Abstract TMP6: A Multi-center Study of Safety and Efficacy of Mechanical Thrombectomy for Acute Ischemic Stroke Patients with Emergent Large Vessel Occlusions Not Meeting Top Tier Evidence Criteria

Background: Recent recommendations for mechanical thrombectomy (MT) of acute ischemic stroke (AIS) patients with emergent large-vessel occlusions (ELVO) appropriately award top tier evidence (TTE) to the same selective criteria that were employed in recent clinical trials. We sought to evaluate the safety and efficacy of MT in AIS patients with ELVO who fail TTE criteria in a prospective multi-center study. Methods: Data on consecutive AIS patients with ELVO who underwent mechanical thrombectomy were collected from 6 high-volume endovascular centers. Standard safety and efficacy outcomes were compared between patients meeting and failing TTE criteria. Results: TTE criteria for MT were fulfilled in 349 (60%) cases (mean age 63±18 years; 47% men; median admission NIHSS-score 17 points, interquartile range 14-21), whereas 234 (40%) patients did not meet TTE criteria (mean age 62±19 years; 53% men; median admission NIHSS-score 16 points, interquartile range 9-21). (Table 1) The two most common reasons for failing TTE criteria were location of intracranial occlusion (n=144) and treatment window (n=108). In multivariate logistic regression models adjusting for potential confounders cases failing TTE criteria had similar safety (three-month mortality and symptomatic intracranial hemorrhage) and efficacy (three-month functional independence) outcomes with patients meeting TTE. Location of occlusion and proposed time-window according to TTE was also not related to any safety or efficacy outcome. (Table 2) Conclusions: Approximately 40% of AIS patients with ELVO offered MT do not fulfill TTE criteria for MT. Our multi-center experience indicates that MT may be offered to these patients with similar safety and efficacy to ELVO cases meeting TTE. Evidence-based medicine requires that health care providers understand published data and how those data might apply to a given patient’s treatment options. In a changing treatment environment this is a dynamic process.

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Reperfusion Therapy Frequency and Outcomes in Mild Ischemic Stroke in the United States

Stroke ◽

10.1161/strokeaha.120.030898 ◽

2020 ◽

Vol 51 (11) ◽

pp. 3241-3249 ◽

Cited By ~ 1

Author(s):

Hamidreza Saber ◽

Kasra Khatibi ◽

Viktor Szeder ◽

Satoshi Tateshima ◽

Geoffrey P. Colby ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intracranial Hemorrhage ◽

Odds Ratio ◽

Mechanical Thrombectomy ◽

Reperfusion Therapy ◽

Interquartile Range ◽

Nihss Score ◽

Discharge Disposition ◽

Younger Age

Background and Purpose: More than half of patients with acute ischemic stroke have minor neurological deficits; however, the frequency and outcomes of reperfusion therapy in regular practice has not been well-delineated. Methods: Analysis of US National Inpatient Sample of hospitalizations with acute ischemic stroke and mild deficits (National Institutes of Health Stroke Scale [NIHSS] score 0–5) from October 1, 2016, to December 31, 2017. Patient- and hospital-level characteristics associated with use and outcome of reperfusion therapies were analyzed. Primary outcomes included excellent discharge disposition (discharge to home without assistance); poor discharge disposition (discharge to facility or death); in-hospital mortality; and radiological intracranial hemorrhage. Results: Among 179 710 acute ischemic stroke admissions with recorded NIHSS during the 15-month study period, 103 765 (57.7%) had mild strokes (47.3% women; median age, 69 [interquartile range, 59–79] years; median NIHSS score of 2 [interquartile range, 1–4]). Considering reperfusion therapies among strokes with documented NIHSS, mild deficit hospitalizations accounted for 40.0% of IVT and 10.7% of mechanical thrombectomy procedures. Characteristics associated with IVT and with mechanical thrombectomy utilization were younger age, absence of diabetes, higher NIHSS score, larger/teaching hospital status, and Western US region. Excellent discharge outcome occurred in 48.2% of all mild strokes, and in multivariable analysis, was associated with younger age, male sex, White race, lower NIHSS score, absence of diabetes, heart failure, and kidney disease, and IVT use. IVT was associated with increased likelihood of excellent outcome (odds ratio, 1.90 [95% CI, 1.71–2.13], P <0.001) despite an increased risk of intracranial hemorrhage (odds ratio, 1.41 [95% CI, 1.09–1.83], P <0.001). Conclusions: In national US practice, more than one-half of acute ischemic stroke hospitalizations had mild deficits, accounting for 4 of every 10 IVT and 1 of every 10 mechanical thrombectomy treatments, and IVT use was associated with increased discharge to home despite increased intracranial hemorrhage.

