Mechanical thrombectomy for anterior circulation stroke: 5-year experience in a statewide service with differences in pretreatment time metrics across two hospitals sites

ObjectiveTo audit our institutional mechanical thrombectomy (MT) outcomes for acute anterior circulation stroke and examine the influence of workflow time metrics on patient outcomes.MethodsA database of 100 MT cases was maintained throughout May 2010—February 2015 as part of a statewide service provided across two tertiary hospitals (H1 and H2). Patient demographics, stroke and procedural details, blinded angiographic outcomes, and 90-day modified Rankin Scale (mRS) scores were recorded. The following time points in stroke treatment were recorded: stroke onset, hospital presentation, CT imaging, arteriotomy, and recanalization. Statistical analysis of outcomes, predictors of outcome, and differences between the hospitals was carried out.ResultsThrombolysis in Cerebral Infarction (TICI) 2b/3 reperfusion was 79%. Forty-nine per cent of patients had good clinical outcomes (mRS 0–2). In a subgroup analysis of 76 patients with premorbid mRS 0–1 and first CT performed ≤4.5 h after stroke onset, 60% had good clinical outcomes. Patient and disease characteristics were matched between the two hospitals. H1 had shorter times between hospital presentation and CT (32 vs 55 min, p=0.01), CT and arteriotomy (33 vs 69 min, p=0.00), and stroke onset and recanalization (198 vs 260 min, p=0.00). These time metrics independently predicted good clinical outcome. Median days spent at home in the first 90 days was greater at H1 (61 vs 8, p=0.04) than at H2. A greater proportion of patients treated at H1 were independent (mRS 0–2) at 90 days (54% vs 42%); however, this was not statistically significant (p=0.22).ConclusionsOutcomes similar to randomized controlled trials are attainable in ‘real-world’ settings. Workflow time metrics were independent predictors of clinical outcome, and differed between the two hospitals owing to site-specific organizational differences.

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Clinical Outcome After Endovascular Thrombectomy in 3 Triage Concepts

Stroke ◽

10.1161/strokeaha.120.030520 ◽

2021 ◽

Author(s):

Fatih Seker ◽

Jens Fiehler ◽

Markus A. Möhlenbruch ◽

Christian Herweh ◽

Fabian Flottmann ◽

...

Keyword(s):

Clinical Outcome ◽

Primary Outcome Measure ◽

National Institutes Of Health ◽

Stroke Onset ◽

Treatment Quality ◽

Secondary Outcome ◽

Good Clinical Outcome ◽

Anterior Circulation ◽

Stroke Treatment ◽

Significant Difference

Background and Purpose: NEUROSQUAD (Stroke Treatment: Quality and Efficacy in Different Referral Systems) is a prospective, observational, bicenter study comparing 3 triage pathways in endovascular stroke treatment: mothership, drip and ship (DS), and transferring a neurointerventionalist to a remote hospital for thrombectomy (drive the doctor [DD]). Methods: Patients with anterior circulation stroke and premorbid modified Rankin Scale (mRS) score 0–3 who underwent thrombectomy within 24 hours after stroke onset were included. Primary outcome measure was good clinical outcome defined as 90-day mRS score 0–2 or clinical recovery to the status before stroke onset (ie, equal premorbid mRS and 90-day mRS). Secondary outcome measures were successful reperfusion, National Institutes of Health Stroke Scale at discharge, and mRS shift. Results: In total, 360 patients were included in this study, of whom 111 patients (30.8%) were in the mothership group, 204 patients (56.7%) were in the DS group, and 45 patients (12.5%) were in the DD group. Good clinical outcome was achieved similarly in all three groups (mothership, 45.9%; DS, 43.1%; DD, 40.0%; P =0.778). Likewise, frequency of successful reperfusion was similar in all three groups (mothership, 86.5%; DS, 85.3%; DD, 82.2%; P =0.714). There was no significant difference among the groups regarding the National Institutes of Health Stroke Scale at discharge ( P =0.115) and mRS shift ( P =0.342). In the multivariate analysis, triage concept was not an independent predictor of good outcome (unadjusted odds ratio, 0.89 [CI, 0.64–1.23]; P =0.479). Conclusions: Our data suggest that clinical outcome after thrombectomy is similar in mothership, DS, and DD. Hence, DD can be a valuable triage option in acute stroke treatment.

