Clot imaging characteristics predict first pass effect of aspiration—first approach to thrombectomy

2021 ◽  
pp. 159101992110191
Author(s):  
Muhammad Waqas ◽  
Weizhe Li ◽  
Tatsat R Patel ◽  
Felix Chin ◽  
Vincent M Tutino ◽  
...  
Keyword(s):  
Internal Carotid ◽  
Validation Cohort ◽  
Area Under The Curve ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
First Pass Effect ◽  
Imaging Characteristics ◽  
First Pass ◽  
Sensitivity Specificity ◽  
Youden’S Index

Background The value of clot imaging in patients with emergent large vessel occlusion (ELVO) treated with thrombectomy is unknown. Methods We performed retrospective analysis of clot imaging (clot density, perviousness, length, diameter, distance to the internal carotid artery (ICA) terminus and angle of interaction (AOI) between clot and the aspiration catheter) of consecutive cases of middle cerebral artery (MCA) occlusion and its association with first pass effect (FPE, TICI 2c-3 after a first attempt). Results Patients ( n = 90 total) with FPE had shorter clot length (9.9 ± 4.5 mm vs. 11.7 ± 4.6 mm, P = 0.07), shorter distance from ICA terminus (11.0 ± 7.1 mm vs. 14.7 ± 9.8 mm, P = 0.048), higher perviousness (39.39 ± 29.5 vs 25.43 ± 17.6, P = 0.006) and larger AOI (153.6 ± 17.6 vs 140.3 ± 23.5, P = 0.004) compared to no-FPE patients. In multivariate analysis, distance from ICA terminus to clot ≤13.5 mm (odds ratio (OR) 11.05, 95% confidence interval (CI) 2.65–46.15, P = 0.001), clot length ≤9.9 mm (OR 7.34; 95% CI 1.8–29.96, P = 0.005), perviousness ≥ 19.9 (OR 2.54, 95% CI 0.84–7.6, P = 0.09) and AOI ≥ 137°^ (OR 6.8, 95% CI 1.55–29.8, P = 0.011) were independent predictors of FPE. The optimal cut off derived using Youden’s index was 6.5. The area under the curve of a score predictive of FPE success was 0.816 (0.728–0.904, P < 0.001). In a validation cohort ( n = 30), sensitivity, specificity, positive and negative predictive value of a score of 6–10 were 72.7%, 73.6%, 61.5% and 82.3%. Conclusions Clot imaging predicts the likelihood of achieving FPE in patients with MCA ELVO treated with the aspiration-first approach.

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.

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.

scholarly journals Revalidation of the RACE scale after its regional implementation in Catalonia: a triage tool for large vessel occlusion

2018 ◽  
Vol 11 (8) ◽  
pp. 751-756 ◽  
Author(s):  
David Carrera ◽  
Montse Gorchs ◽  
Marisol Querol ◽  
Sònia Abilleira ◽  
Marc Ribó ◽  
...  
Keyword(s):  
Area Under The Curve ◽  
Its Region ◽  
Final Diagnosis ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Geographical Differences ◽  
Vessel Occlusion ◽  
Remote Areas ◽  
Direct Admission ◽  
Sensitivity Specificity

Background and purposeOur aim was to revalidate the RACE scale, a prehospital tool that aims to identify patients with large vessel occlusion (LVO), after its region-wide implementation in Catalonia, and to analyze geographical differences in access to endovascular treatment (EVT).MethodsWe used data from the prospective CICAT registry (Stroke Code Catalan registry) that includes all stroke code activations. The RACE score evaluated by emergency medical services, time metrics, final diagnosis, presence of LVO, and type of revascularization treatment were registered. Sensitivity, specificity, and area under the curve (AUC) for the RACE cut-off value ≥5 for identification of both LVO and eligibility for EVT were calculated. We compared the rate of EVT and time to EVT of patients transferred from referral centers compared with those directly presenting to comprehensive stroke centers (CSC).ResultsThe RACE scale was evaluated in the field in 1822 patients, showing a strong correlation with the subsequent in-hospital evaluation of the National Institute of Health Stroke Scale evaluated at hospital (r=0.74, P<0.001). A RACE score ≥5 detected LVO with a sensitivity 0.84 and specificity 0.60 (AUC 0.77). Patients with RACE ≥5 harbored a LVO and received EVT more frequently than RACE <5 patients (LVO 35% vs 6%; EVT 20% vs 6%; all P<0.001). Direct admission at a CSC was independently associated with higher odds of receiving EVT compared with admission at a referral center (OR 2.40; 95% CI 1.66 to 3.46), and symtoms onset to groin puncture was 133 min shorter.ConclusionsThis large validation study confirms RACE accuracy to identify stroke patients eligible for EVT, and provides evidence of geographical imbalances in the access to EVT to the detriment of patients located in remote areas.

