Modified Thrombolysis in Cerebral Infarction 2C/Thrombolysis in Cerebral Infarction 3 Reperfusion Should Be the Aim of Mechanical Thrombectomy

Machine Learning Analysis of the Cerebrovascular Thrombi Proteome in Human Ischemic Stroke: An Exploratory Study

Objective: Mechanical retrieval of thrombotic material from acute ischemic stroke patients provides a unique entry point for translational research investigations. Here, we resolved the proteomes of cardioembolic and atherothrombotic cerebrovascular human thrombi and applied an artificial intelligence routine to examine protein signatures between the two selected groups.

Methods: We specifically used n = 32 cardioembolic and n = 28 atherothrombotic diagnosed thrombi from patients suffering from acute stroke and treated by mechanical thrombectomy. Thrombi proteins were successfully separated by gel-electrophoresis. For each thrombi, peptide samples were analyzed by nano-flow liquid chromatography coupled to tandem mass spectrometry (nano-LC-MS/MS) to obtain specific proteomes. Relative protein quantification was performed using a label-free LFQ algorithm and all dataset were analyzed using a support-vector-machine (SVM) learning method. Data are available via ProteomeXchange with identifier PXD020398. Clinical data were also analyzed using SVM, alone or in combination with the proteomes.

Results: A total of 2,455 proteins were identified by nano-LC-MS/MS in the samples analyzed, with 438 proteins constantly detected in all samples. SVM analysis of LFQ proteomic data delivered combinations of three proteins achieving a maximum of 88.3% for correct classification of the cardioembolic and atherothrombotic samples in our cohort. The coagulation factor XIII appeared in all of the SVM protein trios, associating with cardioembolic thrombi. A combined SVM analysis of the LFQ proteome and clinical data did not deliver a better discriminatory score as compared to the proteome only.

Conclusion: Our results advance the portrayal of the human cerebrovascular thrombi proteome. The exploratory SVM analysis outlined sets of proteins for a proof-of-principle characterization of our cohort cardioembolic and atherothrombotic samples. The integrated analysis proposed herein could be further developed and retested on a larger patients population to better understand stroke origin and the associated cerebrovascular pathophysiology.

Influence of first-pass effect on recanalization outcomes in the era of mechanical thrombectomy: a systemic review and meta-analysis

PURPOSE

This systematic review and meta-analysis summarized the current literature to compare the safety and efficacy between first-pass effect (FPE) and multiple-pass effect (MPE) for thrombectomy in treatment of acute ischemic stroke (AIS).

METHODS

Major databases were searched for studies which reported clinical outcomes regarding successful or complete recanalization after first pass of mechanical thrombectomy in AIS. The assessment of bias was performed using different scales. I² statistic was used to evaluate heterogeneity between reviewers. Subgroup, meta-regression, and sensitivity analyses were conducted to explore the source of heterogeneity. Visualization of funnel plots was used to evaluate publication bias.

RESULTS

A total of 9 studies were eligible for final analysis. For successful recanalization (mTICI 2b-3), favorable outcomes were seen in 49.7% (95% confidence interval (CI): 40.5-58.9%) and 34.7% (95% CI: 26.8-42.7%) of FPE and MPE patients, respectively. Mortality at 3 months was 13.8% (95% CI: 10.8-16.9%) and 26.0% (95% CI: 17.7-34.2%), respectively. For complete recanalization (mTICI 2c-3), proportion of favorable outcomes were 62.7% (95% CI: 51.2-74.2%) and 47.7% (95% CI: 37.4-58.0%) in FPE and MPE; mortality was seen in 11.5% (95% CI: 4.9-18.2%) and 17.0% (95% CI: 5.2-28.7%), respectively. For AIS with successful recanalization, FPE had more favorable outcome (odds ratio (OR): 1.85, 95% CI: 1.48-2.30; p < 0.01; I² = 0%) and lower mortality than MPE (OR: 0.58, 95% CI: 0.42-0.79; p = 0.001; I² = 61.9%). Similar results were seen in a subgroup analysis of patients with complete recanalization, with FPE having better outcome (OR: 1.79, 95% CI: 1.40-2.28; p < 0.01; I² = 0%) and lower mortality risk (OR: 0.61, 95% CI: 0.44-0.86; p = 0.005; I² = 0%) compared to MPE.

CONCLUSION

FPE is associated with better outcomes than MPE after achieving successful or complete recanalization.

Mechanical Thrombectomy in Medium Vessel Occlusions: Blind Exchange With Mini-Pinning Technique Versus Mini Stent Retriever Alone

BACKGROUND AND PURPOSE

Mechanical thrombectomy techniques for intracranial medium vessel occlusions (MeVOs) have evolved in recent years, although the optimal approach is still unclear. The aim of this study was to investigate the effectiveness and safety of mechanical thrombectomy in MeVOs using mini (0.017 inches microcatheter compatible) stent retrievers combined with low-profile (0.035 inches distal inner diameter) distal aspiration catheters through the blind exchange/mini-pinning (BEMP) technique compared with mini stent retrievers alone.

METHODS

Retrospective review of a prospectively maintained database of patients treated with the BEMP technique or mini stent retriever alone for intracranial MeVOs from 2017 to 2020 in a comprehensive stroke center. Both groups were compared about baseline characteristics, occlusion site, clinical presentation, clot cause, procedural outcomes (MeVO first-pass and final expanded Thrombolysis in Cerebral Ischemia score, the mini stent retriever used, number of passes with the front-line approach, and need of rescue therapy), safety outcomes (emboli to unwanted territories and hemorrhagic complications), and clinical outcomes at 90 days. Multivariable logistic regression analysis was performed with potential predictors of vessel recanalization to find independent variables associated with MeVO first-pass expanded Thrombolysis in Cerebral Ischemia 2c/3 recanalization.

RESULTS

We reviewed 102 patients/106 MeVOs treated with the BEMP technique (n=56) or mini stent retriever (n=50). There was a higher rate of MeVO first-pass expanded Thrombolysis in Cerebral Ischemia 2c/3 recanalization (57% versus 34%, P=0.017), lower need of rescue therapy (7.1% versus 22%, P=0.028), and lower rate of emboli to new territory (1.8% versus 12%, P=0.035) and symptomatic intracranial hemorrhage (1.9% versus 12.8%, P=0.038) with the BEMP technique. After multivariable analysis, the sole independent factor associated to MeVO first-pass expanded Thrombolysis in Cerebral Ischemia 2c/3 recanalization was the BEMP technique (odds ratio, 2.72 [95% CI, 1.19-6.22]; P=0.018).

CONCLUSIONS

In the setting of MeVOs, the BEMP technique may lead to higher rates of the first-pass recanalization and a lower incidence of symptomatic intracranial hemorrhage than mini stent retrievers alone.

Benefit of first-pass complete reperfusion in thrombectomy is mediated by limited infarct growth

BACKGROUND AND PURPOSE

The number of clot retrieval attempts required to achieve complete reperfusion by mechanical thrombectomy impacts functional outcome in acute ischaemic stroke (AIS). Complete reperfusion [expanded Treatment In Cerebral Infarction (eTICI) score = 3] at first pass (FP), is associated with the highest rates of favorable outcome compared to complete reperfusion by multiple passes. The aim of the present study was to investigate the relationship between FP complete reperfusion and infarct growth (IG).

