Groin complications in endovascular mechanical thrombectomy for acute ischemic stroke: a 10-year single center experience

BackgroundThe increasing utilization of balloon guide catheters (BGCs) in thrombectomy therapy for ischemic stroke has led to concerns about large-bore sheaths causing vascular groin complications.Objective To retrospectively assess the impact of large large-bore sheaths and vascular closure devices on groin complication rates at a comprehensive stroke center over a 10-year period.MethodsRadiological and clinical records of patients with acute ischemic stroke who underwent mechanical endovascular therapy with an 8Fr or larger sheaths were reviewed. A groin complication was defined as the formation of a groin hematoma, retroperitoneal hematoma, femoral artery pseudoaneurysm, or the need for surgical repair. Information collected included size of sheath, type of hemostatic device, and anticoagulation status of the patient. Blood bank records were also analyzed to identify patients who may have had an undocumented blood transfusion for a groin hematoma.ResultsA total of 472 patients with acute ischemic stroke who underwent mechanical thrombectomy with a sheath and BGC sized 8Fr or larger were identified. 260 patients (55.1%) had tissue Plasminogen Activator (tPA) administered as part of stroke treatment. Vascular closure devices were used in 97.9% of cases (n=462). Two patients were identified who had definite groin complications and a further two were included as having possible complications. There was a very low rate of clinically significant groin complications (0.4–0.8%) associated with the use of large-bore sheaths.ConclusionsThese findings suggest that concerns for groin complications should not preclude the use of BGCs and large-bore sheaths in mechanical thrombectomy for acute ischemic stroke.

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Abstract 1122‐000194: Incidence of Access Site Complications in Patients Receiving Tenecteplase as Bridging Therapy to Endovascular Treatment

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000194 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Brigitte Percival ◽

Yenna Le ◽

Nasar Ali ◽

Sindhu Sahito ◽

Abdallah Amireh ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Real Life ◽

University Hospital ◽

Access Site ◽

Bridging Therapy ◽

Artery Pseudoaneurysm ◽

Access Site Complication ◽

Groin Hematoma

Introduction : Mechanical thrombectomy (EVT) is the standard of endovascular care for acute ischemic stroke secondary to large vessel occlusion. Alteplase in conjunction with EVT has a strong safety profile with low incidence of complications including groin hematoma. Our objective was to evaluate the incidence of groin hematoma in EVT following bridging therapy tenecteplase (TNK) as this is not well‐described in the literature. Methods : Retrospective review of prospectively collected data for patients with acute ischemic stroke who underwent mechanical thrombectomy at a University Hospital. Incidence of access site complication including groin hematoma, retroperitoneal hematoma, blood loss and femoral artery pseudoaneurysm with or without the need for surgical intervention were reviewed. Rates of use of other antithrombotic agents were also noted. Social Science Statistics was used for data analysis. Results : From October of 2020 to April of 2021, of 348 ischemic stroke patients, 16 had LVO identified on CT and received TNK prior to mechanical thrombectomy (Females = 6; age, 63.25 95% CI [54.9207, 71.5793]); Mean weight = 78kg, 95% CI [67.68, 88.32]). Five subjects (31.25%) received intra‐arterial non‐thrombolytics. None received intra‐arterial thrombolytics. Three patients (18.75%) received therapeutic heparin during the procedure. Four patients (25%) were started on non‐thrombolytic infusion during the periprocedural period. One subject (6.25%) was started on stroke nomogram heparin infusion less than 24 hours post‐intervention. One subject (6.25%) developed groin hematoma that did not require intervention. This subject received intra‐arterial non‐thrombolytics during procedure and IV non‐thrombolytics during the peri‐procedural period. Conclusions : Our single center experience with TNK outside of the clinical trial setting with concomitant use of other antithrombotics suggests safety of bridging strategy. Larger prospective ‘real‐life’ studies are required to validate our findings.

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Cerebral endothelial cell-derived small extracellular vesicles enhance neurovascular function and neurological recovery in rat acute ischemic stroke models of mechanical thrombectomy and embolic stroke treatment with tPA

Journal of Cerebral Blood Flow & Metabolism ◽

10.1177/0271678x21992980 ◽

2021 ◽

pp. 0271678X2199298

Author(s):

Chao Li ◽

Chunyang Wang ◽

Yi Zhang ◽

Owais K Alsrouji ◽

Alex B Chebl ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Extracellular Vesicles ◽

