Abstract WMP8: Results of Trevo Acute Ischemic Stroke Thrombectomy Registry: Predictors of Clinical Outcome

Background and Purpose: Recent randomized clinical trial (RCTs) demonstrated efficacy of mechanical thrombectomy using stent-retrievers in acute ischemic stroke (AIS) patients. The main purpose of TRevo ACute Ischemic StroKe (TRACK) stent-retriever thrombectomy multicenter registry is to demonstrate safety and efficacy in real life clinical practice.

Methods: The investigator-initiated TRACK multicenter registry recruited 24 sites in north America to submit demographic, clinical, site-adjudicated angiographic, and outcome data on consecutive AIS patients treated with Trevo stent-retriever device as the first treatment option. Standard clinical safety (symptomatic intracranial hemorrhage (sICH), and mortality) and efficacy (revascularization and disability) outcomes and predictors of clinical outcome were analyzed.

Results: 624 patients were enrolled in the TRACK registry. Median age was 68 years (range 16-94, 118 (18.1%) >80), male gender was 51.4%, and 67.7% were white. The median National Institutes of Health Stroke Severity Scale (NIHSS) was 17 (IQR 13-22). Transfer cases were 50.6% with IV-rtPA use in 318 cases (51.3%). Median onset to groin puncture (OTG) time was 283 min (IQR 198.5-443), and groin puncture to revascularization was 66 min (IQR 37.5-103). Anterior circulation occlusion was 86.2% (MCA/M2 in 55.2% followed by ICA in 15.9% and M2 in 12.7%). Use of GA was in 389 cases (62.3%), number of passes were ≤ 3 in 92% of the cases (1: 45.2%, 2:28%, and 3:18.7%), 291 (46.7%) had BGC use. Rescue use was seen in 21.7%. Revascularization of ≥ TIMI 2 was 81.8% and ≥ TICI 2b was 70%. The primary outcome of mRS of ≥ 2 was 48.3% in the full cohort, and 50.6% in TREVO-2 like group. sICH and mortality were 7.2%, and 20.1% in the full cohort vs 6.9% and 17.5% in the TREVO-2 like group, respectively. The independent predictors of clinical outcome were lower baseline NIHSS, younger age, use of BGC, successful recanalization, and no general anesthesia (GA).

Conclusions: The real life clinical practice Trevo registry demonstrated good clinical outcome and high rate of recanalization. Younger age, lower baseline NIHSS, use of balloon guide catheter, successful recanalization, and avoiding endotrachaeal GA independent predictors of good clinical outcome.

Predictors of poor outcome despite recanalization: a multiple regression analysis of the NASA registry

BACKGROUND

Mechanical thrombectomy with stent-retrievers results in higher recanalization rates compared with previous devices. Despite successful recanalization rates (Thrombolysis in Cerebral Infarction (TICI) score ≥2b) of 70-83%, good outcomes by 90-day modified Rankin Scale (mRS) score ≤2 are achieved in only 40-55% of patients. We evaluated predictors of poor outcomes (mRS >2) despite successful recanalization (TICI ≥2b) in the North American Solitaire Stent Retriever Acute Stroke (NASA) registry.

METHODS

Logistic regression was used to evaluate baseline characteristics and recanalization outcomes for association with 90-day mRS score of 0-2 (good outcome) vs 3-6 (poor outcome). Univariate tests were carried out for all factors. A multivariable model was developed based on backwards selection from the factors with at least marginal significance (p≤0.10) on univariate analysis with the retention criterion set at p≤0.05. The model was refit to minimize the number of cases excluded because of missing covariate values; the c-statistic was a measure of predictive power.

RESULTS

Of 354 patients, 256 (72.3%) were recanalized successfully. Based on 234 recanalized patients evaluated for 90-day mRS score, 116 (49.6%) had poor outcomes. Univariate analysis identified an increased risk of poor outcome for age ≥80 years, occlusion site of internal carotid artery (ICA)/basilar artery, National Institute of Health Stroke Scale (NIHSS) score ≥18, history of diabetes mellitus, TICI 2b, use of rescue therapy, not using a balloon-guided catheter or intravenous tissue plasminogen activator (IV t-PA), and >30 min to recanalization (p≤0.05). In multivariable analysis, age ≥80 years, occlusion site ICA/basilar, initial NIHSS score ≥18, diabetes, absence of IV t-PA, ≥3 passes, and use of rescue therapy were significant independent predictors of poor 90-day outcome in a model with good predictive power (c-index=0.80).

