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Start, Stop, Continue? The Benefit of Overlapping Intravenous Thrombolysis and Mechanical Thrombectomy : A Matched Case-control Analysis from the German Stroke Registry. Clin Neuroradiol 2023; 33:187-197. [PMID: 35881162 PMCID: PMC10014683 DOI: 10.1007/s00062-022-01200-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 07/08/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Here we compare the procedural and clinical outcome of patients undergoing thrombectomy with running thrombolysis to matched controls with completed intravenous therapy and an only marginally overlapping activity. METHODS Patients from 25 sites in Germany were included, who presented with an acute ischemic stroke. Patients' baseline characteristics (including ASPECTS, NIHSS and mRS), grade of reperfusion, and functional outcome 24 h and at day 90 after intervention were extracted from the German Stroke Registry (n = 2566). In a case-control design we stepwise matched the groups due to age, sex and time to groin puncture and time to flow restoration. RESULTS In the initial cohort (overlap group n = 864, control group n = 1702) reperfusion status (median TICI in overlap group vs. control group: 3 vs. 2b), NIHSS after 24 h, early neurological improvement parameters, mRS at 24 h and at day 90 were significantly better in the overlap group (p < 0.001) with a similar risk of bleeding (2.9% vs. 2.4%) and death (18% vs. 22%). After adjustment mRS at day 90 still showed a trend for lower disability scores in the overlap group (3 IQR 1-5 vs. 3 IQR 1-6, p = 0.09). While comparable bleeding risk could be maintained (4% in both groups), there were significantly more deaths in the control group (18% vs. 30%, p = 0.006). CONCLUSION The presented results support the approach of continuing and completing a simultaneous administration of intravenous thrombolysis during mechanical thrombectomy procedures.
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Switch Strategy from Direct Aspiration First Pass Technique to Solumbra Improves Technical Outcome in Endovascularly Treated Stroke. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18052670. [PMID: 33800902 PMCID: PMC7967538 DOI: 10.3390/ijerph18052670] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 02/24/2021] [Accepted: 03/01/2021] [Indexed: 01/01/2023]
Abstract
Background: The major endovascular mechanic thrombectomy (MT) techniques are: Stent-Retriever (SR), aspiration first pass technique (ADAPT) and Solumbra (Aspiration + SR), which are interchangeable (defined as switching strategy (SS)). The purpose of this study is to report the added value of switching from ADAPT to Solumbra in unsuccessful revascularization stroke patients. Methods: This is a retrospective, single center, pragmatic, cohort study. From December 2017 to November 2019, 935 consecutive patients were admitted to the Stroke Unit and 176/935 (18.8%) were eligible for MT. In 135/176 (76.7%) patients, ADAPT was used as the first-line strategy. SS was defined as the difference between first technique adopted and the final technique. Revascularization was evaluated with modified Thrombolysis In Cerebral Infarction (TICI) with success defined as mTICI ≥ 2b. Procedural time (PT) and time to reperfusion (TTR) were recorded. Results: Stroke involved: Anterior circulation in 121/135 (89.6%) patients and posterior circulation in 14/135 (10.4%) patients. ADAPT was the most common first-line technique vs. both SR and Solumbra (135/176 (76.7%) vs. 10/176 (5.7%) vs. 31/176 (17.6%), respectively). In 28/135 (20.7%) patients, the mTICI was ≤ 2a requiring switch to Solumbra. The vessel’s diameter positively predicted SS result (odd ratio (OR) 1.12, confidence of interval (CI) 95% 1.03–1.22; p = 0.006). The mean number of passes before SS was 2.0 ± 1.2. ADAPT to Solumbra improved successful revascularization by 13.3% (107/135 (79.3%) vs. 125/135 (92.6%)). PT was superior for SS comparing with ADAPT (71.1 min (CI 95% 53.2–109.0) vs. 40.0 min (CI 95% 35.0–45.2); p = 0.0004), although, TTR was similar (324.1 min (CI 95% 311.4–387.0) vs. 311.4 min (CI 95% 285.5–338.7); p = 0.23). Conclusion: Successful revascularization was improved by 13.3% after switching form ADAPT to Solumbra (final mTICI ≥ 2b was 92.6%). Vessel’s diameter positively predicted recourse to SS.