Mechanical Thrombectomy ◽

Infarct Volume ◽

Artery Occlusion ◽

Therapeutic Effects ◽

Vessel Occlusion ◽

Healthy Human ◽

Stroke Treatment

Treatment of patients with cerebral large vessel occlusion with thrombectomy and tissue plasminogen activator (tPA) leads to incomplete reperfusion. Using rat models of embolic and transient middle cerebral artery occlusion (eMCAO and tMCAO), we investigated the effect on stroke outcomes of small extracellular vesicles (sEVs) derived from rat cerebral endothelial cells (CEC-sEVs) in combination with tPA (CEC-sEVs/tPA) as a treatment of eMCAO and tMCAO in rat. The effect of sEVs derived from clots acquired from patients who had undergone mechanical thrombectomy on healthy human CEC permeability was also evaluated. CEC-sEVs/tPA administered 4 h after eMCAO reduced infarct volume by ∼36%, increased recanalization of the occluded MCA, enhanced cerebral blood flow (CBF), and reduced blood-brain barrier (BBB) leakage. Treatment with CEC-sEVs given upon reperfusion after 2 h tMCAO significantly reduced infarct volume by ∼43%, and neurological outcomes were improved in both CEC-sEVs treated models. CEC-sEVs/tPA reduced a network of microRNAs (miRs) and proteins that mediate thrombosis, coagulation, and inflammation. Patient-clot derived sEVs increased CEC permeability, which was reduced by CEC-sEVs. CEC-sEV mediated suppression of a network of pro-thrombotic, -coagulant, and -inflammatory miRs and proteins likely contribute to therapeutic effects. Thus, CEC-sEVs have a therapeutic effect on acute ischemic stroke by reducing neurovascular damage.

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Abstract P488: The Impact of First Pass Effect on Acute Ischemic Stroke Clinical Outcomes: Why We Need to Continue to Improve Mechanical Thrombectomy?

Stroke ◽

10.1161/str.52.suppl_1.p488 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Ameer E Hassan ◽

Mahmoud Dibas ◽

Amr Ehab El-Qushayri ◽

Sherief Ghozy ◽

Adam A Dmytriw ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Clinical Outcomes ◽

Mechanical Thrombectomy ◽

Functional Independence ◽

Vessel Occlusion ◽

First Pass Effect ◽

Improved Outcomes ◽

First Pass ◽

The Impact

Background: Mechanical thrombectomy (MT) has significantly improved outcomes of acute ischemic stroke (AIS) patients due to large vessel occlusion (LVO). The first-pass effect (FPE), defined as achieving complete reperfusion (mTICI3/2c) with a single pass, was reported to be associated with higher functional independence rates following EVT and has been emphasized as an important procedural target. We compared MT outcomes in patients who achieved FPE to those who did not in a real world large database. Method: A retrospective analysis of LVO pts who underwent MT from a single center prospectively collected database. Patients were stratified into those who achieved FPE and non-FPE. The primary outcome (discharge and 90 day mRS 0-2) and safety (sICH, mortality and neuro-worsening) were compared between the two groups. Results: Of 580 pts, 261 (45%) achieved FPE and 319 (55%) were non-FPE. Mean age was (70 vs 71, p=0.051) and mean initial NIHSS (16 vs 17, p=0.23) and IV tPA rates (37% bs 36%, p=0.9) were similar between the two groups. Other baseline characteristics were similar. Non-FPE pts required more stenting (15% vs 25%, p=0.003), and angioplasty (19% vs 29%, p=0.01). The FPE group had significantly more instances of discharge (33% vs 17%, p<0.001), and 90-day mRS score 0-2 (29% vs 20%, p<0.001), respectively. Additionally, the FPE group had a significant lower mean discharge NIHSS score (12 vs 17, p<0.001). FPE group had better safety outcomes with lower mortality (14.2% vs 21.6%, p=0.03), sICH (5.7% vs 13.5, p=0.004), and neurological worsening (71.3% vs 78.4%, p=0.02), compared to the non-FPE group. Conclusion: Patients with first pass complete or near complete reperfusion with MT had higher functional independence rates, reduced mortality, symptomatic hemorrhage and neurological worsening. Improvement in MT devices and techniques is vital to increase first pass effect and improve clinical outcomes.

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Abstract WP25: The Impact of Body Mass Index on Outcomes of Mechanical Thrombectomy for Acute Ischemic Stroke

Stroke ◽

10.1161/str.51.suppl_1.wp25 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Stephanie Chen ◽

David McCarthy ◽

Vasu Saini ◽

Marie Brunet ◽

Eric Peterson ◽

...

