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Ikeda H, Ishibashi R, Kinosada M, Uezato M, Hata H, Kaneko R, Osuki T, Akaike N, Tanimura M, Torimaki S, Fujiwara T, Nishi R, Wada M, Yokochi Y, Hayashi T, Takada K, Kurosaki Y, Chin M, Yamagata S. Learning Curve Effect of Combined Technique Thrombectomy as First-Line Attempt for Acute Ischemic Stroke: A Single-Center Retrospective Study. World Neurosurg 2024:S1878-8750(24)00901-X. [PMID: 38810873 DOI: 10.1016/j.wneu.2024.05.138] [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: 11/12/2023] [Revised: 05/20/2024] [Accepted: 05/21/2024] [Indexed: 05/31/2024]
Abstract
OBJECTIVES We retrospectively examined the initial experience and learning curve after the introduction of thrombectomy with the combined technique using an aspiration catheter and a stent retriever as first-line attempt for acute ischemic stroke. METHODS Consecutive patients undergoing thrombectomy for acute ischemic stroke at our institution between January 2020 and December 2022 were divided into 3 groups according to the year of thrombectomy. Patient characteristics and procedural, safety, and clinical outcomes were compared between the three year periods to determine predictors of favorable clinical outcome. RESULTS In 2020, 2021, and 2022, the numbers of patients were 74, 70, and 90, respectively, with similar patient characteristics across the three years; successful recanalization rates were 79.7%, 97.1%, and 93.3%, respectively (P < 0.01 for the first 2 years); median procedure times were 67, 43, and 32 minutes, respectively (P < 0.01 for the first 2 years and P = 0.018 for the last 2 years); first pass effect rates were 20.3%, 41.4%, and 44.4%, respectively (P < 0.01 for the first 2 years); symptomatic intracranial hemorrhage rates were 14.9%, 2.9%, and 1.1%, respectively (P = 0.018 for the first 2 years); and percentages of modified Rankin Scale score 0-2 at 90 days were 24.3%, 42.9%, and 41.1%, respectively (P = 0.022 for the first 2 years). Procedure time (P = 0.038) and successful recanalization (P = 0.041) were independent predictors of favorable clinical outcome. CONCLUSIONS The learning curve effect of the combined technique may be associated with better clinical outcome due to increased successful recanalization rates, shortened procedure time, and reduced symptomatic intracranial hemorrhage.
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Affiliation(s)
- Hiroyuki Ikeda
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan.
| | - Ryota Ishibashi
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Masanori Kinosada
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Minami Uezato
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Hidenobu Hata
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Ryosuke Kaneko
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Takuya Osuki
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Natsuki Akaike
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Mai Tanimura
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Shinya Torimaki
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toshio Fujiwara
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Ryosuke Nishi
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Makoto Wada
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yasunori Yokochi
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Tomoko Hayashi
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kensuke Takada
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yoshitaka Kurosaki
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Masaki Chin
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Sen Yamagata
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
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2
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Wassélius J, Hall E, Ramgren B, Andersson T, Ullberg T. Procedural factors associated with successful recanalization in patients with acute ischemic stroke treated with endovascular thrombectomy-a nationwide register-based observational study. Interv Neuroradiol 2024:15910199241248268. [PMID: 38646674 DOI: 10.1177/15910199241248268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024] Open
Abstract
INTRODUCTION Several studies have addressed technical aspects of endovascular thrombectomy (EVT), but it is not well known how procedural factors contribute to technical success in routine healthcare. The aim was to explore factors associated with technically successful EVT on nationwide scale. METHODS We did an observational register-based study assessing factors associated with technical success off anterior circulation EVT in Sweden. The main outcome was successful recanalization defined as modified treatment in cerebral ischemia score 2b-3. The association between baseline and treatment variables and successful recanalization were explored using Chi-square(d) test and univariable logistic regression. Multivariable logistic regression was used to define predictors of successful recanalization. RESULTS The study included 3211 patients treated during 2015 to 2020. Successful recanalization was achieved in 83.1% (2667) with a gradual improvement in technical outcome over the period. After adjustment for age and occlusion location, thet use of general anesthesia, balloon guide catheter (BGC) and an operator with an overall success rate of >85% were independent predictors of successful recanalization. An overall operator success rate of <80% or 80-85%, and an annual center volume lower than 50 were predicitors of recanalization failure. CONCLUSION This study illustrates factors associated with procedural success in endovascular thrombectomy on a nationwide scale including the use of general anesthesia, BGC, annual center volumes >50 cases per year and the overall success rate of the individual operator. It highlights the potential benefit of systematic performance measurements, benchmarking, and continuous training to bring all centers and operators to the highest level of performance.
