Mechanical thrombectomy in acute ischemic stroke due to large vessel occlusion in the anterior circulation and low baseline National Institute of Health Stroke Scale score: a multicenter retrospective matched analysis

Background: There is very limited data on the use of advanced neuroimaging to select patients with acute ischemic stroke and large vessel occlusion for intraarterial therapy beyond 6 hours from onset. Our aim is to report the outcome of patients with acute ischemic stroke and large artery occlusion who presented beyond 6 hours from onset, had favorable MRI imaging profile, and underwent mechanical embolectomy. Methods: This is a single institution retrospective study between December 1st, 2015, and July 30 th , 2016 with acute ischemic stroke and anterior circulation large vessel occlusion (LVO) with ASPECTS of 6 or more and beyond 6 hours from symptoms onset. Favorable imaging profile was defined as 1) DWI lesion volume (as defined as apparent diffusion coefficient < 620 X 10-6 mm2/s) of 70 mL or less AND 2) Penumbra volume (as defined by volume of tissue with Tmax >6 sec) of 15 mL or greater AND 3) A mismatch ratio of 1.8 or more AND 4) Volume of tissue with perfusion lesion with Tmax > 10 sec is less than 100 mL. Good outcome was defined as a 90 day mRS≤2. Results: In the study period, 41 patients met the inclusion criteria; 22 (53.6%) had favorable imaging profile and underwent mechanical embolectomy. The median age was 75 years (59-92), 68.2% were females; the median time from last known normal to groin puncture was 684.5 minutes (range 363-1628) and the median admission NIHSS score was 17.5 (range 4-28). The rate of good outcomes in this series was similar to that in a patient level pooled meta-analysis of the recent endovascular trials (68.2% vs. 46.0%, p=0.07). The rate of good outcome matches that of the EXTEND-IA trial that selected patients using perfusion imaging (68.2% vs. 71.0%, p = 1.00). None of the patients in our cohort had symptomatic intracereberal hemorrhage. Conclusion: Advanced MR imaging may help select patients with acute ischemic stroke and anterior circulation large vessel occlusion for embolectomy beyond the treatment window used in most endovascular trials.

Download Full-text

Workflow Intervals of Endovascular Acute Stroke Therapy During On- Versus Off-Hours

Stroke ◽

10.1161/strokeaha.119.025381 ◽

2019 ◽

Vol 50 (10) ◽

pp. 2842-2850 ◽

Cited By ~ 3

Author(s):

Wouter H. Hinsenveld ◽

Inger R. de Ridder ◽

Robert J. van Oostenbrugge ◽

Jan A. Vos ◽

Adrien E. Groot ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Large Vessel ◽

Complication Rates ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Significant Difference

Background and Purpose— Endovascular treatment (EVT) of patients with acute ischemic stroke because of large vessel occlusion involves complicated logistics, which may cause a delay in treatment initiation during off-hours. This might lead to a worse functional outcome. We compared workflow intervals between endovascular treatment–treated patients presenting during off- and on-hours. Methods— We retrospectively analyzed data from the MR CLEAN Registry, a prospective, multicenter, observational study in the Netherlands and included patients with an anterior circulation large vessel occlusion who presented between March 2014 and June 2016. Off-hours were defined as presentation on Monday to Friday between 17:00 and 08:00 hours, weekends (Friday 17:00 to Monday 8:00) and national holidays. Primary end point was first door to groin time. Secondary end points were functional outcome at 90 days (modified Rankin Scale) and workflow time intervals. We stratified for transfer status, adjusted for prognostic factors, and used linear and ordinal regression models. Results— We included 1488 patients of which 936 (62.9%) presented during off-hours. Median first door to groin time was 140 minutes (95% CI, 110–182) during off-hours and 121 minutes (95% CI, 85–157) during on-hours. Adjusted first door to groin time was 14.6 minutes (95% CI, 9.3–20.0) longer during off-hours. Door to needle times for intravenous therapy were slightly longer (3.5 minutes, 95% CI, 0.7–6.3) during off-hours. Groin puncture to reperfusion times did not differ between groups. For transferred patients, the delay within the intervention center was 5.0 minutes (95% CI, 0.5–9.6) longer. There was no significant difference in functional outcome between patients presenting during off- and on-hours (adjusted odds ratio, 0.92; 95% CI, 0.74–1.14). Reperfusion rates and complication rates were similar. Conclusions— Presentation during off-hours is associated with a slight delay in start of endovascular treatment in patients with acute ischemic stroke. This treatment delay did not translate into worse functional outcome or increased complication rates.

