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Pérez-García C, Castaño M, Llibre JC, Vargas L, López-Frías A, Rosati S, López JL, Venegas J, González E, Fondevila J, Espinosa de Rueda M, Zamarro J, Baldi S, Díaz T, de la Rosa C, Chaviano Grajera J, Ballenilla Marco F, Cuba V, Muñoz Olmedo JM, Mendez JC, Remollo S, Bermejo R, Morales E, Gómez-Escalonilla C, Moreu M. Impact of double stent retriever configuration on first-pass effect in stroke: a multicenter study. J Neurointerv Surg 2024:jnis-2024-022297. [PMID: 39288975 DOI: 10.1136/jnis-2024-022297] [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: 07/29/2024] [Accepted: 08/31/2024] [Indexed: 09/19/2024]
Abstract
BACKGROUND Efficient recanalization of occluded cerebral arteries is crucial in the treatment of acute ischemic stroke. Double stent retrievers have shown the potential to enhance the rates of recanalization on the first pass. This study aims to evaluate the efficacy and safety of the double stent retriever technique and the predictors of achieving first-pass effect in patients with acute ischemic stroke. METHODS This prospective multicenter study involved 209 patients from 16 comprehensive stroke centers in Spain. Patients with occlusions in the anterior circulation were treated using the Aperio Hybrid double stent retriever. The study examined various deployment techniques, including simultaneous and sequential deployment and stent configurations, comparing the Y-shaped and parallel configurations. RESULTS The double stent retriever technique achieved a first-pass effect in 72.7% of cases and a final successful recanalization rate of 99.5%. The Y-shaped configuration was significantly associated with higher recanalization rates on the first pass (OR 2.59, 95% CI 1.18 to 5.68, P=0.02). Procedural complications were mild to moderate in 6.7% and severe in 1.5% of cases, with symptomatic intracranial hemorrhage occurring in 3.3% of patients. At 3 months follow-up, 57.2% of patients achieved a good clinical outcome, with a mortality rate of 15.1%. CONCLUSION The findings support the efficacy of the double stent retriever technique, particularly the Y-shaped configuration, in achieving high recanalization rates on the first pass with an acceptable safety profile. This technique may offer clinical benefits for future acute ischemic stroke treatment protocols.
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Affiliation(s)
| | - Miguel Castaño
- Interventional Neuroradiology, Hospital Universitario de Salamanca, Salamanca, Spain
| | - Juan Carlos Llibre
- Interventional Neuroradiology, Hospital Universitario de Salamanca, Salamanca, Spain
| | - Luis Vargas
- Interventional Neuroradiology, Hospital Universitario de Salamanca, Salamanca, Spain
| | | | - Santiago Rosati
- Interventional Neuroradiology, Hospital Clinico San Carlos, Madrid, Spain
| | - Jose Luis López
- Interventional Neuroradiology, Hospital Universitario de Burgos, Burgos, Spain
| | - Jesus Venegas
- Interventional Neuroradiology, Hospital Universitario de Burgos, Burgos, Spain
| | - Eva González
- Interventional Neuroradiology, Hospital Universitario Cruces, Barakaldo, Spain
| | - Jon Fondevila
- Interventional Neuroradiology, Hospital Universitario Cruces, Barakaldo, Spain
| | - Mariano Espinosa de Rueda
- Interventional Neuroradiology, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Spain
| | - Joaquín Zamarro
- Interventional Neuroradiology, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Spain
| | - Sebastián Baldi
- Interventional Neuroradiology, Complejo Asistencial Universitario de Leon, Leon, Spain
| | - Teresa Díaz
- Interventional Neuroradiology, Hospital Regional Universitario de Malaga, Malaga, Spain
| | - Carmen de la Rosa
- Interventional Neuroradiology, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Spain
| | | | | | - Victor Cuba
- Interventional Neuroradiology, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Spain
| | - José M Muñoz Olmedo
- Interventional Neuroradiology, Hospital Universitario de Getafe, Getafe, Spain
| | - Jose Carlos Mendez
- Interventional Neuroradiology, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Sebastian Remollo
- Interventional Neuroradiology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Rebeca Bermejo
- Interventional Neuroradiology, Hospital de Navarra, Pamplona, Spain
| | - Edison Morales
- Interventional Neuroradiology, Hospital Universitario Basurto, Bilbao, Spain
| | | | - Manuel Moreu
- Interventional Neuroradiology, Hospital Clinico San Carlos, Madrid, Spain
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2
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Patki P, Simon S, Costanzo F, Manning KB. Current Approaches and Methods to Understand Acute Ischemic Stroke Treatment Using Aspiration Thrombectomy. Cardiovasc Eng Technol 2024:10.1007/s13239-024-00735-0. [PMID: 38886306 DOI: 10.1007/s13239-024-00735-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 05/21/2024] [Indexed: 06/20/2024]
Abstract
Acute ischemic stroke occurs when a blood clot occludes a cerebral artery. Mechanical interventions, primarily stent retrievers and aspiration thrombectomy, are used currently for removing the occluding clot and restoring blood flow. Aspiration involves using a long catheter to traverse the cerebral vasculature to reach the blood clot, followed by application of suction through the catheter bore. Aspiration is also used in conjunction with other techniques such as stent retrievers and balloon guide catheters. Despite the wide use of aspiration, our physical understanding of the process and the causes of the failure of aspiration to retrieve cerebral clots in certain scenarios is not well understood. Experimental and computational studies can help develop the capability to provide deeper insights into the procedure and enable development of new devices and more effective treatment methods. We recapitulate the aspiration-based thrombectomy techniques in clinical practice and provide a perspective of existing engineering methods for aspiration. We articulate the current knowledge gap in the understanding of aspiration and highlight possible directions for future engineering studies to bridge this gap, help clinical translation of engineering studies, and develop new patient-specific stroke therapy.
