Thrombectomy with embed aspiration in acute ischaemic stroke

BACKGROUND

In addition to stent retrievers, direct aspiration has become a reasonable thrombectomy strategy.

OBJECTIVES

We carried out the thrombectomy by guiding the aspiration catheter fully over the clot and performing immediate manual aspiration; we call this procedure "embed aspiration".

METHODS

In this prospective, non-randomised, single-centre study, we included all patients treated at a high volume-of-care stroke centre between 2017 and 2018 for the TRIANA (Thrombectomy in Andalusia using Aspiration) registry. Thrombectomy was carried out by embed aspiration. Patients were classified according to the success (eTICI 2b67-2c-3) or failure (eTICI 0-1-2a-2b50) of the procedure. Baseline clinical data and outcomes were compared, and multivariate analysis was performed.

RESULTS

The embed aspiration technique was used in 370 patients. Treatment was successful in 90.3% of patients. Mean puncture-to-recanalisation time was 25 minutes. The overall rate of good outcomes (mRS 0-2) at 3 months was 64%.

CONCLUSIONS

This study supports real-life evidence that standardised embed aspiration may be an alternative to stent retrievers for thrombectomy.

Endarterectomy, Stenting, or Medical Treatment for Symptomatic Carotid Near-Occlusion: Results from CAOS, a Multicenter Registry Study

BACKGROUND AND PURPOSE

The treatment of symptomatic carotid near-occlusion is controversial. Our aim was to analyze the results of carotid endarterectomy and carotid artery stent placement in patients with symptomatic carotid near-occlusion and to identify factors related to technical failure, periprocedural complications, and restenosis.

MATERIALS AND METHODS

We conducted a multicenter, prospective nonrandomized study. Patients with angiography-confirmed carotid near-occlusion were included. We assessed the revascularization rate and periprocedural stroke or death. Twenty-four-month clinical and carotid imaging follow-up was performed, and rates of carotid restenosis or occlusion, ipsilateral stroke, and mortality were analyzed. Carotid artery stent placement, carotid endarterectomy, and medical treatment were compared.

RESULTS

One hundred forty-one patients were included. Forty-four carotid artery stent placement and 23 carotid endarterectomy procedures were performed within 6 months after the event. Complete revascularization was achieved in 83.6%, 81.8% in the carotid artery stent placement group and 87% with carotid endarterectomy (P = .360). Periprocedural stroke or death occurred in 6% (carotid artery stent placement = 2.3%; carotid endarterectomy = 13%; P = .077) and was not related to revascularization failure. The carotid restenosis or occlusion rate was 8.3% (5% restenosis, 3.3% occlusion); with carotid artery stent placement it was 10.5%; and with carotid endarterectomy it was 4.5% (P = .419). The 24-month cumulative rate of ipsilateral stroke was 4.8% in the carotid artery stent placement group, 17.4% for carotid endarterectomy, and 13.1% for medical treatment (P = .223). Mortality was 12%, 4.5%, and 5.6%, respectively (P = .422). Revascularization failure and restenosis occurred more frequently in patients with full collapse compared with patients without full collapse (33.3% versus 5.6%, P = .009; 21.4% versus 2.9%, P = .032, respectively).

CONCLUSIONS

Carotid artery stent placement and carotid endarterectomy are associated with high rates of failure and periprocedural stroke. Carotid near-occlusion with full collapse appears to be associated with an increased risk of technical failure and restenosis. Carotid near-occlusion revascularization does not seem to reduce the risk of stroke at follow-up compared with medical treatment.

Antithrombotic Treatment after Carotid Stenting in Patients with Concomitant Atrial Fibrillation

BACKGROUND AND PURPOSE

Antithrombotic therapy following carotid artery stent placement with concomitant atrial fibrillation is not well-established. Our aim was to assess the safety and efficacy of the combination of direct oral anticoagulants and a P2Y12 inhibitor at 30 days after carotid artery stent placement in patients with atrial fibrillation.

MATERIALS AND METHODS

We designed an observational single-center study including patients who underwent carotid artery stent placement with concomitant atrial fibrillation. We studied 3 groups according to antithrombotic therapy: 1) the direct oral anticoagulants plus clopidogrel (DC) group: receiving direct oral anticoagulants plus a P2Y12 inhibitor; 2) the triple therapy group: anticoagulation and dual antiplatelet therapy; and 3) the dual antiplatelet therapy group: following dual antiplatelet therapy alone. The safety outcome was a major or clinically relevant non-major bleeding event at the first month. The efficacy outcomes were the thromboembolic events (myocardial infarction, stroke, systemic embolism, or stent thrombosis).

