Effect of Retrievable Stent Size on Endovascular Treatment of Acute Ischemic Stroke: A Multicenter Study

Enhancing the First-Pass Effect in Acute Stroke: The Impact of Stent Retriever Characteristics

Introduction: Although stentrievers (SRs) have been a mainstay of mechanical thrombectomy (MT), and current guidelines recommend the use of SRs in the treatment of large vessel occlusion stroke (LVO), there is a paucity of studies in the literature comparing SRs directly against each other in terms of mechanical and functional properties. Timely access to endovascular therapy and the ability to restore intracranial flow in a safe, efficient, and efficacious manner have been critical to the success of MT. This study aimed to investigate the impact of contemporary SR characteristics, including model, brand, size, and length, on the first-pass effect (FPE) in patients with acute ischemic stroke. Methods: Consecutive patients with M1 occlusion treated with a single SR+BGC were recruited from the ROSSETTI registry. The primary outcome was the FPE that was defined as modified (mFPE) or true (tFPE) for the achievement of modified thrombolysis in cerebral infarction (mTICI) grades 2b-3 or 3 after a single device pass, respectively. We compared patients who achieved mFPE with those who achieved tFPE according to SR characteristics. Results: We included 610 patients (52.3% female and 47.7% male, mean age 75.1 ± 13.62 years). mFPE was achieved in 357 patients (58.5%), whereas tFPE was achieved in 264 (43.3%). There was no significant association between SR characteristics and mFPE or tFPE. Specifically, the SR size did not show a statistically significant relationship with improvement in FPE. Similarly, the length of the SR did not yield significant differences in the mFPE and tFPE, even when the data were grouped. Conclusions: Our data indicate that contemporary SR-mediated thrombectomy characteristics, including model, brand, size, and length, do not significantly affect the FPE.

Impact of stent retriever size on clinical outcomes in the RECO registry

Objective

In the RECO study, we investigated the impact of the operator's choice of stent retriever size on patients with internal carotid artery (ICA) occlusion.

Methods

Data from the RECO Registry, a prospective multicentre study, were utilized. Patients who underwent mechanical thrombectomy (MT) were divided according to the size of the stent into the RECO 4 × 20 group, the RECO 5 × 30 group and the RECO 6 × 30 group. The outcome measures assessed in the study were the 3-month modified Rankin Scale (mRS) score, occurrence of any intracranial haemorrhage (aICH), workflow timing, recanalization success rate, number of attempts, and all-cause mortality within a 3-month period.

Results

Analysis was conducted on a total of 89 patients with ICA occlusion. RECO 4 × 20, 5 × 30, and 6 × 30 stent retrievers were used in 19 (21.3%), 52 (58.4%), and 18 (20.2%) patients, respectively. The demographic and baseline characteristics showed considerable similarity across the three groups. The puncture-to-recanalization time of the RECO 6 × 30 group [56.5 min (IQR, 41.5-80.8)] was significantly shorter than that of the RECO 4 × 20 group [110 min (IQR, 47-135)]. In 10 out of 18 patients (55.6%), the RECO 6 × 30 stent retriever achieved reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score 2b-3) after the initial attempt, surpassing the rates of 31.6% in the RECO 4 × 20 group and 32.7% in the RECO 5 × 30 group. In the RECO 4 × 20 group, the median number of passes was 2 (IQR, 1-3); in the RECO 5 × 30 group, it was 2 (IQR, 1-3); and in the RECO 6 × 30 groups, it was 1 (IQR, 1-2.5). There were no statistically significant differences observed among the three groups concerning aICH or good outcomes (mRS score 0-2).

Conclusion

Our study demonstrated the practical implications of stent-retriever size selection in the context of the MT for ICA occlusion. The routine use of a RECO 6 × 30 stent retriever holds the potential for early revascularization in clinical practice. The significant reduction in the puncture-to-reperfusion time and the greater first-pass effect associated with this stent size underscore its efficiency in treating ICA occlusion.