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Affiliation(s)
- Johan Wassélius
- Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences Lund, Lund University, , Lund, Sweden
| | - Emma Hall
- Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences Lund, Lund University, , Lund, Sweden
| | - Birgitta Ramgren
- Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences Lund, Lund University, , Lund, Sweden
| | - Tommy Andersson
- Departments of Neuroradiology, Karolinska University Hospital and Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Imaging, AZ Groeninge Hospital, Kortrijk, Belgium
| | - Teresa Ullberg
- Department of Clinical Sciences Lund, Lund University, , Lund, Sweden
- Department of Neurology, Skåne University Hospital, Malmö, Sweden
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Liu C, Liu Y, Li Z, Gong P, Xu Z, Zhou J, Zhang W. Cumulative experience improves the procedures of mechanical thrombectomy. BMC Neurol 2022; 22:37. [PMID: 35078425 PMCID: PMC8787876 DOI: 10.1186/s12883-022-02562-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 01/07/2022] [Indexed: 11/24/2022] Open
Abstract
Background Mechanical thrombectomy has been widely performed for large vessel occlusion stroke. The present study aimed to determine whether cumulative experience could improve thrombectomy outcomes. Methods In this retrospective single-center analysis, patients who underwent mechanical thrombectomy with the Solitaire stent in 3 years from 25 April 2015 were enrolled in the current study. Patients’ characteristics, durations of admission and treatment, recanalization rates, clinical outcomes, and hemorrhage transformation rates were compared among the 3 years. Logistic analysis was used to analyze the independent correlation of the years and procedural outcomes. Results A total of 222 patients underwent mechanical thrombectomy in the 3 years: 50 in the first year, 68 in the second year, and 104 in the third year. Door-to-puncture time (P < 0.001) and puncture-to-recanalization time (P = 0.033) decreased significantly among the 3 years, while successful recanalization rates increased (P = 0.001). Logistic regression analysis showed an independent increase in the successful recanalization rates in the second year and third year (P = 0.020, P = 0.001) as compared to that in the first year. Conclusions Cumulative experience might improve the procedures of mechanical thrombectomy. The current findings suggested a potential benefit for centralization in the treatment of large vessel occlusion stroke.
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Seo WK, Nam HS, Chung JW, Kim YD, Kim KH, Bang OY, Kim BM, Kim GM, Jeon P, Heo JH. TAB-TICI Score: Successful Recanalization Score After Endovascular Thrombectomy in Acute Stroke. Front Neurol 2021; 12:692490. [PMID: 34721254 PMCID: PMC8551570 DOI: 10.3389/fneur.2021.692490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 08/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: Successful reperfusion therapy is supposed to be comprehensive and validated beyond the grade of recanalization. This study aimed to develop a novel scoring system for defining the successful recanalization after endovascular thrombectomy. Methods: We analyzed the data of consecutive acute stroke patients who were eligible to undergo reperfusion therapy within 24 h of onset and who underwent mechanical thrombectomy using a nationwide multicenter stroke registry. A new score was produced using the predictors which were directly linked to the procedure to evaluate the performance of the thrombectomy procedure. Results: In total, 446 patients in the training population and 222 patients in the validation population were analyzed. From the potential components of the score, four items were selected: Emergency Room-to-puncture time (T), adjuvant devices used (A), procedural intracranial bleeding (B), and post-thrombectomy reperfusion status [Thrombolysis in Cerebral Infarction (TICI)]. Using these items, the TAB-TICI score was developed, which showed good performance in terms of discriminating early neurological aggravation [AUC 0.73, 95% confidence interval (CI) 0.67–0.78, P < 0.01] and favorable outcomes (AUC 0.69, 95% CI 0.64–0.75, P < 0.01) in the training population. The stability of the TAB-TICI score was confirmed by external validation and sensitivity analyses. The TAB-TICI score and its derived grade of successful recanalization were significantly associated with the volume of thrombectomy cases at each site and in each admission year. Conclusion: The TAB-TICI score is a valid and easy-to-use tool to more comprehensively define successful recanalization after endovascular thrombectomy in acute stroke patients with large vessel occlusion.
