Outcomes and Complications of Endovascular Mechanical Thrombectomy in the Treatment of Acute Posterior Circulation Occlusions: A Systematic Review

Nomogram to predict prognosis in patients with posterior circulation acute ischemic stroke after mechanical thrombectomy

Purpose

This study aimed to investigate the risk factors of prognosis and hemorrhagic transformation after mechanical thrombectomy (MT) in patients with posterior circulation acute ischemic stroke (PC-AIS) caused by large vessel occlusion. We sought to develop a nomogram for predicting the risk of poor prognosis and symptomatic intracerebral hemorrhage (sICH) in patients with PC-AIS.

Methods

A retrospective analysis was conducted on 81 patients with PC-AIS who underwent MT treatment. We collected clinical information from the patients to assessed sICH and prognosis based on CT results and National Institutes of Health Stroke Scale (NIHSS) scores. Subsequently, they were followed up for 3 months, and their prognosis was assessed using the Modified Rankin Scale. We used the least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression to determine the factors affecting prognosis to construct a nomogram. The nomogram's performance was assessed through receiver operating characteristic curves, calibration curves, decision curve analysis, and clinical impact curves.

Results

Among the 81 patients with PC-AIS, 33 had a good prognosis, 48 had a poor prognosis, 19 presented with sICH, and 62 did not present with sICH. The results of the LASSO regression indicated that variables, including HPT, baseline NIHSS score, peak SBP, SBP CV, SBP SD, peak SBP, DBP CV, HbA1c, and BG SD, were predictors of patient prognosis. Variables such as AF, peak SBP, and peak DBP predicted the risk of sICH. Multivariate logistic regression revealed that baseline NIHSS score (OR = 1.115, 95% CI 1.002-1.184), peak SBP (OR = 1.060, 95% CI 1.012-1.111), SBP CV (OR = 1.296, 95% CI 1.036-1.621) and HbA1c (OR = 3.139, 95% CI 1.491-6.609) were independent risk factors for prognosis. AF (OR = 6.823, 95% CI 1.606-28.993), peak SBP (OR = 1.058, 95% CI 1.013-1.105), and peak DBP (OR = 1.160, 95% CI 1.036-1.298) were associated with the risk of sICH. In the following step, nomograms were developed, demonstrating good discrimination, calibration, and clinical applicability.

Conclusion

We constructed nomograms to predict poor prognosis and risk of sICH in patients with PC-AIS undergoing MT. The model exhibited good discrimination, calibration, and clinical applicability.

Evaluating the safety and efficacy of transradial approach for thrombectomy in posterior circulation stroke. A systematic literature review and meta-analysis

BACKGROUND

Transradial access (TRA) is becoming more popular in neurointerventional radiology procedures and has been associated with reduced mortality, morbidity and access site complications. Guidelines state that TRA is a feasible option for posterior circulation thrombectomy however the evidence base is limited and no systematic literature review has yet been undertaken to evaluate its safety and efficacy.

METHODS

The Cochrane Library, PubMed, Web of Science, Scopus, TRIP and Embase databases were searched. Outcomes collected included TICI scores, puncture to recanalisation time, mRS scores at 90 days and access site complications.

RESULTS

291 records were identified and 31 full text articles were assessed for eligibility. Eight studies met the inclusion criteria and were meta-analysed. The rate of TICI 2b-3 was 94.7% (89.7-99.8% at 95% CI), TICI 3 was 67.9% (42.2-93.6% at 95% CI) and mRS 0-2 at 90 days was 49.8% (31.5-68.1% at 95% CI). Median puncture to reperfusion times were extracted from three studies as 24 (IQR 18-40), 24 (IQR 17.5-56.5) and 27 (IQR 24-33.5) minutes. No access site complications were reported. TICI 2b-3, TICI 3 and mRS scores were comparable to data for transfemoral access (TFA) from a large systematic review. Puncture to recanalisation times appeared lower than the TFA data but statistical comparison of this outcome was not possible.

CONCLUSIONS

The use of TRA in posterior circulation thrombectomy is safe and effective with comparable results to TFA. Further research with a larger sample size is required to fully investigate the potential for shortened puncture to recanalisation times.

