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Background: The Nimbus stent-retriever (NSR) was developed for mechanical thrombectomy of wall-adherent thrombi in cerebral arteries. It features a novel geometry with a proximal spiral section and a distal barrel section. The new device is designed to retrieve tough clots with a micro-clamping technique. In the first case series reporting on the NSR, we share our initial experience about the first 12 treated cases. Methods: In total, 12 patients (5 men, 7 women; mean age 78 years) with occlusion of the internal carotid artery or the middle cerebral artery (M1 or M2 segment) were treated with the NSR, 11 after unsuccessful recanalization attempts with conventional stent-retrievers or aspiration thrombectomy. Results: Retrieving maneuvers with the NSR recovered a thrombus in 7 patients (58%), of which 6 resulted in vessel recanalization mTICI ≥ 2b. Successful recanalization improved the mTICI score by a median of 3 points. In 5 of 7 cases, this required only one thrombectomy maneuver. In 5 cases, no improvement of recanalization could be achieved with the NSR (1–3 attempts). No NSR-related complications occurred in this case series. Conclusions: In our initial experience, the NSR appeared to be a safe and effective second-line stent-retriever after unsuccessful MT with conventional stent-retrievers or aspiration thrombectomy allowing for mTICI ≥ 2b rescue thrombectomy in ab 50% of cases. No NSR associated complications occurred in our case series. [ABSTRACT FROM AUTHOR]

This study sought to scrutinize the clinical outcomes associated with first-pass mechanical thrombectomy strategies in the management of intracranial atherosclerosis (ICAS)–related large vessel occlusion (LVO). Within this post-hoc analysis of the The Endovascular Treatment With vs Without Tirofiban for Patients with Large Vessel Occlusion Stroke (RESCUE BT) trial, we compared data pertaining to patients with ICAS-LVO situated in the anterior circulation who underwent initial therapeutic interventions utilizing either aspiration thrombectomy or stent-retriever thrombectomy. The analysis encompassed the assessment of intraprocedural recanalization, rescue procedures involving balloon angioplasty or stenting, 48-hour reocclusion rates, occurrences of cerebral hemorrhagic complications, and 90-day Modified Rankin Scale scores. Among the 948 patients encompassed in the RESCUE BT trial, a total of 230 patients with ICAS-LVO in the anterior circulation were enrolled in the study. Of these, 111 underwent aspiration thrombectomy as the first-pass therapy, while 119 patients underwent stent-retriever thrombectomy as the initial intervention. The difference in first pass recanalization rates between aspiration thrombectomy and stent-retriever thrombectomy was not statistically significant (17.1% vs. 14.3%, P = 0.555), and mechanical thrombectomy success rates (90.1% vs. 90.8%, P = 0.864), the use of balloon angioplasty or stenting for rescue therapy (54.6% vs. 45.9%, P = 0.189; 23.4% vs. 25.2%, P = 0.752), and favorable 90-day Modified Rankin Scale outcomes (53.2% vs. 40.3%, P = 0.051) showed no statistically significant differences. Both aspiration thrombectomy and stent-retriever thrombectomy can be considered as primary therapeutic options for patients presenting with ICAS-LVO in the anterior circulation. [ABSTRACT FROM AUTHOR]

BACKGROUND: Endovascular mechanical thrombectomy (MT) changed acute ischaemic stroke management and is considered the standard of care for patients with proximal anterior circulation occlusion. MT improves functional independence, without an increase in mortality. Despite its advantages, up to 20% of patients treated with MT do not have successful recanalization, leading to poor clinical outcome. We present a case of an acute ischaemic stroke of the anterior circulation due to occlusion of the common carotid artery successfully submitted to surgical thrombectomy after failed MT. CASE REPORT: A 43-year-old male, with prior history of diabetes, hypertension, dyslipidaemia and heart failure was admitted at the emergency unit with acute bilateral lower limb ischaemia, due to cardioembolic phenomena. He was submitted to bilateral femoral thrombectomy and started endovenous unfractionated heparin. On the fifth postoperative day he developed sudden depression of cognitive status and left side hemiplegia of brachial predominance. Computed tomography angiography revealed an occlusion of brachiocephalic trunk, right subclavian artery and common carotid artery, preserving its branches. MT, performed by interventional neuroradiology, was unsuccessful (no recanalization or clinical improvement). After multidisciplinary discussion, the patient underwent urgent surgical thrombectomy through carotid and transaxillary approaches. Postoperatively, the patient’s mental status and left sided motor function recovered progressively over time. Three months after, patient maintains anticoagulation with warfarin, without neurological sequalae. CONCLUSION: The low rate of recanalization and poor clinical outcome after MT failure underlines the need for alternative rescue approaches. Surgical thrombectomy could represent a lifeline. More studies are needed to corroborate its efficacy in patients with anterior circulation acute ischaemic stroke.

Objective: Intra-procedural WEB device migration is a scarcely reported complication that necessitates prompt intervention. Case Presentation: Endovascular treatment of two broad necked flow-related aneurysms was planned aided by WEB-SL (Woven EndoBridge-single layer) devices in a 71-year-old female with known left temporal arteriovenous malformation. Inadvertent distal migration occurred while performing a control angiogram with an automated iodine injector. Immediate retrieval was successfully performed using a Solitaire stent-retriever. Conclusion: To our knowledge, we report for the first time the successful retrieval of a distally migrated WEB using a stent-retriever device. [ABSTRACT FROM AUTHOR]

We aimed to describe the initial experience of mechanical thrombectomy using tandem double stent retrievers combined with intermediate catheter aspiration to treat refractory severe hemorrhagic (SH)-cerebral venous sinus thrombosis (CVST). All refractory SH-CVST patients treated with mechanical thrombectomy using tandem double stent retriever (SR) combined with intermediate catheter aspiration (MT-TDSA) in our institution were retrospectively reviewed. MT-TDSA is a technique that fully engages the clot with double SRs and retrieves the clot using a double SR in combination with aspiration from an intermediate catheter. Demographics, clinical manifestation, medical history, the location of the occluded venous sinus, intraoperative details, procedure-related complications, and modified Rankin Scale (1, 6, 12 months postoperatively) were collected and analyzed. Fourteen patients (median age, 43 years) with refractory SH-CVST were treated with MT-TDSA between January 2016 and January 2020. Ten of 14 (71.4%) had a successful intraoperative recanalization rate (>90%) using MT-TDSA. No procedure-related complications occurred. Eleven patients had good clinical outcomes (modified Rankin Scale score 0–2 at 12 months postoperatively). MT-TDSA for refractory SH-CVST might improve clot-capturing ability and remove blood clots from cerebral venous sinuses effectively and safely, achieving good clinical outcomes. [ABSTRACT FROM AUTHOR]

