Impact of Race on Outcomes in the Endovascular and Microsurgical Treatment in Patients With Intracranial Aneurysms

BACKGROUND AND OBJECTIVES

The impact of race on outcomes in the treatment of intracranial aneurysm (IA) remains unclear. We aimed to investigate the relationship between race classified into White, Black, Hispanic, and other and treatment outcomes in patients with ruptured and unruptured IAs.

METHODS

The study population consisted of 2836 patients with IA with endovascular treatment or microsurgical treatment (MST) from 16 centers in the United States and Asia, all participating in the observational "STAR" registry. The primary outcome was a 90-day modified Rankin Scale of 0 to 2. Secondary outcomes included periprocedural cerebral infarction and intracranial hemorrhage, perioperative symptomatic cerebral vasospasm in ruptured IA and mortality, and all causes of mortality within 90 days.

RESULTS

One thousand fifty-three patients were White (37.1%), 350 were Black (12.3%), 264 were Hispanic (9.3%), and 1169 were other (41.2%). Compared with White patients, Hispanic patients had a significantly lower proportion of primary outcome (adjusted odds ratio [aOR] 0.36, 95% CI, 0.23-0.56) and higher proportion of the periprocedural cerebral infarction, perioperative mortality, and all causes of mortality (aOR 2.53, 95% CI, 1.40-4.58, aOR 1.84, 95% CI, 1.00-3.38, aOR 1.83, 95% CI, 1.06-3.17, respectively). Outcomes were not significantly different in Black and other patients. The subgroup analysis showed that Hispanic patients with age ≥65 years (aOR 0.19, 95% CI, 0.10-0.38, interaction P = .048), Hunt-Hess grades 0 to 3 (aOR 0.29, 95% CI, 0.19-0.46, interaction P = .03), and MST (aOR 0.24, 95% CI, 0.13-0.44, interaction P = .04) had a significantly low proportion of primary outcome.

CONCLUSION

This study demonstrates that Hispanic patients with IA are more likely to have a poor outcome at 90 days after endovascular treatment or MST than White patients. Physicians have to pay attention to the selection of treatment modalities, especially for Hispanic patients with specific factors to reduce racial discrepancies.

Impact of Procedure Time on First Pass Effect in Mechanical Thrombectomy for Anterior Circulation Acute Ischemic Stroke

BACKGROUND AND OBJECTIVES

First pass effect (FPE) is a metric increasingly used to determine the success of mechanical thrombectomy (MT) procedures. However, few studies have investigated whether the duration of the procedure can modify the clinical benefit of FPE. We sought to determine whether FPE after MT for anterior circulation large vessel occlusion acute ischemic stroke is modified by procedural time (PT).

METHODS

A multicenter, international data set was retrospectively analyzed for anterior circulation large vessel occlusion acute ischemic stroke treated by MT who achieved excellent reperfusion (thrombolysis in cerebral infarction 2c/3). The primary outcome was good functional outcome defined by 90-day modified Rankin scale scores of 0-2. The primary study exposure was first pass success (FPS, 1 pass vs ≥2 passes) and the secondary exposure was PT. We fit-adjusted logistic regression models and used marginal effects to assess the interaction between PT (≤30 vs >30 minutes) and FPS, adjusting for potential confounders including time from stroke presentation.

RESULTS

A total of 1310 patients had excellent reperfusion. These patients were divided into 2 cohorts based on PT: ≤30 minutes (777 patients, 59.3%) and >30 minutes (533 patients, 40.7%). Good functional outcome was observed in 658 patients (50.2%). The interaction term between FPS and PT was significant ( P = .018). Individuals with FPS in ≤30 minutes had 11.5% higher adjusted predicted probability of good outcome compared with those who required ≥2 passes (58.2% vs 46.7%, P = .001). However, there was no significant difference in the adjusted predicted probability of good outcome in individuals with PT >30 minutes. This relationship appeared identical in models with PT treated as a continuous variable.

CONCLUSION

FPE is modified by PT, with the added clinical benefit lost in longer procedures greater than 30 minutes. A comprehensive metric for MT procedures, namely, FPE 30 , may better represent the ideal of fast, complete reperfusion with a single pass of a thrombectomy device.

Gender Differences in Procedural Clinical Complications and Outcomes of Intracranial Aneurysms: Analysis of the Stroke Thrombectomy and Aneurysm Registry

BACKGROUND AND OBJECTIVES

Some studies have shown that female patients had a poorer prognosis after endovascular treatment for ruptured intracranial aneurysm than male patients. However, data have been sparse regarding differences in the periprocedural and perioperative complication rate with ruptured and unruptured intracranial aneurysms.

METHODS

This retrospective cohort study used data from the Stroke Thrombectomy and Aneurysm Registry, a database of 9 institutions in the United States, Europe, and Asia. The study presented intracranial aneurysms after microsurgical and/or endovascular treatment from January 1, 2013, to December 31, 2022. The primary outcome was incidence of periprocedural cerebral infarction. Secondary outcomes were periprocedural intracranial hemorrhage, periprocedural mortality, perioperative vasospasm, and functional outcome at 90 days after procedure.

RESULTS

Among 3342 patients with aneurysm, 2447 were female and 857 were male, and the mean age of female and male patients was 59.6 and 57.1 years, respectively. Current smoker, family history of aneurysm, and ruptured aneurysm were observed in 23.5% vs 35.7 %, 10.8 % vs 5.7%, and 28.2% vs 40.5% of female and male patients, respectively. In female patients, internal carotid artery aneurysms were more commonly observed (31.1% vs 17.3%); however, anterior cerebral artery aneurysms were less commonly observed (18.5% vs 33.8%) compared with male patients. Periprocedural cerebral infarction rate was lower in female than male patients (2.4% vs 4.4%; P = .002). The adjusted odds ratio of primary outcome of female to male patients was 0.72 (95% CI, 0.46-1.12). Incidence of periprocedural intracranial hemorrhage and periprocedural mortality and perioperative symptomatic vasospasm and functional outcome was similar in both groups. In subgroup analysis, periprocedural cerebral infarction due to microsurgical treatment occurred frequently in male patients while incidence in endovascular treatment was similar in both groups (interaction P = .005).

CONCLUSION

This large multicenter registry of patients undergoing intracranial aneurysm treatment found that female patients were not at increased risk of perioperative complications.

Comparison between transradial and transfemoral mechanical thrombectomy for ICA and M1 occlusions: insights from the Stroke Thrombectomy and Aneurysm Registry (STAR)

BACKGROUND

The role for the transradial approach for mechanical thrombectomy is controversial. We sought to compare transradial and transfemoral mechanical thrombectomy in a large multicenter database of acute ischemic stroke.

METHODS

The prospectively maintained Stroke Thrombectomy and Aneurysm Registry (STAR) was reviewed for patients who underwent mechanical thrombectomy for an internal carotid artery (ICA) or middle cerebral artery M1 occlusion. Multivariate regression analyses were performed to assess outcomes including reperfusion time, symptomatic intracerebral hemorrhage (ICH), distal embolization, and functional outcomes.

RESULTS

A total of 2258 cases, 1976 via the transfemoral approach and 282 via the transradial approach, were included. Radial access was associated with shorter reperfusion time (34.1 min vs 43.6 min, P=0.001) with similar rates of Thrombolysis in Cerebral Infarction (TICI) 2B or greater reperfusion (87.9% vs 88.1%, P=0.246). Patients treated via a transradial approach were more likely to achieve at least TICI 2C (59.6% vs 54.7%, P=0.001) and TICI 3 reperfusion (50.0% vs 46.2%, P=0.001), and had shorter lengths of stay (mean 9.2 days vs 10.2, P<0.001). Patients treated transradially had a lower rate of symptomatic ICH (8.0% vs 9.4%, P=0.047) but a higher rate of distal embolization (23.0% vs 7.1%, P<0.001). There were no significant differences in functional outcome at 90 days between the two groups.

CONCLUSIONS

Radial and femoral thrombectomy resulted in similar clinical outcomes. In multivariate analysis, the radial approach had improved revascularization rates, fewer cases of symptomatic ICH, and faster reperfusion times, but higher rates of distal emboli. Further studies on the optimal approach are necessary based on patient and disease characteristics.

Comparative Outcomes of Mechanical Thrombectomy in Acute Ischemic Stroke Patients with ASPECTS 2-3 vs. 4-5

BACKGROUND

The influence of Alberta Stroke Program Early CT Score (ASPECTS) on outcomes following mechanical thrombectomy (MT) for acute ischemic stroke (AIS) patients with low ASPECTS remains unknown. In this study, we compared the outcomes of AIS patients treated with MT for large vessel occlusion (LVO) categorized by ASPECTS value.

METHODS

We conducted a retrospective analysis involving 305 patients with AIS caused by LVO, defined as the occlusion of the internal carotid artery and/or the M1 segments of the middle cerebral artery, stratified into two groups: ASPECTS 2-3 and 4-5. The primary outcome was favorable outcome defined as a 90-day modified Rankin Scale (mRS) score of 0-3. Secondary outcomes were 90-day mRS 0-2, 90-day mortality, any intracerebral hemorrhage (ICH), and symptomatic ICH (sICH). We performed multivariable logistic regression analysis to evaluate the impact of ASPECTS 2-3 vs. 4-5 on outcomes.

