Abstract P10: Posterior Circulation Strokes Are Less Likely to Receive Alteplase or Mechanical Thrombectomy: Analysis From the IAC Study

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Narendra S Kala ◽  
Shadi Yaghi ◽  
Adam H De Havenon ◽  
Ava L Liberman ◽  
Eva Mistry ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
The United States ◽  
Posterior Circulation ◽  
Cardioembolic Stroke ◽  
Stroke Severity ◽  
Fisher Exact Test ◽  
Posterior Circulation Stroke ◽  
Severity Scores ◽  
Treatment Trends ◽  
To Receive

Background: Emergent treatment with intravenous thrombolysis and mechanical thrombectomy improved outcomes in patients with acute ischemic stroke. We aim to identify differences in acute stroke treatment trends between strokes occurring in the anterior versus posterior circulation. Methods: The IAC (Initiation of Anticoagulation after Cardioembolic stroke) study represents pooled data registry of 8 comprehensive stroke centers across the United States and included patients with cardioembolic stroke in the setting of AFib. In a post hoc analysis, we identified and separated patients into posterior circulation stroke (PCS) and anterior circulation stroke (ACS) groups based on imaging. Patients without infarct locations or those with multi-circulation infarcts were excluded. We compared baseline characteristics, stroke severity and the treatment trends with alteplase (tPA) and mechanical thrombectomy (MT) in PCS vs ACS using Fisher exact test, t-test and non-parametric tests. We then performed multivariable logistic regression adjusted for baseline differences to determine the associations between PCS and tPA or MT. Results: Of the 2084 patients in IAC cohort, 1589 met inclusion criteria for this study, in which 294 (22.7%) had PCS. Mean age was 76.8 years, 29.3% received tPA and 26.9% had MT. When compared to ACS, patients with PCS were more likely to be men (55.4% vs 45.6%, p=0.003), have diabetes (42.8% vs 29.8, p< 0.001) and lower median NIHSS score on admission (4 vs 8, p<0.001). Patients with PCS were less likely to receive tPA (16.3% vs 32.3%, p<0.001) or MT (10.9% vs 30.6%, p<0.001). Other variables were not significantly different. When adjusted for baseline differences, patients with PCS remained less likely to be treated with tPA (adjusted OR 0.49, 95%CI 0.35-0.70, p<0.001) or MT (adjusted OR 0.38, 95%CI 0.25-0.58, p<0.001). Conclusion: Posterior circulation strokes are half as likely to receive thrombolytic therapy and almost a third as likely to have thrombectomy, even after adjusting for baseline stroke severity scores. This is possibly due to difficulty in timely identification and diagnostic delays. There is need for better tools incorporating posterior circulation stroke signs and symptoms to allow for early detection and treatment.

scholarly journals Access to Mechanical Thrombectomy for Ischemic Stroke in the United States

Stroke ◽  
2021 ◽  
Author(s):  
Hooman Kamel ◽  
Neal S. Parikh ◽  
Abhinaba Chatterjee ◽  
Luke K. Kim ◽  
Jeffrey L. Saver ◽  
...  
Keyword(s):  
United States ◽  
Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Stroke Care ◽  
The United States ◽  
Sensitivity Analyses ◽  
Stroke Severity ◽  
Discharge Data ◽  
Cerebral Vessel

Background and Purpose: Mechanical thrombectomy helps prevent disability in patients with acute ischemic stroke involving occlusion of a large cerebral vessel. Thrombectomy requires procedural expertise and not all hospitals have the staff to perform this intervention. Few population-wide data exist regarding access to mechanical thrombectomy. Methods: We examined access to thrombectomy for ischemic stroke using discharge data from calendar years 2016 to 2018 from all nonfederal emergency departments and acute care hospitals across 11 US states encompassing 80 million residents. Facilities were classified as hubs if they performed mechanical thrombectomy, gateways if they transferred patients who ultimately underwent mechanical thrombectomy, and gaps otherwise. We used standard descriptive statistics and unadjusted logistic regression models in our primary analyses. Results: Among 205 681 patients with ischemic stroke, 100 139 (48.7% [95% CI, 48.5%–48.9%]) initially received care at a thrombectomy hub, 72 534 (35.3% [95% CI, 35.1%–35.5%]) at a thrombectomy gateway, and 33 008 (16.0% [95% CI, 15.9%–16.2%]) at a thrombectomy gap. Patients who initially received care at thrombectomy gateways were substantially less likely to ultimately undergo thrombectomy than patients who initially received care at thrombectomy hubs (odds ratio, 0.27 [95% CI, 0.25–0.28]). Rural patients had particularly limited access: 27.7% (95% CI, 26.9%–28.6%) of such patients initially received care at hubs versus 69.5% (95% CI, 69.1%–69.9%) of urban patients. For 93.8% (95% CI, 93.6%–94.0%) of patients with stroke at gateways, their initial facility was capable of delivering intravenous thrombolysis, compared with 76.3% (95% CI, 75.8%–76.7%) of patients at gaps. Our findings were unchanged in models adjusted for demographics and comorbidities and persisted across multiple sensitivity analyses, including analyses adjusting for estimated stroke severity. Conclusions: We found that a substantial proportion of patients with ischemic stroke across the United States lacked access to thrombectomy even after accounting for interhospital transfers. US systems of stroke care require further development to optimize thrombectomy access.

