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Goyal M, Jadhav AP, Bonafe A, Deiner H, Pereira V, Levy E, Baxter B, Jovin T, Jahan R, Menon B, Saver J. Abstract TP25: Analysis of Workflow and Time to Treatment in the Swift Prime Randomized Controlled Trial. Stroke 2016. [DOI: 10.1161/str.47.suppl_1.tp25] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
Timely recanalization in large vessel occlusive disease is essential to achieving good outcomes in patients with AIS. As such, the SWIFT PRIME study design incorporated aggressive time metrics and real time direct feedback. We systemically investigated variables affecting the time spent during discrete patient process steps including patient transport, selection and treatment delivery in patients treated in the SWIFT PRIME trial.
Methods:
Data was analyzed from the SWIFT PRIME trial, a global, multi-center, prospective, randomized, open, blinded endpoint (PROBE) IDE study comparing functional outcomes in AIS subjects treated with either IV t-PA alone (93 patients) or IV t-PA in combination with Solitaire device (93 patients). Each patient enrollment was analyzed for workflow and direct feedback was provided to the enrolling site.
Results:
The median time from Emergency Department (ED) arrival to groin puncture was 90 minutes (interquartile range [IQR], 69 - 120) and ED arrival to reperfusion time was 139 minutes (IQR, 108 - 169). The median ED to imaging start time was 16 minutes (IQR, 10-23.5), puncture to device deployment was 24 minutes (IQR, 18-33), and device deployment to reperfusion was 8 minutes (IQR, 5-23). The association between time intervals and baseline characteristics of the patient, mode of arrival at the endovascular-capable hospital and procedural characteristics was evaluated with multivariate negative binomial regression using a logarithmic link function (Figure).
Conclusions:
Detailed attention to workflow with iterative feedback and aggressive time goals leads to a highly efficient workflow. Future steps for improvement include faster triage and transport of patients to endovascular capable centers as well as advancements in treating patients with difficult anatomical features.
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Bonafe A, Saver J, Goyal M, Jahan R, Diener HC, Levy E, Pereira V, Cognard C, Yavagal D, Albers GW. Abstract TP50: Efficacy of Stent-retriever Thrombectomy in MRI Vs. CT Perfusion Selected Patients in SWIFT PRIME. Stroke 2016. [DOI: 10.1161/str.47.suppl_1.tp50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The majority of patients enrolled in SWIFT PRIME had CT perfusion imaging immediately prior to randomization; 34 patients were randomized following a diffusion and perfusion MRI.
Methods:
Patients with MCA (M1) and distal carotid occlusions were randomized to treatment with tPA alone vs. tPA + Solitaire stent retriever. The primary outcome was the distribution of the mRS at 90 days. The same automated software (RAPID) was used for both MRI and CTP patients to identify patients with the Target mismatch profile for enrollment.
Results:
MRI selection was performed in 34 patients; CTP in 139. Mean age was 71 years (MRI) vs. 68 years (CTP), p=0.08; baseline NIHSS was 17 in both groups. Target mismatch profile was present in 95% (MRI) vs. 83% (CTP), p=0.3. Median time from ER arrival to randomization was 69 min (MRI) vs. 67 min (CTP), p=0.61. A higher percentage of the MRI group was transferred from an outside hospital (59% vs. 35%, p=0.02) and therefore the time from stroke onset to randomization was longer in the MRI group (236 minutes vs. 179 minutes, p=0.003.) Baseline median ischemic core volumes were similar in the MRI vs. CTP group (7 ml vs. 5 ml); baseline perfusion lesions were larger in the MRI group (133 ml vs. 97 ml, P=0.01)
Reperfusion rates (> 90%/TICI 3) did not differ in the Solitaire treated patients in the MRI (94%) vs. CTP (85%) groups, p=0.7. The primary efficacy analysis (distribution of mRS at 90 days) demonstrated a statistically significant benefit in both the MRI (p=0.02) and CTP subgroups (p=0.01). Among MRI selected patients, mRS 0-2 at 90 days occurred in 63% of the Solitaire group vs. 33% of the tPA alone group (ARR 30%, p=0.17) and infarct growth was reduced (17 ml vs. 50 ml, p=0.089). CTP selected patients had mRS 0-2 rates at 90 days of 60% in the Solitaire group vs. 40% tPA alone (ARR 20%, p=0.025) and a reduction in infarct growth (14 vs. 27 ml, p=0.047).
Conclusions:
Although MRI selected patients in SWIFT PRIME were slightly older and treated longer after symptom onset, they demonstrated a statistically significant benefit on the primary efficacy endpoint. Reductions in infarct growth and rates of favorable clinical outcomes in the MR subgroup were also comparable to those seen in the CT perfusion subgroup.
