Abstract 1122‐000201: Is Neutrophilia a Risk Factor for Fast Stroke Progression in Large Vessel Occlusion?

Introduction : Rapid stroke progressors with large vessel occlusion (LVO) have a worse prognosis than their time‐matched cohorts receiving IV thrombolytics and/or mechanical thrombectomy. Our objective was to evaluate the association of neutrophilia with rapid stroke progression. Methods : Initial white blood cell (WBC) and absolute neutrophil counts (ANC) were collected for subjects presenting with acute ischemic stroke secondary to LVO who received IV thrombolytics and/or mechanical thrombectomy within 4.5 and 6 hours, respectively. Rapid stroke progression was determined by Alberta Stroke Program Early CT Score (ASPECTS) on initial CT head. Baseline and discharge NIHSS, age, and follow up mRS were also compared to presenting WBC and ANC. Spearman’s rho was used for correlation. Social Science Statistics was used for data analysis. Results : From October 2020 to April 2021, the association between neurophilia and stroke progression was evaluated in 19 subjects receiving tenecteplase (n = 16; 6 females; age, 63.25 95% CI [54.9207, 71.5793]) and alteplase (n = 4; 2 females; mean age 59, 95% CI [38.13, 79.87]) for LVO causing disabling neurological deficits. Mechanical thrombectomy was attempted in all subjects. The association between higher ANC and lower ASPECTS score reached statistical significance (rs = ‐0.49255, p = 0.04457). There was no significant association of white blood cell (WBC) and ASPECTS score. WBC and ANC were not associated with baseline or discharge NIHSS, age, or follow up mRS. Conclusions : Rapid stroke progression as measured by presenting ASPECTS score may be associated with neutrophilia. Larger prospective clinical trials are needed to validate our results.

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Abstract 1122‐000189: Is Neutrophilia a Risk Factor for Fast Stroke Progression in Large Vessel Occlusion?

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000189 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Jawad Kirmani ◽

Farah Fourcand ◽

Nancy Gadallah ◽

Arifa Ghori ◽

Danisette Torres ◽

...

Keyword(s):

Blood Cell ◽

White Blood Cell ◽

Mechanical Thrombectomy ◽

Statistical Significance ◽

Large Vessel ◽

Neurological Deficits ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Ct Head

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The Safety and Feasibility of Mechanical Thrombectomy for Mild Acute Ischemic Stroke With Large Vessel Occlusion

Neurosurgery ◽

10.1093/neuros/nyz354 ◽

2019 ◽

Vol 86 (6) ◽

pp. 802-807 ◽

Cited By ~ 1

Author(s):

Gabor Toth ◽

Santiago Ortega-Gutierrez ◽

Jenny P Tsai ◽

Russell Cerejo ◽

Sami Al Kasab ◽

...

Keyword(s):

Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Infarct Volume ◽

Invasive Procedure ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Symptomatic Intracerebral Hemorrhage ◽

Significant Difference

Abstract BACKGROUND Prospective evidence to support mechanical thrombectomy (MT) for mild ischemic stroke with large vessel occlusion (LVO) is lacking. There is uncertainty about using an invasive procedure in patients with mild symptoms. OBJECTIVE To evaluate the safety and feasibility of MT in patients with mild symptoms and LVO. METHODS Our single-arm prospective pilot study recruited patients with LVO and initial National Institute of Health Stroke Scale (NIHSS) <6, who underwent standard MT. Primary safety endpoints were symptomatic intracerebral hemorrhage (sICH), and/or worsening NIHSS by ≥4 points. Secondary endpoints included angiographic recanalization, NIHSS change, final infarct volume, and modified Rankin score (mRS). RESULTS We enrolled 20 patients (mean age 65.6 ± 12.3 yr; 45% females). Thrombolysis in Cerebral Ischemia 2B/3 thrombectomy was achieved in 95%. No patients suffered sICH. One patient (5%) had neurologic worsening within 24 h because of underlying intracranial stenosis. No other complications or safety concerns were identified. Median NIHSS was significantly better at discharge (0.5, P = .007) and at last follow-up (0, P < .001) than before treatment (3). Mean post vs preintervention infarct volumes were small without significant difference (1.2 ml, P = .434). Most patients (85%) were discharged directly home. Excellent clinical outcome (mRS 0-1) at last follow-up was seen in 95% of patients. CONCLUSION This is one of the first specifically designed prospective studies showing that MT is safe and feasible in patients with low NIHSS and LVO. Chronic underlying vasculopathy may be a challenging dilemma. We observed excellent clinical and radiographic outcomes, but randomized controlled trials are needed to demonstrate the efficacy of MT in this unique cohort.

