Search

Background: Underlying intracranial stenosis is the most common cause of failed mechanical thrombectomy in patients with acute ischemic stroke with large vessel occlusion. Adjunct emergent stenting is sometimes performed to improve or maintain reperfusion, despite limited data regarding its safety or efficacy., Methods: We conducted a prospective multicenter observational international cohort study. Patients were enrolled between January 2022 and December 2023 at 25 thrombectomy-capable centers in North America, Europe, and Asia. Consecutive patients treated with mechanical thrombectomy were included if they were identified as having underlying intracranial stenosis, defined as 50% to 99% residual stenosis of the target vessel or intraprocedural reocclusion. The primary outcome was functional independence, defined as a modified Rankin Scale score of 0 to 2 at 90 days. After applying inverse probability of treatment weighting based on propensity scores, we compared outcomes among patients who underwent adjunct emergent intracranial stenting (stenting) versus those who received mechanical thrombectomy alone., Results: A total of 417 patients were included: 218 patients treated with mechanical thrombectomy alone (168 anterior circulation) and 199 with mechanical thrombectomy plus stenting (144 anterior circulation). Patients in the stenting group were less likely to be non-Hispanic White (51.8% versus 62.4%, P =0.03) and less likely to have diabetes (33.2% versus 43.1%, P =0.037) or hyperlipidemia (43.2% versus 56%, P =0.009). In addition, there was a lower rate of IV thrombolysis use in the stenting group (18.6% versus 27.5%, P =0.03). There was a higher rate of successful reperfusion (modified Treatment in Cerebral Infarction score ≥2B) in the stenting versus mechanical thrombectomy-alone group (90.9% versus 77.9%, P <0.001) and a higher rate of a 24-hour infarct volume of <30 mL (n=260, 67.9% versus 50.3%, P =0.005). The overall complication rate was higher in the stenting group (12.6% versus 5%, P =0.006), but there was not a significant difference in the rate of symptomatic hemorrhage (9% versus 5.5%, P =0.162). Functional independence at 90 days was significantly higher in the stenting group (42.2% versus 28.4%, adjusted odds ratio, 2.67 [95% CI, 1.66-4.32])., Conclusions: In patients with underlying stenosis who achieved reperfusion with mechanical thrombectomy, adjunct emergent stenting was associated with better functional outcome without a significantly increased risk of symptomatic hemorrhage., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT05403593., Competing Interests: Dr Al Kasab has received grant funding from Stryker Neurovascular. Dr Inoa reports compensation from MicroVention, Inc for consultant services; employment by Semmes Murphey Clinic; compensation from Cerenovus for consultant services; compensation from Imperative Care, Inc for consultant services; compensation from Medtronic for consultant services; grants from Medtronic; compensation from Siemens for consultant services; compensation from viz.ai for consultant services; compensation from Penumbra, Inc for consultant services; and compensation from Stryker for consultant services. Dr Starke reports grants from Medtronic USA, Inc; compensation from Penumbra, Inc for consultant services; grants from National Institutes of Health (NIH) Clinical Center; and compensation from Arthur L. and Elaine V. Johnson Foundation for consultant services. Dr Bender reports compensation from Stryker Corporation for consultant services. Dr Maier reports compensation from Bristol Myers Squibb Company for other services and compensation from PFIZER PHARMA GMBH for other services. Dr Grossberg reports grants from Emory Neurosurgery Catalyst; grants from Georgia Research Alliance; compensation from Imperative Care, Inc for consultant services; grants from Uniformed Services University-Surgical Critical Care Initiative; grants from National Institute of Neurological Disorders and Stroke; compensation from Cognition for consultant services; grants from Emory Medical Care Foundation; and compensation from NTI for consultant services. Dr Jabbour reports compensation from Medtronic USA, Inc for consultant services. Dr Psychogios reports travel support from Medtronic; travel support from Siemens Healthineers AG; grants from Phenox, Inc; grants from Rapid Medical Ltd; grants from Penumbra, Inc; grants from Siemens Healthineers AG; travel support from Stryker Neurovascular, Inc; grants from Stryker Neurovascular, Inc; compensation from Siemens Healthineers AG for consultant services; grants from Medtronic; grants from Bangerter-Rhyner Stiftung; grants from Swiss National Science Foundation (SNF); travel support from Penumbra, Inc; and travel support from Phenox, Inc. Dr Samaniego reports compensation from MicroVention, Inc for consultant services; compensation from Johnson and Johnson for consultant services; compensation from Medtronic for consultant services; compensation from Rapid Medical for consultant services; and employment