Abstract 56: Incidence of Large Vessel Occlusions in Children Who Present Within Extended Thrombectomy Treatment Window

Introduction: Mechanical thrombectomy (MT) should be considered in children with persistent deficits with large vessel occlusion (LVO), although the recognition and diagnosis of stroke is often delayed. With the recent extension of treatment windows to 24 hours in adult studies, more children may now be MT candidates. The aim of this project was to examine LVO incidence in childhood strokes that present within 24 hours of symptom onset. Methods: Patients with clinical and radiographic confirmed stroke from 1995-2018 were identified via internal database search. Patients with last known normal < 24 hours and imaging within the MT time window (24 hours) were included for analysis. A pediatric neuroradiologist independently reviewed imaging to confirm presence/absence of LVO. Results: Of 165 patients with childhood stroke, 60 (36.3%) had last known normal <24 hours and vessel imaging within the MT timeframe (table). Fourteen patients (8.5%) had an LVO; nine with internal carotid or M1 and five with M2 occlusions. Median time from symptom onset to imaging was 6.47 hours in LVO patients. Most common stroke etiologies with LVO were unilateral focal cerebral arteriopathy of childhood (5) and other (5). One of the LVO patients underwent MT. Conclusions: At our institution, over 1/3 rd of patients presented within 24 hour of symptom onset with vascular imaging, and nearly 1/4 of those children (8.5% overall) had an LVO amenable to potential MT. While not all children with LVO will be MT candidates, this study shows that significant numbers of children present with LVO within the adult MT treatment window.

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Abstract WP20: Efficacy and Safety of Mechanical Thrombectomy in Emergent Large Vessel Occlusions with Concomitant Cervical Internal Carotid Artery Occlusion

Stroke ◽

10.1161/str.48.suppl_1.wp20 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Nitin Goyal ◽

Georgios Tsivgoulis ◽

Abhi Pandhi ◽

Yasser M Khorchid ◽

Abhishek Ojha ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Mechanical Thrombectomy ◽

Large Vessel ◽

Efficacy And Safety ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Aspiration Thrombectomy ◽

Cervical Internal Carotid Artery

Introduction: Recently, five published major randomized controlled clinical trials have demonstrated that timely mechanical thrombectomy (MT) of acute ischemic strokes (AIS) with emergent large vessel occlusion (ELVO) is safe and improves functional outcomes. However, data evaluating the efficacy and safety of MT in ELVO patients with concomitant cervical internal carotid artery (cICA) occlusion is limited. The purpose of this study is to evaluate efficacy and safety of MT in ELVO patients with concomitant cICA occlusion Methods: We prospectively analyzed consecutive AIS patients with anterior circulation ELVO who underwent stent-retriever or primary aspiration thrombectomy at two tertiary stroke centers. Outcome measures in our study were 3-month mortality and modified ranking scale (mRS), as well as symptomatic intracranial hemorrhage (sICH). Safety and efficacy outcomes were compared between ELVO patients with and without concomitant cICA occlusion. Results: A total of 137 AIS patients had anterior circulation ELVO and underwent MT (age 63 ± 14, 49% male, median NIHSS 17, IQR [13-20]). ELVO patients with concomitant cICA occlusion (n=19) did not differ in terms of rates of sICH (0% versus 11%, p=0.21), complete recanalization (68 % versus 68%, p=1.00), onset to groin puncture time (minutes [IQR] 268 [211-379] versus 225 [165-312], p=0.47), 3-month mortality (35% versus 26 %, p=0.55), and mRS of 0-2 at 3 months (41% versus 45%, p=0.80) when compared with ELVO patients without concomitant cICA occlusion (n=118). Admission NIHSS was higher among ELVO patients with concomitant cICA occlusion (median [IQR], 18 [15-22] versus 16 [12-19], p=0.01), and they tended to have higher groin puncture to recanalization time (minutes [IQR] 74 [42-97] versus 49 [38-78], p=0.09). The ordinal shift analysis did not show any difference in favorable outcomes in two groups in unadjusted analyses or after adjustment for admission NIHSS and groin to recanalization time (common OR=0.78 [95% CI: 0.27-2.29, p=0.66]). Angioplasty was performed in 11 of 19 ELVO patients with concomitant cICA occlusion. Three patients required stent placement. Discussion: Our study indicates that MT can be performed safely and effectively in ELVO patients with concomitant cICA occlusion.

