Mechanical thrombectomy beyond the circle of Willis: efficacy and safety of different techniques for M2 occlusions

2021 ◽  
pp. neurintsurg-2021-017425
Author(s):  
Leonardo Renieri ◽  
Iacopo Valente ◽  
Adam A Dmytriw ◽  
Ajit S Puri ◽  
Jasmeet Singh ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Mechanical Thrombectomy ◽  
Circle Of Willis ◽  
Stent Retriever ◽  
National Institutes Of Health ◽  
Neurological Deficits ◽  
Stent Retrievers ◽  
Subarachnoid Hemorrhages ◽  
Combined Technique

BackgroundM2 segment occlusions represent approximately one-third of non-lacunar ischemic stroke and can lead to permanent neurological deficits. Various techniques are available for mechanical thrombectomy beyond the circle of Willis, but data evaluating their effectiveness and safety are lacking.MethodsA retrospective review of patients with ischemic stroke undergoing mechanical thrombectomy for M2 occlusions from 13 centers in North American and Europe was performed. Tandem or multiple-territory occlusions were excluded. The primary outcome was 90-day modified Rankin Scale and reperfusion rates across stent-retriever, direct aspiration and combined techniques.ResultsThere were 465 patients (mean age 71.48±14.03 years, 53.1% female) with M2 occlusions who underwent mechanical thrombectomy. Stent-retriever alone was used in 133 (28.6%), direct aspiration alone in 93 (20.0%) and the combined technique in 239 (51.4%) patients. Successful reperfusion was achieved with the combined technique in 198 (82.2%; OR 2.6 (1.1–6.9)), with stent-retriever alone in 112 (84.2%; OR 9.2 (1.9–44.6)) and with direct aspiration alone in 62 (66.7%; referencecategory). Intraprocedural subarachnoid hemorrhages (iSAH) were 36 (7.7%) and were more likely to occur in patients treated with the stent-retrievers (OR 5.0 (1.1–24.3)) and combined technique (OR 4.6 (1.1–20.9)). Good clinical outcome was achieved in 260 (61.8%) patients, while 59 (14.0%) patients died. Older age, higher baseline NIHSS (National Institutes of Health Stroke Scale), parenchymal hemorrhage and iSAH were associated with poor outcome while successful recanalization and higher baseline ASPECTS (Alberta Stroke Program Early CT Score) were associated with good outcome. No differences were found among the three techniques in terms of clinical outcome.ConclusionStent-retrievers and a combined approach for M2 occlusions seem more effective than direct aspiration, but with higher rates of iSAH. This leads to no detectable difference in clinical outcome at 3 months.

Mechanical thrombectomy using a Solitaire stent retriever in the treatment of pediatric acute ischemic stroke

2019 ◽  
Vol 23 (3) ◽  
pp. 363-368 ◽  
Author(s):  
Bing Zhou ◽  
Xiao-Chuan Wang ◽  
Jun-Yi Xiang ◽  
Ming-Zhao Zhang ◽  
Bo Li ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Balloon Dilation ◽  
Stent Retriever ◽  
National Institutes Of Health ◽  
Clinical Prognosis ◽  
Nihss Score ◽  
Grade 3

OBJECTIVEMechanical thrombectomy using a Solitaire stent retriever has been widely applied as a safe and effective method in adult acute ischemic stroke (AIS). However, due to the lack of data, the safety and effectiveness of mechanical thrombectomy using a Solitaire stent in pediatric AIS has not yet been verified. The purpose of this study was to explore the safety and effectiveness of mechanical thrombectomy using a Solitaire stent retriever for pediatric AIS.METHODSBetween January 2012 and December 2017, 7 cases of pediatric AIS were treated via mechanical thrombectomy using a Solitaire stent retriever. The clinical practice, imaging, and follow-up results were reviewed, and the data were summarized and analyzed.RESULTSThe ages of the 7 patients ranged from 7 to 14 years with an average age of 11.1 years. The preoperative National Institutes of Health Stroke Scale (NIHSS) scores ranged from 9 to 22 with an average of 15.4 points. A Solitaire stent retriever was used in all patients, averaging 1.7 applications of thrombectomy and combined balloon dilation in 2 cases. Grade 3 on the modified Thrombolysis In Cerebral Infarction scale of recanalization was achieved in 5 cases and grade 2b in 2 cases. Six patients improved and 1 patient died after thrombectomy. The average NIHSS score of the 6 cases was 3.67 at discharge. The average modified Rankin Scale score was 1 at the 3-month follow-up. Subarachnoid hemorrhage after thrombectomy occurred in 1 case and that patient died 3 days postoperatively.CONCLUSIONSThis study shows that mechanical thrombectomy using a Solitaire stent retriever has a high recanalization rate and excellent clinical prognosis in pediatric AIS. The safety of mechanical thrombectomy in pediatric AIS requires more clinical trials for confirmation.