RESULTS

Fifty-nine patients (19.3%) had ASPECTS 2-3 and 246 (80.7%) had ASPECTS 4-5. Favorable outcomes showed no significant difference between the two groups (adjusted odds ratio [aOR]= 1.13, 95% confidence interval [CI]: 0.52-2.41, p=0.80). There were also no significant differences in 90-day mRS 0-2 (aOR= 1.65, 95% CI: 0.66-3.99, p=0.30), 90-day mortality (aOR= 1.14, 95% CI: 0.58-2.20, p=0.70), any ICH (aOR= 0.54, 95% CI: 0.28-1.00, p=0.06), and sICH (aOR= 0.70, 95% CI: 0.27-1.63, p = 0.40) between the groups.

CONCLUSIONS

AIS patients with LVO undergoing MT with ASPECTS 2-3 had similar outcomes compared to ASPECTS 4-5.

Thrombectomy in Stroke Patients With Low Alberta Stroke Program Early Computed Tomography Score: Is Modified Thrombolysis in Cerebral Infarction (mTICI) 2c/3 Superior to mTICI 2b?

BACKGROUND AND PURPOSE

Outcomes following mechanical thrombectomy (MT) are strongly correlated with successful recanalization, traditionally defined as modified Thrombolysis in Cerebral Infarction (mTICI) ≥2b. This retrospective cohort study aimed to compare the outcomes of patients with low Alberta Stroke Program Early Computed Tomography Score (ASPECTS; 2-5) who achieved mTICI 2b versus those who achieved mTICI 2c/3 after MT.

METHODS

This study utilized data from the Stroke Thrombectomy and Aneurysm Registry (STAR), which combined databases from 32 thrombectomy-capable stroke centers between 2013 and 2023. The study included only patients with low ASPECTS who achieved mTICI 2b, 2c, or 3 after MT for internal carotid artery or middle cerebral artery (M1) stroke.

RESULTS

Of the 10,229 patients who underwent MT, 234 met the inclusion criteria. Of those, 98 (41.9%) achieved mTICI 2b, and 136 (58.1%) achieved mTICI 2c/3. There were no significant differences in baseline characteristics between the two groups. The 90-day favorable outcome (modified Rankin Scale score: 0-3) was significantly better in the mTICI 2c/3 group than in the mTICI 2b group (adjusted odds ratio 2.35; 95% confidence interval [CI] 1.18-4.81; P=0.02). Binomial logistic regression revealed that achieving mTICI 2c/3 was significantly associated with higher odds of a favorable 90-day outcome (odds ratio 2.14; 95% CI 1.07-4.41; P=0.04).

CONCLUSION

In patients with low ASPECTS, achieving an mTICI 2c/3 score after MT is associated with a more favorable 90-day outcome. These findings suggest that mTICI 2c/3 is a better target for MT than mTICI 2b in patients with low ASPECTS.

Effect of intravenous thrombolysis before endovascular therapy on outcomes in patients with large core infarct

BACKGROUND

The safety and efficacy of bridging therapy with intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) in patients with large core infarct has not been sufficiently studied. In this study, we compared the efficacy and safety outcomes between patients who received IVT+MT and those treated with MT alone.

METHODS

This is a retrospective analysis of the Stroke Thrombectomy Aneurysm Registry (STAR). Patients with Alberta Stroke Program Early CT Score (ASPECTS) ≤5 treated with MT were included in this study. Patients were divided into two groups based on pre-treatment IVT (IVT, no IVT). Propensity score matched analysis were used to compare outcomes between groups.

RESULTS

A total of 398 patients were included; 113 pairs were generated using propensity score matching analyses. Baseline characteristics were well balanced in the matched cohort. The rate of any intracerebral hemorrhage (ICH) was similar between groups in both the full cohort (41.4% vs 42.3%, P=0.85) and matched cohort (38.55% vs 42.1%, P=0.593). Similarly, the rate of significant ICH was similar between the groups (full cohort: 13.1% vs 16.9%, P=0.306; matched cohort: 15.6% vs 18.95, P=0.52). There was no difference in favorable outcome (90-day modified Rankin Scale 0-2) or successful reperfusion between groups. In an adjusted analysis, IVT was not associated with any of the outcomes.

CONCLUSION

Pretreatment IVT was not associated with an increased risk of hemorrhage in patients with large core infarct treated with MT. Future studies are needed to assess the safety and efficacy of bridging therapy in patients with large core infarct.

Health inequities and socioeconomic factors predicting the access to treatment for unruptured intracranial aneurysms in the USA in the last 20 years: interaction effect of race, gender, and insurance

BACKGROUND

The literature suggests that minority racial and ethnic groups have lower treatment rates for unruptured intracranial aneurysms (UIA). It is uncertain how these disparities have changed over time.

METHODS

A cross-sectional study using the National Inpatient Sample database covering 97% of the USA population was carried out.

RESULTS

A total of 213 350 treated patients with UIA were included in the final analysis and compared with 173 375 treated patients with aneurysmal subarachnoid hemorrhage (aSAH) over the years 2000-2019. The mean (SD) age of the UIA and aSAH groups was 56.8 (12.6) years and 54.3 (14.1) years, respectively. In the UIA group, 60.7% were white patients, 10.2% were black patients, 8.6% were Hispanic, 2% were Asian or Pacific Islander, 0.5% were Native Americans, and 2.8% were others. The aSAH group comprised 48.5% white patients, 13.6% black patients, 11.2% Hispanics, 3.6% Asian or Pacific Islanders, 0.4% Native Americans, and 3.7% others. After adjusting for covariates, black patients (OR 0.637, 95% CI 0.625 to 0.648) and Hispanic patients (OR 0.654, 95% CI 0.641 to 0.667) had lower odds of treatment compared with white patients. Medicare patients had higher odds of treatment than private patients, while Medicaid and uninsured patients had lower odds. Interaction analysis showed that non-white/Hispanic patients with any insurance/no insurance had lower treatment odds than white patients. Multivariable regression analysis showed that the treatment odds of black patients has improved slightly over time, while the odds for Hispanic patients and other minorities have remained the same over time.

CONCLUSION

This study from 2000 to 2019 shows that disparities in the treatment of UIA have persisted but have slightly improved over time for black patients while remaining constant for Hispanic patients and other minority groups.

Outcomes of mechanical thrombectomy in stroke patients with extreme large infarction core

BACKGROUND

Recent clinical trials have demonstrated that patients with large vessel occlusion (LVO) and large infarction core may still benefit from mechanical thrombectomy (MT). In this study, we evaluate outcomes of MT in LVO patients presenting with extremely large infarction core Alberta Stroke Program Early CT Score (ASPECTS 0-2).

METHODS

Data from the Stroke Thrombectomy and Aneurysm Registry (STAR) was interrogated. We identified thrombectomy patients presenting with an occlusion in the intracranial internal carotid artery (ICA) or M1 segment of the middle cerebral artery and extremely large infarction core (ASPECTS 0-2). A favorable outcome was defined by achieving a modified Rankin scale of 0-3 at 90 days post-MT. Successful recanalization was defined by achieving a modified Thrombolysis In Cerebral Ischemia (mTICI) score ≥2B.

RESULTS

We identified 58 patients who presented with ASPECTS 0-2 and underwent MT . Median age was 70.0 (59.0-78.0) years, 45.1% were females, and 202 (36.3%) patients received intravenous tissue plasminogen activator. There was no difference regarding the location of the occlusion (p=0.57). Aspiration thrombectomy was performed in 268 (54.6%) patients and stent retriever was used in 70 (14.3%) patients. In patients presenting with ASPECTS 0-2 the mortality rate was 4.5%, 27.9% had mRS 0-3 at day 90, 66.67% ≥70 years of age had mRS of 5-6 at day 90. On multivariable analysis, age, National Institutes of Health Stroke Scale on admission, and successful recanalization (mTICI ≥2B) were independently associated with favorable outcomes.

CONCLUSIONS

This multicentered, retrospective cohort study suggests that MT may be beneficial in a select group of patients with ASPECTS 0-2.

Mechanical thrombectomy for the treatment of primary and secondary anterior cerebral artery occlusions: insights from STAR

BACKGROUND

The safety and efficacy of mechanical thrombectomy (MT) for the treatment of acute anterior cerebral artery (ACA) occlusions have not clearly been delineated. Outcomes may be impacted based on whether the occlusion is isolated to the ACA (primary ACA occlusion) or occurs in conjunction with other cerebral arteries (secondary).

METHODS

We performed a retrospective review of the multicenter Stroke Thrombectomy and Aneurysm (STAR) database. All patients with MT-treated primary or secondary ACA occlusions were included. Baseline characteristics, procedural outcomes, complications, and clinical outcomes were collected. Primary and secondary ACA occlusions were compared using the Mann-Whitney U test and Kruskal-Willis test for continuous variables and the χ2 test for categorical variables.

RESULTS

The study cohort comprised 238 patients with ACA occlusions (49.2% female, median (SD) age 65.6 (16.7) years). The overall rate of successful recanalization was 75%, 90-day good functional outcome was 23%, and 90-day mortality was 35%. There were 44 patients with a primary ACA occlusion and 194 patients with a secondary ACA occlusion. When adjusted for baseline variables, the rates of successful recanalization (68% vs 76%, P=0.27), 90-day good functional outcome (41% vs 19%, P=0.38), and mortality at 90 days (25% vs 38%, P=0.12) did not differ between primary and secondary ACA occlusion groups.

