Abstract 148: Mechanical Thrombectomy for Distal Occlusions: Efficacy, Functional and Safety Outcomes. Insights From the STAR Collaboration

Background: Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke due to large vessel occlusions. There is strong evidence supporting the benefit of MT in proximal anterior circulation vessel occlusions and basilar occlusions. However, data regarding the efficacy and safety of MT in distal occlusions is scarce. In this study, we aim to report the efficacy, functional and safety outcomes of MT for distal occlusions. Methods: This a retrospective study from 14 comprehensive stroke centers across 4 countries. For the purpose of this study, distal occlusion was defined as MCA occlusion distal to M2 (M3-4 segments), any segments of ACA and any segments of PCA. Patients with concomitant proximal occlusions were excluded from this study. Results: Of 2826 patients, 111 patients were included in this study (mean (SD) age: 69 (13), 51% of patients were female, and 52% received tPA). Median onset to groin time was 241 (IQR, 136 minutes), median NIHSS on admission was 11 (IQR, 8), and median ASPECTS was 10 (IQR, 1). The procedure was done using ADAPT, stent retriever, and Solumbra techniques in 58%, 17% and 15% of patients respectively. Successful revascularization (mTICI 2b-3) and complete revascularization (mTICI 3) were achieved in 78% and 35% of our cohort, respectively. Median procedure time (puncture to revascularization or end of the procedure) was 29 minutes (IQR 42 minutes) and the median number of attempts was 1 (IQR=2). Five percent of patients suffered procedural complications Hemorrhagic complications occurred in 11% of patients of whom only 4% were PH2 hemorrhage. At the last follow up, mRS 0-2 was achieved in 53% of patients. Conclusion: Up to our knowledge, this represents the largest study to the date investigating the safety and efficacy of MT in distal occlusions treatment. MT was safe and achieved a high rate of successful revascularization with an acceptable safety profile.

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Predictors of Poor Outcome after Successful Mechanical Thrombectomy in Patients with Acute Anterior Circulation Stroke

Journal of Clinical Interventional Radiology ISVIR ◽

10.1055/s-0037-1612600 ◽

2017 ◽

Vol 01 (03) ◽

pp. 139-143 ◽

Cited By ~ 2

Author(s):

Yosuke Tajima ◽

Michihiro Hayasaka ◽

Koichi Ebihara ◽

Masaaki Kubota ◽

Sumio Suda

Keyword(s):

Clinical Outcome ◽

Cerebral Artery ◽

Mechanical Thrombectomy ◽

Infarct Volume ◽

Complete Revascularization ◽

Anterior Circulation ◽

Clinical Imaging ◽

Good Outcome ◽

Poor Outcome ◽

Favorable Clinical Outcome

AbstractSuccessful revascularization is one of the main predictors of a favorable clinical outcome after mechanical thrombectomy. However, even if mechanical thrombectomy is successful, some patients have a poor clinical outcome. This study aimed to investigate the clinical, imaging, and procedural factors that are predictive of poor clinical outcomes despite successful revascularization after mechanical thrombectomy in patients with acute anterior circulation stroke. The authors evaluated 69 consecutive patients (mean age, 74.6 years, 29 women) who presented with acute ischemic stroke due to internal cerebral artery or middle cerebral artery occlusions and who were successfully treated with mechanical thrombectomy between July 2014 and November 2016. A good outcome was defined as a modified Rankin Scale score of 0 to 2 at 3 months after treatment. The associations between the clinical, imaging, and procedural factors and poor outcome were evaluated using logistic regression analyses. Using multivariate analyses, the authors found that the preoperative National Institute of Health Stroke Scale (NIHSS) score (odds ratio [OR], 1.152; 95% confidence interval [CI], 1.004–1.325; p = 0.028), the diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) (OR, 0.604; 95% CI, 0.412–0.882; p = 0.003), and a Thrombolysis in Cerebral Infarction (TICI) 2b classification (OR, 4.521; 95% CI, 1.140–17.885; p = 0.026) were independent predictors of poor outcome. Complete revascularization to reduce the infarct volume should be performed, especially in patients with a high DWI-ASPECTS, to increase the likelihood of a good outcome.

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Mechanical thrombectomy for basilar artery thrombosis: a comparison of outcomes with anterior circulation occlusions

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012797 ◽

2016 ◽

Vol 9 (12) ◽

pp. 1173-1178 ◽

Cited By ~ 21

Author(s):

María Alonso de Leciñana ◽

Michal M Kawiorski ◽

Álvaro Ximénez-Carrillo ◽

Antonio Cruz-Culebras ◽

Andrés García-Pastor ◽

...