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

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.

scholarly journals Comparison of non–stent retriever and stent retriever mechanical thrombectomy devices for the endovascular treatment of acute ischemic stroke

2017 ◽  
Vol 126 (4) ◽  
pp. 1123-1130 ◽  
Author(s):  
Kate A. Hentschel ◽  
Badih Daou ◽  
Nohra Chalouhi ◽  
Robert M. Starke ◽  
Shannon Clark ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Independent Predictor ◽  
Univariate Analysis ◽  
Standard Of Care ◽  
Stent Retriever ◽  
Radiographic Outcomes ◽  
Scale Scores ◽  
Stent Retrievers

OBJECTIVE Mechanical thrombectomy is standard of care for the treatment of acute ischemic stroke. However, limited data are available from assessment of outcomes of FDA-approved devices. The objective of this study is to compare clinical outcomes, efficacy, and safety of non–stent retriever and stent retriever thrombectomy devices. METHODS Between January 2008 and June 2014, 166 patients treated at Jefferson Hospital for Neuroscience for acute ischemic stroke with mechanical thrombectomy using Merci, Penumbra, Solitaire, or Trevo devices were retrospectively reviewed. Primary outcomes included 90-day modified Rankin Scale (mRS) score, recanalization rate (thrombolysis in cerebral infarction [TICI score]), and incidence of symptomatic intracranial hemorrhages (ICHs). Univariate analysis and multivariate logistic regression determined predictors of mRS Score 3–6, mortality, and TICI Score 3. RESULTS A total of 99 patients were treated with non–stent retriever devices (Merci and Penumbra) and 67 with stent retrievers (Solitaire and Trevo). Stent retrievers yielded lower 90-day NIH Stroke Scale scores and higher rates of 90-day mRS scores ≤ 2 (22.54% [non–stent retriever] vs 61.67% [stent retriever]; p < 0.001), TICI Score 2b–3 recanalization rates (79.80% [non–stent retriever] vs 97.01% [stent retriever]; p < 0.001), percentage of parenchyma salvaged, and discharge rates to home/rehabilitation. The overall incidence of ICH was also significantly lower (40.40% [non–stent retriever] vs 13.43% [stent retriever]; p = 0.002), with a trend toward lower 90-day mortality. Use of non–stent retriever devices was an independent predictor of mRS Scores 3–6 (p = 0.002), while use of stent retrievers was an independent predictor of TICI Score 3 (p < 0.001). CONCLUSIONS Stent retriever mechanical thrombectomy devices achieve higher recanalization rates than non–stent retriever devices in acute ischemic stroke with improved clinical and radiographic outcomes and safety.

scholarly journals “Y-stent retriever”: a new rescue technique for refractory large-vessel occlusions?

