Abstract WP70: Reperfusion Therapy in Posterior Circulation Large Vessel Occlusion With Perfusion Deficits May Be Safe and Improve Outcomes Beyond 4.5 Hours

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Sujan Teegala Reddy ◽  
Kaushik Parsha ◽  
Deep Pujara ◽  
Clark Sitton ◽  
Sean Savitz ◽  
...  
Keyword(s):  
Ct Perfusion ◽  
Reperfusion Therapy ◽  
Functional Independence ◽  
Posterior Circulation ◽  
Large Vessel ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
To Receive ◽  
Perfusion Deficits

Introduction: Whether reperfusion therapy is safe and efficacious in acute ischemic strokes (AIS) due to posterior circulation large vessel occlusions (PCLVO) beyond 4.5 hrs is unknown. Methods: A retrospective analysis of AIS due to PCLVO presenting to a comprehensive stroke center up to 24 hrs from last known well. Patients were stratified based on the treatment received into reperfusion therapy (IV-tPA and/or endovascular thrombectomy) and no reperfusion therapy. All patients received CT/CTA and CT perfusion with RAPID mismatch determination. Functional independence (90 day mRS 0-2) and sICH were primary and secondary outcomes. The two groups were compared in the overall cohort in an ordinal logistic regression and in a propensity matched analyses. Results: Between 8/2017 and 5/2019, 52 patients were included [reperfusion = 23(44%) vs no-reperfusion=29(56%)]. Reperfusion rate beyond 4.5 hours was 26% (6/23). The two groups were similar at baseline except for larger perfusion delays (Tmax>6s) volume [median (IQR), 16 (0, 46) vs. 0 (0, 25) cc, p=0.03], and higher presentation NIHSS [median (IQR), 10 (5, 21) vs. 4 (1, 8), p=0.004] in the reperfusion group. Reperfusion was associated with higher functional independence rates 10 (43%) vs. 8 (28%), p=0.23 (fig 1), and a trend for a shift towards better outcomes adj cOR 1.89, 95% CI=0.59-6.13, p=0.29. There was no difference in sICH rates 9% vs. 0%, P=0.19. In a propensity matched analysis on NIHSS and perfusion deficit of 14 pairs, reperfusion was associated with statistically significant higher mRS 0-2 rates 9 (64%) vs. 1 (7%), p=0.004 (fig 2). Functional independence rates did not differ in the reperfusion group in relation to time (47% <4.5 hrs vs. 33%≥4.5 hrs), p=0.36 for heterogeneity. Conclusion: PCLVOs with more severe strokes and large perfusion deficits were more likely to receive reperfusion which was associated with a shift towards better outcomes both earlier and beyond 4.5 hours without worsening safety outcomes.

Abstract TP248: Reduced Door-in-Door-Out Time Increases the Likelihood of Endovascular Thrombectomy for Large Vessel Occlusion Patients

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Kavit Shah ◽  
Shashvat Desai ◽  
Benjamin Morrow ◽  
Pratit Patel ◽  
Habibullah Ziayee ◽  
...  
Keyword(s):  
Internal Carotid ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
To Receive ◽  
Rapid Transfer

Introduction: Endovascular thrombectomy (EVT) is recommended for patients with large vessel occlusion (LVO) presenting within 24 hours of last seen well (LSW). Unfortunately, patients transferred from spoke hospitals to receive EVT have poorer outcomes compared to those presenting directly to the hub, underscoring the importance of rapid transfer timing - door-in-door-out (DIDO). Methods: Data were analyzed from consecutive acute ischemic stroke patients with proximal large vessel occlusions (LVO) transferred to our comprehensive stroke center for EVT. The following variable were studied: DIDO, baseline NIHSS/mRS, presentation CT ASPECTs, site of LVO, treatment, and clinical outcome. Results: Ninety patients with internal carotid or middle cerebral artery (M1) occlusion at the spoke hospital were included in the study. At the hub hospital, 75% (68) underwent emergent cerebral angiography (DSA) with intent to perform EVT. Reasons for not undergoing angiography at hub hospital included large stroke burden (59%) and improvement in NIHSS score (41%). Overall, DIDO time was 184 (130-285) minutes. Mean DIDO time was significantly lower for patients who underwent DSA at hub hospital compared to patients who did not (207 versus 272 minutes, p=0.031). 92% (12) of patients with DIDO <=120 minutes (n=13) underwent EVT compared to 73% (56) of patients with DIDO >120 minutes (n=77). Every 30-minute delay after 120 minutes lead to a 6% reduction in the likelihood of EVT. Lower DIDO time [OR-0.92 (0.9-0.96), p=0.04] and higher ASPECTS score [OR-1.4 (1.1-1.9), p=0.013] at spoke hospital are predictors of EVT at hub hospital. Conclusion: Reduced DIDO times are associated with higher likelihood of receiving EVT. DIDO should be treated on par as in-hospital time metrics and methods should be in place to optimize transfer times.

