Outcomes with General Anesthesia Compared to Conscious Sedation for Endovascular Treatment of Medium Vessel Occlusions: Results of an International Multicentric Study

BACKGROUND

Optimal anesthetic strategy for the endovascular treatment of stroke is still under debate. Despite scarce data concerning anesthetic management for medium and distal vessel occlusions (MeVOs) some centers empirically support a general anesthesia (GA) strategy in these patients.

METHODS

We conducted an international retrospective study of MeVO cases. A propensity score matching algorithm was used to mitigate potential differences across patients undergoing GA and conscious sedation (CS). Comparisons in clinical and safety outcomes were performed between the two study groups GA and CS. The favourable outcome was defined as a modified Rankin Scale (mRS) 0-2 at 90 days. Safety outcomes were 90-days mortality and symptomatic intracranial hemorrhage (sICH). Predictors of a favourable outcome and sICH were evaluated with backward logistic regression.

RESULTS

After propensity score matching 668 patients were included in the CS and 264 patients in the GA group. In the matched cohort, either strategy CS or GA resulted in similar rates of good functional outcomes (50.1% vs. 48.4%), and successful recanalization (89.4% vs. 90.2%). The GA group had higher rates of 90-day mortality (22.6% vs. 16.5%, p < 0.041) and sICH (4.2% vs. 0.9%, p = 0.001) compared to the CS group. Backward logistic regression did not identify GA vs CS as a predictor of good functional outcome (OR for GA vs CS = 0.95 (0.67-1.35)), but GA remained a significant predictor of sICH (OR = 5.32, 95% CI 1.92-14.72).

CONCLUSION

Anaesthetic strategy in MeVOs does not influence favorable outcomes or final successful recanalization rates, however, GA may be associated with an increased risk of sICH and mortality.

Use of the pRESET LITE thrombectomy device in combined approach for medium vessel occlusions: A multicenter evaluation

PURPOSE

Our purpose was to assess the efficacy and safety of the pRESET LITE stent retriever (Phenox, Bochum, Germany), designed for medium vessel occlusion (MeVO) in acute ischemic stroke (AIS) patients with a primary MeVO.

METHODS

We performed a retrospective analysis of the MAD MT Consortium, an integration of prospectively maintained databases at 37 academic institutions in Europe, North America, and Asia, of AIS patients who underwent mechanical thrombectomy with the pRESET LITE stent retriever for a primary MeVO. We subcategorized occlusions into proximal MeVOs (segments A1, M2, and P1) vs. distal MeVOs/DMVO (segments A2, M3-M4, and P2). We reviewed patient and procedural characteristics, as well as angiographic and clinical outcomes.

RESULTS

Between September 2016 and December 2021, 227 patients were included (50% female, median age 78 [65-84] years), of whom 161 (71%) suffered proximal MeVO and 66 (29%) distal MeVO. Using a combined approach in 96% of cases, successful reperfusion of the target vessel (mTICI 2b/2c/3) was attained in 85% of proximal MeVO and 97% of DMVO, with a median of 2 passes (IQR: 1-3) overall. Periprocedural complications rate was 7%. Control CT at day 1 post-MT revealed a hemorrhagic transformation in 63 (39%) patients with proximal MeVO and 24 (36%) patients with DMVO, with ECASS-PH type hemorrhagic transformations occurring in 3 (1%) patients. After 3 months, 58% of all MeVO and 63% of DMVO patients demonstrated a favorable outcome (mRS 0-2).

CONCLUSION

Mechanical thrombectomy using the pRESET LITE in a combined approach with an aspiration catheter appears effective for primary medium vessel occlusions across several centers and physicians.

First pass effect as an independent predictor of functional outcomes in medium vessel occlusions: An analysis of an international multicenter study

INTRODUCTION

First pass effect (FPE), achievement of complete recanalization (mTICI 2c/3) with a single pass, is a significant predictor of favorable outcomes for endovascular treatment (EVT) in large vessel occlusion stroke (LVO). However, data concerning the impact on functional outcomes and predictors of FPE in medium vessel occlusions (MeVO) are scarce.

PATIENTS AND METHODS

We conducted an international retrospective study on MeVO cases. Multivariable logistic modeling was used to establish independent predictors of FPE. Clinical and safety outcomes were compared between the two study groups (FPE vs non-FPE) using logistic regression models. Good outcome was defined as modified Rankin Scale 0-2 at 3 months.