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Mechanical Thrombectomy of Large Vessel Occlusions in COVID-19 Related Stroke: Endovascular and Clinical Outcomes

10.21203/rs.3.rs-49068/v1 ◽

2020 ◽

Author(s):

Anas S. Al-Smadi ◽

Srishti Abrol ◽

Ali Luqman ◽

Parthasarathi Chamiraju ◽

Hani Abujudeh

Keyword(s):

Clinical Outcomes ◽

Mechanical Thrombectomy ◽

Case Series ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Ischemic Disease ◽

Patient Demographics

Abstract Background and PurposeStroke is a drastic complication and a poor prognostic marker of COVID-19 disease which emphasizes the importance of early identification and management of this complication. In this case series, we describe our experience of mechanical thrombectomy of large vessel occlusions (LVO) in patients with COVID-19.MethodsWe performed a retrospective study of a series of confirmed COVID-19 patients who underwent endovascular thrombectomy for acute cerebrovascular ischemic disease with large vessel occlusion. Patient demographics, presentations, lab values, angiographic and clinical outcomes were also reviewed.ResultsThree COVID-19 patients with large vessel occlusion who underwent endovascular thrombectomy were identified in our multi-center institution. Two patients had respiratory symptoms prior presentation and one patient presented initially with clinical deficits. Two patients had anterior circulation occlusion in the middle cerebral artery territory vs one had posterior circulation occlusion in the basilar artery. There was good angiographic outcome post thrombectomy in all patients, however poor clinical outcomes noted with no significant improvement in neurological manifestations in comparison with baseline at presentation. All patients developed critically severe symptoms during hospitalization requiring intubation and one patient died of COVID-19 related respiratory failure.ConclusionIn this small case series, we noted worse clinical outcomes in COVID-19 related LVO stroke despite effective thrombectomy, which may be related to the underlying COVID-19 disease and/or the nature of clot in these patients.

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Comparison of clinical outcomes in patients with acute ischemic strokes treated with mechanical thrombectomy using either Solumbra or ADAPT techniques

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2015-012122 ◽

2015 ◽

Vol 8 (11) ◽

pp. 1123-1128 ◽

Cited By ~ 93

Author(s):

Josser E Delgado Almandoz ◽

Yasha Kayan ◽

Mark L Young ◽

Jennifer L Fease ◽

Jill M Scholz ◽

...

Keyword(s):

Clinical Outcome ◽

Clinical Outcomes ◽

Internal Carotid ◽

Mechanical Thrombectomy ◽

Independent Predictor ◽

National Institutes Of Health ◽

Good Clinical Outcome ◽

Anterior Circulation ◽

First Pass ◽

Symptomatic Intracranial Hemorrhage

PurposeTo compare rates of symptomatic intracranial hemorrhage (SICH) and good clinical outcome at 90 days in patients with ischemic strokes from anterior circulation emergent large vessel occlusions (ELVO) treated with mechanical thrombectomy using either Solumbra or A Direct Aspiration first-Pass Thrombectomy (ADAPT) techniques.MethodsWe compared clinical characteristics, procedural variables, and clinical outcomes in patients with anterior circulation ELVOs treated with mechanical thrombectomy using either a Solumbra or ADAPT technique at our institution over a 38-month period. SICH was defined using the SITS-MOST criteria. A good clinical outcome was defined as a modified Rankin Scale score of 0–2 at 90 days.ResultsOne hundred patients were included, 55 in the Solumbra group and 45 in the ADAPT group. Patients in the ADAPT group had higher National Institutes of Health Stroke Scale (NIHSS) (19.2 vs 16.8, p=0.02) and a higher proportion of internal carotid artery terminus thrombi (42.2% vs 20%, p=0.03) than patients in the Solumbra group. Patients in the ADAPT group had a trend toward a lower rate of SICH than patients in the Solumbra group (2.2% vs 12.7%, p=0.07). Patients in the ADAPT group had a significantly higher rate of good clinical outcome at 90 days than patients in the Solumbra group (55.6% vs 30.9%, p=0.015). Use of the ADAPT technique (OR 6 (95% CI 1.0 to 31.2), p=0.049) was an independent predictor of a good clinical outcome at 90 days in our cohort.ConclusionsIn our cohort, the ADAPT technique was associated with significantly higher good clinical outcomes at 90 days in patients with acute ischemic stroke due to anterior circulation ELVOs treated with mechanical thrombectomy.