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Lemmens R, Hamilton SA, Liebeskind DS, Tomsick TA, Demchuk AM, Nogueira RG, Marks MP, Jahan R, Gralla J, Yoo AJ, Yeatts SD, Palesch YY, Saver JL, Pereira VM, Broderick JP, Albers GW, Lansberg MG. Effect of endovascular reperfusion in relation to site of arterial occlusion. Neurology 2016; 86:762-70. [PMID: 26802090 DOI: 10.1212/wnl.0000000000002399] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 10/28/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess whether the association between reperfusion and improved clinical outcomes after stroke differs depending on the site of the arterial occlusive lesion (AOL). METHODS We pooled data from Solitaire With the Intention for Thrombectomy (SWIFT), Solitaire FR Thrombectomy for Acute Revascularisation (STAR), Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution Study 2 (DEFUSE 2), and Interventional Management of Stroke Trial (IMS III) to compare the strength of the associations between reperfusion and clinical outcomes in patients with internal carotid artery (ICA), proximal middle cerebral artery (MCA) (M1), and distal MCA (M2/3/4) occlusions. RESULTS Among 710 included patients, the site of the AOL was the ICA in 161, the proximal MCA in 389, and the distal MCA in 160 patients (M2 = 131, M3 = 23, and M4 = 6). Reperfusion was associated with an increase in the rate of good functional outcome (modified Rankin Scale [mRS] score 0-2) in patients with ICA (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.7-7.2) and proximal MCA occlusions (OR 6.2, 95% CI 3.8-10.2), but not in patients with distal MCA occlusions (OR 1.4, 95% CI 0.8-2.6). Among patients with M2 occlusions, a subset of the distal MCA cohort, reperfusion was associated with excellent functional outcome (mRS 0-1; OR 2.2, 95% CI 1.0-4.7). CONCLUSIONS The association between endovascular reperfusion and better clinical outcomes is more profound in patients with ICA and proximal MCA occlusions compared to patients with distal MCA occlusions. Because there are limited data from randomized controlled trials on the effect of endovascular therapy in patients with distal MCA occlusions, these results underscore the need for inclusion of this subgroup in future endovascular therapy trials.
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Adams HP, El Ahmadieh TY, Albers GW, Alexandrov AV, Anrather J, Arai K, Aronowski J(J, Auer RN, Awad IA, Ay H, Baltan S, Batjer HH, Benavente OR, Bendok BR, Bershad EM, Bonati LH, Bookland MJ, Bousser MG, Braca JA, Broderick JP, Brown MM, Brown WE, Brust JC, Bushnell C, Bösel J, Canhão P, Caplan LR, Castellanos M, Chamorro A, Chandler JP, Chen J, Chopp M, Chrissobolis S, Chabriat H, Cramer SC, Cucchiara BL, Dannenbaum MJ, Davis PH, Dawson TM, Dawson VL, Day AL, del Zoppo GJ, Diener HC, Di Tullio MR, Dobkin BH, Dzialowski I, Economos A, Eddleman CS, Elkind MS, Feigin VL, Ferro JM, Findlay JM, Furie KL, Fusco MR, Field TS, Geibprasert S, Gensic AP, Gobin YP, Goldberg MP, Goldstein LB, Gonzales NR, Gounis MJ, Greenberg SM, Gregson BA, Grotta JC, Gutierrez J, Hacke W, Hallenbeck JM, Haršány M, Heiferman DM, Homma S, Howard G, Howard VJ, Hwang JY, Iadecola C, Jahan R, Joutel A, Jüttler E, Kase CS, Kasner SE, Katan M, Khader Eliyas J, Khan M, Kim H, Kidwell CS, Kim JS, Krings T, Krishnamurthi R, Kurth T, Lamy C, Lansberg MG, Levy EI, Liebeskind DS, Lo EH, Loftus CM, Lyden PD, Mas JL, Massari F, Meckler JM, Mendelow AD, Meschia JF, Messé SR, Mitchel P, Morgenstern LB, Mokin M, Moskowitz MA, Mullen MT, Nedergaard M, Neugebauer H, Newell DW, Norrving B, O'Donnell M, Ofengeim D, Ogata J, Ogilvy CS, Pancioli AM, Parsha K, Parsons MW, Pawlikowska L, Pérez A, Perez-Pinzon MA, Powers WJ, Puetz V, Puri AS, Ransom BR, Roine RO, Rundek T, Russin JJ, Sacco RL, Spetzler RF, Sattenberg RJ, Saver JL, Savitz SI, Schönenberger S, Seshadri S, Sharma VK, Shi Y, Shoamanesh A, Silverboard G, Singhal AB, Sobey CG, Stapf C, Su H, Suarez JI, Sykora M, Tatlisumak T, El Tecle N, terBrugge KG, Thompson JW, Tilley BC, Tournier-Lasserve E, Tsivgoulis G, Vilela MD, von Kummer R, Wakhloo AK, Wagner KR, Warach S, Weksler BB, Werring D, Willey JZ, Wintermark M, Wolf PA, Wong LK, Woo D, Wright C, Xi G, Yamaguchi T, Yasaka M, Young WL, Zammar SG, Zahuranec DB, Zhang F, Zhang H, Zhang JH, Zhang ZG, Zukin RS, Zweifler RM. List of Contributors. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00090-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Jahan R, Saver JL. Endovascular Treatment of Acute Ischemic Stroke. