Thrombectomy 24 hours after stroke: beyond DAWN

Background and purposeThe results of the DAWN trial support the benefit of thrombectomy in patients with anterior circulation large vessel occlusion (LVO) acute stroke presenting within 6–24 hours from time last known well (TLKW). We sought to evaluate the characteristics and outcomes of patients who met DAWN criteria but underwent thrombectomy beyond 24 hours of TLKW.MethodsA retrospective review of endovascular thrombectomy databases at three comprehensive stroke centers was performed to identify all patients who received thrombectomy beyond 24 hours of TLKW and otherwise met the DAWN criteria. Baseline characteristics, efficacy, and safety outcomes were compared with patients in the DAWN trial intervention arm.ResultsTwenty-one patients met the inclusion criteria. Rates of successful reperfusion (mTICI2b–3: 81% vs 84%, P=0.72), 90-day functional independence (modified Rankin Scale score 0–2, 43% vs 48%, P=0.68), and symptomatic intracranial hemorrhage (5% vs 6%, P=0.87) were comparable across the two groups.ConclusionThrombectomy appears to be safe and feasible in patients with acute ischemic stroke due to LVO meeting all DAWN trial criteria but treated beyond 24 hours of TLKW with outcomes comparable to patients in the DAWN trial intervention arm. Further studies are warranted to validate these findings.

Download Full-text

Thrombectomy for acute ischemic stroke in nonagenarians compared with octogenarians

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-015147 ◽

2019 ◽

Vol 12 (3) ◽

pp. 266-270 ◽

Cited By ~ 7

Author(s):

Eric S Sussman ◽

Blake Martin ◽

Michael Mlynash ◽

Michael P Marks ◽

David Marcellus ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Independence ◽

Inclusion Criteria ◽

Related Factors ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Improved Outcomes ◽

Symptomatic Intracranial Hemorrhage ◽

The Difference

IntroductionMultiple randomized trials have shown that endovascular thrombectomy (EVT) leads to improved outcomes in acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Elderly patients were poorly represented in these trials, and the efficacy of EVT in nonagenarian patients remains uncertain.MethodsWe performed a retrospective cohort study at a single center. Inclusion criteria were: age 80–99, LVO, core infarct <70 mL, and salvageable penumbra. Patients were stratified into octogenarian (80–89) and nonagenarian (90–99) cohorts. The primary outcome was the ordinal score on the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included dichotomized functional outcome (mRS ≤2 vs mRS ≥3), successful revascularization, symptomatic intracranial hemorrhage (ICH), and mortality.Results108 patients met the inclusion criteria, including 79 octogenarians (73%) and 29 nonagenarians (27%). Nonagenarians were more likely to be female (86% vs 58%; p<0.01); there were no other differences between groups in terms of demographics, medical comorbidities, or treatment characteristics. Successful revascularization (TICI 2b–3) was achieved in 79% in both cohorts. Median mRS at 90 days was 5 in octogenarians and 6 in nonagenarians (p=0.09). Functional independence (mRS ≤2) at 90 days was achieved in 12.5% and 19.7% of nonagenarians and octogenarians, respectively (p=0.54). Symptomatic ICH occurred in 21.4% and 6.4% (p=0.03), and 90-day mortality rate was 63% and 40.9% (p=0.07) in nonagenarians and octogenarians, respectively.ConclusionsNonagenarians may be at higher risk of symptomatic ICH than octogenarians, despite similar stroke- and treatment-related factors. While there was a trend towards higher mortality and worse functional outcomes in nonagenarians, the difference was not statistically significant in this relatively small retrospective study.

Download Full-text

Abstract TP28: Intravenous Thrombolysis is Associated With Better Functional Outcomes in Endovascular Thrombectomy Patients Requiring Multiple-Passes to Achieve Reperfusion

Stroke ◽

10.1161/str.51.suppl_1.tp28 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Christopher Blair ◽

Cecilia Cappelen-Smith ◽

Dennis Cordato ◽

Leon Edwards ◽

Amer Mitchelle ◽

...