RESULTS

Of 959 patients with carotid artery stent placement, 91 met the inclusion criteria, including 24 patients in the DC group, 42 patients in the triple therapy group, and 25 in the dual antiplatelet therapy group. The mean age was 72.27 (SD, 8.1 ) years, with similar baseline characteristics. The median CHA₂DS₂-VASc score for each group was 6 (interquartile range  = 5-6), 5 (interquartile range = 4-6), and 5 (interquartile range = 4-6), respectively. The median HAS-BLED score was 4 in the 3 groups (P = .17). The primary safety end point was 23.8% in the triple therapy group compared with 4% in the dual antiplatelet therapy group (P = .032), with no bleeding events in the DC group (P = .007). There was 1 stent thrombosis in DC group and a cardioembolic stroke in the dual antiplatelet therapy group (P = .41).

CONCLUSIONS

Among patients with carotid artery stent placement with atrial fibrillation, triple therapy confers a high bleeding risk. A regimen of direct oral anticoagulants plus a P2Y12 inhibitor might confer a good safety profile with significantly lower rates of bleeding and optimal efficacy.

B-type natriuretic peptide over N-terminal pro-brain natriuretic peptide to predict incident atrial fibrillation after cryptogenic stroke

BACKGROUND AND PURPOSE

B-type natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) are well-known surrogates of atrial fibrillation (AF) detection but studies usually present data on either BNP or NT-proBNP. The aim was to determine and directly compare the validity of the two biomarkers as a tool to predict AF and guide prolonged cardiac monitoring in cryptogenic stroke patients.

METHODS

Non-lacunar acute ischaemic stroke (<72 h) patients over 55 years of age with cryptogenic stroke after standard evaluation were included in the Crypto-AF study and blood was collected. BNP and NT-proBNP levels were determined by automated immunoassays. AF was assessed by 28 days' monitoring. Highest (optimizing specificity) and lowest (optimizing sensitivity) quartiles were used as biomarker cut-offs to build predictive models adjusted by sex and age. The integrated discrimination improvement index (IDI) and DeLong test were used to compare the performance of the two biomarkers.

RESULTS

From 320 patients evaluated, 218 were included in the analysis. AF was detected in 50 patients (22.9%). NT-proBNP (P < 0.001) and BNP (P < 0.001) levels were higher in subjects with AF and their levels correlated (r = 0.495, P < 0.001). BNP showed an increased area under the curve (0.720 vs. 0.669; P = 0.0218) and a better predictive capacity (IDI = 3.63%, 95% confidence interval 1.36%-5.91%) compared to NT-proBNP. BNP performed better than NT-proBNP in a specific model (IDI = 3.7%, 95% confidence interval 0.87%-6.5%), whilst both biomarkers performed similarly in the case of a sensitive model.

CONCLUSIONS

Both BNP and NT-proBNP were increased in cryptogenic stroke patients with AF detection. Interestingly, BNP outperforms NT-proBNP, especially in terms of specificity.

Ultrasonographic and hemodynamic characteristics of patients with symptomatic carotid near-occlusion: results from a multicenter registry study

PURPOSE

The ultrasonographic and hemodynamic features of patients with carotid near-occlusion (CNO) are still not well known. Our aim was to describe the ultrasonographic and hemodynamic characteristics of a cohort of patients with CNO.

METHODS

A prospective, observational, nationwide, and multicenter study was conducted from January/2010 to May/2016. Patients with digital subtraction angiography (DSA)-confirmed CNO were included. We collected information on clinical and demographic characteristics, carotid and transcranial ultrasonography and DSA findings, presence of full-collapse, collateral circulation, and cerebrovascular reactivity (CVR).

RESULTS

One hundred thirty-five patients were analyzed. Ultrasonographic and DSA diagnosis of CNO were concordant in only 44%. This disagreement was related to the presence/absence of full-collapse: 45% of patients with CNO with full-collapse were classified as a complete carotid occlusion, and 40% with a CNO without full-collapse were interpreted as severe stenosis (p < 0.001). Mean velocities (mV) and pulsatility indexes (PIs) were significantly lower in the ipsilateral middle cerebral artery compared with the contralateral (43 cm/s vs 58 cm/s, p < 0.001; 0.80 vs 1.00, p < 0.001). Collateral circulation was identified in 92% of patients, with the anterior communicating artery (73%) being the most frequent. CVR was decreased or exhausted in 66% of cases and was more frequent in patients with a poor or absent collateral network compared with patients with ≥ 2 collateral arteries (82% vs 56%, p = 0.051).