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Thrombectomy by primary aspiration technique in a patient with critical internal carotid artery stenosis

10.5327/1516-3180.591 ◽

2021 ◽

Author(s):

Yasmim Nadime José Frigo ◽

Hendrick Henrique Fernandes Gramasco ◽

Igor Oliveira Fonseca ◽

Mateus Felipe dos Santos ◽

Rodrigo Bazan ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Mechanical Thrombectomy ◽

Large Vessel ◽

Neurological Deficits ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Clinical Prognosis ◽

Aspiration Technique

Context: Stroke is one of the main leaders of death and disability in the world. Currently, mechanical thrombectomy with stent retrievers is the technique of choice for large vessel occlusion, however, the primary aspiration technique has been proposed as a fast and safe alternative. Case report: J.E.M, male, 57 years old, hypertensive, atrial fibrillation. Started claudication of neurological deficits, with intermittent paresthesia in left upper limb for 2 days. Admitted with NIHSS 2 (nasolabial sulcus erasure and hypoesthesia in LUL), in thrombolysis window, has seen in cerebral and neck angiotomography critical stenosis of the internal carotid artery and in CT scan with perfusion Mismatch volume 72 ml and infinite ratio. Since the patient did not have sufficient criteria for thrombolysis and since the clinical prognosis was unfavorable, a diagnostic arteriography was indicated, which showed ICAR stenosis 90%. The patient proceeded with angioplasty and stenting using the ADPAT technique and mechanical thrombectomy due to occlusion in segment M1 with total recanalization (TICI 3) and NIHSS after and at discharge of 0. Conclusion: The advent of thrombectomy impacts the improvement of functional dependence and the reduction of mortality, especially in stroke with large vessel occlusion, whose treatment with thrombolytic therapy only has a low chance of recanalization.

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Abstract P11: Clinical Utility of Aspects in Late Window Stroke Thrombectomy Patients: Insights From Star

Stroke ◽

10.1161/str.52.suppl_1.p11 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Guilherme B Porto ◽

Zachary Hubbard ◽

Sami Al Kasab ◽

Eyad Almallouhi ◽

Robert Starke ◽

...

Keyword(s):

Ct Scan ◽

Symptom Onset ◽

Mechanical Thrombectomy ◽

Multivariable Analysis ◽

Star Collaboration ◽

Outcome Data ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Aspiration Thrombectomy

Introduction: Recent trials have proven safety and efficacy of mechanical thrombectomy for patients presenting with emergent large vessel occlusion beyond 6 hours of symptom onset. While evidence supports using baseline CT scan to evaluate the candidacy for mechanical thrombectomy for patients presenting in the early window, late window trials have used advanced imaging such as CT and MR perfusion. We aim to assess outcomes of MT stratified by admission Alberta Stroke Program Early CT Score (ASPECTS). Methods: We used data from the prospectively maintained registries of 28 stroke centers in the Stroke Thrombectomy and Aneurysm (STAR) collaboration. Demographics, comorbidities, LVO site, ASPECTS, MT technique, radiographic and clinical outcome data were collected. Patients with M1 or ICA occlusion were included in these analyses. Multivariable analysis was performed using a generalized linear model with logit link to assess for variables associated with favorable outcomes. Results: 3356 patients in the STAR database were reviewed and 347 (10.3%) of those underwent MT in the late window (table). Median age was 69, 189 (54.5%) were female, and 181 (52.2%) were white. 295 patients ASPECTS ≥6. In this group, 200 (68.8%) had M1 occlusion, and the remaining had ICA occlusion. Aspiration thrombectomy was used in 139 (47.1%) of patients. Successful reperfusion was achieved (mTICI≥2b) in 264 (76.1%). sICH was observed in 15 (5.1%). Excellent functional outcome (mRS 0-2) was observed in 124 (42%) patients. ASPECTS score was independently associated with favorable outcomes (aOR 1.2, 95% CI 1.1-1.4, P=0.006). Conclusion: Excellent outcomes are observed in patients with good ASPECT score presenting in the late window irrespective of perfusion criteria. Admission CT scan could be used to triage patients presenting with emergent large vessel occlusion beyond 6 hours of symptom onset.

