Abstract 1122‐000125: Underlying ICAD is Associated with Worse Outcome in Acute Large Vessel Occlusion Undergoing Endovascular Therapy

Introduction : Acute large vessel occlusion (LVO) can be secondary to thromboembolism or underlying intracranial atherosclerotic disease (ICAD). Data on the management of LVO due to underlying ICAD are scarce. We hypothesized that patients with ICAD would have worse clinical outcomes following mechanical thrombectomy (MT) than those without ICAD. Methods : We performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center between 01/2018 and 05/2021. Presence of underlying ICAD at the site of LVO was determined by the treating interventionalist. We compared outcomes including in‐hospital mortality and 90‐day modified Rankin Scale (mRS) between those with and without underlying ICAD, adjusting for relevant covariates using logistic regression. Results : Among 195 patients (mean age 67.4+15.1 years, 56.9% female, 81% black, median NIHSS score 15), underlying ICAD was present in 39 (20.0%). Stent‐retrievers were used 196 patients with only 3 having rescue stent placement. There were no significant differences in baseline factors amongst the two groups except diabetes was more common (69.2% vs. 49.7%, p = 0.028) and intravenous thrombolysis provided less often (17.9% vs. 36.5%, p = 0.027) in those with ICAD. TICI 2B or higher was achieved in 82.1% of ICAD compared with 94.3% of non‐ICAD patients (p = 0.012). Mortality was more common (50.0% vs. 30.8%, p = 0.025) and good functional outcome (mRS 0–2) at 90 days was less common (10.8% vs. 30.0%, p = 0.002) in the ICAD group. Adjusting for age, diabetes, intravenous thrombolysis, baseline NIHSS score, and final TICI score, underlying ICAD was an independent predictor of mRS 0–2 at 90 days (OR 4.5, 95% CI 1.4‐14.2, p = 0.010). Conclusions : Underlying ICAD is associated with 4.5‐fold increase in poor functional outcome in patients with LVO undergoing traditional MT. Further research is needed to understand factors associated with poor outcomes investigate alternative interventional approaches and medical management in this high‐risk population.

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A Case of Successful Intravenous Thrombolysis Bridged with Repeated Endovascular Treatment in Acute Basilar Artery Occlusion

Case Reports in Neurology ◽

10.1159/000507752 ◽

2020 ◽

Vol 12 (Suppl. 1) ◽

pp. 34-40

Author(s):

Binh Nguyen Pham ◽

Hoang Thi Phan ◽

Trung Quoc Nguyen ◽

Thang Huy Nguyen

Keyword(s):

Functional Outcome ◽

Basilar Artery ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

Large Vessel ◽

Arterial Blood Flow ◽

Basilar Artery Occlusion ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Nihss Score

Acute basilar artery occlusion (BAO) is a neurological emergency that has a high rate of mortality and poor functional outcome. Endovascular therapy (ET) is the gold standard therapy for large vessel occlusion stroke of the anterior circulation. Whether ET can also be effectively and safely performed in early recurrent large vessel occlusion, especially in BAO, is unclear. We describe a case of successful recanalization and independent functional outcome of a BAO patient treated with intravenous thrombolysis combined with repeated ET. The patients was a 32-year-old man with a history of heavy smoking and drinking who presented to the Emergency Department with dizziness and hypertension, and progressed over the next 13 h to left hemiparesis and mild dysarthria with an NIHSS score of 7. CT angiography demonstrated occlusion of the proximal basilar artery (BA). Intravenous alteplase was given followed by ET. The first intervention failed and over the next 8 h, the patient’s NIHSS score increased to 12. A second attempt with balloon angioplasty managed to reconstitute arterial blood flow with a severe residual stenosis of the proximal BA. Subsequently, the patient progressed into deep coma with reocclusion of the BA demonstrated on transcranial Doppler. A third intervention with emergent stenting resulted in complete recanalization of the BA and excellent neurological recovery. This patient received three endovascular treatments within 24 h due to reocclusion of the BA and achieved good outcomes. In conclusion, repeated ET for early recurrent BAO is feasible in carefully selected patients.