Evaluation of effectiveness and safety of the large-format pRESET 6-50 thrombectomy stent-retriever in the endovascular treatment of ischemic stroke: real-world experiences from two tertiary comprehensive stroke centers

Objective

Mechanical thrombectomy (MT) has become the standard treatment for acute ischemic stroke (AIS) with large vessel occlusion (LVO). First-pass (FP) reperfusion of the occluded vessel and fewer passes with stent retrievers show improvement in functional outcomes in stroke patients, while higher numbers of passes are associated with higher complication rates and worse outcomes. Studies indicate that a larger size of the stent-retriever is associated with a higher rate of first-pass reperfusion and improved clinical outcomes. In this retrospective study, we investigated the clinical performance of a recently developed and one of the largest stent-retrievers available in the treatment of LVO (pRESET 6-50, phenox GmbH, Bochum).

Materials and methods

All consecutive patients with ischemic stroke due to proximal large vessel occlusion treated with MT using the pRESET 6-50 stent-retriever in two tertiary stroke centers between 09/2021 and 07/2022 were included in this study. The reperfusion rate after MT was quantified by the modified thrombolysis in cerebral infarction (mTICI) score, and functional neurological outcome was evaluated with the National Institutes of Health Stroke Scale (NIHSS) score and the major early neurological recovery (mENR) rate after 24 h. Successful FP reperfusion was defined as mTICI ≥ 2b. Successful and complete reperfusion were defined as mTICI ≥ 2b and mTICI ≥ 2c, respectively.

Results

In total, 98 patients (52 men and 46 women) with a median age of 75 (range 25-95 years) were included. A total of 70 (72%) patients presented with an occlusion of the middle cerebral artery (MCA) in the M1 segment, 6 (6%) patients with an occlusion of the M2 segment, 17 (17%) patients with an occlusion of the internal carotid artery (ICA), and 5 (5%) patients with an occlusion of the obstructed basilar artery (BA). Successful FP reperfusion was achieved in 58 patients (62%). Successful and complete reperfusion were achieved in 95 (97%) and 82 (83%) patients, respectively. The median National Institutes of Health Stroke Scale (NIHSS) in all treated patients improved from 17 to 7.5. Major early neurological recovery (mENR) was observed in 34 patients (35.1%).

Conclusion

MT with the pRESET 6-50 stent-retriever achieves high successful first-pass and final reperfusion rates in patients with AIS and LVO. The results of this study support the thesis to use large-format stent-retriever in proximal vessel occlusion MT whenever feasible in order to improve high FP and final reperfusion rate, which are known predictors of good clinical outcome.

MASTRO I: Meta-Analysis and Systematic Review of thrombectomy stent retriever outcomes: comparing functional, safety and recanalization outcomes between EmboTrap, Solitaire and Trevo in acute ischemic stroke

Aim: Stent-retriever (SR) thrombectomy has demonstrated superior outcomes in patients with acute ischemic stroke compared with medical management alone, but differences among SRs remain unexplored. We conducted a Systematic Review/Meta-Analysis to compare outcomes between three SRs: EmboTrap®, Solitaire™, and Trevo®. Methods: We conducted a PRISMA-compliant Systematic Review among English-language studies published after 2014 in PubMed/MEDLINE that reported SRs in ≥25 patients. Functional and safety outcomes included 90-day modified Rankin scale (mRS 0-2), mortality, symptomatic intracranial hemorrhage (sICH), and embolization to new territory (ENT). Recanalization outcomes included modified thrombolysis in cerebral infarction (mTICI) and first-pass recanalization (FPR). We used a random effects Meta-Analysis to compare outcomes; subgroup and outlier-influencer analysis were performed to explore heterogeneity. Results: Fifty-one articles comprising 9,804 patients were included. EmboTrap had statistically significantly higher rates of mRS 0-2 (57.4%) compared with Trevo (50.0%, p = 0.013) and Solitaire (45.3%, p < 0.001). Compared with Solitaire (20.4%), EmboTrap (11.2%, p < 0.001) and Trevo (14.5%, p = 0.018) had statistically significantly lower mortality. Compared with Solitaire (7.7%), EmboTrap (3.9%, p = 0.028) and Trevo (4.6%, p = 0.049) had statistically significantly lower rates of sICH. There were no significant differences in ENT rates across all three devices (6.0% for EmboTrap, 5.3% for Trevo, and 7.7% for Solitaire, p = 0.518). EmboTrap had numerically higher rates of recanalization; however, no statistically significant differences were found. Conclusion: The results of our Systematic Review/Meta-Analysis suggest that EmboTrap may be associated with significantly improved functional outcomes compared with Solitaire and Trevo. EmboTrap and Trevo may be associated with significantly lower rates of sICH and mortality compared with Solitaire. No significant differences in recanalization and ENT rates were found. These conclusions are tempered by limitations of the analysis including variations in thrombectomy techniques in the field, highlighting the need for multi-arm RCT studies comparing different SR devices to confirm our findings.

