Abstract P496: Clot Characteristics in Mechanical Thrombectomy: Interim Analysis of the EXCELLENT Registry

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Raul Nogueira ◽  
Adnan H Siddiqui ◽  
Simon F De Meyer ◽  
Karen Doyle ◽  
Jens Fiehler ◽  
...  
Keyword(s):  
Interim Analysis ◽  
Mechanical Thrombectomy ◽  
Large Artery ◽  
Large Vessel Occlusion ◽  
First Line ◽  
Vessel Occlusion ◽  
Stroke Etiology ◽  
Standardized Protocol ◽  
Artery Disease ◽  
Abstract Submission

Introduction: Red blood cell (RBC) rich vs fibrin rich clots have different mechanical properties and greater knowledge about clot composition in the context of clinical, imaging, and procedural factors in mechanical thrombectomy (MT) may help with procedural optimization. The EXCELLENT Registry (NCT03685578) is a prospective, global, multi-center, observational registry of EmboTrap as the first line MT device for large vessel occlusion (LVO). We present an interim analysis of clot collected per pass in the registry. Methods: Five hundred thirty-three clot specimens from 376 subjects were collected by 20 sites and sent for analysis by independent Central Labs under standardized protocol. Analysis was interrupted by COVID-19, but the labs were fully operational as of June 2020 and on track to deliver results for 300 subjects in Q4. At the time of abstract submission, composition data for 234 clots from 163 subjects was available. All available data will be presented at the time of the conference. Results: Cardioembolic etiology (n=100) was associated with lower RBC (40.2 vs 47.2%) and higher fibrin content (31.7 vs 26.7%) compared to large artery disease (n=12). Hyperdense/vessel susceptibility sign (78+, 24-, per independent imaging core lab) corresponded to higher mean RBC content (44.4 vs 34.9%). Treatment with IV tPA (60+, 91-) had no clear impact on clot composition (42.3 vs 40.6% RBC; 30.4 vs 30.0% fibrin). Notably, clots retrieved with the first 2 passes of were more RBC rich (42.1 vs 28.0%) and clots retrieved in higher passes had a higher average fibrin content (35.5 vs 29.6%) suggesting that higher fibrin content leads to greater refractoriness. Conclusions: Clot density/susceptibility on baseline imaging, stroke etiology and number of thrombectomy passes were associated with differential clot composition. These findings may have potential implications for the development of better MT strategies.

scholarly journals Stroke thrombectomy complication management

2021 ◽  
pp. neurintsurg-2021-017349
Author(s):  
Sara M Pilgram-Pastor ◽  
Eike I Piechowiak ◽  
Tomas Dobrocky ◽  
Johannes Kaesmacher ◽  
Juergen Den Hollander ◽  
...  
Keyword(s):  
Treatment Efficacy ◽  
Mechanical Thrombectomy ◽  
Complication Management ◽  
Line Treatment ◽  
Large Vessel Occlusion ◽  
First Line ◽  
Invasive Treatment ◽  
Vessel Occlusion ◽  
Endovascular Mechanical Thrombectomy ◽  
First Line Treatment

Endovascular mechanical thrombectomy (EVT) is widely accepted as the first-line treatment for acute ischemic stroke in patients with large vessel occlusion. Being an invasive treatment, this method is associated with various preoperative, perioperative, and postoperative complications. These complications may influence peri-interventional morbidity and mortality and therefore treatment efficacy and clinical outcome. The aim of this review is to discuss the most common types of complications associated with EVT, the probable mechanisms of injury, and effective methods to manage and prevent complications.

scholarly journals Selecting the Appropriate First-Line Strategy Based on Hyperdense Vessel Sign in Acute Ischemic Stroke Increases First Pass Recanalization: A Tertiary Center Experience

2022 ◽  
Author(s):  
Uday Bhanu Kovilapu ◽  
Narendra Jain ◽  
Atul Mishra ◽  
Virender Malik
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Rescue Therapy ◽  
Large Vessel Occlusion ◽  
First Line ◽  
Vessel Occlusion ◽  
Tertiary Center ◽  
First Pass ◽  
Noncontrast Computed Tomography