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Affiliation(s)
- Woo-Keun Seo
- Department of Neurology and Stroke Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Department of Digital Health, Samsung Advanced Institute for Health Science & Technology (SAIHST), Sungkyunkwan University, Seoul, South Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Jong-Won Chung
- Department of Neurology and Stroke Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Keon-Ha Kim
- Department of Radiology, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, South Korea
| | - Oh Young Bang
- Department of Neurology and Stroke Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Byung Moon Kim
- Interventional Neuroradiology, Yonsei University College of Medicine, Seoul, South Korea
| | - Gyeung-Moon Kim
- Department of Neurology and Stroke Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Pyoung Jeon
- Department of Radiology, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, South Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
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5
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Seo KD, Kang MJ, Lee JK, Suh SH, Lee KY. Mechanical thrombectomy reduces the gap in treatment outcomes of ischemic stroke between hospital levels of care: analysis of a Korean nationwide data. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1227. [PMID: 34532364 PMCID: PMC8421926 DOI: 10.21037/atm-21-2342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/25/2021] [Indexed: 11/06/2022]
Abstract
Background Mechanical thrombectomy (MT) of ischemic stroke was demonstrated to be effective in clinical trials and was reported to have favorable outcomes in real clinical settings since 2015. We aimed to determine the national trends of MT and compare the outcomes between the different levels of treating hospital. Methods We obtained data from the nationwide database from 2008 to 2017. Patients with ischemic stroke who received MT were identified using the International Classification of Disease Codes. Good outcome was defined as discharge to home, and a poor outcome was defined as cerebral hemorrhage, physical disability, or death. The study period was divided into three (off-label MT, transitional, MT period). Hospital groups where MT was performed were divided into tertiary and non-tertiary hospitals. Results In MT period, 47.0% of the MT procedures were performed in non-tertiary hospitals compared with 36.1% in off-label MT period. Comparison of the 3-month mortality between patients who were treated in tertiary vs. non-tertiary hospitals revealed significant lower mortality in tertiary hospital through all period. The incidence of cerebral hemorrhage and physical disability did not differ between hospital groups. However, the percentage of patients discharged home was 41.4% for tertiary hospitals and 42.4% for non-tertiary hospitals, which was not statistically different in MT period (P=0.4671). Conclusions Analysis of the nationwide data confirmed that the extent of increase in MT was higher in non-tertiary hospitals than tertiary hospitals. In addition, no significant difference was revealed in the number of favorable clinical outcome between the hospital groups during MT period.