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Susceptibility vessel sign on MRI predicts better clinical outcome in patients with anterior circulation acute stroke treated with stent retriever as first-line strategy

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-014217 ◽

2018 ◽

Vol 11 (4) ◽

pp. 328-333 ◽

Cited By ~ 6

Author(s):

Romain Bourcier ◽

Wagih Ben Hassen ◽

Sébastien Soize ◽

Pascal Roux ◽

Julien Labreuche ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Clinical Outcomes ◽

Prospective Studies ◽

Mechanical Thrombectomy ◽

Stent Retriever ◽

Modified Rankin Scale ◽

First Line ◽

Anterior Circulation ◽

Shift Analysis

BackgroundSusceptibility vessel sign (SVS) can be a useful MRI biomarker of an occlusion but its relationship with clinical outcomes of acute ischemic stroke (AIS) is yet to be fully elucidated.ObjectiveTo investigate SVS in relation to the clinical outcomes after mechanical thrombectomy using a stent retriever (SR) as first-line approach in patients with AIS.Material and methodsWe included patients with a first-line SR approach for anterior AIS from the the Contact Aspiration vs Stent Retriever for Successful Revascularization (ASTER) and THRombectomie des Artères CErebrales (THRACE) trials when both baseline imaging of SVS and 90-day modified Rankin Scale (mRS) scores were available. Patients were assigned to two groups based on the presence of an SVS (independent core laboratory), and the overall distributions of the mRS score at 90 days (shift analysis) and clinical independence (mRS score ≤2) were compared.Results217 patients were included and SVS was diagnosed in 76.0% of cases (n=165, 95% CI 70.4% to 81.7%). After adjustment for potential confounders, SVS+ was significantly associated with 90-day mRS improvement (adjusted common OR=2.75; 95% CI 1.44 to 5.26) and favorable outcome (adjusted common OR=2.76; 95% CI 1.18 to 6.45).ConclusionBased on results for patients of the ASTER and THRACE trials receiving first-line SR treatment, SVS was associated with lower disability at 3 months. Large prospective studies using MRI-based thrombus evaluation are warranted.

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In-Hospital Intravenous Thrombolysis Offers No Benefit in Mechanical Thrombectomy in Optimized Tertiary Stroke Center Setting

CardioVascular and Interventional Radiology ◽

10.1007/s00270-020-02727-8 ◽

2020 ◽

Author(s):

Juha-Pekka Pienimäki ◽

Jyrki Ollikainen ◽

Niko Sillanpää ◽

Sara Protto

Keyword(s):

Clinical Outcome ◽

Acute Stroke ◽

Mechanical Thrombectomy ◽

Clinical Laboratory ◽

Intravenous Thrombolysis ◽

Stroke Patients ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Ordinal Logistic Regression Analysis ◽

Stroke Center

Abstract Purpose Mechanical thrombectomy (MT) is the first-line treatment in acute stroke patients presenting with large vessel occlusion (LVO). The efficacy of intravenous thrombolysis (IVT) prior to MT is being contested. The objective of this study was to evaluate the efficacy of MT without IVT in patients with no contraindications to IVT presenting directly to a tertiary stroke center with acute anterior circulation LVO. Materials and Methods We collected the data of 106 acute stroke patients who underwent MT in a single high-volume stroke center. Patients with anterior circulation LVO eligible for IVT and directly admitted to our institution who subsequently underwent MT were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of intravenous thrombolysis on 3-month clinical outcome (mRS) was analyzed with univariate tests and binary and ordinal logistic regression analysis. Results Fifty-eight out of the 106 patients received IVT + MT. These patients had 2.6-fold higher odds of poorer clinical outcome in mRS shift analysis (p = 0.01) compared to MT-only patients who had excellent 3-month clinical outcome (mRS 0–1) three times more often (p = 0.009). There were no significant differences between the groups in process times, mTICI, or number of hemorrhagic complications. A trend of less distal embolization and higher number of device passes was observed among the MT-only patients. Conclusions MT without prior IVT was associated with an improved overall three-month clinical outcome in acute anterior circulation LVO patients.