Abstract Background: The data pertaining to selecting an optimal first-line strategy (stent retriever [SR] vs. contact aspiration [CA]) based on noncontrast computed tomography (NCCT) in cases of acute ischemic stroke consequent to large vessel occlusion (LVO) is lacking. Aims: This article studies the influence of hyperdense vessel sign (HVS) in selecting optimal first-line strategy, with intention of increasing first-pass recanalization (FPR). Methods: Upfront approach at our center is SR technique with rescue therapy (CA) adoption consequent to three failed SR attempts to achieve successful recanalization. Data of patients with acute LVO who underwent mechanical thrombectomy from June 2017 to May 2020 was retrospectively analyzed. Patients were classified into HVS (+) and HVS (–) cohort. Rate of successful recanalization (first pass, early, and final) and efficacy of rescue therapy was assessed between the two cohorts. Results: Of 52 patients included, 28 and 24 were assigned to the HVS (+) and HVS (–) cohort, respectively. FPR was observed in 50% of HVS (+) and 20.9% of HVS (–) (p = 0.029). Early recanalization was documented in 64.2% of HVS (+) and 37.5% of HVS (–) (p = 0.054). Rescue therapy need was higher in patients not demonstrating HVS (p = 0.062). Successful recanalization was achieved with rescue therapy in 50% of HVS (–) group. Conclusion: A higher FPR is achievable following individualized first-pass strategy (based on NCCT appearance of clot), instead of a generalized SR first-pass approach. This CT imaging-based strategy is a step closer to achieving primary angiographic goal of FPR.

Abstract 194: Preliminary Results from the FIRST Trial: Natural History of Acute Stroke from Large Vessel Occlusion

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Vallabh Janardhan ◽  
Ryan M Gianatasio ◽  
Sherman H Chen ◽  
Parita Bhuva ◽  
Mark M Murray ◽  
...  
Keyword(s):  
Placebo Group ◽  
Natural History ◽  
Interim Analysis ◽  
Mechanical Thrombectomy ◽  
Large Vessel ◽  
Adverse Event Rate ◽  
Delayed Presentation ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
History Of

Purpose: Current literature has limited information on the natural history of the stroke cohort eligible for mechanical thrombectomy. The placebo group from the PROACT II study is often used as a historical control, despite differences in entry criteria. Reported herein are data in a stroke cohort eligible for mechanical thrombectomy but untreated due to unavailability or inability to initiate endovascular treatment within the 8-hr window due to delayed presentation. The goal is to compare the functional independence rate with the PROACT placebo group. Methods: The FIRST Trial is a prospective, multicenter, natural history study of a stroke cohort eligible for but untreated by mechanical thrombectomy presenting within 8 hrs of symptom onset from a large vessel occlusion and a NIHSS of at least 10. The primary endpoint is functional outcome at 90 days as defined by a mRS 0-2. Results are reported from an interim analysis. Results: Fifty-nine (59) patients were enrolled and met study criteria for this interim analysis. The mean age was 68.2 ± 17 years; median NIHSS was 18 (5-34). Target vessel occlusions were in the ICA (35.7%), MCA (60.7%), and other (3.6%). At admission, the TIMI 0-1 rate was 89% (49/55), and the TICI 0-1 rate was 89% (48/54). Of these, only 10% (3/30) showed spontaneous recanalization (TIMI 2-3 or TICI 2a-3). Eleven of 55 (20%) patients achieved a good 90-day outcome, and 24 of 59 (40.7%) died. The serious adverse event rate was 52.6% (30/57), including respiratory failure (8 cases) and pneumonia (4 cases). A total of 6 (10%) patients suffered intracerebral hemorrhage (ICH). Below is a comparison of the MCA cohort vs. PROACT II placebo patients. Conclusion: Compared with PROACT II placebo patients, the stroke cohort eligible for mechanical thrombectomy who were untreated have a lower rate of recanalization and worse outcome. These results indicate it may not be appropriate to use the PROACT placebo patients as historical controls for mechanical thrombectomy trials.