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Affiliation(s)
- Priyanka Patki
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, PA, 16802, USA
| | - Scott Simon
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Francesco Costanzo
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, PA, 16802, USA
- Center for Neural Engineering, The Pennsylvania State University, University Park, PA, 16802, USA
- Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park, PA, 16802, USA
| | - Keefe B Manning
- Department of Biomedical Engineering, The Pennsylvania State University, University Park, PA, 16802, USA.
- Center for Neural Engineering, The Pennsylvania State University, University Park, PA, 16802, USA.
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA.
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3
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Pederson JM, Hardy N, Lyons H, Sheffels E, Touchette JC, Brinjikji W, Kallmes DF, Kallmes KM. Comparison of Balloon Guide Catheters and Standard Guide Catheters for Acute Ischemic Stroke: An Updated Systematic Review and Meta-analysis. World Neurosurg 2024; 185:26-44. [PMID: 38296042 DOI: 10.1016/j.wneu.2024.01.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 01/21/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVE The objective of this study was to update our 2021 systematic review and meta-analysis which reported that balloon guide catheters (BGC) are associated with superior clinical and angiographic outcomes compared to standard guide catheters for treatment of acute ischemic stroke. METHODS We conducted a systematic review of 7 electronic databases to identify literature published between January 2010 and September 2023 reporting BGC versus non-BGC approaches. Primary outcomes were final modified thrombolysis in cerebral infarction (mTICI) ≥2b, first-pass effect (mTICI ≥2c on first pass), and modified Rankin scale 0-2 at 90 days. The risk of bias was assessed using the Newcastle Ottawa Scale. A separate random effects model was fitted for each outcome. Subgroup analyses by first-line approach were conducted. RESULTS Twenty-four studies comprising 8583 patients were included (4948 BGC; 3635 non-BGC; 1561 BGC + Stent-retriever; 1297 non-BGC + Stent-retriever). Nine studies had low risk of bias, 3 were moderate risk, and 12 were high risk. Patients treated with BGCs had higher odds of achieving mTICI 2b/3, first-pass effect mTICI 2c/3, and modified Rankin scale 0-2 at 90 days (P < 0.001). The number of patients needed to treat in order to achieve one additional successful recanalization is 17. BGC + Stent-retriever was associated with higher odds of mTICI≥2b, 90-day modified Rankin scale 0-2, and reduced odds of 90-day mortality compared to non-BGC + Stent-retrievers. The main limitation was the absence of randomized trials. CONCLUSIONS These findings corroborate our previous results suggesting that MT using BGCs is associated with better safety and effectiveness outcomes for acute ischemic stroke, especially BGC + Stent-retrievers.
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Affiliation(s)
- John M Pederson
- Superior Medical Experts, St. Paul, Minnesota, USA; Nested Knowledge, Inc, St. Paul, Minnesota, USA.
| | - Nicole Hardy
- Superior Medical Experts, St. Paul, Minnesota, USA
| | - Hannah Lyons
- Superior Medical Experts, St. Paul, Minnesota, USA
| | | | | | | | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kevin M Kallmes
- Superior Medical Experts, St. Paul, Minnesota, USA; Nested Knowledge, Inc, St. Paul, Minnesota, USA
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4
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Kaneko N, Sakuta K, Imahori T, Gedion H, Ghovvati M, Tateshima S. Devices and Techniques. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:257-262. [PMID: 38025255 PMCID: PMC10657731 DOI: 10.5797/jnet.ra.2023-0054] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 09/06/2023] [Indexed: 12/01/2023]
Abstract
This extensive review explores the intricacies of the three principal mechanical thrombectomy techniques: the stent retriever technique, contact aspiration technique, and a combined approach, and their application in managing acute ischemic stroke. Each technique operates uniquely on the thrombus, leading to differences in their efficacy. Factors including clot size, clot stiffness, vessel tortuosity, and the angle of interaction between the aspiration catheter and the clot significantly influence these differences. Clinical trials and meta-analyses have shown the overall equivalency of these techniques for the treatments of large vessel occlusion and distal medium vessel occlusions. However, there are nuanced differences that emerge under specific clinical circumstances, highlighting the absence of a one-size-fits-all strategy in acute ischemic stroke management. We emphasize the need for future investigations to elucidate these nuances further, aiming to refine procedural strategies and individualize patient care for optimal outcomes.