CONCLUSIONS

Age, occlusion site, high NIHSS, diabetes, no IV t-PA, ≥3 passes, and use of rescue therapy are associated with poor 90-day outcome despite successful recanalization.

Influence of age on clinical and revascularization outcomes in the North American Solitaire Stent-Retriever Acute Stroke Registry

BACKGROUND AND PURPOSE

The Solitaire With the Intention for Thrombectomy (SWIFT) and thrombectomy revascularization of large vessel occlusions in acute ischemic stroke (TREVO 2) trial results demonstrated improved recanalization rates with mechanical thrombectomy; however, outcomes in the elderly population remain poorly understood. Here, we report the effect of age on clinical and angiographic outcome within the North American Solitaire-FR Stent-Retriever Acute Stroke (NASA) Registry.

METHODS

The NASA Registry recruited sites to submit data on consecutive patients treated with Solitaire-FR. Influence of age on clinical and angiographic outcomes was assessed by dichotomizing the cohort into ≤80 and >80 years of age.

RESULTS

Three hundred fifty-four patients underwent treatment in 24 centers; 276 patients were ≤80 years and 78 were >80 years of age. Mean age in the ≤80 and >80 cohorts was 62.2±13.2 and 85.2±3.8 years, respectively. Of patients >80 years, 27.3% had a 90-day modified Rankin Score ≤2 versus 45.4% ≤80 years (P=0.02). Mortality was 43.9% and 27.3% in the >80 and ≤80 years cohorts, respectively (P=0.01). There was no significant difference in time to revascularization, revascularization success, or symptomatic intracranial hemorrhage between the groups. Multivariate analysis showed age >80 years as an independent predictor of poor clinical outcome and mortality. Within the >80 cohort, National Institutes of Health Stroke Scale (NIHSS), revascularization rate, rescue therapy use, and symptomatic intracranial hemorrhage were independent predictors of mortality.

CONCLUSION

Greater than 80 years of age is predictive of poor clinical outcome and increased mortality compared with younger patients in the NASA registry. However, intravenous tissue-type plasminogen activator use, lower NIHSS, and shorter revascularization time are associated with better outcomes. Further studies are needed to understand the endovascular therapy role in this cohort compared with medical therapy.

North American SOLITAIRE Stent-Retriever Acute Stroke Registry

Background and Purpose—

Previous work that predated the availability of the safer stent-retriever devices has suggested that general anesthesia (GA) may have a negative impact on outcomes in patients with acute ischemic stroke undergoing endovascular therapy.

Methods—

We reviewed demographic, clinical, procedural (GA versus local anesthesia [LA], etc), and site-adjudicated angiographic and clinical outcomes data from consecutive patients treated with the Solitaire FR device in the investigator-initiated North American SOLITAIRE Stent-Retriever Acute Stroke (NASA) Registry. The primary outcomes were 90-day modified Rankin Scale, mortality, and symptomatic intracranial hemorrhage.

Results—

A total of 281 patients from 18 centers were enrolled. GA was used in 69.8% (196/281) of patients. Baseline demographic and procedural factors were comparable between the LA and GA groups, except the former demonstrated longer time-to-groin puncture (395.4±254 versus 337.4±208 min; P =0.04), lower National Institutes of Health Stroke Scale (NIHSS; 16.2±5.8 versus 18.8±6.9; P =0.002), lower balloon-guide catheter usage (22.4% versus 49.2%; P =0.0001), and longer fluoroscopy times (39.5±33 versus 28±22.8 min; P =0.008). Recanalization (thrombolysis in cerebral infarction ≥2b; 72.94% versus 73.6%; P =0.9) and rate of symptomatic intracranial hemorrhage (7.1% versus 11.2%; P =0.4) were similar but modified Rankin Scale ≤2 was achieved in more LA patients, 52.6% versus 35.6% (odds ratio, 1.4 [1.1–1.8]; P =0.01). In multivariate analysis, hypertension, NIHSS, unsuccessful revascularization, and GA use (odds ratio, 3.3 [1.6–7.1]; P =0.001) were associated with death. When only anterior circulation and elective GA patients were included, there was a persistent difference in good outcomes in favor of LA patients (50.7% versus 35.5%; odds ratio, 1.3 [1.01–1.6]; P =0.04).