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Dabigatran Reversal Before Intravenous Tenecteplase in Acute Ischemic Stroke

Stroke ◽

10.1161/strokeaha.119.028327 ◽

2020 ◽

Vol 51 (5) ◽

pp. 1616-1619 ◽

Cited By ~ 2

Author(s):

James Beharry ◽

Michael J. Waters ◽

Roy Drew ◽

John N. Fink ◽

Duncan Wilson ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Scale Score ◽

Clinical Laboratory ◽

Intravenous Thrombolysis ◽

Interquartile Range ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion

Background and Purpose— Reversal of dabigatran before intravenous thrombolysis in patients with acute ischemic stroke has been well described using alteplase but experience with intravenous tenecteplase is limited. Tenecteplase seems at least noninferior to alteplase in patients with intracranial large vessel occlusion. We report on the experience of dabigatran reversal before tenecteplase thrombolysis for acute ischemic stroke. Methods— We included consecutive patients with ischemic stroke receiving dabigatran prestroke treated with intravenous tenecteplase after receiving idarucizumab. Patients were from 2 centers in New Zealand and Australia. We reported the clinical, laboratory, and radiological characteristics and their functional outcome. Results— We identified 13 patients receiving intravenous tenecteplase after dabigatran reversal. Nine (69%) were male, median age was 79 (interquartile range, 69–85) and median baseline National Institutes of Health Stroke Scale score was 6 (interquartile range, 4–21). Atrial fibrillation was the indication for dabigatran therapy in all patients. All patients had a prolonged thrombin clotting time (median, 80 seconds [interquartile range, 57–113]). Seven patients with large vessel occlusion were referred for endovascular thrombectomy, 2 of these patients (29%) had early recanalization with tenecteplase abrogating thrombectomy. No patients had parenchymal hemorrhage or symptomatic hemorrhagic transformation. Favorable functional outcome (modified Rankin Scale score, 0–2) occurred in 8 (62%) patients. Two deaths occurred from large territory infarction. Conclusions— Our experience suggests intravenous thrombolysis with tenecteplase following dabigatran reversal using idarucizumab may be safe in selected patients with acute ischemic stroke. Further studies are required to more precisely estimate the efficacy and risk of clinically significant hemorrhage.

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Balloon-mounted stents for acute intracranial large vessel occlusion secondary to presumed atherosclerotic disease: evolution in an era of supple intermediate catheters

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-014877 ◽

2019 ◽

Vol 11 (10) ◽

pp. 975-978 ◽

Cited By ~ 2

Author(s):

Bradley A Gross ◽

Shashvat M Desai ◽

Gregory Walker ◽

Brian Thomas Jankowitz ◽

Ashutosh Jadhav ◽

...

Keyword(s):

Large Vessel ◽

Atherosclerotic Disease ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Disease Evolution ◽

Nihss Score ◽

Good Outcome ◽

Intracranial Atherosclerotic Disease ◽

Primary Stenting ◽

Grade 3

IntroductionTreatment of acute large vessel occlusion (LVO) stroke secondary to intracranial atherosclerotic disease (ICAD) is more nuanced with disparate and infrequently reported outcomes. The deployment of balloon-mounted stents presents an expedient approach with renewed feasibility in the modern era of supple intermediate catheters.MethodsA prospectively maintained endovascular stroke database was searched for patients undergoing intracranial stenting with balloon-mounted stents for acute LVO. Demographic, angiographic, and clinical data were extracted to determine procedural technique and success, measured both angiographically and clinically.ResultsSixty patients underwent stenting for acute LVO secondary to ICAD. Mean presenting National Institutes of Health Stroke Scale (NIHSS) score was 18 and 62% of treated sites were in the posterior circulation. Cases were performed under IV conscious sedation unless the patient was already intubated. Successful recanalization was achieved in 93% of cases (Thrombolysis in Cerebral Infarction (TICI) grade 2b in 48% and TICI grade 3 in 45%). Mean improvement in NIHSS score on post-procedure day 1 was 3.4. Good outcome (modified Rankin Scale score 0–2) at 3 months was 34% and the mortality rate was 34%. The rate of peri-procedural symptomatic hemorrhage was 8% and the rate of acute/subacute stent thrombosis was 7%. In this small cohort, patient age, sex, presenting NIHSS, comorbidities, smoking, tissue plasminogen activator administration, and stent location were not significant predictors of recanalization or good outcome.ConclusionTreatment of acute LVO stroke with balloon-mounted stents for ICAD has reperfusion rates and clinical outcomes comparable to thrombectomy, with higher rates of hemorrhage and mortality. Because stent placement was performed after attempted thrombectomy, a trial of primary stenting versus thrombectomy should be considered in patients suspected of underlying ICAD.