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Affiliation(s)
- Naoki Kaneko
- Division of Interventional Neuroradiology, Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Kenichi Sakuta
- Division of Interventional Neuroradiology, Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Taichiro Imahori
- Division of Interventional Neuroradiology, Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Department of Neurosurgery, Kita-harima Medical Center, Ono, Hyogo, Japan
| | | | - Mahsa Ghovvati
- Division of Interventional Neuroradiology, Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Satoshi Tateshima
- Division of Interventional Neuroradiology, Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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5
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Huo X, Sun D, Hu M, Raynald, Jia B, Tong X, Ma G, Wang A, Ma N, Gao F, Mo D, Miao Z. Mechanical thrombectomy with combined stent retriever and contact aspiration versus stent retriever alone for acute large vessel occlusion: data from ANGEL-ACT registry. Stroke Vasc Neurol 2023; 8:318-326. [PMID: 36720506 PMCID: PMC10512085 DOI: 10.1136/svn-2022-001765] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 12/22/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND AND PURPOSE An analysis of the ASTER 2 trial revealed similar final recanalisation levels and clinical outcomes in acute large vessel occlusion (LVO) stroke between stent retrieval (SR) alone as a first-line mechanical thrombectomy (MT) technique (SR alone first-line) and concomitant use of contact aspiration (CA) plus SR as a first-line MT technique (SR+CA first-line). The purpose of the present study was to compare the safety and efficacy of SR+CA first-line with those of SR alone first-line for patients with LVO in China. METHODS We conducted the present study by using the data from the ANGEL-ACT registry. We divided the selected patients into SR+CA first-line and SR alone first-line groups. We performed logistic regression and generalised linear models with adjustments to compare the angiographic and clinical outcomes, including successful/complete recanalisation after the first technique alone and all procedures, first-pass successful/complete recanalisation, number of passes, 90-day modified Rankin Scale, procedure duration, rescue treatment and intracranial haemorrhage within 24 hours. RESULTS Of the 1233 enrolled patients, 1069 (86.7%) received SR alone first-line, and 164 (13.3%) received SR+CA first-line. SR+CA first-line was associated with more thrombectomy passes (3 (2-4) vs 2 (1-2); β=1.77, 95% CI=1.55 to 1.99, p<0.001), and longer procedure duration (86 (60-129) min vs 80 (50-122) min; β=10.76, 95% CI=1.08 to 20.43, p=0.029) than SR alone first-line group. Other outcomes were comparable (all p>0.05) between the two groups. CONCLUSIONS Patients undergoing SR+CA first-line had more thrombectomy passes and longer procedure duration than patients undergoing SR alone first-line. Additionally, we suggested that SR+CA first-line was not superior to SR alone first-line in final recanalisation level, first-pass recanalisation level and 90-day clinical outcomes in the Chinese population.
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Affiliation(s)
- Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mingkai Hu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Raynald
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gaoting Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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6
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Munoz A, Jabre R, Orenday-Barraza JM, Eldin MS, Chen CJ, Al-Saiegh F, Abbas R, El Naamani K, Gooch MR, Jabbour PM, Tjoumakaris S, Rosenwasser RH, Herial NA. A review of mechanical thrombectomy techniques for acute ischemic stroke. Interv Neuroradiol 2023; 29:450-458. [PMID: 35238227 PMCID: PMC10399505 DOI: 10.1177/15910199221084481] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/10/2022] [Accepted: 02/14/2022] [Indexed: 02/04/2023] Open
Abstract
Mechanical thrombectomy is established as standard of care in the management of acute ischemic stroke due to large vessel occlusion and evidence-based guidelines for mechanical thrombectomy have been defined. As research continues to further expand the eligibility criteria for thrombectomy and the number of thrombectomy procedures increase worldwide, there is also growing focus on innovation of thrombectomy devices, procedural techniques, and related outcomes. Thrombectomy primarily involves use of stent retrievers and distal aspiration techniques, but variations and different combinations of techniques have been reported. As this is a rapidly evolving area in stroke management, there is debate as to which, if any, of these techniques leads to improved clinical outcomes over another and there is a lack of data comparing them. In this review, currently published and distinct techniques of mechanical thrombectomy are described methodically along with illustrations to aid in understanding the subtle differences between the techniques. The perceived benefits of each variation are discussed.
