Endovascular treatment of acute ischemic stroke in patients with recurrent intracranial large vessel occlusion

Endovascular thrombectomy after 24 hours for patients with acute ischemic stroke due to large vessel occlusion: A systematic review and meta-analysis of outcomes

OBJECTIVE

To evaluate the role of endovascular thrombectomy (EVT) in patients presenting with acute ischemic stroke (AIS) due to large vessel occlusion in the very late window (>24 hours).

METHODS

A systematic review was conducted according to PRISMA guidelines using PubMed, CINAHL, Scopus, and Google Scholar databases till 2024. Quality assessment was performed using the Newcastle-Ottawa Scale (NOS). Outcomes were analyzed with a single-arm meta-analysis (Sidik-Jonkman model) and a double-arm meta-analysis (Mantel-Haenszel model) to compare EVT within and after 24 hours, reporting pooled risk ratios. Analysis was performed using STATA version 18.0 and Review Manager version 5.4.1, with p<0.05 considered significant.

RESULTS

This review included 35 studies with 15,086 patients. The proportion of symptomatic intracerebral hemorrhage (sICH) in patients treated with EVT after 24 hours was 4.78 % (95 % CI: 3.20 %-6.58 %), with a risk ratio (RR) of 0.85 (95 % CI: 0.44-1.64) compared to EVT patients treated within 24 hours. The pooled percentage for functional independence (90 day mRS 0-2) was 35.73 % (95 % CI- 27.26 %, 44.64 %) with a risk ratio of 0.85 (95 % CI: 0.34, 2.09). The proportion of the 90-day mortality was 22.30 % (95 % CI: 16.12 %, 29.09 %), with a risk ratio of 1.08 (95 % CI: 0.73, 1.61). The overall proportion of intracerebral hemorrhage (ICH) was 12.23 % (95 % CI: 5.47-20.86) following EVT after 24 hours.

CONCLUSION

Patients treated with EVT after 24 hours have comparable safety and effectiveness to those treated within 24 hours. The outcomes suggest that EVT after 24 hours is a viable treatment option, offering similar benefits to earlier intervention.

Repeated mechanical thrombectomy for recurrent large vessel occlusion: A systematic review and meta-analysis

BACKGROUND

Mechanical thrombectomy (MT) is the standard treatment for acute large vessel occlusion (LVO). Recurrent LVO can still occur in patients who already underwent MT for the first LVO. This study aimed to evaluate the efficacy of repeating MT for recurrent LVO.

METHODS

This meta-analysis of the available literature was conducted to summarize the current evidence regarding repeated MT outcomes in patients with recurrent LVO. All studies with ≥ 1 outcomes of interest were included. The Newcastle-Ottawa Scale (NOS) was used for risk of bias assessment.

RESULTS

Twenty studies, 10 observational (n = 21,251 patients) and 10 case reports (n = 10 patients), were included. 266 patients (62.78% females) with recurrent LVO were identified, with an overall prevalence of 1.6% and a mean age of 65.67 ± 16.23 years. Cardio-embolism was the most common mechanism in both times, with a median of 15 days between the first and second LVOs. Compared with pre-intervention, the first and second MTs significantly reduced the National Institute of Health Stroke Scale (NIHSS) score, (mean difference (MD) = -8.91) and (MD = -5.97) respectively, with a significant difference (p = 0.001). The rate of favorable outcome (modified Rankin scale (mRS) score 0-3) was 82.6% and 59.2% after the first and second MTs respectively, with a significant difference (p < 0.001).

CONCLUSION

In properly selected recurrent LVO patients, repeated MT is efficacious and safe. A prior MT procedure should not discourage aggressive treatment as many patients may achieve favorable outcomes.

Laterality of previous stoke affects endovascular thrombectomy outcomes

BACKGROUND

Investigations into the effect of previous stroke on thrombectomy outcomes have yielded conflicting results, and are limited by small sample sizes. We present the results of a large single center retrospective study aimed at investigating the effect of chronic stroke laterality on thrombectomy outcomes.

METHODS

A prospectively maintained database was queried for all thrombectomy cases conducted between December 2014 and January 2020, and patient imaging was prospectively reviewed for evidence of prior supratentorial infarction. Procedural, clinical, and demographic characteristics were recorded, and good clinical outcome was defined as a 90 day modified Rankin Scale (mRS) score of <2 or mRS score unchanged if baseline was >2.

RESULTS

The final analysis cohort included 555 patients, 79 of whom were found to have radiographic evidence of prior chronic infarcts. On univariate analysis, patients with any chronic supratentorial infarct achieved a lower rate of good clinical outcome than patients with no chronic infarct (22.8% vs 41.0%, p=0.0021). With regard to subgroups, this difference remained only in patients with ipsilateral (14.3%, p=0.0018) and bilateral (11.8%, p=0.015) lesions. Patients with chronic contralateral supratentorial infarcts were no less likely to achieve good outcomes (40.7%, p=0.98). After multivariate regression controlling for age, sex, and baseline mRS, chronic ipsilateral infarcts (OR 0.22, CI 0.07 to 0.67) and chronic bilateral infarcts (OR 0.19, CI 0.04 to 0.85) were the only independent predictors of poor outcome in endovascular thrombectomy patients.

CONCLUSIONS

In this single center retrospective study of thrombectomy patients with chronic supratentorial infarcts, the laterality of the previous stroke significantly affected the likelihood of good clinical outcomes.

Repeated Endovascular Thrombectomy in Patients with Acute Ischemic Stroke in a Single Center

BACKGROUND

Patients with acute ischemic stroke treated with endovascular thrombectomy may be treated with repeat endovascular thrombectomy (rEVT) in case of recurrent large vessel occlusion (LVO). The purpose of this study is to report the frequency, timing, and outcomes of rEVT in a single center.

MATERIALS AND METHODS

We retrospectively reviewed our databases for anterior or posterior circulation rEVT cases. Patient characteristics, procedural data, and functional outcomes (modified Rankin scale at 90 days) were analyzed. Early and late recurrence of stroke was divided at 30 days.

RESULTS

Of 1025 patients treated between January 2011 and January 2020, 23 (2.2%) underwent rEVT. The median time between the first and second procedure was 185 days; 7 (30.4%) patients were re-treated within 30 days. Eleven patients (47.8%) had different occlusion sites between the two procedures. Good clinical outcome of patients with late ipsilateral recurrence was significantly higher than that of patients with late contralateral recurrence (83.3% vs. 16.7, p = 0.027). Overall good functional outcome after the second procedure was 43.5% (10/23). Overall good functional outcome of early and late recurrence groups were similar (57.1% vs. 37.5%, p = 0.650). One patient died due to an underlying cardiac problem.

CONCLUSION

rEVT can be performed in patients with recurrent stroke of LVO. Ipsilateral recurrence of stroke was associated with good clinical outcome after rEVT.