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Treatment of Acute Ischemic Stroke due to Large Vessel Occlusion With COVID-19

Stroke ◽

10.1161/strokeaha.120.030574 ◽

2020 ◽

Vol 51 (8) ◽

pp. 2540-2543 ◽

Cited By ~ 33

Author(s):

Simon Escalard ◽

Benjamin Maïer ◽

Hocine Redjem ◽

François Delvoye ◽

Solène Hébert ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Intravenous Thrombolysis ◽

Stroke Onset ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Neurological Improvement ◽

Poor Outcomes

Background and Purpose: Higher rates of strokes have been observed in patients with coronavirus disease 2019 (COVID-19), but data regarding the outcomes of COVID-19 patients suffering from acute ischemic stroke due to large vessel occlusion (LVO) are lacking. We report our initial experience in the treatment of acute ischemic stroke with LVO in patients with COVID-19. Methods: All consecutive patients with COVID-19 with acute ischemic stroke due to LVO treated in our institution during the 6 first weeks of the COVID-19 outbreak were included. Baseline clinical and radiological findings, treatment, and short-term outcomes are reported. Results: We identified 10 patients with confirmed COVID-19 treated for an acute ischemic stroke due to LVO. Eight were men, with a median age of 59.5 years. Seven had none or mild symptoms of COVID-19 at stroke onset. Median time from COVID-19 symptoms to stroke onset was 6 days. All patients had brain imaging within 3 hours from symptoms onset. Five patients had multi-territory LVO. Five received intravenous alteplase. All patients had mechanical thrombectomy. Nine patients achieved successful recanalization (mTICI2B-3), none experienced early neurological improvement, 4 had early cerebral reocclusion, and a total of 6 patients (60%) died in the hospital. Conclusions: Best medical care including early intravenous thrombolysis, and successful and prompt recanalization achieved with mechanical thrombectomy, resulted in poor outcomes in patients with COVID-19. Although our results require further confirmation, a different pharmacological approach (antiplatelet or other) should be investigated to take in account inflammatory and coagulation disorders associated with COVID-19.

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Direct Intra-arterial thrombectomy in order to Revascularize AIS patients with large vessel occlusion Efficiently in Chinese Tertiary hospitals: A Multicenter randomized clinical Trial (DIRECT-MT)—Protocol

International Journal of Stroke ◽

10.1177/1747493019882837 ◽

2019 ◽

Vol 15 (6) ◽

pp. 689-698 ◽

Cited By ~ 3

Author(s):

Pengfei Yang ◽

Kilian M Treurniet ◽

Lei Zhang ◽

Yongwei Zhang ◽

Zifu Li ◽

...

