Search

Background and Purpose: Infarct growth rate (IGR) in acute ischemic stroke is highly variable. We sought to evaluate impact of symptom-reperfusion time on outcomes in patients undergoing mechanical thrombectomy (MT)., Methods: A prospectively maintained database from January,2012-August,2020 was reviewed. All patients with isolated MCA-M1 occlusion who achieved complete reperfusion(mTICI2C-3), had a witnessed symptom onset and follow-up MRI were included. IGR was calculated as final infarct volume (FIV)(ml)/symptom onset to reperfusion time(hours) and was dichotomized according to the median value into slow-(SP) versus fast-progressors (FP). The primary analysis aimed to evaluate the impact of symptom-reperfusion time on 90-day mRS in SP and FP. Secondary analysis was performed to identify predictors of IGR., Results: A total of 137 patients were eligible for analysis. Mean age was 63 ± 15.4 years and median IGR was 5.13ml/hour. SP(n = 69) had higher median ASPECTS, lower median rCBF<30% lesion volume, higher proportion of favorable collaterals and hypoperfusion intensity ratio (HIR)<0.4, higher minimal mean arterial blood pressure before reperfusion, and lower rates of general anesthesia compared to FP(n = 68). Symptom-reperfusion time was comparable between both groups. SP had higher rates of 90-day mRS0-2(71.9%vs.38.9%,aOR;7.226,95%CI[2.431-21.482],p < 0.001) and lower median FIV. Symptom-reperfusion time was associated with 90-day mRS0-2 in FP (aOR;0.541,95%CI[0.309-0.946],p = 0.03) but not in SP (aOR;0.874,95%CI[0.742-1.056],p = 0.16). On multivariable analysis, high ASPECTS and favorable collaterals in the NCCT/CTA model, and low rCBF<30% and HIR<0.4 in the CTP model were independent predictors of SP., Conclusions: The impact of symptom-reperfusion time on outcomes significantly varies across slow-versus fast-progressors. ASPECTS, collateral score, rCBF<30%, and HIR define stroke progression profile.

Background: The clinical efficacy of mechanical thrombectomy has been unequivocally demonstrated in multiple randomized clinical trials. However, these studies were performed in carefully selected centers and utilized strict inclusion criteria., Aim: We aimed to assess the clinical effectiveness of mechanical thrombectomy in a prospective registry., Methods: A total of 2008 patients from 76 sites across 12 countries were enrolled in a prospective open-label mechanical thrombectomy registry. Patients were categorized into the corresponding cohorts of the SWIFT-Prime, DAWN, and DEFUSE 3 trials according to the basic demographic and clinical criteria without considering specific parenchymal imaging findings. Baseline and outcome variables were compared across the corresponding groups., Results: As compared to the treated patients in the actual trials, registry-derived patients tended to be younger and had lower baseline ASPECTS. In addition, time to treatment was earlier and the use of intravenous tissue plasminogen activator (IV-tPA) and general anesthesia were higher in DAWN- and DEFUSE-3 registry derived patients versus their corresponding trials. Reperfusion rates were higher in the registry patients. The rates of 90-day good outcome (mRS0-2) in registry-derived patients were comparable to those of the patients treated in the corresponding randomized clinical trials (SWIFT-Prime, 64.5% vs. 60.2%; DAWN, 50.4% vs. 48.6%; Beyond-DAWN: 52.4% vs. 48.6%; DEFUSE 3, 52% vs. 44.6%, respectively; all P  > 0.05). Registry-derived patients had significant less disability than the corresponding randomized clinical trial controls (ordinal modified Rankin Scale (mRS) shift odds ratio (OR), P  < 0.05 for all)., Conclusion: Our study provides favorable generalizability data for the safety and efficacy of thrombectomy in the "real-world" setting and supports that patients may be safely treated outside the constraints of randomized clinical trials.