Endovascular treatment of acute ischemic stroke with a fully radiopaque retriever: A randomized controlled trial

Objective

The Neurohawk retriever is a new fully radiopaque retriever. A randomized controlled non-inferiority trial was conducted to compare the Neurohawk and the Solitaire FR in terms of safety and efficacy. In order to evaluate the efficacy and safety of endovascular treatment in acute ischemic stroke (AIS) caused by intracranial atherosclerotic disease (ICAD) larger vessel occlusion (LVO), a sub-analysis was performed.

Methods

Acute ischemic stroke patients aged 18-80 years with LVO in the anterior circulation were randomly assigned to undergo thrombectomy with either the Neurohawk or the Solitaire FR. The primary efficacy endpoint was successful reperfusion (mTICI 2b-3) rate by the allocated retriever. A relevant non-inferiority margin was 12.5%. Safety outcomes were symptomatic intracranial hemorrhage (sICH) and all-cause mortality within 90 days. Secondary endpoints included first-pass effect (FPE), modified FPE, and favorable outcomes at 90 days. In subgroup analysis, the patients were divided into the ICAD group and non-ICAD group according to etiology, and baseline characteristics, angiographic, and clinical outcomes were compared.

Results

A total of 232 patients were involved in this analysis (115 patients in the Neurohawk group and 117 in the Solitaire group). The rates of successful reperfusion with the allocated retriever were 88.70% in the Neurohawk group and 90.60% in the Solitaire group (95%CI of the difference, -9.74% to 5.94%; p = 0.867). There were similar results in FPE and mFPE in both groups. The rate of sICH seemed higher in the Solitaire group (13.16% vs. 7.02%, p = 0.124). All-cause mortality and favorable outcome rates were comparable as well. In subgroup analysis, 58 patients were assigned to the ICAD group and the remaining 174 to the non-ICAD group. The final successful reperfusion and favorable outcome rates showed no statistically significant differences in two groups. Mortality within 90 days was relatively lower in the ICAD group (6.90% vs. 17.24%; p = 0.054).

Conclusion

The Neurohawk retriever is non-inferior to the Solitaire FR in the mechanical thrombectomy of large vessel occlusion-acute ischemic stroke (LVO-AIS). The sub-analysis suggested that endovascular treatment including thrombectomy with the retriever and essential rescue angioplasty is effective and safe in AIS patients with intracranial atherosclerotic disease-larger vessel occlusion (ICAD-LVO).

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT04995757, number: NCT04995757.

Comparison of First-Pass Effect in Aspiration vs. Stent-Retriever for Acute Intracranial ICA Occlusion

