Abstract WP439: Who Benefits From CT-Angiography Previous Intravenous Thrombolysis?

Background: Endovascular treatment (EVT) is an effective treatment in strokes with persistent large artery occlusion despite previous intravenous thrombolisis (IVT) as rescue treatment. Performing computer tomography angiography (CTA) before IVT could allow early activation of neurointerventional teams; however routine CTA could delay unnecessary door-to-needle time of IVT and may be infeasible. Methods: We reviewed stroke code activations between May 2011 and June 2015 in our comprehensive stroke center and divided into groups based on NIHSS and patency of arterial occlusion according to non-enhanced CT on admission (dense artery sign or dot sign) and baseline CTA. We assessed patients treated with IVT and selected to EVT according to results in CTA post-IVT. We analyze percentage of recanalization or migration of thrombus after IVT alone and variables associated to successful treatment. Results: Of 2856 stroke codes registered during the study period 1810 were diagnosis of ischemic strokes. We treated 520 patients with IVT, 202 had a radiological evidence of large artery occlusion (55%M1, 32% M2, 5%TICA, 5%ICA, 3% basilar). Thirty-two percent of patients showed changes in CTA carried out after IVT(17% successfully recanalized, 15% distal migration of thrombus) so they were not selected to endovascular treatment. There were significant difference between M1 and M2 occlusion regarding changes in CTA after IVT (23% vs 70%; p<0.001). In multivariate logistic regression a baseline score NIH<10 was associated with higher percentage of recanalization with rtPA despite signs of large vessel occlusion (78% vs 32%; p:0.001). In receiver operating characteristic analysis higher baseline NIH was associated with persistent occlusion after IVT (area under curve=0.79;95% CI, 0.6-0.9; P:0.001) with optima threshold of 10 ( Sensivity 84%, Specificity 74%). Conclusions: We consider defer CTA angiography until after IVT in stroke code patients with moderate clinical impairment (NIH<10) or M2-segment occlusion, because they achieve a high percentage of arterial recanalization. CTA previous IVT could be unnecessary, provide unreliable information and delay IVT in that clinical group but could be useful to plan EVT in patients with higher NIH scores.

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Endovascular therapy in patients with large vessel occlusion due to cardioembolism versus large-artery atherosclerosis

Therapeutic Advances in Neurological Disorders ◽

10.1177/1756286421999017 ◽

2021 ◽

Vol 14 ◽

pp. 175628642199901

Author(s):

Meredeth Zotter ◽

Eike I. Piechowiak ◽

Rupashani Balasubramaniam ◽

Rascha Von Martial ◽

Kotryna Genceviciute ◽

...

Keyword(s):

Heart Failure ◽

Endovascular Therapy ◽

Independent Predictor ◽

Intravenous Thrombolysis ◽

Stent Retriever ◽

Large Vessel ◽

Large Artery ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Significant Difference