Keyword(s):

Body Mass Index ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Body Mass ◽

Linear Correlation ◽

Mechanical Thrombectomy ◽

Functional Independence ◽

Normal Weight ◽

Vessel Occlusion ◽

The Impact

Background: Obesity is an established risk factor for acute ischemic stroke (AIS), but its impact on clinical outcomes and mortality after AIS remains controversial. In this study, we evaluate the association of body mass index (BMI) on outcomes after mechanical thrombectomy (MT) for large vessel occlusion acute ischemic stroke (LVOS). Methods: We reviewed our prospective MT database for LVOS between 2015 and 2018. BMI was analyzed as a continuous and categorical variable with underweight BMI <18.5, normal BMI 18.5-24.9, overweight BMI 25-29.9, and obese BMI>30. Multivariate analysis was used to determine predictors of outcome. Results: 335 patients underwent MT with 7 (2.1%) patients classified as underweight, 107 (31.9%) normal, 141 (42.1%) overweight, and 80 (23.9%) obese. Compared to normal weight (reference), obese patients had higher rates of hypertension and hyperlipidemia, while underweight patients had higher rates of previous stroke and presentation NIHSS. The time from symptom onset to puncture, procedural techniques, and reperfusion success (>TICI 2b) was not significantly different between BMI categories. There was a significant inverse linear correlation between BMI and symptomatic hemorrhagic. In patients with successful reperfusion (>TICI 2b), there was also a significant bell-shaped relationship between BMI and functional independence (mRS < 3) with both low and high BMIs associated with worse outcomes. In patients without post-procedural symptomatic hemorrhage, there was a significant linear correlation between BMI and inpatient mortality. Conclusion: In LVOS patients treated with MT, BMI is inversely related with post-procedural symptomatic hemorrhage. Yet in those whom reperfusion is achieved, both lower and higher than normal BMI were associated with worse functional outcomes. Thus, the obesity paradox does not appear to pertain to mechanical thrombectomy, although larger prospective studies are necessary.

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Role of the Neurosurgeon in Acute Ischemic Stroke Treatment From Triage to Intensive Care Unit

Neurosurgery ◽

10.1093/neuros/nyz013 ◽

2019 ◽

Vol 85 (suppl_1) ◽

pp. S47-S51

Author(s):

Kimberly P Kicielinski ◽

Christopher S Ogilvy

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Stroke Care ◽

Stroke Patients ◽

Acute Setting ◽

Stroke Treatment

Abstract As ischemic stroke care advances with more patients eligible for mechanical thrombectomy, so too does the role of the neurosurgeon in these patients. Neurosurgeons are an important member of the team from triage through the intensive care unit. This paper explores current research and insights on the contributions of neurosurgeons in care of acute ischemic stroke patients in the acute setting.

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The Impact of Age on Mortality and Disability in Patients With Ischemic Stroke Who Underwent Cerebral Reperfusion Therapy: A Brazilian Cohort Study

Frontiers in Aging Neuroscience ◽

10.3389/fnagi.2021.649902 ◽

2021 ◽

Vol 13 ◽

Author(s):

Natália Eduarda Furlan ◽

Gustavo José Luvizutto ◽

Pedro Tadao Hamamoto Filho ◽

Silméia Garcia Zanati Bazan ◽

Gabriel Pinheiro Modolo ◽

...

Keyword(s):

Cohort Study ◽

Ischemic Stroke ◽

Hospital Discharge ◽

Functional Disability ◽

Mechanical Thrombectomy ◽

Reperfusion Therapy ◽

Secondary Outcome ◽

Stroke Treatment ◽

Cerebral Reperfusion ◽

The Impact

Introduction: The main driver for increased stroke prevalence is the aging of the population; however, the best evidenced-based strategies for stroke treatment and prevention are not always followed for older patients. Therefore, the aim was studying the association of age with clinical outcomes (mortality and functional disability) in stroke patients who underwent cerebral reperfusion therapy at hospital discharge and 90 days after ictus.Methods: This was a retrospective (stroke databank analysis) cohort study of participants who had been diagnosed with ischemic stroke and undergone intravenous cerebral reperfusion therapy or mechanical thrombectomy. The variable of interest was patient age, which was categorized into four groups: (1) up to 59 years; (2) 60 to 69 years; (3) 70 to 79 years old; and (4) above 79 years. The primary outcome was mortality at hospital discharge and 90 days after stroke, and the secondary outcome was functional capacity at hospital discharge and 90 days after stroke.Results: A total of 281 patients was included in the study (235 treated by thrombolysis alone, and 46 treated with mechanical thrombectomy). The mean age of the total sample was 67 ± 13.1 years. The oldest patients had the most unfavorable outcomes, except for mortality rate, at hospital discharge (mRS > 2; OR: 1.028; 95% CI 1.005 to 1.051; p = 0.017; mRS > 3; OR: 1.043, 95% CI 1.018 to 1.069; p = 0.001) and 90 days after stroke (mRS > 2; OR: 1.028; 95% CI 1.005 to 1.051; p = 0.017; mRS > 3; OR: 1.043, 95% CI 1.018 to 1.069; p = 0.001).Conclusion: Cerebral reperfusion was a viable treatment for ischemic stroke in both elderly and very elderly patients, as it did not increase mortality. However, it was observed that older individuals had worse functional outcomes at hospital discharge and 90 days after stroke.