The purpose of this study is to evaluate the best endovascular approach (aspiration or stent-retriever) and the impact of stent retriever size and length on clinical and angiographic outcomes in patients with acute intracranial ICA occlusion. We conducted a retrospective analysis of a prospective database of consecutive patients with acute intracranial ICA occlusion undergoing endovascular treatment in four Comprehensive Stroke Center between June-2019 and December-2020. We include 121 patients; Stent-retriever (SR) was used as first technical approach in 107 patients (88.4%) and aspiration was used in 14 patients (11.6%). SR group had higher rate of FPE compared to aspiration group (29 vs. 0%, p = 0.02). In SR subgroup, treatment highlighted higher FPE in the 6 × 50 SR (37.7%), than in the rest of the SR which are 21.2% (4–5 mm size and 20–50 mm length SR) and 19% (6 mm size and 25–40 mm length SR), but it was not found to be statistically significant. There were no other significant differences across the groups regarding primary angiographic or clinical outcomes. In our intracranial ICA occlusion series, stent retrievers were superior to direct aspiration in obtaining FPEs and mFPEs, and longer devices achieved better results with no statistically significant difference. Further studies evaluating the effects of different ICA clot removal approaches are warranted to confirm these results.

Comparison of stent retriever thrombectomy using 3-dimensional patient-specific models of intracranial circulation with actual middle cerebral artery occlusion thrombectomy cases

BACKGROUND AND PURPOSE

Stent retriever (SR) thrombectomy is commonly used for the treatment of emergent large vessel occlusion (ELVO) in acute ischemic stroke. Clot imaging parameters such as clot length, diameter, distance to the internal carotid artery terminus, and vessel angle where the SR is deployed may predict the likelihood of achieving first pass effect (FPE). Most of the proposed factors that seem to affect recanalization success have been studied individually, and conflicting data derived from clinical versus in vitro studies using 3-dimensional printed models of intracranial circulation currently exist.

METHODS

Using patient-specific 3-dimensional phantoms of the cervical and intracranial circulation, we simulated middle cerebral arteries (MCA) M1 and M2 occlusions treated with SR thrombectomy using Solitaire (Medtronic) or Trevo (Styker). Our primary outcome was FPE, defined as Thrombolysis in Cerebral Infarction score of 2c-3 achieved after a single thrombectomy attempt. We also performed retrospective analysis of same clot imaging characteristics of consecutive cases of MCA occlusion and its association with FPE matching the 3-dimensional in vitro experiments. Analysis was conducted using IBM SPSS Statistics Version 25 (IBM Corp., Armonk, NY). Chi-square tests and bivariate logistic regressions were the main statistical tests used in analysis. A p-value of less than .05 was considered to indicate statistical significance. Ninety-five confidence intervals (95% CI) were generated.

RESULTS

We compared 41 thrombectomy experiments performed using patient-specific 3-dimensional in vitro models with a retrospective cohort of 41 patients treated with SR thrombectomy. We found that in the in vitro cohort, higher MCA angulation was associated with a lower likelihood of FPE (odds ratio [OR] = 0.967, 95% CI = 0.944-0.991, p = .008). Meanwhile in the in vivo cohort, higher MCA angulation was associated with a higher likelihood of FPE (OR = 1.039, 95% CI = 1.003-1.077, p = .033). Neither clot length nor location of clot (M1 vs. M2) was associated with a difference in FPE rates in either cohort.

DISCUSSION

Comparison of SR thrombectomy performed during actual MCA occlusion cases versus patient-specific 3-dimensional replicas revealed MCA angulation as an independent predictor of procedure success or failure. However, the opposite direction of effect was observed between the two studied environments, indicating potential limitations of studying SR thrombectomy using 3-dimensional models of LVO.

Risks of Undersizing Stent Retriever Length Relative to Thrombus Length in Patients with Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Results regarding the association of thrombus length, stent retriever length, and recanalization success in patients with acute ischemic stroke are inconsistent. We hypothesized that the ratio of thrombus length to stent retriever length may be of particular relevance.

MATERIALS AND METHODS

Patients with acute ischemic stroke undergoing stent retriever thrombectomy at our institution between January 2010 and December 2018 were reviewed retrospectively. Thrombus length was assessed by measuring the susceptibility vessel sign on SWI using a 1.5T or 3T MR imaging scanner. Multivariable logistic regression models were used to determine the association between thrombus length, stent retriever length, and thrombus length/stent retriever length ratio with first-pass recanalization, overall recanalization, and embolization in new territories. Results are shown as adjusted ORs with 95% CIs. Additional mediation analyses were performed to test for indirect effects on first-pass recanalization and overall recanalization success.