METHODS

Anterior AIS patients with baseline and 24-h diffusion-weighted magnetic resonance imaging were included from two prospective registries. IG was measured by voxel-based segmentation of initial and 24-h diffusion-weighted imaging lesions. IG and favorable 3-month modified Rankin Scale (mRS) score (≤ 2) were compared between patients in whom complete reperfusion (eTICI 3) was achieved with a single pass (FP group) and those for whom multiple passes were required (MP group), after matching for confounding factors. Mediation analysis was performed to examine the association between FP and 3-month mRS score, with IG as mediating variable.

RESULTS

A total of 200 patients were included, of whom 118 (28.9%) had FP complete reperfusion. In case-control analysis, the FP group had lower IG than the MP group [8.7 (5.4-12.9) ml vs. 15.2 (11-22.6) ml, respectively; P = 0.03). Favorable outcome was higher in the FP population compared to a matched MP population (70.9% vs. 53.2%, respectively; P = 0.04). FP compete reperfusion (eTICI 3) was independently associated with favorable outcome in multivariable regression analysis [odds ratio 1.86, 95% confidence interval (CI) 1.01-4.39; P = 0.04]. The effect of complete reperfusion at FP on functional outcome was explained by limited IG in mediation analysis [indirect effect: -0.32 (95% CI -0.47 to -0.09)].

CONCLUSION

Complete reperfusion at FP is independently associated with significant decrease in IG compared to complete reperfusion by multiple attempts, explaining better functional outcomes.

Prediction of mTICI 3 recanalization and clinical outcomes in endovascular thrombectomy for acute ischemic stroke: a retrospective study in the Taiwan registry

PURPOSE

Early recanalization for acute ischemic stroke (AIS) due to large vessel occlusion (LVO) by endovascular thrombectomy (EVT) is strongly related to improved functional outcomes. With data obtained from the Taiwan registry, the factors associated with mTICI 3 recanalization and clinical outcomes in EVT are investigated.

METHODS

From January 2014 to September 2016, 108 patients who underwent EVT for AIS due to LVO in 11 medical centers throughout Taiwan were included. Complete recanalization is defined as achieving modified thrombolysis in cerebral infarction (mTICI) grade 3. Good clinical outcomes are defined by the modified Rankin scale (mRS) 0-2 at 3 months after EVT. Clinical and imaging parameters for predicting mTICI 3 recanalization and good clinical outcomes are analyzed.

RESULTS

Of the 108 patients who received EVT, 54 (50%) patients had mTICI 3 recanalization. Having received aspiration only and the use of IV-tPA are shown to be significant predictors for mTICI 3 recanalization with odds ratios of 2.61 and 2.53 respectively. Forty-six (42.6%) patients experienced good 3-month clinical outcomes (mRS 0-2). Pretreatment collateral statuses, NIHSS scores, time lapses between symptoms to needle, and the occurrence of hemorrhage at 24 h are all significant predictors for good outcomes with odds ratios of 2.88, 0.91, 0.99, and 0.31 respectively.

CONCLUSIONS

Prediction of mTICI 3 recanalization and clinical outcomes offer valuable clinical information for treatment planning in EVT.

Thrombolysis in Cerebral Infarction 2b Reperfusions: To Treat or to Stop?

In patients undergoing mechanical thrombectomy, achieving complete (Thrombolysis in Cerebral Infarction 3) rather than incomplete successful reperfusion (Thrombolysis in Cerebral Infarction 2b) is associated with better functional outcome. Despite technical improvements, incomplete reperfusion remains the final angiographic result in 40% of patients according to recent trials. As most incomplete reperfusions are caused by distal vessel occlusions, they are potentially amenable to rescue strategies. While observational data suggest a net benefit of up to 20% in functional independence of incomplete versus complete reperfusions, the net benefit of secondary improvement from Thrombolysis in Cerebral Infarction 2b to 3 reperfusion might differ due to lengthier procedures and delayed reperfusion. Current strategies to tackle distal vessel occlusions consist of distal (microcatheter) aspiration, small adjustable stent retrievers, and administration of intra-arterial thrombolytics. While there are promising reports evaluating those techniques, all available studies show relevant limitations in terms of selection bias, single-center design, or nonconsecutive patient inclusion. Besides an assessment of risks associated with rescue maneuvers, we advocate that the decision-making process should also include a consideration of potential outcomes if complete reperfusion would successfully be achieved. These include (1) a futile angiographic improvement (hypoperfused territory is already infarcted), (2) an unnecessary angiographic improvement (the patient would not have developed infarction if no rescue maneuver was performed), and (3) a successful rescue maneuver with clinical benefit. Currently there is paucity of data on how these scenarios can be predicted and the decision whether to treat or to stop in a patient with incomplete reperfusion involves many unknowns. To advance the status quo, we outline current knowledge gaps and avenues of potential research regarding this clinically important question.

Local Anesthesia Without Sedation During Thrombectomy for Anterior Circulation Stroke Is Associated With Worse Outcome

BACKGROUND AND PURPOSE

The best anesthetic management for mechanical thrombectomy of large vessel occlusion strokes is still uncertain and could impact the quality of reperfusion and clinical outcome. We aimed to compare the efficacy and safety outcomes between local anesthesia (LA) and conscious sedation in a large cohort of acute ischemic stroke patients with anterior circulation large vessel occlusion strokes treated with mechanical thrombectomy in current, everyday clinical practice.

METHODS

Patients undergoing mechanical thrombectomy for anterior large vessel occlusion strokes at 4 comprehensive stroke centers in France between January 1, 2018, and December 31, 2018, were pooled from the ongoing prospective multicenter observational Endovascular Treatment in Ischemic Stroke Registry in France. Intention-to-treat and per-protocol analyses were used.

RESULTS

Among the included 1034 patients, 762 were included in the conscious sedation group and 272 were included in the LA group. In the propensity score matched cohort, the rate of favorable outcome (90-day modified Rankin Scale score 0-2) was significantly lower in the LA group than in the conscious sedation group (40.0% versus 52.0%, matched relative risk=0.76 [95% CI, 0.60-0.97]), as well as the rate of successful reperfusion (modified Thrombolysis in Cerebral Infarction grade 2b-3; 76.6% versus 87.1%; matched relative risk=0.88 [95% CI, 0.79-0.98]). There was no difference in procedure time between the 2 groups. In the inverse probability of treatment weighting-propensity score-adjusted cohort, similar significant differences were found for favorable outcomes and successful reperfusion. In inverse probability of treatment weighting-propensity score-adjusted cohort, a higher rate of 90-day mortality and a lower parenchymal hematoma were observed after LA. The sensitivity analysis restricted to our per-protocol sample provided similar results in the matched- and inverse probability of treatment weighting-propensity cohorts.

CONCLUSIONS

In the Endovascular Treatment in Ischemic Stroke registry mainly included patients in early time window (<6 hours), LA was associated with lower odds of favorable outcome, successful reperfusion, and higher odds of mortality compared with conscious sedation for mechanical thrombectomy of large vessel occlusion.

Effectiveness and Technical Considerations of Solitaire Platinum 4×40 mm Stent Retriever in Mechanical Thrombectomy with Solumbra Technique

OBJECTIVE

The Solitaire Platinum 4×40 mm stent retriever contains radiopaque markers with a long length. We evaluated the effect of Solitaire Platinum 4×40 mm stent retriever in Solumbra technique thrombectomy, and compared it with shorter Solitaire stent retrievers.