by University of Iowa. Dr Burkhardt reports compensation from MicroVention, Inc for consultant services; compensation from Longeviti Neuro Solutions LLC for consultant services; compensation from Q`Apel Medical for consultant services; compensation from Stryker for consultant services; and compensation from Cerenovous for consultant services. A.E. Hassan reports compensation from MicroVention, Inc for consultant services; compensation from Stryker Corporation for consultant services; compensation from GE Healthcare for consultant services; compensation from Penumbra, Inc for consultant services; compensation from Medtronic for consultant services; employment by Valley Baptist Medical Center; compensation from viz.ai for consultant services; and compensation from Cerenovus for consultant services. Dr Altschul reports compensation from Stryker Corporation for consultant services; compensation from Medtronic USA, Inc for consultant services; securities holdings in Von Vascular, Inc; stock options in Glia Medical; compensation from MicroVention, Inc for consultant services; compensation from Synchron for consultant services; compensation from Q’apel for consultant services; and compensation from Johnson and Johnson International for consultant services. Dr Mascitelli reports compensation from Imperative Care, Inc for consultant services and compensation from Stryker for consultant services. Dr Regenhardt reports compensation from Genomadix for consultant services; compensation from S2N Health for consultant services; compensation from Rapid Medical Ltd for data and safety monitoring services; and compensation from Penumbra, Inc for other services. Dr Wolfe reports employment by Wake Forest Baptist Health School of Medicine. Dr Ezzeldin reports compensation from viz.ai for consultant services; compensation from Imperative Care, Inc for consultant services; and an ownership stake in Galaxy Therapeutics. Dr Limaye reports compensation from Medtronic USA, Inc for consultant services and grants from Scientia Vascular. Dr Grandhi reports compensation from Cerenovus for consultant services; grants from Scientia Neurovascular; compensation from Stryker for consultant services; compensation from Integra LifeSciences Corporation for consultant services; compensation from Medtronic for consultant services; compensation from Balt USA, LLC for consultant services; and compensation from Rapid Medical Ltd for consultant services. Dr Tjoumakaris reports compensation from Medtronic for consultant services; compensation from MicroVention, Inc for consultant services; compensation from MicroVention, Inc for consultant services; and employment by Thomas Jefferson University. Dr Raz reports compensation from Q Apel for consultant services; compensation from MicroVention, Inc for consultant services; compensation from Johnson and Johnson International for consultant services; compensation from imperative care for consultant services; stock holdings in Siemens; compensation from Medtronic for consultant services; compensation from Phenox for consultant services; compensation from Scientia for consultant services; compensation from Balt USA, LLC for consultant services; and employment by NYU Langone Medical Center. Syed F Zaidi: Dr Zaidi reports grants from Genentech USA, Inc. Dr Spiotta reports compensation from RapidAI for consultant services; compensation from Penumbra, Inc for consultant services; and compensation from Terumo for consultant services. Dr Kicielinski reports employment by Elsevier and compensation from Penumbra, Inc for other services. Dr Zaidat reports a patent issued for Ischemic stroke device. Dr Derdeyn reports compensation from NoNO for data and safety monitoring services; stock options in Euphrates Vascular; compensation from Silk Road Medical, Inc for data and safety monitoring services; and compensation from Penumbra, Inc for data and safety monitoring services. Dr Derdeyn reports data safety monitoring boards (Penumbra–MIND [A Prospective, Multicenter Study of Artemis a Minimally Invasive Neuro Evacuation Device, in the Removal of Intracerebral Hemorrhage], THUNDER [Acute Ischemic Stroke Study With the Penumbra System Including Thunderbolt Aspiration Tubing]; Silk Road–NITE [Neuroprotection in Transcarotid Embolectomy]; NoNO–ESCAPE NEXT [Efficacy and Safety of Nerinetide in Participants With Acute Ischemic Stroke Undergoing Endovascular Thrombectomy Excluding Thrombolysis], FRONTIER); stock options–Euphrates Vascular. Dr Nguyen reports compensation from Aruna for consultant services; compensation from American Stroke Association for other services; compensation from Kaneka for other services; compensation from Genentech for other services; and compensation from Brainomix for consultant services. Dr de Havenon reports NIH/National Institute of Neurological Disorders and Stroke funding (K23NS105924, UG3NS130228, R01NS130189) and has received consultant fees from Integra and Novo Nordisk, royalty fees from UpToDate, and has equity in TitinKM and Certus. The other authors report no conflicts.