Keyword(s):

Lower Boundary ◽

Intravenous Thrombolysis ◽

Large Vessel ◽

Atherosclerotic Disease ◽

Considerable Proportion ◽

Probe Design ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Intracranial Atherosclerotic Disease

Rationale Intravenous thrombolysis combined with mechanical thrombectomy (MT) has been proven safe and clinical effective in patients with acute ischemic stroke of anterior circulation large vessel occlusion. However, despite reperfusion, a considerable proportion of patients do not recover. Incidence of symptomatic intracerebral hemorrhage was similar between patients treated with the combination of intravenous thrombolysis and MT, as compared to intravenous thrombolysis alone, suggesting that this complication should be attributed to pre-treatment with intravenous thrombolysis. Conversely, intravenous thrombolysis may be beneficial in patients with small clots occluding intracranial arteries with underlying intracranial atherosclerotic disease, not accessible for MT. Aim To assess whether direct MT is non-inferior compared to combined intravenous thrombolysis plus MT in patients with AIS due to an anterior circulation large vessel occlusion, and to assess treatment effect modification by presence of intracranial atherosclerotic disease. Sample size Aim to randomize 636 patients 1:1 to receive direct MT (intervention) or combined intravenous thrombolysis plus MT (control). Design This is a multicenter, prospective, open label parallel group trial with blinded outcome assessment (PROBE design) assessing non-inferiority of direct MT compared to combined intravenous thrombolysis plus MT. Outcomes The primary outcome is the score on the modified Rankin Scale assessed blindly at 90 (±14) days. An common odds ratio, adjusted for the prognostic factors (age, NIHSS, collateral score), representing the shift on the 6-category mRS scale measured at three months, estimated with ordinal logistic regression, will be the primary effect parameter. Non-inferiority is established if the lower boundary of the 95% confidence interval does not cross 0.8. Discussion DIRECT-MT could result in improved therapeutic efficiency and cost reduction in treatment of anterior circulation large vessel occlusion stroke.

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Predictor of 90-day functional outcome after mechanical thrombectomy for large vessel occlusion stroke: NIHSS score of 10 or less at 24 hours

Journal of Neurosurgery ◽

10.3171/2019.10.jns191991 ◽

2019 ◽

pp. 1-7

Author(s):

Mirja M. Wirtz ◽

Philipp Hendrix ◽

Oded Goren ◽

Lisa A. Beckett ◽

Heather R. Dicristina ◽

...

Keyword(s):

Ischemic Stroke ◽

Functional Outcome ◽

Mechanical Thrombectomy ◽

Characteristic Curve ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Nihss Score ◽

Neurological Improvement ◽

Good Functional Outcome

OBJECTIVEMechanical thrombectomy is the established treatment for acute ischemic stroke due to large vessel occlusion (LVO). The authors sought to identify early predictors of a favorable outcome in stroke patients treated with mechanical thrombectomy.METHODSConsecutive patients with ischemic stroke due to LVO who underwent mechanical thrombectomy at a Comprehensive Stroke Center in the US between 2016 and 2018 were retrospectively reviewed. Demographics, stroke and treatment characteristics, as well as functional outcome at 90 days were collected. Clinical predictors of 90-day functional outcome were assessed and compared to existing indices for prompt neurological improvement. Analyses of area under the receiver operating characteristic curve were performed to estimate the optimal thresholds for absolute 24-hour and delta (change in) National Institutes of Health Stroke Scale (NIHSS) scores for functional outcome prediction.RESULTSA total of 156 patients (median age 71.5 years) underwent 159 mechanical thrombectomies. The M1 segment of the middle cerebral artery was the most frequent site of occlusion (57.2%). The median NIHSS score before thrombectomy was 18 (IQR 14–24). A postthrombectomy Thrombolysis in Cerebral Infarction score of 2B or 3 was achieved in 147 procedures (92.4%). The median NIHSS score 24 hours after thrombectomy was 14 (IQR 6–22). Good functional outcome at 90 days (modified Rankin Scale score 0–2) was achieved in 37 thrombectomies (23.9%). An absolute 24-hour NIHSS score ≤ 10 (OR 25.929, 95% CI 8.448–79.582, p < 0.001) and a delta NIHSS score ≥ 8 between baseline and 24 hours (OR 4.929, 95% CI 2.245–10.818, p < 0.001) were associated with good functional outcome at 90 days. The 24-hour NIHSS score cutoff of 10 outperformed existing indices for prompt neurological improvement in the ability to predict 90-day functional outcome.CONCLUSIONSAn NIHSS score ≤ 10 at 24 hours after mechanical thrombectomy was independently associated with good functional outcome at 90 days.