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Efficacy of Mechanical Thrombectomy using Penumbra ACETM Aspiration Catheter Compared to Stent Retriever SolitaireTM FR in Patients with Acute Ischemic Stroke

Brain Sciences ◽

10.3390/brainsci11040504 ◽

2021 ◽

Vol 11 (4) ◽

pp. 504

Author(s):

Dalibor Sila ◽

Markus Lenski ◽

Maria Vojtková ◽

Mustafa Elgharbawy ◽

František Charvát ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Clinical Outcomes ◽

Mechanical Thrombectomy ◽

Binary Logistic Regression ◽

Stent Retriever ◽

Good Clinical Outcome ◽

Significant Difference ◽

Aspiration Technique

Background: Mechanical thrombectomy is the standard therapy in patients with acute ischemic stroke (AIS). The primary aim of our study was to compare the procedural efficacy of the direct aspiration technique, using Penumbra ACETM aspiration catheter, and the stent retriever technique, with a SolitaireTM FR stent. Secondarily, we investigated treatment-dependent and treatment-independent factors that predict a good clinical outcome. Methods: We analyzed our series of mechanical thrombectomies using a SolitaireTM FR stent and a Penumbra ACETM catheter. The clinical and radiographic data of 76 patients were retrospectively reviewed. Using binary logistic regression, we looked for the predictors of a good clinical outcome. Results: In the Penumbra ACETM group we achieved significantly higher rates of complete vessel recanalization with lower device passage counts, shorter recanalization times, shorter procedure times and shorter fluoroscopy times (p < 0.001) compared to the SolitaireTM FR group. We observed no significant difference in good clinical outcomes (52.4% vs. 56.4%, p = 0.756). Predictors of a good clinical outcome were lower initial NIHSS scores, pial arterial collateralization on admission head CT angiography scan, shorter recanalization times and device passage counts. Conclusions: The aspiration technique using Penumbra ACETM catheter is comparable to the stent retriever technique with SolitaireTM FR regarding clinical outcomes.

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Abstract WP25: Gender Disparity in Mechanical Thrombectomy Outcomes: The Role of Arterial Caliber

Stroke ◽

10.1161/str.48.suppl_1.wp25 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Mark A Davison ◽

Kavantissa M Keppetipola ◽

Bichun Ouyang ◽

Michael Chen

Keyword(s):