scholarly journals Mechanical thrombectomy using the new Tigertriever in acute ischemic stroke patients – A Swiss prospective multicenter study

2020 ◽  
Vol 26 (5) ◽  
pp. 598-601
Author(s):  
Philipp Gruber ◽  
Michael Diepers ◽  
Alexander von Hessling ◽  
Johannes Weber ◽  
Timo Kahles ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
First Line ◽  
Prospective Multicenter Study ◽  
Vessel Occlusion ◽  
First Pass ◽  
Reperfusion Rate

Purpose Tigertriever is a novel operator-adjustable clot retriever designed to enhance the operator's options to control the interaction of retriever and clot. The aim of this study was to assess the feasibility, safety and efficacy of the Tigertriever device system. Methods Prospective multi-center registry study at three comprehensive stroke centers in Switzerland from 2017 to 2019 of patients with acute ischemic stroke (AIS) and large vessel occlusion (LVO) using Tigertriever as a first-line device. Results 30 AIS patients (median age 72.5 years (IQR 64–79), 50% women) with a median NIHSS on admission of 11 (IQR 6-13) and a median ASPECT score of 9 (IQR 7–10) were treated with the new Tigertriever and included in this study. The first-pass effect was 24% (n = 7). A good recanalization (eTICI 2 b/2c/3) was achieved in 94% of the cases. Median mRS at 90 days was 1 (IQR 1–2). Conclusion This study demonstrated feasibility, safety and effectiveness of the Tigertriever in AIS patients with LVO with a high reperfusion rate.

‘Real-world’ comparison of first-line direct aspiration and stent retriever mechanical thrombectomy for the treatment of acute ischemic stroke in the anterior circulation: a multicenter international retrospective study

2019 ◽  
Vol 11 (10) ◽  
pp. 957-963 ◽  
Author(s):  
Michael Martini ◽  
J Mocco ◽  
Aquilla Turk ◽  
Adnan H Siddiqui ◽  
David Fiorella ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Real World ◽  
Mechanical Thrombectomy ◽  
Stent Retriever ◽  
Large Vessel ◽  
Treatment Technique ◽  
Large Vessel Occlusion ◽  
First Line ◽  
Vessel Occlusion

BackgroundThrombectomy for anterior large vessel occlusion less than 24 hours since last known well is now standard of care. Certain aspects of clinical trials may limit generalizability to ’real-world' practice.ObjectiveTo compare revascularization rates and outcomes for direct aspiration (ADAPT) and stent retriever thrombectomy following anterior acute ischemic stroke (AIS) in a real-life setting.MethodsData from the most recent 20 consecutive patients with AIS treated with mechanical thrombectomy between 2015 and 2016 were collected from 15 high-volume stroke centers across North America for a total of 300 cases. Patients with proximal anterior large vessel occlusions were dichotomized by primary treatment technique. Ordinal logistic regression assessed the effects of clinical variables on patient disability using 90-day modified Rankin Scale (mRS) scores.ResultsAdequate revascularization (Thrombolysis in Cerebral Infarction ≥2b) was ultimately achieved in 91.2% of first-line direct aspiration (ADAPT) cases with an average of 1.9±1.9 passes and in 87.5% of stent retriever cases with an average of 1.7±1.0 passes. Time from groin puncture to revascularization was shorter for ADAPT cases. The mean 90-day mRS score for both groups was 3.0±2.4. Number of passes using primary technique, and postintervention intracranial hemorrhage, were significant predictors of 90-day mRS scores after ADAPT, while age and preprocedure mRS score were predictive of outcomes following first-line stent retriever.ConclusionsOur data show similar adequate revascularization rates and 90-day functional outcomes for first-line direct aspiration and stent retrievers for anterior large vessel occlusion in a real-world setting. These results support the findings of other prospective trials evaluating the two techniques.