Keyword(s):

Functional Outcomes ◽

Intravenous Thrombolysis ◽

Functional Independence ◽

Independent Effect ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Multiple Pass ◽

First Pass

Introduction: In patients with anterior circulation stroke with large vessel occlusion (LVO), recent data suggest that successful reperfusion (mTICI≥2b) after a single device pass results in more favourable functional outcomes in comparison to patients requiring multiple passes. It is unclear if this effect represents an epiphenomenon or a true independent effect. Methods: A prospectively maintained database of EVT was interrogated for patients presenting with anterior circulation LVO with onset to groin puncture times of ≤ 6 hours from January 2016 to March 2019. Three-month functional outcomes were compared between first-pass reperfusion and multiple-pass reperfusion patients using logistic regression. Results: A total of 169 patients were identified (mean age 71 yrs, 44% female, median NIHSS 17, intravenous thrombolysis (IVT) in 47%). Successful reperfusion (mTICI≥2b) was achieved with the first-pass (FP) in 80 patients (47%) and multiple-passes (MP) in 89 patients (53%). First pass patients had better outcomes when compared to MP patients (mRS 0-2 71% vs 31%, p < 0.001). No difference in functional outcomes was seen between FP patients who received IVT and those that did not (mRS 0-2 68% vs 75%, p = 0.459). Multiple-pass patients who received IVT achieved higher rates of functional independence than those who did not (mRS 0-2 40% vs 27%, p = 0.035). Conclusion: Intravenous thrombolysis may improve functional recovery in EVT patients requiring multiple-passes to achieve reperfusion. Prospective studies should be considered.

Download Full-text

Thrombectomy 6-24 hours after stroke in trial ineligible patients

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-013915 ◽

2018 ◽

Vol 10 (11) ◽

pp. 1033-1037 ◽

Cited By ~ 28

Author(s):

Shashvat M Desai ◽

Marcelo Rocha ◽

Bradley J Molyneaux ◽

Matthew Starr ◽

Cynthia L Kenmuir ◽

...

Keyword(s):

Time Window ◽

Functional Independence ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Off Label ◽

Symptomatic Intracranial Hemorrhage ◽

Comprehensive Stroke Center ◽

Stroke Center

Background and purposeThe DAWN and DEFUSE-3 trials demonstrated the benefit of endovascular thrombectomy (ET) in late-presenting acute ischemic strokes due to anterior circulation large vessel occlusion (ACLVO). Strict criteria were employed for patient selection. We sought to evaluate the characteristics and outcomes of patients treated outside these trials.MethodsA retrospective review of acute ischemic stroke admissions to a single comprehensive stroke center was performed during the DAWN trial enrollment period (November 2014 to February 2017) to identify all patients presenting in the 6–24 hour time window. These patients were further investigated for trial eligibility, baseline characteristics, treatment, and outcomes.ResultsApproximately 70% (n=142) of the 204 patients presenting 6–24 hours after last known well with NIH Stroke Scale score ≥6 and harboring an ACLVO are DAWN and/or DEFUSE-3 ineligible, most commonly due to large infarct burden (38%). 26% (n=37) of trial ineligible patients with large vessel occlusion strokes received off-label ET and 30% of them achieved functional independence (modified Rankin Scale 0–2) at 90 days. Rates of symptomatic intracranial hemorrhage and mortality were 8% and 24%, respectivelyConclusionTrial ineligible patients with large vessel occlusion strokes receiving off-label ET achieved outcomes comparable to DAWN and DEFUSE-3 eligible patients. Patients aged <80 years are most likely to benefit from ET in this subgroup. These data indicate a larger population of patients who can potentially benefit from ET in the expanded time window if more permissive criteria are applied.