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Affiliation(s)
- Kwon-Duk Seo
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Min Jin Kang
- Institute of Health Insurance and Clinical Research, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jae Kwang Lee
- Institute of Health Insurance and Clinical Research, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Sang Hyun Suh
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung-Yul Lee
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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6
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Zhu F, Ben Hassen W, Bricout N, Kerleroux B, Janot K, Gory B, Anxionnat R, Richard S, Marchal A, Blanc R, Piotin M, Consoli A, Trystram D, Rodriguez Regent C, Desilles JP, Weisenburger-Lile D, Escalard S, Herbreteau D, Ifergan H, Lima Maldonado I, Labreuche J, Henon H, Naggara O, Lapergue B, Boulouis G. Effect of Operator's Experience on Proficiency in Mechanical Thrombectomy: A Multicenter Study. Stroke 2021; 52:2736-2742. [PMID: 34233462 DOI: 10.1161/strokeaha.120.031940] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND PURPOSE We aimed to evaluate among trained interventional neuroradiologist, whether increasing individual experience was associated with an improvement in mechanical thrombectomy (MT) procedural performance metrics. METHODS Individual MT procedural data from 5 centers of the Endovascular Treatment in Ischemic Stroke registry and 2 additional high-volume stroke centers were pooled. Operator experience was defined for each operator as a continuous variable, cumulating the number of MT procedures performed since January 2015, as MT became standard of care or, if later than this date, since the operator started performing mechanical thrombectomies in autonomy. We tested the associations between operator's experience and procedural metrics. RESULTS A total of 4516 procedures were included, performed by 36 operators at 7 distinct centers, with a median of 97.5 endovascular treatment procedures per operator (interquartile range, 57-170.2) over the study period. Higher operator's experience, analyzed as a continuous variable, was associated with a significantly shorter procedural duration (β estimate, -3.98 [95% CI, -5.1 to -2.8]; P<0.001), along with local anesthesia and M1 occlusion location in multivariable models. Increasing experience was associated with better Thrombolysis in Cerebral Infarction scores (estimate, 1.02 [1-1.04]; P=0.013). CONCLUSIONS In trained interventional neuroradiologists, increasing experience in MT is associated with significantly shorter procedural duration and better reperfusion rates, with a theoretical ceiling effect observed after around 100 procedures. These results may inform future training and practice guidelines to set minimal experience standards before autonomization, and to set-up operators' recertification processes tailored to individual case volume and prior experience.
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Affiliation(s)
- François Zhu
- Department of Diagnostic and Therapeutic Neuroradiology, F-54000, CHRU Nancy and IADI, INSERM U1254, F-54000, Université de Lorraine, Nancy, France (F.Z., B.G., R.A.)
| | - Wagih Ben Hassen
- GHU Paris Psychiatrie et Neurosciences, Hospitalier Sainte Anne, Service d'imagerie Morphologique et Fonctionnelle, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, INSERM, Université de Paris (W.B.H., B.K., D.T., C.R.R., O.N., G.B.)
| | - Nicolas Bricout
- Department of Neuroradiology, CHRU Lille, France (N.B., A.M.)
| | - Basile Kerleroux
- GHU Paris Psychiatrie et Neurosciences, Hospitalier Sainte Anne, Service d'imagerie Morphologique et Fonctionnelle, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, INSERM, Université de Paris (W.B.H., B.K., D.T., C.R.R., O.N., G.B.).,Department of Neuroradiology, CHRU Tours, Tours, France (B.K., K.J., D.H., H.I., G.B.)
| | - Kevin Janot
- Department of Neuroradiology, CHRU Tours, Tours, France (B.K., K.J., D.H., H.I., G.B.)
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, F-54000, CHRU Nancy and IADI, INSERM U1254, F-54000, Université de Lorraine, Nancy, France (F.Z., B.G., R.A.)
| | - René Anxionnat
- Department of Diagnostic and Therapeutic Neuroradiology, F-54000, CHRU Nancy and IADI, INSERM U1254, F-54000, Université de Lorraine, Nancy, France (F.Z., B.G., R.A.)
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, CHRU Nancy and INSERM U1116, F-54000, Université de Lorraine, Nancy, France (S.R.)
| | - Adrien Marchal
- Department of Neuroradiology, CHRU Lille, France (N.B., A.M.)
| | - Raphael Blanc
- Department of Neuroradiology, Fondation Ophtalmologique A. de Rothschild, Paris, France (R.B., M.P., J.-P.D., S.E.)
| | - Michel Piotin
- Department of Neuroradiology, Fondation Ophtalmologique A. de Rothschild, Paris, France (R.B., M.P., J.-P.D., S.E.)
| | - Arturo Consoli
- Department of Neuroradiology, Foch Hospital, Suresnes, France (A.C.)
| | - Denis Trystram
- GHU Paris Psychiatrie et Neurosciences, Hospitalier Sainte Anne, Service d'imagerie Morphologique et Fonctionnelle, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, INSERM, Université de Paris (W.B.H., B.K., D.T., C.R.R., O.N., G.B.)