Importance: There is substantial controversy with regards to the adequacy and use of noncontrast head computed tomography (NCCT) for late-window acute ischemic stroke in selecting candidates for mechanical thrombectomy., Objective: To assess clinical outcomes of patients with acute ischemic stroke presenting in the late window who underwent mechanical thrombectomy stratified by NCCT admission in comparison with selection by CT perfusion (CTP) and diffusion-weighted imaging (DWI)., Design, Setting, and Participants: In this multicenter retrospective cohort study, prospectively maintained Stroke Thrombectomy and Aneurysm (STAR) database was used by selecting patients within the late window of acute ischemic stroke and emergent large vessel occlusion from 2013 to 2021. Patients were selected by NCCT, CTP, and DWI. Admission Alberta Stroke Program Early CT Score (ASPECTS) as well as confounding variables were adjusted. Follow-up duration was 90 days. Data were analyzed from November 2021 to March 2022., Exposures: Selection by NCCT, CTP, or DWI., Main Outcomes and Measures: Primary outcome was functional independence (modified Rankin scale 0-2) at 90 days., Results: Among 3356 patients, 733 underwent late-window mechanical thrombectomy. The median (IQR) age was 69 (58-80) years, 392 (53.5%) were female, and 449 (65.1%) were White. A total of 419 were selected with NCCT, 280 with CTP, and 34 with DWI. Mean (IQR) admission ASPECTS were comparable among groups (NCCT, 8 [7-9]; CTP, 8 [7-9]; DWI 8, [7-9]; P = .37). There was no difference in the 90-day rate of functional independence (aOR, 1.00; 95% CI, 0.59-1.71; P = .99) after adjusting for confounders. Symptomatic intracerebral hemorrhage (NCCT, 34 [8.6%]; CTP, 37 [13.5%]; DWI, 3 [9.1%]; P = .12) and mortality (NCCT, 78 [27.4%]; CTP, 38 [21.1%]; DWI, 7 [29.2%]; P = .29) were similar among groups., Conclusions and Relevance: In this cohort study, comparable outcomes were observed in patients in the late window irrespective of neuroimaging selection criteria. Admission NCCT scan may triage emergent large vessel occlusion in the late window.

Ischemic stroke prompts a strong inflammatory response, which is associated with exacerbated outcomes. In this study, we investigated mechanistic regulators of neutrophil extracellular trap (NET) formation in stroke and whether they contribute to stroke outcomes. NET-forming neutrophils were found throughout brain tissue of ischemic stroke patients, and elevated plasma NET biomarkers correlated with worse stroke outcomes. Additionally, we observed increased plasma and platelet surface-expressed high-mobility group box 1 (HMGB1) in stroke patients. Mechanistically, platelets were identified as the critical source of HMGB1 that caused NETs in the acute phase of stroke. Depletion of platelets or platelet-specific knockout of HMGB1 significantly reduced plasma HMGB1 and NET levels after stroke, and greatly improved stroke outcomes. We subsequently investigated the therapeutic potential of neonatal NET-inhibitory factor (nNIF) in stroke. Mice treated with nNIF had smaller brain infarcts, improved long-term neurological and motor function, and enhanced survival after stroke. nNIF specifically blocked NET formation without affecting neutrophil recruitment after stroke. Importantly, nNIF also improved stroke outcomes in diabetic and aged mice and was still effective when given 1 hour after stroke onset. These results support a pathological role for NETs in ischemic stroke and warrant further investigation of nNIF for stroke therapy.