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00065-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Albers GW, Goyal M, Jahan R, Bonafe A, Diener HC, Levy EI, Pereira VM, Cognard C, Cohen DJ, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, Baxter BW, Devlin TG, Lopes DK, Reddy VK, de Rochemont RDM, Singer OC, Bammer R, Saver JL. Ischemic core and hypoperfusion volumes predict infarct size in SWIFT PRIME. Ann Neurol 2015; 79:76-89. [PMID: 26476022 DOI: 10.1002/ana.24543] [Citation(s) in RCA: 130] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 10/01/2015] [Accepted: 10/15/2015] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Within the context of a prospective randomized trial (SWIFT PRIME), we assessed whether early imaging of stroke patients, primarily with computed tomography (CT) perfusion, can estimate the size of the irreversibly injured ischemic core and the volume of critically hypoperfused tissue. We also evaluated the accuracy of ischemic core and hypoperfusion volumes for predicting infarct volume in patients with the target mismatch profile. METHODS Baseline ischemic core and hypoperfusion volumes were assessed prior to randomized treatment with intravenous (IV) tissue plasminogen activator (tPA) alone versus IV tPA + endovascular therapy (Solitaire stent-retriever) using RAPID automated postprocessing software. Reperfusion was assessed with angiographic Thrombolysis in Cerebral Infarction scores at the end of the procedure (endovascular group) and Tmax > 6-second volumes at 27 hours (both groups). Infarct volume was assessed at 27 hours on noncontrast CT or magnetic resonance imaging (MRI). RESULTS A total of 151 patients with baseline imaging with CT perfusion (79%) or multimodal MRI (21%) were included. The median baseline ischemic core volume was 6 ml (interquartile range= 0-16). Ischemic core volumes correlated with 27-hour infarct volumes in patients who achieved reperfusion (r = 0.58, p < 0.0001). In patients who did not reperfuse (<10% reperfusion), baseline Tmax > 6-second lesion volumes correlated with 27-hour infarct volume (r = 0.78, p = 0.005). In target mismatch patients, the union of baseline core and early follow-up Tmax > 6-second volume (ie, predicted infarct volume) correlated with the 27-hour infarct volume (r = 0.73, p < 0.0001); the median absolute difference between the observed and predicted volume was 13 ml. INTERPRETATION Ischemic core and hypoperfusion volumes, obtained primarily from CT perfusion scans, predict 27-hour infarct volume in acute stroke patients who were treated with reperfusion therapies.
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Kim JT, Jahan R, Saver JL. Impact of Glucose on Outcomes in Patients Treated With Mechanical Thrombectomy: A Post Hoc Analysis of the Solitaire Flow Restoration With the Intention for Thrombectomy Study. Stroke 2015; 47:120-7. [PMID: 26658447 DOI: 10.1161/strokeaha.115.010753] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 11/04/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Sparse data are available regarding the association between hyperglycemia and outcomes in acute ischemic stroke patients receiving mechanical thrombectomy (MT). We investigated whether hyperglycemia affected the outcomes of subjects treated with MT in the Solitaire Flow Restoration With the Intention for Thrombectomy (SWIFT) multicenter randomized trial, overall and according to reperfusion status after MT. METHODS We analyzed the relationships between the presenting glucose level as a continuous variable and presenting hyperglycemia (>140 mg/dL glucose) as a binary variable and several outcomes of interest. Subjects were stratified according to the completeness of reperfusion (Thrombolysis In Myocardial Ischemia scale 3 versus 0-2) after MT. Excellent outcome at 3 months was defined as a modified Rankin scale score of 0-1. RESULTS Among all patients undergoing MT, patients with hyperglycemia less frequently exhibited an excellent outcome at 3 months than patients without hyperglycemia, 13% versus 34%; P=0.01. Presenting glucose levels did not differ among patients achieving complete reperfusion and incomplete reperfusion. Among patients with incomplete reperfusion, after adjustment for covariates, higher glucose levels were independently associated with worse outcome at 3 months (per 10 mg/dL increase in glucose: odds ratio for modified Rankin scale score 0-1 at 3 months 0.58, 95% confidence interval 0.34-0.99; P=0.047). In contrast, among patients with complete reperfusion, differences in presenting glucose levels by final outcome did not reach statistical significance. CONCLUSIONS In patients treated with MT, hyperglycemia was independently associated with worse outcome at 3 months, and the negative effects of hyperglycemia may have been exacerbated in patients with incomplete reperfusion after MT. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01054560.