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Impact of Glycosylated Hemoglobin on the Prognosis of Patients with Acute Ischemic Stroke Treated with Arterial Thrombolysis

The Heart Surgery Forum ◽

10.1532/hsf.2929 ◽

2020 ◽

Vol 23 (4) ◽

pp. E447-E451

Author(s):

Wentong Ling ◽

Qiong Chen ◽

Pu Huang ◽

Dengke Han ◽

Wenjun Wu

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Hba1c Level ◽

Poor Prognosis ◽

Glycosylated Hemoglobin ◽

Complication Rates ◽

Nihss Score ◽

Prognosis Group ◽

The Impact ◽

Arterial Thrombolysis

Background: To investigate the impact of glycosylated hemoglobin (HbA1c) on the prognosis of patients with acute ischemic stroke (AIS) treated with intra-arterial thrombolysis (IAT). Methods: The clinical data of 136 patients with AIS treated with IAT at the Zhongshan City People’s Hospital were retrospectively analyzed. The patients were divided into a high HbA1c group (HHbA1c) (≥6.5%) and a normal HbA1c group (NHbA1c) (<6.5%). According to National Institutes of Health Stroke Scale (NIHSS) score after thrombolysis, patients were divided into a good prognosis group (GP) (≥4 or <4 points reduction) and a poor prognosis group (PP) (≤4 or >4 points reduction). Results: There were significant differences in the HbA1c and glucose levels, NIHSS scores at admission and at discharge, complication rates, and mortality rates between groups HHbA1c and NHbA1c (P < .05) and between groups GP and PP (P < .05). The multivariate logistic regression analysis showed that HbA1c level (odds ratio [OR] 0.717; 95% confidence interval [CI] 0.545 to 0.889) and NIHSS score at admission (OR 0.894; 95% CI 0.814 to 0.982) were risk factors for neurological improvement in IAT-treated patients with AIS. Conclusions: HbA1c level is associated with neurological function improvement in IAT-treated patients with AIS and can be used as a serological indicator of poor prognosis.

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Abstract WP2: Anesthesia Technique and Outcomes of Mechanical Thrombectomy in Patients With Acute Ischemic Stroke

Stroke ◽

10.1161/str.48.suppl_1.wp2 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Kimon Bekelis ◽

Symeon Missios ◽

Todd MacKenzie ◽

Stavropoula Tjoumakaris ◽

Pascal Jabbour

Keyword(s):

New York ◽

Ischemic Stroke ◽

General Anesthesia ◽

Acute Ischemic Stroke ◽

Instrumental Variable ◽

Mechanical Thrombectomy ◽

Conscious Sedation ◽

Case Fatality ◽

Anesthesia Technique ◽

The Impact

Background: The impact of anesthesia technique on the outcomes of mechanical thrombectomy for acute ischemic stroke remains an issue of debate, and has not been studied in clinical trials. We investigated the association of general anesthesia with outcomes in patients undergoing mechanical thrombectomy for ischemic stroke. Methods: We performed a cohort study involving patients undergoing mechanical thrombectomy for ischemic stroke from 2009-2013, who were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database. An instrumental variable (hospital rate of general anesthesia) analysis was used to simulate the effects of randomization and investigate the association of anesthesia technique with case-fatality and length of stay (LOS). Results: Of the 1,308 patients undergoing mechanical thrombectomy for acute ischemic stroke, 492 (37.6%) underwent general anesthesia, and 816 (62.4%) underwent conscious sedation. Employing an instrumental variable analysis, we identified that general anesthesia was associated with a 6.4% increased case-fatality (95% CI, 1.9% to 11.0%), and 8.4 days longer LOS (95% CI, 2.9 to 14.0) in comparison to conscious sedation. This corresponded to 15 patients needing to be treated with conscious sedation to prevent one death. Our results were robust in a sensitivity analysis utilizing mixed effects regression, and propensity score adjusted regression models. Conclusions: Using a comprehensive all-payer cohort of acute ischemic stroke patients undergoing mechanical thrombectomy in New York State, we identified an association of general anesthesia with increased case fatality and LOS. These considerations should be taken into account when standardizing acute stroke care.