CONCLUSION

Clinical and procedural outcomes are similar between MT-treated primary and secondary ACA occlusions for select patients. Our findings demonstrate the need for established criteria to determine ideal patient and ACA stroke characteristics amenable to MT treatment.

Comparison of balloon guide catheter versus non-balloon guide catheter for mechanical thrombectomy in patients with distal medium vessel occlusion

BACKGROUND

Several studies have established the safety and efficacy of balloon guide catheters (BGCs) for large vessel occlusions. However, the utility of BGCs remains largely unexplored for distal medium vessel occlusions (DMVOs). In this study, we aim to compare the outcomes of BGC vs. Non-BGC in patients undergoing mechanical thrombectomy (MT) for DMVO.

METHOD

This retrospective study from the Stroke Thrombectomy and Aneurysm Registry (STAR) encompassed adult patients with acute anterior cerebral artery, posterior cerebral artery, and middle cerebral artery-M2-3-4 occlusions. Procedure times, safety, recanalization, and neurological outcomes were compared between the two groups, with subgroup analysis based on first-line thrombectomy techniques.

RESULTS

A total of 1508 patients were included, with 231 patients (15.3%) in the BGC group and 1277 patients (84.7%) in the non-BGC group. The BGC group had a lower modified Thrombolysis in Cerebral Infarction (mTICI) score ≥2C (43.2% vs 52.7%, P=0.01), longer time from puncture to intracranial access (15 vs 8 min, P<0.01), and from puncture to final recanalization (97 vs 34 min, P<0.01). In the Solumbra subgroup, the first pass effect (FPE) rate was lower in the BGC group (17.4% vs 30.7%, P=0.03). Regarding clinical outcomes, the BGC group had a lower rate of distal embolization (8.8% vs 14.9%, P=0.03).

CONCLUSION

Our study found that use of BGC in patients with DMVO was associated with lower mTICI scores, decreased FPE rates, reduced distal embolization, and longer procedure times.

Predictors of Angiographic Outcome After Failed Thrombectomy for Large Vessel Occlusion: Insights from the Stroke Thrombectomy and Aneurysm Registry

BACKGROUND

Mechanical thrombectomy failure (MTF) occurs in approximately 15% of cases.

OBJECTIVE

To investigate factors that predict MTF.

METHODS

This was a retrospective review of prospectively collected data from the Stroke Thrombectomy and Aneurysm Registry. Patients who underwent mechanical thrombectomy (MT) for large vessel occlusion (LVO) were included. Patients were categorized by mechanical thrombectomy success (MTS) (≥mTICI 2b) or MTF (

RESULTS

A total of 6780 patients were included, and 1001 experienced anterior circulation MTF. Patients in the MTF group were older (73 vs 72, P = .044) and had higher poor premorbid modified Rankin Scale (mRS) (10.8% vs 8.4%, P = .017). Onset to puncture time was greater in the MTF group (273 vs 260 min, P = .08). No significant differences were found between the access site, use of balloon guide catheter, frontline technique, or first-pass devices between the MTF and MTS groups. More complications occurred in the MTF group (14% vs 5.8%), including symptomatic intracerebral hemorrhage (9.4% vs 6.1%) and craniectomies (10% vs 2.8%) ( P < .001). On UVA, age, poor pretreatment mRS, increased number of passes, and increased procedure time were associated with MTF. Internal carotid artery, M1, and M2 occlusions had decreased odds of MTF. Poor preprocedure mRS, number of passes, and procedure time remained significant on MVA. A subgroup analysis of posterior circulation LVO revealed that number of passes and total procedure time correlated with increased odds of MTF ( P < .001) while rescue stenting was associated with less odds of MTF (odds ratio 0.20, 95% CI 0.06-0.63). Number of passes remained significant on MVA of posterior circulation occlusion subgroup analysis.

CONCLUSION

Anterior circulation MTF is associated with more complications and worse outcomes. No differences were found between techniques or devises used for the first pass during MT. Rescue intracranial stenting may decrease the likelihood of MTF for posterior circulation MT.

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Key Words Collapse

MESH Headings

• Humans
• Stroke/surgery
• Thrombectomy/methods
• Cerebral Hemorrhage
• Retrospective Studies
• Aneurysm
• Registries
• Treatment Outcome
• Brain Ischemia/therapy

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Affiliation(s)

Matthew Webb Department of Neurosurgery, University of Texas Health Science Center San Antonio, San Antonio , Texas , USA
Muhammed Amir Essibayi Medical University of South Carolina, Charleston , South Carolina , USA
Sami Al Kasab Medical University of South Carolina, Charleston , South Carolina , USA
Ilko L Maier University Medical Center Göttingen, Göttingen , Germany
Marios-Nikos Psychogios University Hospital Basel, Basel , Switzerland
Jonathan A Grossberg Emory University, Atlanta , Georgia , USA
Ali Alawieh Emory University, Atlanta , Georgia , USA
Stacey Quintero Wolfe Wake Forest University, Winston-Salem , North Carolina , USA
Adam Arthur University of Tennessee Health Science Center, Memphis , Tennessee , USA
Travis Dumont Bannner University of Arizona Medical Center, Tucson , Arizona , USA
Peter Kan University of Texas Medical Branch, Galveston , Texas , USA
Joon-Tae Kim Chonnam National University Hospital, Gwangju , South Korea
Reade De Leacy Mount Sinai Health System, New York , New York , USA
Joshua Osbun Washington University in St. Louis, St. Louis , Missouri , USA
Ansaar Rai Department of Neuroradiology, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
Pascal Jabbour Department of Neuroradiology, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
Min S Park Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
Roberto Crosa University of Virginia, Charlottesville , Virginia , USA
Michael R Levitt Centro Endovascular Neurológico, Médica Uruguaya, Montevideo , Uruguay
Adam Polifka University of Washington, Seattle , Washington , USA
Shinichi Yoshimura University of Florida, Gainesville , Florida , USA
Charles Matouk Hyogo College of Medicine, Nishinomiya , Japan
Richard W Williamson Yale School of Medicine, New Haven , Connecticut , USA
Isabel Fragata Allegheny General Hospital, Pittsburgh , Pennsylvania , USA
Shakeel A Chowdhry Centro Hospitalar Universitário de Lisboa Central, Lisboa , Portugal
Robert M Starke NorthShore University Health System, Evanston , Illinois , USA
Edgar A Samaniego University of Miami Health System, Miami , Florida , USA
Hugo Cuellar University of Iowa, Iowa City , Iowa , USA
Alejandro Spiotta Medical University of South Carolina, Charleston , South Carolina , USA
Justin Mascitelli Department of Neurosurgery, University of Texas Health Science Center San Antonio, San Antonio , Texas , USA

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The effect of occlusion location and technique in mechanical thrombectomy for minor stroke

INTRODUCTION

Endovascular mechanical thrombectomy (MT) is an established treatment for large vessel occlusion strokes with a National Institutes of Health Stroke Scale (NIHSS) score of 6 or higher. Data pertaining to minor strokes, medium, or distal vessel occlusions, and most effective MT technique is limited and controversial.

METHODS

A multicenter retrospective study of all patients treated with MT presenting with NIHSS score of 5 or less at 29 comprehensive stroke centers. The cohort was dichotomized based on location of occlusion (proximal vs. distal) and divided based on MT technique (direct aspiration first-pass technique [ADAPT], stent retriever [SR], and primary combined [PC]). Outcomes at discharge and 90 days were compared between proximal and distal occlusion groups, and across MT techniques.

RESULTS

The cohort included 759 patients, 34% presented with distal occlusion. Distal occlusions were more likely to present with atrial fibrillation (p = 0.008) and receive IV tPA (p = 0.001). Clinical outcomes at discharge and 90 days were comparable between proximal and distal groups. Compared to SR, patients managed with ADAPT were more likely to have a modified Rankin Scale of 0-2 at discharge and at 90 days (p = 0.024 and p = 0.013). Primary combined compared to ADAPT, prior stroke, multiple passes, older age, and longer procedure time were independently associated with worse clinical outcome, while successful recanalization was positively associated with good clinical outcomes.

CONCLUSIONS

Proximal and distal occlusions with low NIHSS have comparable outcomes and safety profiles. While all MT techniques have a similar safety profile, ADAPT was associated with better clinical outcomes at discharge and 90 days.

Microsurgical clipping and endovascular management of unruptured anterior circulation aneurysms: how age, frailty, and comorbidity indexes influence outcomes

OBJECTIVE

Frailty is one of the important factors in predicting the outcomes of surgery. Many surgical specialties have adopted a frailty assessment in the preoperative period for prognostication; however, there are limited data on the effects of frailty on the outcomes of cerebral aneurysms. The object of this study was to find the effect of frailty on the surgical outcomes of anterior circulation unruptured intracranial aneurysms (UIAs) and compare the frailty index with other comorbidity indexes.