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Slater LA, Coutinho JM, Gralla J, Nogueira RG, Bonafé A, Dávalos A, Jahan R, Levy E, Baxter BJ, Saver JL, Pereira VM. TICI and Age: What's the Score? AJNR Am J Neuroradiol 2015; 37:838-43. [PMID: 26611995 DOI: 10.3174/ajnr.a4618] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 09/07/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Previous studies have suggested that advanced age predicts worse outcome following mechanical thrombectomy. We assessed outcomes from 2 recent large prospective studies to determine the association among TICI, age, and outcome. MATERIALS AND METHODS Data from the Solitaire FR Thrombectomy for Acute Revascularization (STAR) trial, an international multicenter prospective single-arm thrombectomy study and the Solitaire arm of the Solitaire FR With the Intention For Thrombectomy (SWIFT) trial were pooled. TICI was determined by core laboratory review. Good outcome was defined as an mRS score of 0-2 at 90 days. We analyzed the association among clinical outcome, successful-versus-unsuccessful reperfusion (TICI 2b-3 versus TICI 0-2a), and age (dichotomized across the median). RESULTS Two hundred sixty-nine of 291 patients treated with Solitaire in the STAR and SWIFT data bases for whom TICI and 90-day outcome data were available were included. The median age was 70 years (interquartile range, 60-76 years) with an age range of 25-88 years. The mean age of patients 70 years of age or younger was 59 years, and it was 77 years for patients older than 70 years. There was no significant difference between baseline NIHSS scores or procedure time metrics. Hemorrhage and device-related complications were more common in the younger age group but did not reach statistical significance. In absolute terms, the rate of good outcome was higher in the younger population (64% versus 44%, P < .001). However, the magnitude of benefit from successful reperfusion was higher in the 70 years of age and older group (OR, 4.82; 95% CI, 1.32-17.63 versus OR 7.32; 95% CI, 1.73-30.99). CONCLUSIONS Successful reperfusion is the strongest predictor of good outcome following mechanical thrombectomy, and the magnitude of benefit is highest in the patient population older than 70 years of age.
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Coutinho JM, Liebeskind DS, Slater LA, Nogueira RG, Baxter BW, Levy EI, Siddiqui AH, Goyal M, Zaidat OO, Davalos A, Bonafé A, Jahan R, Gralla J, Saver JL, Pereira VM. Mechanical Thrombectomy for Isolated M2 Occlusions: A Post Hoc Analysis of the STAR, SWIFT, and SWIFT PRIME Studies. AJNR Am J Neuroradiol 2015; 37:667-72. [PMID: 26564442 DOI: 10.3174/ajnr.a4591] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 08/11/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE Mechanical thrombectomy is beneficial for patients with acute ischemic stroke and a proximal anterior occlusion, but it is unclear if these results can be extrapolated to patients with an M2 occlusion. The purpose of this study was to examine the technical aspects, safety, and outcomes of mechanical thrombectomy with a stent retriever in patients with an isolated M2 occlusion who were included in 3 large multicenter prospective studies. MATERIALS AND METHODS We included patients from the Solitaire Flow Restoration Thrombectomy for Acute Revascularization (STAR), Solitaire With the Intention For Thrombectomy (SWIFT), and Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment (SWIFT PRIME) studies, 3 large multicenter prospective studies on thrombectomy for ischemic stroke. We compared outcomes and technical details of patients with an M2 with those with an M1 occlusion. All patients were treated with a stent retriever. Imaging data and outcomes were scored by an independent core laboratory. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction score of 2b/3. RESULTS We included 50 patients with an M2 and 249 patients with an M1 occlusion. Patients with an M2 occlusion were older (mean age, 71 versus 67 years; P = .04) and had a lower NIHSS score (median, 13 versus 17; P < .001) compared with those with an M1 occlusion. Procedural time was nonsignificantly shorter in patients with an M2 occlusion (median, 29 versus 35 minutes; P = .41). The average number of passes with a stent retriever was also nonsignificantly lower in patients with an M2 occlusion (mean, 1.4 versus 1.7; P = .07). There were no significant differences in successful reperfusion (85% versus 82%, P = .82), symptomatic intracerebral hemorrhages (2% versus 2%, P = 1.0), device-related serious adverse events (6% versus 4%, P = .46), or modified Rankin Scale score 0-2 at follow-up (60% versus 56%, P = .64). CONCLUSIONS Endovascular reperfusion therapy appears to be feasible in selected patients with ischemic stroke and an M2 occlusion.