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Implications of limiting mechanical thrombectomy to patients with emergent large vessel occlusion meeting top tier evidence criteria

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2015-012206 ◽

2016 ◽

Vol 9 (3) ◽

pp. 225-228 ◽

Cited By ~ 22

Author(s):

Rohini Bhole ◽

Nitin Goyal ◽

Katherine Nearing ◽

Andrey Belayev ◽

Vinodh T Doss ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Time Window ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Strict Adherence ◽

Nihss Score ◽

Neurological Improvement ◽

Symptomatic Intracerebral Hemorrhage ◽

Increased Risk

BackgroundRecent guidelines for endovascular management of emergent large vessel occlusion (ELVO) award top tier evidence to the same selective criteria in recent trials. We aimed to understand how guideline adherence would have impacted treatment numbers and outcomes in a cohort of patients from a comprehensive stroke center.MethodsA retrospective observational study was conducted using consecutive emergent endovascular patients. Mechanical thrombectomy (MT) was performed with stent retrievers or large bore clot aspiration catheters. Procedural outcomes were compared between patients meeting, and those failing to meet, top tier evidence criteria.Results126 patients receiving MT from January 2012 to June 2015 were included (age 31–89 years, National Institutes of Health Stroke Scale (NIHSS) score 2–38); 62 (49%) patients would have been excluded if top tier criteria were upheld: pretreatment NIHSS score <6 (10%), Alberta Stroke Program Early CT score <6 (6.5%), premorbid modified Rankin Scale (mRS) score ≥2 (27%), M2 occlusion (10%), posterior circulation (32%), symptom to groin puncture >360 min (58%). 26 (42%) subjects had more than one top tier exclusion. Symptomatic intracerebral hemorrhage (sICH) and systemic hemorrhage rates were similar between the groups. 3 month mortality was 45% in those lacking top tier evidence compared with 26% (p=0.044), and 3 month mRS score 0–2 was 33% versus 46%, respectively (NS). After adjusting for potential confounders, top tier treatment was not associated with neurological improvement during hospitalization (β −8.2; 95% CI −24.6 to −8.2; p=0.321), 3 month mortality (OR=0.38; 95% CI 0.08 to 1.41), or 3 month favorable mRS (OR=0.97; 95% CI 0.28 to 3.35).ConclusionsOur study showed that with strict adherence to top tier evidence criteria, half of patients may not be considered for MT. Our data indicate no increased risk of sICH and a potentially higher mortality that is largely due to treatment of patients with basilar occlusions and those treated at an extended time window. Despite this, good functional recovery is possible, and consideration of MT in patients not meeting top tier evidence criteria may be warranted.

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E-098 Mechanical thrombectomy in the extended 24 hour time window for acute ischemic stroke patients with large vessel occlusion

10.1136/neurintsurg-2020-snis.131 ◽

2020 ◽

Author(s):

S Salam ◽

C Powers ◽

S Nimjee ◽

P Youssef ◽

S Heaton ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Time Window ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion

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Stroke and mechanical thrombectomy in patients with COVID-19: technical observations and patient characteristics

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016220 ◽

2020 ◽

Vol 12 (7) ◽

pp. 648-653 ◽

Cited By ~ 30

Author(s):