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Affiliation(s)
- Alfredo Munoz
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Roland Jabre
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jose M Orenday-Barraza
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Mohamed Shehab Eldin
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Fadi Al-Saiegh
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Rawad Abbas
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michael Reid Gooch
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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7
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Hafeez MU, Essibayi MA, Raper D, Tanweer O, Sattur M, Al-Kasab S, Burks J, Townsend R, Alsbrook D, Dumont T, Park MS, Goyal N, Arthur AS, Maier I, Mascitelli J, Starke R, Wolfe S, Fargen K, Spiotta A, Kan PT. Predictors and outcomes of first pass efficacy in posterior circulation strokes: Insights from STAR collaboration. Interv Neuroradiol 2022:15910199221149080. [PMID: 36579794 DOI: 10.1177/15910199221149080] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: First-pass efficacy (FPE) has been established as an important predictor of favorable functional outcomes after endovascular thrombectomy (ET) in anterior circulation strokes. In this retrospective cohort study, we investigate predictors and clinical outcomes of FPE in posterior circulation strokes (pcAIS). Methods: The Stroke Thrombectomy and Aneurysm Registry database was used to identify pcAIS patients who achieved FPE. Their baseline characteristics and outcomes were compared with the non-FPE group. The primary outcome was a 90-day modified Rankin Scale (mRS) of 0-3. Univariate (UVA) and multivariate (MVA) analyses were done to evaluate predictors of FPE. Safety outcomes included distal emboli, vessel rupture, symptomatic intracranial hemorrhage, and mortality. Results: Of 359 patients, 179 (50%) achieved FPE. Clot burden, occlusion site, and ET technique-related variables were similar between the two groups except for shorter procedure time with FPE. The primary outcome was significantly better with FPE (56.4% vs. 32.8%, p < 0.001). Complications were similar except for a higher rate of distal emboli in non-FPE group (11.1% vs. 3.2%, p = 0.032). Atrial fibrillation (Afib) had increased odds (aOR: 2.06, 95% CI; 1.24, 3.4, p = 0.005) and prior ischemic stroke had decreased odds (aOR: 0.524, 95% CI; 0.28, 0.97, p = 0.04) of FPE. Afib was the only independent predictor of FPE on MVA (1.94, 95% CI; 1.1, 3.43, p = 0.022). Conclusions: Higher rate of FPE in Afib-related pcAIS could possibly be explained by the differences in clot composition and degree of in-situ atherosclerotic disease burden. Future studies are warranted to explore the relationship of clot composition with ET outcomes.
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Affiliation(s)
- Muhammad U Hafeez
- Department of Neurology, 3989Baylor College of Medicine, Houston, TX, USA
| | - Muhammed A Essibayi
- Department of Neurosurgery, 2345Medical University of South Carolina, Charleston, SC, USA
| | - Daniel Raper
- Department of Neurosurgery, 3989Baylor College of Medicine, Houston, TX, USA
| | - Omar Tanweer
- Department of Neurosurgery, 3989Baylor College of Medicine, Houston, TX, USA
| | - Mithun Sattur
- Department of Neurosurgery, 2345Medical University of South Carolina, Charleston, SC, USA
| | - Sami Al-Kasab
- Department of Neurosurgery, 2345Medical University of South Carolina, Charleston, SC, USA
| | - Joshua Burks
- Department of Neurosurgery, University of Miami Health System, Miami, FL, USA
| | - Robert Townsend
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Diana Alsbrook
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Travis Dumont
- Department of Neurosurgery, University of Arizona, Tuscon, AZ, USA
| | - Min S Park
- Department of Neurosurgery, 2358University of Virginia, Charlottesville, VA, USA
| | - Nitin Goyal
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ilko Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Justin Mascitelli
- Department of Neurosurgery, 14742University of Texas Health Science Center, San Antonio, TX, USA
| | - Robert Starke
- Department of Neurosurgery, University of Miami Health System, Miami, FL, USA
| | - Stacey Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kyle Fargen
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Alejandro Spiotta
- Department of Neurosurgery, 2345Medical University of South Carolina, Charleston, SC, USA
| | - Peter T Kan
- Department of Neurosurgery, 12338University of Texas Medical Branch, Galveston, TX, USA
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8
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Al Saiegh F, Munoz A, Velagapudi L, Theofanis T, Suryadevara N, Patel P, Jabre R, Chen CJ, Shehabeldin M, Gooch MR, Jabbour P, Tjoumakaris S, Rosenwasser RH, Herial NA. Patient and procedure selection for mechanical thrombectomy: Toward personalized medicine and the role of artificial intelligence. J Neuroimaging 2022; 32:798-807. [PMID: 35567418 DOI: 10.1111/jon.13003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/27/2022] [Accepted: 04/29/2022] [Indexed: 12/27/2022] Open
Abstract
Mechanical thrombectomy (MT) for ischemic stroke due to large vessel occlusion is standard of care. Evidence-based guidelines on eligibility for MT have been outlined and evidence to extend the treatment benefit to more patients, particularly those at the extreme ends of a stroke clinical severity spectrum, is currently awaited. As patient selection continues to be explored, there is growing focus on procedure selection including the tools and techniques of thrombectomy and associated outcomes. Artificial intelligence (AI) has been instrumental in the area of patient selection for MT with a role in diagnosis and delivery of acute stroke care. Machine learning algorithms have been developed to detect cerebral ischemia and early infarct core, presence of large vessel occlusion, and perfusion deficit in acute ischemic stroke. Several available deep learning AI applications provide ready visualization and interpretation of cervical and cerebral arteries. Further enhancement of AI techniques to potentially include automated vessel probe tools in suspected large vessel occlusions is proposed. Value of AI may be extended to assist in procedure selection including both the tools and technique of thrombectomy. Delivering personalized medicine is the wave of the future and tailoring the MT treatment to a stroke patient is in line with this trend.