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Raychev R, Tateshima S, Vinuela F, Sayre J, Jahan R, Gonzalez N, Szeder V, Duckwiler G. Predictors of thrombotic complications and mass effect exacerbation after pipeline embolization: The significance of adenosine diphosphate inhibition, fluoroscopy time, and aneurysm size. Interv Neuroradiol 2015; 22:34-41. [PMID: 26537850 DOI: 10.1177/1591019915609125] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 07/03/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The mechanisms leading to delayed rupture, distal emboli and intraparenchymal hemorrhage in relation to pipeline embolization device (PED) placement remain debatable and poorly understood. The aim of this study was to identify clinical and procedural predictors of these perioperative complications. METHODS We conducted a retrospective review of consecutive patients who underwent PED placement. We utilized a non-commercial platelet aggregation method measuring adenosine diphosphate (ADP)% inhibition for evaluation of clopidogrel response. To our knowledge, this is the first study to test ADP in neurovascular procedures. Multivariable regression analysis was used to identify the strongest predictor of three separate outcomes: (1) thrombotic complications, (2) hemorrhagic complications, and (3) aneurysm mass effect exacerbation RESULTS Permanent complication-related morbidity and mortality at 3 months was 6% (3/48). No specific predictors of hemorrhagic complications were identified. In the univariate analysis, the strongest predictors of thrombotic complications were: ADP% inhibition<49 (p=0.01), aneurysm size (p=0.04) and fluoroscopy time (p=0.002). In the final multivariate analysis, among all baseline variables, fluoroscopy time exceeding 52 min was the only factor associated with thrombotic complications (p=0.007). Aneurysm size≥18 mm was the single predictor of mass effect exacerbation (p=0.039). CONCLUSIONS Procedural complexity, reflected by fluoroscopy time, is the strongest predictor of thrombotic complications in this study. ADP% inhibition is a reliable method of testing clopidogrel response in neurovascular procedures and values of <50% may predict thrombotic complications. Interval mass effect exacerbation after PED placement may be anticipated in large aneurysms exceeding 18 mm.
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Shi ZS, Duckwiler GR, Jahan R, Tateshima S, Gonzalez NR, Szeder V, Saver JL, Kim D, Ali LK, Starkman S, Vespa PM, Salamon N, Villablanca JP, Viñuela F, Feng L, Loh Y, Liebeskind DS. New Cerebral Microbleeds After Mechanical Thrombectomy for Large-Vessel Occlusion Strokes. Medicine (Baltimore) 2015; 94:e2180. [PMID: 26632753 PMCID: PMC5059022 DOI: 10.1097/md.0000000000002180] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The interval appearance of cerebral microbleeds (CMBs) after endovascular treatment has never been described. We investigated the frequency and predictors of new CMBs that developed shortly after mechanical thrombectomy for acute ischemic stroke, and its impact on clinical outcome.We retrospectively analyzed patients with large-vessel occlusion strokes treated with Merci Retriever, Penumbra System, or stent-retriever devices. Serial T2*-weighted gradient-recall echo (GRE) magnetic resonance imaging (MRI) before and 48 h after endovascular thrombectomy were assessed to identify new CMBs. We examined independent factors associated with new CMBs after mechanical thrombectomy. We analyzed the association of the presence, burden, and distribution of new CMBs with clinical outcome.A total of 187 consecutive patients with serial GRE were enrolled in this study. CMBs were evident in 36 (19.3%) patients before mechanical thrombectomy. New CMBs occurred in 41 (21.9%) patients after mechanical thrombectomy. Of the 68 new CMBs, 45 appeared in the lobar location, 18 in the deep location and 5 in the infratentorial location. The presence of baseline CMBs was associated with new CMBs after mechanical thrombectomy (OR 5.38; 95% CI 2.13-13.59; P < 0.001), no matter whether the patients were treated primarily with mechanical thrombectomy or with intravenous thrombolysis followed by mechanical thrombectomy. Patients with new CMBs did not have increased rates of hemorrhagic transformation, in-hospital mortality, and modified Rankin Scale score 4 to 6 at discharge.New CMBs are common after mechanical thrombectomy in one-fifth of patients with acute ischemic stroke. Baseline CMBs before mechanical thrombectomy predicts the development of new CMBs. New CMBs after mechanical thrombectomy do not influence clinical outcome.