Conclusions—

The NASA Registry has demonstrated that clinical outcomes and survival are significantly better in patients treated with LA, without increased symptomatic intracranial hemorrhage risk. Future trials should prospectively evaluate the effect of GA on outcomes.

Abstract W P305: Processes Trends and Current Clinical Outcomes for IV TPA and Endovascular Stroke Therapies from the INterventional Stroke Therapy Outcomes Registry

Background: There is no national stroke registry that tracks emergency intra-hospital processes of care and 90-day clinical outcomes for both IV TPA and/or emergency endovascular stroke treatment (EVT). We created the INterventional Stroke Therapy Outcomes Registry (INSTOR®) to address this lack of data.

Methods: INSTOR is a sophisticated point-and-click analytical tool that tracks emergency processes and clinical outcomes (90-day modified Rankin Scale (mRS) in standard stacked bar chart) for both IV TPA and EVT for acute stroke. Complex analyses are performed in real-time and presented in multiple graphic formats. Single and multivariate risk adjustment for IV TPA and EVT therapies are performed based upon the presence or absence of diabetes, initial stroke severity, age, hypertension, atrial fibrillation, and, for EVT, original location of clot.

Results: Since start of use of INSTOR over 30 months ago (data from 10 sites, over 2368 patients, 542 treated ischemic strokes), median times for arrival to CT have declined from 31 to 17 minutes and scan interpretation from 47 to 40 minutes. Arrival to IV TPA has declined from 81 to 70 minutes, and “decision” (TPA-order) to TPA-started from 20 to 13 minutes. Current 90-day mRS 0-1 for IV TPA (minimum NIHSS null, median 11, maximum 36) is 16% for diabetic patients versus 26% for non-diabetic patients. For IV TPA patients, the overall percentage of mRS 0-1 is 22.6 while mRS 0-2 is 44%. However, for those presenting with NIHSS 6-9, mRS 0-2 at 90-days is 76% while those presenting with NIHSS 10-14, it is 43%. For EVT (minimum NIHSS null, median 17, maximum 38), 90-day mRS 0-2 for IV+EVT is 56% at 90-days vs. 32% for EVT alone and variation is shown based upon original clot location. The rate of symptomatic intracranial hemorrhage is 3.8% for IV TPA alone, 6.6% for IV+EVT, and 8.7% for EVT alone.

Conclusions: INSTOR is a unique quality improvement tool that presents instant online graphical and numerical analyses of numerous processes of care and clinical outcomes that can be used to improve care.

Balloon guide catheter improves revascularization and clinical outcomes with the Solitaire device: analysis of the North American Solitaire Acute Stroke Registry

BACKGROUND AND PURPOSE

Efficient and timely recanalization is an important goal in acute stroke endovascular therapy. Several studies demonstrated improved recanalization and clinical outcomes with the stent retriever devices compared with the Merci device. The goal of this study was to evaluate the role of the balloon guide catheter (BGC) and recanalization success in a substudy of the North American Solitaire Acute Stroke (NASA) registry.

METHODS

The investigator-initiated NASA registry recruited 24 clinical sites within North America to submit demographic, clinical, site-adjudicated angiographic, and clinical outcome data on consecutive patients treated with the Solitaire Flow Restoration device. BGC use was at the discretion of the treating physicians.

