identify associations between outcomes and brain regions involved in ischemic lesions. Methods: For consecutive LVO patients with post-EVT MRI, acute ischemic lesions were manually segmented from DWI and spatially normalized. Individual lesion volumes were automatically parcellated (atlas-defined 94 cortical regions, 14 subcortical nuclei, 20 white matter tracts) and then reduced to ten anatomically plausible lesion patterns using unsupervised dimensionality reduction techniques. Ninety-day modified Rankin Scale (mRS) was modeled via Bayesian regression, taking the ten lesion patterns as inputs and controlling for lesion size, age, sex, acute NIH Stroke Scale, alteplase, and TICI 2b-3 reperfusion. Results: We identified 153 LVO patients with mean age 68±15 years and 51% female. Median NIHSS was 16 (IQR 13-20), 56% received alteplase, and 84% achieved TICI2b-3. The lesion patterns predictive of 90-day mRS involved bilateral subcortical nuclei, pre- and postcentral gyri, insular and opercular cortex, as well as left-sided inferior frontal and angular gyri ( Figure 1A ). Lesions affecting white matter tracts had the highest relevance predicting 90-day mRS ( Figure 1B ). Conclusions: These data describe the significance for outcomes of specific brain regions involved in ischemic lesions on MRI after EVT. Future work in additional datasets is needed to confirm these granular findings.

Abstract P360: Clot Burden Score and Collateral Score: Emerging Predictors of Outcome

Introduction: With the recent advancement, there are still large number of stroke patients who end up with poor outcome despite getting thrombectomy. Clot extent, location, and collateral integrity are found to be important determinants of outcome in acute stroke. The CBS is a scoring system (0-10) to define the extent of thrombus on CTA. The collateral grading system is scored on a scale of 0-3 on CTA. The purpose of this study is to compare the relationship of clot extent and collaterals with clinical and radiological outcome. Hypothesis: A novel clot burden score (CBS) and collateral score (CS) are important determinants of outcomes and serve as useful additional stroke outcome predictors. Methods: One hundred and twenty eight stroke patients with large vessel occlusion who underwent endovascular thrombectomy in our institution were reviewed retrospectively. CBS and CS were calculated on CTA by a neuroradiologist and a vascular neurologist and reached a consensus who were blinded about clinical information. Patients were dichotomized using collateral scores as good (&gt;/=2) vs bad collaterals (0-1). Univariate and multivariate analysis is performed. Results: A total of 128 patients included in the study. Poor collateral is found to be associated with prior history of Afib (47% vs 32%) whereas smoking is found to be associated with good collaterals (38% vs 29%). Low CBS (higher clot burden) is associated more with poor collaterals (70% vs 46%). Poor collateral is associated with higher inhouse mortality (23% vs 9%) and increase number of patients with mRS of 5-6 at 3 months (42% vs 21%). Revascularization rate TICI 2b-3 is not found to be significantly associated with the degree of collaterals (93% with good collaterals whereas 78% in poor collaterals) Conclusions: CBS and CS are useful additional markers predicting clinical and radiologic outcomes and could be potentially used clinically as an adjunct to other imaging and clinical features to stratify patient risk better.

Abstract P545: First Pass TICI 2b versus Multiple Passes TICI 3 for Acute Ischemic Stroke Patients: Is First Pass TICI 2b Enough?

Background and Objective: Prompt and complete reperfusion with mechanical thrombectomy (MT) is essential to improve outcome in acute ischemic strokes (AIS) with large vessel occlusion (LVO). Recently, first-pass effect (FPE), defined as achieving complete reperfusion with a single pass, has been emphasized as a potentially important MT target. We aimed to compare outcomes between patients who achieve mTICI 2b with first pass to those with multiple devise passes (MDP) mTICI 3. Methods: From a single comprehensive stroke center database, we retrospectively grouped LVO pts treated with MT into those who achieved mTICI 2b after a single pass and mTICI 3 after MDP. Clinical outcome (discharge and 90-day mRS), discharge NIHSS and safety (sICH, neurological worsening, mortality) were compared between the two groups. Results: Of 186 pts included, 153 (82%) achieved mTICI 3 with MDP, and 33 (18%) had mTICI 2b after a single pass. Mean age (71 vs 69), NIHSS (17 vs 16, p=0.2) were similar between the two groups. Patients with a single pass mTICI 2b had numerically higher IV tPA administration (33% vs 46%, p=.16). There was no difference in other baseline characteristics. There was no significant difference in discharge (21% vs 24.2%, p=0.65) and 90-day mRS 0-2 (24% vs 24%, p=0.5), MDP mTICI 3 and single pass mTICI 2b, respectively. Also, there was no difference in discharge NIHSS score (13.6 vs 16.7, p=0.26), mortality (16.3% vs 18.2%, p=0.8) and sICH rates (7.8% vs 18.2%, p=0.095) or neurological worsening (76.5% vs 69.7%, p=1). Conclusion: Our results did not show a significant difference between mTICI 3 with multiple passes and mTICI 2b after a single pass. Future large studies are warranted to explore the possibility of extending the first pass effect to patients who achieve mTICI 2b with a single pass.