| | - Christine Rodriguez Regent
- GHU Paris Psychiatrie et Neurosciences, Hospitalier Sainte Anne, Service d'imagerie Morphologique et Fonctionnelle, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, INSERM, Université de Paris (W.B.H., B.K., D.T., C.R.R., O.N., G.B.)
| | - Jean-Philippe Desilles
- Department of Neuroradiology, Fondation Ophtalmologique A. de Rothschild, Paris, France (R.B., M.P., J.-P.D., S.E.)
| | | | - Simon Escalard
- Department of Neuroradiology, Fondation Ophtalmologique A. de Rothschild, Paris, France (R.B., M.P., J.-P.D., S.E.)
| | - Denis Herbreteau
- Department of Neuroradiology, CHRU Tours, Tours, France (B.K., K.J., D.H., H.I., G.B.)
| | - Heloise Ifergan
- Department of Neuroradiology, CHRU Tours, Tours, France (B.K., K.J., D.H., H.I., G.B.)
| | | | - Julien Labreuche
- CHRU Lille, EA 2694, Santé Publique: épidémiologie et Qualité des Soins, Lille, France (J.L.)
| | - Hilde Henon
- Department of Neurology, Stroke Unit, CHRU Lille, Lille, France (H.H.)
| | - Olivier Naggara
- GHU Paris Psychiatrie et Neurosciences, Hospitalier Sainte Anne, Service d'imagerie Morphologique et Fonctionnelle, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, INSERM, Université de Paris (W.B.H., B.K., D.T., C.R.R., O.N., G.B.)
| | - Bertrand Lapergue
- Department of Neurology, Stroke Unit, Foch Hospital, Suresnes, France (D.W.-L., B.L.)
| | - Grégoire Boulouis
- GHU Paris Psychiatrie et Neurosciences, Hospitalier Sainte Anne, Service d'imagerie Morphologique et Fonctionnelle, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266, INSERM, Université de Paris (W.B.H., B.K., D.T., C.R.R., O.N., G.B.).,Department of Neuroradiology, CHRU Tours, Tours, France (B.K., K.J., D.H., H.I., G.B.)
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7
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Mocco J, Siddiqui AH, Fiorella D, Alexander MJ, Arthur AS, Baxter BW, Budzik RF, Froehler MT, Hanel RA, Lena J, Persaud S, Puri AS, Rai AT, Wintermark M, Woodward K, Zhang X, Turk A. POSITIVE: Perfusion imaging selection of ischemic stroke patients for endovascular therapy. J Neurointerv Surg 2021; 14:126-132. [PMID: 33632884 DOI: 10.1136/neurintsurg-2021-017315] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 01/22/2021] [Accepted: 01/22/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The PerfusiOn imaging Selection of Ischemic sTroke patIents for endoVascular thErapy (POSITIVE) trial was designed to evaluate functional outcome in patients with emergent large vessel occlusion (ELVO) presenting within 0-12 hours with pre-specified bifurcated arms of early and late window presentation, who were selected for endovascular thrombectomy with non-vendor specific commercially available perfusion imaging software. Recent trials demonstrating the benefit of thrombectomy up to 16-24 hours following ELVO removed equipoise to randomize late window ELVO patients and therefore the trial was halted. METHODS Up to 200 patients were to be enrolled in this FDA-cleared, prospective, randomized, multicenter international trial to compare thrombectomy and best medical management in patients with ELVO ineligible for or refractory to treatment with IV tissue plasminogen activator (IV-tPA) selected with perfusion imaging and presenting within 0-12 hours of last seen normal. The primary outcome was 90-day clinical outcome as measured by the raw modified Rankin Scale (mRS) with scores 5 and 6 collapsed (mRS shift analysis). RESULTS The POSITIVE trial suspended enrollment with the release of results from the DAWN trial and was stopped after the release of the DEFUSE 3 trial results. Thirty-three patients were enrolled (21 for medical management and 12 for thrombectomy). Twelve of the 33 patients were enrolled in the 6-12 hour cohort. Despite the early cessation, the primary outcome demonstrated statistically significant superior clinical outcomes for patients treated with thrombectomy (P=0.0060). The overall proportion of patients achieving an mRS score of 0-2 was 75% in the thrombectomy cohort and 43% in the medical management cohort (OR 4.00, 95% CI 0.84 to 19.2). CONCLUSION POSITIVE supports the already established practice of delayed thrombectomy for appropriately selected patients presenting within 0-12 hours selected by perfusion imaging from any vendor. The results of the POSITIVE trial are consistent with other thrombectomy trials. The statistically significant effect on functional improvement, despite the small number of patients, reinforces the robust benefits of thrombectomy. CLINICAL TRIAL REGISTRATION NCT01852201.
