Abstract P545: First Pass TICI 2b versus Multiple Passes TICI 3 for Acute Ischemic Stroke Patients: Is First Pass TICI 2b Enough?

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Ameer E Hassan ◽  
Mahmoud Dibas ◽  
Sherief Ghozy ◽  
Amr Ehab El-Qushayri ◽  
Adam A Dmytriw ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Vessel Occlusion ◽  
Single Pass ◽  
First Pass Effect ◽  
Significant Difference ◽  
First Pass ◽  
P 16 ◽  
Baseline Characteristics ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background and Objective: Prompt and complete reperfusion with mechanical thrombectomy (MT) is essential to improve outcome in acute ischemic strokes (AIS) with large vessel occlusion (LVO). Recently, first-pass effect (FPE), defined as achieving complete reperfusion with a single pass, has been emphasized as a potentially important MT target. We aimed to compare outcomes between patients who achieve mTICI 2b with first pass to those with multiple devise passes (MDP) mTICI 3. Methods: From a single comprehensive stroke center database, we retrospectively grouped LVO pts treated with MT into those who achieved mTICI 2b after a single pass and mTICI 3 after MDP. Clinical outcome (discharge and 90-day mRS), discharge NIHSS and safety (sICH, neurological worsening, mortality) were compared between the two groups. Results: Of 186 pts included, 153 (82%) achieved mTICI 3 with MDP, and 33 (18%) had mTICI 2b after a single pass. Mean age (71 vs 69), NIHSS (17 vs 16, p=0.2) were similar between the two groups. Patients with a single pass mTICI 2b had numerically higher IV tPA administration (33% vs 46%, p=.16). There was no difference in other baseline characteristics. There was no significant difference in discharge (21% vs 24.2%, p=0.65) and 90-day mRS 0-2 (24% vs 24%, p=0.5), MDP mTICI 3 and single pass mTICI 2b, respectively. Also, there was no difference in discharge NIHSS score (13.6 vs 16.7, p=0.26), mortality (16.3% vs 18.2%, p=0.8) and sICH rates (7.8% vs 18.2%, p=0.095) or neurological worsening (76.5% vs 69.7%, p=1). Conclusion: Our results did not show a significant difference between mTICI 3 with multiple passes and mTICI 2b after a single pass. Future large studies are warranted to explore the possibility of extending the first pass effect to patients who achieve mTICI 2b with a single pass.

scholarly journals Trevo 6 × 25mm vs. 4 × 30mm in Mechanical Thrombectomy of M1 LVO

2021 ◽  
Vol 12 ◽  
Author(s):  
Marion John Oliver ◽  
Emily Brereton ◽  
Muhib A. Khan ◽  
Alan Davis ◽  
Justin Singer
Keyword(s):  
Mechanical Thrombectomy ◽  
Perioperative Complications ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
First Pass Effect ◽  
Significant Difference ◽  
First Pass ◽  
Stent Retrievers ◽  
Complications And Mortality

Objectives: Our primary objective was to determine the successful rate of recanalization of M1 large vessel occlusion using either the Trevo 4 × 30 mm or 6 × 25 mm stent during mechanical thrombectomy. Our secondary objectives were to determine differences between the use of these two stent retrievers regarding first-pass effect, periprocedural complications, and mortality in the first 90 days.Methods: This is a retrospective cohort study. Data regarding the stent used, recanalization, number of passes, periprocedural complications, and mortality were determined via our mechanical thrombectomy database along with chart review.Conclusion: When comparing Trevo 4 × 30 mm to 6 × 25 mm stent retrievers used in mechanical thrombectomy for middle cerebral artery large-vessel occlusion causing stroke, there is no statistically significant difference in successful recanalization rates, first-pass effect, perioperative complications, or mortality at 90 days. Studies like this will hopefully lead to further prospective, randomized controlled trials that will help show experts in the field an additional way to perform this procedure effectively and safely.

Abstract 1122‐000175: Comparison of Transradial Artery Versus Transfemoral Artery Access Mechanical Thrombectomy at a Comprehensive Stroke Center