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Affiliation(s)
- Fadi Al Saiegh
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alfredo Munoz
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Lohit Velagapudi
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Thana Theofanis
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Neil Suryadevara
- Department of Neurology, Upstate Medical University, Syracuse, New York, USA
| | - Priyadarshee Patel
- Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Roland Jabre
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mohamed Shehabeldin
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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9
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Pop R, Finitsis SN, Arquizan C, Elhorany M, Naggara O, Darcourt J, Clarençon F, Richard S, Marnat G, Bourcier R, Sibon I, Dargazanli C, Blanc R, Lapergue B, Consoli A, Eugene F, Vannier S, Caroff J, Denier C, Boulanger M, Gauberti M, Rouchaud A, Macian F, Rosso C, Turc G, Ozkul-Wermester O, Albucher JF, Le Bras A, Evain S, Wolff V, Timsit S, Gentric JC, Bourdain F, Veunac L, Papagiannaki C, Gory B. Poor clinical outcome despite successful basilar occlusion recanalization in the early time window: incidence and predictors. J Neurointerv Surg 2022; 15:415-421. [PMID: 35428738 DOI: 10.1136/neurintsurg-2022-018769] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/03/2022] [Indexed: 11/04/2022]
Abstract
BackgroundEndovascular treatment (EVT) for basilar artery occlusions (BAO) is associated with a higher rate of futile recanalization compared with anterior circulation procedures. We aimed to identify the incidence and predictors of poor clinical outcome despite successful reperfusion in current clinical practice.MethodsWe used data from the ETIS (Endovascular Treatment in Ischemic Stroke) registry, a prospective multicenter observational registry of stroke treated with EVT in France. Patients undergoing EVT for acute BAO from January 2014 to May 2019 successfully treated within 8 hours from onset were included. Predictors of 90-day poor outcome (modified Rankin Scale (mRS) 4–6) were researched within patients with successful (modified Thrombolysis In Cerebral Infarction (mTICI 2b-3)) and excellent (mTICI 2c-3) reperfusion.ResultsAmong 242 patients treated within 8 hours, successful reperfusion was achieved in 195 (80.5%) and excellent reperfusion in 120 (49.5%). Poor outcome was observed in 107 (54.8%) and 60 (50%) patients, respectively. In patients with successful early reperfusion, age, higher initial National Institutes of Health Stroke Scale (NIHSS) score, lower posterior circulation Alberta Stroke Programme Early CT Score (pc-ASPECTS), and absence of prior intravenous thrombolysis were independent predictors of poor outcome. The only treatment factor with an independent predictive value was first-pass mTICI 2b-3 reperfusion (adjusted OR 0.13, 95% CI 0.05 to 0.37, p<0.001). In patients with excellent early reperfusion, independent predictors were age, initial NIHSS score, first-pass mTICI 2c-3 reperfusion, and hemorrhagic transformation on post-interventional imaging.ConclusionsEarly successful reperfusion with EVT occurred in 80.5% of patients, and the only treatment-related factor predictive of clinical outcome was first pass mTICI 2b-3 reperfusion. Further research is warranted to identify the optimal techniques and devices associated with first pass reperfusion in the posterior circulation.