RESULTS

Eight hundred thirty-six patients with a final mTICI ⩾ 2b were included in this analysis. FPE was observed in 302 patients (36.1%). In multivariable analysis, hypertension (aOR 1.55, 95% CI 1.10-2.20) and lower baseline NIHSS score (aOR 0.95, 95% CI 0.93-0.97) were independently associated with an FPE. Good outcomes were more common in the FPE versus non-FPE group (72.8% vs 52.8%), and FPE was independently associated with favorable outcome (aOR 2.20, 95% CI 1.59-3.05). 90-day mortality and intracranial hemorrhage (ICH) were significantly lower in the FPE group, 0.43 (95% CI, 0.25-0.72) and 0.55 (95% CI, 0.39-0.77), respectively.

CONCLUSION

Over 2/3 of patients with MeVOs and FPE in our cohort had a favorable outcome at 90 days. FPE is independently associated with favorable outcomes, it may reduce the risk of any intracranial hemorrhage, and 3-month mortality.

Incidence and clinical outcomes of perforations during mechanical thrombectomy for medium vessel occlusion in acute ischemic stroke: A retrospective, multicenter, and multinational study

BACKGROUND

Mechanical thrombectomy (MT) has revolutionized the treatment of acute ischemic stroke (AIS) due to large vessel occlusion (LVO), but its efficacy and safety in medium vessel occlusion (MeVO) remain less explored. This multicenter, retrospective study aims to investigate the incidence and clinical outcomes of vessel perforations (confirmed by extravasation during an angiographic series) during MT for AIS caused by MeVO.

METHODS

Data were collected from 37 academic centers across North America, Asia, and Europe between September 2017 and July 2021. A total of 1373 AIS patients with MeVO underwent MT. Baseline characteristics, procedural details, and clinical outcomes were analyzed.

RESULTS

The incidence of vessel perforation was 4.8% (66/1373). Notably, our analysis indicates variations in perforation rates across different arterial segments: 8.9% in M3 segments, 4.3% in M2 segments, and 8.3% in A2 segments (p = 0.612). Patients with perforation had significantly worse outcomes, with lower rates of favorable angiographic outcomes (TICI 2c-3: 23% vs 58.9%, p < 0.001; TICI 2b-3: 56.5% vs 88.3%, p < 0.001). Functional outcomes were also worse in the perforation group (mRS 0-1 at 3 months: 22.7% vs 36.6%, p = 0.031; mRS 0-2 at 3 months: 28.8% vs 53.9%, p < 0.001). Mortality was higher in the perforation group (30.3% vs 16.8%, p = 0.008).

CONCLUSION

This study reveals that while the occurrence of vessel perforation in MT for AIS due to MeVO is relatively rare, it is associated with poor functional outcomes and higher mortality. The findings highlight the need for increased caution and specialized training in performing MT for MeVO. Further prospective research is required for risk mitigation strategies.

Cardiorespiratory Events in Children During Chemoembolization of Ophthalmic Artery for Retinoblastoma

Retinoblastoma (RB) is the most common eye neoplasm in childhood, accounting for 2.5% to 4% of all pediatric cancers. Recent approaches to treat RB include localized administration of chemotherapy, such as super-selective ophthalmic artery chemotherapy. Although localized chemotherapy aims that minimize systemic side effects, some adverse cardio-respiratory reactions have been described as associated with this therapy. Our case report describes the cardiorespiratory severe events presented secondary to super-selective chemotherapy of the ophthalmic artery, to which we must be prepared to avoid fatal outcomes

Transvenous Pressure Monitoring Guides Endovascular Treatment of Vein of Galen Malformation: A Technical Note

INTRODUCTION

Vein of Galen malformations (VGMs) are complex congenital arteriovenous malformations that generally require serial endovascular treatment sessions to slowly correct the high-flow fistulous connections that cause increased venous pressures and ultimately lead to the classic presentations of heart failure, hydrocephalus, and intracranial hemorrhages. Despite the advances in endovascular technology and embolic materials, the resolution of embolization is often limited to the subjective view of diminished flow on angiograms.

CASE REPORT

An 8-month-old patient with a VGM developed clinical signs of heart failure and growing head circumference with ventriculomegaly. The patient was treated endovascularly with a transvenous approach for coil embolization while undergoing continuous monitoring of the post-malformation venous pressures. The arterial and venous systolic blood pressures (SBP) were collected at serial time points and used to measure estimated 95% confidence interval bounds for arteriovenous SBP gradients and determine when sufficient coil embolization and flow reduction was thought to be achieved.