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Mechanical thrombectomy of large vessel occlusion in acute ischemic stroke: A single-center study

Journal of the Neurological Sciences ◽

10.1016/j.jns.2019.10.723 ◽

2019 ◽

Vol 405 ◽

pp. 149

Author(s):

M. Pishjoo ◽

M. Javdani Yekta ◽

M. Farzan ◽

E. Vafadar ◽

M. Sobhani ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Single Center ◽

Vessel Occlusion ◽

Single Center Study ◽

Center Study

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

Journal of Neurosurgery Pediatrics ◽

10.3171/2018.9.peds18242 ◽

2019 ◽

Vol 23 (3) ◽

pp. 363-368 ◽

Cited By ~ 1

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.

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PCV37 Cost-Effectiveness Analysis of IV-TPA Followed By Mechanical Thrombectomy with Stent-Retriever Versus IV-TPA ALONE in the Treatment of ACUTE Ischemic Stroke Due to Large Vessel Occlusion in Portugal

Value in Health ◽

10.1016/j.jval.2020.08.528 ◽

2020 ◽

Vol 23 ◽

pp. S493

Author(s):

V. Genovez ◽

J. Sargento ◽

L. Veloso ◽

E. Machado ◽

M. Ribeiro ◽

...

Keyword(s):

Ischemic Stroke ◽

Cost Effectiveness ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Cost Effectiveness Analysis ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Effectiveness Analysis ◽

Iv Tpa

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Safety and efficacy of mechanical thrombectomy in acute ischemic stroke of anticoagulated patients

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2017-013714 ◽

2018 ◽

Vol 10 (12) ◽

pp. e29-e29 ◽

Cited By ~ 10

Author(s):

Vincent L’Allinec ◽

Marielle Ernst ◽

Mathieu Sevin-Allouet ◽

Nathalie Testard ◽

Béatrice Delasalle-Guyomarch ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intracranial Hemorrhage ◽

Mechanical Thrombectomy ◽

Univariate Analysis ◽

Recombinant Tissue Plasminogen Activator ◽

Reperfusion Therapy ◽

Safety And Efficacy ◽

Risk Of Death ◽

Anticoagulated Patients

BackgroundAnticoagulated patients (APs) are currently excluded from acute ischemic stroke reperfusion therapy with intravenous recombinant tissue plasminogen activator (IV-rtPA); however, these patients could benefit from mechanical thrombectomy (MT). Evidence for MT in this condition remains scarce. The aim of this study was to analyze the safety and efficacy of MT in APs.MethodsWe analyzed three patient groups from two prospective registries: APs with MT (AP-MT group), non-anticoagulated patients treated with MT (NAP-MT group), and non-anticoagulated patients treated with IV-rtPA and MT (NAP-IVTMT group). Univariate and multivariate logistic regression were used to evaluate treatment efficacy with modified Rankin Scale (mRS) ≤2 and safety (radiologic intracranial hemorrhage (rICH), symptomatic intracranial hemorrhage (sICH) and death rate at 3 months) between groups.Results333 patients were included in the study, with 44 (12%) in the AP-MT group, 105 (31%) in the NAP-MT group, and 188 (57%) in the NAP-IVTMT group. Univariate analysis showed that the AP-MT group was older (P<0.001), more often had atrial fibrillation (P<0001), and had a higher ASPECTS (P<0.006 and P<0.002) compared with the NAP-MT group and NAP-IVTMT groups, respectively. Multivariate analysis showed that the AP-MT group had a lower risk of rICH (OR 2.77, 95% CI 1.01 to 7.61, P=0.05) but a higher risk of death at 3 months (OR 0.26, 95% CI 0.09 to 0.76, P=0.01) compared with the NAP-IVTMT group. No difference was found between the AP-MT and NAP-MT groups.ConclusionsWith regard to intracranial bleeding and functional outcome at 3 months, MT in APs seems as safe and efficient as in NAPs. However, there is a higher risk of death at 3 months in the AP-MT group compared with the NAP-IVTMT group.

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Abstract 3314: The Role of Bridging with Intravenous Thrombolysis in Endovascular Therapy of Acute Ischemic Stroke.

Stroke ◽

10.1161/str.43.suppl_1.a3314 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Omar Kass-Hout ◽

Tareq Kass-Hout ◽

Maxim Mokin ◽

David Orion ◽

Shadi Jahshan ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Combined Therapy ◽