METHODS

A retrospective study was performed utilizing the National Inpatient Sample (NIS) database (2016-2018). The Hospital Frailty Risk Score (HFRS) was used to assess frailty. On the basis of the HFRS, the whole cohort was divided into low-risk (0-5), intermediate-risk (> 5 to 15), and high-risk (> 15) frailty groups. The analyzed outcomes were nonhome discharge, complication rate, extended length of stay, and in-hospital mortality.

RESULTS

In total, 37,685 patients were included in the analysis, 5820 of whom had undergone open surgical clipping and 31,865 of whom had undergone endovascular management. Mean age was higher in the high-risk frailty group than in the low-risk group for both clipping (63 vs 55.4 years) and coiling (64.6 vs 57.9 years). The complication rate for open surgical clipping in the high-risk frailty group was 56.1% compared to 0.8% in the low-risk group. Similarly, for endovascular management, the complication rate was 60.6% in the high-risk group compared to 0.3% in the low-risk group. Nonhome discharges were more common in the high-risk group than in the low-risk group for both open clipping (87.8% vs 19.7%) and endovascular management (73.1% vs 4.4%). Mean hospital charges for clipping were $341,379 in the high-risk group compared to $116,892 in the low-risk group. Mean hospital charges for coiling were $392,861 in the high-risk frailty group and $125,336 in the low-risk group. Extended length of stay occurred more frequently in the high-risk frailty group than in the low-risk group for both clipping (82.9% vs 10.7%) and coiling (94.2% vs 12.7%). Frailty had higher area under the receiver operating characteristic curve values than those for other comorbidity indexes and age in predicting outcomes.

CONCLUSIONS

Frailty affects surgical outcomes significantly and outperforms age and other comorbidity indexes in predicting outcome. It is imperative to include frailty assessment in preoperative planning.

Abstract WP164: Acute Carotid Stenting Versus Conservative Management For Tandem Carotid Occlusions: Insights From STAR

Introduction: Management of anterior circulation emergent large vessel occlusion with tandem carotid occlusion (TCO) remains a challenge during mechanical thrombectomy (MT). To day, there is no consensus regarding emergent carotid stenting (ECS) in the setting of MT with TCO. We aimed to compare the outcomes of ECS versus conservative management (MT alone) among patients with TCO.

Methods: Data from the Stroke Thrombectomy and Aneurysm Registry between 2010 and 2022 was interrogated. Only patients with concomitant occlusions of cervical carotid and proximal ipsilateral intracranial segments of the ICA or MCA were included in the analyses. We compared baseline, procedural charecteristics, successful reperfusion (mTICI 2b-3), favorable 90-day good outcomes (mRS 0-2), intravenous tPA administration and symptomatic ICH between patients who did or did not undergo ECS. Multivariate regression was performed adjusting for variables of clinical importance. Propensity score matching for IV tPA use was performed to explore its safety with stenting.

Results: Among 9812 thrombectomy patients, 688 patients had TCO; 132 underwent emergent stenting and 444 had MT alone. Patients who did not undergo ECS had a higher prevalence of atrial fibrillation (33.9% Vs 9.2%, P<.001), higher admission NIHSS scores (18 Vs 14, P<.001), shorter time from symptom onset to puncture (275 minutes Vs 333 minutes, P=0.029), and were predominantly women (59.2% Vs 33.6%, P<0.001).Patients with stenting had lower mortality rates ( 17.5% Vs 29.6%, P=0.009), and higher rates of successful reperfusion (83% Vs 95%, P=0.001). No difference in mRS 0-2 (37.5% Vs 30.4%, P=0.178) or sICH were seen (11.1% Vs 15.4%, P=0.219). Propensity score matching analysis (n=129 in each group) demonstrated better rates of reperfusion (94.8 Vs 84.4%, P=0.011) in the stenting group. Advanced age, higher admission NIHSS and lower ASPECT scores were associated with worse clinical outcomes.

Conclusion: ECS during MT for TCO appears to be safe and is associated with better clinical and angiographic outcomes compared to conservative management.

Abstract 48: Outcomes And Risk Of Hemorrhagic Transformation Following Mechanical Thrombectomy In Primary Distal Posterior Cerebral Artery Occlusions-subgroup Analysis From STAR

Background: While mechanical thrombectomy (MT) has become the standard of care for acute stroke patients presenting with large vessel occlusion (LVO) and salvageable brain tissue, limited data is currently available regarding the benefits of MT in patents with medium vessel occlusions (MeVO) especially in the posterior circulation (P2 occlusions).

Methods: We used the Stroke Thrombectomy and Aneurysm registry (STAR) which included data from 35 stroke centers in North America, Europe, Asia, and South America. We included patients who presented with MeVO in the M2, M3 or P2 segments and underwent MT. We used a Generalized Linear Model to assess the relationship between location of occlusion and outcomes.

Results: 9812 patients were included in STAR at the time of this analysis; 43 underwent MT for P2 occlusion, 130 underwent MT for M3 occlusion; and 1273 underwent MT for M2 occlusion. There was no difference in age, sex, race, rate of IV-tPA and stroke severity between patients in all 3 groups (Table 1). There was a trend toward lower rate of atrial fibrillation in patients with P2 and M3 occlusions. Patients with P2 occlusions were less likely to achieve successful recanalization (modified treatment in cerebral infarction score≥2b); intraarterial thrombolysis was used less in P2 occlusions (4.7% compared to 16.2% in M3 occlusions and 10.1% in M2 occlusions). However, there was no difference in the rate of successful first pass. On multivariable analysis, P2 occlusions were not associated with hemorrhagic transformation (OR 2.0, 95% CI 0.7-5.7, P 0.186), 90-day mortality (OR 0.5, 95% CI 0.2-1.4, P 0.183), or 90-day favorable outcome (OR 2.0, 95% CI 0.9-4.4, P 0.084).

Conclusions: In this multicenter study, there was no significant difference in safety and efficacy of MT in patients with MeVOs in posterior circulation (P2 occlusions) compared to M2 and M3 occlusions. Improved techniques for successful recanalization are needed for posterior circulation MeVOs.

Abstract 98: The Impact Of Aspiration Catheter Size On Thrombectomy Outcomes Using Adapt Technique-analysis From The STAR Registry

Introductions: Clinical trials have shown that aspiration thrombectomy is as safe and effective as stent-retriever thrombectomy. Multiple improvements have been made to the aspiration technique over the last few years. In this study, we aim to assess the effect of aspiration catheter bore size on the outcomes of A direct aspiration first pass technique (ADAPT) thrombectomy.

Methods: We included patients who underwent ADAPT thrombectomy for M1 or internal carotid artery terminus (ICA-T) occlusions in the Stroke Thrombectomy and Aneurysm (STAR) database. Patients included between July 2016 and July 2022. We compared baseline characteristics, procedural metrics and outcomes between patients who underwent thrombectomy using small bore (0.035”-0.060”), medium bore (0.062”-0.068”) and large bore (0.070”-0.074”) catheters.

Results: A total of 1158 patients were included; 576 (49.7%) females, 645 (70%) White, and 464 (40.6%) received IV-tPA. No difference was noticed in age, sex, and vascular risk factors between the 3 different groups. There was higher rate of IV-tPA in the small-bore catheter group (48.8%) compared to the medium and large bore catheter groups (38.4% and 36.7%, respectively) (P=0.03). Procedure duration was shorter when using medium (20 min) and large (18 min) compared to small bore catheters (30 min) (P=0.01). Both medium and large bore catheters were associated with higher rate of successful recanalization (88.9% and 87.9%, respectively) compared to small bore catheters (81.6%) (P=0.010). However, the difference in successful recanalization or procedure duration between medium and large bore catheters was not significant. No difference was noted in the rate of symptomatic hemorrhagic transformation (sICH) (4.7%, 5.3%, and 7.1%; P=0.345), 90-day favorable outcome (modified Rankin Scale 0-2) (41.8%, 39.3%, 40.8%; P=0.766) or 90-day mortality (18.1%, 23.5%, 24.4%; P=0.111) between the groups.

Conclusions: Higher rate of successful recanalization and shorter procedure duration were observed when using medium and large bore aspiration catheters compared with small bore catheters in ADAPT technique. However, these procedural benefits were not observed when comparing large bore to medium bore catheters.

Abstract TP154: Outcomes Of Acute Carotid Stenting With Or Without Intravenous Thrombolysis Among Patients With Acute Tandem Occlusion: Insights From STAR

Introduction: Emergency carotid artery stenting during mechanical thrombectomy has emerged as an effective emergent treatment for tandem carotid occlusions. Nevertheless, scarce evidence is available about the safety of this procedure in patients who received intravenous tPA before thrombectomy. Herein, we investigate the safety of acute carotid stenting among patients who received intravenous tPA in a large international multicenter registry.

Methods: Patients from the Stroke Thrombectomy and Aneurysm Registry between 2010 and 2022 were analyzed. Only patients with concomitant occlusions of cervical carotid and proximal ipsilateral intracranial segments of the internal carotid or middle cerebral artery were included in the final analyses. Patients were divided into two groups, depending on tPA administration. The primary outcome was 90-day good clinical outcome (mRS 0-2), and the primary safety outcome was symptomatic intracranial hemorrhage. Univariate and multivariate regressions were performed adjusting for variables of clinical importance.