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Sacks D, AbuAwad MK, Ahn SH, Baerlocher MO, Brady PS, Cole JW, Dhand S, Fox BD, Gemmete JJ, Kee-Sampson JW, McCollom V, Patel PJ, Radvany MG, Tomalty RD, Vadlamudi V, Webb MS, Wojak JC. Society of Interventional Radiology Training Guidelines for Endovascular Stroke Treatment. J Vasc Interv Radiol 2019; 30:1523-1531. [DOI: 10.1016/j.jvir.2019.08.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 08/13/2019] [Accepted: 08/13/2019] [Indexed: 01/19/2023] Open
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The Role of Interventional Radiologists in Acute Ischemic Stroke Interventions: A Joint Position Statement from the Society of Interventional Radiology, the Cardiovascular and Interventional Radiology Society of Europe, and the Interventional Radiology Society of Australasia. J Vasc Interv Radiol 2019; 30:131-133. [DOI: 10.1016/j.jvir.2018.09.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 09/29/2018] [Indexed: 11/18/2022] Open
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Lim J, Magarik JA, Froehler MT. The CT-Defined Hyperdense Arterial Sign as a Marker for Acute Intracerebral Large Vessel Occlusion. J Neuroimaging 2017; 28:212-216. [DOI: 10.1111/jon.12484] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 10/16/2017] [Indexed: 11/28/2022] Open
Affiliation(s)
- Jaims Lim
- Department of Neurological Surgery; Vanderbilt University Medical Center; Nashville TN
| | - Jordan A. Magarik
- Department of Neurological Surgery; Vanderbilt University Medical Center; Nashville TN
- Cerebrovascular Program; Vanderbilt University Medical Center; Nashville TN
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Sacks D. Interventional Radiologists and Endovascular Therapy for Acute Ischemic Strokes. J Vasc Interv Radiol 2017; 28:1137-1140. [PMID: 28735933 DOI: 10.1016/j.jvir.2017.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 03/05/2017] [Accepted: 03/09/2017] [Indexed: 10/19/2022] Open
Affiliation(s)
- David Sacks
- Department of Interventional Radiology, Reading Health System, 6th and Spruce Sts., West Reading, PA 19612.
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Bridging-therapy with intravenous recombinant tissue plasminogen activator improves functional outcome in patients with endovascular treatment in acute stroke. J Neurol Sci 2016; 372:300-304. [PMID: 28017233 DOI: 10.1016/j.jns.2016.12.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 11/21/2016] [Accepted: 12/01/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Although endovascular treatment for proximal cerebral vessel occlusion is very effective, it remains controversial if intravenous thrombolysis (IVT) prior to endovascular treatment is superior compared to endovascular treatment alone. In this study we compared functional outcomes and recanalization rates of endovascularly treated stroke patients with and without bridging IVT. METHODS Patients with acute large artery occlusion within the anterior and posterior cerebral circulation eligible for intraarterial revascularization with and without prior IVT were included in this monocentric, prospective observational study. Modified Rankin Scale (mRS) and National Institute of Health Stroke Scale (NIHSS) were determined at baseline, discharge and 90-days follow up after stroke. Successful reperfusion was defined as a Thrombolysis in Cerebral Infarction (TICI) scale 2b-3. RESULTS Of the 109 patients included, 81 (74%) received bridging therapy with i.v.-rtPA prior to endovascular treatment, 28 (26%) received endovascular treatment alone. There was no difference in groin-to-reperfusion time between the groups (54 vs 50min; p=0.657), but a trend towards a higher reperfusion rate in patients with bridging therapy (69 vs 15 patients, p=0.099). Mean improvement of the NIHSS during hospitalization was 8 points (SD; ±8) in the bridging-group and 2 points (SD, ±7) in the non-bridging-group (p=0.001). Number of patients with discharge mRS 0-2 (34 vs 5; p=0.024) and 90-days mRS 0-2 (35 vs 6; p=0.061) was higher in the bridging-group compared to the non-bridging-group. CONCLUSIONS This study provides evidence that bridging therapy with i.v.-rtPA improves functional outcome in patients eligible for endovascular treatment. Further studies are needed to confirm our findings and to identify patients most likely benefitting from bridging therapy.
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Schönenberger S, Bösel J. [Peri-interventional management of acute endovascular stroke treatment]. DER NERVENARZT 2016; 86:1217-25. [PMID: 26311331 DOI: 10.1007/s00115-015-4269-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Due to the ground breaking consistent evidence that supports the effect of endovascular stroke treatment (EST), many acute care hospitals and stroke centers will have to be prepared to provide this treatment in an optimal way within the coming years. In addition to the intervention itself, patient preparation, stabilization and monitoring during the treatment as well as the aftercare represent significant challenges and have mostly not yet been sufficiently investigated. Under these aspects, the questions of optimal sedation and airway management have received the highest attention. Based on retrospective study results it already seems to be justified, respecting certain criteria, to prefer EST with the patient under conscious sedation (CS) in comparison to general anesthesia (GA) and to only switch to GA in cases of emergency until this question has been clarified by prospective studies. This and other aspects of peri-interventional management, such as logistics, monitoring, blood pressure, ventilation settings, postprocedural steps of intensive or stroke unit care and imaging follow-up are summarized in this overview. The clinical and radiological selection of patients and thus the decision for intervention or technical aspects of the intervention itself will not be part of this article.