METHODS

A total of 70 patients who underwent Solumbra technique thrombectomy with equal diameter (4 mm) and different length (40 vs. 20 mm) Solitaire stent retrievers were divided into two groups : the Solitaire Platinum 4×40 mm stent (4×40) group and the Solitaire FR 4×20 mm stent or Solitaire Platinum 4×20 mm stent (4×20) group. The clinical outcomes, Thrombolysis in Cerebral Infarction score, the first pass reperfusion status, and complications were evaluated and compared between the two groups. Multivariate analysis was performed to evaluate the predictive factors for reperfusion and complete reperfusion from the first pass.

RESULTS

Higher first-pass reperfusion and complete reperfusion were achieved in the 4×40 group (68.0% and 48.0%) than in the 4×20 group (46.7% and 33.3%; p=0.004 and 0.007, respectively). In multivariate analysis, radiopaque device and longer stent retriever were correlated with first-pass reperfusion (p=0.014 and 0.008, respectively) and first-pass complete reperfusion (p=0.022 and 0.012, respectively).

CONCLUSION

Our study demonstrated the usefulness of the Solitaire Platinum 4×40 mm stent retriever, which led to higher firstpass reperfusion and complete reperfusion rates than the Solitaire FR 4×20 mm stent or the Solitaire Platinum 4×20 mm stent, especially in Solumbra technique thrombectomy.

Mechanical thrombectomy for a 12-year-old boy with acute ischemic stroke: A case report

RATIONALE

Acute ischemic stroke (AIS) is one of the most severe diseases that endanger human health. It is very common among middle-aged and elderly people, but it is rare in children. The treatment varies among children and adults, since the cause for AIS in children differs from that in adults. In adults with AIS, endovascular therapy has been recommended, but guidelines for endovascular therapy in children with AIS have not been established yet. In China, few relevant evidence is present so far in clinical research of mechanical thrombectomy in the treatment for children with AIS.

PATIENT CONCERNS

A 12-year-old boy without any special physical collision and trauma was admitted to emergency department of Changsha central hospital due to hemiplegia of left limbs for 3 hours.

DIAGNOSES

He was diagnosed with AIS after magnetic resonance imaging (MRI) examination and magnetic resonance angiography (MRA) examination. Cerebral infarction in the right parietal, temporal, insular, and frontal lobes was revealed by the MRI test. The MRA test detected occlusions in right internal carotid artery, A1 segment of right anterior cerebral artery, right middle cerebral artery, and distal branch.

INTERVENTIONS

Mechanic thrombectomy and antiplatelet aggregation therapy with clopidogrel helped the patient to recover, along with active rehabilitation training.

OUTCOMES

A significant improvement in muscle strength of his left limbs was proved. He walked by himself and had 2 of Modified Rankin Scale (MRS). At 1-year follow-up visit, he recovered well except feeling a bit pain of left lower limb when walking, with finally MRS of 1.

CONCLUSIONS

Mechanical thrombectomy can be performed safely for children with AIS, but needs a further research with large samples.

Embolus Retriever with Interlinked Cages (ERIC) versus conventional stent retrievers for thrombectomy: a propensity score-based analysis

BACKGROUND

The Embolus Retriever with Interlinked Cages (ERIC) is one of the latest devices for thrombectomies. It has several architectural features that are supposed to enhance its ability to remove clots and prevent distal emboli. We aimed to compare ERIC with standard stent retrievers (SRs) using propensity score (PS) matching.

METHODS

The clinical and radiological data of all consecutive patients treated with ERIC or standard FDA-approved stent retrievers were collected from a prospective multicenter registry. We compared procedural outcomes (recanalization rates according to the modified Thrombolysis In Cerebral Infarction (mTICI) score and procedural complications) and clinical outcomes (modified Rankin Scale (mRS) and mortality at 3 months). Matching of the populations with PS was performed to account for differences in baseline characteristics.

RESULTS

A total of 1230 patients were included. In both the PS-matched cohort (195 ERIC patients, 630 SR patients) and the inverse probability of treatment weighting PS-adjusted cohort (206 ERIC patients, 1024 SR patients) there was no difference in terms of successful recanalization (modified TICI score ≥2b), good clinical outcome (mRS=0-2 or equal to pre-stroke mRS), or mortality at 3 months. Patients treated with first-line ERIC had a higher rate of complete recanalization (mTICI 3); however, they also required more passes and more frequent rescue therapy than the SR patient group.

CONCLUSION

In a large multicenter registry with PS matching, the ERIC device provided equivalent angiographic and clinical results to conventional SRs.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov Unique identifier: NCT03776877.

Motor evoked potentials during revascularization in ischemic stroke predict motor pathway ischemia and clinical outcome

OBJECTIVE

The relevance of motor evoked potential (MEP) recovery during mechanical endovascular thrombectomy (MT) in patients with ischemic stroke is unclear. We correlated MEP recovery during MT to symptom improvement and to ischemia in eloquent motor areas on magnetic resonance imaging (MRI) and compared the predictive value of MEPs to visual angiographic reperfusion status, classified by modified Thrombolysis in Cerebral Infarction grading (mTICI).

METHODS

Patients with hemisyndrome and large-vessel occlusion undergoing MT were included (n35, 49% females; 73.9 ± 14.5 years; n31 anterior circulation). MEPs were elicited transcranially and recorded at the abductor pollicis brevis muscle bilaterally throughout the procedure. An MRI was acquired within 7 days after MT.

RESULTS

The median door-to-needle time was 3.5 hours. Median National Institutes of Health Stroke Scale at presentation was 16 (7 - 37). Median Modified Rankin Scale score was 4 at day 7 and 3 months. After MT, MEP-recovery occurred in 21 cases after a median time span of 4.5 min [range 2 - 11 min]. Symptom improvement at day 7 (3 months) was noted in 22 (21) cases. Absence of ischemia on postinterventional MRI was noted in 21 cases, 19 of whom showed MEP-recovery. Stratified for symptom improvement at day 7, sensitivity (specificity) of MEP-recovery was 86% (85%) and of mTICI ≥ 2b was 95% (23%). Stratified for absence of ischemia on postinterventional MRI, sensitivity (specificity) of MEP-recovery was 90% (86%) and of mTICI ≥ 2b was of 95% (21%).

CONCLUSIONS

MEP recovery occurs early after successful endovascular mechanical revascularization and is superior to mTICI grading in predicting postoperative neurological outcome and postoperative motor-pathway ischemia.

SIGNIFICANCE

This is a new, significant and clinically important study since it emphasizes the additional value of MEP monitoring in a field, which has been traditionally unaffiliated with neurophysiological monitoring.

2B, 2C, or 3

Background and Purpose—

A score of ≥2B on the modified Thrombolysis in Cerebral Infarction scale is generally regarded as successful reperfusion after endovascular treatment for ischemic stroke. The extended Thrombolysis in Cerebral Infarction (eTICI) includes a 2C grade, which indicates near-perfect reperfusion. We investigated how well the respective eTICI scores of 2B, 2C, and 3 correlate with clinical outcome after endovascular treatment.

Methods—

We used data from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry, a prospective, nationwide registry of endovascular treatment in the Netherlands. We included patients with a proximal intracranial occlusion of the anterior circulation for whom final antero-posterior and lateral digital subtraction angiography imaging was available. Our primary outcome was the distribution on the modified Rankin Scale at 90 days per eTICI grade. We performed (ordinal) logistic regression analyses, using eTICI 2B as reference group, and adjusted for potential confounders.