Results: Among 9812 with acute ischemic stroke in the registry, 132 patients had acute tandem occlusion and underwent carotid stenting; of those, 60 patients received IV tPA. Compared to non-intravenous thrombolytics, patients with IV tPA had a higher male prevalence (78.3% Vs 54.4%, P=0.005) and better ASPECT scores (9 Vs 8, P=0.022) with a shorter time from onset to puncture (241 Vs 672 minutes, P<0.001). There was no difference in rates of successful revascularization (94% Vs 95.5%, P=NS), good clinical outcome (50.8% Vs 61.4%, P=NS), symptomatic intracranial hemorrhage (15.3% Vs 14.5%, P=NS) or procedural complications (15% Vs 11.6%, P=NS) between the tPA and non-tPA groups.

Conclusion: The use of IV tPA did not affect the safety or efficacy of emergent carotid stenting in the setting of acute tandem occlusion.

Drip and Ship versus Mothership Model in the Middle Cerebral Artery Stroke: A Propensity-Matched Real-World Analysis Through National Inpatient Sample Data

BACKGROUND

The superiority of mechanical thrombectomy and intravenous thrombolysis versus intravenous thrombolysis alone for acute ischemic stroke caused by large vessel occlusions has been established. This treatment can be organized into 2 models: drip and ship (DS) versus mothership (MS). We analyzed the National Inpatient Sample (NIS) data to compare the outcomes between these models in real-world settings.

METHODS

NIS data were queried for 2017-2018 and propensity matching was used to match the differences. Outcomes for each group (disability at discharge and procedural complications) were compared.

RESULTS

A total of 1226 patients were included in analysis (DS, n = 540; MS, n = 686) and groups were matched with respect to age, gender, and comorbidities. A total of 930 patients were included in the final analysis after propensity matching (DS, n = 465, MS, n = 465). The mean age in the DS group was 68.9 years (standard deviation [SD], 14.7) and 69.4 years (SD, 14) in the MS group (P = 0.752). The mean National Institutes of Health Stroke Scale score was 16.75 (SD, 6.07) in the DS group and 16.54 (SD, 5.99) in the MS group (P = 0.478). At discharge, minimal disability was noted in 22.4% in the DS group versus 26.2% in the MS group (P = 0.293). In-hospital mortality was lower in the MS group (8.8% vs. 7.1%; P = 0.32). The intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) rates were higher in the DS group (ICH, 24.3% vs. 18.7%; IVH, 2.4% vs. 0.9%) (ICH, P = 0.038; IVH, P = 0.068).

CONCLUSIONS

Analyzing the efficacy and safety profile of DS versus MS models with the NIS database showed a trend toward better discharge outcomes and lower mortality for the MS group, although it did not reach statistical significance.

Mapping of thoracic aorta growth rate on serial self-navigated 3D whole-heart magnetic resonance angiographies by image registration

Introduction

Accurate and reproducible assessment of aortic diameters and their growth rate is of key importance for the management of patients with thoracic aortic aneurysms [1,2]. It has been recently shown that image registration permits the assessment of progressive aortic dilation on ECG-gated contrast-enhanced CT angiography, outperforming manual quantification and allowing for 3D aortic size and growth mapping [3]. However, exposure to radiation makes it convenient to limit the use of CT for serial follow-up, especially in young patients. Self-navigated 3D whole-heart CMR acquisitions provides excellent image quality overcoming these limitations [4].

Purpose

To evaluate the accuracy and reproducibility of registration-based assessment of aortic dilation using self-navigated 3D whole-heart CMR acquisitions.

Methods

Fifteen patients with two self-navigated 3D whole-heart CMR images obtained at least 1 year apart were included. Aortic root and thoracic aorta diameters were measured by 2 independent observers both manually (multiplanar reconstruction) and with the registration-based technique. To perform registration-based assessment, the aorta was semi-automatically segmented and typical anatomical landmarks were placed by each observer at baseline [3]. Geometrical mapping between baseline and follow-up acquisitions was obtained using deformable image registration, and applied to the baseline aortic surface points to obtain their location at follow-up. Finally, aortic diameters and their growth rate were automatically measured and used to calculated 3D aortic dilation maps. Agreement between techniques and their inter-observer reproducibility were calculated.

Results

Patients age was 27.2±14.5 years and 40% were male. Mean follow-up duration was 2.7±1.6 years. Compared to manual assessment, the registration-based technique presented low bias and excellent agreement for aortic diameters (Table 1), and low bias and moderate agreement for growth rates both in the aortic root and the thoracic aorta (Table, Fig. 1A). The techniques presented similar inter-observer reproducibility in the assessment of aortic diameters (Table 1), while the registration-based method demonstrated much higher inter-observer reproducibility in the assessment of growth rates in the aortic root and the thoracic aorta (Table 1, Fig. 1A and B). Three-dimensional mapping of thoracic aortic diameters and growth was highly reproducible (mean regional ICC=0.90 for diameters; 0.82 for growth rate).

Conclusion

The assessment of the dilation rate of the thoracic aorta via registration of serial self-navigated 3D whole-heart CMR acquisitions is accurate and reproducible in the aortic root and the thoracic aorta. Thus, it allows to assess local aortic growth without the drawbacks of CT.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto de Salud Carlos III and Ministerio de Ciencia e Innovaciόn (Spain)

Comparison of transradial and transfemoral access for the Woven EndoBridge embolization of intracranial aneurysms: A single-center experience

BACKGROUND

Transradial access has been adopted more commonly in the neuroendovascular field. However, the experience of using this access for the Woven EndoBridge embolization of intracranial aneurysms is still in the early stage.

OBJECTIVE

This study aimed to compare the outcomes between transradial access and transfemoral access for the Woven EndoBridge embolization of intracranial aneurysms.

METHODS

This is a retrospective analysis of consecutive intracranial aneurysms treated with Woven EndoBridge placement between May 2019 and August 2020 by the senior author at a high-volume center. The aneurysms of all sizes and locations treated with Woven EndoBridge placement with or without adjunctive stent or coiling were included. Patient demographics, aneurysm and treatment characteristics, procedural complications, and angiographic and functional outcomes were compared between two approaches.

RESULTS

This study included a total of 34 patients with intracranial aneurysms (median age 60 years, female-to-male ratio 2:1). Of these, the radial access was utilized in 20 (58.8%) patients, while the femoral access was used in 14 (41.2%) patients. A Woven EndoBridge device was successfully deployed in all cases, and none of the patients required a crossover to another access. There were no significant differences in baseline characteristics, procedure time and fluoroscopy time, outcomes, and complication rates between both groups.

CONCLUSION

Our report suggests the possible feasibility and safety of the transradial access for the Woven EndoBridge embolization of intracranial aneurysms. However, the results of this study are suggestive rather than conclusive, and there is still a need for future large prospective studies.

Prognostic significance of age within the adolescent and young adult acute ischemic stroke population after mechanical thrombectomy: insights from STAR

OBJECTIVE

Although younger adults have been shown to have better functional outcomes after mechanical thrombectomy (MT) for acute ischemic stroke (AIS), the significance of this relationship in the adolescent and young adult (AYA) population is not well defined given its undefined rarity. Correspondingly, the goal of this study was to determine the prognostic significance of age in this specific demographic following MT for large-vessel occlusions.

METHODS

A prospectively maintained international multi-institutional database, STAR (Stroke Thrombectomy and Aneurysm Registry), was reviewed for all patients aged 12-18 (adolescent) and 19-25 (young adult) years. Parameters were compared using chi-square and t-test analyses, and associations were interrogated using regression analyses.

RESULTS

Of 7192 patients in the registry, 41 (0.6%) satisfied all criteria, with a mean age of 19.7 ± 3.3 years. The majority were male (59%) and young adults (61%) versus adolescents (39%). The median prestroke modified Rankin Scale (mRS) score was 0 (range 0-2). Strokes were most common in the anterior circulation (88%), with the middle cerebral artery being the most common vessel (59%). The mean onset-to-groin puncture and groin puncture-to-reperfusion times were 327 ± 229 and 52 ± 42 minutes, respectively. The mean number of passes was 2.2 ± 1.2, with 61% of the cohort achieving successful reperfusion. There were only 3 (7%) cases of reocclusion. The median mRS score at 90 days was 2 (range 0-6). Between the adolescent and young adult subgroups, the median mRS score at last follow-up was statistically lower in the adolescent subgroup (1 vs 2, p = 0.03), and older age was significantly associated with a higher mRS at 90 days (coefficient 0.33, p < 0.01).

CONCLUSIONS

Although rare, MT for AIS in the AYA demographic is both safe and effective. Even within this relatively young demographic, age remains significantly associated with improved functional outcomes. The implication of age-dependent stroke outcomes after MT within the AYA demographic needs greater validation to develop effective age-specific protocols for long-term care across both pediatric and adult centers.

The Pipeline Embolization Device: a decade of lessons learned in the treatment of posterior circulation aneurysms in a multicenter cohort

OBJECTIVE

The Pipeline Embolization Device (PED) has prompted a paradigm shift in the approach to posterior circulation aneurysms. The year 2021 marks a decade since FDA approval of this flow diverter, and during this time operators have adapted to its off-label uses. The authors examined whether case selection, practice trends, and patient outcomes have changed over this 10-year period.