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Affiliation(s)
- Raoul Pop
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
- Interventional Radiology, Institut de Chirurgie Guidée par l'Image, Strasbourg, France
- University of Strasbourg, INSERM UMR-S1255, Strasbourg, France
| | | | - Caroline Arquizan
- Neurology, Hôpital Gui de Chauliac, Montpellier, Languedoc-Roussillon, France
| | - Mahmoud Elhorany
- Interventional Neuroradiology, Hopital Universitaire Pitie Salpetriere, Paris, France
| | - Olivier Naggara
- Radiology, Saint Anne Hospital Centre, Paris, Île-de-France, France
| | - Jean Darcourt
- Radiology, Hôpital Purpan, Toulouse, Midi-Pyrénées, France
| | - Frédéric Clarençon
- Sorbonne Universite, Paris, Île-de-France, France
- Neuroradiology, Hopital Universitaire Pitie Salpetriere, Paris, Île-de-France, France
| | - Sébastien Richard
- Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
| | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, University Hospital Centre Bordeaux, Bordeaux, Aquitaine, France
| | | | | | - Cyril Dargazanli
- Neuroradiology, Centre Hospitalier Regional Universitaire de Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Raphaël Blanc
- Departement of interventional neuroradiology, Fondation Rothschild, Paris, Île-de-France, France
| | - Bertrand Lapergue
- Neurology, Hopital Foch, Suresnes, Île-de-France, France
- Université de Versailles Saint-Quentin-en-Yvelines, Versailles, Île-de-France, France
| | - Arturo Consoli
- Diagnostic and Interventional Neuroradiology, Hospital Foch, Suresnes, France
- Interventional Neurovascular Unit, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
| | | | | | - Jildaz Caroff
- Department of Interventional Neuroradiology - NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | | | - Marion Boulanger
- Department of Neurology, Centre Hospitalier Universitaire de Caen, Caen, Basse-Normandie, France
| | - Maxime Gauberti
- Neuroradiology, Centre Hospitalier Universitaire de Caen, Caen, Basse-Normandie, France
| | - Aymeric Rouchaud
- Interventional neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges, France
- CNRS, XLIM, UMR 7252, Limoges University, Limoges, Nouvelle-Aquitaine, France
| | - Francisco Macian
- Department of Neurology, Centre Hospitalier Universitaire de Limoges, Limoges, Limousin, France
| | - Charlotte Rosso
- Urgences cérébro-vasculaires, Hopital Universitaire Pitie Salpetriere, Paris, Île-de-France, France
| | - Guillaume Turc
- Neurology, Groupe Hospitalier Universitaire Paris psychiatrie & neurosciences, Paris, Île-de-France, France
| | | | | | - Anthony Le Bras
- Department of Radiology, Centre Hospitalier Bretagne Atlantique, Vannes, Bretagne, France
- CHU Rennes Service de radiologie et d'imagerie médicale, Rennes, France
| | - Sarah Evain
- Department of Neurology, Centre Hospitalier Bretagne Atlantique, Vannes, Bretagne, France
| | - Valerie Wolff
- Neurology, University Hospitals Strasbourg, Strasbourg, Alsace, France
| | - Serge Timsit
- Department of Neurology, Centre Hospitalier Universitaire de Brest, Brest, Bretagne, France
| | | | - Frédéric Bourdain
- Department of Neurology, Centre Hospitalier de la Cote Basque, Bayonne, Aquitaine, France
| | - Louis Veunac
- Department of Neuroradiolology, Centre Hospitalier de la Cote Basque, Bayonne, Aquitaine, France
| | - Chrysanthi Papagiannaki
- Interventional Neuroradiology, Centre Hospitalier Universitaire de Rouen, Rouen, Normandie, France
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nancy, Nancy, Lorraine, France
- IADI, INSERM U1254, Universite de Lorraine, Nancy, Lorraine, France
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10
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Schartz DA, Ellens NR, Kohli GS, Akkipeddi SMK, Colby GP, Bhalla T, Mattingly TK, Bender MT. A Meta-analysis of Combined Aspiration Catheter and Stent Retriever versus Stent Retriever Alone for Large-Vessel Occlusion Ischemic Stroke. AJNR Am J Neuroradiol 2022; 43:568-574. [PMID: 35301225 PMCID: PMC8993196 DOI: 10.3174/ajnr.a7459] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/11/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND The efficacy of combined aspiration catheter and stent retriever compared with stent retriever alone for the treatment of large-vessel occlusion acute ischemic stroke is unclear. PURPOSE Our aim was to conduct a systematic literature review and meta-analysis on several metrics of efficacy comparing aspiration catheter and stent retriever with stent retriever alone. DATA SOURCES MEDLINE and the Cochrane Library Databases were searched. Randomized controlled trials and case-control and cohort studies were included. STUDY SELECTION Ten comparative studies were included detailing a combined 1495 patients with aspiration catheter and stent retriever and 1864 with stent retrievers alone. DATA ANALYSIS Data on first pass effect (TICI 2b/2c/3 after first pass), final successful reperfusion (modified TICI ≥2b), and 90-day functional independence (mRS ≤ 2) were collected. Meta-analysis was performed using a random-effects model. DATA SYNTHESIS There was a pooled composite first pass effect of 40.8% (611/1495) versus 32.6% (608/1864) for aspiration catheter and stent retriever and stent retriever alone, respectively (P < .0001). Similarly, on a meta-analysis, aspiration catheter and stent retriever were associated with a higher first pass effect compared with stent retriever alone (OR = 1.63; 95% CI, 1.20-2.21; P = .002; I2 = 72%). There was no significant difference in composite rates of successful reperfusion between aspiration catheter and stent retriever (72.8%, 867/1190) and stent retriever alone (70.8%, 931/1314) (P = .27) or on meta-analysis (OR = 1.31; CI, 0.81-2.12; P = .27; I2 = 82%). No difference was found between aspiration catheter and stent retriever and stent retriever alone on 90-day functional independence (OR = 1.02; 95% CI, 0.77-1.36; P = .88; I2 = 40%). LIMITATIONS This study is limited by high interstudy heterogeneity. CONCLUSIONS On meta-analysis, aspiration catheter and stent retriever are associated with a superior first pass effect compared with stent retriever alone, but they are not associated with statistically different final reperfusion or functional independence.