RESULTS

There were 354 patients included in the NASA registry. BGC data were reported in 338 of 354 patients in this subanalysis, of which 149 (44%) had placement of a BGC. Mean age was 67.3±15.2 years, and median National Institutes of Health Stroke Scale score was 18. Patients with BGC had more hypertension (82.4% versus 72.5%; P=0.05), atrial fibrillation (50.3% versus 32.8%; P=0.001), and were more commonly administered tissue plasminogen activator (51.6% versus 38.8%; P=0.02) compared with patients without BGC. Time from symptom onset to groin puncture and number of passes were similar between the 2 groups. Procedure time was shorter in patients with BGC (120±28.5 versus 161±35.6 minutes; P=0.02), and less adjunctive therapy was used in patients with BGC (20% versus 28.6%; P=0.05). Thrombolysis in cerebral infarction 3 reperfusion scores were higher in patients with BGC (53.7% versus 32.5%; P<0.001). Distal emboli and emboli in new territory were similar between the 2 groups. Discharge National Institutes of Health Stroke Scale score (mean, 12±14.5 versus 17.5±16; P=0.002) and good clinical outcome at 3 months were superior in patients with BGC compared with patients without (51.6% versus 35.8%; P=0.02). Multivariate analysis demonstrated that the use of BGC was an independent predictor of good clinical outcome (odds ratio, 2.5; 95% confidence interval, 1.2-4.9).

CONCLUSIONS

Use of a BGC with the Solitaire Flow Restoration device resulted in superior revascularization results, faster procedure times, decreased need for adjunctive therapy, and improved clinical outcome.

The effect of resveratrol on contractility of non-pregnant rat uterus: the contribution of K(+) channels

This study was aimed to evaluate resveratrol (1-100 μM) effect on the spontaneous rhythmic contractions (SRC), oxytocin-induced (0.2 nM, POxC) phasic and tonic (20 nM, TOxC) contractions of isolated rat uterus. The SRC and POxC were more sensitive to resveratrol than TOxC (pD2 values: 4.53 and 4.66 versus 4.06). Different blockers of K(+) channels (glibenclamide, tetraethylamonium, iberiotoxin, 4-aminopyridine) antagonized the response to resveratrol on the SRC and phasic contractions, but did not antagonize the effect of resveratrol on the TOxC. In order to compare the relaxant activities of resveratrol on the TOxC with that of potassium channel openers, a separate experiments with NS 1619, a highly specific big Ca(2+)-sensitive K(+) (BKCa) channels opener and pinacidil, a predominant opener of ATP-sensitive K(+) (KATP) channels were done. NS 1619 (10-100 μM) and pinacidil (10-100 μM) produced more potent inhibition of TOxC than resveratrol (pD2 values were 6.00 and 5.29). Iberiotoxin, a highly selective BKCa channels blocker, antagonized the response to NS 1619 and glibenclamide, a highly selective KATP channels blocker, antagonized the response to pinacidil on the TOxC. To test K(+)- and extracellular Ca(2+)- independent mechanism(s) of resveratrol on TOxC, a K(+)-rich, Ca(2+)-free solution was used. Under this condition, only high concentrations (≥30 μM) of resveratrol inhibited TOxC. Western blots analysis confirmed expression of Kir6.1, Kir6.2, KCa1.1, Kv2.1 and Kv4.2. channel proteins in myometrium. Thus, the effect of resveratrol is dependent on the types of contractions. The inhibitory response of resveratrol on the SRC and phasic contractions involves different myometrial K(+)- channels. When applied in high concentrations, resveratrol has an additional K(+)- channels independent mechanism(s) of action. As the effects of NS 1619, pinacidil and resveratrol on the TOxC are different, we can conclud that resveratrol does not behave as a classical potassium channel opener.

North American Solitaire Stent Retriever Acute Stroke registry: post-marketing revascularization and clinical outcome results

BACKGROUND

Limited post-marketing data exist on the use of the Solitaire FR device in clinical practice. The North American Solitaire Stent Retriever Acute Stroke (NASA) registry aimed to assess the real world performance of the Solitaire FR device in contrast with the results from the SWIFT (Solitaire with the Intention for Thrombectomy) and TREVO 2 (Trevo versus Merci retrievers for thrombectomy revascularization of large vessel occlusions in acute ischemic stroke) trials.

METHODS

The investigator initiated NASA registry recruited North American sites to submit retrospective angiographic and clinical outcome data on consecutive acute ischemic stroke (AIS) patients treated with the Solitaire FR between March 2012 and February 2013. The primary outcome was a Thrombolysis in Myocardial Ischemia (TIMI) score of ≥2 or a Treatment in Cerebral Infarction (TICI) score of ≥2a. Secondary outcomes were 90 day modified Rankin Scale (mRS) score, mortality, and symptomatic intracranial hemorrhage.