Results—

In total, 2807/3637 (77%) patients met the inclusion criteria. Of these, 17% achieved reperfusion grade eTICI 0 to 1, 14% eTICI 2A, 25% eTICI 2B, 12% eTICI 2C, and 32% eTICI 3. Groups differed in terms of age ( P <0.001) and occlusion location ( P <0.01). Procedure times decreased with increasing reperfusion grades. We found a positive association between reperfusion grade and functional outcome, which continued to increase after eTICI 2B (adjusted common odds ratio, 1.22 [95% CI, 0.96–1.57] for eTICI 2C versus 2B; adjusted common odds ratio, 1.33 [95% CI, 1.09–1.62] for eTICI 3 versus 2B).

Conclusions—

Our results indicate a continuous relationship between reperfusion grade and functional outcome, with eTICI 3 leading to the best outcomes. Although this implies that interventionists should aim for the highest possible reperfusion grade, further research on the optimal strategy is necessary.

Evolution of Stroke Thrombectomy Techniques to Optimize First-Pass Complete Reperfusion

Since 2015, endovascular therapy (EVT) has become the standard of care for acute ischemic stroke (AIS) due to large vessel occlusion. It is a safe and highly effective treatment, and its number needed to treat of 2.6 is one of the highest throughout medicine. The ultimate goal when performing EVT is to maximize chances of good outcome through achievement of fast first-pass complete reperfusion, as incomplete and delayed reperfusion increases complication rates and negatively affects outcome. Since EVT has been established as standard of care, new devices have been developed and treatment techniques have been refined. This review provides a brief overview about the rationale for and history of EVT, followed by a detailed step-by-step description of how to perform EVT using the BADDASS (BAlloon guide with large bore Distal access catheter with Dual Aspiration with Stent-retriever as Standard approach), a combined technique, which is in our opinion the safest and most effective way to achieve fast first-pass complete reperfusion. We also discuss treatment strategies for patients with simultaneous high-grade carotid stenosis/pseudoocclusion/occlusion and gaining carotid access in challenging arch anatomy, as these are commonly encountered situations in AIS, and conclude with an outlook on new technologies and future directions of EVT.

Impact of early division of the middle cerebral artery on outcome following mechanical thrombectomy

BACKGROUND

Mechanical thrombectomy has become the standard care for acute ischemic stroke caused by large vessel occlusion. However, complete reperfusion cannot be achieved in all cases, and several factors influencing the results of mechanical thrombectomy have been investigated. Among others, a tortuous anatomy is associated with lower rates of complete reperfusion. We aimed to investigate whether an early division of the middle cerebral artery has an impact on reperfusion results in mechanical thrombectomy.

METHODS

Retrospective review of consecutive patients with M1 occlusion treated endovascularly between January 2016 and December 2019 at three tertiary care centers. The study group was dichotomized based on the length of the M1 segment. Early division of the middle cerebral artery was defined as a maximum length of 10 mm of the M1 segment. Primary endpoints were first-pass mTICI scores of 3, ≥2c, and ≥2b. Secondary endpoints contained final reperfusion, number of device-passes, time interval from groin puncture to reperfusion, rate of postinterventional symptomatic intracranial hemorrhage, and frequency of emboli of new territory.

RESULTS

Among 284 included patients, 70 presented with an early division of the M1 segment (25%). Reperfusion results did not differ significantly between early and late division of M1. A higher rate of symptomatic intracranial hemorrhage was found in the group with an early M1 division treated with aspiration only (14.3% vs. 0%; p = 0.013). Patients with late M1 division had a significantly higher rate of large artery sclerosis (19.2% vs. 8.6%, p = 0.039).

CONCLUSION

The anatomic variant of an early division of the middle cerebral artery was not a predictor for incomplete reperfusion.

Optimizing Stroke Care for Patients with Large Vessel Occlusions: Current State of the Art and Future Directions

Acute ischemic stroke (AIS) is a severely disabling disease. Endovascular therapy is a powerful and highly effective treatment option for these patients and has recently become standard of care. The benefits of endovascular treatment (EVT) are tremendous both from a patient and from an economic perspective, since it dramatically improves individual patient outcomes while reducing long-term healthcare costs at the same time. The effect of EVT is highly time-dependent. Thus, the overarching goal in AIS is to quickly transport and diagnose the patient to minimize treatment delays. In this review, we provide an overview about the current state of stroke care, propose a fast and simplified imaging protocol and management approach for AIS patients. We also highlight the challenges we are currently facing in endovascular stroke treatment and suggest possible solutions to overcome these.

Futile complete recanalization: patients characteristics and its time course

As the goal of mechanical thrombectomy is shifting toward mTICI-3 rather than mTICI-2b, we sought to clarify the limitation of the effect of mTICI-3. A post-hoc analysis of a registry of large-vessel occlusion stroke from 46 centers was conducted. Among 2,420 registered patients, 725 patients with anterior circulation occlusion who achieved successful reperfusion were analyzed. We compared outcomes between patients with mTICI-3 and mTICI-2b, and investigated how the effect of mTICI-3 changed according to baseline characteristics and time course. The proportion of patients with favorable outcomes (mRS 0–2 at day 90) was higher among patients with mTICI-3 compared to those with mTICI-2b (adjusted OR, 2.10; 95% CI, 1.49–2.97). There was no heterogeneity in the effect of mTICI-3 with respect to age, neurological deficit, alteplase use, occluded vessels, or infarct size. mTICI-3 was associated with favorable outcomes when the puncture-to-reperfusion time was <80 minutes (adjusted OR, 2.28; 95% CI, 1.52–3.41), but not when the puncture-to-reperfusion time was ≥80 minutes. A significant heterogeneity was found in the effect of mTICI-3 reperfusion across the puncture-to-reperfusion time subgroups (P for interaction = 0.025). Until when operators should continue the procedure after mTICI-2b has been achieved, needs to be studied.

Public Health and Cost Benefits of Successful Reperfusion After Thrombectomy for Stroke

Background and Purpose—

The benefit that endovascular thrombectomy offers to patients with stroke with large vessel occlusions depends strongly on reperfusion grade as defined by the expanded Thrombolysis in Cerebral Infarction (eTICI) scale. Our aim was to determine the lifetime health and cost consequences of the quality of reperfusion for patients, healthcare systems, and society.

Methods—

A Markov model estimated lifetime quality-adjusted life years (QALY) and lifetime costs of endovascular thrombectomy–treated patients with stroke based on eTICI grades. The analysis was performed over a lifetime horizon in a United States setting, adopting healthcare and societal perspectives. The reference case analysis was conducted for stroke at 65 years of age. National health and cost consequences of improved eTICI 2c/3 reperfusion rates were estimated. Input parameters were based on best available evidence.

Results—

Lifetime QALYs increased for every grade of improved reperfusion (median QALYs for eTICI 0/1: 2.62; eTICI 2a: 3.46; eTICI 2b: 5.42; eTICI 2c: 5.99; eTICI 3: 6.73). Achieving eTICI 3 over eTICI 2b reperfusion resulted on average in 1.31 incremental QALYs as well as healthcare and societal cost savings of $10 327 and $20 224 per patient. A 10% increase in the eTICI 2c/3 reperfusion rate of all annually endovascular thrombectomy–treated patients with stroke in the United States is estimated to yield additional 3656 QALYs and save $21.0 million and $36.8 million for the healthcare system and society, respectively.