Background and aims: To investigate whether stroke aetiology affects outcome in patients with acute ischaemic stroke who undergo endovascular therapy. Methods: We retrospectively analysed patients from the Bernese Stroke Centre Registry (January 2010–September 2018), with acute large vessel occlusion in the anterior circulation due to cardioembolism or large-artery atherosclerosis, treated with endovascular therapy (±intravenous thrombolysis). Results: The study included 850 patients (median age 77.4 years, 49.3% female, 80.1% with cardioembolism). Compared with those with large-artery atherosclerosis, patients with cardioembolism were older, more often female, and more likely to have a history of hypercholesterolaemia, atrial fibrillation, current smoking (each p < 0.0001) and higher median National Institutes of Health Stroke Scale (NIHSS) scores on admission ( p = 0.030). They were more frequently treated with stent retrievers ( p = 0.007), but the median number of stent retriever attempts was lower ( p = 0.016) and fewer had permanent stent placements ( p ⩽ 0.004). Univariable analysis showed that patients with cardioembolism had worse 3-month survival [72.7% versus 84%, odds ratio (OR) = 0.51; p = 0.004] and modified Rankin scale (mRS) score shift ( p = 0.043) and higher rates of post-interventional heart failure (33.5% versus 18.5%, OR = 2.22; p < 0.0001), but better modified thrombolysis in cerebral infarction (mTICI) score shift ( p = 0.025). Excellent (mRS = 0–1) 3-month outcome, successful reperfusion (mTICI = 2b–3), symptomatic intracranial haemorrhage and Updated Charlson Comorbidity Index were similar between groups. Propensity-matched analysis found no statistically significant difference in outcome between stroke aetiology groups. Stroke aetiology was not an independent predictor of favourable mRS score shift, but lower admission NIHSS score, younger age and independence pre-stroke were (each p < 0.0001). Stroke aetiology was not an independent predictor of heart failure, but older age, admission antithrombotics and dependence pre-stroke were (each ⩽0.027). Stroke aetiology was not an independent predictor of favourable mTICI score shift, but application of stent retriever and no permanent intracranial stent placement were (each ⩽0.044). Conclusion: We suggest prospective studies to further elucidate differences in reperfusion and outcome between patients with cardioembolism and large-artery atherosclerosis.

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Abstract 26: RACE to Treat Stroke

Stroke ◽

10.1161/str.47.suppl_1.26 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Andrea M Korsnack ◽

Andrea Adams

Keyword(s):

Endovascular Treatment ◽

Acute Stroke ◽

Arterial Occlusion ◽

First Responders ◽

Artery Occlusion ◽

Large Vessel ◽

Stroke Severity ◽

Large Artery ◽

Stroke Patients ◽

Conversion Disorders

Background: Endovascular treatment was shown to drastically improve stroke patient outcomes but earlier identification of eligible patients is crucial. First responders are instrumental to the rapid identification and transportation of stroke patients to the nearest appropriate facility for acute stroke care especially when endovascular intervention is an option. Purpose: To develop and evaluate the effectiveness of an algorithm for first responders to use to differentiate which stroke patients should be transported to the closest Interventional Stroke Center for treatment. Method: We revised the County-Level Emergency Medical Services (EMS) protocol and algorithm to include the Rapid Arterial oCclusion Evaluation (RACE) scale in addition to the Cincinnati Prehospital Stroke Scale (CPPS). Together these simple in-the-field scales assess stroke severity and identify patients with acute stroke and large artery occlusion in a prehospital setting. Lucas County EMS staff received a four hour block of continuing education with credit on acute stroke, the updated protocol and algorithm, and use of the new RACE scale in addition to the CPPS. Effectiveness of the training and use of the RACE alert was measured by the percent of patients accurately identified with and without large artery occlusion. Results: Training was provided to 450 EMS staff in several in-person sessions in June 2015. The RACE protocol went citywide on July first. Of the 18 patients brought in to our hospital by EMS in July using the RACE protocol, 72% were identified correctly using the tool. Of these, 6 were identified correctly as having large vessel occlusions and 7 were correctly identified as not having large vessel occlusions. The remaining 5 patients transported by EMS were identified as large vessel occlusions, but were not found to have strokes (seizures, intoxication, and conversion disorders). Conclusion: Our data suggests that first responders can accurately differentiate between which stroke patients could benefit from endovascular treatment using a simple algorithm. Future evaluation could measure the relationship between accurate pre-hospital identification and treatment rates.

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Acute Ischaemic Stroke Cooperation Group of Endovascular Treatment (ANGEL) registry: study protocol for a prospective, multicentre registry in China

Stroke and Vascular Neurology ◽

10.1136/svn-2018-000188 ◽

2019 ◽

Vol 4 (1) ◽

pp. 57-60 ◽

Cited By ~ 4

Author(s):

Xiaochuan Huo ◽

Ning Ma ◽

Dapeng Mo ◽

Feng Gao ◽

Ming Yang ◽

...

