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

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

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2015-011763 ◽

2015 ◽

Vol 8 (6) ◽

pp. 568-570 ◽

Cited By ~ 17

Author(s):

Veer A Shah ◽

Coleman O Martin ◽

Angela M Hawkins ◽

William E Holloway ◽

Shilpa Junna ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Complication Rates ◽

Artery Pseudoaneurysm ◽

Stroke Treatment ◽

Vascular Closure Devices ◽

Clinical Records ◽

The Impact ◽

Groin Hematoma

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 T P187: Regionalization of Endovascular Therapy for Acute Ischemic Stroke in California, 2009-2010

Stroke ◽

10.1161/str.45.suppl_1.tp187 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Jay Chol Choi ◽

Renee Y Hsia ◽

Anthony S Kim

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Health Planning ◽

Stroke Therapy ◽

Stroke Patients ◽

Stroke Treatment ◽

Transport Distance ◽

Procedural Volume ◽

Endovascular Stroke Therapy

Background: The regional availability of hospitals with expertise in applying endovascular therapy for acute ischemic stroke is critical to ongoing efforts to develop effective interventions for this time-sensitive indication. We sought to assess the geographic proximity of stroke patients in California to centers that perform endovascular stroke therapy. Methods: We identified all hospitalizations for ischemic stroke at all 366 non-federal acute care hospitals in California from 2009 to 2010, including the subset where endovascular stroke therapy was employed, using data from the Office of Statewide Health Planning and Development. ZIP code centroids were used to estimate the geographic distance between a treating hospital and the patient’s residence. Using these distances, we estimated the proportion of stroke patients that lived within 2-hour (65 mile) transport distance to a hospital that performed certain threshold volumes of endovascular stroke cases each year. Results: From 2009-10, endovascular stroke treatment was used in 643 of 104,350 (0.6%) hospital discharges for ischemic stroke in California. A majority (60%) of these procedures were performed at hospitals that performed at least 12 procedures per year, and 83% of these procedures were performed at hospitals that performed at least 6 procedures per year. Of the 366 hospitals, 54 (15%) performed at least one endovascular stroke procedure per year. The median number of procedures per hospital per year was 3.5 (IQR 1-9). In-hospital mortality for endovascular stroke therapy was 21%, and a higher procedural volume at the hospital level was not associated with lower mortality. Most (86%) stroke patients lived within 65 miles of a center that performed at least 6 procedures per year (median with IQR, 9.5[7-17]), and 97% were within 65 miles of a center that performed at least 1 procedure per year. Conclusion: In 2009-10, less than 1% of ischemic stroke hospitalizations in California involved the use of endovascular stroke therapy. Most patients lived within a 2-hour transport distance from a center that performed at least one endovascular procedure per year.

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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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Standardized Reporting of Workflow Metrics in Acute Ischemic Stroke Treatment: Why and How?

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.121.000177 ◽

2021 ◽

Author(s):

Mayank Goyal ◽

Jeffrey L. Saver ◽

Aravind Ganesh ◽

Rosalie V. McDonough ◽

Yvo B.W.E.M. Roos ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

The Other ◽

Time Dependent ◽

Time Intervals ◽

Stroke Treatment ◽

Basic Set ◽

Standardized Reporting

Abstract The benefit of acute ischemic stroke (AIS) treatment is highly time dependent. Although studies on workflow improvement in AIS are increasingly gaining attention, there is a lack of consensus and consistency regarding the definition, measurement, and reporting of AIS workflow times. We discuss the challenges related to defining and measuring workflow times in AIS and propose a basic set of time intervals that should be reported in AIS workflow studies. We particularly focus on patients undergoing mechanical thrombectomy. Importantly, endovascular treatment workflow times should always be reported in conjunction with reperfusion quality because one is not informative without the other. We further suggest standardized reporting of workflow times that includes the 90th percentile in addition to medians and interquartile ranges, means, and SDs. The proposed methodology serves as a framework for AIS studies and aids further discussion on workflow‐related AIS research.