To report our initial experience with the novel low-profile APERIO Hybrid17 Thrombectomy Device (AP17) for proximal and distal vessel occlusions in acute ischemic stroke. A multicentric retrospective analysis of patients treated with the AP17 was performed. The primary effectiveness endpoint was first-pass TICI ≥2b (Thrombolysis in cerebral infarction scale). The primary safety endpoint was the occurrence of hemorrhagic complications. Further outcome measures were number of passes, device-related complications, and 3-month functional outcome. The AP17 was used in 71 patients (mean age: 73 years) with a median baseline National Institutes of Health Stroke Scale score of 9. Treated vessels were the carotid-T in 8 cases (11%), the M1-segment in 16 (23%), the M2-segment in 29 (41%), the anterior cerebral artery in 3 (4%), and basilar/posterior cerebral arteries in 15 (21%). The rates of first-pass and final TICI ≥2b were 75.6% and 92.7%, retrospectively, with a mean number of passes of 3 ± 2. Final TICI ≥2b rates were comparable between large and medium vessel occlusions. Symptomatic intracranial hemorrhages were recorded in 2 cases (2.8%). At 3-month clinical follow-up, a modified Rankin scale score ≤2 was achieved in 69.0% (29/42). The all-cause mortality at discharge was 17.4%. The AP17 was associated with a reasonable safety and efficacy profile for both proximal and distal vessel occlusions. These results may contribute to establish mechanical thrombectomy for distal occlusions. [ABSTRACT FROM AUTHOR]

Textural analysis is pivotal in augmenting the diagnosis and outcomes of endovascular procedures for stroke patients. Due to the detection of changes imperceptible to the human eye, this type of analysis can potentially aid in deciding the optimal type of endovascular treatment. We included 40 patients who suffered from acute ischemic stroke caused by large vessel occlusion, and calculated 130 different textural features based on the non-enhanced CT scan using an open-source software (3D Slicer). Using chi-squared and Mann–Whitney tests and receiver operating characteristics analysis, we identified a total of 21 different textural parameters capable of predicting the outcome of thrombectomy (quantified as the mTICI score), with variable sensitivity (50–97.9%) and specificity (64.6–99.4%) rates. In conclusion, CT-based radiomics features are potential factors that can predict the outcome of thrombectomy in patients suffering from acute ischemic stroke, aiding in the decision between aspiration, mechanical, or combined thrombectomy procedure.

Background and Purpose: The aim of this multicenter study was to compare the clinical outcome, safety, and efficacy of the full‐length radiopaque Aperio Hybrid stent retriever (APH) with the precursor Aperio thrombectomy device (AP). Methods: Multicentric retrospective analysis of patients with stroke, treated with the APH and AP due to an acute ischemic stroke by large vessel occlusions in the anterior or posterior circulation, was performed. We focused on the comparison of favorable clinical outcome (modified Rankin Scale, 0‐2) after 3 months, favorable reperfusion rates (thrombolysis in cerebral infarction scale ≥ 2b), and the complication rate. Results: A total of 51 patients (female: n = 33, 64.7%, mean age 73 ± 16 years) with a median baseline National Institutes of Health Stroke Scale: 15 were treated with the APH or AP. Favorable outcome in patients treated with APH was excellent (44.0%) and comparable to the AP (36.8%). The rate of final favorable reperfusion for both devices was outstanding (APH 31/31 and AP 20/20). The overall complication rate for the APH was slightly higher compared to the AP (32.3%/15.0%). Symptomatic intracranial hemorrhage was recorded in 0 of 51 cases. The all‐cause mortality rate at 90 days was 20.0% for the APH and comparable for the AP (21.1%). Conclusions: Comparable clinical outcome, efficacy, and safety of the AP and the recently introduced APH were demonstrated. Both devices appeared feasible, efficient, and safe with regard to endovascular treatment in large vessel occlusion. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background and Purpose: Successful recanalization after the first pass of the device in endovascular thrombectomy (EVT) can significantly improve patients' prognosis. We aimed to investigate the possible factors that influence achieving the first-pass effect (FPE). Methods: We retrospectively analyzed the patients who underwent EVT caused by anterior circulation large vessel occlusion stroke (ALVOS) in our center. The FPE was defined as a successful recanalization [modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3 defined as modified FPE (mFPE); mTICI 3 as true FPE (tFPE)] after one pass of the device without rescue therapy. Univariate and multivariate regression analyses were used to explore the predictors of FPE and the relationship between FPE and prognosis. Results: There were 278 patients (age, 69.3 ± 10.9 years, male, 51.1%) included, 30.2% of them achieved mFPE, while 21.2% achieved tFPE. We found the higher clot burden score (CBS), the truncal-type occlusion, and the favorable anatomy of both extracranial and intracranial segments of the internal carotid artery (ICA) were associated with achieving mFPE. The higher CBS and truncal-type occlusion were statistically significant predictors of tFPE. Moreover, FPE was significantly associated with improved clinical outcomes, regardless of mFPE and tFPE. Conclusions: The CBS, tortuosity of ICA, and angiographic occlusion type were independent predictors of achieving FPE. The rate of improved clinical and safety outcomes was higher in patients with FPE, which has important clinical significance. [ABSTRACT FROM AUTHOR]

Aim: Mechanical thrombectomy (MT) of symptomatic occlusion of cerebral artery has become a standard treatment in acute ischemic stroke (IS) patients. The aim of the presented study was to evaluate if centers performing endovascular treatment of acute ischemic stroke meet the recommendations established by the international multi-society consensus. Methods: The national prospective observational multicenter study METRICS (Mechanical Thrombectomy Quality Indicators Study in Czech Stroke Centers) was conducted in Czech Republic in year 2019. Twelve of 15 centers performing mechanical trombectomy were participating on study. All technical and clinical data were collected prospectively and achieved results were subsequently compared with the recommendations established by international multi-society consensus. Results: In 12 centers 1178 (86%) patients (50.3% males, median of age 72 years, range 18-98 years) by MT were treated in 2019 and the collected data of these patients were analyzed. IV thrombolysis prior MT was performed in 827 (70.2%) patients and 445 (37.8%) patients were transferred secondarily for MT from primary stroke centers to dedicated comprehensive centers. Achieved data from the study METRICS were subsequently evaluated for individual participating centers. The concordance of results with the recommendations of multi-society consensus was very high. Five centers met parameters of all recommendations. Remaining centers did not meet sporadic criteria only and most parameters had borderline values. Conclusion: The results of METRICS study showed that it is possible meet the recommended values of parameters stated in the international multi-society consensus even in a real world practice across the Czech Republic. [ABSTRACT FROM AUTHOR]

Background and PurposeSuccessful recanalization after the first pass of the device in endovascular thrombectomy (EVT) can significantly improve patients' prognosis. We aimed to investigate the possible factors that influence achieving the first-pass effect (FPE).MethodsWe retrospectively analyzed the patients who underwent EVT caused by anterior circulation large vessel occlusion stroke (ALVOS) in our center. The FPE was defined as a successful recanalization [modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3 defined as modified FPE (mFPE); mTICI 3 as true FPE (tFPE)] after one pass of the device without rescue therapy. Univariate and multivariate regression analyses were used to explore the predictors of FPE and the relationship between FPE and prognosis.ResultsThere were 278 patients (age, 69.3 ± 10.9 years, male, 51.1%) included, 30.2% of them achieved mFPE, while 21.2% achieved tFPE. We found the higher clot burden score (CBS), the truncal-type occlusion, and the favorable anatomy of both extracranial and intracranial segments of the internal carotid artery (ICA) were associated with achieving mFPE. The higher CBS and truncal-type occlusion were statistically significant predictors of tFPE. Moreover, FPE was significantly associated with improved clinical outcomes, regardless of mFPE and tFPE.ConclusionsThe CBS, tortuosity of ICA, and angiographic occlusion type were independent predictors of achieving FPE. The rate of improved clinical and safety outcomes was higher in patients with FPE, which has important clinical significance.