Download Full-text

Dabigatran Reversal Before Intravenous Tenecteplase in Acute Ischemic Stroke

Stroke ◽

10.1161/strokeaha.119.028327 ◽

2020 ◽

Vol 51 (5) ◽

pp. 1616-1619 ◽

Cited By ~ 2

Author(s):

James Beharry ◽

Michael J. Waters ◽

Roy Drew ◽

John N. Fink ◽

Duncan Wilson ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Scale Score ◽

Clinical Laboratory ◽

Intravenous Thrombolysis ◽

Interquartile Range ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion

Background and Purpose— Reversal of dabigatran before intravenous thrombolysis in patients with acute ischemic stroke has been well described using alteplase but experience with intravenous tenecteplase is limited. Tenecteplase seems at least noninferior to alteplase in patients with intracranial large vessel occlusion. We report on the experience of dabigatran reversal before tenecteplase thrombolysis for acute ischemic stroke. Methods— We included consecutive patients with ischemic stroke receiving dabigatran prestroke treated with intravenous tenecteplase after receiving idarucizumab. Patients were from 2 centers in New Zealand and Australia. We reported the clinical, laboratory, and radiological characteristics and their functional outcome. Results— We identified 13 patients receiving intravenous tenecteplase after dabigatran reversal. Nine (69%) were male, median age was 79 (interquartile range, 69–85) and median baseline National Institutes of Health Stroke Scale score was 6 (interquartile range, 4–21). Atrial fibrillation was the indication for dabigatran therapy in all patients. All patients had a prolonged thrombin clotting time (median, 80 seconds [interquartile range, 57–113]). Seven patients with large vessel occlusion were referred for endovascular thrombectomy, 2 of these patients (29%) had early recanalization with tenecteplase abrogating thrombectomy. No patients had parenchymal hemorrhage or symptomatic hemorrhagic transformation. Favorable functional outcome (modified Rankin Scale score, 0–2) occurred in 8 (62%) patients. Two deaths occurred from large territory infarction. Conclusions— Our experience suggests intravenous thrombolysis with tenecteplase following dabigatran reversal using idarucizumab may be safe in selected patients with acute ischemic stroke. Further studies are required to more precisely estimate the efficacy and risk of clinically significant hemorrhage.

Download Full-text

Intra-Arterial Adjunctive Medications for Acute Ischemic Stroke During Mechanical Thrombectomy

Stroke ◽

10.1161/strokeaha.120.031738 ◽

2021 ◽

Vol 52 (4) ◽

pp. 1192-1202

Author(s):

Vanessa H.E. Chen ◽

Grace K.H. Lee ◽

Choon-Han Tan ◽

Aloysius S.T. Leow ◽

Ying-Kiat Tan ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intracranial Hemorrhage ◽

Risk Ratio ◽

Mechanical Thrombectomy ◽

Large Vessel ◽

Tissue Type ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Symptomatic Intracranial Hemorrhage

Background and Purpose: In patients with acute ischemic stroke with large vessel occlusion, the role of intra-arterial adjunctive medications (IAMs), such as urokinase, tPA (tissue-type plasminogen activator), or glycoprotein IIb/IIIa inhibitors, during mechanical thrombectomy (MT) has not been clearly established. We aim to evaluate the efficacy and safety of concomitant or rescue IAM for acute ischemic stroke with large vessel occlusion patients undergoing MT. Methods: We searched Medline, Embase, and Cochrane Stroke Group Trials Register databases from inception until March 13, 2020. We analyzed all studies with patients diagnosed with acute ischemic stroke with large vessel occlusion in the anterior or posterior circulation that provided data for the two treatment arms, (1) MT+IAM and (2) MT only, and also reported on at least one of the following efficacy outcomes, recanalization and 90-day modified Rankin Scale, or safety outcomes, symptomatic intracranial hemorrhage and 90-day mortality. Data were collated in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results: Sixteen nonrandomized observational studies with a total of 4581 patients were analyzed. MT only was performed in 3233 (70.6%) patients, while 1348 (29.4%) patients were treated with both MT and IAM. As compared with patients treated with MT alone, patients treated with combination therapy (MT+IAM) had a higher likelihood of achieving good functional outcome (risk ratio, 1.13 [95% CI, 1.03–1.24]) and a lower risk of 90-day mortality (risk ratio, 0.82 [95% CI, 0.72–0.94]). There was no significant difference in successful recanalization (risk ratio, 1.02 [95% CI, 0.99–1.06]) and symptomatic intracranial hemorrhage between the two groups (risk ratio, 1.13 [95% CI, 0.87–1.46]). Conclusions: In acute ischemic stroke with large vessel occlusion, the use of IAM together with MT may achieve better functional outcomes and lower mortality rates. Randomized controlled trials are warranted to establish the safety and efficacy of IAM as adjunctive treatment to MT.