scholarly journals Thrombectomy 6-24 hours after stroke in trial ineligible patients

2018 ◽  
Vol 10 (11) ◽  
pp. 1033-1037 ◽  
Author(s):  
Shashvat M Desai ◽  
Marcelo Rocha ◽  
Bradley J Molyneaux ◽  
Matthew Starr ◽  
Cynthia L Kenmuir ◽  
...  
Keyword(s):  
Time Window ◽  
Functional Independence ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Off Label ◽  
Symptomatic Intracranial Hemorrhage ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background and purposeThe DAWN and DEFUSE-3 trials demonstrated the benefit of endovascular thrombectomy (ET) in late-presenting acute ischemic strokes due to anterior circulation large vessel occlusion (ACLVO). Strict criteria were employed for patient selection. We sought to evaluate the characteristics and outcomes of patients treated outside these trials.MethodsA retrospective review of acute ischemic stroke admissions to a single comprehensive stroke center was performed during the DAWN trial enrollment period (November 2014 to February 2017) to identify all patients presenting in the 6–24 hour time window. These patients were further investigated for trial eligibility, baseline characteristics, treatment, and outcomes.ResultsApproximately 70% (n=142) of the 204 patients presenting 6–24 hours after last known well with NIH Stroke Scale score ≥6 and harboring an ACLVO are DAWN and/or DEFUSE-3 ineligible, most commonly due to large infarct burden (38%). 26% (n=37) of trial ineligible patients with large vessel occlusion strokes received off-label ET and 30% of them achieved functional independence (modified Rankin Scale 0–2) at 90 days. Rates of symptomatic intracranial hemorrhage and mortality were 8% and 24%, respectivelyConclusionTrial ineligible patients with large vessel occlusion strokes receiving off-label ET achieved outcomes comparable to DAWN and DEFUSE-3 eligible patients. Patients aged <80 years are most likely to benefit from ET in this subgroup. These data indicate a larger population of patients who can potentially benefit from ET in the expanded time window if more permissive criteria are applied.

Functional Outcome, Recanalization, and Hemorrhage Rates After Large Vessel Occlusion Stroke Treated With Tenecteplase Before Thrombectomy

Neurology ◽  
2021 ◽  
pp. 10.1212/WNL.0000000000012915
Author(s):  
Gaspard Gerschenfeld ◽  
Didier Smadja ◽  
Guillaume Turc ◽  
Stephane Olindo ◽  
François-Xavier Laborne ◽  
...  
Keyword(s):  
Functional Independence ◽  
Similar Rate ◽  
Routine Care ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Direct Admission ◽  
Comprehensive Stroke Center ◽  
Stroke Center