Keyword(s):

Ischaemic Stroke ◽

Endovascular Treatment ◽

Acute Ischaemic Stroke ◽

Treatment Algorithm ◽

Functional Independence ◽

Artery Occlusion ◽

Large Artery ◽

Vessel Occlusion ◽

Treatment Delivery ◽

Safety Endpoint

Background and purposeEndovascular treatment could improve functional outcomes and reduce mortality in patients with intracranial large artery occlusion. This registry aims to evaluate the endovascular treatment delivery and to improve endovascular treatment algorithm in clinical practice for patients with stroke in China.Methods and analysisThis multicentric, nationwide, prospective registry plans to include 20 stroke centres and recruit 900 consecutive AIS patients with large-artery occlusion under endovascular treatment. This registry will enrol acute large vessel occlusion patients suitable for endovascular treatment and the inclusion and exclusion criteria. In this study, 90 days functional independence (modified Rankin Scale score ≤2) is the primary efficacy endpoint. The procedural efficacy endpoint of this registry is target artery recanalisation defined by modified Thrombolysis in Cerebral Infarction score 2b or 3 after endovascular therapy. Symptomatic intracranial haemorrhage with 24±3 hours after the procedure is the primary safety endpoint of this registry.Ethics and disseminationBeijing Tiantan Hospital’s Ethics committee and all other participating centres approved the protocol and data collection of Acute Ischaemic Stroke Cooperation Group of Endovascular Treatment registry. Each participant or representative had a written informed consent.

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ENDOVASCULARAPPROACHES TOACUTE ISCHEMIC STROKE- INDIAN PERSPECTIVE

PERSPECTIVES IN MEDICAL RESEARCH - 2 ◽

10.47799/pimr.0703.02 ◽

2020 ◽

Vol 7 (3) ◽

pp. 7-14

Author(s):

Pramod Dhonde ◽

N. Kadam

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

Review Literature ◽

Large Artery ◽

Stroke Event ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Indian Perspective

Aim: To review literature about endovascular approaches to acute ischemic stroke and provide Indian perspective about managing these cases. Brief Summary: In acute ischemic stroke cases, intravenous thrombolysis (IVT) with altepase within 4.5 hours has been the standard of care. Due to certain limitations of IVT, in pooled patientlevel data from 5 trials (HERMES [Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials], which included the 5 trials MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND-IA), mechanical thrombectomy (MT) is indicated for patients with acute ischemic stroke due to a large artery occlusion (LVO) in the anterior circulation who can be treated within 24 hours of the time last known to be well (ie, at neurologic baseline), regardless of whether they received intravenous alteplase for the same ischemic stroke event. The maximum benefit can be achieved within 6 hours of onset of symptoms. There are studies suggesting the benefit of MT in posterior circulation stroke as well as in distal arteries. We are going to review the methodology of endovascular techniques in brief alongwith Indian perspective on feasibility of this treatment approach in AIS. Conclusion: Mechnicalthrombectomy is certainly an effective modality of treatment in large vessel occlusion in anterior circulation within 24 hours. More awareness regarding the approach in India, can reduce the stroke morbidity and mortality in many of the cases in future

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Bridging Therapy and Direct Thrombectomy for Acute Ischemic Stroke: A Prospective Cohort Study

Journal of Stroke Medicine ◽

10.1177/2516608520976275 ◽

2020 ◽

Vol 3 (2) ◽

pp. 124-130

Author(s):

Trung Quoc Nguyen ◽

Anh Le Tuan Truong ◽

Hoang Thi Kim Phan ◽

Duan Duy Nguyen ◽

Khang Vinh Nguyen ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Therapy Group ◽