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Impact of intravenous thrombolysis on functional outcome in patients with mild ischemic stroke without large vessel occlusion or rapidly improving symptoms

International Journal of Stroke ◽

10.1177/1747493019874719 ◽

2019 ◽

Vol 15 (4) ◽

pp. 429-437 ◽

Cited By ~ 1

Author(s):

Marcellina Isabelle Haeberlin ◽

Ulrike Held ◽

Ralf W Baumgartner ◽

Dimitrios Georgiadis ◽

Philipp O Valko

Keyword(s):

Ischemic Stroke ◽

Functional Outcome ◽

Intravenous Thrombolysis ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion ◽

Early Improvement ◽

Treatment Type ◽

Best Medical Treatment

Background Optimal treatment strategy in patients with mild ischemic stroke remains uncertain. While functional dependency or death has been reported in up to one-third of non-thrombolyzed mild ischemic stroke patients, intravenous thrombolysis is currently not recommended in this patient group. Emerging evidence suggests two risk factors—rapid early improvement and large vessel occlusion—as main associates of unfavorable outcome in mild ischemic stroke patients not undergoing intravenous thrombolysis. Aims To analyze natural course as well as safety and three-month outcome of intravenous thrombolysis in mild ischemic stroke without rapid early improvement or large vessel occlusion. Methods Mild ischemic stroke was defined by a National Institute of Health Stroke Scale score ≤6. We used the modified Rankin Scale (mRS) to compare three-month functional outcome in 370 consecutive mild ischemic stroke patients without early rapid improvement and without large vessel occlusion, who either underwent intravenous thrombolysis (n = 108) or received best medical treatment (n = 262). Results Favorable outcome (mRS ≤ 1) was common in both groups (intravenous thrombolysis: 91%; no intravenous thrombolysis: 90%). Although intravenous thrombolysis use was independently associated with a higher risk of asymptomatic hemorrhagic transformation (OR = 4.62, p = 0.002), intravenous thrombolysis appeared as an independent predictor of mRS = 0 at three months (OR = 3.33, p < 0.0001). Conclusions Mild ischemic stroke patients without rapidly improving symptoms and without large vessel occlusion have a high chance of favorable three-month outcome, irrespective of treatment type. Patients receiving intravenous thrombolysis, however, more often achieved complete remission of symptoms, which particularly in mild ischemic stroke may constitute a meaningful endpoint.

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Endovascular therapy in patients with large vessel occlusion due to cardioembolism versus large-artery atherosclerosis

Therapeutic Advances in Neurological Disorders ◽

10.1177/1756286421999017 ◽

2021 ◽

Vol 14 ◽

pp. 175628642199901

Author(s):

Meredeth Zotter ◽

Eike I. Piechowiak ◽

Rupashani Balasubramaniam ◽

Rascha Von Martial ◽

Kotryna Genceviciute ◽

...

Keyword(s):

Heart Failure ◽

Endovascular Therapy ◽

Independent Predictor ◽

Intravenous Thrombolysis ◽

Stent Retriever ◽

Large Vessel ◽

Large Artery ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Significant Difference