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Affiliation(s)
- D A Schartz
- From the Departments of Imaging Sciences (D.A.S.)
| | - N R Ellens
- Neurosurgery (N.R.E., G.S.K., S.M.K.A., T.B., T.K.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - G S Kohli
- Neurosurgery (N.R.E., G.S.K., S.M.K.A., T.B., T.K.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - S M K Akkipeddi
- Neurosurgery (N.R.E., G.S.K., S.M.K.A., T.B., T.K.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - G P Colby
- Department of Neurological Surgery (G.P.C.), University of California Los Angeles, Los Angeles, California
| | - T Bhalla
- Neurosurgery (N.R.E., G.S.K., S.M.K.A., T.B., T.K.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - T K Mattingly
- Neurosurgery (N.R.E., G.S.K., S.M.K.A., T.B., T.K.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - M T Bender
- Neurosurgery (N.R.E., G.S.K., S.M.K.A., T.B., T.K.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
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11
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Okuda T, Arimura K, Matsuo R, Tokunaga S, Hara K, Yamaguchi S, Yoshida H, Kurogi R, Kameda K, Ito O, Tsumoto T, Iihara K, Mizokami T, Uwatoko T, Nishimura A, Iwaki K, Mizoguchi M. Efficacy of combined use of a stent retriever and aspiration catheter in mechanical thrombectomy for acute ischemic stroke. J Neurointerv Surg 2021; 14:892-897. [PMID: 34544828 DOI: 10.1136/neurintsurg-2021-017837] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/08/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The efficacy of combined stent retriever (SR) and aspiration catheter (AC; combined technique: CBT) use for acute ischemic stroke (AIS) is unclear. We investigated the safety and efficacy of single-unit CBT (SCBT)-retrieving the thrombus as a single unit with SR and AC into the guide catheter-compared with single use of either SR or contact aspiration (CA). METHODS We analysed 763 consecutive patients who underwent mechanical thrombectomy for AIS between January 2013 and January 2020, at six comprehensive stroke centers. Patients were divided into SCBT and single device (SR/CA) groups. The successful recanalization with first pass (SRFP) and other procedural outcomes were compared between groups. RESULTS Overall, 240 SCBT and 301 SR/CA (SR 128, CA 173) patients were analyzed. SRFP (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2c, 43.3% vs 27.9%, p<0.001; mTICI 3, 35.8% vs 25.5%, p=0.009) and final mTICI ≥2b recanalization (89.1% vs 82.0%, p=0.020) rates were significantly higher, puncture-to-reperfusion time was shorter (median (IQR) 43 (31.5-69) vs 55 (38-82.2) min, p<0.001), and the number of passes were fewer (mean±SD 1.72±0.92 vs 1.99±1.01, p<0.001) in the SCBT group. Procedural complications were similar between the groups. In subgroup analysis, SCBT was more effective in women, cardioembolic stroke patients, and internal carotid artery and M2 occlusions. CONCLUSIONS SCBT increases the SRFP rate and shortens the puncture-to-reperfusion time without increasing procedural complications.