Download Full-text

Abstract P559: Sex Differences in Clinical Outcomes After Endovascular Thrombectomy for Large Vessel Occlusion Stroke: A Sub-Analysis of the SELECT Study

Stroke ◽

10.1161/str.52.suppl_1.p559 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Johanna T Fifi ◽

Thanh Nguyen ◽

Sarah Song ◽

Anjail Z Sharrief ◽

Deep Pujara ◽

...

Keyword(s):

Sex Differences ◽

Functional Independence ◽

Large Vessel ◽

Repeated Measure ◽

Large Vessel Occlusion ◽

Post Discharge ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Discharge Disposition

Background: Women have been shown to have greater disability than men after acute ischemic stroke (AIS) treated by thrombolysis. Whether endovascular thrombectomy (EVT) outcomes differ by sex with AIS from large vessel occlusion (LVO) is controversial. We compared sex differences in EVT outcomes and assessed relationship to post-discharge improvement. Methods: In SELECT prospective cohort, EVT treated anterior circulation LVOs (ICA, MCA M1/M2) ≤24 hrs from LKW were stratified by sex. Discharge, 90-day mRS were compared in all patients and a propensity matched cohort. We evaluated mRS improvement (discharge to 90-day) using repeated measure mixed regression with linear approximation of mRS. Results: Of 285 patients, 139 (48.8%) were women, and older (mean IQR 69 years (57,81) vs 65 (56,75), p=0.04) with similar NIHSS (17 (11,22) vs 16 (12,20), p=0.44). Women had smaller perfusion lesion 109 (66,151) vs 154 (104,198) cc, p<0.001) and better collaterals on CTA/CTP but similar ischemic core size 8 (0,25) vs 11 (0,38) cc, p=0.22. Discharge functional independence rates, mean (IQR) mRS were similar (women 39% vs men 46%, p=0.14, and mRS: 3 vs 3, p=0.43). 90-day mRS 0-2 did not differ between women and men (50% vs 55%, aOR 0.77, 95% CI 0.39-1.50, p=0.39) and mean (IQR) mRS: 2 (1,4) vs 2 (0,4). Larger predicted mRS score improvement trend seen in men (2.62 vs 2.21, reduction 0.41) than women (2.65 vs 2.46, reduction: 0.19, p=0.21), Fig 2A. In propensity matched 65 pairs, women exhibited worse 90-day mRS 0-2 (46% vs 60%, aOR 0.41, 95% CI 0.16-1.00, p=0.05). mRS improvement from discharge to 90-day was significantly larger in men (2.49 vs 1.88, reduction 0.61 vs women 2.52 vs 2.44, reduction 0.08, p=0.04), despite similar discharge disposition Fig 2B. Conclusion: Women had similar discharge outcomes as men following EVT, but improvement at 90 days was significantly worse in women. Further exploration of the influence of post-discharge factors to identify target interventions is warranted.

Download Full-text

Comparison of Prior Bridging Intravenous Thrombolysis With Direct Endovascular Thrombectomy for Anterior Circulation Large Vessel Occlusion: Systematic Review and Meta-Analysis

Frontiers in Neurology ◽

10.3389/fneur.2021.602370 ◽

2021 ◽

Vol 12 ◽

Author(s):

Zhao-Ji Chen ◽

Xiao-Fang Li ◽

Cheng-Yu Liang ◽

Lei Cui ◽

Li-Qing Yang ◽

...

Keyword(s):

Meta Analysis ◽

Intravenous Thrombolysis ◽

Functional Independence ◽

Large Vessel Occlusion ◽

Bridging Therapy ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Significant Difference