Efficacy and safety of rescue stenting following failed mechanical thrombectomy for anterior circulation large vessel occlusion: propensity score analysis

2019 ◽  
Vol 12 (3) ◽  
pp. 271-273 ◽  
Author(s):  
Feng Peng ◽  
Junfang Wan ◽  
Wenhua Liu ◽  
Wenguo Huang ◽  
Li Wang ◽  
...  
Keyword(s):  
Propensity Score ◽  
Propensity Score Matching ◽  
Mechanical Thrombectomy ◽  
Propensity Score Analysis ◽  
Artery Occlusion ◽  
Large Vessel ◽  
Large Artery ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion

PurposeTo evaluate the effectiveness and safety of rescue stenting (RS) after failed mechanical thrombectomy (MT) for patients with large artery occlusion in the anterior circulation.MethodsConsecutive patients who experienced failed reperfusion and subsequently did or did not undergo RS at 16 comprehensive stroke centers were enrolled from January 2015 to June 2018. Propensity score matching was used to achieve baseline balance between the patient groups. Symptomatic intracranial hemorrhage (sICH) at 48 hours and the modified Rankin Scale scores and mortality at 3 months in the two groups were compared.ResultsA total of 90 patients with RS and 117 patients without RS after failed MT were enrolled. Propensity score matching analysis selected 132 matched patients. The good outcome rate was significantly higher in matched patients with RS than in those without RS (36.4% vs 19.7%, p=0.033), whereas the sICH (13.6% vs 21.2%, p=0.251) and mortality (31.9% vs 43.9%, p=0.151) were not significantly different between the groups.ConclusionsRS seems to be an effective safe choice for patients with large vessel occlusion of the anterior circulation who underwent failed MT.

Effect of stroke etiology on endovascular thrombectomy with or without intravenous alteplase: a subgroup analysis of DIRECT-MT

2022 ◽  
pp. neurintsurg-2021-018275
Author(s):  
Pengfei Xing ◽  
Xiaoxi Zhang ◽  
Hongjian Shen ◽  
Fang Shen ◽  
Lei Zhang ◽  
...  
Keyword(s):  
Treatment Strategy ◽  
Combined Therapy ◽  
Large Vessel ◽  
Large Artery ◽  
Efficacy And Safety ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Stroke Etiology ◽  
Ordinal Logistic Regression Analysis ◽  
Intravenous Alteplase

BackgroundStroke etiology might influence the clinical outcomes in patients with large vessel occlusion receiving endovascular treatment (EVT) with or without thrombolysis.ObjectiveTo examine whether stroke etiology resulted in different efficacy and safety in patients treated with EVT-alone or EVT preceded by intravenous alteplase (combined therapy).MethodsWe assessed the efficacy and safety of treatment strategy based on prespecified stroke etiology, cardioembolism (CE), large-artery atherosclerosis (LAA), and undetermined cause (UC) for patients enrolled in the DIRECT-MT trial. The primary outcome was the modified Rankin Scale (mRS) score at 90 days. Multivariate ordinal logistic regression analysis was used to calculate the adjusted common OR for a shift of better mRS score for EVT-alone versus combined therapy. A term was entered to test for interaction.ResultsIn this study, 656 patients were grouped into three prespecified stroke etiologic subgroups. The adjusted common ORs for improvement in the 90-day ordinal mRS score with EVT-alone were 1.2 (95% CI 0.8 to 1.8) for CE, 1.6 (95% CI 0.8 to 3.3) for LAA, and 0.8 (95% CI 0.5 to 1.3) for UC. Compared with CE, EVT-alone was more likely to result in an mRS score of 0–1 (pinteraction=0.047) and extended Thrombolysis in Cerebral Infarction ≥2b (pinteraction=0.041) in the LAA group. The differences in mortality and symptomatic intracranial hemorrhage within 90 days were not significant between the subgroups (p＞0.05).ConclusionsThe results did not support the hypothesis that a specific treatment strategy based on stroke etiology should be used for patients with large vessel occlusion (NCT03469206).