RESULTS

354 patients underwent treatment for AIS using the Solitaire FR device in 24 centers. Mean time from onset to groin puncture was 363.4±239 min, mean fluoroscopy time was 32.9±25.7 min, and mean procedure time was 100.9±57.8 min. Recanalization outcome: TIMI ≥2 rate of 83.3% (315/354) and TICI ≥2a rate of 87.5% (310/354) compared with the operator reported TIMI ≥2 rate of 83% in SWIFT and TICI ≥2a rate of 85% in TREVO 2.

CLINICAL OUTCOME

42% (132/315) of NASA patients demonstrated a 90 day mRS ≤2 compared with 37% (SWIFT) and 40% (TREVO 2). 90 day mortality was 30.2% (95/315) versus 17.2% (SWIFT) and 29% (TREVO 2).

CONCLUSIONS

The NASA registry demonstrated that the Solitaire FR device performance in clinical practice is comparable with the SWIFT and TREVO 2 trial results.

Bulk and surface properties of liquid Al-Cr and Cr-Ni alloys

The energetics of mixing and structural arrangement in liquid Al-Cr and Cr-Ni alloys has been analysed through the study of surface properties (surface tension and surface segregation), dynamic properties (chemical diffusion) and microscopic functions (concentration fluctuations in the long-wavelength limit and chemical short-range order parameter) in the framework of statistical mechanical theory in conjunction with quasi-lattice theory. The Al-Cr phase diagram exhibits the existence of different intermetallic compounds in the solid state, while that of Cr-Ni is a simple eutectic-type phase diagram at high temperatures and includes the low-temperature peritectoid reaction in the range near a CrNi(2) composition. Accordingly, the mixing behaviour in Al-Cr and Cr-Ni alloy melts was studied using the complex formation model in the weak interaction approximation and by postulating Al(8)Cr(5) and CrNi(2) chemical complexes, respectively, as energetically favoured.

Family and psychopathological impact of sexual abuses

The aim of the study is family and psychopathological analysis of the sexual abuse in Bosnia and Herzegovina in the period 01. January 1999. to 31. December 2009, as well as the increase of sexual violence which is more expressed through the level of violence.

Methods

Experimental group consists of n = 150 forensically processed people, who are under security measures and under treatment after the rape. The control group consists of n = 150 forensically processed people after the recidivistic property delicts. The design is a multicentric longitudinal study of the sexual abudes acts.

Results

Socio-demographic differences for the gender are highly significant: p > 0.001, and broken family, migration, and diseases in family are of lower significance. EPQ test shows differences between groups - violent: M±SD = extroversion: 15.53 ± 7.55, neuroticism: 9.10 ± 6.23, psychoticisms: 14.03 ± 5.11, Lay -scale: 10.33 ± 6.70, and recidivists: extroversion: 19. 11 ± 6.55 neuroticism: 6.55 ± 3.11, psychoticims: 9.10 ± 3.05, Lay -scale: 11.20 ± 6.60. BAI test has these significances - violent: numbness: 3.77 ± 0.77 tension: 2.05 ± 0.78 uncontrolness: 1.62 ± 0.85, and recidivists: neurosis: 1.91 ± 0.71, fear: 1.60 ± 0.85 and sweating: 1.85 ± 0.60 with significance P < 0.01. PIE in violent has increased values of destruction and aggression, and in recidivists exploration and conformism.

Conclusion

The destruction score is high in violators in psychological tests, which results in the following psychopathological content: immaturity, personality disorder, post-traumatic conditions. Recommendations in the treatment of violators and recidivists also have forensic significance, except for expertise.

Psychosocial Characteristics of Homicides in Bosnia and Herzegovina

Aim

The aim of this study was to identify differences between the individuals who committed homicide in BiH during the period from 01. January 1999. to 31. December 2009. in the evidently “violent” and “non-violent” way.

Methods

Two groups were investigated: 125 “violent” cases who committed homicide of an intimate partner (or filicide) and 125 “non-violent homicides” who killed people who were not members of the immediate family. Social-demographic and psychosocial characteristics of the two groups were investigated and compared. Instruments used in the study included: General Data List (GDL), test of personality characteristics (EPQ - Eizenck HJ), anxiety test (BAI - Beck AT), and emotion index profile (P.I.E - Plutchik R.).