Low-Dose Eptifibatide for Tandem Occlusion in Stroke: Safety and Carotid Artery Patency

Maintaining carotid patency and avoiding symptomatic intracranial hemorrhage are competing concerns in tandem occlusions. This study provides data regarding the safety and efficacy of eptifibatide in stroke from tandem occlusion of the extracranial carotid artery and the intracranial carotid or middle cerebral artery. This is a retrospective analysis of 58 consecutive patients who received low-dose eptifibatide (135-mcg/kg bolus, 1-mcg/kg/min infusion) during treatment of tandem occlusions. Brain imaging and carotid sonography were performed at 24-36 hours. mRS was documented at 90 days, and carotid sonography, at 30-60 days. The median age and NIHSS score were 64 years and 15, respectively. Twenty-five patients (43%) received tPA. ASPECTSs were 8-10 in 47 (81%) and 5-7 in 11 (19%) patients. Thirty-eight patients had angioplasty/stent placement acutely; 20 had angioplasty alone. Symptomatic intracranial hemorrhage occurred in 1 patient (2%). TICI 2b or higher was achieved in 56 patients (96%). Fifty-seven of 58 patients had clinical follow-up at 90 days (1 lost to follow up). The 90-day mRS was 0-2 in 42 patients (72%). There were 4/58 (7%) re-occlusions within 24-36 hours, all originally treated with stent placement. Forty-nine of 53 surviving patients had carotid sonography at 30-60 days, with 3 delayed re-occlusions, 2 with stents and 1 with angioplasty alone. The overall carotid patency at 30-60 days was 42/49 (86%). Carotid re-occlusion was not associated with clinical decline. Low-dose eptifibatide seemed to be safe in tandem occlusions (symptomatic intracranial hemorrhage, 2%), although asymptomatic cervical carotid artery re-occlusions still occurred in 14% of patients.

Impact of Clot Shape on Successful M1 Endovascular Reperfusion.

Objectives: The susceptibility-vessel-sign (SVS) allows thrombus visualization, length estimation and composition, and it may impact reperfusion during mechanical thrombectomy (MT). SVS can also describe thrombus shape in the occluded artery: in the straight M1-segment (S-shaped), or in an angulated/traversing a bifurcation segment (A-shaped). We determined whether SVS clot shape influenced reperfusion and outcomes after MT for proximal middle-cerebral-artery (M1) occlusions.Methods: Between May 2015 and March 2018, consecutive patients who underwent MT at one comprehensive stroke center and who had a baseline MRI with a T2* sequence were included. Clinical, procedural and radiographic data, including clot shape on SVS [angulated/bifurcation (A-SVS) vs. straight (S-SVS)] and length were assessed. Primary outcome was successful reperfusion (TICI 2b-3). Secondary outcome were MT complication rates, MT reperfusion time, and clinical outcome at 90-days. Predictors of outcome were assessed with univariate and multivariate analyses.Results: A total of 62 patients were included. 56% (35/62) had an A-SVS. Clots were significantly longer in the A-SVS group (19 mm vs. 8 mm p = 0.0002). Groups were otherwise well-matched with regard to baseline characteristics. There was a significantly lower rate of successful reperfusion in the A-SVS cohort (83%) compared to the S-SVS cohort (96%) in multivariable analysis [OR 0.04 (95% CI, 0.002–0.58), p = 0.02]. There was no significant difference in long term clinical outcome between groups.Conclusion: Clot shape as determined on T2* imaging, in patients presenting with M1 occlusion appears to be a predictor of successful reperfusion after MT. Angulated and bifurcating clots are associated with poorer rates of successful reperfusion.