Objectives: With growing evidence of its efficacy for patients with large-vessel occlusion (LVO) ischemic stroke, the use of endovascular thrombectomy (EVT) has increased. The "weekend effect," whereby patients presenting during weekends/off hours have worse clinical outcomes than those presenting during normal working hours, is a critical area of study in acute ischemic stroke (AIS). Our objective was to evaluate whether a "weekend effect" exists in patients undergoing EVT., Methods: This retrospective, cross-sectional analysis of the 2016-2018 Nationwide Inpatient Sample data included patients ≥18 years with documented diagnosis of ischemic stroke (ICD-10 codes I63, I64, and H34.1), procedural code for EVT, and National Institutes of Health Stroke Scale (NIHSS) score; the exposure variable was weekend vs. weekday treatment. The primary outcome was in-hospital death; secondary outcomes were favorable discharge, extended hospital stay (LOS), and cost. Logistic regression models were constructed to determine predictors for outcomes., Results: We identified 6052 AIS patients who received EVT (mean age 68.7±14.8 years; 50.8% female; 70.8% White; median (IQR) admission NIHSS 16 (10-21). The primary outcome of in-hospital death occurred in 560 (11.1%); the secondary outcome of favorable discharge occurred in 1039 (20.6%). The mean LOS was 7.8±8.6 days. There were no significant differences in the outcomes or cost based on admission timing. In the mixed-effects models, we found no effect of weekend vs. weekday admission on in-hospital death, favorable discharge, or extended LOS., Conclusion: These results demonstrate that the "weekend effect" does not impact outcomes or cost for patients who undergo EVT for LVO., Competing Interests: Declaration of Competing Interest Dr. de Havenon's department has received funding from AMAG and Regeneron pharmaceuticals for investigator-initiated research and Dr. de Havenon receives royalties from UpToDate, Inc. Dr. Grandhi is a consultant for Cerenovus, Medtronic Neurovascular, and Balt Neurovascular., (Published by Elsevier Inc.)

There is an absence of specific evidence or guideline recommendations on blood pressure management for large vessel occlusion stroke patients. Until randomized data are available, the periprocedural blood pressure management of patients undergoing endovascular thrombectomy can be viewed in two phases relative to the achievement of recanalization. In the hyperacute phase, prior to recanalization, hypotension should be avoided to maintain adequate penumbral perfusion. The American Heart Association guidelines should be followed for the upper end of prethrombectomy blood pressure: ≤185/110 mm Hg, unless post-tissue plasminogen activator administration when the goal is <180/105 mm Hg. After successful recanalization (thrombolysis in cerebral infarction [TICI]: 2b-3), we recommend a target of a maximum systolic blood pressure of < 160 mm Hg, while the persistently occluded patients (TICI < 2b) may require more permissive goals up to <180/105 mm Hg. Future research should focus on generating randomized data on optimal blood pressure management both before and after endovascular thrombectomy, to optimize patient outcomes for these divergent clinical scenarios., Competing Interests: None., (Thieme. All rights reserved.)

Background: Endovascular thrombectomy is a promising treatment for acute ischemic stroke in children, but outcome and technical data in pediatric patients with large-vessel occlusions are lacking., Objective: To assess technical and clinical outcomes of thrombectomy in pediatric patients., Methods: We undertook a retrospective cohort study of pediatric patients who experienced acute ischemic stroke from April 2017 to April 2019 who had immediate, 30-, and 90-d follow-up. Patients were treated with endovascular thrombectomy at 5 US pediatric tertiary care facilities. We recorded initial and postprocedural modified Thrombolysis in Cerebral Infarction (mTICI) grade ≥ 2b, initial and postprocedural Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score, and pediatric modified Rankin scale (mRS) score 0 to 2 at 90 d., Results: There were 23 thrombectomies in 21 patients (mean age 11.6 ± 4.9 yr, median 11.5, range 2.1-19; 52% female). A total of 19 (83%) thrombectomies resulted in mTICI grade ≥ 2b recanalization. The median PedNIHSS score was 13 on presentation (range 4-33) and 2 (range 0-26) at discharge (mean reduction 11.3 ± 6.1). A total of 14 (66%) patients had a mRS score of 0 to 2 at 30-d follow-up; 18/21 (86%) achieved that by 90 d. The median mRS was 1 (range 0-4) at 30 d and 1 (range 0-5) at 90 d. One patient required a blood transfusion after thrombectomy., Conclusion: In this large series of pediatric patients treated with endovascular thrombectomy, successful recanalization was accomplished via a variety of approaches with excellent clinical outcomes; further prospective longitudinal study is needed., (Copyright © 2020 by the Congress of Neurological Surgeons.)