Keyword(s):

Basilar Artery ◽

Endovascular Procedures ◽

Mechanical Thrombectomy ◽

Time Lapse ◽

Anterior Circulation ◽

Basilar Artery Thrombosis ◽

Artery Thrombosis ◽

Procedural Complications ◽

Symptomatic Intracranial Hemorrhage ◽

Baseline Characteristics

Background and purposeThe benefits of mechanical thrombectomy (MT) in basilar artery occlusions (BAO) have not been explored in recent clinical trials. We compared outcomes and procedural complications of MT in BAO with anterior circulation occlusions.MethodsData from the Madrid Stroke Network multicenter prospective registry were analyzed, including baseline characteristics, procedure times, procedural complications, symptomatic intracranial hemorrhage (SICH), modified Rankin Scale (mRS), and mortality at 3 months.ResultsOf 479 patients treated with MT, 52 (11%) had BAO. The onset to reperfusion time lapse was longer in patients with BAO (median (IQR) 385 min (320–540) vs 315 min (240–415), p<0.001), as was the duration of the procedures (100 min (40–130) vs 60 min (39–90), p=0.006). Moreover, the recanalization rate was lower (75% vs 84%, p=0.01). A trend toward more procedural complications was observed in patients with BAO (32% vs 21%, p=0.075). The frequency of SICH was 2% vs 5% (p=0.25). At 3 months, patients with BAO had a lower rate of independence (mRS 0–2) (40% vs 58%, p=0.016) and higher mortality (33% vs 12%, p<0.001). The rate of futile recanalization was 50% in BAO versus 35% in anterior circulation occlusions (p=0.05). Age and duration of the procedure were significant predictors of futile recanalization in BAO.ConclusionsMT is more laborious and shows more procedural complications in BAO than in anterior circulation strokes. The likelihood of futile recanalization is higher in BAO and is associated with greater age and longer procedure duration. A refinement of endovascular procedures for BAO might help optimize the results.

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Abstract 2219: Trevo System: Single Center Experience With A Novel Mechanical Thrombectomy Device

Stroke ◽

10.1161/str.43.suppl_1.a2219 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Nuno M Mendonça ◽

Alan Flores ◽

Jorge Pagola ◽

Marta Rubiera ◽

David Rodríguez-Luna ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Functional Independence ◽

Median Number ◽

Single Center Experience ◽

Procedural Complications ◽

Thrombectomy Device ◽

Number Of Passes

Background and Purpose: Recent reports have indicated that mechanical thrombectomy may have potential as a treatment for acute ischemic stroke. This study aims to describe the safety and effectiveness of Trevo RetrieverTM (Concentric Medical Inc, Mountain View, California) using StentrieverTM technology, in revascularization of patients with acute ischemic stroke. Methods: Prospective study evaluating the clinical, radiological and functional outcome of 13 patients with an angiographically verified occlusion of the anterior cerebral circulation. All patients underwent thrombectomy with TR as monotherapy or in combination with intra-arterial thrombolysis, within the first 8 hours from symptoms onset. Successful revascularization was defined as thrombolysis in cerebral ischemia grade 2a to 3. Good outcome was defined as modified Rankin Scale score ≤ 2. Results: Median baseline NIHSS score was 19 (16-22). The occlusion site was MCA in 8 patients and ICA in 5 patients. Five patients received IV tPA before endovascular procedure. Revascularization was achieved in 10 of 13 patients (77%). The median number of passes for maximal recanalization was 2 (1-3) and the mean time from groin puncture to recanalization was 95±31 minutes. No significant intra-procedural complications occurred. Four patients (30%) died during the 90-day follow-up period and 4 patients (30%) achieved functional independence at 3 months. Conclusions: Early clinical experience suggests that the TR can allow safe and effective revascularization in certain subjects with acute ischemic stroke.

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Abstract WP32: Introducing STAR: A Multicenter International Collaborative Registry of Real-World Outcomes After Mechanical Thrombectomy for Ischemic Stroke

Stroke ◽

10.1161/str.51.suppl_1.wp32 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Ali M Alawieh ◽