ObjectiveTo investigate in routine care the efficacy and safety of IV thrombolysis (IVT) with tenecteplase prior to mechanical thrombectomy (MT) in patients with large vessel occlusion acute ischemic strokes (LVO-AIS), either secondarily transferred after IVT or directly admitted to a comprehensive stroke center (CSC).MethodsWe retrospectively analyzed clinical and procedural data of patients treated with 0.25 mg/kg tenecteplase within 270 minutes of LVO-AIS who underwent a brain angiography. The main outcome was 3-month functional independence (modified Rankin scale score ≤ 2). Recanalization (revised Treatment in Cerebral Ischemia score 2b-3), was evaluated before (pre-MT) and after MT (final).ResultsWe included 588 patients (median age 75 years [interquartile range (IQR) 61-84]; 315 women [54%]; median NIH Stroke Scale [NIHSS] score 16 [IQR 10-20]), of which 520 (88%) were secondarily transferred after IVT. Functional independence occurred in 47% (n = 269/570; 95%CI 43.0-51.4) of patients. Pre-MT recanalization occurred in 120 patients (20.4%; 95%CI 17.2-23.9), at a similar rate across treatment paradigms (direct admission, n = 14/68 [20.6%]; secondary transfer, n = 106/520 [20.4%]; p > .99) despite a shorter median IVT-to-puncture time in directly admitted patients (38 [IQR 23-55] vs 86 [IQR 70-110] minutes; p < .001). Final recanalization was achieved in 492 patients (83.7%; 95%CI 80.4-86.6). Symptomatic intracerebral hemorrhage occurred in 2.5% of patients (n = 14/567; 95%CI 1.4-4.1).ConclusionsTenecteplase before MT is safe, effective and achieves a fast recanalization in everyday practice in patients secondarily transferred or directly admitted to a CSC, in line with published results. These findings should encourage its wider use in bridging therapy.Classification of EvidenceThis study provides class IV evidence that tenecteplase within 270 minutes of LVO-AIS is increases the probability of functional independence.

scholarly journals Initial experience with React 68 aspiration catheter

2020 ◽  
Vol 26 (3) ◽  
pp. 358-363
Author(s):  
Scott B Raymond ◽  
Mehr Nasir-Moin ◽  
Matthew J Koch ◽  
James D Rabinov ◽  
Thabele Leslie-Mazwi ◽  
...  
Keyword(s):  
Performance Measures ◽  
Posterior Circulation ◽  
Large Vessel ◽  
Initial Experience ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Patient Demographics ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Comparable Period

Introduction We describe our initial experience with the React 68 catheter (Medtronic, Dublin, Ireland), an FDA-approved catheter designed for aspiration in cases of emergent large vessel occlusion, as compared with the ACE 68 catheter (Penumbra, Alameda, CA). Methods This observational study followed consecutive patients treated with the React catheter over a seven-month period at a comprehensive stroke center. Use of the device was per discretion of the operator. Patient demographics, thrombectomy technique, reperfusion scoring, and disposition were assessed. Performance was compared with patients treated with the ACE 68 catheter over a comparable period. Results We treated 47 patients using the React 68 catheter using either aspiration alone or a combination of aspiration and stent retriever technique. The catheter was used in a variety of circumstances including proximal and distal occlusions involving the anterior and posterior circulation. Modified TICI 2b-3 was achieved in 45 of the 47 patients. The React 68 was comparable to the ACE 68 by all performance measures. Conclusion The React 68 catheter is a large-bore reperfusion catheter with trackability suitable for use in direct aspiration for recanalization of emergent large vessel occlusion.

Effect of “drip-and-ship” and “drip-and-drive” on endovascular treatment of acute ischemic stroke with large vessel occlusion: a single-center retrospective study

2021 ◽  
pp. 028418512110068
Author(s):  
Yu Hang ◽  
Zhen Yu Jia ◽  
Lin Bo Zhao ◽  
Yue Zhou Cao ◽  
Huang Huang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Primary Stroke Center ◽  
Secondary Endpoints ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background Patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) were usually transferred from a primary stroke center (PSC) to a comprehensive stroke center (CSC) for endovascular treatment (drip-and-ship [DS]), while driving the doctor from a CSC to a PSC to perform a procedure is an alternative strategy (drip-and-drive [DD]). Purpose To compare the efficacy and prognosis of the two strategies. Material and Methods From February 2017 to June 2019, 62 patients with LVO received endovascular treatment via the DS and DD models and were retrospectively analyzed from the stroke alliance based on our CSC. Primary endpoint was door-to-reperfusion (DTR) time. Secondary endpoints included puncture-to-recanalization (PTR) time, modified Thrombolysis in Cerebral Infarction (mTICI) rates at the end of the procedure, and modified Rankin Scale (mRS) at 90 days. Results Forty-one patients received the DS strategy and 21 patients received the DD strategy. The DTR time was significantly longer in the DS group compared to the DD group (315.5 ± 83.8 min vs. 248.6 ± 80.0 min; P < 0.05), and PTR time was shorter (77.2 ± 35.9 min vs. 113.7 ± 69.7 min; P = 0.033) compared with the DD group. Successful recanalization (mTICI 2b/3) was achieved in 89% (36/41) of patients in the DS group and 86% (18/21) in the DD group ( P = 1.000). Favorable functional outcomes (mRS 0–2) were observed in 49% (20/41) of patients in the DS group and 71% (15/21) in the DD group at 90 days ( P = 0.089). Conclusion Compared with the DS strategy, the DD strategy showed more effective and a trend of better clinical outcomes for AIS patients with LVO.