RESULTS

The main analysis included 418 patients (mean age, 74.9 years). Increasing stent retriever length was associated with first-pass recanalization. Decreasing thrombus length and lower thrombus length/stent retriever length ratios were associated with first-pass recanalization and overall recanalization. Thrombus length and stent retriever length showed no association with first-pass recanalization or overall recanalization once thrombus length/stent retriever length ratio was factored in, while thrombus length/stent retriever length ratio remained a significant factor in both models (adjusted OR, 0.316 [95% CI, 0.112-0.892]; P = .030 and adjusted OR, = 0.366 [95% CI, 0.194-0.689]; P = .002). Mediation analyses showed that decreasing thrombus length and increasing stent retriever length had a significant indirect effect on first-pass recanalization mediated through thrombus length/stent retriever length ratio. The only parameter associated with embolization in new territories was an increasing thrombus length/stent retriever length ratio (adjusted OR, 5.079 [95% CI, 1.332-19.362]; P = .017).

CONCLUSIONS

Information about thrombus and stent length is more valuable when combined. High thrombus length/stent retriever length ratios, which may raise the risk of unsuccessful recanalization and embolization in new territories, should be avoided by adapting stent retriever selection to thrombus length whenever possible.

First-Pass Reperfusion by Mechanical Thrombectomy in Acute M1 Occlusion: The Size of Retriever Matters

Introduction: Single-pass complete reperfusion using stent retrievers has been shown to improve functional outcome in patients with large vessel occlusion strokes. The aim of this study was to investigate the optimal size of stent retrievers to achieve one-pass complete reperfusion by mechanical thrombectomy. Methods: The study evaluated the results of aspiration-assisted mechanical thrombectomy of acute isolated occlusion of the middle cerebral artery in the M1 segment with a novel 5 × 40-mm stent retriever compared to the usual 4 × 20-mm device. Reperfusion status was quantified using the Thrombolysis In Cerebral Infarction (TICI) scale. We hypothesized that thrombectomy of M1 occlusions with 5 × 40-mm stent retriever yields higher rates of complete first-pass reperfusion (FP) (TICI ≥2c after one pass) and successful or modified FP (mFP) (TICI ≥2b after one pass) than thrombectomy with 4 × 20. We included isolated M1 occlusions treated with pRESET 5 × 40 (phenox) as first-choice device for thrombectomy and compared with M1 occlusions treated with pRESET 4 × 20. We excluded patients with additional occlusions or tandem stenosis or who received an intracranial stent or angioplasty as a part of the endovascular treatment. Results: One hundred thirteen patients were included in the 4 × 20 group and 57 patients in the 5 × 40 group. The 5 × 40 group achieved higher FP compared to 4 × 20 group [61.4% (35 of 57 patients) vs. 40.7% (46 of 113), respectively; adjusted odds ratio (OR) and 95% confidence interval (95% CI) = 2.20 (1.08-4.48), p = 0.030] and a higher mFP [68.4%, 39 of 57 patients vs. 48.7%, 55 of 113; adjusted OR (95% CI) = 2.11 (1.04-4.28), p = 0.037]. Frequency of successful reperfusion (TICI ≥2b) was similar in both groups (100 vs. 97.3%), but frequency of complete reperfusion (TICI ≥2c) was higher in the 5 × 40 group [82.5 vs. 61.9%, adjusted OR (95% CI) = 2.47 (1.01-6.04), p = 0.047]. Number of passes to achieve reperfusion was lower in the 5 × 40 group than in the 4 × 20 group [1.6 ± 1.1 vs. 2 ± 1.4, p = 0.033; adjusted incidence rate ratio (95% CI) = 0.84 (0.69-1.03), p = 0.096]. Modified Rankin scale at 90 days was similar in 5 × 40 and 4 × 20 groups. Conclusions: The size of stent retriever matters in acute M1 occlusions treated with aspiration-assisted mechanical thrombectomy. A longer stent retriever with a larger nominal diameter achieves a higher complete and successful FP and higher successful reperfusion compared to a shorter stent retriever.