Arthur Wang ◽

Grace K Mandigo ◽

Peter D Yim ◽

Philip M Meyers ◽

Sean D Lavine

Keyword(s):

Internal Carotid ◽

Mechanical Thrombectomy ◽

Artery Occlusion ◽

Large Vessel ◽

Consecutive Series ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Coagulation Abnormalities ◽

Basilar Arteries

BackgroundCOVID-19 infections have been shown to be associated with a range of thromboembolic disease.ObjectiveTo describe our endovascular experience in a consecutive series of patients with COVID-19 who presented with large vessel occlusions, and to describe unique findings in this population.MethodsMechanical thrombectomy was performed on five consecutive patients with COVID-19 with large vessel occlusions. A retrospective study of these patients was performed. Patient demographics, laboratory values, mechanical thrombectomy technique, and clinical and angiographic outcomes were reviewed.ResultsFour patients with COVID-19 presented with anterior circulation occlusions and one patient with COVID-19 presented with both anterior and posterior circulation occlusions. All patients had coagulation abnormalities. Mean patient age was 52.8 years. Three patients presented with an intracranial internal carotid artery occlusion. Two patients presented with an intracranial occlusion and a tandem thrombus in the carotid bulb. One patient presented with an occlusion in both the internal carotid and basilar arteries. Clot fragmentation and distal emboli to a new vascular territory were seen in two of five (40%) patients, and downstream emboli were seen in all five (100%) patients. Patient clinical outcome was generally poor in this series of patients with COVID-19 large vessel occlusion.ConclusionOur series of patients with COVID-19 demonstrated coagulation abnormalities, and compared with our previous experience with mechanical thrombectomy in large vessel occlusion, this group of patients were younger, had tandem or multiple territory occlusions, a large clot burden, and a propensity for clot fragmentation. These patients present unique challenges that make successful revascularization difficult.

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Tandem stents thrombectomy as a rescue treatment for refractory large vessel occlusions

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-015822 ◽

2020 ◽

Vol 13 (1) ◽

pp. 33-38

Author(s):

Haowen Xu ◽

Shanling Peng ◽

Tao Quan ◽

Yongjie Yuan ◽

Zibo Wang ◽

...

Keyword(s):

Clinical Outcome ◽

Internal Carotid ◽

Mechanical Thrombectomy ◽

National Institutes Of Health ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Good Clinical Outcome ◽

Vessel Occlusion ◽

Nihss Score ◽

Rescue Treatment

BackgroundMechanical thrombectomy with a stent retriever (SR) and/or aspiration is the 'gold standard' for the treatment of acute ischemic stroke due to large vessel occlusion (LVO). However, sometimes clots may not be retrievable with a single SR alone or combined with aspiration.ObjectiveTo assess the safety and efficacy of a novel tandem stents thrombectomy (TST) technique as a rescue treatment for acute LVO that is refractory to conventional attempts.MethodsAll patients treated with the TST technique as rescue treatment after failure of conventional attempts were retrospectively reviewed. The postprocedural angiographic and clinical outcome, including modified Thrombolysis in Cerebral infarction (mTICI) grade, National Institutes of Health Stroke Scale (NIHSS) score, and modified Rankin Scale (mRS) score, was assessed.ResultsNine patients (mean age, 65.2 years; median NIHSS score 18) with middle cerebral artery M1 segment (n=6) and terminal internal carotid artery (n=3) occlusions were included in the study. The TST technique was performed as a rescue treatment after unsuccessful stent thrombectomy alone (four cases) and stent thrombectomy plus aspiration (five cases). Successful recanalization (mTICI 2b/3) was achieved in all patients. No procedure-related complications occurred except reversible vasospasms were observed in three patients and one patient developed hemorrhage transformation after the procedure, but was asymptomatic. Three patients had good clinical outcome (mRS score 0–2 at 90 days). Two patients (22.2%) died.ConclusionsThe TST technique seems to be a safe and effective rescue treatment for acute LVO that is refractory to conventional attempts.

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