Background: Whether bridging treatment combining intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) is superior to direct EVT alone for emergent large vessel occlusion (LVO) in the anterior circulation is unknown. A systematic review and a meta-analysis were performed to investigate and assess the effect and safety of bridging treatment vs. direct EVT in patients with LVO in the anterior circulation.Methods: PubMed, EMBASE, and the Cochrane library were searched to assess the effect and safety of bridging treatment and direct EVT in LVO. Functional independence, mortality, asymptomatic and symptomatic intracranial hemorrhage (aICH and sICH, respectively), and successful recanalization were evaluated. The risk ratio and the 95% CI were analyzed.Results: Among the eight studies included, there was no significant difference in the long-term functional independence (OR = 1.008, 95% CI = 0.845–1.204, P = 0.926), mortality (OR = 1.060, 95% CI = 0.840–1.336, P = 0.624), recanalization rate (OR = 1.015, 95% CI = 0.793–1.300, P = 0.905), and the incidence of sICH (OR = 1.320, 95% CI = 0.931–1.870, P = 0.119) between bridging therapy and direct EVT. After adjusting for confounding factors, bridging therapy showed a lower recanalization rate (effect size or ES = −0.377, 95% CI = −0.684 to −0.070, P = 0.016), but there was no significant difference in the long-term functional independence (ES = 0.057, 95% CI = −0.177 to 0.291, P = 0.634), mortality (ES = 0.693, 95% CI = −0.133 to 1.519, P = 0.100), and incidence of sICH (ES = −0.051, 95% CI = −0.687 to 0.585, P = 0.875) compared with direct EVT. Meanwhile, in the subgroup analysis of RCT, no significant difference was found in the long-term functional independence (OR = 0.927, 95% CI = 0.727–1.182, P = 0.539), recanalization rate (OR = 1.331, 95% CI = 0.948–1.867, P = 0.099), mortality (OR = 1.072, 95% CI = 0.776–1.481, P = 0.673), and sICH incidence (OR = 1.383, 95% CI = 0.806–2.374, P = 0.977) between patients receiving bridging therapy and those receiving direct DVT.Conclusion: For stroke patients with acute anterior circulation occlusion and who are eligible for intravenous thrombolysis, there is no significant difference in the clinical effect between direct EVT and bridging therapy, which needs to be verified by more randomized controlled trials.

Download Full-text

Clinical and Neuroimaging Outcomes of Direct Thrombectomy vs Bridging Therapy in Large Vessel Occlusion: Analysis of the SELECT Cohort Study

Neurology ◽

10.1212/wnl.0000000000012063 ◽

2021 ◽

pp. 10.1212/WNL.0000000000012063

Author(s):

Amrou Sarraj ◽

James Grotta ◽

Gregory W. Albers ◽

Ameer E. Hassan ◽

Spiros Blackburn ◽

...

Keyword(s):

Functional Outcomes ◽

Functional Independence ◽

Stroke Severity ◽

Large Vessel Occlusion ◽

Bridging Therapy ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Subgroup Analyses ◽