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Recent guidelined for the early endovascular management of patients with acute ischemic stroke and practical aspects of their implementation

Endovascular Neuroradiology ◽

10.26683/2304-9359-2018-2(24)-20-29 ◽

2018 ◽

Vol 24 (2) ◽

pp. 20-29

Author(s):

А.М. Netliukh ◽

V.М. Shevaga ◽

A.V. Payenok ◽

В.M. Salo ◽

О.Ya. Kobyletskyi

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Cerebral Ischaemia ◽

Mechanical Thrombectomy ◽

Radiology Department ◽

Stroke Treatment ◽

Stent Retrievers ◽

Reperfusion Rate ◽

Arterial Thrombolysis

Objective — to estimate safety and effectiveness of intra-arterial treatment for acute ischemic stroke in the interventional radiology department of multiprofile hospital. Materials and methods. Urgent endovascular treatment was applied at 15 patients with acute ischemic stroke in carotid circulation during 2015–2017. Mechanical intra-arterial therapy with thrombectomy by stent-retrievers and thromboaspiration was used at accordingly six and two recent cases (during 2017); in 7 cases intra-arterial thrombolysis was the treatment option (2015–2016). Results. The article consist brief review of literature about acute ischemic stroke treatment and discussion concerning results of treatment of selected patients. Mechanical thrombectomy or thromboaspiration were effective in 75.0 % of cases with good recanalization rate opposite to 42.9 % at 7 patients treated by either intra-arterial or bridging thrombolysis with rt-PA. Unexpected technical failures of mechanical thrombectomy regarding recent clinical guidelines for ischemic stroke management following are discussed on example of 2 clinical cases. Conclusions. Endovascular treatment of ischemic stroke has a high safety and well-known efficacy. It became evident at our patients that following current management guidelines for thrombectomy with stent-retrievers or thromboaspiration after thrombotic occlusions of extracranial and proximal segments of intracranial arteries allowed attaining in 2017 reperfusion rate 2b/3 Modified Treatment in Cerebral Ischaemia Scale in majority of cases. Intra-arterial thrombolysis contributed to the reperfusion rate 2b/3 on the Modified Treatment in Cerebral Ischaemia scale just in 42.9 % of cases, which indicates its lower effectiveness.

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Improvement of Endovascular Stroke Treatment: A 24-Hour Neuroradiological On-Site Service Is Not Enough

BioMed Research International ◽

10.1155/2018/9548743 ◽

2018 ◽

Vol 2018 ◽

pp. 1-8 ◽

Cited By ~ 5

Author(s):

Omid Nikoubashman ◽

Kolja Schürmann ◽

Ahmed E. Othman ◽

Jan-Philipp Bach ◽

Martin Wiesmann ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Working Hours ◽

Out Of Hours ◽

Stroke Treatment ◽

Workflow Optimization ◽

Rescue Chain

Background and Purpose. With the advent of endovascular stroke treatment (EST) with mechanical thrombectomy, stroke treatment has also become more challenging. Purpose of this study was to investigate whether a fulltime neuroradiological on-site service and workflow optimization with a structured documentation of the interdisciplinary stroke workflow resulted in improved procedural times. Material and Methods. Procedural times of 322 consecutive patients, who received EST (1) before (n=96) and (2) after (n=126) establishing a 24-hour neuroradiological on-site service as well as (3) after implementation of a structured interdisciplinary workflow documentation (“Stroke Check”) (n=100), were analysed. Results. A fulltime neuroradiological on-site service resulted in a nonsignificant improvement of procedural times during out-of-hours admissions (p≥0.204). Working hours and out-of-hours procedural times improved significantly, if additional workflow optimization was realized (p≤0.026). Conclusions. A 24-hour interventional on-site service is a major prerequisite to adequately provide modern reperfusion therapies in patients with acute ischemic stroke. However, simple measures like standardized and focused documentation that affect the entire interdisciplinary pre- and intrahospital stroke rescue chain seem to be important.

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Implications of the use of mechanical thrombectomy on outcome in large vessel occlusion following the 2015 landmark trials

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-015903 ◽

2020 ◽

Vol 13 (1) ◽

pp. 4-7

Author(s):

Okkes Kuybu ◽

Vijayakumar Javalkar ◽

Abdallah Amireh ◽

Arshpreet Kaur ◽

Roger E Kelley ◽

...