Background: Three randomized clinical trials have reported similar safety and efficacy for contact aspiration and stent-retriever thrombectomy., Aim: We aimed to determine whether the combined technique (stent-retriever + contact aspiration) was superior to stent-retriever alone as first-line thrombectomy strategy in a patient cohort where balloon guide catheter was universally used., Methods: A prospectively maintained mechanical thrombectomy database from January 2018 to December 2019 was reviewed. Patients were included if they had anterior circulation proximal occlusion ischemic stroke (intracranial ICA or MCA-M1/M2 segments) and underwent stent-retriever alone thrombectomy or stent-retriever + contact aspiration as first-line therapy. The primary outcome was the first-pass effect (mTICI2c-3). Secondary outcomes included modified first-pass effect (mTICI2b-3), successful reperfusion (mTICI2b-3) prior to and after any rescue strategy, and 90-day functional independence (mRS ≤ 2). Safety outcomes included rate of parenchymal hematoma type-2 and 90-day mortality. Sensitivity analyses were performed after dividing the overall cohort according to first-line modality into two matched groups., Results: A total of 420 patients were included in the analysis (mean age 64.4 years; median baseline NIHSS 16 (11-21)). As compared to first-line stent-retriever alone, first-line stent-retriever + contact aspiration resulted in similar rates of first-pass effect (53% vs. 51%, adjusted odds ratio (aOR) 1.122, 95%CI (0.745-1.691), p = 0.58), modified first-pass effect (63% vs. 60.4%, aOR1.250, 95%CI (0.782-2.00), p = 0.35), final successful reperfusion (97.6% vs. 98%, p = 0.75), and higher chances of successful reperfusion prior to any rescue strategy (81.8% vs. 72.5%, aOR 2.033, 95%CI (1.209-3.419), p = 0.007). Functional outcome and safety measures were comparable between both groups. Likewise, the matched analysis (148 patient-pairs) demonstrated comparable results for all clinical and angiographic outcomes except for significantly higher rates of successful reperfusion prior to any rescue strategies with the first-line stent-retriever + contact aspiration treatment (81.8% vs. 73.6%, aOR 1.881, 95%CI (1.039-3.405), p = 0.037)., Conclusions: Our findings reinforce the findings of ASTER-2 trial in that the first-line thrombectomy with a combined technique did not result in increased rates of first-pass reperfusion or better clinical outcomes. However, the addition of contact aspiration after initial stent-retriever failure might be beneficial in achieving earlier reperfusion.

Background: The effect of time from stroke onset to thrombectomy in the extended time window remains poorly characterized., Aim: We aimed to analyze the relationship between time to treatment and clinical outcomes in the early versus extended time windows., Methods: Proximal anterior circulation occlusion patients from a multicentric prospective registry were categorized into early (≤6 h) or extended (>6-24 h) treatment window. Patients with baseline National Institutes of Health Stroke Scale (NIHSS) ≥ 10 and intracranial internal carotid artery or middle cerebral artery-M1-segment occlusion and pre-morbid modified Rankin scale (mRS) 0-1 ("DAWN-like" cohort) served as the population for the primary analysis. The relationship between time to treatment and 90-day mRS, analyzed in ordinal (mRS shift) and dichotomized (good outcome, mRS 0-2) fashion, was compared within and across the extended and early windows., Results: A total of 1603 out of 2008 patients qualified. Despite longer time to treatment (9[7-13.9] vs. 3.4[2.5-4.3] h, p  < 0.001), extended-window patients ( n  = 257) had similar rates of symptomatic intracranial hemorrhage (sICH; 0.8% vs. 1.7%, p  = 0.293) and 90-day-mortality (10.5% vs. 9.6%, p  = 0.714) with only slightly lower rates of 90-day good outcomes (50.4% vs. 57.6%, p  = 0.047) versus early-window patients ( n  = 709). Time to treatment was associated with 90-day disability in both ordinal (adjusted odd ratio (aOR), ≥ 1-point mRS shift: 0.75; 95%CI [0.66-0.86], p  < 0.001) and dichotomized (aOR, mRS 0-2: 0.73; 95%CI [0.62-0.86], p  < 0.001) analyses in the early- but not in the extended-window (aOR, mRS shift: 0.96; 95%CI [0.90-1.02], p  = 0.15; aOR, mRS0-2: 0.97; 95%CI [0.90-1.04], p  = 0.41). Early-window patients had significantly lower 90-day functional disability (aOR, mRS shift: 1.533; 95%CI [1.138-2.065], p  = 0.005) and a trend towards higher rates of good outcomes (aOR, mRS 0-2: 1.391; 95%CI [0.972-1.990], p  = 0.071)., Conclusions: The impact of time to thrombectomy on outcomes appears to be time dependent with a steep influence in the early followed by a less significant plateau in the extended window. However, every effort should be made to shorten treatment times regardless of ischemia duration.