Core Volume

Objective:To evaluate the comparative safety and efficacy of direct endovascular thrombectomy(dEVT) compared to bridging therapy(BT:IV-tPA+EVT) and assess if BT potential benefit relates to stroke severity, size and initial presentation to EVT vs. non-EVT center.Methods:In a prospective multicenter cohort-study of imaging selection for endovascular thrombectomy[SELECT], anterior-circulation large vessel occlusion (LVO) patients presenting to EVT-capable centers within 4.5hours from last-known-well were stratified into BT vs. dEVT. The primary outcome was 90-day functional independence[modified Rankin Scale(mRS)=0-2]. Secondary outcomes included a shift across 90-day mRS grades, mortality, symptomatic intracranial hemorrhage. We also performed subgroup-analyses according to initial presentation to EVT-capable center (direct versus transfer), stroke severity and baseline infarct core volume.Results:We identified 226 LVOs (54%:men, mean age:65.6±14.6years, median NIHSS-score: 17, 28% received dEVT). Median time from arrival to groin-puncture did not differ in BT-patients when presenting directly[dEVT:1.43 (IQR=1.13-1.90) hours vs. BT:1.58(IQR=1.27-2.02)hours,p=0.40] or transferred to EVT-capable centers[dEVT:1.17 (IQR: 0.90-1.48) hours vs. BT:1.27 (IQR: 0.97-1.87) hours,p=0.24]. BT was associated with higher odds of 90-day functional independence (57% vs. 44%,aOR=2.02,95%CI:1.01-4.03,p=0.046) and functional improvement (adjusted cOR=2.06,95%CI:1.18-3.60,p=0.011), and lower likelihood of 90-day mortality (11% vs. 23%,aOR: 0.20,95%CI:0.07-0.58,p=0.003). No differences in any other outcomes were detected. In subgroup-analyses, BT patients with baseline NIHSS-scores<15 had higher functional independence likelihood compared to dEVT (aOR=4.87,95%CI:1.56-15.18,p=0.006); this association was not evident for patients with NIHSS-scores≥15 (aOR=1.05,95%CI:0.40-2.74,p=0.92). Similarly, functional outcomes improvements with BT were detected in patients with core volume strata (Ischemic core <50cc: aOR: 2.10, 95% CI:1.02-4.33, p=0.044 vs ischemic core ≥50cc: aOR: 0.41,95% CI:0.01-16.02,p=0.64) and transfer status (transferred: aOR: 2.21,95% CI:0.93-9.65,p=0.29 vs direct to EVT center: aOR:1.84,95%CI:0.80-4.23,p=0.15).Conclusions:Bridging therapy appears to be associated with better clinical outcomes, especially with milder NIHSS-scores, smaller presentation core volumes and those who were “dripped and shipped”. We did not observe any potential benefit of bridging therapy in patients with more severe strokes.Classification of Evidence:This study provides Class III evidence that for patients with ischemic stroke from anterior-circulation LVO within 4.5 hours from last-known-well, bridging therapy compared to direct endovascular thrombectomy leads to better 90-day functional outcomes.

Download Full-text

Endovascular Thrombectomy in Acute Ischemic Stroke

10.1093/med/9780190850036.003.0009 ◽

2018 ◽

Author(s):

A. Elisabeth Abramowicz

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

The United States ◽

Functional Independence ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Artery Embolism ◽

Number Of Patients

Endovascular thrombectomy (EVT) for acute ischemic stroke is a new and powerful treatment modality that restores functional independence to many victims. Although it has been proved of value in large-vessel occlusion of the anterior circulation, it is also used in basilar artery embolism. Time to successful reperfusion is a major determinant of recovery. A subset of patients has robust collaterals and will benefit from treatment up to 24 hours after stroke onset; the presence of salvageable brain tissue (penumbra) must be ascertained by specialized imaging. The number of patients who can benefit from EVT is estimated at 100,000/year in the United States alone in more than 300 designated Thrombectomy-Capable Stroke Centers. EVT is a new anesthetic emergency. Anesthesiologists must be actively involved in creating protocol-driven care for acute ischemic stroke patients.

Download Full-text

SOFIA catheter for direct aspiration of large vessel occlusion stroke: A single-center cohort and meta-analysis

Interventional Neuroradiology ◽

10.1177/15910199211005328 ◽

2021 ◽

pp. 159101992110053

Author(s):

Federico Bolognini ◽

Pablo A Lebedinsky ◽

Mariano Musacchio ◽

Mariette Delaitre ◽

Abdoulaye M Traoré ◽

...

Keyword(s):