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Affiliation(s)
- J Mocco
- Neurosurgery, The Mount Sinai Hospital, New York, New York, USA
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - David Fiorella
- Neurosurgery, Stony Brook University, Stony Brook, New York, USA.,SUNY SB, Stony Brook, New York, USA
| | | | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.,Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | | | - Michael T Froehler
- Cerebrovascular Program, Vanderbilt University, Nashville, Tennessee, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Jonathan Lena
- Neurosciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Steven Persaud
- Neurosurgery, The Mount Sinai Hospital, New York, New York, USA
| | - Ajit S Puri
- Radiology, University of Massachusetts, Worcester, Massachusetts, USA
| | - Ansaar T Rai
- Neurointerventional Radiology, West Virginia University, Morgantown, West Virginia, USA
| | - Max Wintermark
- Radiology, University of Virginia, Charlottesville, Virginia, USA
| | - Keith Woodward
- Britton Woodward, Britton Woodward, Knoxville, Tennessee, USA
| | - Xiangnan Zhang
- Neurosurgery, The Mount Sinai Hospital, New York, New York, USA
| | - Aquilla Turk
- Neurosurgery, Prisma Health Upstate, Greenville, South Carolina, USA
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8
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Nogueira RG, Haussen DC, Castonguay A, Rebello LC, Abraham M, Puri A, Alshekhlee A, Majjhoo A, Farid H, Finch I, English J, Mokin M, Froehler MT, Kabbani M, Taqi MA, Vora N, Khoury RE, Edgell RC, Novakovic R, Nguyen T, Janardhan V, Veznedaroglu E, Prabhakaran S, Budzik R, Frankel MR, Nordhaus BL, Zaidat OO. Site Experience and Outcomes in the Trevo Acute Ischemic Stroke (TRACK) Multicenter Registry. Stroke 2019; 50:2455-2460. [DOI: 10.1161/strokeaha.118.024639] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
It remains unclear how experience influences outcomes after the advent of stent retriever technology. We studied the relationship between site experience and outcomes in the Trevo Acute Ischemic Stroke multicenter registry.
Methods—
The 24 sites that enrolled patients in the Trevo Acute Ischemic Stroke registry were trichotomized into low-volume (<2 cases/month), medium-volume (2–4 cases/month), and high-volume centers (>4 cases/month). Baseline features, imaging, and clinical outcomes were compared across the 3 volume strata. A multivariable analysis was performed to assess whether outcomes were influenced by site volumes.
Results—
A total of 624 patients were included and distributed as low- (n=188 patients, 30.1%), medium- (n=175, 28.1%), and high-volume (n=261, 41.8%) centers. There were no significant differences in terms of age (mean, 66±16 versus 67±14 versus 65±15;
P
=0.2), baseline National Institutes of Health Stroke Scale (mean, 17.6±6.5 versus 16.8±6.5 versus 17.6±6.9;
P
=0.43), or occlusion site across the 3 groups. Median (interquartile range) times from stroke onset to groin puncture were 266 (181.8–442.5), 239 (175–389), and 336.5 (221.3–466.5) minutes in low-, medium-, and high-volume centers, respectively (
P
=0.004). Higher efficiency and better outcomes were seen in higher volume sites as demonstrated by shorter procedural times (median, 97 versus 67 versus 69 minutes;
P
<0.001), higher balloon guide catheter use (40% versus 36% versus 59%;
P
≤0.0001), and higher rates of good outcome (90-day modified Rankin Scale [mRS], ≤2; 39% versus 50% versus 53.4%;
P
=0.02). There were no appreciable differences in symptomatic intracranial hemorrhage or 90-day mortality. After adjustments in the multivariable analysis, there were significantly higher chances of achieving a good outcome in high- versus low-volume (odds ratio, 1.67; 95% CI, 1.03–2.7;
P
=0.04) and medium- versus low-volume (odds ratio, 1.75; 95% CI, 1.1–2.9;
P
=0.03) centers, but there were no significant differences between high- and medium-volume centers (
P
=0.86).