Keyword(s):

Ischemic Stroke ◽

Hospital Mortality ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Intravenous Thrombolysis ◽

Binary Logistic Regression ◽

Standard Of Care ◽

Vessel Occlusion ◽

Stroke Treatment ◽

Before And After

BackgroundThe effectiveness of mechanical thrombectomy (MT) was demonstrated in five landmark trials published in2015.Mechanical thrombectomy is now standard of care for acute ischemic stroke and has been growing in popularity after publication of landmark trials.ObjectiveTo analyze outcomes and trends of the use of MT and intravenous thrombolysis (IVT) in patients with acute ischemic stroke in US hospitals before and after publication of these trials.MethodsPatients discharged with a diagnosis of ischemic stroke between 2012 to 2017 were diagnosed using ICD codes from the National Inpatient Sample. Thereafter, patients given acute stroke treatment were identified using the corresponding procedure codes for IVT and MT. The primary clinical outcomes of in-hospital mortality and disability were then compared between two time periods: 2012–2014 (pre-landmark trials) and 2015–2017 (post-landmark trials). Binary logistic regression and Χ2 tests were used for statistical analysis.ResultsA total of 57 675 patients (median age 68.9 years (range 18-90), 50.1% female) were identified with acute procedures. Of these patients, 57.6% were from the post-landmark trials time period. Despite an increased number of cases, the rate of IVT decreased from 84.3% to 75.9% and the rate of IVT+MT decreased from 7.1% to 6.3%. After publication of the pivotal trials in 2015, the rates of MT increased from 8.7% to 17.8%. Significant reductions of in-hospital mortality (7.1% vs 8.7%, p<0.001) and disability (64% vs 66.2%, p<0.001) were noted.ConclusionThe analysis showed a significant increase in the proportion of patients receiving MT after 2015. This has translated into reduction of in-hospital mortality and improvement in disability.

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A multicenter study of the safety and effectiveness of mechanical thrombectomy for patients with acute ischemic stroke not meeting top-tier evidence criteria

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012905 ◽

2017 ◽

Vol 10 (1) ◽

pp. 10-16 ◽

Cited By ~ 24

Author(s):

Nitin Goyal ◽

Georgios Tsivgoulis ◽

Donald Frei ◽

Aquilla Turk ◽

Blaise Baxter ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Standard Of Care ◽

High Volume ◽

Functional Independence ◽

Functional Improvement ◽

Complication Rates ◽

Logistic Regression Models ◽

Symptomatic Intracerebral Hemorrhage

BackgroundWhile mechanical thrombectomy (MT) has become the standard of care for patients with acute ischemic stroke (AIS) with emergent large-vessel occlusions (ELVO), recently published guidelines appropriately award top-tier evidence to the same selective criteria that were employed in completed clinical trials. We sought to evaluate the safety and effectiveness of MT in patients with AIS with ELVO who do not meet top-tier evidence criteria (TTEC).MethodsWe conducted an observational study on consecutive patients with AIS with ELVO who underwent MT at six high-volume endovascular centers. Standard safety outcomes (3-month mortality, symptomatic intracranial hemorrhage) and effectiveness outcomes (3-month functional independence: modified Rankin Scale scores of 0–2) were compared between patients meeting and failing TTEC.ResultsThe sample consisted of 349 (60%) controls fulfilling TTEC and 234 (40%) non-TTEC patients. Control patients meeting TTEC for MT tended to have higher functional independence rates at 3 months (47% vs 39%; p=0.055), while the rates of symptomatic intracerebral hemorrhage (sICH) were similar (9%) in both groups (p=0.983). In multivariable logistic regression models, adherence to TTEC for MT was not independently related to any safety outcome (sICH: OR 0.71, 95% CI 0.30 to 1.68, p=0.434; 3-month mortality: OR 1.27, 95% CI 0.69 to 2.33, p=0.448) or effectiveness outcome (3-month functional independence: OR 0.81, 95% CI 0.48 to 1.37, p=0.434; 3-month functional improvement: OR 0.73, 95% CI 0.48 to 1.11, p=0.138) after adjusting for potential confounders.ConclusionsApproximately 40% of patients with AIS with ELVO offered MT do not fulfill TTEC for MT. Patients who did not meet TTEC had high rates of good clinical outcome and low complication rates.

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