METHODS

This study is a retrospective review of consecutive posterior circulation aneurysms managed with the PED at four academic institutions in the US between January 1, 2011, and January 1, 2021. Factors related to case selection, rates of aneurysm occlusion, or complications were identified and evaluated. Angiographic outcomes as well as thromboembolic and hemorrhagic complications were investigated.

RESULTS

This study included 117 patients (median age 60 years). At a median follow-up of 12 months, adequate occlusion (> 90%) was attained in 73.2% of aneurysms. Aneurysm occlusion rates were similar over the study interval. Thromboembolic and hemorrhagic complications were reported in 12.0% and 6.0% of the procedures, respectively. There was a nonsignificant trend toward a decline in the rate of thromboembolic (14.1% in 2011-2015 vs 9.4% in 2016-2021, p = 0.443) and hemorrhagic (9.4% in 2011-2015 vs 1.9% in 2016-2021, p = 0.089) complications.

CONCLUSIONS

The authors observed a trend toward a decline in the rate of thromboembolic and hemorrhagic complications with improved operator experience in using the PED for posterior circulation aneurysms. The use of single-device PED flow diversion significantly increased, as did the tendency to treat smaller aneurysms and observe large unruptured fusiform/dolichoectatic lesions. These findings reflect changes attributable to evolving judgment with maturing experience in PED use.

Substernal goitre presenting with upper and lower extremity oedema

Substernal goitre is characterised by compressive symptoms of the airway and oesophagus. Chronic, progressive symptoms usually result in surgical removal. We report a rare presentation of substernal goitre in a male in his early 70s who suffered from severe bilateral lower extremity (LE) lymphoedema, resulting in immobility and nursing home placement, and left upper extremity lymphoedema. Our initial assessment led to a filariasis work-up, which was negative, due to the patient's prior 2-year residence in India and service overseas. Chest CT scan revealed an incidental substernal goitre extending posterior to the left innominate vein and aortic arch to the level of the left mainstem bronchus. The patient underwent a left hemithyroidectomy via cervical excision and sternotomy and had an uneventful recovery with resolution of lymphoedema and mobility. Despite extensive literature regarding clinical presentations of substernal goitre, severe lymphoedema of the LE is not a well-established association.

Clinical, laboratory, electrocardiogaphic and multimodality imaging outcome predictors in cardiac amyloidosis

Background

Cardiac affectation in amyloidosis is presented among 50% patients what implies worse prognostic. Early diagnosis and prognostic stratification is mandatory after the appearance of new therapies that could modify the course of the disease.

Purpose

The aim of the present study was to evaluate the main outcome predictors with multiparametric approach including clinical, laboratory, electrocardiographic and imaging parameters in patients with cardiac amyloidosis (CA).

Methods

We recruited patients (p) prospectively followed in our cardiomyopathy unit, for a mean period of 10 years (from 2010 to 2020) who were diagnosed with CA. Baseline clinical, laboratory and echocardiographic data were obtained. We collected cardiovascular risk factors and previous events. We performed a multimodality imaging study including echocardiogram (TTE) and cardiac magnetic resonance (CMR). TTE hallmarks of CA were recorded, as well as CMR parameters of cardiac function, myocardial mass and tissue characterization. Finally we evaluated the parameters related with mortality in the follow-up.

Results

A total of 98 p were included, with a mean age of 67.5±16.9 years old. Mean follow-up was 42,2±32 months. 22 p (24,4%) had light-chain amyloidosis (AL), 34 p (37,8%) wild type transthyretin amyloidosis (ATTRwt) and 34 p (37,8%) familiar transthyretin amyloidosis (ATTRm). 43p (47.78%) died in the follow-up. Factors related with mortality in the the follow-up where the age (HR 1.08, ppresence of hypertension (HR 2.81, p=0,002) diabetes (HR 3.12, p=0,001) and previous stroke (HR 2.69, p=0,01); NYHA class at diagnosis (HR 2.49, p&lt;0.001), low voltage (HR 2.31, p=0,008) and pseudoinfarct pattern at ECG (HR 1.9, p=0,003); elevated BNP (HR 10.29, p&lt;0.001) and creatinine (HR 1.42, p=0,02); septum (HR 1.09, p=0,001) and posterior wall (HR 1,14, p&lt;0,001)thickness, left ventricular ejection fraction (HR 0.96, p=0,0031) global longitudinal strain (HR 1.18, p&lt;0.001), ratio E/A (HR 2.29, p&lt;0,001) and E/e' (HR 1.13, p=0,003) and left atrium size (HR 1,05, p=0,006) at echo; and the presence of left atrium fibrosis (HR 4.17, p&gt;0,001) and extension of late gadolinium enhancement (HR 1,06, p=0,03) at CMR. When evaluated within a multivariate analysis in a Cox regression model, the independent variables associated with mortality were NYHA class at diagnosis (p=0.002) and amyloidosis type (p=0.002) ATTRm had a better prognosis than ATTRwt and AL (Log-rank p&lt;0.001).

Conclusion

Mortality in cardiac amyloid patients is high. Clinical parameters like hypertension, diabetes, previous stroke and NYHA class at diagnosis; laboratory parameters like BNP and creatinine, main systolic and diastolic function at TTE, presence of auricular fibrosis and extension of late gadolinium enhancement at CRM are related with mortality in the follow-up. Among different types of CA, patients with ATTRm had a better prognosis, which may have therapeutic implications with the appearance of new therapies.

Funding Acknowledgement

Type of funding sources: None. Mortality

Evaluation of myocardial strain assessed by CMR tissue-tracking to predict adverse cardiovascular events in patients with cardiac amyloidosis

Background

Cardiac affectation in amyloidosis is presented among 50% patients what implies worse prognostic. Early diagnosis and prognostic stratification is mandatory after the appearance of new therapies that could modify the course of the disease.

Purpose

The aim of our study was to assess the prognostic value of cardiac magnetic resonance parameters, including Tissue deformation, in cardiac amyloidosis patients.

Methods

We recruited patients (p) prospectively followed in our cardiomyopathy unit, for a mean period of 10 years (from 2010 to 2020) who were diagnosed with CA. Baseline clinical, laboratory and echocardiographic data were obtained. Contrast-enhanced CMR was performed on a 1.5 T clinical scanner. Routine analysis was performed with a semi-automatic software for volumetric analysis. When late gadolinium enhancement was present, percentage of area of enhancement (LGE) was calculated.All strain parameters were measured off-line using dedicated software. Left ventricular circumferential strain (CS) measurements were obtained using mid-ventricular level short-axis cine views. Longitudinal strain (LS) derived from cine SSFP of 2-, 3-, and 4-chamber long axis views.Finally we evaluated the CMR parameters related with the combined event of mortality and heart failure in the follow-up.

Results

A total of 98 p were included, with a mean age of 67.5±16.9 years old. Mean follow-up was 42,2±32 months. 22 p (24,4%) had light-chain amyloidosis (AL), 34 p (37,8%) wild type transthyretin amyloidosis (ATTRwt) and 34 p (37,8%) familiar transthyretin amyloidosis (ATTRm). 59p (60,8%) died or present heart failure during the follow-up. Patients who died or present heart failure in the follow-uo had lower left ventricular ejection fraction (48,25±12,2% vs 56,13±11,03%, p=0,003), higher myocardial mass (156,05±54,8g vs 120,84±56,1g, p=0,007), higher LGE (8,6±6,8% vs 4,4±2%), worst GLS (−14,76±6,1% vs −18,67±6,2%) and worst GCS (−23,3±9,7% vs −30,04±9,1%). Both, GLS and GCS were independently associated with the combined event of dead or heart failure when evaluated within a multivariate analysis in a Cox regression model, but GCS was the stronger predictor of events in the follow-up over other CMR parameters like LGE an myocardial mass (p&lt;0,001). Tertile distribution for GCS identified subgroups with different adverse events, particularly for the lowest-risk tertile: GCS &lt;−34%, who had a combinated event in 13,6% of cases, significantly lower than patients in the mid-risk tertile (41,5%) and highest-risk tertile (53,8%) (Log-rank p=0,02)

Conclusion

Mortality and appearance of heart failure in cardiac amyloid patients is high. The assessment of myocardial strain parameters by CMR tissue-tracking in this population is useful to predict adverse outcomes in the follow-up. Particularly, GCS, stratify patients in subgroups with different risk of events, with added value to classical CMR parameters.

Funding Acknowledgement

Type of funding sources: None. Death & Heart Failure by GCS

Prognostic value of baseline versus 6-month follow infarct size in patients with reperfused STEMI

Background

Acute infarct size is a predictor of clinical outcomes in acute ST segment elevation myocardial infarction (STEMI) patients, although its prognostic value has differed between studies. In acute STEMI, infarct size is often overestimated due to the presence of extensive myocardial oedema, a confounder that is no longer present at a 6-month follow-up study. It was our purpose to assess whether infarct size in the acute phase or at 6-months follow-up provided superior prognostic information in STEMI patients.

Methods

STEMI patients who underwent successful primary percutaneous revascularization were included and a cardiac magnetic resonance (CMR) was performed between 5–7 days after STEMI and at 6 months to study infarct size (as a % of myocardial mass). The primary endpoint was a composite of cardiovascular mortality, hospitalization for heart failure and ventricular arrhythmia.