Conclusions—
Stroke center volumes significantly influence efficiency and outcomes in mechanical thrombectomy.
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Affiliation(s)
- Raul G. Nogueira
- From the Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N., D.C.H., L.C.R., M.R.F.)
| | - Diogo C. Haussen
- From the Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N., D.C.H., L.C.R., M.R.F.)
| | | | - Leticia C. Rebello
- From the Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N., D.C.H., L.C.R., M.R.F.)
| | - Michael Abraham
- Department of Neurology, University of Kansas Medical Center, University of Massachusetts Medical School, Worcester (M.A.)
| | - Ajit Puri
- Department of Neurosurgery, University of Massachusetts Medical School, Worcester (A.P.)
- Department of Radiology, University of Massachusetts Medical School, Worcester (A.P.)
| | - Amer Alshekhlee
- Department of Neurology, SSM Neuroscience Institutes, DePaul Health, Bridgeton, MO (A.A.)
| | - Aniel Majjhoo
- Department of Neurology, McLaren Flint Neuroscience Institute, Flint, MI (A.M.)
- Department of Neurology, McLaren Flint Neuroscience Institute, Flint, MI (A.M.)
| | - Hamed Farid
- Neurointerventional Radiology, St. Jude Medical Center, Chicago, IL (H.F.)
| | - Ira Finch
- Department of Interventional Radiology, John Muir Medical Center, Walnut Creek, CA (I.F.)
| | - Joey English
- Department of Neurology, California Pacific Medical Center, San Francisco (J.E.)
| | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa (M.M.)
| | - Michael T. Froehler
- Cerebrovascular Program, Neurosurgery, Radiology, Vanderbilt University Medical Center, Nashville, TN (M.T.F.)
| | - Mo Kabbani
- Department of Neurointervention, Gundersen Lutheran Medical Foundation, Inc, La Crosse, WI (M.K.)
| | - Muhammad A. Taqi
- Department of Neurology, Desert Regional Medical Center, Palm Springs, CA (M.A.T.)
| | - Nirav Vora
- Department of Neuroradiology, Riverside Radiology, Columbus, OH (N.V., R.B.)
| | - Ramy El Khoury
- Department of Neurology, Tulane University School of Medicine, New Orleans, LA (R.E.K.)
| | - Randall C. Edgell
- Department of Surgery, Saint Louis University Hospital, St. Louis, MO (R.C.E.)
- Department of Neurology, Saint Louis University Hospital, St. Louis, MO (R.C.E.)
| | - Roberta Novakovic
- Department of Radiology, University of Texas Southwestern, Dallas (R.N.)
- Department of Neurology, University of Texas Southwestern, Dallas (R.N.)
| | - Thanh Nguyen
- Department of and Neurotherapeutics, University of Texas Southwestern, Dallas (R.N.)
- Department of Neurology, Boston Medical Center, MA (T.N.)
- Department of Neurosurgery, Boston Medical Center, MA (T.N.)
| | | | | | - Shyam Prabhakaran
- Department of Neurosurgery, Drexel Neurosciences Institute, Philadelphia, PA (E.V.)
| | - Ron Budzik
- Department of Neuroradiology, Riverside Radiology, Columbus, OH (N.V., R.B.)
| | - Michael R. Frankel
- From the Department of Neurology, Emory University School of Medicine, Atlanta, GA (R.G.N., D.C.H., L.C.R., M.R.F.)
| | | | - Osama O. Zaidat
- Department of Neurosciences, Mercy Health–St. Vincent Medical Center, Toledo, OH (B.L.N., O.O.Z.)