Shakeel Chowdhry ◽

Italo Linfante ◽

Jonathan Grossberg ◽

Benjamin Gory ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Real World ◽

Mechanical Thrombectomy ◽

Standard Of Care ◽

Outcome Data ◽

Treatment Level ◽

Current Standard ◽

Anterior Circulation ◽

Standard Of Care Treatment

Introduction: Mechanical thrombectomy (MT) for acute stroke is the current standard of care treatment. Level 1 evidence for efficacy of thrombectomy has been established in multiple randomized controlled trials on selective patient populations; however, the high effect size of MT had led multiple centers in the US and globally to expand their patient selection to include populations that were not studied in major trials. To provide ongoing data on MT outcomes in different patient populations from the real-world, we have initiated an international multicenter initiative, STAR (Stroke Thrombectomy and Aneurysm Registry). Methods: STAR is a multicenter and international platform to curate patient outcome data after MT for acute ischemic stroke at comprehensive stroke centers. STAR includes all patients who underwent MT for acute ischemic stroke irrespective of age, time from onset, ASPECT score, and NIHSS. Patients were curated from 01/2015 to date and is prospectively maintained. Patient charts are reviewed for demographics, baseline functioning, and admission deficits. Procedure notes are reviewed for technical variables and technical outcomes. Clinical outcomes were collected at 90-day follow-up by stroke neurologist. Results: A total of 24 centers globally have enrolled in STAR. By December 2018, the total number of enrolled and verified patients in STAR was 3,850 (mean age 69±14, 51% females). Anterior circulation strokes were treated in 89% of cases, average NIHSS on admission was 15.5±7, and 73% had pre-stroke mRS below 2. Around 51% of patients received IV-tPA. Mechanical thrombectomy was performed using aspiration (45%), stent retriever (28%), primary combined approach (24%) or intracranial stenting (3%). Successful recanalization was achieved in 84% of cases, the rate of favorable outcome (mRS 0-2) was 41%, and mortality was 25%. Complication rate was 6% and rate of symptomatic post-procedural hemorrhage was 6%. Conclusions: STAR represent a large real-world international registry for outcomes after MT, and constitutes a statistically robust platform to study real-world practice outcome in patient sub-populations that are under-represented in randomized trials. Link: https://medicine.musc.edu/departments/neurosurgery/star

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Mechanical Thrombectomy for Distal Occlusions: Efficacy, Functional and Safety Outcomes: Insight from the STAR collaboration

World Neurosurgery ◽

10.1016/j.wneu.2021.04.136 ◽

2021 ◽

Author(s):

Mohammad Anadani ◽

Ali Alawieh ◽

Reda Chalhoub ◽

Pascal Jabbour ◽

Robert M. Starke ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Star Collaboration ◽

Safety Outcomes

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TREVO stent-retriever mechanical thrombectomy for acute ischemic stroke secondary to large vessel occlusion registry

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2017-013328 ◽

2017 ◽

Vol 10 (6) ◽

pp. 516-524 ◽

Cited By ~ 46

Author(s):

Osama O Zaidat ◽

Alicia C Castonguay ◽

Raul G Nogueira ◽

Diogo C Haussen ◽

Joey D English ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Practice ◽

Acute Ischemic Stroke ◽

Real World ◽

Randomized Clinical Trials ◽

Mechanical Thrombectomy ◽

Stent Retriever ◽

Large Vessel ◽

Complete Revascularization ◽

Anterior Circulation

BackgroundRecent randomized clinical trials (RCTs) demonstrated the efficacy of mechanical thrombectomy using stent-retrievers in patients with acute ischemic stroke (AIS) with large vessel occlusions; however, it remains unclear if these results translate to a real-world setting. The TREVO Stent-Retriever Acute Stroke (TRACK) multicenter Registry aimed to evaluate the use of the Trevo device in everyday clinical practice.MethodsTwenty-three centers enrolled consecutive AIS patients treated from March 2013 through August 2015 with the Trevo device. The primary outcome was deﬁned as achieving a Thrombolysis in Cerebral Infarction (TICI) score of ≥2b. Secondary outcomes included 90-day modified Rankin Scale (mRS), mortality, and symptomatic intracranial hemorrhage (sICH).ResultsA total of 634patients were included. Mean age was 66.1±14.8 years and mean baseline NIH Stroke Scale (NIHSS) score was 17.4±6.7; 86.7% had an anterior circulation occlusion. Mean time from symptom onset to puncture and time to revascularization were 363.1±264.5 min and 78.8±49.6 min, respectively. 80.3% achieved TICI ≥2b. 90-day mRS ≤2 was achieved in 47.9%, compared with 51.4% when restricting the analysis to the anterior circulation and within 6 hours (similar to recent AHA/ASA guidelines), and 54.3% for those who achieved complete revascularization. The 90-day mortality rate was 19.8%. Independent predictors of clinical outcome included age, baseline NIHSS, use of balloon guide catheter, revascularization, and sICH.ConclusionThe TRACK Registry results demonstrate the generalizability of the recent thrombectomy RCTs in real-world clinical practice. No differences in clinical and angiographic outcomes were shown between patients treated within the AHA/ASA guidelines and those treated outside the recommendations.