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Okawa M, Tateshima S, Liebeskind D, Rao N, Jahan R, Gonzalez N, Szeder V, Ali L, Kim D, Saver J, Duckwiler G. Early Loss of Immediate Reperfusion While Stent Retriever in Place Predicts Successful Final Reperfusion in Acute Ischemic Stroke Patients. Stroke 2015; 46:3266-9. [PMID: 26451013 DOI: 10.1161/strokeaha.115.010794] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 07/29/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Degree of stent retriever engagement with target thrombi may be reflected by (1) immediate reperfusion (IR) on first deployment, indicating displacement of clot toward the vessel wall, and (2) by early loss of IR (ELOIR), indicating penetration of retriever struts through the thrombus. The relation of these early findings to final reperfusion and clinical outcomes has not been well delineated. METHODS We investigated IR and ELOIR in patients undergoing stent retriever mechanical thrombectomy at an academic medical center between March 2012 and June 2014. RESULTS Among 56 patients, IR itself was not associated with final successful reperfusion, which occurred in 66.7% of IR patients and 71.4% of non-IR patients (P=0.999). However, ELOIR was associated with a higher rate of final successful reperfusion (92% versus 44%; P=0.046). Patients with ELOIR had a higher nominal rate of final favorable outcome (42% versus 22%; P=0.64). CONCLUSIONS ELOIR during the embedding period after deployment of stent retrievers is associated with successful final reperfusion, likely because of greater thrombus engagement with the stent retriever. ELOIR may be a useful finding to guide duration of embedding time in clinical practice and design of novel stent retrievers.
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Macisaac RL, Khatri P, Bendszus M, Bracard S, Broderick J, Campbell B, Ciccone A, Dávalos A, Davis SM, Demchuk A, Diener HC, Dippel D, Donnan GA, Fiehler J, Fiorella D, Goyal M, Hacke W, Hill MD, Jahan R, Jauch E, Jovin T, Kidwell CS, Liebeskind D, Majoie CB, Martins SCO, Mitchell P, Mocco J, Muir KW, Nogueira R, Saver JL, Schonewille WJ, Siddiqui AH, Thomalla G, Tomsick TA, Turk AS, White P, Zaidat O, Lees KR. A collaborative sequential meta-analysis of individual patient data from randomized trials of endovascular therapy and tPA vs. tPA alone for acute ischemic stroke: ThRombEctomy And tPA (TREAT) analysis: statistical analysis plan for a sequential meta-analysis performed within the VISTA-Endovascular collaboration. Int J Stroke 2015; 10 Suppl A100:136-44. [DOI: 10.1111/ijs.12622] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 07/16/2015] [Indexed: 11/30/2022]
Abstract
Rationale Endovascular treatment has been shown to restore blood flow effectively. Second-generation medical devices such as stent retrievers are now showing overwhelming efficacy in clinical trials, particularly in conjunction with intravenous recombinant tissue plasminogen activator. Aims and Design This statistical analysis plan utilizing a novel, sequential approach describes a prospective, individual patient data analysis of endovascular therapy in conjunction with intravenous recombinant tissue plasminogen activator agreed upon by the Thrombectomy and Tissue Plasminogen Activator Collaborative Group. Study outcomes This protocol will specify the primary outcome for efficacy, as ‘favorable’ outcome defined by the ordinal distribution of the modified Rankin Scale measured at three-months poststroke, but with modified Rankin Scales 5 and 6 collapsed into a single category. The primary analysis will aim to answer the questions: ‘what is the treatment effect of endovascular therapy with intravenous recombinant tissue plasminogen activator compared to intravenous tissue plasmi-nogen activator alone on full scale modified Rankin Scale at 3 months?’ and ‘to what extent do key patient characteristics influence the treatment effect of endovascular therapy?’. Key secondary outcomes include effect of endovascular therapy on death within 90 days; analyses of modified Rankin Scale using dichotomized methods; and effects of endovascular therapy on symptomatic intracranial hemorrhage. Several secondary analyses will be considered as well as expanding patient cohorts to intravenous recombinant tissue plasminogen activator-ineligible patients, should data allow. Discussion This collaborative meta-analysis of individual participant data from randomized trials of endovascular therapy vs. control in conjunction with intravenous thrombolysis will demonstrate the efficacy and generalizability of endovascular therapy with intravenous thrombolysis as a concomitant medication.