CONCLUSION

The accuracy of carotid ultrasonography in the diagnosis of CNO seems to be limited, with significant discrepancies with DSA. Decreased ipsilateral mV, PI, and CVR suggest a hemodynamic compromise in patients with CNO.

The risk of recurrent stroke at 24 months in patients with symptomatic carotid near-occlusion: results from CAOS, a multicentre registry study

BACKGROUND AND PURPOSE

The risk of recurrent stroke amongst patients with symptomatic carotid near-occlusion (SCNO) has not been clearly established, and its management remains controversial. The aim was to define the 24-month risk of recurrent stroke and to analyse the effect of the different treatment modalities (medical treatment and revascularization) in a population of patients with SCNO.

METHODS

A multicentre, nationwide, prospective study from January 2010 to May 2016 was performed. Patients with angiography-confirmed SCNO were included. The primary end-point was ipsilateral ischaemic stroke including periprocedural events within 24 months following the presenting event. Revascularization results and periprocedural complications, ipsilateral transient ischaemic attack, disabling or fatal stroke, and mortality were also noted.

RESULTS

The study population comprised 141 patients from 17 Spanish centres. Seventy patients (49.6%) were treated by revascularization (carotid stenting in 47, endarterectomy in 23). Complete revascularization was achieved in 58 patients (83%). Periprocedural stroke or death occurred in 5.7%. The 24-month cumulative incidence of the primary end-point was 11.1% (95% confidence interval 5.8-16.4; n = 15), 12% in the medical treatment group and 10.2% in the revascularization group, log-rank P = 0.817. The cumulative rates of ipsilateral ischaemic stroke or transient ischaemic attack, disabling or fatal stroke, and mortality, were 17%, 4.5% and 7.5%, respectively.

CONCLUSIONS

The rate of ipsilateral ischaemic stroke in patients with SCNO seems to be lower than the known rate associated with severe carotid stenosis without near-occlusion. The potential benefit of revascularization in the prevention of stroke in patients with SCNO may be influenced by the effectiveness and safety of the procedure.

Analysis of cerebrovascular disease mortality trends in Andalusia (1980-2014)

INTRODUCTION

In recent decades, mortality rates for cerebrovascular diseases (CVD) have decreased significantly in many countries. This study analyses recent tendencies in CVD mortality rates in Andalusia (1980-2014) to identify any changes in previously observed sex and age trends.

PATIENTS AND METHODS

CVD mortality and population data were obtained from Spain's National Statistics Institute database. We calculated age-specific and age-standardised mortality rates using the direct method (European standard population). Joinpoint regression analysis was used to estimate the annual percentage change in rates and identify significant changes in mortality trends. We also estimated rate ratios between Andalusia and Spain.

RESULTS

Standardised rates for both males and females showed 3 periods in joinpoint regression analysis: an initial period of significant decline (1980-1997), a period of rate stabilisation (1997-2003), and another period of significant decline (2003-2014).

CONCLUSIONS

Between 1997 and 2003, age-standardised rates stabilised in Andalusia but continued to decrease in Spain as a whole. This increased in the gap between CVD mortality rates in Andalusia and Spain for both sexes and most age groups.

Analysis of cerebrovascular mortality trends in Spain from 1980 to 2011

INTRODUCTION

In recent decades, mortality rates for cerebrovascular diseases (CVD) have declined significantly in many countries. This study analyses changes in CVD mortality rates in Spain (1980-2011) to determine if previously observed trends remain.

PATIENTS AND METHODS

Data on CVD mortality rates and the population data needed for the analysis were provided by Spain's National Statistics Institute. We calculated age-specific mortality rate, age-standardised overall mortality, and age-truncated mortality (35-64 years) using the direct method and standard European population structure. Joinpoint analysis was used to estimate the percentage of annual change in rates and identify significant changes in trends.

RESULTS

CVD mortality rate decreased considerably and continuously over the last 32 years in all age groups and in both sexes in Spain. For both sexes, joinpoint analysis identifies a final period with more marked decline: 2005-2011 in women (-6.3%) and 2007-2011 in men (-7.2%).