Rescue Therapy ◽

Meta Analysis ◽

Functional Independence ◽

Large Vessel ◽

Study Cohort ◽

Large Vessel Occlusion ◽

First Line ◽

Vessel Occlusion ◽

Global Rate ◽

Symptomatic Intracranial Hemorrhage

Background and Purpose Direct aspiration (DA) using large-bore distal aspiration catheters is an established strategy for the endovascular thrombectomy (EVT) of large-vessel occlusion stroke (LVOS). However, the performance of individual catheters like SOFIA has yet to be examined. Methods We present a cohort of 144 consecutive patients treated with first-line DA and SOFIA 6 F Plus catheter for LVOS. We also conducted a systematic review of the literature searching multiple databases for reports on thrombectomy with DA and SOFIA catheters and performed a meta-analysis of recanalization, safety, and clinical outcomes. Results In the study cohort a successful recanalization (mTICI 2b-3) rate of 75.7% was achieved with DA alone, the global rate for functional independence (90-day mRS 0-2) was 40.3%. For the metanalysis we selected nine articles that included a total of 758 patients treated with first-line thrombectomy with the SOFIA catheters. The mTICI 2b-3 rate was 71.6% (95%CI, 66.3-76.5%) while a rescue stent-retriever was used in 24.1% (95%CI, 17.7-31.9%) of cases. The overall mTICI2b-3 rate after DA and rescue therapy was 88.9% (95%CI, 82.6-93.1%). We found a pooled estimate of 45.6% (95%CI, 38.6-52.8%) for functional independence, a mortality within 90 days of 19% (95%CI, 14.1-25.0%) and a rate of 5.8% (95%CI, 4.2-8.0%) of symptomatic intracranial hemorrhage. Conclusion The DA approach for LVOS with the SOFIA catheters is highly effective with an efficacy and safety profile comparable to those found in contemporary thrombectomy trials and observational studies that use other devices or approaches.

Download Full-text

Abstract 202: Endovascular Therapy for Acute Ischemic Stroke With Distal Large Vessel Occlusion in the Anterior Circulation

Stroke ◽

10.1161/str.47.suppl_1.202 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Amrou Sarraj ◽

Navdeep Sangha ◽

Muhammad Shazam Hussain ◽

Dolora Wisco ◽

Nirav Vora ◽

...

Keyword(s):

Endovascular Therapy ◽

Primary Outcome ◽

Large Vessel ◽

Secondary Outcome ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Good Outcome ◽

Baseline Characteristics ◽

Iv Tpa

Introduction: Five RCTs demonstrated the superiority of endovascular therapy (EVT) over best medical management (MM) for acute ischemic strokes (AIS) with large vessel occlusion (LVO) in the anterior circulation. Patients with M2 occlusions, however, were underrepresented (95 randomized; 51 EVT treated). Evidence from RCTs of the benefit of EVT for M2 occlusions is lacking, as reflected in the recent AHA guidelines. Methods: A retrospective cohort was pooled from 10 academic centers from 1/12 to 4/15 of AIS patients with LVO isolated to M2 presenting within 8 hours from last known normal (LKN). Patients were divided into EVT and MM groups. Primary outcome was 90 day mRS (good outcome 0-2); secondary outcome was sICH. Logistic regression compared the 2 groups. Univariate and multivariate analyses evaluated predictors of good outcome in the EVT group. Results: Figure 1 shows participating centers, 522 patients (288 EVT and 234 MM) were identified. Table (1) shows baseline characteristics. MM treated patients were older and had higher IV tPA treatment rates, otherwise the 2 groups were balanced. 62.7 % EVT patients had mRS 0-2 at 90 days compared to 35.4 % MM (figure 2). EVT patients had 3 times the odds of good outcome as compared to MM patients (OR: 3.1, 95% CI:2.1-4.4, P <0.001) even after adjustment for age, NIHSS, ASPECTS, IV tPA and LKN to door time (OR: 3.2, 95%CI: 2-5.2, P<0.001). sICH rate was 5.6 %, which was not statistically different than the MM group (table 1, P=0.1). Age, NIHSS, good ASPECTS, LKN to reperfusion time and successful reperfusion mTICI ≥ 2b were independent predictors of good outcome in EVT patients. There was a linear relationship between good outcome and time LKN to reperfusion (Figure 3). Conclusion: Despite inherent limitations of its retrospective design, our study suggests that EVT may be effective and safe for distal LVO (M2) relative to best MM. A trial randomizing M2 occlusions to EVT vs. MM is warranted to confirm these findings.

Download Full-text