Results

A total of 796 patients were included (mean age 58.3±11.5 years, 82.4% male, 52.3% anterior infarction). During a mean follow-up of 59 months, 59 patients (7.4%) presented with the primary end-point (cardiovascular death n=7, hospitalization for heart failure n=52, ventricular arrhythmia n=1). ROC curve analysis (figure 1) showed a non-significant difference between baseline and 6-month infarct size for the prediction of the primary endpoint (baseline AUC 0.685 95% CI 0.610–0.760, 6-month AUC 0.713 95% CI 0.643–0.782, p=0.60). Optimal cut-off values for baseline and 6-months follow-up infarct size for prediction of outcomes, respectively 22% and 17.5%, were used for Kaplan-Meier curve analysis (figure 2).

Conclusion

Infarct size estimated during the first week after STEMI and at 6-months follow-up showed similar predictive value and with similar cut-off values. Therefore, the prognostic information provided by infarct size can be obtained during initial STEMI admission and does not require a waiting period for infarct size stabilization.

Funding Acknowledgement

Type of funding sources: None. ROC curve analysisKaplan-Meier analysis

Quantitative analysis of tegmen bone mineral density in obese and non-obese patients

BACKGROUND

Certain factors have been linked to lateral skull base demineralisation or erosion, which may predispose to spontaneous cerebrospinal fluid leak. There are relatively few quantitative reports of skull base changes in patient populations.

METHOD

A novel refined measurement algorithm for quantification of tegmen bone mineral density was developed, and bone mineral density between obese and non-obese patient groups was compared. Computed tomography scans were analysed by three blinded reviewers, and tegmen bone mineral densities were compared.

RESULTS

There were 23 patients in the obese group and 27 matched controls in the non-obese group. Inter-rater reliability was 'strong' to 'near complete' (κ = 0.75-0.86). No differences in tegmen bone mineral density were found between the groups (p = 0.64). The number of active blood pressure medications correlated positively with lateral skull base bone mineral density.

CONCLUSION

A novel, refined, quantitative measurement algorithm for the assessment of tegmen bone mineral density was developed and validated. Obesity was not found to significantly affect tegmen bone mineral density.

Direct thrombectomy versus bridging thrombolysis with mechanical thrombectomy in middle cerebral artery stroke: a real-world analysis through National Inpatient Sample data

OBJECTIVE

A paradigm shift in the management of acute ischemic stroke (AIS) due to large-vessel occlusion (LVO) occurred after 2015 when 7 randomized controlled trials demonstrated better outcomes using second-generation thrombectomy devices combined with best medical management than did stand-alone intravenous thrombolysis (IVT) with tissue plasminogen activator (tPA). All recently published landmark trials were designed to study the outcome of mechanical thrombectomy (MT); therefore, the majority of the patients enrolled in these trials received intravenous tPA. Currently, initiating IVT before MT is a matter of debate. Recent trials (DIRECT-MT, DEVT) exploring this clinical question showed noninferiority of MT alone compared with the combined treatment. With this uncertainty, the authors aimed to explore real-world data through the latest National Inpatient Sample (NIS) to compare the safety and outcomes of MT alone with bridging IVT and MT in AIS due to LVO in the middle cerebral artery (MCA).

METHODS

NIS data from 2017 to 2018 were analyzed to compare the outcomes and safety profiles of patients who underwent MT+IVT with those who underwent MT alone.

RESULTS

A total of 2895 patients were included in the final analysis (MT, n = 1669; MT+IVT, n = 1226). The mean National Institutes of Health Stroke Scale score was 16.2 (SD 6.1) in the MT group and 16.6 (SD 5.97) in the MT+IVT group (p = 0.04). With respect to comorbidities, the two groups did not differ in rates of hypertension (p = 0.730), atrial fibrillation/flutter (p = 0.828), and smoking status (p = 0.914). The rate of diabetes mellitus was significantly higher in the MT group (28%) than in the MT+IVT group (22.1%) (p < 0.001). The frequency of intracerebral hemorrhage (ICH) in the MT group was 17.7% (n = 296) and 21.5% (n = 263) in the MT+IVT group (p = 0.012). Intraventricular hemorrhage (p = 0.875), subarachnoid hemorrhage (p = 0.99), and vasospasm (p = 0.976) did not differ significantly between the groups. The primary outcome considered was disability status between the groups; 23.8% of patients in the MT+IVT group had minimal disability versus 18.2% in the MT group (p = 0.001). The risk of progressing to severe disability from minimal disability decreased with the addition of IVT to MT (OR 0.762, 95% CI 0.637-0.912). The adjusted odds ratio for ICH in the MT+IVT group was 1.28 (95% CI 1.043-1.571, p = 0.018) and 2.676 (95% CI 1.259-5.686, p = 0.01) for access-site hemorrhages.

CONCLUSIONS

In the analysis of the NIS database, the MT+IVT group had significantly higher rates of minimal disability at the time of hospital discharge versus the MT-alone group, despite a higher rate of ICH. The question of whether to treat patients with MT+IVT rather than MT alone is currently being addressed in ongoing prospective clinical trials (SWIFT-DIRECT [NCT03494920], MR CLEAN-NO IV [ISRCTN80619088], and DIRECT-SAFE [NCT03494920]). The results of these studies will contribute to greater understanding and progressive improvement in outcomes for AIS patients.

Intramuscular myxoma of the longus colli mistaken for a cervical rootlet schwannoma

An 86-year-old woman was referred to the otolaryngology clinic for a 1-year history of a painless, slow-growing neck mass. Physical examination showed a fixed, immobile right level II neck mass with normal vocal cord movement. MRI demonstrated a lobulated mass laterally displacing the carotid vessels, consistent with a schwannoma. Despite the pathognomonic radiographic findings for schwannoma, core needle biopsy of the mass was consistent with intramuscular myxoma (IM), which rarely presents in the head and neck region. After multiple years of slow growth with bulging into the pharynx, the patient ultimately underwent surgery to reduce the risk of airway compromise. The location of this IM together with its unusual imaging appearance is a unique finding in the head and neck and adds to the differential diagnoses for neck masses displacing the carotid sheath.

Utilization of the large-bore Penumbra JET 7 reperfusion catheter in thrombectomy for acute ischemic stroke: A single-center experience

BACKGROUND AND PURPOSE

The Penumbra JET 7 reperfusion catheter is used in the revascularization of large vessel occlusions in acute ischemic stroke. Description of its use in clinical practice remains limited. Our purpose is to describe our initial experience with the Penumbra JET 7 reperfusion catheter and to report on its safety and efficacy in different thrombectomy techniques.

MATERIALS AND METHODS

We conducted a retrospective study of 50 patients treated with thrombectomy using the Penumbra JET 7 reperfusion catheter. Mean patient age and admission National Institutes of Health Stroke Scale were 70.6 and 17.76, respectively. The most common sites of vessel occlusion were the M1 segment (72%) followed by distal internal carotid artery (14%). Thrombectomy was performed using the direct aspiration first-pass technique and/or aspiration in conjunction with a stent retriever.

RESULTS

Revascularization was achieved in a total of 44 cases (88%). Successful navigation of the Penumbra JET 7 reperfusion catheter to the occlusion site with clot engagement was achieved in 94% of cases. Mean time from vascular access to revascularization was 31.60 min. No catheter-related complications occurred. Clinical outcome data were collected from 43 patients (86%). Of those patients, 51% achieved good outcome (modified Rankin score of 0-2) at 60 or more days follow-up, 28% had poor outcome (modified Rankin score of 3-5), and 9 patients died (21%).

CONCLUSION

The use of the Penumbra JET 7 reperfusion catheter for treatment of acute ischemic stroke was observed to be safe and effective with appropriate revascularization outcomes in different thrombectomy techniques.

Sternoclavicular Amyloid Arthropathy in a Patient With End-Stage Renal Disease

Amyloidosis is an extracellular deposition of amyloid located in different organs or in a systemic distribution. We present a case of a 78 year-old male with hemodyalisis assosciated amyloidosisis involving the right sternoclavicular joint. Clinical and imaging implications are described.

A novel technique for stenting in cases of refractory intracranial stenosis

Endovascular management of intracranial stenosis is one of the most controversial subjects in neurointervention. Previous level 1 evidence shows superiority of medical management but more recent studies have shown improved outcomes in selective patients. We describe a case demonstrating a new method for stenting of intracranial stenosis using a single system with Coyote angioplasty balloon (Boston Scientific) and the Atlas stent (Stryker).

The Relationship Between Obstructive Sleep Apnea and Ruptured Intracranial Aneurysms

STUDY OBJECTIVES

The role of obstructive sleep apnea (OSA) in the overall outcome of ruptured intracranial aneurysms (RIAs) is unknown. We have investigated the role of OSA in overall outcome of RIAs.

METHODS

Data from 159 consecutive patients were retrospectively reviewed. A chi-square test and regression analysis were performed to determine the significant difference. A value of P < .05 was considered significant.