Effects of a step-by-step inpatient rehabilitation program on self-care ability and quality of life in patients with acute cerebral infarction following intravascular stent implantation: a prospective cohort study

Objective

This study aims to evaluate the influence of a step-by-step inpatient rehabilitation program (SIRP) on the self-care capability and quality of life of patients who have undergone intravascular stent implantation to treat large vessel occlusion during acute cerebral infarction (ACI).

Methods

This study included a cohort of 90 patients with ACI who received intravascular stent implantations at a tertiary hospital in the Third Affiliated Hospital of Anhui Medical University from January 2020 to February 2024. The patients were followed up for at least 3 months. Cohort grouping was based on the type of nursing care each patient received. The observation group participated in SIRP along with receiving routine nursing care, whereas the control group received only routine nursing care. Key outcome measures included the Barthel index, the National Institute of Health Stroke Scale (NIHSS) score, the incidence of complications, length of hospital stay, and 36-item short-form survey (SF-36) scores. These parameters were compared between the two groups.

Results

At the time of admission, there were no significant differences in demographic data, NIHSS score, Barthel index, or SF-36 scores between the observation and control groups (all p > 0.05). However, at 3 months postoperatively, the observation group showed significant improvements, with higher average scores in the Barthel index (62.49 ± 7.32 vs. 53.16 ± 4.37, p < 0.001) and SF-36 scores (502.33 ± 14.28 vs. 417.64 ± 9.65, p < 0.001). Additionally, this group had significantly lower NIHSS scores (3.38 ± 1.19 vs. 10.24 ± 2.10, p < 0.001), fewer complications (3 vs. 15, p = 0.002), and shorter hospital stays (12.40 ± 1.68 vs. 15.56 ± 1.87, p < 0.001).

Conclusion

Implementing SIRP notably enhanced self-care capabilities and overall quality of life, while also reducing complication rates and the length of hospital stays for patients with ACI who underwent intravascular stent implantation. This underscores the potential benefits of incorporating structured rehabilitation programs in the treatment and recovery processes of such patients.

First pass effect of mechanical thrombectomy for acute vertebrobasilar artery occlusion: data from the ANGEL-ACT registry

BACKGROUND

To explore the incidence, predictors, and association of first pass effect (FPE) on clinical outcomes of mechanical thrombectomy (MT) for acute vertebrobasilar artery occlusion (VBAO) in the Asian population.

METHODS

We selected patients from the ANGEL-ACT registry. We defined FPE as complete recanalization after one MT attempt without rescue treatment, multiple pass effect (MPE) as complete recanalization after >1 MT attempt or after one MT attempt with rescue treatment, and incomplete recanalization (ICR) as a modified Thrombolysis in Cerebral Ischemia score of 2b, independent of the number of MT attempts. We conducted multivariable logistic analyses to identify the independent predictors of FPE and to compare the outcomes, including favorable outcome, mortality within 90 days, and intracranial hemorrhage (ICH) among the FPE, MPE, and ICR groups.

RESULTS

Two hundred and seventy-nine patients, 68 with FPE (24.4%), 114 with MPE (40.9%), and 83 with ICR (29.7%), were included. Underlying intracranial atherosclerosis disease (ICAD) (adjusted OR (aOR) 0.16, 95% CI 0.08 to 0.34, P<0.001) was independently associated with a low chance of FPE. Furthermore, FPE was associated with a favorable outcome compared with MPE and ICR (MPE vs FPE, aOR 0.49, 95% CI 0.25 to 0.97, P=0.040; ICR vs FPE, aOR 0.38, 95% CI 0.18 to 0.81, P=0.012), and decreased mortality (MPE vs FPE, aOR 2.57, 95% CI 1.04 to 6.36, P=0.041) compared with MPE but similar mortality to ICR (P=0.374). No difference was found for ICH among the three groups (P>0.05).

CONCLUSIONS

FPE occurred in 24.4% of patients with VBAO in our cohort, which was associated with improved clinical outcomes compared with MPE and ICR. VBAO with underlying ICAD was less likely to achieve FPE.

TRIAL REGISTRATION NUMBER

NCT03370939.