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Taha Nisar ◽  
Jimmy Patel ◽  
Amit Singla ◽  
Priyank Khandelwal
Keyword(s):  
Mechanical Thrombectomy ◽  
Retrospective Chart Review ◽  
Functional Independence ◽  
Binary Logistic Regression Analysis ◽  
Transfemoral Approach ◽  
Outcome Parameters ◽  
Significant Difference ◽  
First Pass ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Introduction : The transradial approach (TRA) is being increasingly adopted by neuro‐interventionists and has emerged as an alternative to the traditional transfemoral approach (TFA) for mechanical thrombectomy (MT). We aim to compare various time, technical and outcome parameters in patients who undergo MT via TRF vs. TRA approach. Methods : We performed a retrospective chart review of patients who underwent MT at a comprehensive stroke center from 7/2016 to 12/2020. We compared patients who underwent MT via TRA vs. TRF with respect to time from angio suite arrival to puncture, first pass, second pass and recanalization; time from puncture to first pass, second pass and recanalization; time from arrival to the emergency department (ED) to puncture, first pass, second pass and recanalization; the number of passes, rate of switching, achievement of TICI≥2b score, functional independence (3‐month mRS≤2), 3‐month mortality and neurological improvement (improvement in NIHSS by ≥4 points) on day 1 and 3. A binary logistic regression analysis was performed, controlling for age, sex, NIHSS, type of anesthesia (general vs. moderate), laterality, and location of clot (internal carotid or middle cerebral artery), ASPECTS≥6, presenting mean arterial pressure, blood glucose, Hb A1C, LDL, intravenous alteplase. Results : 217 patients met our inclusion criteria. The mean age was 64.09±14.4 years. 42 (19.35%) patients underwent MT through the TRA approach. There was a significantly higher rate of conversion from TRA approach to TRF approach (11.90% vs.2.28%; OR, 105.59; 95% CI,5.71‐1954.67; P 0.002), but no difference in various time, technical and outcome parameters, as shown in the table. Conclusions : Our study demonstrates no significant difference between TRA and TRF approaches with respect to various time, technical and outcome parameters, with a notable exception of a significantly higher rate of conversion from TRA to TRF approach.

Abstract P562: The Safety Of Mechanical Thrombectomy In Nonagenarians In A Majority Hispanic Population

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Nura Salhadar ◽  
WONDWOSSEN TEKLE ◽  
Amrou Sarraj ◽  
Ameer E Hassan
Keyword(s):  
Primary Outcome ◽  
Mechanical Thrombectomy ◽  
Statistical Significance ◽  
Hispanic Population ◽  
Vessel Occlusion ◽  
Border Communities ◽  
Baseline Characteristics ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
The Impact

Background and objective: Elderly patients were underrepresented in RCTs that proved the efficacy and safety of mechanical thrombectomy (MT) in acute ischemic strokes (AIS) due to large vessel occlusion (LVO). Additionally, the impact of race and socio-economics in AIS outcomes is well-reported. We sought to assess MT clinical outcomes in Hispanic Octogenarians and Nonagenarians that reside in underserved border communities. Methods: A retrospective cohort study from a prospectively collected comprehensive stroke center database was conducted. The primary outcome was discharge (mRS 0-2). Secondary outcomes were NIHSS improvement ≥4 points at discharge, sICH, mortality and length of stay (LOS). A two-tailed t-test assessed statistical significance between the two groups. Results: Of 202 included patients, 172 (85%) were octogenarians and 30 nonagenarians (17%). Nonagenarians had higher rates of females (80% vs 59%; p<0.05), similar rates of Hispanics (57% vs. 63%, p-xx) and a trend towards higher NIHS (20 vs. 17, P=0.09). Other baseline characteristics were similar (Table 1). Time last known well to arrival to MT center and to recanalization were longer in octogenarians, all other time metrics did not differ. Nonagenarians had numerically lower favorable outcomes at discharge (7% vs. 16%, p=0.11) as compared to octogenarians. Rates of clinical improvement on NIHSS were similar (27% vs. 23%, p=0.74). Mortality (23% vs. 28%, p=0.63) and sICH (7% vs 4%, p=0.46), octogenarians and nonagenarians, respectively. Octogenarians trended towards longer LOS (10 vs 6 days, p=0.05). Conclusions: Both groups had lower favorable good outcome rates than MT outcomes reported in RCTs. Nonagenarians had numerically lower favorable outcomes but mortality and sICH were similar. Further studies are warranted to further assess the impact of age and socioeconomics on MT outcomes.

