Long-term outcomes of thrombectomy for acute ischaemic stroke by occluded artery and stroke aetiology: a PRAGUE-16 substudy

Stenting with dual-layer CGuard stent in acute sub-occlusive carotid artery stenosis and in tandem occlusions: a monocentric study

PURPOSE

Double-layer design carotid stents have been cast in a negative light since several investigations reported high rates of in-stent occlusions, at least in the acute setting of tandem occlusions. CGuard is a new generation double-layered stent that was designed to prevent periinterventional embolic events. The aim of this study was to analyze the safety and efficacy of the CGuard in emergent CAS and for the acute treatment of tandem occlusions in comparison with the single-layer Carotid Wallstent (CWS) system.

METHODS

All patients who underwent CAS with CGuard or CWS after intracranial mechanical thrombectomy (MT) between 11/2018 and 12/2022 were identified from our local thrombectomy registry. Clinical, interventional and neuroimaging data were analyzed. Patency of the stent was assessed within 72 h. Intracranial hemorrhage and modified Rankin score (mRS) at discharge were the main endpoints.

RESULTS

In total, 86 stent procedures in 86 patients were included (CWS: 44, CGuard: 42). CGuard had a lower, but not statistically significant rate (p = 0.431) of in-stent occlusions (n = 2, 4.8%) when compared to the CWS (n = 4, 9.1%). Significant in-stent stenosis was found in one case in each group. There was no statistically significant difference in functional outcome at discharge between the two groups with a median mRS for CGuard of 2 (IQR:1-5) vs. CWS 3 (IQR:2-4).

CONCLUSION

In our series, the rate of in-stent occlusions after emergent CAS was lower with the dual-layer CGuard when compared to the monolayer CWS. Further data are needed to evaluate the potential benefit of the design in more detail.

Endovascular therapy in patients with internal carotid artery occlusion and patent circle of Willis

BACKGROUND

Occlusion of the internal carotid artery (ICA) may extend into the middle or anterior cerebral artery (ICA-T) or be confined to the intracranial (ICA-I) or extracranial segment (ICA-E). While there is excellent evidence for endovascular therapy (EVT) in ICA-T occlusions, studies on EVT in non-tandem ICA-I or ICA-E occlusions are scarce.

OBJECTIVE

To characterize EVT-treated patients with ICA-I- and ICA-E occlusion by comparing them with ICA-T occlusions.

METHODS

The German Stroke Registry (GSR), a national, multicenter, prospective registry was searched for EVT-treated patients with isolated ICA occlusion between June 2015 and December 2021. We stratified patients by ICA occlusion site: (a) ICA-T, (b) ICA-I, (c) ICA-E. Baseline factors, procedural variables, technical (modified Thrombolysis in Cerebral Infarction (mTICI)), and functional outcomes (modified Rankin scale score at 3 months) were analyzed.

RESULTS

Of 13 082 GSR patients, 2588 (19.8%) presented with an isolated ICA occlusion, thereof 1946 (75.2%) ICA-T, 366 (14.1%) ICA-I, and 276 (10.7%) ICA-E patients. The groups differed in age (77 vs 76 vs 74 years, Ptrend=0.02), sex (53.4 vs 48.9 vs 43.1% female, Ptrend<0.01), and stroke severity (median National Institutes of Health Stroke Scale score at admission 17 vs 14 vs 13 points, Ptrend<0.001). In comparison with ICA-T occlusions, both ICA-I and ICA-E occlusions had lower rates of successful recanalization (mTICI 2b/3: 85.4% vs 80.4% vs 76.3%; aOR (95% CI for ICA-I vs ICA-T 0.71 (0.53 to 0.95); aOR (95% CI) for ICA-E vs ICA-T 0.57 (0.42 to 0.78)). In adjusted analyses, ICA-E occlusion was associated with worse outcome when compared with ICA-T occlusion (mRS ordinal shift, cOR (95% CI) 0.70 (0.52 to 0.93)).

CONCLUSION

Patient characteristics and outcomes differ substantially between ICA-T, ICA-I, and ICA-E occlusions. These results warrant further studies on EVT in ICA-I and ICA-E patients.

Mechanical thrombectomy in ischemic stroke after cardiovascular procedures: a propensity-matched cohort analysis

BACKGROUND

Stroke after a cardiovascular procedure (CVP) is a devastating complication adversely affecting outcome. Mechanical thrombectomy (MT) has not been investigated systematically in this population.

OBJECTIVE

To carry out a retrospective study in patients undergoing MT for early stroke after CVP, aiming to further characterize this cohort of patients, and to evaluate the efficacy, safety, procedural characteristics, and outcome of MT.

METHODS

A single-center stroke registry of patients who received MT was analyzed. Baseline and procedural parameters, mortality, functional outcome, recanalization rates, and complications were evaluated. Propensity score matching was carried out, identifying a control cohort with non-periprocedural large vessel occlusion (LVO).