Basilar artery occlusion management: Specialist perspectives from an international survey

BACKGROUND AND PURPOSE

Two early basilar artery occlusion (BAO) randomized controlled trials did not establish the superiority of endovascular thrombectomy (EVT) over medical management. While many providers continue to recommend EVT for acute BAO, perceptions of equipoise in randomizing patients with BAO to EVT versus medical management may differ between clinician specialties.

METHODS

We conducted an international survey (January 18, 2022 to March 31, 2022) regarding management strategies in acute BAO prior to the announcement of two trials indicating the superiority of EVT, and compared responses between interventionalists (INTs) and non-interventionalists (nINTs). Selection practices for routine EVT and perceptions of equipoise regarding randomizing to medical management based on neuroimaging and clinical features were compared between the two groups using descriptive statistics.

RESULTS

Among the 1245 respondents (nINTs = 702), INTs more commonly believed that EVT was superior to medical management in acute BAO (98.5% vs. 95.1%, p < .01). A similar proportion of INTs and nINTs responded that they would not randomize a patient with BAO to EVT (29.4% vs. 26.7%), or that they would only under specific clinical circumstances (p = .45). Among respondents who would recommend EVT for BAO, there was no difference in the maximum prestroke disability, minimum stroke severity, or infarct burden on computed tomography between the two groups (p > .05), although nINTs more commonly preferred perfusion imaging (24.2% vs. 19.7%, p = .04). Among respondents who indicated they would randomize to medical management, INTs were more likely to randomize when the National Institutes of Health Stroke Scale was ≥10 (15.9% vs. 6.9%, p < .01).

CONCLUSIONS

Following the publication of two neutral clinical trials in BAO EVT, most stroke providers believed EVT to be superior to medical management in carefully selected patients, with most indicating they would not randomize a BAO patient to medical treatment. There were small differences in preference for advanced neuroimaging for patient selection, although these preferences were unsupported by clinical trial data at the time of the survey.

Effectiveness and safety of mechanical thrombectomy for acute ischaemic stroke in Latin American countries: A systematic review

OBJECTIVE

To describe the use, effectiveness, and safety outcomes of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) in Latin American countries.

MATERIALS AND METHODS

Studies reporting MT outcomes for AIS in Latin America were identified in CINAHL, MEDLINE, Web of Science, SciELO, EMBASE, and LILACS databases. Synthesis was conducted according to effectiveness (recanalization rates) and safety measures (mortality and functional independence at 90 days).

RESULTS

Seventeen studies were included, mainly from public and university hospitals. MT utilization varied from 2.6% to 50.1%, while successful recanalization ranged from 63% to 95%. Functional independence 90 days after stroke (a modified Rankin scale score of 0 to 2) was achieved in less than 40% across most studies. Mortality rates were below 30%; studies with posterior circulation strokes reported higher mortality rates. The randomized trial reported better health outcomes for functional independence among patients in the MT group (OR 2.28; 95% CI, 1.41 - 3.69), favoring MT over standard care.

CONCLUSIONS

The included studies had great methodological heterogeneity due to differences in study design, the MT time window, and stroke location. The only randomized trial showed improved functional independence and lower mortality rates with MT than with standard care. The rest of the studies reported similar findings to available literature. Efforts to improve stroke care are reflected in improved patient outcomes in the region. Future studies should consider standard time window criteria and reduce the risk of bias by including representative samples and comparison groups.

Endovascular Treatment Combined With Standard Medical Treatment Improves Outcomes of Posterior Circulation Stroke: A Systematic Review and Meta-Analysis

Aims

Whether endovascular treatment (EVT) can further improve the prognosis of patients with posterior circulation ischemic stroke (PCIS) is unclear. This meta-analysis aims to compare the efficacy and safety of PCIS patients treated with EVT plus standard medical treatment (SMT) and SMT alone.

Methods

We systematically searched for relevant randomized controlled trials (RCTs) and prospective cohort trials in MEDLINE, EMBASE, and the Cochrane Library up to February 2022. The primary outcome was favorable functional outcome of the modified Rankin Scale (mRS) with scores of 0-2 or 0-3; secondary outcomes included successful recanalization rate, intracranial hemorrhage (ICH), or symptomatic intracranial hemorrhage (sICH) after treatment and 90-day mortality.