Ischemic Stroke ◽

Clinical Outcomes ◽

Mechanical Thrombectomy ◽

Vascular Anatomy ◽

Gender Disparity ◽

Circle Of Willis ◽

Large Vessel ◽

Consecutive Series ◽

Anterior Circulation ◽

Men And Women

Introduction: Despite level 1a evidence demonstrating the clinical benefit of mechanical thrombectomy in selected large vessel ischemic stroke patients, a gender disparity exists. Women not only have less favorable clinical outcomes after all stroke types, but the causes of this disparity remain elusive. Gender differences in cerebral vascular anatomy have been previously published. We hypothesize that differences in circle of Willis diameters may contribute to the gender disparity seen in clinical outcomes after mechanical thrombectomy for acute ischemic stroke. Methods: Clinical and radiographic data from a consecutive series undergoing mechanical thrombectomy for anterior circulation large vessel ischemic strokes were reviewed. Measurements of the proximal middle cerebral artery (M1) segment and supraclinoid internal carotid artery (ICA) diameters were obtained in a standardized fashion from the thrombectomy procedure angiogram. All M1 measurements were recorded at 3 mm of the vessel origin while ICA measurements were taken 3 mm proximal to the ICA terminus. Covariates included age, occlusion location, vascular risk factors, admission NIHSS score and final TICI grade. Modified Rankin score (mRS) at 90 days was the dependent variable. Variable significance between male and female cohorts was determined using student T-Tests. Multivariate regression analysis was also performed. Results: Ninety-four patients (41 female) between 6/2013 and 6/2016 fit the inclusion criteria. ICA terminus measurements for men and women were 3.07 mm (SD=0.46) and 2.88 mm (SD=0.47), respectively. M1 origin measurements for men and women were 2.46 mm (SD=0.31) and 2.21 mm (SD=0.37), respectively. Male ICA terminus and M1 origin measurements were larger than female (p = 0.05 and p < 0.001, respectively). 61% of men vs. 25% of women had 90-day mRS ≤ 2. Multivariate analysis indicated that only age was significantly associated with 90-day mRS ≤ 2. Conclusions: Our single center series suggests that differences in intracranial vessel diameter may contribute to the gender disparity in outcomes after mechanical thrombectomy. Smaller circle of Willis arterial diameters may compromise collateral blood flow and increase the difficulty in achieving sufficient reperfusion.

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Predictors of Poor Outcome after Successful Mechanical Thrombectomy in Patients with Acute Anterior Circulation Stroke

Journal of Clinical Interventional Radiology ISVIR ◽

10.1055/s-0037-1612600 ◽

2017 ◽

Vol 01 (03) ◽

pp. 139-143 ◽

Cited By ~ 2

Author(s):

Yosuke Tajima ◽

Michihiro Hayasaka ◽

Koichi Ebihara ◽

Masaaki Kubota ◽

Sumio Suda

Keyword(s):

Clinical Outcome ◽

Cerebral Artery ◽

Mechanical Thrombectomy ◽

Infarct Volume ◽

Complete Revascularization ◽

Anterior Circulation ◽

Clinical Imaging ◽

Good Outcome ◽

Poor Outcome ◽

Favorable Clinical Outcome

AbstractSuccessful revascularization is one of the main predictors of a favorable clinical outcome after mechanical thrombectomy. However, even if mechanical thrombectomy is successful, some patients have a poor clinical outcome. This study aimed to investigate the clinical, imaging, and procedural factors that are predictive of poor clinical outcomes despite successful revascularization after mechanical thrombectomy in patients with acute anterior circulation stroke. The authors evaluated 69 consecutive patients (mean age, 74.6 years, 29 women) who presented with acute ischemic stroke due to internal cerebral artery or middle cerebral artery occlusions and who were successfully treated with mechanical thrombectomy between July 2014 and November 2016. A good outcome was defined as a modified Rankin Scale score of 0 to 2 at 3 months after treatment. The associations between the clinical, imaging, and procedural factors and poor outcome were evaluated using logistic regression analyses. Using multivariate analyses, the authors found that the preoperative National Institute of Health Stroke Scale (NIHSS) score (odds ratio [OR], 1.152; 95% confidence interval [CI], 1.004–1.325; p = 0.028), the diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) (OR, 0.604; 95% CI, 0.412–0.882; p = 0.003), and a Thrombolysis in Cerebral Infarction (TICI) 2b classification (OR, 4.521; 95% CI, 1.140–17.885; p = 0.026) were independent predictors of poor outcome. Complete revascularization to reduce the infarct volume should be performed, especially in patients with a high DWI-ASPECTS, to increase the likelihood of a good outcome.

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Abstract WP372: Hydration Status and Clinical Outcomes in Acute Ischemic Stroke Patients Undergoing Mechanical Thrombectomy

Stroke ◽

10.1161/str.51.suppl_1.wp372 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Mona N Bahouth ◽