Stroke has been the second to third most common cause of death in both developing and most developed countries, including the Czech Republic, for many years. Globally, stroke affects about 15 million people a year and is responsible for more than 5 million deaths a year, representing about 10 % of all deaths. Another more than 50 % of patients remain non-self-sufficient after stroke. As a result, strokes are among the most common causes of death and are the most common cause of disability in the population. Acute recanalization of the occluded cerebral artery by pharmacological or endovascular recanalization represents a significant advance in the treatment of ischemic stroke over the last 20 years in Czech Republic. [ABSTRACT FROM AUTHOR]

Aim: Mechanical thrombectomy (MT) of symptomatic occlusion of cerebral artery has become a standard treatment in acute ischemic stroke (IS) patients. Based on analysis of previously published results, the recommendations for the centers performing MT were introduced in the year 2018 and became accepted as indicators of quality of care. The aim of presented study was to evaluate if our center was able to follow the recommendations established by international multi-society consensus, and furthermore, to assess a trend of recommended indicators during the time using a comparison of our results between years 2016 and 2019. Methods: All consecutive acute IS patients with large vessel occlusion both in anterior and posterior circulation treated in our center in the year 2019 were included in the analysis. All demographic and clinical data, as well as time parameters and treatment results were collected prospectively. Data were subsequently compared with recommended values of individual parameters of multi-society consensus. The results of the year 2019 were subsequently compared with those from the year 2016 to assess a trend in our center. Results: In total, 152 patients (52% of males, mean age: 71.2 ± 13.2 years) were indicated to MR in our center in the year 2019. In 75% of patients indicated to MT, brain imaging was started within 23 min after patient's arrival to center, groin puncture was performed within 62 min after patient's arrival to center (primary transport), and in 70% of patients, recanalization was achieved within 34 min after groin puncture. Recanalization (mTICI = 2b) was achieved in 133 (87.5%) patients a completed (mTICI 3) in 102 67.2%) patients. Eighty (52.6%) patients reached good 3-month clinical outcome (mRS 0-2). Symptomatic intracerebral hemorrhage after MT occurred in 5 (3.4%) patients. Conclusion: Our results showed that it was possible fulfill the recommended values of parameters stated in the international multisociety consensus also in Czech Republic and thus, the can be recommended as indicators of quality of care. [ABSTRACT FROM AUTHOR]

For the last several years while treating acute ischemic strokes methods of endovascular interventions are favorably applied. Similar treatment methods are characterized by large therapeutic window, high efficiency and effect persistence comparing to systemic thrombolytic therapy. In the present article we present clinic observance for endovascular mechanical thromboembolectomy with stent-retriever and further balloon angioplasty in a patient with acute ischemic stroke in the area of stenotic lesion of internal carotid artery wedge-shaped aspect.

Thrombolysis and mechanical thrombectomy have revolutionized the care of patients with acute ischemic stroke. The number of patients who can benefit from these treatments continues to increase as new studies demonstrate that not just time since stroke onset but also collateral circulation influences outcome. Technologies such as telestroke, mobile stroke units, and artificial intelligence are playing an increasing role in identifying and treating stroke. Stroke-systems-of-care models continue to streamline the delivery of definitive revascularization in the age of mechanical thrombectomy.

In 2015, multiple randomized clinical trials showed an unparalleled treatment benefit of stent-retriever thrombectomy as compared to standard medical therapy for the treatment of a large artery occlusion causing acute ischemic stroke. A short time later, the HERMES collaborators presented the patient-level pooled analysis of five randomized clinical trials, establishing class 1, level of evidence A for stent-retriever thrombectomy, in combination with intravenous thrombolysis when indicated to treat ischemic stroke. In the years following, evidence continues to mount for expanded use of this therapy for a broader category of patients. The enabling technology that changed the tide to support endovascular treatment of acute ischemic stroke is the stent-retriever. This review summarizes the history of intra-arterial treatment of stroke, introduces the biomechanics of embolus extraction with stent-retrievers, describes technical aspects of the intervention, provides a description of hemodynamic implications of stent-retriever embolectomy, and proposes future directions for a more comprehensive, multi-modal endovascular approach for the treatment of acute ischemic stroke. [ABSTRACT FROM AUTHOR]

Background: The stent retriever assisted vacuum-locked extraction (SAVE) technique was introduced as an effective thrombectomy method in stroke patients suffering from intracranial large vessel occlusion (LVO). This article presents our multicenter, large-scale experience with SAVE. Methods: The study involved a retrospective core team analysis of 200 patients undergoing mechanical thrombectomy using the SAVE technique due to intracranial LVO at 4 German centers. Primary endpoints were first-pass and overall complete/near complete reperfusion, defined as a modified thrombolysis in cerebral infarction (mTICI) score of 2c and 3. Secondary endpoints were the number of passes, time from groin puncture to reperfusion, embolization to new territories (ENT), postinterventional symptomatic intracranial hemorrhage (sICH), and favorable outcome at discharge, defined as a modified Rankin Scale (mRS) score ≤ 2. Results: The median age was 78 years (interquartile range IQR 68–85). Median National Institutes of Health stroke scale (NIHSS) at admission was 16 (IQR 12–20). Occlusions sites were: internal carotid artery (ICA-T) in 39/200 (19.5%), M1 in 126/200 (63%), M2 in 30/200 (15%), and others in 5/200 (2.5%) cases. The primary endpoints were documented in 114/200 (57% first pass mTICI 2c or 3) and 154/200 (77% overall mTICI 2c or 3) patients, respectively. The overall median time from groin puncture to reperfusion was 34 min (IQR 25–52) with a median of 1 (IQR 1–2) attempts. An ENT was observed in 3 patients (1.5%) and the rate of sICH was 2.6%. The rate of successful reperfusion (mTICI ≥ 2b) on final angiograms was 95%. At discharge, 73/200 (36.5%) patients revealed a favorable outcome. Conclusion: Mechanical thrombectomy using the SAVE technique seems to be effective, fast and safe. First-line use of SAVE leads to high rates of complete and near complete reperfusion. [ABSTRACT FROM AUTHOR]

Background: The inadvertent detachment of stent retrievers during mechanical thrombectomy is an extremely rare but feared complication associated with poor clinical outcomes. We discuss management considerations after an unexpected disconnection of the pRESET stent retriever during mechanical thrombectomy, based on clinical experience and mechanical and phantom studies. Methods: We present a clinical course of rare accidents of stent-retriever separation inside an intracranial vessel that occurred in patients in a comprehensive stroke centre between 2018 and 2020. We designed a phantom study to assess the Tigertriever’s ability to remove a detached stent retriever from intercranial vessels. In the mechanical study, several types of stent retrievers were evaluated in order to find the weakest point at which detachment occurred. Results: Two patients (~0.7%) with inadvertent stent-retriever detachment were found in our database. Failed attempts of endovascular removal with no recanalization at the end of procedure were reported in both cases. mRS after 3 months was three and four respectively. In the mechanical study, the Tigertriever was the most resistant to detachment and was followed by Embotrap > pRESET > 3D Separator. In the phantom study, the pRESET device detached in a configuration resembling the M1 segment was successfully removed with the Tigertriever. Conclusions: Conservative management of the inadvertent detachment of stent retrievers during mechanical thrombectomy in large vessel occlusion may be acceptable in order to avoid further periprocedural complications after unsuccessful device removal attempts. Based on the phantom and mechanical studies, the Tigertriever may be a useful tool for the removal of detached pRESET devices.