Conclusions—

Improved reperfusion grants patients with stroke additional QALYs and leads to long-term cost savings. Procedural strategies to achieve complete reperfusion should be assessed for safety and feasibility, even when initial reperfusion seems to be adequate.

Blood Pressure Management Following Acute Ischemic Stroke: A Review of Primary Literature

Elevated blood pressure is common in patients with acute ischemic stroke. While this may occur secondary to the body's own response to preserve cerebral blood flow, elevated blood pressure may also increase the risk of hemorrhagic transformation. Current guidelines recommend various blood pressure goals based upon multiple factors, including thresholds specific to certain treatment interventions. Despite these guidelines, there is limited evidence to support specific blood pressure targets, and variability in clinical practice is common. The purpose of this review was to discuss blood pressure management in adult patients with acute ischemic stroke, focusing on appropriate targets in the setting of alteplase administration, mechanical thrombectomy, and hemorrhagic transformation.

Multiphase adjuvant neuroprotection: A novel paradigm for improving acute ischemic stroke outcomes

While several large pivotal clinical trials recently revealed a substantial benefit of endovascular thrombectomy for acute ischemic stroke (AIS) caused by large-vessel occlusion, many patients still experience mediocre prognosis. Enlargement of the ischemic core, failed revascularization, incomplete reperfusion, distal embolization, and secondary reperfusion injury substantially impact the salvaging of brain tissue and the functional outcomes of AIS. Here, we propose novel concept of “Multiphase Adjuvant Neuroprotection” as a new paradigm that may help guide our search for adjunctive treatments to be used together with thrombectomy. The premise of multiphase adjuvant neuroprotection is based on the diverse and potentially nonoverlapping pathophysiologic mechanisms that are triggered before, during, and after thrombectomy therapies. Before thrombectomy, strategies should focus on preventing the growth of the ischemic core; during thrombectomy, improving recanalization while reducing distal embolization and maximizing reperfusion are of significant importance; after reperfusion, strategies should focus on seeking targets to reduce secondary reperfusion injury. The concept of multiphase adjuvant neuroprotection, wherein different strategies are employed throughout the various phases of clinical care, might provide a paradigm to minimize the final infarct size and improve functional outcome in AIS patients treated with thrombectomy. With the success of thrombectomy in selected AIS patients, there is now an opportunity to revisit stroke neuroprotection. Notably, if the underlying mechanisms of these neuroprotective strategies are identified, their role in the distinct phases will provide further avenues to improve patient outcomes of AIS.

Vertebrobasilar Artery Calcification and Outcomes in Posterior Circulation Large Vessel Occlusion Thrombectomy

Background and Purpose- Intracranial carotid artery calcification is associated with worse outcome in anterior circulation stroke patients who undergo endovascular thrombectomy. We investigated the association between vertebrobasilar artery calcification (VBAC) and outcome in patients undergoing endovascular thrombectomy for posterior circulation large vessel occlusion. Methods- Consecutive patients treated for posterior circulation large vessel occlusion from a prospective single-center registry were studied. VBAC was manually segmented on computed tomography brain scans. The associations between VBAC and VBAC volume, functional independence (90-day modified Rankin Scale score of 0-2), and 90-day mortality were assessed using propensity score-adjusted logistic regression. Results- Sixty-four posterior circulation large vessel occlusion patients were included. Twenty-five (39.1%) patients had VBAC, and of these, the median (interquartile range) VBAC volume was 19.8 (6.65-23.4) mm³. VBAC was associated with reduced functional independence (OR, 0.19 [95% CI, 0.04-0.78]; P=0.03) and increased mortality (OR, 9.44 [95% CI, 2.43-36.62]; P=0.005). Larger VBAC volumes were a significant predictor of reduced functional independence and increased mortality. Conclusions- VBAC is an independent predictor of outcome in patients undergoing endovascular thrombectomy for posterior circulation large vessel occlusion. Considering the presence of VBAC might improve prognostication and shared treatment decision-making between patients, families, and physicians.

Integrating Multi-Omics Data to Identify Novel Disease Genes and Single-Neucleotide Polymorphisms

Stroke ranks the second leading cause of death among people over the age of 60 in the world. Stroke is widely regarded as a complex disease that is affected by genetic and environmental factors. Evidence from twin and family studies suggests that genetic factors may play an important role in its pathogenesis. Therefore, research on the genetic association of susceptibility genes can help understand the mechanism of stroke. Genome-wide association study (GWAS) has found a large number of stroke-related loci, but their mechanism is unknown. In order to explore the function of single-nucleotide polymorphisms (SNPs) at the molecular level, in this paper, we integrated 8 GWAS datasets with brain expression quantitative trait loci (eQTL) dataset to identify SNPs and genes which are related to four types of stroke (ischemic stroke, large artery stroke, cardioembolic stroke, small vessel stroke). Thirty-eight SNPs which can affect 14 genes expression are found to be associated with stroke. Among these 14 genes, 10 genes expression are associated with ischemic stroke, one gene for large artery stroke, six genes for cardioembolic stroke and eight genes for small vessel stroke. To explore the effects of environmental factors on stroke, we identified methylation susceptibility loci associated with stroke using methylation quantitative trait loci (MQTL). Thirty-one of these 38 SNPs are at greater risk of methylation and can significantly change gene expression level. Overall, the genetic pathogenesis of stroke is explored from locus to gene, gene to gene expression and gene expression to phenotype.

Combined use of contact aspiration and the stent retriever technique versus stent retriever alone for recanalization in acute cerebral infarction: the randomized ASTER 2 study protocol

RATIONALE

Mechanical thrombectomy (MT) using a stent retriever (SR) device is currently the recommended treatment in ischemic stroke due to anterior circulation large vessel occlusion. Combining contact aspiration (CA) with SR is a promising new treatment, although it was not found to be superior to SR alone as first-line treatment for achieving successful reperfusion.

AIM

To determine whether endovascular treatment combining first-line use of CA and SR is more efficient than SR alone.

METHODS

The ASTER 2 clinical trial is a prospective, randomized, multicenter, open-label trial with a blinded endpoint. We included patients admitted with suspected anterior circulation ischemic stroke secondary to large vessel occlusion <8 hours from symptom onset. They were randomly allocated in a 1:1 ratio to one of two treatment groups (combined CA and SR or SR alone). In the case of failure of the assigned technique after three attempts, other adjunctive techniques were applied.

STUDY OUTCOME

The primary outcome is the rate of successful/complete reperfusion (modified Thrombolysis In Cerebral Infarction (mTICI) score 2c/3) after the entire endovascular procedure. Secondary outcomes include reperfusion rates after the assigned first-line intervention alone and at the end of the procedure, procedural times, change in NIH Stroke Scale score at 24 hours, intracerebral hemorrhage at 24 hours, procedure-related serious adverse events, the modified Rankin Scale score, and all-cause mortality at 90 days and 1 year. The cost effectiveness of the two procedures will also be analyzed.

DISCUSSION

This is the first head-to-head randomized trial to directly compare the efficacy of the combined use of CA and SR versus SR alone. This prospective trial aims to demonstrate the synergistic effects of CA and SR devices in first-line endovascular treatment.

Effect of workflow metrics on clinical outcomes of low diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) patients subjected to mechanical thrombectomy

BACKGROUND

Although accumulating evidence has demonstrated the benefit of mechanical thrombectomy (MT) in patients with low Alberta Stroke Program Early Computed Tomography Score (ASPECTS), it is still unclear how workflow metrics impact the clinical outcomes of this subgroup of patients.