RESULTS

Overall 913 patients were included (mean age 73.0 (±13.0) years, 52.5% female, median National Institutes of Health Stroke Scale score 15 (10-19)). Eleven patients with a LVO after a recent (<30 days postoperatively) CVP were identified (n=3 transcatheter aortic valve and n=1 surgical aortic valve replacements (SAVR), n=3 coronary bypass grafting (CABG) surgeries, n=2 SAVR+CABG, and n=2 aortic surgeries). After matching, 8 patients in the CVP group were compared with 16 patients in the matched cohort. Comparable rates of reperfusion were achieved. Time from symptom onset to groin puncture (171.5 min (136.3, 178.3) vs 284.0 min (215.0, 490.5); p=0.039), as well as recanalization (195.0 min (146.0, 201.0) vs 419.0 min (274.0, 613.0); p=0.028) was faster in the CVP group. However, this was not reflected by an improved outcome (modified Rankin Scale score after 90 days: 5.5 (3.3, 6.0) vs 5.0 (4.0, 6.0), mortality after 90 days 50.0% vs 37.5%). Complications did not differ between the groups.

CONCLUSIONS

Use of MT for LVO stroke in patients after a recent CVP is a safe and efficient treatment in comparison with patients with a non-periprocedural LVO undergoing MT.

The many roles of urgent catheter interventions: from myocardial infarction to acute stroke and pulmonary embolism

INTRODUCTION

Cardiovascular diseases (CVDs) are the leading cause of cardiovascular mortality and a major contributor to disability worldwide. The prevalence of CVDs is continuously increasing, and from 1990 to 2019, it has doubled. Global cardiovascular mortality has increased from 12.1 million in 1990 to 18.6 million cases in 2019. The development of therapeutic options for these diseases is at the forefront of interest concerning the extensive socio-economic consequences. Modern endovascular transcatheter therapeutic options contribute to the reduction of cardiovascular morbidity and mortality.

AREAS COVERED

The article concentrates on the triad of the most common causes of acute cardiovascular mortality and morbidity - myocardial infarction, ischemic stroke, and pulmonary embolism. Current evidence-based indications, specific interventional techniques, and remaining unsolved issues are reviewed and compared. A personal perspective on the possible implications for the future is provided.

EXPERT OPINION

Primary angioplasty for ST-segment elevation myocardial infarction is a well-established therapeutic option with proven mortality benefits. We suppose that catheter-based interventions for acute stroke will spread quickly from centers of excellence to routine clinical practice. We believe that ongoing research will provide a basis for the expansion of interventional treatment of pulmonary embolism soon.

Hyperattenuations on flat-panel computed tomography after successful recanalization of mechanical thrombectomy for anterior circulation occlusion

Background

To evaluate intraparenchymal hyperattenuation (IPH) on flat-panel computed tomography (FPCT) findings and their clinical usefulness for predicting prognosis after successful mechanical thrombectomy (MT) for acute occlusion of anterior circulation.

Methods

A retrospective review was conducted for 158 consecutive patients undergoing mechanical thrombectomy during the last six years. After excluding those with posterior circulation occlusion or incomplete recanalization and those without FPCT, 82 patients were finally included. Immediate post-procedural IPH on FPCT was categorized into four patterns (none, striatal, cortical, or combined pattern). Follow-up magnetic resonance images or CT scans after 48 hours from MT were analyzed according to FPCT findings. The existence of hemorrhagic transformation, intracerebral hemorrhage, and brain swelling was evaluated. Functional clinical outcomes were accessed with post-procedural 3-month modified Rankin scales (mRS).

Results

Of 82 patients, 34 patients were found to have IPH (16 with a striatal pattern, 8 with a cortical pattern, and 10 with a combined pattern). Hemorrhagic complication (P<0.001), brain swelling (P<0.001), and poor mRS scores (P=0.042) showed significant differences according to IPH patterns. Multivariate logistic regression analysis revealed that the presence of a striatal pattern (OR: 13.26, P<0.001), cortical pattern (OR: 11.61, P=0.009), and combined pattern (OR: 45.34, P<0.001) independently predicted hemorrhagic complications. The location of the occlusion (OR: 4.13, P=0.034), cortical pattern (OR: 5.94, P=0.039), and combined pattern (OR: 39.85, P=0.001) predicted brain swelling. Age (OR: 1.07, P=0.006) and the presence of a combined pattern (OR: 10.58, P=0.046) predicted poor clinical outcomes.

Conclusions

FPCT is a rapid and effective tool for a prompt follow-up just after MT to predict prognosis. Those with striatal patterns showed relatively good clinical outcomes despite significant hemorrhage. Cortical IPH patterns independently predicted a high rate of post-procedural hemorrhage or brain swelling. Combined pattern is a strong predictor for both radiologic and poor clinical outcomes.