Effectiveness and Technical Considerations of Solitaire Platinum 4×40 mm Stent Retriever in Mechanical Thrombectomy with Solumbra Technique

OBJECTIVE

The Solitaire Platinum 4×40 mm stent retriever contains radiopaque markers with a long length. We evaluated the effect of Solitaire Platinum 4×40 mm stent retriever in Solumbra technique thrombectomy, and compared it with shorter Solitaire stent retrievers.

METHODS

A total of 70 patients who underwent Solumbra technique thrombectomy with equal diameter (4 mm) and different length (40 vs. 20 mm) Solitaire stent retrievers were divided into two groups : the Solitaire Platinum 4×40 mm stent (4×40) group and the Solitaire FR 4×20 mm stent or Solitaire Platinum 4×20 mm stent (4×20) group. The clinical outcomes, Thrombolysis in Cerebral Infarction score, the first pass reperfusion status, and complications were evaluated and compared between the two groups. Multivariate analysis was performed to evaluate the predictive factors for reperfusion and complete reperfusion from the first pass.

RESULTS

Higher first-pass reperfusion and complete reperfusion were achieved in the 4×40 group (68.0% and 48.0%) than in the 4×20 group (46.7% and 33.3%; p=0.004 and 0.007, respectively). In multivariate analysis, radiopaque device and longer stent retriever were correlated with first-pass reperfusion (p=0.014 and 0.008, respectively) and first-pass complete reperfusion (p=0.022 and 0.012, respectively).

CONCLUSION

Our study demonstrated the usefulness of the Solitaire Platinum 4×40 mm stent retriever, which led to higher firstpass reperfusion and complete reperfusion rates than the Solitaire FR 4×20 mm stent or the Solitaire Platinum 4×20 mm stent, especially in Solumbra technique thrombectomy.

Adjustment of Stent Retriever Length to Clot Extent Affects First-Pass Reperfusion in Endovascular Treatment of Acute Ischemic Stroke

BACKGROUND

Stent retriever technology has evolved, and significantly longer devices have become available for mechanical thrombectomy (MT) of large cerebral vessel occlusions in ischemic stroke. We hypothesized that increased stent retriever length may improve the rate of complete angiographic reperfusion and decrease the respective number of attempts, resulting in a better clinical outcome.

METHODS

Retrospective analysis of patients with large vessel occlusion in the anterior and posterior circulation treated with stent retriever MT. The study group was dichotomized into short (20 mm) and long (>20 mm) retrievers using propensity matching. In the anterior circulation, the clot burden score was evaluated. Primary end points were first-pass modified thrombolysis in cerebral infarction (mTICI) 3 reperfusion and first-pass mTICI ≥ 2b reperfusion, and the secondary end point was functional independence (defined as modified Rankin Scale score 0-2) at discharge and 90 days.

RESULTS

Overall, 394 patients were included in the analysis. In the anterior circulation, short stent retrievers had a significantly higher rate of first-pass reperfusion in cases with low clot burden (mTICI 3: 27% vs. 17%; p = 0.009; mTICI ≥ 2b: 42 vs. 30%; p = 0.005) and in middle cerebral artery occlusions (mTICI ≥ 2b: 51 vs. 41%; p = 0.024). Higher rates of favorable outcome at discharge and 90 days were observed for the short stent retriever group (p < 0.001).

CONCLUSION

Stent retriever length should be adjusted to clot burden score and vessel occlusion site.

Endovascular Treatment of Acute Ischemic Stroke Due to Intracranial Atherosclerotic Large Vessel Occlusion : A Systematic Review

OBJECTIVE

To evaluate the efficacy and safety of endovascular treatment (ET) of acute ischemic stroke (AIS) caused by intracranial atherosclerotic large vessel occlusion (ICAS-LVO).

METHODS

A systemic review and meta-analysis were conducted on studies published between July 2005 and October 2018 on the outcomes of ET in patients with AIS due to ICAS-LVO. The outcomes of the ICAS-LVO and embolic LVO groups were also compared.