Intravenous Thrombolysis ◽

Functional Independence ◽

Artery Occlusion ◽

Large Artery ◽

Bridging Therapy ◽

Vessel Occlusion ◽

Reperfusion Rate

Background: It remains controversial if intravenous thrombolysis (IVT) prior to mechanical thrombectomy (MTE) is superior to MTE alone in patients with acute ischemic stroke caused by large vessel occlusion. We aim to compare functional outcomes, mortality, reperfusion, and intracranial hemorrhage rates in bridging therapy (IVT prior thrombectomy) and MTE alone groups within 6 h from symptom onset. Materials and Methods: Consecutive hospitalized patients (September 2017 and July 2018) with acute large artery occlusion within the anterior cerebral circulation eligible for MTE with or without prior IVT were included. A modified Rankin Scale score of 0 to 2 was considered as good functional outcome at 90 days. Successful reperfusion was defined as a Thrombolysis in Cerebral Infarction scale of 2b to 3. Results: Of the 124 patients included, 56 (45.2%) received bridging therapy and 68 (54.8%) received MTE alone. Patients receiving bridging therapy were younger (median, 56 vs 63, P = .045) and had shorter onset-to-groin time (median, 270 vs 370 min, P < .001) than those receiving MTE alone. Successful reperfusion rate was significantly greater in the bridging therapy group (87.5% vs 72.1%, P = 0.03). There were no statistically significant differences between the 2 groups in functional independence (bridging 58.9% vs 75.0%, P = 0.07), mortality at 90 days (bridging 14.3% vs 7.4%, P = 0.22), parenchymal hematoma type 2 (bridging 3.6% vs 2.9%, P > .99), and any hemorrhage (bridging 42.3% vs 26.5%, P = 0.07). Conclusion: Compared to MTE alone, bridging therapy with IVT improved the reperfusion rate but not other outcomes. Further clinical trials are needed to confirm our findings.

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Utility of Intravenous Alteplase Prior to Endovascular Stroke Treatment: A Systematic Review and Meta-analysis of RCTs

Neurology ◽

10.1212/wnl.0000000000012390 ◽

2021 ◽

pp. 10.1212/WNL.0000000000012390

Author(s):

Aristeidis Katsanos ◽

Guillaume Turc ◽

Marios Psychogios ◽

Johannes Kaesmacher ◽

Lina Palaiodimou ◽

...

Keyword(s):

Endovascular Treatment ◽

Meta Analysis ◽

Intravenous Thrombolysis ◽

Functional Improvement ◽

Vessel Occlusion ◽

Serious Adverse Events ◽

Random Effects Models ◽

Stroke Treatment ◽

Randomized Controlled Clinical Trials ◽

Significant Difference

Objective:To provide a critical appraisal on the evidence from randomized-controlled clinical trials (RCTs) on the utility of direct endovascular treatment (dEVT) compared to the combination of endovascular treatment preceded by intravenous thrombolysis (bridging therapy, BT) for patients with acute large vessel occlusion (LVO).Methods:Eligible RCTs were identified by searching Medline and Scopus. We calculated the corresponding odds ratios (ORs) and 95% confidence intervals (95%CI) and pooled estimates using random-effects models. The primary outcome was the probability of modified Rankin scale (mRS) score of 0-2 at 3 months.Results:We included 3 studies comprising 1092 patients. No difference between dEVT and BT groups was detected for the outcomes of mRS 0-2 (OR=1.08,95%CI:0.85-1.38; adjusted OR=1.11, 95%CI:0.76-1.63), mRS 0-1 (OR=1.10, 95%CI:0.84-1.43; adjusted OR=1.16, 95%CI:0.84-1.61) and functional improvement at 3 months (common OR=1.08, 95%CI:0.88-1.34; adjusted common OR=1.09, 95%CI:0.86-1.37). Patients receiving dEVT had significantly lower likelihood of successful recanalization prior to the endovascular procedure compared to BT (OR=0.37, 95%CI:0.18-0.77). Patients receiving dEVT had lower intracranial bleeding rates compared to those receiving BT (OR=0.67, 95%CI:0.49-0.92), however, without significant difference in the probability of symptomatic intracranial hemorrhage. No differences in all-cause mortality, serious adverse events or procedural complications between the two groups were uncovered.Conclusions:We detected no differences in functional outcomes of IV thrombolysis eligible patients with an acute LVO receiving dEVT compared to BT. Since uncertainty for most endpoints remains large and the available data is not able to exclude the possibility of overall benefit or harm, further RCTs are needed.