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Raychev R, Jahan R, Liebeskind D, Clark W, Nogueira RG, Saver J. Determinants of Intracranial Hemorrhage Occurrence and Outcome after Neurothrombectomy Therapy: Insights from the Solitaire FR With Intention For Thrombectomy Randomized Trial. AJNR Am J Neuroradiol 2015; 36:2303-7. [PMID: 26316567 DOI: 10.3174/ajnr.a4482] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 04/16/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Intracranial hemorrhage is the most dreaded complication of neurothrombectomy therapy for acute ischemic stroke. The determinants of intracranial hemorrhage and its impact on clinical course remain incompletely delineated. The purpose of this study is to further investigate the clinical and procedural factors leading to intracranial hemorrhage and to define the clinical impact of different hemorrhagic subtypes. MATERIALS AND METHODS We analyzed data prospectively collected in the Solitaire FR With Intention for Thrombectomy randomized clinical trial. A multivariable logistic regression model was used to identify independent clinical, imaging, and procedural predictors of any intracranial hemorrhage and of 7 intracranial hemorrhage subtypes. Univariate analysis was used to determine the impact of each of the intracranial hemorrhage subtypes on clinical outcome. RESULTS Among the 144 enrolled patients, any radiologic intracranial hemorrhage (21.3% versus 38.2%, P = .035), symptomatic intracranial hemorrhage (1.1% versus 10.9%, P = .012), and subarachnoid hemorrhage (2.2% versus 12.7%, P = .027) occurred less frequently in the Solitaire FR than in the Merci retriever arms. The most common independent determinant of hemorrhage occurrence was rescue therapy with intra-arterial rtPA, which was associated with any intracranial hemorrhage and 4 subtypes and tended to be used more frequently in the Merci group (10.9% versus 3.4%; P = .09). Among the hemorrhage subtypes, basal ganglionic hemorrhage had the strongest impact on good clinical outcome at 90 days (OR, 0.30; P = .025) and was associated with higher reperfusion, prolonged time to treatment, and rescue therapy with intra-arterial rtPA. CONCLUSIONS Intracranial hemorrhage, especially subarachnoid and symptomatic intracerebral hemorrhage, occurs less frequently with the Solitaire FR than the Merci retriever, in part due to less frequent use of rescue therapy with intra-arterial rtPA. Basal ganglionic hemorrhage strongly affects clinical outcome and is distinctively related to late reperfusion.
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Albers GW, Goyal M, Jahan R, Bonafe A, Diener HC, Levy EI, Pereira VM, Cognard C, Yavagal DR, Saver JL. Relationships Between Imaging Assessments and Outcomes in Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke. Stroke 2015; 46:2786-94. [PMID: 26316344 DOI: 10.1161/strokeaha.115.010710] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/14/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Imaging findings can predict outcomes in patients with acute stroke. Relationships between imaging findings and clinical and imaging outcomes in patients randomized to intravenous tissue-type plasminogen activator-alone versus tissue-type plasminogen activator plus endovascular therapy (Solitaire device) in the Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) study were assessed. METHODS We evaluated associations between imaging assessments (baseline mismatch profiles/ischemic core volumes and successful reperfusion) with imaging outcomes (27-hour infarct volume/growth) and clinical outcomes (modified Rankin Scale scores at 90 days). Imaging variables that predict favorable clinical outcomes were assessed in both univariate and multivariate models. RESULTS One hundred and ninety-five patients were included. Successful reperfusion and infarct volume (assessed at 27 hours) were powerful independent predictors of favorable clinical outcomes (modified Rankin Scale score of 0-2 at 90 days). Patients with the target mismatch profile at baseline had a higher rate of reperfusion, lesser infarct growth, smaller infarct volumes, and better clinical outcomes in the Solitaire plus tissue-type plasminogen activator (intervention) group than those in the tissue-type plasminogen activator-alone (control) group. Patients with larger mismatch volumes at baseline had a trend toward better treatment response in the intervention group than patients who had smaller (<50 mL) mismatch volumes. CONCLUSIONS Patients who achieved reperfusion had substantially more favorable clinical and imaging outcomes in both the intervention and the control groups. Infarct volume at 27 hours strongly correlated with clinical outcome at 90 days in both treatment groups. SWIFT PRIME patients with the target mismatch profile had a highly favorable response to endovascular therapy on both clinical and imaging outcomes. Both reperfusion and infarct volumes at 27 hours were powerful and independent predictors of 90-day clinical outcomes. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01657461.
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Sheth SA, Jahan R, Gralla J, Pereira VM, Nogueira RG, Levy EI, Zaidat OO, Saver JL. Time to endovascular reperfusion and degree of disability in acute stroke. Ann Neurol 2015; 78:584-93. [PMID: 26153450 DOI: 10.1002/ana.24474] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 06/30/2015] [Accepted: 06/30/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Faster time from onset to recanalization (OTR) in acute ischemic stroke using endovascular therapy (ET) has been associated with better outcome. However, previous studies were based on less-effective first-generation devices, and analyzed only dichotomized disability outcomes, which may underestimate the full effect of treatment. METHODS In the combined databases of the SWIFT and STAR trials, we identified patients treated with the Solitaire stent retriever with achievement of substantial reperfusion (Thrombolysis in Cerebral Infarction [TICI] 2b-3). Ordinal numbers needed to treat values were derived by populating joint outcome tables. RESULTS Among 202 patients treated with ET with TICI 2b to 3 reperfusion, mean age was 68 (±13), 62% were female, and median National Institutes of Health Stroke Scale (NIHSS) score was 17 (interquartile range [IQR]: 14-20). Day 90 modified Rankin Scale (mRS) outcomes for OTR time intervals ranging from 180 to 480 minutes showed substantial time-related reductions in disability across the entire outcome range. Shorter OTR was associated with improved mean 90-day mRS (1.4 vs. 2.4 vs. 3.3, for OTR groups of 124-240 vs. 241-360 vs. 361-660 minutes; p < 0.001). The number of patients identified as benefitting from therapy with shorter OTR were 3-fold (range, 1.5-4.7) higher on ordinal, compared with dichotomized analysis. For every 15-minute acceleration of OTR, 34 per 1,000 treated patients had improved disability outcome. INTERPRETATION Analysis of disability over the entire outcome range demonstrates a marked effect of shorter time to reperfusion upon improved clinical outcome, substantially higher than binary metrics. For every 5-minute delay in endovascular reperfusion, 1 of 100 patients has a worse disability outcome.