Impact of RapidAI mobile application on treatment times in patients with large vessel occlusion

2021 ◽  
pp. neurintsurg-2021-017365
Author(s):  
Mais Al-Kawaz ◽  
Christopher Primiani ◽  
Victor Urrutia ◽  
Ferdinand Hui
Keyword(s):  
Mobile Application ◽  
Secondary Analysis ◽  
Multiple Linear Regression Model ◽  
Stroke Care ◽  
Mobile App ◽  
Large Vessel ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Adjusted Model

BackgroundCurrent efforts to reduce door to groin puncture time (DGPT) aim to optimize clinical outcomes in stroke patients with large vessel occlusions (LVOs). The RapidAI mobile application (Rapid Mobile App) provides quick access to perfusion and vessel imaging in patients with LVOs. We hypothesize that utilization of RapidAI mobile application can significantly reduce treatment times in stroke care by accelerating the process of mobilizing stroke clinicians and interventionalists.MethodsWe analyzed patients presenting with LVOs between June 2019 and October 2020. Thirty-one patients were treated between June 2019 and March 2020 (pre-app group). Thirty-three patients presented between March 2020 and October 2020 (post-app group). Mann–Whitney U test and Kruskal–Wallis tests were used to examine variables that are not normally distributed. In a secondary analysis we analyzed interhospital time metrics between primary stroke centers and our comprehensive stroke center.ResultsBaseline demographic and vascular risk factors were similar in both groups. Use of Rapid Mobile App resulted in 33 min reduction in DGPT (P=0.02), 35 min reduction in door to first pass time (P=0.02), and 37 min reduction in door to recanalization time (P=0.02) in univariate analyses when compared with patients treated pre-app. In a multiple linear regression model, utilization of Rapid Mobile App significantly predicted shorter DGPT (P=0.002). In an adjusted model, National Institutes of Health Stroke Scale (NIHSS) 24 hours after procedure and at discharge were significantly lower in the post-app group (P=0.03). Time of transfer between primary and comprehensive stroke center was comparable in both groups (P=0.26).ConclusionIn patients with LVOs, the implementation of the RapidAI mobile application was independently associated with reductions in intrahospital treatment times.

Detection of Large Vessel Occlusion Stroke in the Prehospital Setting

Stroke ◽  
2021 ◽  
Author(s):  
Laura C.C. van Meenen ◽  
Maritta N. van Stigt ◽  
Arjen Siegers ◽  
Martin D. Smeekes ◽  
Joffry A.F. van Grondelle ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Stroke Care ◽  
Prehospital Setting ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
User Friendliness ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Good Diagnostic Accuracy

A reliable and fast instrument for prehospital detection of large vessel occlusion (LVO) stroke would be a game-changer in stroke care, because it would enable direct transportation of LVO stroke patients to the nearest comprehensive stroke center for endovascular treatment. This strategy would substantially improve treatment times and thus clinical outcomes of patients. Here, we outline our view on the requirements of an effective prehospital LVO detection method, namely: high diagnostic accuracy; fast application and interpretation; user-friendliness; compactness; and low costs. We argue that existing methods for prehospital LVO detection, including clinical scales, mobile stroke units and transcranial Doppler, do not fulfill all criteria, hindering broad implementation of these methods. Instead, electroencephalography may be suitable for prehospital LVO detection since in-hospital studies have shown that quantification of hypoxia-induced changes in the electroencephalography signal have good diagnostic accuracy for LVO stroke. Although performing electroencephalography measurements in the prehospital setting comes with challenges, solutions for fast and simple application of this method are available. Currently, the feasibility and diagnostic accuracy of electroencephalography in the prehospital setting are being investigated in clinical trials.