RESULTS

A total of 17 studies including 1315 subjects with ICAS-LVO were included. In the single-arm meta-analysis, the pooled estimates of successful recanalization rate, favorable outcomes, symptomatic intracranial hemorrhage and mortality were 88% (95% CI (95% confidence interval), 84-92%), 52% (95% CI, 47-56%), 5% (95% CI, 3-7%) and 15% (95% CI, 12-19%) respectively. The preferred primary treatment was stent-retriever thrombectomy (84.1%) and the preferred rescue treatment was stent implantation with or without percutaneous transluminal angioplasty (PTA, 32.7%). In the double-arm meta-analysis, the incidence of symptomatic intracranial hemorrhage was lower in the ICAS-LVO compared to the embolic-LVO group (OR (odds ratio) = 0.60, 95% CI, 0.46-0.77, p < 0.01), whereas the implementation of rescue treatment (OR = 5.94, 95% CI, 3.15-11.19, p < 0.01) and stenting rate (OR = 10.06, 95%CI, 4.43-22.85, p < 0.01) were higher in the ICAS-LVO group. Other parameters were similar in both groups.

CONCLUSION

The use of ET is a safe and effective therapeutic option for AIS due to ICAS-LVO. Stent-retriever thrombectomy and stent-implement are the preferred primary and rescue therapies respectively for ICAS-LVO. Less symptomatic intracranial hemorrhage and higher stenting were observed in the ICAS-LVO compared to the embolic-LVO group.

Endovascular retrograde approach may be a better option for acute tandem occlusions stroke

OBJECTIVE

The endovascular treatment strategy for acute tandem occlusion stroke is challenging, and controversy exists regarding which lesion should be treated first. This study addresses the uncertainty regarding the priority choice for thrombectomy in acute anterior circulation tandem occlusion stroke.

METHODS

We analysed the clinical and angiographic data of tandem stroke patients who underwent interventional therapy from the endovAsCular Treatment of acUte Anterior circuLation ischaemic stroke (ACTUAL) registry. Recanalisation was assessed according to the modified thrombolysis in cerebral infarction score. Clinical outcome was evaluated at 90 days using the modified Rankin scale score.

RESULTS

Sixty tandem occlusion stroke patients were enrolled. Thirty-one (51.7%) patients received anterograde therapy, while 29 (48.3%) patients underwent the retrograde approach. Successful recanalisation (modified thrombolysis in cerebral infarction score 2b-3) occurred in 78.3% (47/60) of patients, and 50.0% (30/60) of patients achieved a modified Rankin scale score of 0-2 at 90 days. Patients undergoing the retrograde approach spent less time in distal occlusion recanalisation (125 (86-167) vs. 95 (74-122) minutes; P = 0.04) and achieved better functional outcomes at 90 days (69.0% (20/29) vs. 32.3% (10/31); P = 0.004) than patients who received anterograde therapy. The retrograde approach was associated with favourable clinical outcomes (odds ratio 0.21; 95% confidence interval 0.07-0.64; P = 0.006).

CONCLUSION

For acute tandem occlusion stroke, favourable outcomes were better in patients undergoing retrograde therapy than in patients who received the anterograde approach. Future randomised trials are warranted to determine the optimal treatment.

Microcatheter navigation through the clot: does size matter?

BACKGROUND

Despite high recanalization rates achieved with endovascular treatment of acute ischemic strokes, around 50% of eligible patients will not achieve a good outcome. Parameters that may determine patient outcomes include: time from puncture to recanalization, the collateral status, the anesthesia regimen, blood pressure management, and distal emboli. Characterization of distal emboli generated during mechanical thrombectomy has been performed in previous studies.

OBJECTIVE

To further investigate the risk of distal embolization associated with microcatheter navigation across the clot.

METHODS

A contrast-enhanced clot analog was used in an in vitro model that mimicked a middle cerebral artery occlusion within a complete circle of Willis vascular replica. The clot was crossed with one of the following microcatheters: Pro18, XT-27 or 3MAX. The emboli generated during the procedure were collected and measured.