Purpose: The mechanical thrombectomy became a standard treatment option in acute ischemic stroke patients with a symptomatic occlusion of large cerebral artery within first six hours after stroke onset. Acute ischemic stroke can also be caused by tandem occlusion. The aim of our retrospective study was to evaluate safety of carotid artery stenting and subsequent mechanical trombectomy (antegrade approach). Methods: All consecutive IS patients treated due to tandem occlusion were enrolled into the retrospective analysis. Neurological deficit was scored using National Institutes of Health Stroke Scale (NIHSS). In all patients we used antegrade technique. Achieved recanalization was rated using Thrombolysis in Cerebral Infarction (TICI) scale. Symptomatic intracerebral haemorrhage (SICH) was assessed according to the SITS-MOST criteria. Ninety day clinical outcome was scored using modified Rankin (mRS) scale with score 0--2 for good outcome. Results: In total 39 patients (79.5% of males, mean age 65.7 years) were treated for TO with a mean score of admission NIHSS 15 points. Overall recanalization (TICI2b/3) was achieved in 94.9% and complete (TICI 3) in 59% of patients. SICH after procedure was detected in 4 patients (10.3%). A good 90-day clinical outcome after 3 months was achieved in 22 patients (56.4%). The rate of 3-month mortality was 15.4%. In the statistical comparison, there was a significant difference in the patency of single-layer and double-layered stents in the early post-operative period (100% vs. 73.3%, p = 0.023), but no significant relationship between stent type and 90-day mRS was found (p = 0.123). Conclusion: Antegrade treatment technique of ischemic stroke patients with tandem occlusion is effective and safe. The use of dual-layer stents increase the risk of early occlusion of the extracranial portion of the ACI, but does not affect the clinical outcome. [ABSTRACT FROM AUTHOR]

Background and Purpose: The application of radiopaque markers to the Solitaire™ stent-retriever for better visibility during mechanical thrombectomy (MT) has the potential to alter the well-known characteristics of the device; however, it is uncertain whether this adjustment influences efficacy or safety of the enhanced stent-retriever. Methods: Retrospective analysis of stroke databases of three comprehensive stroke centers. Our investigation was focused on technical and angiographic parameters, including procedure times, reperfusion results (thrombolysis in cerebral infarction, TICI), periprocedural complications and favorable early neurological recovery at discharge (modified Rankin scale ≤2 or National Institutes of Health Stroke Scale, NIHSS = 0 or ∆NIHSS ≥ 10), from consecutive patients with acute anterior circulation ischemic stroke treated with a Solitaire™ Platinum stent-retriever between October 2016 and March 2017. Results: A total of 75 patients (male: n = 27, 36%, age in years: mean (SD): 75 (±12), median baseline NIHSS: 17 (interquartile range IQR: 11–21), n = 41, 54.7% received additional i. v. thrombolytics) were treated with a median number of 2 device passes (range: 1–5). The median time from groin puncture to final TICI was 56 min (IQR: 41–79). In 69 patients (92%) TICI 2b-3 was achieved. Early neurological recovery was seen in 47 (62.7%) patients. The following periprocedural complications occurred: vasospasms (n = 7, 9.3%), emboli into a new territory (n = 4, 5.3%), symptomatic intracranial hemorrhage (n = 3, 4%), difficulties during device delivery/deployment (n = 1, 1.3%). Conclusion: The usage of the Solitaire™ Platinum stent-retriever for MT in acute ischemic stroke patients was highly effective and was not accompanied by an increased periprocedural complication rate. [ABSTRACT FROM AUTHOR]

Background: Recent trials have proved the efficacy of mechanical thrombectomy over medical treatment for patients with acute ischemic stroke, with the balance of equivalent rates of adverse events. Stent retrievers were applied predominantly in most trials; however, the role of other thrombectomy devices has not been well validated. A direct aspiration first-pass technique (ADAPT) is proposed to be a faster thrombectomy technique than the stent retriever technique. This meta-analysis investigated and compared the efficacy and adverse events of first-line ADAPT with those of first-line stent retrievers in patients with acute ischemic stroke.Methods: A structured search was conducted comprehensively. A total of 1623 papers were found, and 4 articles were included in our meta-analysis. The Critical Appraisal Skills Programme tools were applied to evaluate the quality of studies. The primary outcome was defined as the proportion of patients with the Thrombolysis in Cerebral Ischemia (TICI) scale of 2b/3 at the end of all procedures. Secondary outcomes were the proportion of patients with functional independence (modified Rankin scale of 0–2) at the third month, the proportion of patients with the Thrombolysis in Cerebral Ischemia (TICI) scale of 2b/3 by primary chosen device, and the proportion of patients who received rescue therapies. Safety outcomes were the symptomatic intracranial hemorrhage (sICH) rate and the mortality rate within 3 months.Results: One randomized controlled trial, one prospective cohort study, and two retrospective cohort studies were included. No significant difference between these 2 strategies of management were observed in the primary outcome (TICI scale at the end of all procedures, odds ratio [OR] = 0.78), two secondary outcomes (functional independence at the third month, OR = 1.16; TICI scale by primary chosen device, OR = 1.25), and all safety outcomes (sICH rate, OR = 1.56; mortality rate, OR = 0.91). The proportion of patients who received rescue therapies was higher in the first-line ADAPT group (OR = 0.64).Conclusions: Among first-line thrombectomy devices for patients with ischemic stroke, ADAPT with the latest thrombosuction system was as efficient and safe as stent retrievers.

Background Currently, acute ischemic stroke is still a leading cause of mortality and morbidity. Approximately 2 years ago, mechanical thrombectomy was proven beneficial as a revolutionary new therapy for stroke in the MR‐CLEAN trial (A Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands). However, the mechanisms by which the thrombectomy device, or stent‐retriever, interacts with the thrombus are largely unknown. A better understanding could lead to improved efficacy of mechanical thrombectomy devices. Methods and Results Seven stent‐retrievers with thrombi still entrapped were collected directly after thrombectomy. The stent‐retrievers were studied using micro computed tomography, followed by scanning electron microscopy and light microscopy. Two independent observers rated interaction type and thrombus surface structure (porous filamentous or dense) at the interaction sites. A total of 79 interaction sites between thrombus and stent‐retriever were categorized. Thrombus‐stent‐retriever interaction was found to be adhesive (n=44; 56%) or mechanical (n=35; 44%). Adhesive interaction was most frequently observed at interaction sites with a dense surface, compared with interaction sites with a porous filamentous fibrin surface (38/58; 66% versus 6/21; 29%, P=0.011). Conclusions The interaction between thrombus and stent‐retriever was predominantly adhesive, not mechanical. Adhesive interaction was strongly associated with the presence of a dense thrombus surface without a porous filamentous fibrin network.