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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 1122‐000220: Analysis of Protein Network to Predict Cognition Among Emergent Large Vessel Occlusion Undergoing Mechanical Thrombectomy

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000220 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Chintan Rupareliya ◽

Jacqueline A Frank ◽

Benton Maglinger ◽

Madison Sands ◽

Christopher J McLouth ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Large Vessel ◽

Minor Stroke ◽

Biological Processes ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion ◽

Severe Stroke ◽

Arterial Blood

Introduction : Emergent Large Vessel Occlusion (ELVO) strokes are devastating ischemic vascular events that can cause severe and permanent impairment. The purpose of the current study is to investigate interactions among different proteins at the time of mechanical thrombectomy (MT) which correlates to Montreal Cognitive Assessment (MOCA) scores at discharge and at 90‐day follow‐up. Methods : The Blood And Clot Thrombectomy Registry And Collaboration (BACTRAC) study is a continually enrolling tissue bank (clinicaltrials.gov NCT03153683) and registry from stroke patients undergoing mechanical thrombectomy. Blood samples from systemic arterial blood (internal carotid artery) of twenty‐three patients were collected and sent to Olink Proteomics (Olink Proteomics, Boston, Massachusetts, USA) for analysis of protein expression of 92 cardiometabolic proteins and 92 inflammatory proteins. To determine which proteins had the most significant changes based on MOCA scoring, a series of 184 paired t‐tests were performed. Within each panel, proteins were then ranked based on the associated p values. Benjamini and Hochberg’s linear step‐up procedure was used to control the false discovery rate at 0.05. Pearson Correlation revealed proteins that were significantly related to the patients’ s discharge MOCA score as well as 90‐day follow‐up MOCA. Data and network analyses were performed using IBM SPSS Statistics, SAS v 9.4, and STRING V11. Common proteins between the discharge day miniMoCA and 90 days MOCA were identified. Network of these protein associations was created and biological processes correlating with these networks were identified. Results : Twenty‐two patients (15 with discharge day MiniMOCA and 7 with 90 days MOCA) were included in the analysis. Of these patients, 14 were females, and 9 were obese (BMI>30). 2 had minor stroke (NIHSS: 1–4), 13 had moderate stroke at admission (NIHSS: 5–15), 4 had moderate to severe stroke (NIHSS: 16–20), and 2 patients had severe stroke (NIHSS > 21). 19 patients had associated comorbidities (hypertension, diabetes, and hyperlipidemia). Mean last known normal to thrombectomy completion time was 621 + 333 minutes and mean infarct volume was 18,271 + 16,534 mm3. The 9 overlapping proteins from discharge to 90‐day follow up were later analyzed using interconnected STRING to determine association network and proteomic biological functions. Nine proteins include: DPP4, NCAM1, TGFBI, PRCP, APOM, TIE1, QPCT, MEGF9, and IGFBP3. Biological processes relating to the network of 9 proteins are depicted in table 1. Conclusions : This study uncovers network proteins that play a significant role in cognitive outcomes following ischemic stroke. This will allow future studies to develop predictive biomarkers for treatment and proteomic targets for adjunctive therapies to thrombectomy to improve our ability to treat cognitive dysfunction in ELVO stroke patients.

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Repeated Mechanical Thrombectomy of Recurrent Large Vessel Occlusion: Case Report and Brief Review of the Literature

10.21203/rs.2.9227/v1 ◽

2019 ◽

Author(s):

Yun-Long Ding ◽

Ting-Ting Zhai ◽

Li Ma ◽

Zhi-Qun Gu ◽

Jia-Li Niu ◽

...

Keyword(s):

Anticoagulant Therapy ◽

Mechanical Thrombectomy ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vascular Events ◽

Vessel Occlusion ◽

Case Presentation ◽

Short Period ◽

Recurrent Strokes

Abstract Background Endovascular mechanical thrombectomy (MT) can significantly improve the prognosis of patients with Large Vessel Occlusion (LVO) stroke. It is still unclear whether it is safe and effective to perform MT again in patients with renal failure and atrial fibrillation (AF) in a short period of time. Case presentation We present the case of a LVO petients with concomitant AF and uremia who was successfully treated by MT for M1 segment occlusion of right middle cerebral artery (MCA) with good outcome. 15 days after the first MT, the patient's stroke recurred, angiography again revealed M1 segment and branch occlusion of right MCA, and repeated MT were performed. The recurrent strokes might attributed to no anticoagulant therapy. In an 4-months follow-up, no further vascular events occurred. Conclusions Repeated MT for recurrent LVO appears safe and effective. In patients with uremia and AF, it might be beneficial to give anticoagulant therapy after careful assessment of the patient's condition, which needs further evidence.