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Abstract P486: Mechanical Embolectomy Using a Novel Telescopic System Featuring a Specialized Delivery and 0.088” Aspiration Catheter for the Treatment of Acute Ischemic Stroke: Preliminary Results of the SUMMIT NZ Trial

Stroke ◽

10.1161/str.52.suppl_1.p486 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Ben J McGuinness ◽

James Caldwell ◽

P A Barber ◽

Andrew Holden ◽

Teddy Y Wu ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Standard Of Care ◽

High Rate ◽

Open Label ◽

Vessel Occlusion ◽

Arterial Revascularization ◽

First Line Therapy ◽

Technological Advances ◽

Procedural Complications

Background: The treatment approach of aspiration rather than use of a stent retriever as first-line therapy is increasingly regarded as standard of care for acute ischemic stroke. Continued technological advances include the ongoing development of aspiration embolectomy catheters that are larger in bore, guided by delivery catheters that are more maneuverable through the tortuous neurovasculature. Methods: SUMMIT NZ (ACTRN12619000890134p) was designed as a prospective, single-arm, open label clinical trial at two sites in New Zealand. Eligible participants were patients presenting with acute ischemic stroke from either anterior or posterior circulation large-vessel occlusion within 24 hours of onset, a National Institutes of Health Stroke Scale Score ≥ 6 and a pre-stroke modified Rankin Score of ≤ 2. A novel tapered tip delivery catheter was specifically designed to deliver 0.070” and 0.088” aspiration catheters telescoped through a specialized 8F 90 cm introducer sheath (Route 92 Medical, Inc. San Mateo, CA). The primary effectiveness endpoint was arterial revascularization as measured by a modified Thrombosis in Cerebrovascular Infarction (mTICI) score of 2b or greater at the end of angiography after all endovascular treatments as adjudicated by an independent core laboratory. The primary safety endpoints were device-related peri-procedural complications such as dissection or perforation, symptomatic Intracranial Cerebral Hemorrhage (SICH) at 24 hours and embolization to a previously uninvolved territory. Results: From September 27, 2019 to June 23, 2020, 18 subjects (mean age 69.5, NIHSSS 15.2, time last known well 6.2 hours) were enrolled with a diagnosis of acute ischemic stroke. Acute occlusion was located in the middle cerebral artery (78%, 14/18) and internal carotid artery (22%, 4/18). Successful revascularization was achieved in 94% (17/18) of subjects. No serious adverse device effects have been reported. Conclusions: Preliminary findings suggest that aspiration first mechanical embolectomy using a novel telescoping system including an 0.088” inner diameter aspiration catheter achieves a high rate of arterial revascularization with an acceptable safety profile. A full report on enrollment and results are to be presented.

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Abstract 1122‐000207: Mechanical Thrombectomy of the Fetal Posterior Cerebral Artery

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000207 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Mohamad Abdalkader ◽

Anurag Sahoo ◽

Adam A Dmytriw ◽

Waleed Brinjikji ◽

...

Keyword(s):

Endovascular Treatment ◽

Cerebral Artery ◽

Mechanical Thrombectomy ◽

Clinical Presentation ◽

Posterior Cerebral Artery ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Ct Angiogram ◽

Procedural Complications ◽

High Index Of Suspicion

Introduction : Fetal posterior cerebral artery (FPCA) occlusion is a rare but potentially disabling cause of stroke. While endovascular treatment is established for acute large vessel occlusion (LVO) stroke, FPCA occlusions were excluded from acute ischemic stroke trials. We aim to report the feasibility, safety and outcome of mechanical thrombectomy (MT) in acute FPCA occlusions. Methods : We performed a multi‐center retrospective review of consecutive patients who underwent MT of acute FPCA occlusion. Primary FPCA occlusion was defined as an occlusion that was identified on the pre‐procedure CT angiogram or baseline angiogram whereas a secondary FPCA occlusion was defined as an occlusion that occurred secondary to embolization to a new territory after recanalization of a different LVO. Demographics, clinical presentation, imaging findings, endovascular treatment and outcome were reviewed. Results : There were twenty‐five patients with acute FPCA occlusion who underwent MT, distributed across 14 centers. Median NIHSS on presentation was 16. There were 76% (19/25) of patients who presented with primary FPCA occlusion and 24% (6/25) of patients who had a secondary FPCA occlusion. The configuration of the FPCA was full in 64% patients and partial or “fetal‐type” in 36% of patients. FPCA occlusion was missed on initial CTA in 21% of patients with primary FPCA occlusion (4/19). The site of occlusion was posterior communicating artery in 52%, P2 segment in 40% and P3 in 8% of patients. TICI 2b/3 reperfusion was achieved in 96% of FPCA patients. There were no intra‐procedural complications. At 90 days, 48% (12/25) were functionally independent as defined by mRS≤2. Conclusions : Endovascular treatment of acute FPCA occlusion is safe and technically feasible. A high index of suspicion is important to detect occlusion of the fetal posterior cerebral artery in patients presenting with anterior circulation stroke syndrome and patent anterior circulation.