METHODS

Patients with acute stroke and diffusion-weighted imaging (DWI) ASPECTS ≤5 at baseline, who underwent MT within 6 hours of symptoms onset, were included from a prospectively maintained national multicentric registry between January 1, 2012 to August 31, 2017. The degree of disability was assessed by the modified Rankin Scale (mRS) at 90 days. The primary outcome was functional independence defined as mRS 0 to 2 at 90 days.

RESULTS

The study included 291 patients with baseline DWI-ASPECTS ≤5. Good outcome was achieved in 82 (28.2%) patients, and 104 (35.7%) patients died within 90 days. Successful reperfusion (modified Thrombolysis In Cerebral Infarction (mTICI) 2b-3) rate was 75.3%, and median onset to recanalization (OTR) time was 2 268min. Among time-related variables, OTR emerged as the strongest predictor of primary outcome (adjusted OR for every 60 min 0.59, 95% CI 0.44 to 0.77; p<0.001). mTICI 2c-3 independently predicted a good outcome (adjusted OR 1.91, 95% CI 1.004 to 3.6; p=0.049) along with age and baseline DWI-ASPECTS. Recanalization status failed to significantly impact outcome in the DWI-ASPECTS 0-3 subpopulation.

CONCLUSIONS

Near complete reperfusion (mTICI 2c-3) and OTR are the strongest modifiable outcome predictors in patients with DWI-ASPECTS ≤5 treated with MT.

Ischemia-Reperfusion Injury After Endovascular Thrombectomy for Ischemic Stroke

Background and Purpose- In experimental models of ischemic stroke, abrupt reperfusion is associated with secondary brain damages, responsible for up to 70% of the final lesion size. Whether this remains true in humans is unknown. Methods- Using data from the ASTER randomized trial (Aspiration vs Stent Retriever for Successful Revascularization), we investigated the effect of complete reperfusion (defined as a modified Thrombolysis In Cerebral Infarction 3) after endovascular thrombectomy on early lesion growth as assessed by diffusion-weighted imaging at baseline and 1 day after reperfusion. Results- Among 381 patients included in the trial, 35 achieved complete reperfusion, benefited from both baseline and day 1 diffusion-weighted imaging, lacked significant hemorrhagic transformation, and were, therefore, included in the present study. We found that the median growth of the ischemic lesion between baseline and day 1 was only 0.9 mL after complete reperfusion, representing <4% of the mean lesion size. The actual lesion growth occurring after reperfusion is probably even smaller because this lesion growth occurred, at least in part, between baseline imaging and complete reperfusion, as demonstrated by a statistically significant positive correlation between imaging-to-reperfusion time and lesion growth ( R²=0.116; P=0.048). Conclusions- There is no significant lesion growth after complete reperfusion in most patients. This important discrepancy between clinical and preclinical pathophysiologies should be considered during preclinical evaluation of neuroprotective strategies.

Operator Versus Core Lab Adjudication of Reperfusion After Endovascular Treatment of Acute Ischemic Stroke

Background and Purpose- The modified Treatment In Cerebral Ischemia (mTICI) score is the standard method to quantify the degree of reperfusion after endovascular treatment in acute ischemic stroke. In clinical practice, it is commonly assessed by local operators after the procedure. In clinical trials and registries, mTICI is evaluated by an imaging core lab. The aim of this study was to compare operator mTICI with core lab mTICI scores in patients included in the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry. Methods- All patients with an intracranial carotid or middle cerebral artery occlusion with anteroposterior and lateral digital subtraction angiography runs were included. Operators determined the mTICI score immediately after endovascular treatment. Core lab neuroradiologists were blinded to clinical characteristics and assessed mTICI scores based on pre- and postintervention digital subtraction angiography. The agreement between operator and core lab mTICI scores and their value in the prediction of outcome (score on modified Rankin Scale at 90 days) was determined. Results- In total, 1130 patients were included. The proportion of agreement between operator and core lab mTICI score was 56% (95% CI, 54%-59%). In 33% (95% CI, 31%-36%), mTICI was overestimated by operators. Operators reported a higher rate of successful reperfusion than the core lab (77% versus 67%; difference 10% [95% CI, 6%-14%]; P<0.001). In 252 (33%) of 763 patients scored as incomplete reperfusion by the core lab (mTICI <3), the local read was mTICI 3. Multivariable logistic regression models containing either core lab scored or operator scored successful reperfusion predicted outcome on the full (C statistic of both models: 0.76) or dichotomized modified Rankin Scale (modified Rankin Scale, 0-2; C statistic of both models: 0.83) equally well. Conclusions- Operators tend to overestimate the degree of reperfusion compared with the core lab although this does not affect the accuracy of outcome prediction.

First pass effect with contact aspiration and stent retrievers in the Aspiration versus Stent Retriever (ASTER) trial

BACKGROUND

The 'first pass effect' (FPE), which was originally described with stent retrievers, designates a (near-)complete revascularization obtained after a single device pass with no rescue therapy, and is associated with improved clinical outcome and decreased mortality.

OBJECTIVE

We report the rate and benefits of FPE in the Aspiration versus Stent Retriever (ASTER) trial.

MATERIALS AND METHODS

ASTER is a randomized trial comparing angiographic revascularization with the stent retriever (SR) and contact aspiration (CA) thrombectomy techniques, assessed by an external core laboratory using the modified Thrombolysis in Cerebral Infarction (mTICI) scale. Rates of FPE (defined by mTICI 2c/3 after a single pass with no rescue therapy) were compared between patients treated with SR and CA techniques. Outcomes were compared between FPE-SR and FPE-CA patients, and between FPE and non-FPE patients.

RESULTS

FPE was achieved in 97/336 patients (28.9%), with no significant difference between SR and CA (respectively 53/169 patients (31.3%) vs 44/167 patients (26.3%), adjusted RR for CA versus SR 0.84, 95% CI 0.54 to 1.31; p=0.44). After prespecified adjustment for allocated arm and randomization stratification factors, FPE in patients was associated with a significantly improved clinical outcome and a decreased mortality, and a significantly lower rate of hemorrhagic transformation and procedural complications than in non-FPE patients.

CONCLUSION

In the ASTER trial, similar rates of FPE were achieved with SR and CA, and FPE was associated with a significantly improved outcome. New techniques and devices to improve the rate of FPE are warranted.

TRIAL REGISTRATION NUMBER

Unique identifier: NCT02523261.

Intracranial mechanical thrombectomy of large vessel occlusions in the posterior circulation using SAVE

Background

Mechanical thrombectomy (MT) using stent retriever assisted vacuum-locked extraction (SAVE) is a promising method for anterior circulation strokes. We present our experience with SAVE for large vessel occlusions (LVO) of the posterior circulation.

Methods

We retrospectively analyzed 66 consecutive MT patients suffering from LVO of the posterior circulation. Primary endpoints were first-pass and overall complete/near complete reperfusion, defined as a modified thrombolysis in cerebral infarction (mTICI) score of 2c and 3. Secondary endpoints contained number of passes, time interval from groin puncture to reperfusion and rate of postinterventional symptomatic intracranial hemorrhage (sICH).