ObjectiveTo explore the effects of reperfusion grade rates on clinical outcomes in the setting of stent-retriever-based reperfusion therapy for anterior circulation stroke in early time windows.MethodsSystematic searching of Medline and Embase databases was performed to identify stroke trials of stent-retriever-based therapy versus standard care. Mixed effects meta-regression was used to analyze the trial-level association between reperfusion rates and clinical outcomes.ResultsA total of five trials met the inclusion criteria (n = 1,287). Rates of successful reperfusion [modified thrombolysis in cerebral ischemia grade 2b/3] demonstrated strong evidence for an association with good functional outcomes [modified Rankin scale score (mRS) 0–2] OR 1.59 (95% CI 1.16, 2.19) p = 0.019 and very strong evidence for an association with excellent functional outcomes (mRS 0–1) OR 2.10 (95% CI 1.46, 3.01) p = 0.007. In addition, there was weak evidence for an association with symptomatic intracranial hemorrhage OR 0.54 (95% CI 0.28, 1.04) p = 0.057 and mortality OR 0.69 (95% CI 0.69, 1.01) p = 0.053.ConclusionIn early, stent-retriever-based acute ischemic stroke treatment, reperfusion appears to be a major predictor of outcomes. Every 10% increase in the rates of successful reperfusion is associated with an 11% increase in the probability of achieving good and 17% increase in the probability of achieving excellent outcomes. Symptomatic intracranial hemorrhage and mortality may be decreased as reperfusion rates are improved.

Textural analysis is pivotal in augmenting the diagnosis and outcomes of endovascular procedures for stroke patients. Due to the detection of changes imperceptible to the human eye, this type of analysis can potentially aid in deciding the optimal type of endovascular treatment. We included 40 patients who suffered from acute ischemic stroke caused by large vessel occlusion, and calculated 130 different textural features based on the non-enhanced CT scan using an open-source software (3D Slicer). Using chi-squared and Mann-Whitney tests and receiver operating characteristics analysis, we identified a total of 21 different textural parameters capable of predicting the outcome of thrombectomy (quantified as the mTICI score), with variable sensitivity (50-97.9%) and specificity (64.6-99.4%) rates. In conclusion, CT-based radiomics features are potential factors that can predict the outcome of thrombectomy in patients suffering from acute ischemic stroke, aiding in the decision between aspiration, mechanical, or combined thrombectomy procedure.

Background: Recent trials have proved the efficacy of mechanical thrombectomy over medical treatment for patients with acute ischemic stroke, with the balance of equivalent rates of adverse events. Stent retrievers were applied predominantly in most trials; however, the role of other thrombectomy devices has not been well validated. A direct aspiration first-pass technique (ADAPT) is proposed to be a faster thrombectomy technique than the stent retriever technique. This meta-analysis investigated and compared the efficacy and adverse events of first-line ADAPT with those of first-line stent retrievers in patients with acute ischemic stroke. Methods: A structured search was conducted comprehensively. A total of 1623 papers were found, and 4 articles were included in our meta-analysis. The Critical Appraisal Skills Programme tools were applied to evaluate the quality of studies. The primary outcome was defined as the proportion of patients with the Thrombolysis in Cerebral Ischemia (TICI) scale of 2b/3 at the end of all procedures. Secondary outcomes were the proportion of patients with functional independence (modified Rankin scale of 0–2) at the third month, the proportion of patients with the Thrombolysis in Cerebral Ischemia (TICI) scale of 2b/3 by primary chosen device, and the proportion of patients who received rescue therapies. Safety outcomes were the symptomatic intracranial hemorrhage (sICH) rate and the mortality rate within 3 months. Results: One randomized controlled trial, one prospective cohort study, and two retrospective cohort studies were included. No significant difference between these 2 strategies of management were observed in the primary outcome (TICI scale at the end of all procedures, odds ratio [OR] = 0.78), two secondary outcomes (functional independence at the third month, OR = 1.16; TICI scale by primary chosen device, OR = 1.25), and all safety outcomes (sICH rate, OR = 1.56; mortality rate, OR = 0.91). The proportion of patients who received rescue therapies was higher in the first-line ADAPT group (OR = 0.64). Conclusions: Among first-line thrombectomy devices for patients with ischemic stroke, ADAPT with the latest thrombosuction system was as efficient and safe as stent retrievers. [ABSTRACT FROM AUTHOR]

Background: Our objective was to review economic evaluations on stent-retriever thrombectomy (SRT) added/not added to intravenous (IV) tissue plasminogen activator (t-PA) in acute ischemic stroke (AIS) due to large-vessel occlusion (LVO).Methods: We conducted a systematic review using several electronic databases and searching for studies published from January 2009 to September 2017. Inclusion criteria: any publication type reporting the incremental cost-effectiveness ratio of SRT in people with AIS secondary to LVO. Quality assessment was undertaken with the CHEERS and the Philips’ checklists.Results: Eight original articles (four from North America/four from Europe) were included; of these, seven were model-based cost-effectiveness studies and one was a study conducted alongside a clinical trial. The perspective was the healthcare system in seven studies, and societal in one. The time horizon was lifetime (minimum 20 years) in all but two studies where it was 1 and 5 years. Overall, studies were rated of good quality (mean score 79%; range 70-90). Data sources, effectiveness outcomes and other input parameters were heterogeneous across studies. In three studies, SRT was dominant (less expensive and more effective). In five studies, SRT was more expensive and generated more quality-adjusted life years but had a high probability (79-100%) to be cost-effective at conventional thresholds.Conclusion: This review shows that SRT added/not added to IV t-PA is likely to be cost-effective or even dominant, which is consistent with the opinion from several Health Technology Assessment bodies recommending SRT. However, our findings are supported by primary studies with substantial methodological heterogeneity. [ABSTRACT FROM AUTHOR]

Objective: To explore the effects of reperfusion grade rates on clinical outcomes in the setting of stent-retriever-based reperfusion therapy for anterior circulation stroke in early time windows. Methods: Systematic searching of Medline and Embase databases was performed to identify stroke trials of stent-retriever-based therapy versus standard care. Mixed effects meta-regression was used to analyze the trial-level association between reperfusion rates and clinical outcomes. results: A total of five trials met the inclusion criteria (n = 1,287). Rates of successful reperfusion [modified thrombolysis in cerebral ischemia grade 2b/3] demonstrated strong evidence for an association with good functional outcomes [modified Rankin scale score (mRS) 0-2] OR 1.59 (95% CI 1.16, 2.19) p = 0.019 and very strong evidence for an association with excellent functional outcomes (mRS 0-1) OR 2.10 (95% CI 1.46, 3.01) p = 0.007. In addition, there was weak evidence for an association with symptomatic intracranial hemorrhage OR 0.54 (95% CI 0.28, 1.04) p = 0.057 and mortality OR 0.69 (95% CI 0.69, 1.01) p = 0.053. conclusion: In early, stent-retriever-based acute ischemic stroke treatment, reperfusion appears to be a major predictor of outcomes. Every 10% increase in the rates of successful reperfusion is associated with an 11% increase in the probability of achieving good and 17% increase in the probability of achieving excellent outcomes. Symptomatic intracranial hemorrhage and mortality may be decreased as reperfusion rates are improved. [ABSTRACT FROM AUTHOR]