CONCLUSION

The transvenous pressure monitoring demonstrated progressively increasing pressure gradients between the arterial and venous systems that correlated with the degree of flow reduction on angiographic runs. The patient underwent successful coil embolization of the VGM and had improvement of heart failure and ventricular size in follow-up at 8-month post-op. This provides a novel technique to introduce an objective measurement that can guide the embolization of a VGM.

Abstract TP287: Validation of a Mice Model of Synangiosis to Quantify Neovascularization After Ischemic Stroke

Introduction: Some publications have shown encephalomyosinangiosis (EMAS) as a potential model for surgical indirect revascularizations (SIR). Despite these reports, the validity of this model for neovascularization has not been addressed, in particular the observed variability in vessel proliferation response to ischemia and spontaneous neovascularization. Therefore, we present a systematic quantitative approach to evaluate the validity and variability of EMAS as a SIR model.

Methods: We induced precise cerebral ischemia by ligation of the distal MCA via a 3mm temporal craniotomy on C57/BL6J mice. Subjects were randomly allocated to EMAS (placement of temporalis muscle in direct apposition to the brain) or controls (placement of an inert barrier-Teflon). After surgery, animals received BrdU in drinking water to mark newly formed cells. Brain tissue was harvested 14 days after surgery and stained with CD31, NeuN, anti-BrdU-Ab, and DAPI. New-vessels were defined as BrdU/CD31 co-staining, neuronal survival was quantified with NeuN density percentage. Groups were compared using regression mixed models and variability was evaluated using the heterogeneity of variance (HOV) test.

Results: New-vessels were seen in the control and EMAS groups. The mean number of new vessels was 8 (SD 4.4) in controls vs. 15.8 (SD 5.1) in EMAS. The effect of treatment (EMAS vs. control) was a significant predictor of new-vessel formation (p<0.01, OR = 1.5 (95% CI: 1.1 - 1.9). The HOV between groups was non-significant. However, CD31 staining alone was not different (controls = 0.58 vs EMAS = 0.59). In terms of neuronal survival, the median NeuN density percentage distribution was 0.9% (IQR=1.2) for controls and 1.6% (IQR= 0.8) for EMAS (p = 0.2). The HOV was also non-significant.

Conclusion: EMAS is a suitable model for evaluation of neovascularization after ischemic stroke. However, isolated quantifications of endothelial markers, such as CD31, are insufficient. The use of BrdU, which incorporates in newly synthesized DNA, in combination with endothelial markers is essential to quantify neovascularization. Neovascularization requires time and, as shown in this model, have little impact in neuronal survival in acute stroke.

Abstract TP411: Improving Pediatric Stroke Recognition Among Pediatric Health Care Providers

Introduction: Pediatric acute ischemic stroke (P-AIS) is an under-recognized disease by pediatric healthcare providers, resulting in delay of its diagnosis. In spite of diagnostic tools such as the FAST and BE FAST mnemonics, lack of awareness leads to increased morbidity and mortality. This study aims to elucidate whether a brief educational activity would modify the identification and perception of P-AIS.

Methods: Forty-nine pediatric healthcare providers were surveyed to assess their baseline skills in recognizing P-AIS. Providers attended a 30-minute activity outlining incidence, natural history, diagnosis, and examples of P-AIS treatment. The mnemonics “FAST” and “BE FAST” as applicable to children were futher expounded. Pre and post-surveys assessed providers’ profession, type of practice, ED service involvement, familiarity with the mnemonics, and P-AIS recognition performance for infants and children.

Results: The forty-nine pediatric healthcare providers surveyed had the following degrees: 61% MD, 20% NP, 6% RN, 6% student, 4% PA, 2% DO. Futhermore, 78% work in private outpatient enviroments, 17% in academic outpatient institutions, 4% in private outpatient settings, and only 10% had emergency department involvement. Pre-Activity: 53% had heard of “FAST,” and 8% had heard of “BE FAST.” Correct knowledge of individual letters ranged between 12-39%, with the lowest recognition rates for “B” and “E.” At baseline, 65% of providers correctly recognized pediatric and specifically infant stroke cases. Post-Activity: 97% felt familiar with “BE FAST.”. Correct knowledge of individual letters following the educational activity improved to 100%. 95% of providers correctly recognized P-AIS, and 95% correctly identified infant stroke. Univariate logistic analysis showed that completing the training activity was the only significant factor improving the ability to identify P-AIS (OR: 10.35, CI: 2.2 to 48.2). Profession and type of practice were not significant.

Conclusion: A 30-minute focused educational activity was sufficient to improve the perception and ability to recognize P-AIS among different levels of healthcare providers. The long-term effects of these interventions should be examined.