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Affiliation(s)
- Tomohiro Okuda
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koichi Arimura
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryu Matsuo
- Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - So Tokunaga
- Department of Neuroendovascular Therapy, National Hospital Organisation Kyushu Medical Center, Fukuoka, Fukuoka, Japan
| | - Kenta Hara
- Department of Neuroendovascular Therapy, National Hospital Organisation Kyushu Medical Center, Fukuoka, Fukuoka, Japan
| | - Shinya Yamaguchi
- Department of Neurosurgery, Steel Memorial Yawata Hospital, Kita-Kyushu, Fukuoka, Japan
| | - Hidenori Yoshida
- Department of Neurosurgery, Fukuoka Tokushukai Medical Center, Kasuga, Fukuoka, Japan
| | - Ryota Kurogi
- Department of Neurosurgery, Fukuoka Tokushukai Medical Center, Kasuga, Fukuoka, Japan
| | - Katsuharu Kameda
- Department of Neurosurgery, Shin Koga Hospital, Kurume, Fukuoka, Japan
| | - Osamu Ito
- Department of Neurosurgery, Shin Koga Hospital, Kurume, Fukuoka, Japan.,Department of Neurosurgery, Kieikai Hospital, Fukuoka, Japan
| | - Tomoyuki Tsumoto
- Department of Neuroendovascular Therapy, National Hospital Organisation Kyushu Medical Center, Fukuoka, Fukuoka, Japan.,Department of Neurosurgery, Showa University Fujigaoka Hospital, Kanagawa, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Neurosurgery, National Cerebral and Cardiovascular Center Hospital, Suita, Osaka, Japan
| | - Taichiro Mizokami
- Department of Neurosurgery, Saga -Ken Medical Centre Koseikan, Saga, Saga, Japan
| | - Takeshi Uwatoko
- Department of Cerebrovascular Medicine, Saga Prefecture Medical Center Koseikan, Saga, Saga, Japan
| | - Ataru Nishimura
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Katsuma Iwaki
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masahiro Mizoguchi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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12
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Podlasek A, Dhillon PS, Jewett G, Shahein A, Goyal M, Almekhlafi M. Clinical and Procedural Outcomes with or without Balloon Guide Catheters during Endovascular Thrombectomy in Acute Ischemic Stroke: A Systematic Review and Meta-analysis with First-line Technique Subgroup Analysis. AJNR Am J Neuroradiol 2021; 42:1464-1471. [PMID: 34045301 DOI: 10.3174/ajnr.a7164] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/16/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Balloon guide catheters are increasingly used to improve clot retrieval by temporarily stopping proximal blood flow during endovascular thrombectomy. PURPOSE Our aim was to provide a summary of the literature comparing the procedural and clinical outcomes of endovascular thrombectomy with or without balloon guide catheters, depending on the first-line technique used. DATA SOURCES We used PubMed/MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews. STUDY SELECTION We chose studies that compared using balloon guide catheters with not using them. DATA ANALYSIS Random effects meta-analysis was performed to compare the procedural outcomes measured as the first-pass effect, successful reperfusion, number of passes, procedural duration, arterial puncture to reperfusion time, distal emboli, and clinical outcomes. DATA SYNTHESIS Overall, a meta-analysis of 16 studies (5507 patients, 50.8% treated with balloon guide catheters and 49.2% without them) shows that the use of balloon guide catheters increases the odds of achieving a first-pass effect (OR = 1.92; 95% CI, 1.34-2.76; P < .001), successful reperfusion (OR = 1.85; 95% CI, 1.42-2.40; P < .001), and good functional outcome (OR =1.48; 95% CI, 1.27-1.73; P < .001). Balloon guide catheters reduce the number of passes (mean difference = -0.35; 95% CI, -0.65 to -0.04; P = .02), procedural time (mean difference = -19.73; 95% CI, -34.63 to -4.83; P = .009), incidence of distal or new territory emboli (OR = 0.5; 95% CI, 0.26-0.98; P = .04), and mortality (OR = 0.72; 95% CI, 0.62-0.85; P < .001). Similar benefits of balloon guide catheters are observed when the first-line technique was a stent retriever or contact aspiration, but not for a combined approach. LIMITATIONS The analysis was based on nonrandomized trials with a moderate risk of bias. CONCLUSIONS Current literature suggests improved clinical and procedural outcomes associated with the use of balloon guide catheters during endovascular thrombectomy, especially when using the first-line stent retriever.
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Affiliation(s)
- A Podlasek
- From the Department of Neuroscience and Vascular Simulation (A.P.), School of Medicine, Anglia Ruskin University, Chelmsford, Essex, UK
- National Institute of Health Research Nottingham Biomedical Research Centre (A.P., P.S.D.), University of Nottingham, Nottingham, UK
- Clinical Radiology (A.P., P.S.D.), Queens Medical Centre, Nottingham University Hospitals National Health Service Trust, Nottingham, UK
| | - P S Dhillon
- National Institute of Health Research Nottingham Biomedical Research Centre (A.P., P.S.D.), University of Nottingham, Nottingham, UK
- Clinical Radiology (A.P., P.S.D.), Queens Medical Centre, Nottingham University Hospitals National Health Service Trust, Nottingham, UK
| | - G Jewett
- Department of Clinical Neurosciences (G.J., A.S., M.G., M.A.), University of Calgary, Calgary, Alberta, Canada
| | - A Shahein
- Department of Clinical Neurosciences (G.J., A.S., M.G., M.A.), University of Calgary, Calgary, Alberta, Canada
| | - M Goyal
- Department of Clinical Neurosciences (G.J., A.S., M.G., M.A.), University of Calgary, Calgary, Alberta, Canada
- Department of Radiology (M.G., M.A.), University of Calgary, Calgary, Alberta, Canada
| | - M Almekhlafi
- Department of Clinical Neurosciences (G.J., A.S., M.G., M.A.), University of Calgary, Calgary, Alberta, Canada
- Department of Radiology (M.G., M.A.), University of Calgary, Calgary, Alberta, Canada
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