Results

We identified six studies including 1, 385 PCIS patients (957 with EVT plus SMT; 428 with SMT alone). EVT plus SMT substantially improved 90-day functional outcomes compared with SMT alone [mRS score of 0-2: RR=1.95, 95% CI (1.52 - 2.51), P < 0.001; mRS score of 0-3: RR = 1.85, 95% CI (1.49 - 2.30), P < 0.001, respectively]. Moreover, compared with SMT, combined treatment significantly improved the rate of successful recanalization [RR = 5.03, 95% CI (3.96-6.40), P < 0.001] and reduced 90-day mortality [RR = 0.71, 95% CI (0.63-0.79), P < 0.001] despite a higher risk of ICH [RR = 6.13, 95% CI (2.50-15.02), P < 0.001] and sICH [RR = 10.47, 95% CI [2.79-39.32), P = 0.001].

Conclusion

Low-to-moderate evidence from RCTs and non-RCTs showed that increased ICH and sICH risk of EVT plus SMT did not translate to a higher risk of unfavorable outcomes compared with SMT and could even promote independence at 90 days in a real-world cohort.

Predictors of unfavorable outcome at 90 days in basilar artery occlusion patients

BACKGROUND

In a previous study, basilar artery occlusion (BAO) was shown to lead to death or disability in 80% of the patients. The treatment for BAO patients in the acute stage includes thrombolysis and intra-arterial thrombectomy, but not all patients benefit from these treatments. Thus, understanding the predictors of outcome before initiating these treatments is of special interest.

AIM

To determine the predictors related to the 90-d clinical outcome in patients with BAO in an Asian population.

METHODS

We performed a retrospective case review of patients admitted to a tertiary stroke center between 2015 and 2019. We used the international classification of diseases-10 criteria to identify cases of posterior circulation stroke. A neurologist reviewed every case, and patients fulfilling the criteria defined in the Basilar Artery International Cooperation Study were included. We then analyzed the patients’ characteristics and factors related to the 90-d outcome.

RESULTS

We identified a total of 99 patients as real BAO cases. Of these patients, 33 (33.3%) had a favorable outcome at 90 d (modified Rankin Scale: 0–3). Moreover, 72 patients received intra-arterial thrombectomy, while 13 patients received intravenous tissue-type plasminogen activator treatment. We observed a favorable outcome in 33.3% of the cases and an unfavorable outcome in 66.7% of the cases. We found that the initial National Institutes of Health Stroke Scale (NIHSS) score and several BAO symptoms, including impaired consciousness, tetraparesis, and pupillary abnormalities, were significantly associated with an unfavorable outcome (P < 0.05), while cerebellar symptoms were associated with a favorable outcome (P < 0.05). In the receiver operating characteristic (ROC) analysis, the areas under the ROC curve of initial NIHSS score, impaired consciousness, tetraparesis, cerebellar symptoms, and pupillary abnormalities were 0.836, 0.644, 0.727, 0.614, and 0.614, respectively. Initial NIHSS score showed a higher AUROC (0.836) compared to BAO symptoms.

CONCLUSION

The most important predictor of an unfavorable outcome was the initial NIHSS score. BAO symptoms, including tetraparesis, impaired consciousness, and pupillary abnormality were also related to an unfavorable outcome.

Effect of first pass reperfusion on outcome in patients with posterior circulation ischemic stroke

BACKGROUND

First pass reperfusion (FPR), that is, excellent reperfusion (expanded treatment in cerebral ischemia (eTICI) 2C-3) in one pass, after endovascular treatment (EVT) of an occluded artery in the anterior circulation, is associated with favorable clinical outcome, even when compared with multiple pass excellent reperfusion (MPR). In patients with posterior circulation ischemic stroke (PCS), the same association is expected, but currently unknown. We aimed to assess characteristics associated with FPR and the influence of FPR versus MPR on outcomes in patients with PCS.

METHODS

We used data from the MR CLEAN Registry, a prospective observational study. The effect of FPR on 24-hour National Institutes of Health Stroke Scale (NIHSS) score, as percentage reduction, and on modified Rankin Scale (mRS) scores at 3 months, was tested with linear and ordinal logistic regression models.