RESULTS

The use of Pro18 and XT-27 resulted in a significant reduction of visible particles (size ≥500 µm) as compared with the 3MAX catheter (P<0.003). For the size range between 8 and 200 µm, there was a trend for Pro18 to generate fewer particles (-18%) than XT-27 but without statistical significance (P>0.05). In comparison with previously published data, acquired under the same conditions, it was found that the clot crossing maneuver accounts approximately for 12% of the total number of small emboli (<200 µm) induced during a stent retriever-mediated mechanical thrombectomy procedure via a balloon guide catheter.

CONCLUSIONS

The clot crossing maneuver has a significant effect on the total number of small particles induced during mechanical thrombectomy. Smaller microcatheter sizes should be favored when possible.

Validation of iScore and PLAN Score for Death in Thrombectomy in Acute Stroke Due to Anterior Circulation Large Artery Occlusion

BACKGROUND

To validate iScore and PLAN score in acute anterior circulation large vessel occlusion stroke patients undergoing thrombectomy.

METHODS

iScore and PLAN score were calculated for consecutive acute ischemic stroke undergoing thrombectomy were included and death at 1 month and death at 3 months were recorded. The area under the receiver operating characteristic curve was used to assess the discrimination ability of the scales for death.

RESULTS

Two hundred and twenty-nine patients were included, 25.3% (58 of 229) of patient died at 1 month after thrombectomy and 25.8% (59 of 229) of them died at 3 months after thrombectomy. The receiver operator curve analysis found that iScore (area under the curve [AUC] = .76, 95% confidence interval [CI] .69-.83) was numerically better than PLAN score (AUC = .73, 95% CI .66-.81) for predicting death at day 90. The cut-off for iScore is 193, with sensitivity 64%, specificity 79%, positive predictive value 75% and negative predictive value 69%.

CONCLUSIONS

The iScore scale is a valid predictive tool for death in anterior circulation large vessel occlusions undergoing thrombectomy.

Longer stent retrievers enhance thrombectomy performance in acute stroke

BACKGROUND

Longer stent retrievers have recently become available and have theoretical advantages over their shorter counterparts. We aim to evaluate whether stent retriever length impacts reperfusion rates in stroke thrombectomy.

METHODS

This was a retrospective analysis of a prospectively collected thrombectomy database in which equal diameter (4 mm) stent retrievers were used as the first-line strategy for intracranial internal carotid or middle cerebral artery M1 or M2 occlusions along with a balloon guide catheter from June 2011 to March 2017. The population was dichotomized into long (Trevo 4×30 mm/Solitaire 4×40 mm) or short (Trevo 4×20 mm/Solitaire 4×20 mm) retrievers. The primary outcome was first-pass modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3 reperfusion.

RESULTS

Of 1126 thrombectomies performed within the study period, 420 were included. Age, gender, National Institutes of Health Stroke Scale, ASPECTS, IV tissue plasminogen activator use, stroke etiology, occlusion site, time from last-known-normal to puncture, distribution of Trevo and Solitaire, and the use of newer generation local thromboaspiration devices were comparable between the long and short retrievers. The short retriever group had more frequent hypertension, dyslipidemia, and atrial fibrillation. First-pass mTICI 2b/3 reperfusion was more common in the long retriever group (62% vs 50%; P=0.01). Parenchymal hematomas type 2, subarachnoid hemorrhage, 90-day modified Rankin Scale score 0-2, and mortality were comparable. Multivariable analysis indicated that long retriever (OR 2.2; 95% CI 1.3 to 3.6; P=0.001), radiopaque device (OR 2.1; 95% CI 1.2 to 3.4; P=0.003), and adjuvant local aspiration (OR 2.4; 95% CI 1.3 to 4.3; P=0.003) were independently associated with first-pass reperfusion.

CONCLUSIONS

The use of longer stent retrievers is an independent predictor of first-pass mTICI 2b/3 reperfusion. First-pass reperfusion was also associated with the use of radiopaque devices and adjuvant local aspiration.