Download Full-text

Comparison of Mechanical Thrombectomy with Contact Aspiration, Stent Retriever, and Combined Procedures in Patients with Large-Vessel Occlusion in Acute Ischemic Stroke

Medical Science Monitor ◽

10.12659/msm.913458 ◽

2018 ◽

Vol 24 ◽

pp. 9342-9353 ◽

Cited By ~ 3

Author(s):

Václav Procházka ◽

Tomas Jonszta ◽

Daniel Czerny ◽

Jan Krajca ◽

Martin Roubec ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Stent Retriever ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Combined Procedures

Download Full-text

Endovascular treatment of ischemic large-vessel stroke due to infective endocarditis: case series and review of the literature

Neurological Sciences ◽

10.1007/s10072-020-04599-9 ◽

2020 ◽

Vol 41 (12) ◽

pp. 3517-3525

Author(s):

Lucio D’Anna

Keyword(s):

Ischemic Stroke ◽

Infective Endocarditis ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Case Series ◽

Large Vessel ◽

Controlled Trials ◽

Large Vessel Occlusion ◽

Review Of The Literature ◽

Vessel Occlusion

Abstract Background Mechanical thrombectomy is the standard of care, in selected patients, for acute ischemic stroke with large vessel occlusion but its use in patients with stroke secondary to infective endocarditis is controversial. We report three cases of acute ischemic stroke treated by mechanical thrombectomy and we propose an extensive review of the literature to evaluate the clinical safety and efficacy of thrombectomy in patients with stroke secondary to infective endocarditis. Methods A comprehensive literature search was performed following a pre-specified protocol of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Case reports, cases series, cross-sectional studies, case control studies, randomized controlled trials or nonrandomized controlled trials were considered that included endocarditis-related acute ischemic stroke patients who underwent mechanical thrombectomy. Results The database search yielded 431 relevant records published until January 2020. Nineteen articles fulfilled the eligibility criteria that described thirty patients. After the thrombectomy, 13.3% of the patients experienced intracranial haemorrhage. After the procedure, the median National Institutes of Health Stroke Scale score dropped from 15 (IQR 7) to 2.5 (IQR 5.75). At 90 days, mortality was 23.3% while 46.7% of the patients were functionally independent (mRS ≤ 2). Discussion Based on our review, the use of mechanical thrombectomy in patients with large vessel occlusion due to endocarditis-associated stroke might improve patient outcome but it should be considered on a case by case base as the safety has not been well established yet. Further research on risk stratification is needed to drive clinician during the decision-making process.

Download Full-text

Prestroke Disability and Outcome After Thrombectomy for Emergent Anterior Circulation Large Vessel Occlusion Stroke

Neurology ◽

10.1212/wnl.0000000000012827 ◽

2021 ◽

pp. 10.1212/WNL.0000000000012827

Author(s):

Adam de Havenon ◽

Alicia Castonguay ◽

Raul Nogueira ◽

Thanh N. Nguyen ◽

Joey English ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Primary Outcome ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Anterior Circulation ◽

Vessel Occlusion

ObjectiveTo determine the impact of endovascular therapy for large vessel occlusion stroke in patients with pre-morbid disability versus those without.MethodsWe performed a post-hoc analysis of the TREVO Stent-Retriever Acute Stroke (TRACK) Registry, which collected data on 634 consecutive stroke patients treated with the Trevo device as first-line EVT at 23 centers in the United States. We included patients with internal carotid or middle cerebral (M1/M2 segment) artery occlusions and the study exposure was patient- or caregiver-reported premorbid modified Rank Scale (mRS) ≥2 (premorbid disability, PD) versus premorbid mRS score 0-1 (no premorbid disability, NPD). The primary outcome was no accumulated disability, defined as no increase in 90-day mRS from the patient’s pre-morbid mRS.ResultsOf the 634 patients in TRACK, 407 patients were included in our cohort, of which 53/407 (13.0%) had PD. The primary outcome of no accumulated disability was achieved in 37.7% (20/53) of patients with PD and 16.7% (59/354) of patients with NPD (p<0.001), while death occurred in 39.6% (21/53) and 14.1% (50/354) (p<0.001), respectively. The adjusted odds ratio of no accumulated disability for PD patients was 5.2 (95% CI 2.4-11.4, p<0.001) compared to patients with NPD. However, the adjusted odds ratio for death in PD patients was 2.90 (95% CI 1.38-6.09, p=0.005).ConclusionsIn this study of anterior circulation acute ischemic stroke patients treated with EVT, we found that premorbid disability was associated with a higher probability of not accumulating further disability compared to patients with no premorbid disability, but also with higher probability of death.Classification of EvidenceThis study provides Class II evidence that in anterior circulation acute ischemic stroke treated with EVT, patients with premorbid disability compared to those without disability were more likely not to accumulate more disability but were more likely to die. 

Download Full-text