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Affiliation(s)
- S Schönenberger
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| | - J Bösel
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
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Dorňák T, Herzig R, Kuliha M, Havlíček R, Školoudík D, Šaňák D, Köcher M, Procházka V, Lacman J, Charvát F, Krajina A, Krajíčková D, Král M, Veverka T, Roubec M, Hajduková L, Zapletalová J. Endovascular treatment of acute basilar artery occlusion: time to treatment is crucial. Clin Radiol 2015; 70:e20-7. [PMID: 25703459 DOI: 10.1016/j.crad.2015.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 11/25/2014] [Accepted: 01/16/2015] [Indexed: 11/19/2022]
Abstract
AIM To evaluate the safety and efficacy of multimodal endovascular treatment (EVT) of acute basilar artery occlusion (BAO), including bridging therapy [intravenous thrombolysis (IVT) with subsequent EVT], to compare particular EVT techniques and identify predictors of clinical outcome. MATERIALS AND METHODS This retrospective, multi-centre study comprised 72 acute ischaemic stroke patients (51 males; mean age 59.1 ± 13.3 years) with radiologically confirmed BAO. The following data were collected: baseline characteristics, risk factors, pre-event antithrombotic treatment, neurological deficit at time of treatment, localization of occlusion, time to therapy, recanalization rate, post-treatment imaging findings. Thirty- and 90-day outcomes were evaluated using the modified Rankin scale with a good clinical outcome defined as 0-3 points. RESULTS Successful recanalization was achieved in 94.4% patients. Stepwise binary logistic regression analysis identified the presence of arterial hypertension (OR = 0.073 and OR = 0.067, respectively), National Institutes of Health Stroke Scale (NIHSS) at the time of treatment (OR = 0,829 and OR = 0.864, respectively), and time to treatment (OR = 0.556 and OR = 0.502, respectively) as significant independent predictors of 30- and 90-day clinical outcomes. CONCLUSION Data from this multicentre study showed that multimodal EVT was an effective recanalization method in acute BAO. Bridging therapy shortens the time to treatment, which was identified as the only modifiable outcome predictor.
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Affiliation(s)
- T Dorňák
- Department of Neurology, Palacký University, Olomouc, Czech Republic; Comprehensive Stroke Center, Department of Neurology, University Hospital Olomouc, Czech Republic
| | - R Herzig
- Department of Neurology, Palacký University, Olomouc, Czech Republic; Comprehensive Stroke Center, Department of Neurosurgery, Military University Hospital Prague, Czech Republic.
| | - M Kuliha
- Comprehensive Stroke Center, Department of Neurology, Ostrava University and University Hospital Ostrava, Czech Republic
| | - R Havlíček
- Comprehensive Stroke Center, Department of Neurology, Military University Hospital Prague, Czech Republic
| | - D Školoudík
- Department of Neurology, Palacký University, Olomouc, Czech Republic
| | - D Šaňák
- Comprehensive Stroke Center, Department of Neurology, University Hospital Olomouc, Czech Republic
| | - M Köcher
- Comprehensive Stroke Center, Department of Radiology, Palacký University and University Hospital Olomouc, Czech Republic
| | - V Procházka
- Comprehensive Stroke Center, Department of Radiology, Ostrava University and University Hospital Ostrava, Czech Republic
| | - J Lacman
- Comprehensive Stroke Center, Department of Radiology, Military University Hospital Prague, Czech Republic
| | - F Charvát
- Comprehensive Stroke Center, Department of Radiology, Military University Hospital Prague, Czech Republic
| | - A Krajina
- Comprehensive Stroke Center, Department of Radiology, Charles University and University Hospital Hradec Králové, Czech Republic
| | - D Krajíčková
- Comprehensive Stroke Center, Department of Neurology, Charles University and University Hospital Hradec Králové, Czech Republic
| | - M Král
- Department of Neurology, Palacký University, Olomouc, Czech Republic; Comprehensive Stroke Center, Department of Neurology, University Hospital Olomouc, Czech Republic
| | - T Veverka
- Department of Neurology, Palacký University, Olomouc, Czech Republic; Comprehensive Stroke Center, Department of Neurology, University Hospital Olomouc, Czech Republic
| | - M Roubec
- Comprehensive Stroke Center, Department of Neurology, Ostrava University and University Hospital Ostrava, Czech Republic
| | - L Hajduková
- Comprehensive Stroke Center, Department of Neurology, Military University Hospital Prague, Czech Republic
| | - J Zapletalová
- Department of Medical Biophysics, Palacký University Olomouc, Czech Republic
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