Increased incidence and treatment of intracranial atherosclerotic disease during mechanical thrombectomy is safe, even with an increased number of passes

2021 ◽  
pp. neurintsurg-2020-017114
Author(s):  
Marlon Carl Monayao ◽  
Ahmed A Malik ◽  
Laurie Preston ◽  
Marlon Carl Monayao Sr ◽  
Wondwossen Tekle ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Atherosclerotic Disease ◽  
Vessel Occlusion ◽  
Intracranial Atherosclerotic Disease ◽  
Significant Difference ◽  
Artery Disease ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Angioplasty And Stenting ◽  
Number Of Passes

BackgroundThe incidence of intracranial atherosclerotic disease (ICAD) in acute ischemic stroke treated with mechanical thrombectomy (MT) is not well defined, and its description may lead to improved stroke devices and rates of first pass success.MethodsA retrospective study was performed on MT patients from 2012 to 2019 at a comprehensive stroke center using chart review and angiogram analysis. Angiograms at the time of MT were reviewed for ICAD, and location and severity were recorded. Patients with ICAD were divided according to ICAD location relative to the large vessel occlusion (LVO) site. Statistical analyses were performed on baseline demographics, comorbidities, MT procedure variables, outcome variables, and their association with ICAD.ResultsOf the 533 patients (mean age 70.4 (SD 13.20) years, 43.5% women), 131 (24.6%) had ICAD. There was no significant difference in favorable discharge outcomes (modified Rankin Scale score of 0–2; 23.8% ICAD vs 27.0% non-ICAD; p=0.82) or groin puncture to recanalization times (average 43.5 (range 8–181) min for ICAD vs 40.2 (4–204) min for non-ICAD; p=0.42). Patients with ICAD experienced a significantly higher number of passes (average 1.8 (range 1–7) passes for ICAD vs 1.6 (1–5) passes for non-ICAD; p=0.0059). Adjusting for age, ≥3 device passes, baseline National Institutes of Health Stroke Scale, rates of angioplasty only, rates of concurrent angioplasty and stenting, coronary artery disease and atrial fibrillation incidences, and time from emergency department arrival to recanalization, yielded no significant difference in rates of favorable outcomes between the two groups.ConclusionPatients who underwent MT with underlying ICAD had similar rates of favorable outcomes as those without, but required a higher number of device passes.

First pass effect in patients with large vessel occlusion strokes undergoing neurothrombectomy: insights from the Trevo Retriever Registry

2021 ◽  
pp. neurintsurg-2020-016952
Author(s):  
Ashutosh P Jadhav ◽  
Shashvat M Desai ◽  
Ronald F Budzik ◽  
Rishi Gupta ◽  
Blaise Baxter ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Basilar Artery ◽  
Artery Occlusion ◽  
Large Vessel ◽  
Basilar Artery Occlusion ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Single Pass ◽  
First Pass Effect ◽  
First Pass

BackgroundFirst pass effect (FPE), defined as near-total/total reperfusion of the territory (modified Thrombolysis in Cerebral Infarction (mTICI) 2c/3) of the occluded artery after a single thrombectomy attempt (single pass), has been associated with superior safety and efficacy outcomes than in patients not experiencing FPE.ObjectiveTo characterize the clinical features, incidence, and predictors of FPE in the anterior and posterior circulation among patients enrolled in the Trevo Registry.MethodsData were analyzed from the Trevo Retriever Registry. Univariate and multivariable analyses were used to assess the relationship of patient (demographics, clinical, occlusion location, collateral grade, Alberta Stroke Program Early CT Score (ASPECTS)) and device/technique characteristics with FPE (mTICI 2c/3 after single pass).ResultsFPE was achieved in 27.8% (378/1358) of patients undergoing anterior large vessel occlusion (LVO) thrombectomy. Multivariable regression analysis identified American Society of Interventional and Therapeutic Neuroradiology (ASITN) levels 2–4, higher ASPECTS, and presence of atrial fibrillation as independent predictors of FPE in anterior LVO thrombectomy. Rates of modified Rankin Scale (mRS) score 0–2 at 90 days were higher (63.9% vs 53.5%, p<0.0006), and 90-day mortality (11.4% vs 12.8%, p=0.49) was comparable in the FPE group and non-FPE group. Rate of FPE was 23.8% (19/80) among basilar artery occlusion strokes, and outcomes were similar between FPE and non-FPE groups (mRS score 0–2, 47.4% vs 52.5%, p=0.70; mortality 26.3% vs 18.0%, p=0.43). Notably, there were no difference in outcomes in FPE versus non-FPE mTICI 2c/3 patients.ConclusionTwenty-eight percent of patients undergoing anterior LVO thrombectomy and 24% of patients undergoing basilar artery occlusion thrombectomy experience FPE. Independent predictors of FPE in anterior circulation LVO thrombectomy include higher ASITN levels, higher ASPECTS, and the presence of atrial fibrillation.

Abstract P488: The Impact of First Pass Effect on Acute Ischemic Stroke Clinical Outcomes: Why We Need to Continue to Improve Mechanical Thrombectomy?