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9
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Acute Stroke Interventions Performed by Cardiologists. JACC Cardiovasc Interv 2019; 12:1703-1710. [DOI: 10.1016/j.jcin.2019.05.052] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 05/22/2019] [Accepted: 05/28/2019] [Indexed: 11/22/2022]
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10
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Kannath SK, Rajan JE, Sylaja PN, Sarma PS, Sukumaran S, Sreedharan SE, Kapilamoorthy TR. Dwell Time of Stentriever Influences Complete Revascularization and First-Pass TICI 3 Revascularization in Acute Large Vessel Occlusive Stroke. World Neurosurg 2017; 110:169-173. [PMID: 29113900 DOI: 10.1016/j.wneu.2017.10.155] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 10/26/2017] [Accepted: 10/27/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In acute ischemic stroke with large vessel occlusion, the interaction between the clot retriever and the stent is critical for achieving successful recanalization. The ideal time of stent deployment (dwell time [DT]) to improve revascularization is currently unknown. We systematically analyzed the effect of different DT on final angiographic and clinical outcomes of patients who underwent mechanical thrombectomy. METHODS The DT was progressively increased from 3 minutes to 5 minutes and then 8 minutes during the study period. The effect of DT on recanalization attempts, successful angiographic outcome (thrombolysis in cerebral ischemia [TICI] 2b or TICI 3), total revascularization time, and immediate and 3-month clinical outcomes were evaluated. The DT of 3 minutes and 5 minutes (DT3-5) was compared against DT of 8 minutes (DT8). RESULTS Forty patients were included in the analysis. Good angiographic outcome was observed in 94.1% of patients in the DT8 cohort with an average attempt of 1.2 compared with 78.3% with average attempts of 2.0 in other group. Single-pass good recanalization (TICI 2b or 3) and single-pass complete revascularization (TICI3) was significantly higher in the DT group compared with the DT3-5 group (82.4% vs. 43.5% [P = 0.013] and 42.9% vs. 8.7% [P = 0.003], respectively). A favorable trend toward a reduced overall procedural time (34.59 vs. 55.59 minutes) was observed, but was not statistically significant (P = 0.15). CONCLUSIONS Mild prolongation of DT to 8 minutes improves revascularization outcome with fewer attempts, possibly because of better clot-stent interaction.
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Affiliation(s)
- Santhosh Kumar Kannath
- Neurointervention Center, Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India.
| | - Jayadevan Enakshy Rajan
- Neurointervention Center, Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - P N Sylaja
- Comprehensive Stroke Center, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - P Sankara Sarma
- Achutha Menon Center, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Sajith Sukumaran
- Comprehensive Stroke Center, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Sapna Erat Sreedharan
- Comprehensive Stroke Center, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Tirur Raman Kapilamoorthy
- Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
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11
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Crosa R, Spiotta AM, Negrotto M, Jaume A, Casagrande W. "Y-stent retriever": a new rescue technique for refractory large-vessel occlusions? J Neurosurg 2017; 128:1349-1353. [PMID: 28524799 DOI: 10.3171/2016.12.jns161233] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Long-awaited positive trial data have shown the efficacy of endovascular treatment in patients with ischemic stroke who arrive at the hospital within the first 6 hours with large-vessel occlusion of the anterior circulation. With the introduction of stent retrievers (SRs) for mechanical thrombectomy, efficient and safe large-artery recanalization treatment can be achieved. However, sometimes there are patients who do not attain complete flow restoration following attempts with traditional maneuvers. The authors present the case of a 57-year-old man with acute ischemic stroke due to an M1 embolus that extended into both M2 trunks. This patient was successfully treated with an innovative technique in which a Solitaire SR (Covidien) and a Catch SR (Balt) were used in a "Y" configuration, for which the authors coined the term "Y-stent retriever."
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Affiliation(s)
- Roberto Crosa
- 1Endovascular Neurological Center, Montevideo, Uruguay
| | - Alejandro M Spiotta
- 2Department of Neurosurgery and Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina
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