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Pereira V, Siddiqui A, Jovin T, Yavagal D, Levy E, Bonafé A, Cognard C, Jansen O, Nogueira R, Jahan R, Slater L, Coutinho J, Saver J, Goyal M. P-016 role of balloon guiding catheter in mechanical thrombectomy using stentretrivers subgroup analysis of swift prime: Abstract P-016 Table 1. J Neurointerv Surg 2015. [DOI: 10.1136/neurintsurg-2015-011917.55] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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168
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Raychev R, Tateshima S, Vinuela F, Jahan R, Gonzalez N, Duckwiler G. E-010 critical evaluation of the eclipse sign in different angiographic phases for prediction of successful aneurysm thrombosis after pipeline embolization. J Neurointerv Surg 2015. [DOI: 10.1136/neurintsurg-2015-011917.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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169
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Okawa M, Tateshima S, James S, Szeder V, Gonzalez N, Jahan R, Duckwiler G. E-109 predictors of poor outcome in aneurysm ruptures during embolization. J Neurointerv Surg 2015. [DOI: 10.1136/neurintsurg-2015-011917.184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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170
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Albers G, Bonafe A, Diener H, Levy E, Pereira V, Cognard C, Cohen D, Hacke W, Jansen O, Jovin T, Mattle H, Nogueira R, Siddiqui A, Yavagal D, Baxter B, Devlin T, Lopes D, Reddy V, du Mesnil de Rochemont R, Singer O, Jahan R, Goyal M, Saver J. O-013 early ischemic core volion volumes predict infarct size in swift prime. J Neurointerv Surg 2015. [DOI: 10.1136/neurintsurg-2015-011917.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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171
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Nour M, Tateshima S, Duckwiler G, Jahan R, Gonzalez N, Szeder V, Ai L, Saver J, Liebeskind D. E-084 proximal versus distal occlusions in the posterior circulation: acute stroke etiology in endovascular therapy. J Neurointerv Surg 2015. [DOI: 10.1136/neurintsurg-2015-011917.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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172
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Tateshima S, Seth S, Liang C, Patel N, Ismail A, Freeman D, Szeder V, Jahan R, Duckwiler G. E-108 pulserider stent for challenging basilar tip aneurysms involving scas and pcas. J Neurointerv Surg 2015. [DOI: 10.1136/neurintsurg-2015-011917.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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173
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Tateshima S, Okawa M, Liebeskind D, Jahan R, Gonzalez N, Szeder V, Rao N, Ali L, Kim D, Saver J, Duckwiler G. P-015 flow stasis after the deployment of stent-retriever predicts successful final recanalization in acute stroke patients. J Neurointerv Surg 2015. [DOI: 10.1136/neurintsurg-2015-011917.54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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174
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Mueller-Kronast N, Aziz-Sultan A, Jahan R, Klucznik R, Zaidat O. P-007 interim results of stratis registry. J Neurointerv Surg 2015. [DOI: 10.1136/neurintsurg-2015-011917.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Wainwright JM, Jahan R. Solitaire FR revascularization device 4×40: safety study and effectiveness in preclinical models. J Neurointerv Surg 2015; 8:710-3. [PMID: 26101268 DOI: 10.1136/neurintsurg-2015-011856] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 06/02/2015] [Indexed: 11/04/2022]
Abstract
Recent randomized clinical trials have shown the benefit of stent retrievers for endovascular intervention in patients with acute ischemic stroke. The Solitaire 2 FR 4×40 device was developed to address longer clots as well as procedural difficulties. This study was undertaken to evaluate the safety of the new device in a swine model at 0, 30, and 90 days as well as its in vitro effectiveness. There were no significant differences in the overall animal health, tissue injury, hemorrhagic or thrombogenic events related to device usage. Based on the comparison at multiple time points, the Solitaire 2 4×40 device was similar in safety and usability to the Solitaire 2 4×20 device. Due to the additional length of the device, the Solitaire 2 4×40 device may in fact provide a number of additional technical benefits in the neurothrombectomy treatment of ischemic stroke.
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