Cerebral venous sinus thrombosis (CVST) is generally treated with anticoagulation therapy, however, endovascular therapy is considered for refractory cases. A 42-year-old woman presented with a progressive disturbance in consciousness, and diagnosed CVST in the straight sinus (SS). Recanalization of SS was achieved by emergent thrombectomy using aspiration catheter and stent-retriever system, and her level of consciousness improved immediately. The combined use of them aided the removal of the thrombus located in the SS. [ABSTRACT FROM AUTHOR]

• A new approach for modeling the microcatheter tracking during thrombectomy is proposed. • The catheter tracking simulations are qualitatively validated with clinical images of thrombectomy procedures. • Simulations of thrombectomy with different positions of the microcatheter resulted in different procedure outcomes. • The study highlights the importance of an accurate modeling of the microcatheter tracking. Mechanical thrombectomy is a minimally invasive procedure that aims at removing the occluding thrombus from the vasculature of acute ischemic stroke patients. Thrombectomy success and failure can be studied using in-silico thrombectomy models. Such models require realistic modeling steps to be effective. We here present a new approach to model microcatheter tracking during thrombectomy. For 3 patient-specific vessel geometries, we performed finite-element simulations of the microcatheter tracking (1) following the vessel centerline (centerline method) and (2) as a one-step insertion simulation, where the microcatheter tip was advanced along the vessel centerline while its body was free to interact with the vessel wall (tip-dragging method). Qualitative validation of the two tracking methods was performed with the patient's digital subtraction angiography (DSA) images. In addition, we compared simulated thrombectomy outcomes (successful vs unsuccessful thrombus retrieval) and maximum principal stresses on the thrombus between the centerline and tip-dragging method. Qualitative comparison with the DSA images showed that the tip-dragging method more realistically resembles the patient-specific microcatheter-tracking scenario, where the microcatheter approaches the vessel walls. Although the simulated thrombectomy outcomes were similar in terms of thrombus retrieval, the thrombus stress fields (and the associated fragmentation of the thrombus) were strongly different between the two methods, with local differences in the maximum principal stress curves up to 84%. Microcatheter positioning with respect to the vessel affects the stress fields of the thrombus during retrieval, and therefore, may influence thrombus fragmentation and retrieval in-silico thrombectomy. [ABSTRACT FROM AUTHOR]

Background and purpose: In patients with acute ischemic stroke who receive antiplatelet treatment, uncertainty exists about the effect and safety of intra-arterial treatment. Our aim was to study whether intra-arterial treatment in patients with prior antiplatelet treatment is safe and whether prior antiplatelet treatment modifies treatment effect. Methods: All 500 MR CLEAN patients were included. We estimated the effect of intra-arterial treatment with ordinal logistic regression analysis, and tested for interaction of antiplatelet treatment with intra-arterial treatment on outcome. Furthermore, safety parameters and serious adverse events were analyzed. Results: The 144 patients (29%) on antiplatelet treatment were older, more often male, and had more vascular comorbidity. Intra-arterial treatment effect size after adjustments in antiplatelet treatment patients was 1.7 (95% confidence interval 0.9-3.2), and in no antiplatelet treatment patients 1.8 (95% confidence interval: 1.2-2.6). There was no statistically or clinically significant interaction between prior antiplatelet treatment and the relative effect of intra-arterial treatment (p=0.78). However, in patients on antiplatelet treatment, the effect of successful reperfusion on functional outcome in the intervention arm of the trial was doubled: the absolute risk difference for favorable outcome after successful reperfusion in patients on prior antiplatelet treatment was 39% versus 18% in patients not on prior antiplatelet treatment (Pinteraction=0.025). Patients on antiplatelet treatment more frequently had a symptomatic intracranial hemorrhage (15%) compared to patients without antiplatelet treatment (4%), without differences between the control and intervention arm. Conclusions: Prior treatment with antiplatelet agents did not modify the effect of intra-arterial treatment in patients with acute ischemic stroke presenting with an intracranial large vessel occlusion. There were no safety concerns. In patients with reperfusion, antiplatelet agents may improve functional outcome. [ABSTRACT FROM AUTHOR]

Objective To report the use of a stent-retriever in the management of vasospasm secondary to craniopharyngioma resection. Postoperative improvement was seen both clinically and on perfusion imaging. Methods A patient was admitted for resection of a large craniopharygioma. On day 6 postoperatively the patient had an acute hemiparesis. A computed tomography angiogram and perfusion scan demonstrated acute right-sided cerebral vasospasm and a perfusion defect in the territory of the middle cerebral artery (MCA). Results A pREset 4 × 20 mm stent-retriever was used to dilate the M1 and proximal M2 segments of the right MCA mechanically. This resulted in immediate dilatation of the spastic segment and improvement in the transit time on the angiogram. There was an improvement in the clinical status post-procedure and a computed tomography perfusion performed 24 hours after the procedure showed symmetrical perfusion. A computed tomography angiogram and magnetic resonance imaging performed 1 week later showed a symmetrical appearance to the MCA and no evidence of restricted diffusion. Conclusion The use of commercially available stent-retrievers can cause mechanical dilatation of vasospastic vessels. The stents do not need to be deployed for a prolonged period nor do they need to be implanted to have a prolonged dilatory effect on the spastic vessels. [ABSTRACT FROM AUTHOR]

Background: Brazil is a developing country struggling to reduce its extreme social inequality, which is reflected on shortage of health-care infrastructure, mainly to the low-income class, which depends exclusively on the public health system. In Brazil, less than 1% of stroke patients have access to intravenous thrombolysis in a stroke unit, and constraints to the development of mechanical thrombectomy in the public health system increase the social burden of stroke.Objective: Report the feasibility of mechanical thrombectomy as part of routine stroke care in a Brazilian public university hospital.Methods: Prospective data were collected from all patients treated for acute ischemic stroke with mechanical thrombectomy from June 2011 to March 2016. Combined thrombectomy was performed in eligible patients for intravenous thrombolysis if they presented occlusion of large artery. For those patients ineligible for intravenous thrombolysis, primary thrombectomy was performed as long as there was no evidence of significant ischemia for anterior circulation stroke (Alberta Stroke Program Early CT score  >6) within a 6-hour time window, and also for those patients with wake-up stroke or posterior circulation stroke, regardless of the time of symptoms onset.Results: A total of 161 patients were evaluated, resulting in an overall successful recanalization rate of 76% and symptomatic intracranial hemorrhage rate of 6.8%. At 3 months, 36% of the patients had modified Rankin Scale score less than or equal to 2. The overall mortality rate was 23%.Conclusion: Our study, the first ever large series of mechanical thrombectomy in Brazil, demonstrates acceptable efficacy and safety results, even under restricted conditions outside the ideal scenario of trial studies. [ABSTRACT FROM AUTHOR]