Abstract 1122‐000182: Histological Composition of Large Vessel Occlusion Stroke‐Causing Thrombi to Identify Etiologies: Systematic Review and Meta‐Analysis

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Paul Yeung‐Lai‐Wah ◽  
Kunakorn Atchaneeyasakul ◽  
Kyle Sheu ◽  
Neal Rao ◽  
David Liebeskind ◽  
...  
Keyword(s):  
Blood Cells ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Cryptogenic Stroke ◽  
Large Vessel ◽  
Large Artery ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Histological Difference ◽  
Significant Difference

Introduction : More than a third of large vessel occlusion ischemic strokes do not have clear etiology. Mechanical thrombectomy provides a method to retrieve stroke‐causing thrombi and potentially identifying the etiology. A systematic meta‐analysis is performed to determine if there is a histological difference in red blood cell (RBC) composition of thrombi after the etiology of the stroke is known. Methods : We performed a systematic search through PUBMED and EMBASE. Studies meeting inclusion criteria were identified in which the large vessel occlusion stroke‐causing thrombi histology and etiology of the stroke were determined as either large artery atherosclerotic (LAA), cardioembolic (CE) or cryptogenic. Studies that had the data available or extractable data were selected. Random‐effect models were used to compare the histological difference between each etiology. Results : From inception to August 2021, 4 studies (n = 1022) were used to compare CE vs LAA, 5 studies (n = 1247) were used to compare CE vs cryptogenic and 4 studies (n = 654) were used to compare LAA vs cryptogenic. There was no significant difference in the red blood cells vs white blood cells/fibrin/platelets component between the stroke origins of CE vs LAA (mean difference (MD) ‐1.87; 95% confidence internal [CI]: ‐16.51, 12.78), CE vs cryptogenic (MD 1.18; 95% CI: ‐1.49, 3.86) and LAA vs cryptogenic (MD 7.20; 95% CI: ‐3.93, 18.34). Conclusions : There was no significant gross histological difference between CE, LAA and cryptogenic stroke etiologies and of the large vessel occlusion stroke‐causing thrombi retrieved by mechanical thrombectomy. Further studies into biochemical or genetic markers may be needed to identify stroke etiology.

First-line use of contact aspiration for thrombectomy versus a stent retriever for recanalization in acute cerebral infarction: The randomized ASTER study protocol

2017 ◽  
Vol 13 (1) ◽  
pp. 87-95 ◽  
Author(s):  
Bertrand Lapergue ◽  
Julien Labreuche ◽  
Raphael Blanc ◽  
Xavier Barreau ◽  
Jérome Berge ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Cerebral Infarction ◽  
Primary Outcome ◽  
Mechanical Thrombectomy ◽  
Stent Retriever ◽  
Treatment Technique ◽  
Large Vessel Occlusion ◽  
First Line ◽  
Anterior Circulation ◽  
Vessel Occlusion

Rationale Mechanical thrombectomy with a stent retriever is now the standard of care in anterior circulation ischemic stroke caused by large vessel occlusion. New techniques for mechanical thrombectomy, such as contact aspiration, appear promising to increase reperfusion status and improve clinical outcome. Aim We aim at ascertaining whether contact aspiration is more efficient than the stent retriever as a first-line endovascular procedure. Sample size estimates With a two-sided test (alpha = 5%, power = 90%) and an anticipated rate of spontaneous recanalization and catheterization failures of 15%, we estimate that a sample size of 380 patients will be necessary to detect an absolute difference of 15% in primary outcome (superiority design). Methods and design The ASTER trial is a prospective, randomized, multicenter, controlled, open-label, blinded end-point clinical trial. Patients admitted with suspected ischemic anterior circulation stroke secondary to large vessel occlusion, with onset of symptoms <6 h, will be randomly assigned to contact aspiration or stent retriever in a 1:1 ratio; stratified by center and prior IV thrombolysis. If the assigned treatment technique is not successful after three attempts, another technique will be applied, at the operator’s discretion. Study outcomes The primary outcome will be successful recanalization (modified Thrombolysis in Cerebral Infarction score 2b–3) at the end of the endovascular procedures. Secondary outcome will include successful recanalization after the assigned first-line treatment technique alone, procedural times, the need for a rescue technique, complications and modified Rankin Scale at three months. Discussion No previous head to head randomized trials have directly compared contact aspiration versus stent retriever reperfusion techniques. This prospective trial aims to provide further evidence of benefit of contact aspiration versus stent retriever techniques among patients with ischemic stroke.

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