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Revascularization and functional outcomes after mechanical thrombectomy for acute ischemic stroke in elderly patients

Journal of Neurosurgery ◽

10.3171/2018.12.jns182399 ◽

2020 ◽

Vol 132 (4) ◽

pp. 1182-1187 ◽

Cited By ~ 1

Author(s):

Carrie E. Andrews ◽

Nikolaos Mouchtouris ◽

Evan M. Fitchett ◽

Fadi Al Saiegh ◽

Michael J. Lang ◽

...

Keyword(s):

Ischemic Stroke ◽

Elderly Patients ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Multivariate Logistic Regression Analysis ◽

Standard Of Care ◽

Stroke Severity ◽

Vessel Occlusion ◽

Younger Patients ◽

Success Of Treatment

OBJECTIVEMechanical thrombectomy (MT) is now the standard of care for acute ischemic stroke (AIS) secondary to large-vessel occlusion, but there remains a question of whether elderly patients benefit from this procedure to the same degree as the younger populations enrolled in the seminal trials on MT. The authors compared outcomes after MT of patients 80–89 and ≥ 90 years old with AIS to those of younger patients.METHODSThe authors retrospectively analyzed records of patients undergoing MT at their institution to examine stroke severity, comorbid conditions, medical management, recanalization results, and clinical outcomes. Univariate and multivariate logistic regression analysis were used to compare patients < 80 years, 80–89 years, and ≥ 90 years old.RESULTSAll groups had similar rates of comorbid disease and tissue plasminogen activator (tPA) administration, and stroke severity did not differ significantly between groups. Elderly patients had equivalent recanalization outcomes, with similar rates of readmission, 30-day mortality, and hospital-associated complications. These patients were more likely to have poor clinical outcome on discharge, as defined by a modified Rankin Scale (mRS) score of 3–6, but this difference was not significant when controlled for stroke severity, tPA administration, and recanalization results.CONCLUSIONSOctogenarians, nonagenarians, and centenarians with AIS have similar rates of mortality, hospital readmission, and hospital-associated complications as younger patients after MT. Elderly patients also have the capacity to achieve good functional outcome after MT, but this potential is moderated by stroke severity and success of treatment.

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In-Hospital Intravenous Thrombolysis Offers No Benefit in Mechanical Thrombectomy in Optimized Tertiary Stroke Center Setting

CardioVascular and Interventional Radiology ◽

10.1007/s00270-020-02727-8 ◽

2020 ◽

Author(s):

Juha-Pekka Pienimäki ◽

Jyrki Ollikainen ◽

Niko Sillanpää ◽

Sara Protto

Keyword(s):

Clinical Outcome ◽

Acute Stroke ◽

Mechanical Thrombectomy ◽

Clinical Laboratory ◽

Intravenous Thrombolysis ◽

Stroke Patients ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Ordinal Logistic Regression Analysis ◽

Stroke Center

Abstract Purpose Mechanical thrombectomy (MT) is the first-line treatment in acute stroke patients presenting with large vessel occlusion (LVO). The efficacy of intravenous thrombolysis (IVT) prior to MT is being contested. The objective of this study was to evaluate the efficacy of MT without IVT in patients with no contraindications to IVT presenting directly to a tertiary stroke center with acute anterior circulation LVO. Materials and Methods We collected the data of 106 acute stroke patients who underwent MT in a single high-volume stroke center. Patients with anterior circulation LVO eligible for IVT and directly admitted to our institution who subsequently underwent MT were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of intravenous thrombolysis on 3-month clinical outcome (mRS) was analyzed with univariate tests and binary and ordinal logistic regression analysis. Results Fifty-eight out of the 106 patients received IVT + MT. These patients had 2.6-fold higher odds of poorer clinical outcome in mRS shift analysis (p = 0.01) compared to MT-only patients who had excellent 3-month clinical outcome (mRS 0–1) three times more often (p = 0.009). There were no significant differences between the groups in process times, mTICI, or number of hemorrhagic complications. A trend of less distal embolization and higher number of device passes was observed among the MT-only patients. Conclusions MT without prior IVT was associated with an improved overall three-month clinical outcome in acute anterior circulation LVO patients.

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