Rebecca Gottesman

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Clinical Outcomes ◽

Blood Urea Nitrogen ◽

Mechanical Thrombectomy ◽

Large Vessel ◽

Hydration Status ◽

Creatinine Ratio ◽

Stroke Patients ◽

Anterior Circulation

Introduction: Impaired hydration measured by elevated blood urea nitrogen (BUN) to creatinine ratio has been associated with worsened outcome after acute ischemic stroke. Whether hydration status is relevant for patients with acute ischemic stroke treated with mechanical thrombectomy remains unknown. Materials and Methods: We conducted a retrospective review of consecutive acute ischemic stroke patients who underwent endovascular procedures for anterior circulation large artery occlusion at Johns Hopkins Comprehensive Stroke Centers between 2012 and 2017. A volume contracted state (VCS), was determined based on surrogate lab markers and defined as blood urea nitrogen (BUN) to creatinine ratio greater than 15. Endpoints were achievement of successful revascularization (TICI 2b or 3), early re-occlusion, and short term clinical outcomes including development of early neurological worsening and functional outcome at 3 months. Results: Of the 158 patients who underwent an endovascular procedure, 102 patients had a final diagnosis of anterior circulation large vessel occlusion and met the inclusion criteria for analysis. Volume contracted state was present in 62/102 (61%) of patients. Successful revascularization was achieved in 75/102 (74%) of the cohort. There was no relationship between VCS and successful revascularization, but there was a 1.13 increased adjusted odds (95% CI 1.01, 1.27) of re-occlusion within 24 hours for every point higher BUN/creatinine ratio in the subset of patients who underwent radiological testing for pre-procedure planning (n=57). There was no relationship between VCS and clinical outcomes including early neurological worsening and 3 month outcome. Conclusions: Patients with VCS and large vessel anterior circulation stroke may have a higher odds of early re-occlusion after mechanical thrombectomy than their non-VCS counterparts, but no differences in successful revascularization nor clinical outcomes were present in this cohort. These results may suggest an opportunity for the exploration of pre-procedure hydration to improve outcomes.

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Mechanical Thrombectomy for Middle Cerebral Artery Division Occlusions: A Systematic Review and Meta-Analysis

Interventional Neurology ◽

10.1159/000477589 ◽

2017 ◽

Vol 6 (3-4) ◽

pp. 242-253 ◽

Cited By ~ 4

Author(s):

Hisham Salahuddin ◽

Aixa Espinosa ◽

Mark Buehler ◽

Sadik A. Khuder ◽

Abdur R. Khan ◽

...

Keyword(s):

Systematic Review ◽

Clinical Outcome ◽

Middle Cerebral Artery ◽

Clinical Outcomes ◽

Cerebral Artery ◽

Mechanical Thrombectomy ◽

Meta Analysis ◽

Total N ◽

Clinical Databases ◽

The Impact

Background: Middle cerebral artery division (M2) occlusion was significantly underrepresented in recent mechanical thrombectomy (MT) randomized controlled trials, and the approach to this disease remains heterogeneous. Objective: To conduct a systematic review and meta-analysis of outcomes at 90 days among patients undergoing MT for M2 middle cerebral artery (MCA) occlusions. Methods: Five clinical databases were searched from inception through September 2016. Observational studies reporting 90-day modified Rankin Scale scores for patients undergoing MT for M2 MCA occlusions with an M1 MCA control group were selected. The primary outcome of interest was good clinical outcome 90 days after MT of an M1 or M2 MCA occlusion. Secondary outcomes of interest included mortality and excellent clinical outcome, recanalization rates, significant intracerebral hemorrhage, and procedural complications. Results: A total of 323 publications were identified, and 237 potentially relevant articles were screened. Six studies were included in the analysis (M1 = 1,203, M2 = 258; total n = 1,461). We found no significant differences in good clinical outcomes (1.10 [95% CI, 0.83-1.44]), excellent clinical outcomes (1.07 [0.65-1.79]), mortality at 3 months (0.85 [0.58-1.24]), recanalization rates (1.06 [0.32-3.48]), and significant intracranial hemorrhage (1.19 [0.61-2.30]). Conclusions: MT of M2 MCA occlusions is as safe as that of main trunk MCA occlusions, and comparable in terms of clinical outcomes and hemorrhagic complications. Randomized clinical trials are needed to assess the impact of MT in patients with M2 occlusions, given that M1 MCA occlusions have different natural histories than M2 occlusions.

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