Purpose: The composition of thrombi retrieved during endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) due to large vessel occlusion (LVO) may differ depending on their origin. In this study, we investigated the association between thrombus composition and stroke etiology in a large population of patients from the Dutch MR CLEAN Registry treated with EVT in daily clinical practice.The thrombi of 332 patients with AIS were histologically analyzed for red blood cells (RBC), fibrin/platelets (F/P), and white blood cells (leukocytes) using a machine learning algorithm. Stroke etiology was assessed using the Trial of Org 10,172 in acute stroke treatment (TOAST) classification.The thrombi of cardioembolic origin contained less RBC and more F/P than those of non-cardioembolic origin (25.8% vs 41.2% RBC [p = 0.003] and 67.1% vs 54.5% F/P [p = 0.004]). The likelihood of a non-cardioembolic source of stroke increased with increasing thrombus RBC content (OR 1.02; [95% CI 1.00–1.06] for each percent increase) and decreased with a higher F/P content (OR 1.02; [95% CI 1.00–1.06]). Thrombus composition in patients with a cardioembolic origin and undetermined origin was similar.Thrombus composition is significantly associated with stroke etiology, with an increase in RBC and a decrease in F/P raising the odds for a non-cardioembolic cause. No difference between composition of cardioembolic thrombi and of undetermined origin was seen. This emphasizes the need for more extensive monitoring for arrhythmias and/or extended cardiac analysis in case of an undetermined origin.Methods: The composition of thrombi retrieved during endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) due to large vessel occlusion (LVO) may differ depending on their origin. In this study, we investigated the association between thrombus composition and stroke etiology in a large population of patients from the Dutch MR CLEAN Registry treated with EVT in daily clinical practice.The thrombi of 332 patients with AIS were histologically analyzed for red blood cells (RBC), fibrin/platelets (F/P), and white blood cells (leukocytes) using a machine learning algorithm. Stroke etiology was assessed using the Trial of Org 10,172 in acute stroke treatment (TOAST) classification.The thrombi of cardioembolic origin contained less RBC and more F/P than those of non-cardioembolic origin (25.8% vs 41.2% RBC [p = 0.003] and 67.1% vs 54.5% F/P [p = 0.004]). The likelihood of a non-cardioembolic source of stroke increased with increasing thrombus RBC content (OR 1.02; [95% CI 1.00–1.06] for each percent increase) and decreased with a higher F/P content (OR 1.02; [95% CI 1.00–1.06]). Thrombus composition in patients with a cardioembolic origin and undetermined origin was similar.Thrombus composition is significantly associated with stroke etiology, with an increase in RBC and a decrease in F/P raising the odds for a non-cardioembolic cause. No difference between composition of cardioembolic thrombi and of undetermined origin was seen. This emphasizes the need for more extensive monitoring for arrhythmias and/or extended cardiac analysis in case of an undetermined origin.Results: The composition of thrombi retrieved during endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) due to large vessel occlusion (LVO) may differ depending on their origin. In this study, we investigated the association between thrombus composition and stroke etiology in a large population of patients from the Dutch MR CLEAN Registry treated with EVT in daily clinical practice.The thrombi of 332 patients with AIS were histologically analyzed for red blood cells (RBC), fibrin/platelets (F/P), and white blood cells (leukocytes) using a machine learning algorithm. Stroke etiology was assessed using the Trial of Org 10,172 in acute stroke treatment (TOAST) classification.The thrombi of cardioembolic origin contained less RBC and more F/P than those of non-cardioembolic origin (25.8% vs 41.2% RBC [p = 0.003] and 67.1% vs 54.5% F/P [p = 0.004]). The likelihood of a non-cardioembolic source of stroke increased with increasing thrombus RBC content (OR 1.02; [95% CI 1.00–1.06] for each percent increase) and decreased with a higher F/P content (OR 1.02; [95% CI 1.00–1.06]). Thrombus composition in patients with a cardioembolic origin and undetermined origin was similar.Thrombus composition is significantly associated with stroke etiology, with an increase in RBC and a decrease in F/P raising the odds for a non-cardioembolic cause. No difference between composition of cardioembolic thrombi and of undetermined origin was seen. This emphasizes the need for more extensive monitoring for arrhythmias and/or extended cardiac analysis in case of an undetermined origin.Conclusion: The composition of thrombi retrieved during endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) due to large vessel occlusion (LVO) may differ depending on their origin. In this study, we investigated the association between thrombus composition and stroke etiology in a large population of patients from the Dutch MR CLEAN Registry treated with EVT in daily clinical practice.The thrombi of 332 patients with AIS were histologically analyzed for red blood cells (RBC), fibrin/platelets (F/P), and white blood cells (leukocytes) using a machine learning algorithm. Stroke etiology was assessed using the Trial of Org 10,172 in acute stroke treatment (TOAST) classification.The thrombi of cardioembolic origin contained less RBC and more F/P than those of non-cardioembolic origin (25.8% vs 41.2% RBC [p = 0.003] and 67.1% vs 54.5% F/P [p = 0.004]). The likelihood of a non-cardioembolic source of stroke increased with increasing thrombus RBC content (OR 1.02; [95% CI 1.00–1.06] for each percent increase) and decreased with a higher F/P content (OR 1.02; [95% CI 1.00–1.06]). Thrombus composition in patients with a cardioembolic origin and undetermined origin was similar.Thrombus composition is significantly associated with stroke etiology, with an increase in RBC and a decrease in F/P raising the odds for a non-cardioembolic cause. No difference between composition of cardioembolic thrombi and of undetermined origin was seen. This emphasizes the need for more extensive monitoring for arrhythmias and/or extended cardiac analysis in case of an undetermined origin. [ABSTRACT FROM AUTHOR]

Catheter-based interventions for acute ischaemic stroke currently include clot removal (usually from the medial cerebral artery) with modern stent-retrievers and in one of five patients (who have simultaneous or stand-alone internal carotid occlusion) also extracranial carotid intervention. Several recently published randomized trials clearly demonstrated superiority of catheter-based interventions (with or without bridging thrombolysis) over best medical therapy alone. The healthcare systems should adopt the new strategies for acute stroke treatment (including fast track to interventional lab) to offer the benefits to all suitable acute stroke patients. [ABSTRACT FROM AUTHOR]

The authors present an overview of the trend in endovascular procedure rates for ischemic stroke during the last six years. Mechanical thrombectomy (MT) gained the highest level of evidence in 2015 when positive results of several studies comparing the clinical outcome of MT with intravenous thrombolysis using recombinant tissue plasminogen activator were published. MT has become the most frequent endovascular therapeutic procedure on cerebral vessels. In order to provide this therapy, there has been an active geographical system of qualified cerebrovascular centers at two levels in the Czech Republic since 2010. The authors give a survey of possibilities how to increase the effectiveness of the existing system in terms of both quantitative and qualitative aspects. [ABSTRACT FROM AUTHOR]