2018 ◽  
Vol 128 (5) ◽  
pp. 1349-1353 ◽  
Author(s):  
Roberto Crosa ◽  
Alejandro M. Spiotta ◽  
Matías Negrotto ◽  
Alejandra Jaume ◽  
Walter Casagrande
Keyword(s):  
Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Stent Retriever ◽  
Large Vessel ◽  
Positive Trial ◽  
Large Artery ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Flow Restoration ◽  
Stent Retrievers

Long-awaited positive trial data have shown the efficacy of endovascular treatment in patients with ischemic stroke who arrive at the hospital within the first 6 hours with large-vessel occlusion of the anterior circulation. With the introduction of stent retrievers (SRs) for mechanical thrombectomy, efficient and safe large-artery recanalization treatment can be achieved. However, sometimes there are patients who do not attain complete flow restoration following attempts with traditional maneuvers. The authors present the case of a 57-year-old man with acute ischemic stroke due to an M1 embolus that extended into both M2 trunks. This patient was successfully treated with an innovative technique in which a Solitaire SR (Covidien) and a Catch SR (Balt) were used in a “Y” configuration, for which the authors coined the term “Y-stent retriever.”

Incomplete Large Vessel Occlusions in Mechanical Thrombectomy: An Independent Predictor of Favorable Outcome in Ischemic Stroke

2017 ◽  
Vol 44 (3-4) ◽  
pp. 113-121 ◽  
Author(s):  
Volker Maus ◽  
Seunghwa You ◽  
Alev Kalkan ◽  
Jan Borggrefe ◽  
Christoph Kabbasch ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Mechanical Thrombectomy ◽  
National Institutes Of Health ◽  
Large Vessel ◽  
Favorable Outcome ◽  
Vessel Occlusion ◽  
All Cause Mortality ◽  
Secondary Endpoints ◽  
Favorable Clinical Outcome

Background and Purpose: Cerebral large vessel occlusion (LVO) in acute ischemic stroke (AIS) may be complete (CLVO) or incomplete (ILVO). The influence of ILVO on clinical outcome after mechanical thrombectomy (MT) remains unclear. We investigated primarily the clinical outcome in patients with AIS due to ILVO or CLVO. Methods: Five hundred three consecutive AIS patients with LVO treated with stent-retriever or direct aspiration-based MT between 2010 and 2016 were analyzed. The primary endpoint was favorable clinical outcome (modified Rankin Scale ≤2) at 90 days; secondary endpoints were periprocedural parameters. Results: Forty-nine patients (11.3%) with a median National Institutes of Health Stroke Scale (NIHSS) of 11 presented with ILVO and the remainder presented with CLVO and median NIHSS of 15 (p < 0.001). The median groin puncture-to-reperfusion time was 30 vs. 67 min, respectively (p < 0.001). Successful reperfusion was reached in 47 out of 49 ILVO (95.9%) vs. 298 out of 381 CLVO (78.2%; p < 0.005) with less retrieval maneuvers (1.7 ± 2.2 vs. 3.0 ± 2.5; p < 0.001). The favorable outcome at 90 days was 81% in patients with ILVO vs. 29.1% in CLVO (p < 0.001); respective all-cause mortality rates were 6.4 vs. 28.5% (p < 0.001). Periprocedural complications (6.9%) occurred exclusively in CLVO patients (p < 0.05). ILVO was associated with favorable clinical outcome independent of age and NIHSS in multivariate logistic regression both in the anterior (OR 3.6; 95% CI 1.8-6.9; p < 0.001) and posterior circulation (OR 3.5; 95% CI 1.8-6.9; p < 0.001). Conclusions: AIS due to ILVO is frequent and is associated with a nearly threefold higher chance of favorable clinical outcome at 90 days, independent of age and initial NIHSS compared to CLVO.

scholarly journals More than three passes of stent retriever is an independent predictor of parenchymal hematoma in acute ischemic stroke

2018 ◽  
Vol 11 (7) ◽  
pp. 625-629 ◽  
Author(s):  
Romain Bourcier ◽  
Suzana Saleme ◽  
Julien Labreuche ◽  
Mikael Mazighi ◽  
Robert Fahed ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Primary Outcome ◽  
Mechanical Thrombectomy ◽  
Treated Group ◽  
Stent Retriever ◽  
First Line ◽  
Increased Risk ◽  
The Impact ◽  
Number Of Passes