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Abstract TMP67: Impact of Pre-Hospital Stroke Alerts and Parallel Process on Door-to-Puncture Times in Large Vessel Occlusion

Stroke ◽

10.1161/str.48.suppl_1.tmp67 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Brijesh P Mehta ◽

Raul G Nogueira ◽

Mayank Goyal ◽

Bijoy K Menon ◽

Eric E Smith ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Standard Of Care ◽

Large Vessel ◽

Neurological Deficits ◽

Time Of Arrival ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Time To Treatment ◽

Early Activation ◽

The Impact

Background: Endovascular mechanical thrombectomy is now the standard of care for acute strokes with large vessel occlusion (LVO). Time to reperfusion is a significant predictor of favorable outcomes in strokes caused by LVO. Pre-hospital notification by Emergency Medical Services (EMS) and parallel in-hospital processes may reduce time to treatment. Methods: A single center stroke redesign initiative was launched with implementation of: 1) EMS pre-hospital stroke alerts comprised of last known well (LKW) time, neurological deficits, estimated time of arrival; 2) immediate notification of NeuroInterventionalist (NI) if presence of severe deficits (e.g., gaze preference, aphasia, hemiplegia); 3) early activation (i.e., pre-imaging) of cath lab team based on clinical judgement of NI. Results: A retrospective analysis was performed on 164 consecutive stroke patients transported by EMS who underwent mechanical thrombectomy for LVO from August 2014 to July 2016. The median NIHSS score was 17. Pre-hospital EMS stroke alerts were called in 80% (n=132) of treated patients. Among patients with EMS alerts, the NI was notified prior to imaging in 64% (n=80) of cases and the cath lab team was mobilized in parallel for 33 patients. The median door-to-puncture times for patients with EMS alerts + cath lab activation pre-imaging vs EMS alerts + cath lab activation post-imaging vs no EMS alerts were: 66, 79, and 100 minutes, respectively (p<0.05). The impact of field notification was even more pronounced after hours: median door-to-puncture time 76 minutes with EMS alerts (n=70) compared to 111 minutes without EMS alerts (n=21). For patients treated with bridging therapy (IV tPA + IA thrombectomy), the picture-to-puncture interval was notably shorter among patients with EMS alerts, 62 vs 80 minutes (p<0.05). Conclusion: We demonstrate a stroke system of care aimed to reduce time to treatment in patients with LVO. In the new era of mechanical thrombectomy, this is the first study to show feasibility and efficacy of pre-hospital EMS stroke alerts triggering early activation of the cath lab team in patients with possible LVO. Development of regional stroke protocols aligning EMS with efficient in-hospital processes are now a top priority.

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Progression of cerebral infarction before and after thrombectomy is modified by prehospital pathways

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-017155 ◽

2021 ◽

pp. neurintsurg-2020-017155

Author(s):

Alexander M Kollikowski ◽

Franziska Cattus ◽

Julia Haag ◽

Jörn Feick ◽

Alexander G März ◽

...

Keyword(s):

Patient Characteristics ◽

Large Vessel ◽

Stroke Severity ◽

Large Vessel Occlusion ◽

Time Intervals ◽

Vessel Occlusion ◽

Before And After ◽

Transferred Patients ◽

Stroke Center

BackgroundEvidence of the consequences of different prehospital pathways before mechanical thrombectomy (MT) in large vessel occlusion stroke is inconclusive. The aim of this study was to investigate the infarct extent and progression before and after MT in directly admitted (mothership) versus transferred (drip and ship) patients using the Alberta Stroke Program Early CT Score (ASPECTS).MethodsASPECTS of 535 consecutive large vessel occlusion stroke patients eligible for MT between 2015 to 2019 were retrospectively analyzed for differences in the extent of baseline, post-referral, and post-recanalization infarction between the mothership and drip and ship pathways. Time intervals and transport distances of both pathways were analyzed. Multiple linear regression was used to examine the association between infarct progression (baseline to post-recanalization ASPECTS decline), patient characteristics, and logistic key figures.ResultsASPECTS declined during transfer (9 (8–10) vs 7 (6-9), p<0.0001), resulting in lower ASPECTS at stroke center presentation (mothership 9 (7–10) vs drip and ship 7 (6–9), p<0.0001) and on follow-up imaging (mothership 7 (4–8) vs drip and ship 6 (3–7), p=0.001) compared with mothership patients. Infarct progression was significantly higher in transferred patients (points lost, mothership 2 (0–3) vs drip and ship 3 (2–6), p<0.0001). After multivariable adjustment, only interfacility transfer, preinterventional clinical stroke severity, the degree of angiographic recanalization, and the duration of the thrombectomy procedure remained predictors of infarct progression (R2=0.209, p<0.0001).ConclusionsInfarct progression and postinterventional infarct extent, as assessed by ASPECTS, varied between the drip and ship and mothership pathway, leading to more pronounced infarction in transferred patients. ASPECTS may serve as a radiological measure to monitor the benefit or harm of different prehospital pathways for MT.

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