Results

Median age was 75 years (interquartile range (IQR) 54–81 years). Baseline median National Institutes of Health stroke scale (NIHSS) was 13 (IQR 8–21). Fifty-five (83%) patients had LVO of the basilar artery and 11 (17%) of the posterior cerebral artery. Eighteen (27%) patients were treated with SAVE and 21 (32%) with aspiration only. First pass mTICI2c or 3 and overall mTICI2c or 3 were documented in 11/18 (61%) and 14/18 (78%) with SAVE and in 4/21 (19%) and 13/21 (33%) with aspiration only. Median attempt was 1 (IQR 1–2) with SAVE and 2 (IQR 1–4) with aspiration (p = 0.0249). Median groin to reperfusion time did not differ significantly between groups. The rate of sICH was 5% without any complications in the SAVE cohort.

Conclusion

Mechanical thrombectomy of posterior large vessel occlusions with SAVE is feasible, safe, and effective with high rates of near-complete and complete reperfusion.

When to Stop

Background and Purpose- Substantial proportion of patients who achieve successful recanalization of acute ischemic stroke due to large vessel occlusion do not achieve good functional outcome. We aim to analyze the effect of number of thrombectomy device passes and degree of the recanalization (by modified Thrombolysis in Cerebral Infarction) on the clinical and functional outcome. Methods- Five hundred forty-two consecutive patients underwent mechanical thrombectomy for large vessel occlusion in the anterior circulation at a single tertiary stroke center. Baseline characteristics, number of passes, recanalization degree, clinical outcome at 24 hours (measured by National Institutes of Health Scale score), and functional outcome (measured by modified Rankin Scale at 90 days) were registered. Multivariate analysis was performed to determine the association of number of passes and degree of recanalization with dramatical clinical recovery (final National Institutes of Health Scale score ≤2 or decrease in 8 or more National Institutes of Health Scale score points in 24 hours) and good functional outcome (modified Rankin Scale score ≤2 at 90 days). Results- Four hundred fifty-nine patients (84%) achieved successful recanalization (modified Thrombolysis in Cerebral Infarction 2B-3), 213 (39%) of them after first device pass. In the multivariate analysis, first-pass recanalization and modified Thrombolysis in Cerebral Infarction 3 were independent predictors of good functional outcome (odds ratio, 2.5; 95% CI, 1.4-4.5; P=0.002 and odds ratio, 2.6 CI; 1.5-4.7; P=0.001, respectively) and dramatical clinical recovery (odds ratio, 1.8; 95% CI, 1.1-3; P=0.032 and odds ratio, 2.9; 95% CI, 1.7-5.1; P<0.001, respectively). Rate of recanalization declined after each pass 39% (213/542), 35% (113/310), 33% (63/190), and 24% (26/154) for passes 1 to 4, respectively and 28% (45/158) for every attempt above 4 passes ( P<0.001). In patients who achieved recanalization, a linear association between number of passes and good functional outcome was observed: 1 pass (58.6%), 2 passes (50.5%), 3 passes (48.4%), 4 passes (38.5%), or 5 or more passes (25.6%; P<0.001) as compared with patients who did not achieve recanalization (16.9%). Conclusions- High number of device passes and less degree of recanalization are associated with worse outcome in patients with acute ischemic stroke secondary to large vessel occlusion. Future studies should investigate the optimal number of passes that should be attempted in patients without substantial recanalization.

First-Line Sofia Aspiration Thrombectomy Approach within the Endovascular Treatment of Ischemic Stroke Multicentric Registry: Efficacy, Safety, and Predictive Factors of Success

BACKGROUND AND PURPOSE

After publications on the effectiveness of mechanical thrombectomy by stent retrievers in acute ischemic stroke with large-vessel occlusion, alternative endovascular approaches have been proposed using first-line aspiration catheters. Several devices are currently available to perform A Direct Aspiration First Pass Technique. The Sofia catheter aspiration has been widely used by interventionalists, but data are scarce about its efficacy and safety. Our aim was to report our multicenter thrombectomy experience with first-line Sofia catheter aspiration and to identify independent prognostic factors of clinical and procedural outcomes.

MATERIALS AND METHODS

We performed a retrospective analysis of the prospectively maintained Endovascular Treatment of Ischemic Stroke multicentric registry. Data from consecutive patients who benefited from thrombectomy with a first-line Sofia approach between January 2013 and April 2018 were studied. We excluded other first-line approaches (stent retriever or combined aspiration and stent retriever) and extracranial occlusions. Baseline characteristics, procedural data, and angiographic and clinical outcomes were analyzed.

RESULTS

During the study period, 296 patients were treated. Mean age and initial NIHSS score were, respectively, 69.5 years and 16. Successful reperfusion, defined by the modified TICI 2b/3, was obtained in 86.1% (n = 255; 95% CI, 81.7%-89.9%). Complete reperfusion (modified TICI 3) was obtained in 41.2% (n = 122; 95% CI, 35.5%-47.1%). A first-pass effect was achieved in 24.2% (n = 71; 95% CI, 19.4%-29.6%). A rescue stent retriever approach was required in 29.7% (n = 88; 95% CI, 24.6%-35.3%). The complication rate was 9.5% (n = 28; 95% CI, 6.4%-13.5%). Forty-three percent (n = 122; 95% CI, 37.1%-48.9%) of patients presented with a favorable 3-month outcome (mRS ≤ 2). Older age, M1-occlusion topography, and intravenous thrombolysis use prior to thrombectomy were independent predictors of the first-pass effect.

CONCLUSIONS

The first-line contact aspiration approach appeared safe and efficient with Sofia catheters. These devices achieved very high reperfusion rates with a low requirement for stent retriever rescue therapy, especially for M1 occlusions.

Procedural approaches and angiographic signs predicting first-pass recanalization in patients treated with mechanical thrombectomy for acute ischaemic stroke

BACKGROUND

First-pass recanalization via mechanical thrombectomy (MT) has been associated with improved clinical outcome in patients with acute ischaemic stroke. The optimal approach to achieve first-pass effect (FPE) remains unclear. No study has evaluated angiographic features associated with the achievement of FPE. We aimed to determine the procedural approaches and angiographic signs that may predict FPE.

METHODS

We performed a prospective, multi-centre, observational study of FPE in patients with anterior circulation stroke treated with MT between February and June 2017. MTs were performed using different devices, deployment manoeuvres (standard versus 'Push and Fluff' technique), proximal balloon guide catheter (PBGC), distal aspiration catheter (DAC) or both. The angiographic clot protrusion sign (ACPS) was recorded. Completed FPE (cFPE) was defined as a modified thrombolysis in cerebral infarction score of 2c-3. Associations were sought between cFPE and procedural approaches and angiographic signs.

RESULTS

A total of 193 patients were included. cFPE was achieved in 74 (38.3%) patients. The use of the push and fluff technique (odds ratio (OR) 3.45, 95% confidence interval (CI): 1.28-9.29, p = 0.010), PBGC (OR 3.81, 95% CI: 1.41-10.22, p = 0.008) and ACPS (OR 4.71, 95% CI: 1.78-12.44, p = 0.002) were independently associated with cFPE. Concurrence of these three variables led to cFPE in 82 vs 35% of the remaining cases (p = 0.002).

CONCLUSIONS

The concurrence of the PBGC, the push and fluff technique, and the ACPS was associated with the highest rates of cFPE. Appropriate selection of the thrombectomy device and deployment technique may lead to better procedural outcomes. ACPS could be used to assess clot integration strategies in future trials.