Acute Endovascular Stroke Treatment in Germany in 2019

PurposeSince the incidental discovery and systematic introduction of mechanical endovascular stroke treatment in 2015 there are few reports about the real-life situation in daily clinical practice. The aim of this study was to evaluate the mechanical thrombectomy data documented in the quality assurance database of the German Society for Interventional Radiology and Minimally Invasive Therapy (DeGIR) and the German Society of Neuroradiology (DGNR) in 2019.MethodsWe retrospectively analyzed the clinical and procedural data of all mechanical thrombectomies that were entered into the voluntary nationwide database in 2019. The information of each procedure was provided on a standardized web-based data sheet. Data were exported and analyzed by a group of experts on behalf of the DGNR.ResultsA total of 13,840 data sets from 158 participating centers could be analyzed. Mean age of the patients was 74 ± 13 years; 53.9% were female. Vessel occlusion was located in the anterior circulation in 87.4%, in the posterior circulation in 10.7%. On hospital admission, the median National Institutes of Health Stroke Scale (NIHSS) was 14 (lower/upper quartile 10/19); at hospital discharge, median NIHSS had dropped to 9 (lower/upper quartile 2/12; p < 0.001).Recanalization of the occluded vessel segment was successful (TICI 2b + 3) in 88.4%. The reported complication rate was 7.3%, with subarachnoid hemorrhage as the most frequent complication (3.4%), followed by parenchymal hemorrhage (1.7%) and embolization in new territories (1.2%).Overall, the median time interval from symptom onset to hospital admission was 94 min (quartiles 59/180 min), the median time from hospital admission to groin puncture was 74 min (lower/upper quartile 47/103 min), and the median duration of the procedure 43 min (lower/upper quartile 25.2/73.2 min). A comparison between primary and secondary referral revealed a significant faster symptom-to-intervention time for primary referrals, whereas in-house workflows showed no significant difference.ConclusionThe analysis represents the largest documented cohort of acute stroke patients treated by thrombectomy. The documentation allows for a detailed evaluation of procedural, clinical, logistic and radiation exposure data and might be used for monitoring the quality of the treatment on a nationwide scale.

White Matter Acute Infarct Volume After Thrombectomy for Anterior Circulation Large Vessel Occlusion Stroke is Associated with Long Term Outcomes

ObjectivesDespite the proven efficacy of endovascular thrombectomy (EVT) for large vessel occlusion stroke, over half treated remain functionally disabled or die. Infarct topography may have implications for prognostication, patient selection, and the development of tissue-specific neuroprotective agents. We sought to quantify white matter injury in anterior circulation acute infarcts post-EVT to understand its significance and identify its determinants. Materials and MethodsDemographics, history, presentations, and outcomes for consecutive patients treated with EVT were recorded in a prospectively maintained database at a single center. Acute infarct masks were coregistered to standard space. Standard atlases of white matter, cortex, and basal ganglia were used to determine region-specific infarct volumes. Results167 individuals were identified with median age 69 years and 53% women. 85% achieved adequate reperfusion (TICI 2b-3) after EVT; 43% achieved 90-day functional independence (mRS 0-2). Median infarct volumes were 45cc (IQR 18-122) for total, 17cc (6-49) for white matter, 21cc (4-53) for cortex, and 5cc (1-8) for basal ganglia. The odds of 90-day mRS 0-2 were reduced in patients with larger white matter infarct volume (cc, OR=0.89, 95%CI=0.81-0.96), independent of cortex infarct volume, basal ganglia infarct volume, age, NIHSS, and TICI 2b-3 reperfusion. Reperfusion-to-MRI time was associated with white matter infarct volume (hr, β=0.119, p=0.017), but not cortical or basal ganglia infarct volume. ConclusionsThese data quantitatively describe region-specific infarct volumes after EVT and suggest the clinical relevance of white matter infarct volume as a predictor of long-term outcomes. Further study is warranted to examine delayed white matter infarction and the significance of specific white matter tracts.

Intravenous Tissue Plasminogen Activator in Combination With Mechanical Thrombectomy: Clot Migration, Intracranial Bleeding, and the Impact of "Drip and Ship" on Effectiveness and Outcomes.