scholarly journals Dual Mechanical Thrombectomy for Recanalization of a Resistant Acute Posterior Circulation Stroke

2017 ◽  
Vol 19 (2) ◽  
pp. 96 ◽  
Author(s):  
Ahmet Peker ◽  
Ayça Akgoz ◽  
Ethem Murat Arsava ◽  
Mehmet Akif Topçuoglu ◽  
Anil Arat
Keyword(s):  
Mechanical Thrombectomy ◽  
Posterior Circulation ◽  
Posterior Circulation Stroke

Renal Impairment Is Associated with Intracerebral Hemorrhage after Mechanical Thrombectomy in Vertebrobasilar Stroke

2019 ◽  
Vol 47 (1-2) ◽  
pp. 48-56 ◽  
Author(s):  
Mona Laible ◽  
Ekkehart Jenetzky ◽  
Markus A. Möhlenbruch ◽  
Ulf Neuberger ◽  
Martin Bendszus ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Intracerebral Hemorrhage ◽  
Mechanical Thrombectomy ◽  
Posterior Circulation ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Poor Clinical Outcome ◽  
Treatment Results ◽  
Risk Of Mortality ◽  
Vertebrobasilar Stroke

Background and Purpose: Renal dysfunction (RD) is overall associated with unfavorable functional outcome and higher risk of mortality after acute ischemic stroke. Associations between RD and outcome in patients with acute vertebrobasilar stroke treated with thrombectomy have not been evaluated so far. Materials and Methods: Consecutive patients with vertebrobasilar stroke treated with mechanical thrombectomy between October 2010 and July 2017 at our center were analyzed. RD was defined as glomerular filtration rate (GFR) < 60 mL/min/1.73 m2 at admission. Endpoints were (I) poor clinical outcome (modified Rankin Scale > 2) at 3 months, (II) 3-month mortality, and (III) intracerebral hemorrhage (ICH) after treatment. Results: Overall, 106 patients were included. Median age was 73.0 years (interquartile range 62.0–80.0), and RD was present in 20.8%. Multivariate analysis revealed that RD was associated with a higher risk for any ICH (OR 3.54; 95% CI 1.09–11.49; p = 0.035). Stroke severity at onset predicted poor clinical outcome (OR 1.08; 95% CI 1.03–1.14; p = 0.003). Neither low GFR nor any ICH, but stroke severity (OR 1.08; 95% CI 1.03–1.14; p = 0.002) and poor recanalization results (OR 11.38; 95% CI 2.01–64.41; p = 0.006) were associated with a higher risk for mortality. Conclusions: Patients with RD and acute vertebrobasilar stroke should be thoroughly monitored to prevent ICH after thrombectomy. Our results support performing mechanical thrombectomy in acute stroke patients with large vessel occlusions of the posterior circulation, irrespective of their renal function.

scholarly journals Transradial Approach for Mechanical Thrombectomy of Posterior Circulation Stroke

2018 ◽  
Vol 12 (6) ◽  
pp. 314-319 ◽  
Author(s):  
Taichiro Mizokami ◽  
Takeshi Uwatoko ◽  
Takashi Furukawa ◽  
Eiji Higashi ◽  
Yusuke Sakaki ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Posterior Circulation ◽  
Transradial Approach ◽  
Posterior Circulation Stroke

scholarly journals Monitored anesthesia care during mechanical thrombectomy for stroke: need for data-driven and individualized decisions