RESULTS

The prevalence of OSA in RIAs was fivefold higher in the nonaneurysm patient group, P = .002. The number of patients with hypertension (P < .0001), body mass index ≥ 30 (P < .0001), hyperlipidemia (P = .018), chronic heart disease (P = .002) or prior ischemic stroke (P = .001) was significantly higher in the OSA group. Similarly, the number of wide-neck aneurysms (P < .0001) and aneurysm > 7 mm (P = .004), poor Hunt and Hess grade IV-V (P = .005), vasospasms, (P = .03), and patients with poor Modified Rankin Scale scores (3-6) was significantly higher in the OSA group (P < .0001). Interestingly, for the first time in univariate (P = .01) and multivariate (P = .003) regression analysis, OSA was identified as an individual predictor of unfavorable outcome of RIAs. In addition, hypertension (P = .04), smoking (P = .049), chronic heart disease (P = .01), and Hunt and Hess grade IV-V (P = .04) were revealed as predictors of poor outcome of RIAs.

CONCLUSIONS

This is a novel study to determine the association between OSA and ruptured cerebral aneurysm in terms of comorbidities, size of aneurysm, severity of symptoms, and outcomes after treatment. In addition, for the first time, OSA is identified as a positive predictor of unfavorable outcome of RIAs.

4936Cardiac magnetic resonance strain analysis predicts functional recovery following acute ST-segment elevation myocardial infarction

Background

Late gadolinium enhancement (LGE) is the clinical reference standard for estimation of infarct extension and prediction of functional recovery following reperfused acute ST-segment elevation myocardial infarction (STEMI). Nevertheless, myocardial edema, microvascular obstruction and intramyocardial hemorrhage as well as the timing of image acquisition after contrast administration may influence the extent of LGE and underestimate the potential for recovery. Dobutamine stress testing has been recommended to more accurately predict functional recovery when infarct transmurality is between 25 to 75%. We hypothesized that cardiac magnetic resonance (CMR) tissue tracking strain analysis may provide additional value to LGE for the prediction of functional recovery.

Methods

In 370 patients with STEMI who underwent successful primary percutaneous revascularization and were studied with CMR within 3–5 days of the event, peak systolic longitudinal (LS), circumferential (CS) and radial (RS) strain were analyzed with routine SSFP images of 3 long-axis and a stack of short-axis slices (Tissue Tracking, CVI42®, Figure panel A and B). Inversion-recovery echogradient sequences were analyzed 20 minutes after contrast administration for LGE transmurality (Panel C). All per-segment analysis was performed according to the AHA 16-segment model. CMR was repeated at 6 months and functional recovery was defined as persistent normokinesia or improvement of wall motion score from baseline to 6-month CMR.

Results

At baseline CMR, of a total of 5920 segments 70.4% were normokinetic, 7.2% were hypokinetic, 21.9% were akinetic and 0.6% were dyskinetic. All strain parameters decreased significantly with worsening wall motion. At follow-up, 81.5% of the segments showed functional recovery. All strain parameters were significantly associated with functional recovery (p<0.001) and showed higher predictive value for improvement of wall motion than LGE transmurality (ROC AUC 0.713 LS, 0.710 CS, 0.683 RS and 0.660 LGE). For basal CMR dysfunctional segments, a CS <−10.7% showed the highest accuracy (66%) to predict wall motion improvement, with 58% sensitivity, 76% specificity, 75% positive predictive value (PPV) and 59% negative predictive value (NPV). These results were comparable to LGE transmurality <50% (65% accuracy, 59% sensitivity, 73% specificity, 74% positive predictive value and 58% negative predictive value). Nevertheless, adding CS analysis to a 50% LGE transmurality cutoff was the best combination for prediction of functional recovery and increased the overall accuracy to 70%, with 76% sensitivity, 64% specificity, 65% PPV and 75% NPV.

CS analysis in an inferior STEMI

Conclusions

Acute CMR tissue tracking strain analysis complements LGE assessment for prediction of functional recovery following an STEMI. The combination of LGE infarct transmurality under 50% and a CS strain higher than −10.7% showed the highest accuracy for prediction of recovery of function.

Early Versus Delayed Flow Diversion for Ruptured Intracranial Aneurysms: A Meta-Analysis

OBJECTIVE

The use and timing of flow diversion for aneurysmal subarachnoid hemorrhage is controversial. The objective of this study is to perform a meta-analysis and systematic review to compare overall complication rate between early versus delayed flow diversion for ruptured aneurysms.

METHODS

A literature search for all eligible articles was performed using PubMed, Cochrane, and Web of Science databases. The primary outcome was the overall complication rate (any complication in the perioperative period), and secondary outcomes were 1) hemorrhage and 2) stroke/death (all hemorrhagic/ischemic strokes and/or death).

RESULTS

Thirteen articles including 142 patients met inclusion criteria. Eighty-nine (62.7%) patients underwent early deployment of flow diverters (i.e., 2 days or less). The odds ratio for overall complication rate with early versus delayed flow diversion was 0.95 (95% confidence interval [CI] 0.36-2.49, P = 0.42). The odds ratio for the secondary outcome of hemorrhagic complication for early versus delayed flow diversion was 1.44 (95% CI 0.45-4.52, P = 0.87) and of stroke/death was 1.67 (95% CI 0.5-4.9, P = 0.69). The odds ratio of early versus delayed flow diversion for blister/dissecting/fusiform aneurysms was 0.82 (95% CI 0.29-2.30) and for saccular/giant aneurysms was 2.23 (95% CI 0.17-29.4). At last follow-up, 71.6% of patients had good performance status (modified Rankin Scale score 0-2), and the rate of angiographic aneurysm occlusion was 90.2%.

CONCLUSIONS

This meta-analysis did not show a difference in overall complication rate between early versus delayed flow diversion for ruptured aneurysms. Early flow diversion for ruptured blister/fusiform/dissecting aneurysms carries a lower risk of aneurysm rerupture and overall complications as compared with that for ruptured saccular/giant aneurysms.

Novel Use of Pipeline Stent Device After Inadvertent Microcatheter Rupture During Arteriovenous Fistula Embolization

BACKGROUND

Onyx, a liquid embolic agent, is the mainstay of embolization treatment of arteriovenous malformation or arteriovenous fistula. Microcatheter retention in an embolic cast is a well-known complication. Rupture of catheter with spillage of onyx is a rare phenomenon but can lead to potential occlusion of the parent vessel.

METHODS

We describe a case in which a patient with ruptured arteriovenous fistula experienced rupture of a microcatheter at the proximal part and spillage of onyx on embolization. A Pipeline embolization device (PED) was successfully deployed, and onyx was jailed between the catheter and vessel wall at the third segment of the vertebral artery (V3 segment). A balloon angioplasty helped to complete the opening of the stent.

RESULTS

The procedure was uneventful, and the patient recovered well. Follow-up angiogram revealed patency of posterior circulation. The 6-month follow-up angiogram revealed a patent stent.

CONCLUSIONS

Microcatheter rupture and spillage of onyx during embolization of arteriovenous malformation/arteriovenous fistula is a potential complication, and management should be individualized. The unique close cell design of the PED was successfully used to avoid a potentially life-threatening occlusion of the vertebrobasilar system. To the best of our knowledge, we report for the first time this novel use of PED.

Treatment of Intracranial Aneurysms With the SILK Embolization Device in a Multicenter Study. A Retrospective Data Analysis

BACKGROUND

Flow-diverter technology has become an important stent-based embolization tool in the treatment of complex cerebrovascular pathology. We report here the experience of 4 Spanish centers with using the SILK flow-diverter (SFD) device.

OBJECTIVE

To evaluate the safety and efficacy of using the SFD in the endovascular treatment of intracranial aneurysms with complex morphology.

METHODS

We retrospectively examined a prospectively maintained database of patients treated with SFD devices between July 2008 and December 2013 at 1 of 4 institutions in Spain. Data regarding patient demographics, aneurysm characteristics, and technical procedure were analyzed. Angiographic and clinical findings were recorded during the procedure and at 12 months postoperatively.

RESULTS

A total of 175 SFD devices were implanted in 157 patients (women/men: 119/38; mean, median, and range of age: 56.2, 56.7, and 19-80 years, respectively), who were treated in a delayed manner (3-6 months from the event) for 180 aneurysms (165 unruptured and 15 ruptured). Adverse events (acute and delayed) were observed in 28.7% of cases (45/157), and most were resolved (19.1%; 30/157). Six months after the procedure, total morbidity and mortality were 9.6% (15/157) and 3.2% (5/157), respectively. Long-term imaging follow-up showed complete occlusion, neck remnants, and residual aneurysm in 78.1% (100/128), 14.0% (18/128), and 7.8% (10/128) of cases, respectively.

CONCLUSIONS

The SFD device is an effective tool for the treatment of challenging aneurysms, and allows complete occlusion within a year of the procedure in most patients, with morbidity and mortality comparable to those previously reported for similar devices.

Delayed Spinal Arachnoiditis Following Aneurysmal Subarachnoid Hemorrhage: A Case Report

Spinal arachnoiditis (SA) is a rare and delayed complication of aneurysmal subarachnoid hemorrhage (aSAH). We present a case of delayed SA associated with thoracic and lumbar arachnoid cysts in a patient with aSAH secondary to a ruptured vertebral artery aneurysm. The patient underwent a thoracic laminectomy for decompression of the spinal cord, lysis of arachnoid adhesions, and fenestration of an arachnoid cyst. We present the pathogenesis, diagnosis, treatment, and management of spinal arachnoiditis as a rare complication of aSAH.