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Abstract WP140: Imaging of Clot Porosity Prior to Endovascular Thrombectomy

Stroke ◽

10.1161/str.48.suppl_1.wp140 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

David S Liebeskind ◽

Elijah Agbayani ◽

Graham W Woolf ◽

Baixue Jia ◽

Nerses Sanossian ◽

...

Keyword(s):

Single Phase ◽

Endovascular Procedures ◽

Arterial Occlusion ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

Large Artery ◽

Surface Mapping ◽

Endovascular Thrombectomy ◽

Luminal Narrowing ◽

Close Proximity

Background: Clot characteristics and porosity at the proximal portion of an arterial occlusion may influence potential recanalization. Thrombus permeability may be a factor in intravenous thrombolysis, whereas such features of clots prior to endovascular thrombectomy remains largely unexplored. We developed a technique to image clot porosity and yield quantitative measures that may predict mechanical recanalization. Methods: Consecutive cases of large artery occlusion (ICA or proximal M1 MCA) with single-phase CT angiography (CTA) acquired immediately prior to endovascular thrombectomy were analyzed. 3D-reconstruction, vessel segmentation, centerline extraction, signal intensity gradient calculations and surface mapping of CTA yielded porosity images and quantitative measures. Porosity measures were correlated with angiography parameters and procedural details. Results: 53 consecutive cases of acute stroke with contemporaneous sCTA and DSA were used to generate porosity images. Technical limitations precluded image processing in 9 cases, due to diminished contrast conspicuity in close proximity to bone interfaces. Porosity features on resulting images and the quantitative measures of clot penetration varied markedly, even within the subset of M1 or ICA occlusions, respectively. The occlusions often exhibited long segments (mean 18 ± 11 mm) of luminal narrowing before complete occlusion. Current analyses examine whether higher porosity or greater proximal contrast penetration of the clot is associated with faster recanalization and fewer device passes during endovascular thrombectomy. Conclusions: Clot porosity images and quantitative measures of proximal contrast penetration may be generated from routine CTA. Imaging of clot porosity may be a useful adjunct in planning of endovascular procedures and future strategies may focus on distinguishing atherosclerotic versus thromboembolic large artery occlusions.

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Immediate Effects of First-line Thrombectomy Devices for Intracranial Atherosclerosis-Related Occlusion: Stent Retriever versus Contact Aspiration

10.21203/rs.3.rs-21802/v1 ◽

2020 ◽

Author(s):

Joonsang Yoo ◽

Seong-Joon Lee ◽

Jeong-Ho Hong ◽

Yong-Won Kim ◽

Ji Man Hong ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Similar Efficacy ◽