IntroductionDespite successful recanalization with mechanical thrombectomy (MT) for acute anterior ischemic stroke (AAIS), the number of passes may impact clinical outcome.We analyzed the impact of more than three MT passes (>3) in a trial that evaluated contact aspiration (CA) versus stent retriever (SR) as the first-line technique in AAIS.MethodsWe included patients with mTICI 2b/3 recanalization after MT for isolated intracranial occlusions. The primary outcome was the percentage of patients with a 90-day modified Rankin Scale (mRS)≤2. Secondary outcomes included overall distribution of 90-day mRS, parenchymal hematoma on 24 hours' brain imaging (PH), and 90-day mortality.ResultsAmong the 281 patients included and even after adjustment on time to recanalization, significantly more patients with >3 passes had PH than patients with ≤3 passes in multivariate analysis (adjusted OR, 3.62; 95% CI, 1.55 to 8.44). When the analyses were stratified according to CA vs. SR, patients with >3 passes had a stronger risk of PH than patients with ≤3 passes, only in the SR first-line-treated group (adjusted OR, 9.24; 95% CI, 2.65 to 32.13) and not in the CA first-line-treated group (adjusted RR, 1.73; 95% CI, 0.57 to 5.19). A negative association of borderline significance (P=0.07) between >3 passes and favorable outcome was observed only in SR first-line-treated patients (adjusted OR, 0.33; 95% CI, 0.09 to 1.11).ConclusionsAfter three passes of SR and unlike for three passes of CA, there is an increased risk of PH and a trend toward a worse clinical outcome.

Abstract 1122‐000112: In Vitro Investigation of Endothelial Injury During Mechanical Thrombectomy for Ischemic Stroke

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Maxim Mokin ◽  
Ana Martinez ◽  
Zackary Lorton ◽  
Julia Kretz ◽  
Chris Bashur ◽  
...  
Keyword(s):  
Endothelial Cells ◽  
Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Endothelial Damage ◽  
Stent Retriever ◽  
Endothelial Injury ◽  
Immunofluorescent Staining ◽  
Lumen Diameter ◽  
Stent Retrievers

Introduction : Ischemic stroke (IS) makes up a significant proportion of all strokes, of which large vessel occlusions (LVO) are the most debilitating type. The current clinical standard‐of‐care for IS includes mechanical thrombectomy with stent retrievers. One of the impediments to the success of SR intervention is endothelial injury (EI), which can occur in approximately 30% of cases and impedes vessel reperfusion. Since successful reperfusion of the occluded vessel is instrumental in survival and patient recovery, it is imperative to reduce device injury‐based complications such as vasospasm, and to improve patient outcomes. Methods : In this work, our hypothesis is that EI can be reduced by investigating the mechanisms of stent retriever‐induced injury in vitro using live cell 3D cerebrovascular models. Using true‐scale cerebrovascular phantoms with lumen diameter approximately 4 mm created using 3D printing and PDMS casting, Human Umbilical Vein Endothelial Cells (HUVECs) were seeded on the luminal surface. The in vitro models were coated with fibronectin (density 4 µgrams/cm2) to encourage cell adhesion, and were divided into control and treated samples (n = 3 each). Mechanical thrombectomy was performed using two different clinically used SR (Trevo XP PROVUE 3 × 20 mm and Trevo XP PROVUE 6 × 30 mm) to investigate the extent of stent retriever size on EI on the same diameter lumen. Following thrombectomy, the cerebrovascular models were fixed and stained with immunofluorescent dyes (DAPI, Phalloidin and VE cadherin antibody) and imaged using transmitted light, confocal microscopy and scanning electron microscopy. For quantitative assessment, real time PCR was performed on both control and treated samples. Results : All models were initially confluent and functional, as assessed by immunofluorescent staining (Figure 1 A and B). All treated samples demonstrated EI and endothelial damage, as evidenced by loss of endothelial cell coverage, denuding of the models, stripping / clumping of endothelial cells into non‐physiological three dimensional structures and physical scratching of the in vitro model (Figure 1 C and D). Sizing of stent retriever had a strong influence on the effects on the endothelium, with larger sizes causing more damage. Conclusions : A significant knowledge gap exists in understanding the factors responsible for disruption of the endothelium during mechanical thrombectomy. Using a 3D in vitro platform of cerebrovasculature, we demonstrated that endothelial damage occurs during thrombectomy using stent retrievers. A parameteric investigation is currently ongoing that characterizes the influence of vessel lumen diameter, stent retriever size, number of passes and patient specific vasculature. This work can provide guidelines for optimal stent retriever devices to be used where possible, ultimately reducing EI and improving outcomes of ischemic stroke treatment.