Purpose: Intravenous tissue plasminogen activator (tPA) is indicated prior to mechanical thrombectomy (MT) to treat large vessel occlusion (LVO). However, administration takes time, and rates of clot migration complicating successful retrieval and hemorrhagic transformation may be higher. Given time-to-effectiveness, the benefit of tPA may vary significantly based on whether administration occurs at a thrombectomy-capable center or transferring hospital.Methods: We prospectively evaluated 170 individuals with LVO involving the anterior circulation who underwent MT at our Comprehensive Stroke Center over a 3.5 year period. Two thirds (n = 114) of patients were admitted through our Emergency Department (ED). The other 33% were transferred from outside hospitals (OSH). Patients meeting criteria were bridged with IV tPA; the others were treated with MT alone. Clot migration, recanalization times, TICI scores, and hemorrhage rates were compared for those bridged vs. treated with MT alone, along with modified Rankin scores (mRS) at discharge and 90-day follow-up. Multivariable regression was used to determine the relationship between site of presentation and effect of tPA on outcomes.Results: Patients presenting to an OSH had longer mean discovery to puncture/recanalization times, but were actually more likely to receive IV tPA prior to MT (70 vs. 42%). The rate of clot migration was low (11%) and similar between groups, though slightly higher for those receiving IV tPA. There was no difference in symptomatic ICH rate after tPA. TICI scores were also not significantly different; however, more patients achieved TICI 2b or higher reperfusion (83 vs. 67%, p = 0.027) after tPA, and TICI 0 reperfusion was seen almost exclusively in patients who were not treated with tPA. Those bridged at an OSH required fewer passes before successful recanalization (2.4 vs. 1.6, p = 0.037). Overall, mean mRS scores on discharge and at 90 days were significantly better for those receiving IV tPA (3.9 vs. 4.6, 3.4 vs. 4.4 respectively, p ~ 0.01) and differences persisted when comparing only patients recanalized in under 6 h.Conclusion: Independent of site of presentation, IV tPA before MT appears to lead to better radiographic outcomes, without increased rates of clot migration or higher intracranial hemorrhage risk, and overall better functional outcomes.

Coronary stent implantation for acute basilar artery occlusion with underlying stenosis.

Our aim was to study the effectiveness of coronary stent implantation during the endovascular treatment (EVT) of acute basilar artery occlusion (BAO) with occlusion-underlying intracranial atherosclerotic stenosis (ICAS). We retrospectively analysed 91 consecutive BAO patients who underwent EVT between February 2014 and January 2019 in a single, high-volume neurointerventional centre. We studied the effect of immediate coronary stent implantation on the clinical outcome of BAO with occlusion-underlying stenosis. BAO patients with underlying ICAS (n=41) were characterised by longer symptom-onset-to-reperfusion times (231 min vs 173 min, p=0.0020), lower TICI 2b-3 reperfusion rates (65.85% vs 90.00%, p=0.0084), and higher overall mortality (HR 2.021, p=0.0417) compared to the BAO cases without ICAS (n=50). The patients undergoing stenting (n=18) had lower residual basilar artery (BA) stenosis (14.7% vs 81.0%, p<0.0001), higher chance for functional recovery (OR 7.6, p=0.0250) and higher chance of survival (HR 4.163, p=0.0026) compared to the BAO-ICAS cases treated without coronary stents (n=21). The immediate treatment of the occlusion-underlying stenosis with coronary stents and dual antiplatelet therapy (DAPT) in BAO was associated with improved overall survival and better functional outcomes.

Treatment Approaches and Outcomes for Acute Anterior Circulation Stroke Patients with Tandem Lesions

ObjectivesEndovascular thrombectomy (EVT) has revolutionized stroke care for large vessel occlusions (LVOs). However, over half treated remain functionally disabled or die. Patients with tandem lesions, or severe stenosis/occlusion of the cervical internal carotid artery (ICA) with intracranial LVO, may have technical EVT challenges and worse outcomes. We sought to compare treatments and outcomes for patients with anterior circulation tandem lesions versus isolated LVOs. Materials and MethodsConsecutive tandem lesion and isolated intracranial LVO patients were identified at a single center. Demographics, medical history, presentations, treatments, and outcomes were collected and analyzed. ResultsFrom 381 EVT patients, 62 had tandem lesions related to atherosclerosis (74%) or dissection (26%). Compared to isolated intracranial LVOs, they were younger (63 vs 70, p = 0.003), had less atrial fibrillation (13% vs 40%, p < 0.0001), less adequate reperfusion (TICI 2b-3, 58% vs 82%, p < 0.0001), more intracranial hemorrhage (ICH, 13% vs 5%, p = 0.037), but similar 90-day functional independence (mRS 0–2, 34% vs 43%, p = 0.181). The cervical ICA was treated before intracranial EVT (57%), after (13%), not acutely (22%), or was inaccessible (8%). Acute cervical ICA treatments were stenting (57%) or angioplasty alone (13%). Neither acute stenting nor order of treatment was associated with outcomes (TICI 2b-3, ICH, or 90-day mRS 0-2). Among acutely stented, neither alteplase nor antiplatelets were associated with outcomes or stent patency. ConclusionsTandem lesions were associated with less reperfusion, more ICH, but similar 90-day functional independence. No treatment approach was associated with outcomes. These data illustrate the technical challenges of tandem lesion treatment and underscore the importance of developing new approaches.