Large Vessel ◽

P Value ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Nihss Score

Background: Large vessel occlusions with a high clot burden are less likely to improve with the FDA-approved IV strategy. Endovascular therapy within the first 3 h of stroke symptom onset provides an effective alternative treatment in patients with large vessel occlusion. It is not clear if combination of IV thrombolysis and endovascular approach is superior to endovascular treatment alone. Methods: We retrospectively reviewed all cases of acute ischemic stroke with large vessel occlusion treated within the first 3 h stroke onset during the 2005-2010 period. First group received endovascular therapy within the first 3 h of stroke onset. Second group consisted of patients who received IV thrombolysis within the first 3 h followed by endovascular therapy. We compared the following outcomes: revascularization rates, NIHSS score at discharge, mRS at discharge and 3months, symptomatic hemorrhage rates and mortality. Results: Among 104 patients identified, 42 received combined therapy, and 62 received endovascular therapy only. The two groups had similar demographic (age and sex distribution) and vascular risk factors distribution, as well as NIHSS score on admission (14.8±4.7 and 16.0±5.3; p=0.23). We found no difference in TIMI recanalization rates (Thrombolysis in Myocardial Infarction scale score of 2 or 3) following combined or endovascular therapy alone (83.3% and 79.0%; p=0.59). A preferred outcome, defined as a mRS of 2 or less at 90 days also did not differ between the combined therapy group and the endovascular only group (37.5% and 34.5%; p=0.76). There was no difference in mortality rate (22.5% and 31.0%; p=0.36) and the rate of symptomatic intracranial hemorrhage (9.5% and 8.1%; p=0.73). There was a significant difference in mean time from symptom onset to endovascular treatment between the combined group (227±88 min) and endovascular only group (125±40 min; p<0.0001).Patients with good TIMI recanalization rate of 2 or 3 showed a trend of having a better mRS at 90 days in both bridging (16.67% vs. 41.18%, p-value: 0.3813) and endovascular groups (25% vs. 34.78%, p-value: 0.7326).When analyzing the correlation of mRS at 90 days with the site of occlusion, patients in the bridging group showed a trend of a better outcome when the site of occlusion was ICA (33.3% vs 30%) and MCA (66.67% vs. 27.59%) and worse outcome when the site of occlusion was in the posterior circulation (26.32% vs. 50%), however, these results were not statistically significant (p-values: 0.1735& 0.5366). Conclusion: Combining IV thrombolysis and endovascular therapy achieves similar rates of clinical outcomes, revascularization rates, complications and mortality rates, when compared with endovascular treatment alone. The combined therapy, however, significantly delays initiation of endovascular treatment. A randomized prospective trial comparing both treatment strategies in acute ischemic stroke is warranted

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

Stroke ◽

10.1161/str.51.suppl_1.wp372 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Mona N Bahouth ◽

Rebecca Gottesman

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Clinical Outcomes ◽

Blood Urea Nitrogen ◽

Mechanical Thrombectomy ◽

Large Vessel ◽

Hydration Status ◽

Creatinine Ratio ◽

Stroke Patients ◽

Anterior Circulation

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

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Dabigatran Reversal Before Intravenous Tenecteplase in Acute Ischemic Stroke

Stroke ◽

10.1161/strokeaha.119.028327 ◽

2020 ◽

Vol 51 (5) ◽

pp. 1616-1619 ◽

Cited By ~ 2

Author(s):

James Beharry ◽

Michael J. Waters ◽

Roy Drew ◽

John N. Fink ◽

Duncan Wilson ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Scale Score ◽

Clinical Laboratory ◽

Intravenous Thrombolysis ◽

Interquartile Range ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion

Background and Purpose— Reversal of dabigatran before intravenous thrombolysis in patients with acute ischemic stroke has been well described using alteplase but experience with intravenous tenecteplase is limited. Tenecteplase seems at least noninferior to alteplase in patients with intracranial large vessel occlusion. We report on the experience of dabigatran reversal before tenecteplase thrombolysis for acute ischemic stroke. Methods— We included consecutive patients with ischemic stroke receiving dabigatran prestroke treated with intravenous tenecteplase after receiving idarucizumab. Patients were from 2 centers in New Zealand and Australia. We reported the clinical, laboratory, and radiological characteristics and their functional outcome. Results— We identified 13 patients receiving intravenous tenecteplase after dabigatran reversal. Nine (69%) were male, median age was 79 (interquartile range, 69–85) and median baseline National Institutes of Health Stroke Scale score was 6 (interquartile range, 4–21). Atrial fibrillation was the indication for dabigatran therapy in all patients. All patients had a prolonged thrombin clotting time (median, 80 seconds [interquartile range, 57–113]). Seven patients with large vessel occlusion were referred for endovascular thrombectomy, 2 of these patients (29%) had early recanalization with tenecteplase abrogating thrombectomy. No patients had parenchymal hemorrhage or symptomatic hemorrhagic transformation. Favorable functional outcome (modified Rankin Scale score, 0–2) occurred in 8 (62%) patients. Two deaths occurred from large territory infarction. Conclusions— Our experience suggests intravenous thrombolysis with tenecteplase following dabigatran reversal using idarucizumab may be safe in selected patients with acute ischemic stroke. Further studies are required to more precisely estimate the efficacy and risk of clinically significant hemorrhage.

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