Mechanical thrombectomy after intravenous thrombolysis for acute ischaemic stroke

Dual-phase 16 slice CT angiography in stroke imaging: a poor man's multiphase study?

Multiphase CT angiography (CTA) in collateral assessment provides time-resolved cerebral angiograms of the intracranial vasculature, requiring a high-speed multidetector CT (MDCT) scanner with ≥ 64 slices. Unfortunately, many hospitals are equipped with lower speed MDCT scanners. Herein, we present our experience performing dual-phase CTA (d-CTA) on a 16 slice MDCT with a biphasic rate injection to grade intracranial collaterals as predictor of clinical outcome. 42 patients were evaluated with both dual-phase CTA (d-CTA) and single-phase CTA (s-CTA) for occluded anterior intracranial circulation and collaterals. They were treated with endovascular reperfusion. Univariate and multivariate analyses were performed to define the independent predictors for favorable outcome at 3 months. Good collateral circulation status on d-CTA was associated with a lower median 24-h (5 vs. 7.5, p = 0.03) and discharge (2 vs. 4.6, p = 0.04) NIHSS. A logistic regression model showed that only age (OR 0.95, 95% CI 0.91-0.98, p = 0.03) and good collateral circulation status at d-CTA (OR 4.3, 95% CI 1.87-11.3, p < 0.01) were independent predictors of favorable functional outcome at 3 months, but that s-CTA was not. The collateral status on d-CTA can be a useful predictor for clinical outcome in acute stroke patients. The proposed protocol adapted to a low-speed MDCT scanner could be of particular interest in hospitals without access to the more up-to-date technology.

Comparison of Mechanical Thrombectomy with Contact Aspiration, Stent Retriever, and Combined Procedures in Patients with Large-Vessel Occlusion in Acute Ischemic Stroke

Background

We investigated the properties and effects of 5 mechanical thrombectomy procedures in patients with acute ischemic stroke. The relationships between the type of procedure, the time required, the success of recanalization, and the clinical outcome were analyzed.

Material/Methods

This prospective comparative analysis included 500 patients with acute ischemic stroke and large-vessel occlusion. We compared contact aspiration thrombectomy (ADAPT, n=100), stent retriever first line (SRFL, n=196), the Solumbra technique (n=64), mechanical thrombectomy plus stent implantation (n=81), and a combined procedure (n=59).

Results

ADAPT provided shorter procedure (P<0.001) and recanalization times (P<0.001) than the other techniques. Better clinical outcome was achieved for ischemia in the anterior circulation than ischemia in the posterior fossa (P<0.001). Compared to the other techniques, patients treated with ADAPT procedure had increased odds of achieving better mTICI scores (P=0.002) and clinical outcome (NIHSS) after 7 days (P=0.003); patients treated with SRFL had increased odds of achieving better long-term clinical status (3M-mRS=0–2; P=0.040). Patients with SRFL and intravenous thrombolysis (IVT) had increased odds of better clinical status (3M-mRS=0–2; P=0.031) and decreased odds of death (P=0.005) compared to patients with SRFL without IVT. The other treatment approaches had no additional effect of IVT. Patients with SRFL with a mothership transfer had increased odds of achieving favorable clinical outcome (3M-mRS) compared to SRFL with the drip-and-ship transfer paradigm (P=0.015).

Conclusions

Our results showed that ADAPT and SRFL provided significantly better outcomes compared to the other examined techniques. A mothership transfer and IVT administration contributed to the success of the SRFL approach.

The START nomogram for individualized prediction of the probability of unfavorable outcome after intravenous thrombolysis for stroke

Background and purpose

The nomogram is an important component of modern medical decision-making, which calculates the probability of an event entirely based on individual characteristics. We aimed to develop and validate a nomogram for individualized prediction of the probability of unfavorable outcome in intravenous thrombolysis-treated stroke patients included in the large multicenter Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register.

Methods

All patients registered in the Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register by 179 Italian centers between May 2001 and March 2016 were originally included. The main outcome measure was three-month unfavorable outcome (modified Rankin Scale 3–6). Four non-categorical predictors of unfavorable outcome (baseline National Institutes of Health (NIH) Stroke Scale score: 0–25, age ≥18 years, pre-stroke modified Rankin Scale score: 0–2, and onset-to-treatment time: 0–270 min) were identified a-priori by three neurologists with expertise in the management of stroke. To generate the NIHSS STroke Scale score, Age, pre-stroke mRS score, onset-to-treatment Time (START), the pre-established predictors were entered into a logistic regression model. The discriminative performance of the model was assessed using the area under the receiver operating characteristic curve.

Results

A total of 15,862 patients with complete data for generating the START was randomly dichotomized into training (2/3, n = 10,574) and test (1/3, n = 5288) sets. The area under the receiver operating characteristic curve of START was 0.800 (95% confidence interval: 0.792–0.809) in the training set and 0.815 (95% confidence interval: 0.804–0.822) in the test set.

Conclusions

By using a limited number of non-categorical predictors, the START is the first nomogram developed and validated in a large Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register cohort, which reliably calculates the probability of unfavorable outcome in intravenous thrombolysis-treated stroke patients.