Background and aims: To investigate whether stroke aetiology affects outcome in patients with acute ischaemic stroke who undergo endovascular therapy. Methods: We retrospectively analysed patients from the Bernese Stroke Centre Registry (January 2010–September 2018), with acute large vessel occlusion in the anterior circulation due to cardioembolism or large-artery atherosclerosis, treated with endovascular therapy (±intravenous thrombolysis). Results: The study included 850 patients (median age 77.4 years, 49.3% female, 80.1% with cardioembolism). Compared with those with large-artery atherosclerosis, patients with cardioembolism were older, more often female, and more likely to have a history of hypercholesterolaemia, atrial fibrillation, current smoking (each p < 0.0001) and higher median National Institutes of Health Stroke Scale (NIHSS) scores on admission ( p = 0.030). They were more frequently treated with stent retrievers ( p = 0.007), but the median number of stent retriever attempts was lower ( p = 0.016) and fewer had permanent stent placements ( p ⩽ 0.004). Univariable analysis showed that patients with cardioembolism had worse 3-month survival [72.7% versus 84%, odds ratio (OR) = 0.51; p = 0.004] and modified Rankin scale (mRS) score shift ( p = 0.043) and higher rates of post-interventional heart failure (33.5% versus 18.5%, OR = 2.22; p < 0.0001), but better modified thrombolysis in cerebral infarction (mTICI) score shift ( p = 0.025). Excellent (mRS = 0–1) 3-month outcome, successful reperfusion (mTICI = 2b–3), symptomatic intracranial haemorrhage and Updated Charlson Comorbidity Index were similar between groups. Propensity-matched analysis found no statistically significant difference in outcome between stroke aetiology groups. Stroke aetiology was not an independent predictor of favourable mRS score shift, but lower admission NIHSS score, younger age and independence pre-stroke were (each p < 0.0001). Stroke aetiology was not an independent predictor of heart failure, but older age, admission antithrombotics and dependence pre-stroke were (each ⩽0.027). Stroke aetiology was not an independent predictor of favourable mTICI score shift, but application of stent retriever and no permanent intracranial stent placement were (each ⩽0.044). Conclusion: We suggest prospective studies to further elucidate differences in reperfusion and outcome between patients with cardioembolism and large-artery atherosclerosis.

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Endovascular treatment for AIS with underlying ICAD

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012529 ◽

2016 ◽

Vol 9 (10) ◽

pp. 948-951 ◽

Cited By ~ 34

Author(s):

Sami Al Kasab ◽

Zayed Almadidy ◽

Alejandro M Spiotta ◽

Aquilla S Turk ◽

M Imran Chaudry ◽

...

Keyword(s):

Functional Outcomes ◽

National Institutes Of Health ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Nihss Score ◽

Intracranial Atherosclerotic Disease ◽

Significant Difference ◽

Procedural Complications ◽

Angioplasty And Stenting

BackgroundAcute large vessel occlusion (LVO) can result from thromboemboli or underlying intracranial atherosclerotic disease (ICAD). Although the technique for revascularization differs significantly for these two lesions (simple thrombectomy for thromboemboli and balloon angioplasty and stenting for ICAD), the underlying etiology is often unknown in acute ischemic stroke (AIS).ObjectiveTo evaluate whether procedural complications, revascularization rates, and functional outcomes differ among patients with LVO from ICAD or thromboembolism.MethodsA retrospective review of thrombectomy cases from 2008 to 2015 was carried out for cases of AIS due to underlying ICAD. Thirty-six patients were identified. A chart and imaging review was performed to determine revascularization rates, periprocedural complications, and functional outcomes. Patients with ICAD and acute LVO were compared with those with underlying thromboemboli.ResultsAmong patients with ICAD and LVO, mean National Institutes of Health Stroke Scale (NIHSS) score on admission was 12.9±8.5, revascularization (Thrombolysis In Cerebral Infarction, TICI ≥2b) was achieved in 22/34 (64.7%) patients, 11% had postprocedural intracerebral hemorrhage (PH2), and 14/33 (42.4%) had achieved a modified Rankin Scale (mRS) score of 0–2 at the 3-month follow-up. Compared with patients without underlying ICAD, there was no difference in NIHSS on presentation, or in the postprocedural complication rate. However, procedure times for ICAD were longer (98.5±59.8 vs 37.1±34.2 min), there was significant difference in successful revascularization rate between the groups (p=0.001), and a trend towards difference in functional outcome at 3 months (p=0.07).ConclusionsDespite AIS with underlying ICAD requiring a more complex, technically demanding recanalization strategy than traditional thromboembolic AIS, it appears safe, and good outcomes are obtainable.

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