CONCLUSIONS

CVD mortality rates displayed a marked and continuous decline in Spain between 1980 and 2011. Due to the ageing of the population, doctors expect an increase in CVD prevalence and therefore its magnitude in terms of disability and healthcare costs, which poses a challenge to our health system.

[Evaluation of telephone assessment in stroke and TIA recurrence]

INTRODUCTION

Stroke recurrence is an important issue in stroke registries, but direct patient contact months after stroke is not always feasible. Telephone assessment is often used to evaluate long term stroke outcome, treatments and recurrences. Our aim is to evaluate telephone interview in a stroke registry.

MATERIAL AND METHODS

Three hundred and eighty patients with a stroke or TIA were prospectively registered, evaluating baseline characteristics and type of event. At 6 months, 248 patients were reviewed by structured telephone interview and 132 were reviewed by direct contact. We analysed stroke outcome and disability, treatments and stroke or TIA recurrences.

RESULTS

There were no differences in baseline characteristics and type or severity of the index event. At 6 months, treatments were similar between both groups and 10.5% (40 patients) had a recurrent event. There were no differences in recurrent ischaemic strokes (6.1% in direct contact vs 4.4% telephone, P=.49), but we detected a higher number of TIA in direct examination compared to phone interview (9.1% vs 4.0%, P=.04).

CONCLUSIONS

Telephone assessment of stroke patients is reliable and facilitates stroke registries in detecting long-term treatments and stroke recurrences. However, it is probable that new transient events or TIA are under-estimated.

Internal carotid artery stenting in patients with near occlusion: 30-day and long-term outcome

BACKGROUND AND PURPOSE

The natural history of the carotid NO is poorly characterized, and the management of patients remains controversial. We report the results and complications associated with CAS and follow-up.

MATERIALS AND METHODS

Between March 2000 and March 2009, 116 of 836 CAS procedures were performed in patients with carotid NO (13.9%). A total of 99 men (85.3%) and 17 women (14.7%) with a mean age of 65.8 years were included. Presenting symptoms were TIA in 44 patients (37.9%) and minor stroke or noninvalidating stroke in 61 (52.6%). One hundred five patients (90.5%) were symptomatic.

RESULTS

A distal filter was used for cerebral protection in 92 patients (79.3%). Transient hemodynamic alterations were frequent during balloon inflation: hypotension (37.1%), bradycardia (48.3%), and asystole in 24.1%. Four patients (3.4%) developed a TIA after CAS. Stroke in progression was arrested in the 1 patient (0.9%). The median follow-up period for patients was 36 months. Asymptomatic restenosis >70% occurred in 5 patients (4.3%); asymptomatic occlusion occurred in 3 patients (2.6%). During follow-up, 3 patients (2.6%) experienced a stroke, 1 ipsilateral (at 19 months) and 2 contralateral (at 6 and 30 months, respectively). Thirteen patients (11.2%) died, 7 from vascular causes.

CONCLUSIONS

Our study showed that carotid NO is an under-recognized condition, and CAS would seem to be beneficial when performed by an experienced neurointerventional team.

Volume and composition of emboli in neuroprotected stenting of the carotid artery

BACKGROUND AND PURPOSE

Periprocedural microembolization is a major and permanent risk for patients treated by angioplasty and stent placement of high-grade carotid stenoses. Little is known however about the characteristics and significance of these embolized particles. Our aim was to assess the volume and composition of debris captured by filters during carotid angioplasty and stent placement (CAS) of severe internal carotid artery (ICA) stenoses.

MATERIALS AND METHODS

Institutional review board approval and informed consent from all subjects were obtained. Two hundred one patients (mean age, 66.2 years; range, 35-82 years) with > or = 70% stenosis of the ICA underwent filter-protected CAS. Ultrastructural and semiquantitative analysis of the volume of filters was obtained. Multifactorial statistical analysis was performed to determine factors related to debris volume and composition.

RESULTS

Transient ischemic attack occurred in 6 patients (3%), and a major stroke, in 1 (0.5%). Debris was found in 117 filters (58.2%), with volume <1 lambda (0.001 mL) in 71%. The number of balloon dilations, age older than 65 years, and calcified plaques in pre-CAS angiography were significantly associated with the presence of particulates inside the filters (P < .03, P < .004, and P < .05, respectively).

CONCLUSIONS

Vessel wall and atheromatous plaques are the main source of microemboli during CAS. Embolization is mainly related to the number of balloon dilations during CAS. Planning a proper and individualized strategy for the procedure in each patient is essential to minimize the potential effects of manipulation during CAS.