Artery Occlusion ◽

Stent Retriever ◽

Large Artery ◽

First Line ◽

Vessel Occlusion ◽

Atherosclerotic Stenosis ◽

Significant Difference

Abstract Background: Although stent retriever (SR) is recommended as a frontline device of endovascular treatment (EVT) for embolic large artery occlusion causing acute ischemic stroke, contact aspiration (CA) device showed similar efficacy in the recent trials. However, the efficacy of the both devices as first-line therapy for intracranial atherosclerotic stenosis (ICAS)-related large vessel occlusion has not yet been established. Therefore, we compared the immediate effects and final outcomes of SR and CA as first-line devices for treating ICAS-related occlusions.Methods: We retrospectively analyzed the data of patients who underwent EVT for acute ischemic stroke from the registry of three Korean hospitals. Patients with ICAS-related occlusion who were treated within 24 hours of onset of the symptoms were included. We investigated immediate reperfusion performance, immediate safety outcomes, and 3-month clinical outcomes for the two first-line devices.Results: Of the 720 registered patients, 111 were eligible for this study. Forty-nine patients (44.1%) used SR and 62 (55.9%) used CA as the first-line device. Achieving successful reperfusion immediately after first-line thrombectomy was more frequent in the SR group than that in the CA group (77.6% vs. 43.5%, p = 0.001), with fewer additional rescue treatments (12.2% vs. 59.7%, p < 0.001). The incidence of iatrogenic dissection or rupture was lower in the SR group than that in the CA group (8.2% vs. 29.0%, p = 0.012). After additional rescue treatments, however, the final successful reperfusion rate did not differ between the two groups (SR 87.8% vs. CA 77.4%, p = 0.247), and there was no significant difference in the 3-month good outcomes (modified Rankin Scale, p = 0.524).Conclusions: First-line SR thrombectomy showed higher immediate reperfusion and less vessel injury for ICAS-related occlusions than CA. However, there was no significant difference in the final reperfusion status or 3-month outcomes from additional rescue treatments.

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Immediate Effects of First-line Thrombectomy Devices for Intracranial Atherosclerosis-Related Occlusion: Stent Retriever versus Contact Aspiration

10.21203/rs.3.rs-21802/v2 ◽

2020 ◽

Author(s):

Joonsang Yoo ◽

Seong-Joon Lee ◽

Jeong-Ho Hong ◽

Yong-Won Kim ◽

Ji Man Hong ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Similar Efficacy ◽

Artery Occlusion ◽

Stent Retriever ◽

Large Artery ◽

First Line ◽

Vessel Occlusion ◽

Atherosclerotic Stenosis ◽

Significant Difference

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Bridging Intravenous Thrombolysis Before Mechanical Thrombectomy for Large Artery Occlusion May be Detrimental with Thrombus Fragmentation

Current Neurovascular Research ◽

10.2174/1567202617666191223143831 ◽

2020 ◽

Vol 17 (1) ◽

pp. 18-26 ◽

Cited By ~ 3

Author(s):

Ho Jun Yi ◽

Jae Hoon Sung ◽

Dong Hoon Lee

Keyword(s):

Clinical Outcome ◽

Subgroup Analysis ◽

Mechanical Thrombectomy ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

Stent Retriever ◽

Large Artery ◽

Simultaneous Application

Objective: We investigated whether intravenous thrombolysis (IVT) affected the outcomes and complications of mechanical thrombectomy (MT), specifically focusing on thrombus fragmentation. Methods: The patients who underwent MT for large artery occlusion (LAO) were classified into two groups: MT with prior IVT (MT+IVT) group and MT without prior IVT (MT-IVT) group. The clinical outcome, successful recanalization with other radiological outcomes, and complications were compared, between two groups. Subgroup analysis was also performed for patients with simultaneous application of stent retriever and aspiration. Results: There were no significant differences in clinical outcome and successful recanalization rate, between both groups. However, the ratio of pre- to peri-procedural thrombus fragmentation was significantly higher in the MT+IVT group (14.6% and 16.2%, respectively; P=0.004) compared to the MT-IVT group (5.1% and 6.8%, respectively; P=0.008). The MT+IVT group required more second stent retriever (16.2%), more stent passages (median value = 2), and more occurrence of distal emboli (3.9%) than the MT-IVT group (7.9%, median value = 1, and 8.1%, respectively) (P=0.004, 0.008 and 0.018, respectively). In subgroup analysis, the results were similar to those of the entire patients. Conclusion: Thrombus fragmentation of IVT with t-PA before MT resulted in an increased need for additional rescue therapies, and it could induce more distal emboli. The use of IVT prior to MT does not affect the clinical outcome and successful recanalization, compared with MT without prior IVT. Therefore, we need to reconsider the need for IVT before MT.

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