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Ameer E Hassan ◽  
Mahmoud Dibas ◽  
Amr Ehab El-Qushayri ◽  
Sherief Ghozy ◽  
Adam A Dmytriw ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Clinical Outcomes ◽  
Mechanical Thrombectomy ◽  
Functional Independence ◽  
Vessel Occlusion ◽  
First Pass Effect ◽  
Improved Outcomes ◽  
First Pass ◽  
The Impact

Background: Mechanical thrombectomy (MT) has significantly improved outcomes of acute ischemic stroke (AIS) patients due to large vessel occlusion (LVO). The first-pass effect (FPE), defined as achieving complete reperfusion (mTICI3/2c) with a single pass, was reported to be associated with higher functional independence rates following EVT and has been emphasized as an important procedural target. We compared MT outcomes in patients who achieved FPE to those who did not in a real world large database. Method: A retrospective analysis of LVO pts who underwent MT from a single center prospectively collected database. Patients were stratified into those who achieved FPE and non-FPE. The primary outcome (discharge and 90 day mRS 0-2) and safety (sICH, mortality and neuro-worsening) were compared between the two groups. Results: Of 580 pts, 261 (45%) achieved FPE and 319 (55%) were non-FPE. Mean age was (70 vs 71, p=0.051) and mean initial NIHSS (16 vs 17, p=0.23) and IV tPA rates (37% bs 36%, p=0.9) were similar between the two groups. Other baseline characteristics were similar. Non-FPE pts required more stenting (15% vs 25%, p=0.003), and angioplasty (19% vs 29%, p=0.01). The FPE group had significantly more instances of discharge (33% vs 17%, p<0.001), and 90-day mRS score 0-2 (29% vs 20%, p<0.001), respectively. Additionally, the FPE group had a significant lower mean discharge NIHSS score (12 vs 17, p<0.001). FPE group had better safety outcomes with lower mortality (14.2% vs 21.6%, p=0.03), sICH (5.7% vs 13.5, p=0.004), and neurological worsening (71.3% vs 78.4%, p=0.02), compared to the non-FPE group. Conclusion: Patients with first pass complete or near complete reperfusion with MT had higher functional independence rates, reduced mortality, symptomatic hemorrhage and neurological worsening. Improvement in MT devices and techniques is vital to increase first pass effect and improve clinical outcomes.

Abstract P263: Do Different Sites of Vessel Occlusion Dictate the Need for Intubation Prior to Endovascular Treatment and Have an Effect on Outcome?

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Ameer E Hassan ◽  
Victor M Ringheanu ◽  
Raul G Nogueira ◽  
Laurie Preston ◽  
Adnan I Qureshi ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Functional Independence ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Number Of Patients ◽  
Baseline Characteristics ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Proven Method ◽  
Morbid Conditions

Introduction: Endovascular treatment (EVT) is a widely proven method to treat patients diagnosed with intracranial large vessel occlusion. In order to ensure patients safety prior to and during EVT, preprocedural intubation has been adopted in many centers as a means for airway protection and immobilization. However, the correlation between site of vessel occlusion, need for intubation, and outcomes, has not yet been established. Methods: Through the utilization of a prospectively collected database at a comprehensive stroke center between 2012-2020, demographics, co-morbid conditions, intracerebral hemorrhage, mortality rate, and functional independence outcomes were examined. The outcomes and sites of occlusion between patients receiving mechanical thrombectomy (MT) treated while intubated versus those treated under conscious sedation (CS) were compared. Results: Out of 625 patients treated with MT, a total of 218 (34.9%) were treated while intubated (average age 70.3 ± 13.7, 37.2% women), and 407 (65.1%) were treated while under CS (average age 70.3 ± 13.7, 47.7% women); see Table 1 for baseline characteristics and outcomes. A higher number of patients requiring intubation had an occlusion in the basilar versus those only requiring CS. No differences were noted in regard to the proportion of patients receiving intubation or CS when treated for RMCA, LMCA, or internal carotid artery occlusions. Conclusion: Intubation + MT was associated with significantly worsened outcomes in regard to recanalization rates, functional outcome, and mortality. In anterior circulation strokes, intubation in RMCA patients were found to have poorer clinical outcome. Higher rates of intubation were also found to be needed in patients with basilar occlusions. Further research is required to determine whether site of occlusion dictates the need for intubation, and whether intubation allows for favorable outcome between R and LMCA occlusions.