2021 ◽  
pp. neurintsurg-2020-016732
Author(s):  
Raul G Nogueira ◽  
Mahmoud H Mohammaden ◽  
Timothy P Moran ◽  
Matthew K Whalin ◽  
Raphael Y Gershon ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
High Volume ◽  
Posterior Circulation ◽  
National Institutes Of Health ◽  
Hemispheric Dominance ◽  
Stroke Severity ◽  
Anesthesia Care ◽  
Monitored Anesthesia Care ◽  
Conversion Rates ◽  
High Volume Center

BackgroundThe optimal anesthesia management for patients with stroke undergoing mechanical thrombectomy (MT) during the COVID-19 pandemic has become a matter of controversy. Some recent guidelines have favored general anesthesia (GA) in patients perceived as high risk for intraprocedural conversion from sedation to GA, including those with dominant hemispheric occlusions/aphasia or baseline National Institutes of Health Stroke Scale (NIHSS) score >15. We aim to identify the rate and predictors of conversion to GA during MT in a high-volume center where monitored anesthesia care (MAC) is the default modality.MethodsA retrospective review of a prospectively maintained MT database from January 2013 to July 2020 was undertaken. Analyses were conducted to identify the predictors of intraprocedural conversion to GA. In addition, we analyzed the GA conversion rates in subgroups of interest.ResultsAmong 1919 MT patients, 1681 (87.6%) started treatment under MAC (median age 65 years (IQR 55–76); baseline NIHSS 16 (IQR 11–21); 48.4% women). Of the 1677 eligible patients, 26 (1.6%) converted to GA including 1.4% (22/1615) with anterior and 6.5% (4/62) with posterior circulation strokes. The only predictor of GA conversion was posterior circulation stroke (OR 4.99, 95% CI 1.67 to 14.96, P=0.004). The conversion rates were numerically higher in right than in left hemispheric occlusions (1.6% vs 1.2%; OR 1.37, 95% CI 0.59 to 3.19, P=0.47) and in milder than in more severe strokes (NIHSS ≤15 vs >15: 2% vs 1.2%; OR 0.62, 95% CI 0.28 to 1.36, P=0.23).ConclusionsOur study showed that the overall rate of conversion from MAC to GA during MT was low (1.6%) and, while higher in posterior circulation strokes, it was not predicted by either hemispheric dominance or stroke severity. Caution should be given before changing clinical practice during moments of crisis.

Mechanical thrombectomy for acute ischemic stroke in the posterior circulation: assessment of efficacy and outcome and identification of prognostic factors

2020 ◽  
pp. 028418512096273
Author(s):  
Maciej Szmygin ◽  
Michał Sojka ◽  
Krzysztof Pyra ◽  
Piotr Tarkowski ◽  
Piotr Luchowski ◽  
...  
Keyword(s):  
Mortality Rate ◽  
Clinical Outcome ◽  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Recombinant Tissue Plasminogen Activator ◽  
Posterior Circulation ◽  
Stroke Severity ◽  
Anterior Circulation ◽  
Tissue Plasminogen ◽  
Meta Analyses

Background Mechanical thrombectomy (MT) is well-established in the treatment of acute ischemic anterior circulation stroke. However, there is no evidence from randomized trials or meta-analyses that MT is safe and effective in the treatment of patients with acute ischemic posterior circulation stroke (PCS). Purpose To evaluate the clinical and procedural factors associated with recanalization and outcome of patients with PCS treated with MT. Material and Methods Forty-three patients with PCS (median age 73 years) who underwent treatment with MT were included. Data including demographics, baseline stroke severity, radiological imaging, procedure and post-procedure complications were documented. Clinical outcome was evaluated using the modified Rankin Scale (mRS). The patients were classified into two groups based on clinical outcome (favorable vs. unfavorable mRS after 90 days). Results Median baseline National Institute of Health Stroke Scale (NIHSS) was 17. Twenty patients were eligible for intravenous thrombolysis and received recombinant tissue plasminogen activator before MT. Successful recanalization was observed in 88.4% of patients. After 90 days, favorable outcome (defined as mRS 0–2) was achieved in 26 patients; six patients had an unfavorable outcome (mRs >2). Final mortality rate was 25.5%. Baseline NIHSS, onset to reperfusion time, procedure duration, and successful recanalization had a statistically significant association with outcome. Failed recanalization and occurrence of intracranial hemorrhage were found to be associated with a higher mortality rate. Conclusion MT is feasible and effective method in treatment of PCS. Baseline NIHSS and onset to reperfusion time were found to be independent predictive factors of clinical outcome.