Stent-retriever based mechanical thrombectomy (MT) has gained wide acceptance as the treatment of choice for acute ischaemic stroke (AIS) caused by large vessel occlusion (LVO). The Embotrap 3 is the latest iteration within this class of device. We present our results using the new Embotrap 3 device.We performed a retrospective review of our prospectively maintained database to identify all patients treated with the Embotrap 3 stent-retriever between January 2021 and January 2022. We recorded the baseline demographics, NIHSS, ASPECT score and clot characteristics, first pass and final eTICI scores, complications and 90 day mRS.One hundred and ten patients met the inclusion criteria, average age 69 ± 14 years, 50% were male (n = 55). The median NIHSS at presentation was 18 (range 3–30) and 58.2% received IV tPA prior to MT. The median ASPECT score on plain CT was 8 with average clot length 20.2 ± 14.8 mm (n = 93). The first pass effect (FPE) was seen in 41.8% of cases with modified FPE seen in 59.1%. A 24-hour CT scan (n = 97) showed median ASPECTs of 7. 43.8% of patients achieve mRS ≤ 2 at 90-day mRS (n = 64).The Embotrap 3 stent-retriever has a high rate of FPE and final recanalization in this real world cohort of patients. [ABSTRACT FROM AUTHOR]

Background and purpose: Patients with acute ischemic stroke due to intracranial large vessel occlusion benefit from intra-arterial therapy. Uncertainty exists about the effect of intra-arterial therapy in patients with contraindications for treatment with intravenous alteplase treatment. Our aim was to describe the clinical characteristics of this subgroup of patients and whether intra-arterial therapy is as safe and effective as it is after intravenous alteplase treatment. Methods: All 500 MR CLEAN patients were included and we distinguished between patients who were and were not treated with intravenous alteplase treatment. We estimated the effect of intra-arterial therapy on the shift on the modified Rankin Scale score with ordinal logistic regression analysis and tested for interaction of intravenous alteplase treatment with intra-arterial therapy on outcome. Furthermore, safety parameters and serious adverse events were analyzed. Results: Fifty-five patients (11%) were not treated with intravenous alteplase treatment, mostly because of prolonged coagulation time tests or recent surgery. These patients were older and more often had atrial fibrillation or other vascular comorbidity. There was no interaction between intravenous alteplase treatment and intervention effect (p=0.927). Intra-arterial therapy effect size in patients without intravenous alteplase treatment was 2.06 [95% CI: 0.69–6.13] and in patients with intravenous alteplase treatment 1.71 [95% CI: 1.22–2.40]. There were no safety issues. Conclusions: For patients with acute ischemic anterior circulation stroke caused by intracranial large vessel occlusion, who have contraindications for intravenous alteplase, intra-arterial treatment is not less effective or less safe than in patients who receive the treatment after intravenous alteplase. Clinical trial registration: Clinical trial registration-URL: http://www.trialregister.nl. Unique identifier: (NTR)1804. Clinical trial registration-URL: http://www.controlled-trials.com. Unique identifier: ISRCTN10888758. [ABSTRACT FROM AUTHOR]

Background: In the last 12 months, treatment of acute ischaemic stroke secondary to large vessel occlusion has undergone a paradigm shift. The success of endovascular surgery, and in particular, the use of stent-retrievers, is remarkable. Summary: Beyond percentages and p values, the endovascular trials demonstrated, in their similarities and their differences, the critical elements of successful intervention in acute ischaemic stroke. Patient selection based on non-invasive neuroimaging has emerged as a critical step in acute ischaemic stroke management. The more sophisticated imaging-based selection, those assessing collateral blood flow or ischaemic penumbra appear to be associated with better outcomes and possibly fewer complications. The importance of achieving effective, quality reperfusion is also demonstrated, in a remarkably linear fashion, across the 5 published trials. This may emerge as the single most important determinant of functional outcomes. While reperfusion may succeed time as the preeminent modifiable variable, it remains clear that achieving quality reperfusion in a timely manner should remain the goal of all acute stroke programs. Key Message: Comparing the recent successful endovascular stroke trials, both between one another, and to their unsuccessful predecessors, emphasizes the importance of patient selection, time and reperfusion. Highlighting these factors allows for a better understanding of the challenges facing clinicians and the changes required to be made in hospital systems in order to achieve a new standard of care in treating acute ischaemic stroke. [ABSTRACT FROM AUTHOR]

Stroke is the most common cause of permanent disability, the second most common cause of dementia, and the third most common cause of death in the Western world. About 10% to 20% of strokes are due to large-artery occlusions causing severe disabling strokes. Recently, 5 randomized controlled trials established mechanical thrombectomy in stroke treatment in patients with large-vessel occlusions. The current intra-arterial reperfusion therapies allow high recanalization rates, high rates of favorable clinical outcome, and low complication rates. This review discusses the results of recent randomized trials and describes the current state-of-the-art endovascular treatment in acute ischemic stroke. [ABSTRACT FROM AUTHOR]

Several recent prospective randomized controlled trials of endovascular stroke therapy using latest generation thrombectomy devices, so called stent-retrievers, have shown significantly improved clinical outcome compared to the standard treatment with intra-venous thrombolysis using r-tPA alone. Despite some differences in inclusion criteria between these studies, all required non-invasive vessel imaging to proof occlusion of a major brain supplying vessel. Furthermore, in most studies additional imaging techniques were used to exclude patients with already established large cerebral infarction or unfavorable collateral or penumbral status. Patients with small infarct volume, severe neurological deficits and in whom thrombectomy can be initiated within the first 6 hours after symptom onset seem to benefit the most. Therefore, mechanical thrombectomy using stent-retrievers in addition to intra-venous thrombolysis is recommended for the treatment of acute ischemic stroke with proven major vessel occlusion in the anterior circulation. [ABSTRACT FROM PUBLISHER]

Two placebo-controlled trials have shown that early administration of intravenous recombinant tissue plasminogen activator (rt-PA) after ischemic stroke improves outcomes since 4.5h after symptoms onset; meanwhile another six trials cannot demonstrate it. We also know from the analysis of the pooled data that benefit from treatment decreased as time from stroke onset to start the treatment increased. In addition to time, another important point is patient selection through multimodal imaging, combining data from artery status and salvageable tissue, but nowadays, randomized controlled trials (RCT) cannot demonstrate outcomes benefit of neuroimaging mismatch selection far away from 4.5h from symptoms onset. Focusing in cases of large arterial occlusion we know that recanalization is crucial, so an interesting approach it has been the use of endovascular treatment. The use of intraarterial thrombolysis was tested in two small RCT that demonstrated clear benefit in terms of higher recanalization and also in clinical outcomes. But a new paradigm of stroke treatment may have begun with mechanical thrombectomy. In this field, Merci devices have been overcome by the fully deployed closed-cell self-expanding stents (stent-triever). However even thought the highly rate of recanalization obtained with the stent retrievers compared with the other recanalization treatments, the use of those devices cannot demonstrate clear better outcomes. Thus futile recanalization occurs when successful recanalization fails to improve functional outcome. Recently three randomized controlled trials, Synthesis, IMS-III, and MR-Rescue, have not been demonstrated clear benefit of endovascular treatment. Probably this trials fails in their design in order to prove the superiority of endovascular treatment due to it did not use an optimal target populations, the vascular status were not evaluated in all patients, a relatively high rates of patients did not have enough mismatch, time from baseline n