Abstract P548: Multiple Attempts Complete Reperfusion versus Single Pass Successful Reperfusion: A Sub-Analysis From the Select Study

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Ameer E Hassan ◽  
Spiros Blackburn ◽  
Michael G Abraham ◽  
Wondwossen G Tekle ◽  
Nirav Vora ◽  
...  
Keyword(s):  
Statistical Significance ◽  
Functional Independence ◽  
Multicenter Cohort Study ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Single Pass ◽  
First Pass ◽  
Baseline Characteristics ◽  
Similar Good ◽  
The Ideal

Introduction: Successful and fast reperfusion with endovascular thrombectomy (EVT) improves outcomes in acute ischemic strokes due to large vessel occlusion (LVO). While complete reperfusion (mTICI 3) is the ideal target, multiple passes could prolong EVT and increase complications likelihood without improving clinical outcomes. We hypothesized that pts with a single pass mTICI2b would have similar good outcomes to those with multiple passes mTICI3 with a better safety profile. Methods: From the prospective multicenter cohort study of imaging selection (SELECT), EVT pts who achieved mTICI2b and mTICI3 were stratified into those with single pass vs multiple passes. Functional independence rates at 90 day mRS and safety (sICH, neuro-worsening and mortality) were compared between pts with single pass mTICI 2b and multiple passes mTICI 3. Results: Of 361 pts enrolled, 285 received EVT, of those 70 (25%) achieved mTICI 2b and 159 (56%) mTICI 3. 89 (31%) achieved mTICI 3 with single pass, 70 (25%) with multiple passes, 33 (12%) had mTICI 2b with a single pass and 37 (13%) with multiple passes. Baseline characteristics were similar between the two groups except for larger perfusion deficit (Tmax >6s) volume in pts with multiple passes mTICI3 55 (25, 99) cc vs first pass mTICI 2b 43 (4, 79), p=0.047). Functional independence rates were higher with single pass mTICI 2b as compared to multiple passes mTICI 3 (70% vs 56%, aOR=1.51, 95% CI=0.48-4.76, p=0.78), fig 1 but did not reach statistical significance. Multiple passes mTICI 3 was associated with numerically higher mortality (13% vs 3%, p=0.16) and Neuro-worsening (13% vs 3%, p=0.16) with similar sICH: 4% vs 3%, p=1.00 rates. Conclusion: Complete reperfusion with multiple passes did not confer better outcome rates than single pass mTICI 2b and was associated with worse safety profiles. These results suggest that in the absence of complete reperfusion on first attempt, a single pass mTICI 2b may be sufficient for a successful thrombectomy.

Abstract 1122‐000091: Predictors of Symptomatic Hemorrhagic Transformation After Mechanical Thrombectomy in Acute Ischemic Stroke

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Anqi Luo ◽  
Agnelio Cardenas ◽  
Lee A Birnbaum
Keyword(s):  
Risk Factors ◽  
Mechanical Thrombectomy ◽  
Standard Of Care ◽  
Hemorrhagic Transformation ◽  
Current Standard ◽  
Vessel Occlusion ◽  
Increased Risk ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Iv Tpa

Introduction : Mechanical thrombectomy (MT) has become the current standard of care for large vessel occlusion stroke but is associated with an increased risk of intracranial hemorrhage (ICH). Although several studies have investigated the risk factors, there is still limited, not well‐established data. This study aims to evaluate the risk factors of HT after MT. Methods : We retrospectively reviewed all MT patients who were treated at a single comprehensive stroke center from 12/2016 to 7/2019. Variables included initial NIHSS, blood glucose, initial systolic blood pressure, age, gender, IV tPA, time from door to recanalization, and TICI score. Outcome measures were HT on post‐procedure or 24‐hour post‐tPA head CT/MRI as well as modified Rankin scale (mRS) upon discharge. Results : Among 74 patients (68.8 ± 14 years, men 47.3%), 9 (12.2%) experienced hemorrhagic transformation after thrombectomy. Average admitting NIHSS was significantly higher in the HT group (22 vs 16.8, p = 0.041). TICI 3 after MT was protective for HT (OR 0.078, 95% CI 0.009‐0.663). IV tPA (OR 3.86, 95% CI 1.448‐10.326) was associated with good neurological outcome at discharge (mRS < = 2), but HT was not (OR 0.114, 95% CI 0.013‐0.964). Patients with mRS < = 2 upon discharge were younger (65.2±12 vs 71.9±15, p = 0.04) and had lower initial BG (124±45.8 vs 157±69.6, P = 0.02). Conclusions : TICI 3 score, decreased NIHSS, and lower BG were associated with less HT and better outcomes in our MT cohort. Admitting NIHSS > = 20 may be a reasonable threshold to predict HT after MT. Our findings are consistent with the TICI‐ASPECTS‐glucose (TAG) score to predict sICH; however, we used initial NIHSS as a surrogate for ASPECTS. Further studies may utilize additional quantitative measures such as CTP data to predict HT.

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