scholarly journals Mechanical Thrombectomy for Basilar Artery Occlusion Stroke: A Case Report

2020 ◽  
Vol 58 (228) ◽  
Author(s):  
Subash Phuyal ◽  
Kapil Dawadi ◽  
Raju Paudel ◽  
Ritesh Lamsal ◽  
Pooja Agrawal
Keyword(s):  
Case Report ◽  
Basilar Artery ◽  
Mechanical Thrombectomy ◽  
Significant Risk ◽  
Artery Occlusion ◽  
Posterior Circulation ◽  
Morbidity And Mortality ◽  
Basilar Artery Occlusion ◽  
Posterior Circulation Stroke ◽  
Endovascular Mechanical Thrombectomy

Posterior circulation strokes are potentially devastating events that carry a significant risk of morbidity and mortality. Acute basilar artery occlusion stroke is a rare posterior circulation stroke that needs emergent management. We report the case of a 67-year-old woman who developed an acute basilar artery occlusion. We achieved complete recanalization of the occluded basilar artery and its branches with endovascular mechanical thrombectomy. It is possible to achieve excellent results with mechanical thrombectomy in acute basilar artery occlusion if timely diagnosis and reperfusion can be done. We are not aware of any previous publication from Nepal describing this technique in acute basilar artery occlusion.

Factors Associated with 90-Day Outcomes of Patients with Acute Posterior Circulation Stroke Treated By Mechanical Thrombectomy

2018 ◽  
Vol 109 ◽  
pp. e318-e328 ◽  
Author(s):  
Gang Luo ◽  
Dapeng Mo ◽  
Xu Tong ◽  
David S. Liebeskind ◽  
Ligang Song ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Posterior Circulation ◽  
Factors Associated ◽  
Posterior Circulation Stroke

A Meta-Analysis of Prognostic Factors in Patients with Posterior Circulation Stroke after Mechanical Thrombectomy

2020 ◽  
pp. 1-15
Author(s):  
Kai Xun ◽  
Jiahang Mo ◽  
Shunyi Ruan ◽  
Jinyao Dai ◽  
Wenting Zhang ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Prognostic Factors ◽  
Mechanical Thrombectomy ◽  
Time Window ◽  
Meta Analysis ◽  
Primary Outcome Measure ◽  
Posterior Circulation ◽  
Posterior Circulation Stroke ◽  
Previous Stroke ◽  
Outcome Differences

<b><i>Background:</i></b> Posterior circulation stroke is characterized by poor prognosis because its optimal thrombolysis “time window” is always missed. After mechanical thrombectomy (MT), the recanalization rate of posterior circulation obstruction is significantly increased, but prognosis remains poor. To best manage patients, prognostic factors are needed to inform MT triaging after posterior circulation stroke. <b><i>Methods:</i></b> A systematic literature search was done for the period through April 2020. Studies included those with posterior circulation stroke cases that underwent MT. The primary outcome measure in this study was the modified Rankin Scale on day 90. <b><i>Results:</i></b> No outcome differences were found in gender, atrial fibrillation, smoking, and coronary artery disease (OR = 1.07, 95% CI: 0.90–1.28; OR = 1.02, 95% CI: 0.82–1.26; OR = 1.26, 95% CI: 0.94–1.68; and OR = 0.84, 95% CI: 0.58–1.22, respectively). Hypertension, diabetes mellitus, and previous stroke correlated with poorer prognosis (OR = 0.61, 95% CI: 0.48–0.77; OR = 0.60, 95% CI: 0.50–0.73; and OR = 0.74, 95% CI: 0.55–0.99, respectively). However, hyperlipidemia correlated with better prognosis (OR = 1.28, 95% CI: 1.04–1.58). <b><i>Conclusion:</i></b> Our analysis indicates that hypertension, diabetes mellitus, or previous stroke correlate with poorer outcomes. Intriguingly, hyperlipidemia correlates with better prognosis. These factors may help inform triage decisions when considering MT for posterior circulation stroke patients. However, large, multicenter, randomized controlled trials are needed to validate these observations.

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