RESULTS

Of 224 patients with PCS, 45 patients had FPR, 47 had MPR, and 90 had no excellent reperfusion (eTICI <2C). We did not find an association between any of the patient, imaging, or treatment characteristics and FPR. FPR was associated with better NIHSS (-45% (95% CI: -65% to -12%)) and better mRS scores (adjusted common odds ratio (acOR): 2.16 (95% CI: 1.23 to 3.79)) compared with no FPR. Outcomes after FPR were also more favorable compared with MPR, but the effect was smaller and not statistically significant (NIHSS: -14% (95% CI: -51% to 49%), mRS acOR: 1.50 (95% CI: 0.75 to 3.00)).

CONCLUSIONS

FPR in patients with PCS is associated with favorable clinical outcome in comparison with no FPR. In comparison with MPR, the effect of FPR was no longer statistically significant. Nevertheless, our data support the notion that FPR should be the treatment target to pursue in every patient treated with EVT.

The effects of endovascular clot retrieval and thrombolysis on dysphagia in an Australian quaternary hospital: A retrospective review

Dysphagia (impaired swallowing) is known to contribute to decreased quality of life, and increased length of hospital stay and mortality post-stroke. Despite the advancements in stroke treatment with the introduction of thrombolysis and endovascular clot retrieval (ECR), patients continue to present with high rates of dysphagia. Speech and language therapists and stroke teams should consider the presence of haemorrhagic transformation, success of reperfusion and presence of communication deficits as risk factors for dysphagia post-ECR and/or thrombolysis.

PURPOSE

To establish incidence rates and patterns of dysphagia following the administration of reperfusion therapies in acute ischaemic stroke management.

METHOD

A retrospective review of 193 patients admitted with acute ischaemic stroke to a quaternary stroke unit in Australia over a three year period was completed. Clinical information extracted included demographics, type (thrombolysis and/or endovascular clot retrieval) and success of reperfusion therapy, and the progression of dysphagia and related factors.

RESULTS

Over half of all patients treated with reperfusion therapies presented with dysphagia on initial assessment by speech-language pathology (SLP). The type of reperfusion therapy administered was not significantly correlated with the presence of dysphagia. Dysphagia on initial assessment was significantly correlated with the presence of aphasia on initial assessment, the presence of haemorrhagic transformation, and the success of reperfusion. Increased rates of enteral feeding were also found in this study compared to figures reported in literature.

CONCLUSION

This study identified ongoing high rates of dysphagia amongst this patient population regardless of treatment type, demonstrating the need for ongoing SLP management post stroke. Further research is required in this area to develop an evidence-base for SLPs and the wider medical team and to inform clinical practice guidelines.

WHAT THIS PAPER ADDS

What is already known on the subject Stroke is one of the leading causes of disability and death internationally. Dysphagia (impaired swallowing), a common sequalae of stroke, is known to contribute to decreased quality of life, increased length of hospital stay and mortality. With advancements in technology, treatments for acute ischaemic stroke (endovascular clot retrieval and thrombolysis) are increasing in popularity. However, limited research exists exploring the impact of these therapies on dysphagia. What this paper adds Despite the advancements in stroke treatment, patients continue to present with high rates of dysphagia. Dysphagia following thrombolysis and/or ECR was found to be significantly correlated to the presence of aphasia, haemorrhagic transformation, and the success of reperfusion (regardless of treatment type). Additionally, increased rates of enteral feeding were found amongst this patient population compared to figures reported in the literature for patients following traditional stroke management. Clinical implications of this study Speech-language pathologists and the wider medical team should consider dysphagia as an ongoing consequence of stroke following reperfusion therapies, with consideration for success of reperfusion and adverse outcomes i.e., haemorrhagic transformation. Further research is required to provide an evidence-base and specific guidelines for the management of dysphagia post reperfusion therapies, including use of enteral feeding.

Endovascular Treatment of Acute Ischemic Stroke With the Penumbra System in Routine Practice: COMPLETE Registry Results

Supplemental Digital Content is available in the text.

The purpose of the COMPLETE (International Acute Ischemic Stroke Registry With the Penumbra System Aspiration Including the 3D Revascularization Device) registry was to evaluate the generalizability of the safety and efficacy of the Penumbra System (Penumbra, Inc, Alameda) in a real-world setting.