Background and Purpose: Thromboaspiration technology continues to evolve at an accelerated pace with increasing availability of larger and more navigable devices. Herein, we provide our initial experience with the intracranial navigation of a large-bore (.088" inner diameter) catheters during mechanical thrombectomy (MT)., Methods: Retrospective review of consecutive large vessel occlusion stroke patients in whom a TracStar™ or Zoom 88™ (Imperative Care, Campbell, CA) large-bore catheters were utilized in MT. The primary outcome was successful reperfusion (eTICI2b-3) at the end of the procedure. Safety measures included procedural complications and rates of symptomatic intracranial hemorrhage., Results: Five patients (age,∼50-85 years; baseline NIHSS,17-23) were treated. The .088" catheters were used as the primary tool for contact aspiration in two patients (distal basilar artery and proximal MCA occlusions) with complete thrombus ingestion (eTICI3) during the first pass. In two patients, the .088" catheter was used for flow control where it was placed in the distal M1-segment of a patient with M2 occlusion treated with a combination of stent-retriever and .070" aspiration catheter and in the proximal M1 in a patient with distal M1 occlusion treated with .071" aspiration catheter resulting in eTICI3 reperfusion in both cases. In the fifth patient, the .088" catheter was navigated into the cavernous ICA to support .071" aspiration catheter treatment of an M2 occlusion resulting in eTCI2b67 reperfusion. Procedural duration ranged between 14 and 33 minutes. There were no adverse events., Conclusion: Intracranial navigation of .088" large-bore catheters in MT appears technically feasible and safe. Larger prospective studies are warranted.

Background: Bypassing the emergency department and the computed tomography suite by directly transporting to the neuroangiography suite for imaging assessment and treatment may shorten reperfusion times while maintaining proper patient selection., Objective: To determine whether flat-panel detector multiphase computed tomography angiography protocol is associated with reduced treatment times and a similar safety profile as the standard imaging protocol., Methods: Single-center prospective study of consecutive patients with anterior circulation large vessel occlusion strokes transferred to our facility for consideration of endovascular therapy from May 2016 to December 2017. Those with basilar strokes and/or presenting to the emergency department were excluded. Patients were categorized into two groups: (1) flat-panel detector CT assessment in stroke to reduce times to intra-arterial treatment group, with patients transferred directly to the suite for multiphase computed tomography angiography; and (2) patients undergoing standard protocol including computed tomography ± computed tomography angiography/CT perfusion. The groups were matched for age, baseline National Institute of Health Stroke Scale, and pretreatment glucose. Baseline characteristics, time metrics, and outcomes were compared., Results: Out of 419 patients who underwent endovascular therapy over the study period, 210 patients fit inclusion criteria, with 54 (25.7%) in the flat-panel detector CT assessment in stroke to reduce times to intra-arterial treatment group. After matching, 49 flat-panel detector CT assessment in stroke to reduce times to intra-arterial treatment/control pairs were generated and analyzed. Baseline characteristics were well balanced. Flat-panel detector CT assessment in stroke to reduce times to intra-arterial treatment patients had significantly shorter median door-to-puncture (33 [26.5-47] vs. 55 [44.5-66] min, p  < 0.001), door-to-reperfusion (85 [57.5-115.5] vs. 110 [80-153], p  = 0.005) and picture-to-puncture (18 [13.5-22.5] vs. 42 [32-47.5] min, p  < 0.001) times. There were no differences in rates of successful reperfusion (modified thrombolysis in cerebral infarction 2b-3, 95.9% vs. 100%, p  = 0.5), parenchymal hematomas type-2 (4.1% vs. 2%, p  = 1.00), good outcome (90-day modified Rankin Scale 0-2, 44.9% vs. 40.8%, p  = 0.68), and 90-day mortality (14.3% vs. 22.4%, p  = 0.30)., Conclusion: Directly transferring patients to angiography and using multiphase computed tomography angiography to determine the eligibility for endovascular therapy is safe and may result in a significant reduction in treatment times. Future larger studies are warranted.