Endovascular treatment of acute ischaemic stroke in octogenarians and nonagenarians compared with younger patients

Purpose: Endovascular therapy for emergent large vessel occlusion has been established as the standard approach for acute ischaemic stroke. However, the effectiveness and safety of endovascular therapy in the very elderly population has not been proved. Objective: To determine the safety and effectiveness of endovascular therapy in octogenarians and nonagenarians. Methods: We retrospectively reviewed all patients who underwent endovascular therapy at two stroke centres between April 2012 and July 2018. Functional outcome was assessed using the modified Rankin scale at 90 days after stroke or at discharge. A favourable outcome was defined as a modified Rankin scale score of 0-2 or not worsening of the modified Rankin scale score before stroke. Outcome was compared between younger patients (aged 46-79 years, n = 40) and octogenarians and nonagenarians (aged 80-97 years, n = 19). Results: Octogenarian and nonagenarian patients had pre-stroke functional deficit (modified Rankin scale score >1) more frequently than younger patients (57.9% vs. 20.0%, respectively, P = 0.0059). No difference was observed between very elderly and younger patients in the rate of successful reperfusion (89.5% vs. 67.5%, respectively, P = 0.11), favourable functional outcome (47.4% vs. 45.0%, respectively, P = 1.00) and mortality (21.1% vs. 27.5%, respectively, P = 1.00). On multiple regression analysis, successful reperfusion, concomitant use of intravenous thrombolysis, and out-of-hospital onset were independent predictors of favourable outcome (P = 0.0003, 0.015 and 0.028, respectively). Conclusions: Successful reperfusion, concomitant use of intravenous thrombolysis, and out-of-hospital onset were clinical predictors of favourable outcome. However, we did not observe an age-dependent effect of clinical outcome after endovascular therapy.

Mothership versus drip and ship for thrombectomy in patients who had an acute stroke: a systematic review and meta-analysis

Background

The effectiveness of mechanical thrombectomy (MT) in acute ischemic stroke due to large vessel occlusion is time-dependent. While only stroke centers with endovascular capabilities perform MT, many patients who had a stroke initially present to the closest primary stroke centers capable of administering earlier intravenous thrombolysis, and then require to be transferred to a comprehensive stroke center for MT.

Purpose

To compare the outcomes of this care pathway (drip and ship (DS)) with that whereby patients are directly transferred to a comprehensive stroke center (mothership (MS)).

Methods

We performed a systematic review and meta-analysis of published studies using several electronic databases to determine whether successful reperfusion (modified Thrombolysis In Cerebral Infarction ≥2b), functional independence at 90 days (modified Rankin Scale score ≤2), symptomatic intracranial hemorrhage, and 90-day mortality differed between those who underwent MT with the DS or the MS treatment pathway. Outcomes were meta-analyzed and the results expressed as adjusted relative risk (aRR) for the primary analysis and unadjusted relative risk (uRR) for secondary analysis.

Results

Eight studies including 2068 patients were selected, including one study reporting results fully adjusted for baseline characteristics. Patients undergoing MS had better functional independence than those undergoing DS (uRR=0.87, 95% CI 0.81 to 0.93; aRR=0.87, 95% CI 0.77 to 0.98). No difference was found between the treatment pathways in successful reperfusion (uRR=1.05, 95% CI 0.95 to 1.15; aRR=1.00, 95% CI 0.92 to 1.10), symptomatic intracranial hemorrhage (uRR=1.37, 95% CI 0.91 to 2.06; aRR, 1.53, 95% CI 0.79 to 2.98), and 90-day mortality (uRR=1.00, 95% CI 0.84 to 1.19; aRR=1.21, 95% CI 0.89 to 1.64).

Conclusions

Patients who had an acute ischemic stroke admitted directly to a comprehensive stroke center (MS patients) with endovascular capacities may have better 90-day outcomes than those receiving DS treatment. However, major limitations of current evidence (ie, retrospective studies and selection bias) suggest a need for adequately powered studies. Multicenter randomized controlled trials are expected to answer this question.

Association between age and outcomes following thrombectomy for anterior circulation emergent large vessel occlusion is determined by degree of recanalisation

BACKGROUND

Older patients undergoing thrombectomy for emergent large vessel occlusion have worse outcomes. However, complete or near-complete reperfusion (modified Thrombolysis in Cerebral Ischemia (mTICI) score of 2 c/3) is associated with improved outcomes compared with partial recanalisation (mTICI 2b).

OBJECTIVE

To examine the relationship between outcomes and age separately for the mTICI 2c/3, 2b and 0-2a groups in patients undergoing thrombectomy for anterior circulation emergent large vessel occlusion.

METHODS

Retrospective review of 157 consecutive patients undergoing thrombectomy at a single centre with an occlusion of the internal carotid artery (ICA), M1 or proximal M2 segments of the middle cerebral artery (MCA). Angiograms were graded in a blinded fashion. Patients were divided into three groups: mTICI 0-2a, mTICI 2b, and mTICI 2c/3. Demographics and workflow parameters were compared. Outcomes at 90 days were compared as a function of age, using both the conventional modified Rankin scale (mRs) and utility weighted mRs (UWmRs).

RESULTS

There were 72, 61 and 24 patients in the mTICI 2c/3, 2b and 0-2a groups, respectively. Outcomes were significantly worse with increasing age for the mTICI 2b group, but not for the mTICI 0-2a and 2c/3 groups (P=0.0002). With increasing age, outcomes of the mTICI 2b group approached those of the mTICI 0-2a group. However, outcomes of the mTICI 2c/3 groups were similar for all ages. This association was present for both the original mRs and UWmRs.

CONCLUSION

Increasing age was associated with worse outcomes for those with partial (mTICI 2b) recanalisation, not in patients with complete (mTICI 2c/3) recanalisation.

Redefining 'success': a systematic review and meta-analysis comparing outcomes between incomplete and complete revascularization

BACKGROUND

Conventionally, 'successful' endovascular thrombectomy (EVT) had been defined as achieving revascularization of thrombolysis in cerebral infarction (TICI)-2B or greater, rather than as 'complete' (TICI-3) versus 'incomplete' (TICI-2B) revascularization.

PURPOSE

We performed a systematic review and meta-analysis of studies comparing clinical outcomes between patients with TICI-2B and TICI-3 revascularization.

METHODS

Multiple databases were searched for relevant publications between January 2003 and March 2018. Studies comparing outcomes between the TICI-2B and the TICI-3 group of acute ischemic stroke (AIS) patients treated with EVT were included. Random effects meta-analysis was performed to evaluate outcomes among TICI-2B and TICI-3 groups. The following outcomes were assessed: good neurologic outcome (modified Rankin Scale (mRS)≤2 at day 90), mortality, and intracerebral hemorrhage (ICH).

RESULTS

Twenty-one studies comprising 2747 patients were identified. Patients with TICI-2B revascularization had mRS≤2 at day 90 rates of 46% (391/847) compared with 66% (522/791) for TICI-3 patients (OR 0.46, 95% CI 0.37 to 0.57). Mortality rates were significantly higher in the TICI-2B group (78/570, 14%) than in the TICI-3 group (55/709, 8%) (OR 2.00, 95% CI 1.38 to 2.91). The ICH rates were also significantly higher in the TICI-2B group as compared with the TICI-3 group (31% [134/439] vs. 22% [108/490]; OR 2.20, 95% CI 1.47 to 3.30).

CONCLUSIONS

Differences in all major outcome measures were markedly better in patients with complete versus incomplete but still 'successful' revascularization using prior thresholds, with ORs in the order of those seen in recent definitive trials comparing EVT to an intravenous tissue plasminogen activator.