BackgroundEndovascular thrombectomy is a promising treatment for acute ischemic stroke in children, but outcome and technical data in pediatric patients with large-vessel occlusions are lacking.ObjectiveTo assess technical and clinical outcomes of thrombectomy in pediatric patients.MethodsWe undertook a retrospective cohort study of pediatric patients who experienced acute ischemic stroke from April 2017 to April 2019 who had immediate, 30-, and 90-d follow-up. Patients were treated with endovascular thrombectomy at 5 US pediatric tertiary care facilities. We recorded initial and postprocedural modified Thrombolysis in Cerebral Infarction (mTICI) grade ≥ 2b, initial and postprocedural Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score, and pediatric modified Rankin scale (mRS) score 0 to 2 at 90 d.ResultsThere were 23 thrombectomies in 21 patients (mean age 11.6 ± 4.9 yr, median 11.5, range 2.1-19; 52% female). A total of 19 (83%) thrombectomies resulted in mTICI grade ≥ 2b recanalization. The median PedNIHSS score was 13 on presentation (range 4-33) and 2 (range 0-26) at discharge (mean reduction 11.3 ± 6.1). A total of 14 (66%) patients had a mRS score of 0 to 2 at 30-d follow-up; 18/21 (86%) achieved that by 90 d. The median mRS was 1 (range 0-4) at 30 d and 1 (range 0-5) at 90 d. One patient required a blood transfusion after thrombectomy.ConclusionIn this large series of pediatric patients treated with endovascular thrombectomy, successful recanalization was accomplished via a variety of approaches with excellent clinical outcomes; further prospective longitudinal study is needed.

Background: Traditional endovascular treatments of giant intracranial aneurysms are associated with high rates of complications and retreatment. Our objective was to examine the safety and long-term efficacy of the Pipeline Embolization Device for treatment of these aneurysms. Methods: This retrospective study using the IntrePED database included all patients with giant intracranial aneurysms treated with the Pipeline device between July 2008 and February 2013. Efficacy outcomes were stratified by using the Raymond-Roy Occlusion Classification. Predefined safety outcomes included spontaneous rupture of the target aneurysm; ipsilateral intracranial hemorrhage; ischemic stroke; parent artery stenosis; and sustained cranial neuropathy. Results: Sixty-six embolizations were performed to treat 63 giant intracranial aneurysms (including 2 ruptured): 49 (77.8%) in the anterior and 14 (22.2%) in the posterior circulation. The median follow-up was 22.4 (0.1–60.5) months. Class I angiographic occlusion was achieved in 72.0% (36/50). The neurological morbidity/mortality rate was 23.8% (15/63), with higher rates in the posterior circulation than in the anterior circulation (22.4% vs. 28.6%). Among seven deaths, five had neurological causes. The procedure-related neurological morbidity and mortality rates were 22.7% (15/66) and 7.6% (5/66), respectively. The spontaneous rupture rate was 4.5% (3/66). Two spontaneous ruptures (1 death), 4/4 postprocedural intracranial hemorrhages, and 6/9 ischemic events occurred within 30 days. In-stent stenosis and new-onset cranial neuropathy were not observed during the angiographic follow-up period. Conclusions: Although procedure-related neurological morbidity/mortality rates were not insignificant, this study confirms the feasibility and long-term efficacy of the Pipeline Embolization Device to treat giant intracranial aneurysms. [ABSTRACT FROM AUTHOR]

Carotid artery stenosis is a major cause of acute ischemic strokes in adults. Given the consequences and sequelae of an acute ischemic stroke, intervention while patients are still asymptomatic is a key opportunity for stroke prevention. Although carotid endarterectomy has been the gold standard of treatment for carotid stenosis for many years, recent advances in carotid stenting technology, practitioner experience, and dual antiplatelet therapy have expanded the use for treatments other than endarterectomy. Review of the current literature has demonstrated that endarterectomy and carotid artery stenting produce overall similar results for the treatment of asymptomatic carotid stenosis, but certain factors may help guide physicians and patients in choosing one treatment over the other. Age 70 years and older, renal disease, poor medication compliance, and unstable plaque features all portend better outcomes from endarterectomy, whereas age under 70 years, high cervical location of disease, cardiac disease, and reliable medication compliance favor stenting. The decision to pursue endarterectomy versus stenting is therefore complex, and although large studies have demonstrated similar outcomes, the approach to treatment of asymptomatic carotid stenosis must be optimized for each individual patient to achieve the best possible outcome. [ABSTRACT FROM AUTHOR]