Antiplatelet pretreatment and outcomes following mechanical thrombectomy for emergent large vessel occlusion strokes

2017 ◽  
Vol 10 (9) ◽  
pp. 828-833 ◽  
Author(s):  
Abhi Pandhi ◽  
Georgios Tsivgoulis ◽  
Rashi Krishnan ◽  
Muhammad F Ishfaq ◽  
Savdeep Singh ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Large Vessel ◽  
Vessel Occlusion ◽  
Safety And Efficacy ◽  
Logistic Regression Models ◽  
Scale Scores ◽  
Stroke Center ◽  
Few Data

BackgroundFew data are available regarding the safety and efficacy of antiplatelet (APT) pretreatment in acute ischemic stroke (AIS) patients with emergent large vessel occlusions (ELVO) treated with mechanical thrombectomy (MT). We sought to evaluate the association of APT pretreatment with safety and efficacy outcomes following MT for ELVO.MethodsConsecutive ELVO patients treated with MT during a 4-year period in a tertiary stroke center were evaluated. The following outcomes were documented using standard definitions: symptomatic intracranial hemorrhage (sICH), successful recanalization (SR; modified TICI score 2b/3), mortality, and functional independence (modified Rankin Scale scores of 0–2).ResultsThe study population included 217 patients with ELVO (mean age 62±14 years, 50% men, median NIH Stroke Scale score 16). APT pretreatment was documented in 71 cases (33%). Patients with APT pretreatment had higher SR rates (77% vs 61%; P=0.013). The two groups did not differ in terms of sICH (6% vs 7%), 3-month mortality (25% vs 26%), and 3-month functional independence (50% vs 48%). Pretreatment with APT was independently associated with increased likelihood of SR (OR 2.18, 95% CI1.01 to 4.73; P=0.048) on multivariable logistic regression models adjusting for potential confounders. A significant interaction (P=0.014) of intravenous thrombolysis (IVT) pretreatment on the association of pre-hospital antiplatelet use with SR was detected. APT pretreatment was associated with SR (OR 2.74, 95% CI 1.15 to 6.54; P=0.024) in patients treated with combination therapy (IVT and MT) but not in those treated with direct MT (OR 1.78, 95% CI 0.63 to 5.03; P=0.276).ConclusionAPT pretreatment does not increase the risk of sICH and may independently improve the odds of SR in patients with ELVO treated with MT. The former association appears to be modified by IVT.

scholarly journals Comparative Evaluation of 10 Prehospital Triage Strategy Paradigms for Patients With Suspected Acute Ischemic Stroke

2019 ◽  
Vol 8 (12) ◽  
Author(s):  
Ludwig Schlemm ◽  
Matthias Endres ◽  
Jan F. Scheitz ◽  
Marielle Ernst ◽  
Christian H. Nolte ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Disability Adjusted Life Years ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Disability Adjusted Life ◽  
Life Years ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background The best strategy to identify patients with suspected acute ischemic stroke and unknown vessel status (large vessel occlusion) for direct transport to a comprehensive stroke center instead of a nearer primary stroke center is unknown. Methods and Results We used mathematical modeling to estimate the impact of 10 increasingly complex prehospital triage strategy paradigms on the reduction of population‐wide stroke‐related disability. The model was applied to suspected acute ischemic stroke patients in (1) abstract geographies, and (2) 3 real‐world urban and rural geographies in Germany. Transport times were estimated based on stroke center location and road infrastructure; spatial distribution of emergency medical services calls was derived from census data with high spatial granularity. Parameter uncertainty was quantified in sensitivity analyses. The mothership strategy was associated with a statistically significant population‐wide gain of 8 to 18 disability‐adjusted life years in the 3 real‐world geographies and in most simulated abstract geographies (net gain −4 to 66 disability‐adjusted life years). Of the more complex paradigms, transportation of patients with clinically suspected large vessel occlusion based on a dichotomous large vessel occlusion detection scale to the nearest comprehensive stroke center yielded an additional clinical benefit of up to 12 disability‐adjusted life years in some rural but not in urban geographies. Triage strategy paradigms based on probabilistic conditional modeling added an additional benefit of 0 to 4 disability‐adjusted life years over less complex strategies if based on variable cutoff scores. Conclusions Variable stroke severity cutoff scores were associated with the highest reduction in stroke‐related disability. The mothership strategy yielded better clinical outcome than the drip‐‘n'‐ship strategy in most geographies.

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