Results

Multivariant regressive analysis differentiates violent from non-violent murderers by predictors: education of father (R = 0.950, x2 = 35.10, df = 2, P < 0.001, OR = 0.125 (95%), Cl = 0.127–0.558), living in the place of the crime scene enviroment (R = 0.815, x2 = 46.75, df = 2, P < 0.001, OR = 0.105, CI = 0.110–0.217), gambling abuse and possible recidivism. Within the psycho-logical predictors domain, violent murderers are differentiated from the non-violent ones by psyhoticism (R = 0.750, df = 2, P < 0.001, OR = 0.710 (95%), CI = 0.290–1.770), destructiveness (R = 0.610, df = 2, P < 0.001, OR = 0.575 (95%), CI 0.970–1.435) incorporation in the PIE tests.

Conclusion

For the violent homicides, owing to personal and family history, presence of the microsocial model of violence transfer augmented by heredity. Important hereditary destructiveness was also found and stressed for the violent group. For the cases of nonviolent homicides several facts as poverty and long-term vulnerability were found to provoke accidental homicide.

Anxiety Forms of Patients with Balcans Endemic Nephropaty

Aims

To analyze the forms of anxiety with BEN of the dialyzed patients with sub-hypothesis: socio-demographical, psychopathological, and biological influences.

Method

In B&H dialyzed in 2009. 2879 patients because of chronic renal insufficiency. Dialysis started in B&H on patients with BEN (n = 348) were in the first group, and other the N18 group was formed of patients with other diseases (n = 405). Controls group consists of the patients with other nephrology diseases. Clinical observation lasted from 01.01.2000. to 31.12.2009. when the study was done. Research is a comparative study cut, and the patients are questioned: Renal Registry of B&H, BAI, HDRS, and MMSE.

Results

Patients of the Cases group are the age of: 64.77 ± 8.86, and Controls 53.85 ± 13.6. High socio-demographic significations are the places of living of the Cases group (c2 = 23. 970), P < 0.01; renal diseases in the place of residence (c2 = 23. 970), P < 0.01; in the family (c2 = 23,970); P < =0.001 and the migration (c2 = 4,874); P < 0. 01. BAI scale has very significant group differences P < 0.001 and the level differences at the emerging of the fear, HDRS scale has group signification P < 0.001 and the variables point out depressive and anxiety differences and MMSE cognitive differences.

Conclusion

All patients which are interrogated at the dialysis in B&H from 2000. to 2009 have anxiety. Anxiety is more expressed in Cases group due to Control group, and comorbidity gives endemic factors for presuicidal risk for both groups.

Racial differences in demographics, acute complications, and outcomes in patients with subarachnoid hemorrhage: a large patient series

OBJECT

Few studies have focused on the impact of racial differences in demographics, clinical characteristics, acute complications, and outcomes of patients with aneurysmal subarachnoid hemorrhage (SAH). The purpose of this study was to examine this issue.

METHODS

The authors evaluated prospectively collected data on 1711 adult patients with aneurysmal SAH who were entered into two randomized, double-blind, placebo-controlled trials conducted at neurosurgical centers in North America between 1991 and 1997. Admission characteristics, treatment modalities, in-hospital complications, and 3-month outcomes assessed by application of the Glasgow Outcome Scale were compared using the chi-square test, a t-test, the Wilcoxon rank-sum test, and multiple logistic regressions based on a significance level of 0.05 in 241 African-American, 1342 Caucasian, and 128 other racial minority patients. Caucasian patients were significantly older than patients of other races (p < 0.0001). African-American patients more frequently had a history of hypertension (p < 0.0001) and an elevated blood pressure at the time of admission (p < 0.0001). African-Americans and other racial minorities were more likely to have internal carotid artery aneurysms and Caucasians were more likely to have posterior circulation aneurysms (p = 0.0002). Rates of in-hospital complications were not significantly different except that pulmonary edema occurred more commonly in Caucasians (p = 0.036). After an adjustment was made for significant admission characteristics, the 3-month outcome was not significantly different among the races.

CONCLUSIONS

Race was not found to be a prognostic factor for outcome after aneurysmal SAH. The higher SAH mortality rate previously observed in African-American patients is likely a result of a higher incidence of SAH in this group. These findings highlight the importance of primary prevention programs aimed at modifying risk factors for SAH.