scholarly journals Mechanical thrombectomy in pediatric acute ischemic stroke: Clinical outcomes and literature review

2016 ◽  
Vol 22 (4) ◽  
pp. 426-431 ◽  
Author(s):  
Thomas P Madaelil ◽  
Akash P Kansagra ◽  
DeWitte T Cross ◽  
Christopher J Moran ◽  
Colin P Derdeyn
Keyword(s):  
Ischemic Stroke ◽  
Literature Review ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Preliminary Evidence ◽  
Neurological Deficits ◽  
Effective Treatment Option ◽  
Aggregate Rate ◽  
Favorable Clinical Outcome

There are limited data on outcomes of mechanical thrombectomy for pediatric stroke using modern devices. In this study, we report two cases of pediatric acute ischemic stroke treated with mechanical thrombectomy, both with good angiographic result (TICI 3) and clinical outcome (no neurological deficits at 90 days). In addition, we conducted a literature review of all previously reported cases describing the use of modern thrombectomy devices. Including our two cases, the aggregate rate of partial or complete vessel recanalization was 100% (22/22), and the aggregate rate of favorable clinical outcome was 91% (20/22). This preliminary evidence suggests that mechanical thrombectomy with modern devices may be a safe and effective treatment option in pediatric patients with acute ischemic stroke.

Two-year single-center experience with the ‘Baby Trevo’ stent retriever for mechanical thrombectomy in acute ischemic stroke

2016 ◽  
Vol 9 (6) ◽  
pp. 541-546 ◽  
Author(s):  
Anna Luisa Kühn ◽  
Ajay K Wakhloo ◽  
J Diego Lozano ◽  
Francesco Massari ◽  
Katyucia De Macedo Rodrigues ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Significant Risk ◽  
Stent Retriever ◽  
National Institutes Of Health ◽  
Nihss Score ◽  
Single Center Experience ◽  
Patient Gender

ObjectiveTo evaluate the safety and efficacy of the ‘Baby Trevo’ (Trevo XP ProVue 3×20 mm Retriever) stent retriever for large vessel occlusions (LVOs) in acute ischemic stroke (AIS).Materials and methodsWe retrospectively analyzed our stroke database and included all patients treated with the Baby Trevo for distal LVOs in AIS. Patient gender, mean age, vascular risk factors, National Institutes of Health Stroke Scale (NIHSS) score at presentation, and modified Rankin Scale (mRS) score at baseline and 90-day follow-up were documented. Reperfusion rates for the vessels treated were recorded using the Thrombolysis in Cerebral Infarction (TICI) classification. Occurrence of vasospasm and new or evolving infarcts in the treated vascular territory was documented.ResultsThirty-five subjects with a mean NIHSS score of 18 were included. The Baby Trevo device was used in 38 branches of the anterior and posterior circulations. TICI 2b/3 blood flow was restored after one single pass in 20/38 (52.6%) and after two or three passes in 11 vessels. The remaining vessels required either more than three passes, showed less than a TICI 2b/3 reperfusion (n=3), or demonstrated failure to retrieve the clot (n=4). TICI 2b/3 reperfusion was achieved in 30 patients (85.7%). No vessel injuries, rupture, or significant vasospasm were seen. Overall, a mRS score of ≤2 was seen in 56.5% of the subjects successfully treated with the Baby Trevo at 90 days and in 81.3% of surviving patients; seven patients died (20%).ConclusionsOur preliminary data suggest that the ‘Baby Trevo’ achieves a high recanalization rate without any significant risk. Larger cohort studies are needed to validate the clinical benefit.

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