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Abstract TP390: Ethnic and Regional Disparities in Access to Endovascular Embolectomy for Acute Ischemic Stroke

Stroke ◽

10.1161/str.44.suppl_1.atp390 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Frank Attenello ◽

Peter Adamczyk ◽

Ge Wen ◽

Shuhan He ◽

Jonathan Russin ◽

...

Keyword(s):

Ischemic Stroke ◽

Native Americans ◽

Population Density ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

High Volume ◽

Stroke Treatment ◽

Asian Patients ◽

Procedural Volume ◽

Treatment Volume

Background: Endovascular stroke treatment volume has significantly increased in recent years. Data from the Nationwide Inpatient Sample (NIS) database in 2008 demonstrates an association between improved outcomes and centers that perform substantial procedural volume (>10/year). Few reports have described demographics of patient populations or centers performing mechanical thrombectomy. Methods: We collected data from the 2008 NIS database for patients hospitalized for ischemic stroke, and those undergoing mechanical clot retrieval. Patients were characterized by ethnicity, payment source, and regional hospital variables of population density and median zipcode wealth. Patients were evaluated for admission and treatment at substantial thrombectomy volume centers. Results: Approximately 1.1 million patients were hospitalized for acute stroke, with 2749 patients receiving mechanical thrombectomy in 2008. Asian patients received the highest frequency of intervention (0.39%) with Blacks and Native Americans receiving the lowest (0.18%, 0.17%). Patients from zipcodes with highest median wealth most frequently received intervention (0.29%, p<0.001). Among all stroke patients, Whites, Hispanics, individuals in highest salaried zip codes and patients residing in counties with population > 1 million were most often admitted to centers with substantial endovascular procedural volume (all, p<0.001 in multivariate analysis). Among those undergoing thrombectomy, Hispanics (p=0.03, OR 0.654 [0.442,0.967]), Asians (p=<0.001, 0.205 [0.120,0.350]) and Blacks (p=0.09, OR 0.717[0.489,1.050]), were treated less frequently than Whites at substantial volume centers. Conclusion: Native Americans and Blacks received the lowest frequency of thrombectomy for acute ischemic stroke. Whites, individuals residing in wealthy and high population density regions were more often admitted to centers performing substantial procedural volume. Among patients undergoing mechanical thrombectomy, Whites were more often treated at substantial volume centers than Hispanics, Blacks or Asians. Though noted correlations may be multi-factorial, socioeconomic factors may predict admission and treatment in high volume procedural centers.

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Endovascular Acute Ischemic Stroke Treatment with FlowGate Balloon Guide Catheter: A Single-Center Observational Study of FlowGate Balloon Guide Catheter Use

Interventional Neurology ◽

10.1159/000488601 ◽

2018 ◽

Vol 7 (6) ◽

pp. 327-333 ◽

Cited By ~ 3

Author(s):

Mohamed S. Teleb

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Standard Of Care ◽

Vessel Occlusion ◽

Stroke Treatment ◽

Guide Catheter ◽

Stent Retrievers ◽

Number Of Passes ◽

Single Center Observational Study

Background: Treatment of large vessel occlusion acute ischemic stroke with mechanical thrombectomy has become the standard of care after recent clinical trials. However, the degree of recanalization with stent retrievers remains very important in overall outcomes. We sought to review the utility of a new balloon guide catheter (BGC) in improving the degree of recanalization in conjunction with mechanical thrombectomy. Methods: The medical records of a prospectively collected endovascular ischemic stroke database were reviewed. All consecutive strokes when a FlowGate BGC was used with a thrombectomy stent retriever were identified. Use of a FlowGate BGC, number of passes, final Thrombolysis in Cerebral Infarction (TICI) score, trackability, and use of adjunct devices were all collected and analyzed. Results: Use of a FlowGate BGC resulted in 64% (33/52) first-pass effect (FPE) of TICI 2b/3, and specifically 46% (24/52) TICI 3 FPE (true FPE). A total of 52/62 (84%) of thrombectomy cases were treated with BGCs. In the remaining 10, the BGC was not inflated or used due to the clot not being visualized or the lesions being distal and BGC use thus not deemed appropriate. Adjunct use of an aspiration catheter was seen in 12% (6/52) of cases. The overall success with FlowGate BGCs with one or more passes of TICI 2b/3 was 94% (49/52). Trackability was achieved in 92% (57/62) of cases. Conclusions: Use of the FlowGate BGC as an adjunct to mechanical thrombectomy was associated with good FPE and an overall recanalization of TICI 2b/3 of 94%.

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