scholarly journals Cerebral vessel anatomy as a predictor of first-pass effect in mechanical thrombectomy for emergent large-vessel occlusion

2020 ◽  
pp. 1-9 ◽  
Author(s):  
Shaarada Srivatsa ◽  
Yifei Duan ◽  
John P. Sheppard ◽  
Shivani Pahwa ◽  
Jonathan Pace ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Vessel Diameter ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
First Pass Effect ◽  
First Pass ◽  
Anatomical Parameters

OBJECTIVEMechanical thrombectomy is effective in acute ischemic stroke secondary to emergent large-vessel occlusion, but optimal efficacy is contingent on fast and complete recanalization. First-pass recanalization does not occur in the majority of patients. The authors undertook this study to determine if anatomical parameters of the intracranial vessels impact the likelihood of first-pass complete recanalization.METHODSThe authors retrospectively evaluated data obtained in 230 patients who underwent mechanical thrombectomy for acute ischemic stroke secondary to large-vessel occlusion at their institution from 2016 to 2018. Eighty-six patients were identified as having pure M1 occlusions, and 76 were included in the final analysis. The authors recorded and measured clinical and anatomical parameters and evaluated their relationships to the first-pass effect.RESULTSThe first-pass effect was achieved in 46% of the patients. When a single device was employed, aspiration thrombectomy was more effective than stent retriever thrombectomy. A larger M1 diameter (p = 0.001), decreased vessel diameter tapering between the petrous segment of the internal carotid artery (ICA) and M1 (p < 0.001), and distal collateral grading (p = 0.044) were associated with first-pass recanalization. LASSO (least absolute shrinkage and selection operator) was used to generate a predictive model for recanalization using anatomical variables.CONCLUSIONSThe authors demonstrated that a larger M1 vessel diameter, low rate of vessel diameter tapering along the course of the intracranial ICA, and distal collateral status are associated with first-pass recanalization for patients with M1 occlusions.

Abstract WP40: Balloon Guide Catheter Utilization With Continuous Aspiration Prior to Intracranial Vascular Embolectomy (BGC-CAPTIVE) Associated With Greater Recanalization

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Weiyi Le ◽  
Mahesh V Jayaraman ◽  
Grayson L Baird ◽  
Brian C Mac Grory ◽  
Tina M Burton ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Post Treatment ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
First Pass Effect ◽  
Guide Catheter ◽  
First Pass

Background: Among thrombectomy techniques, Continuous Aspiration Prior to Intracranial Vascular Embolectomy (CAPTIVE) is associated with higher rates of recanalization. Initially, CAPTIVE was performed without a balloon guide catheter (BGC). We aimed to determine the association between BGC usage with final recanalization as well as first pass effect in patients with anterior circulation emergent large vessel occlusion. Methods: We retrospectively reviewed consecutive patients with ICA and M1 occlusions treated with thrombectomy using CAPTIVE over a 45-month period. Post-treatment angiograms were scored by an experienced neurointerventionalist who was blinded to BGC usage and clinical outcome. For both BGC and non-BGC groups, we compared degree of recanalization (using the mTICI 2c scale), first-pass successful recanalization (mTICI 2c/3), and time to recanalization. We examined these results for all patients as well as based on clot location (ICA vs. M1). Results: 357 patients met criteria (median age: 73, median NIHSS: 17) for whom BGC was used in 37/70 (53%) with ICA and 116/287 (40%) with M1 occlusion. Odds of successful reperfusion increased 2.4-fold and odds of complete reperfusion increased 3-fold using BGC (both p<.01). Odds of successful first-pass recanalization (mTICI 2c/3) increased 5-fold for ICA occlusions (p=.004) and 1.7-fold for M1 (p=.03) (See Figure). Recanalization time with BGC for ICA occlusions was faster (22 vs. 36 min, p=.02) but there was no difference in time for M1 occlusions (24 vs. 26 min). Conclusions: BGC usage with the CAPTIVE technique is associated with higher recanalization rates, markedly higher first pass effect (mTICI 2c/3) for both ICA and M1 occlusions, and faster recanalization for ICA occlusions.

scholarly journals Novel Prehospital Triage Scale for Detecting Large Vessel Occlusion and Its Cause

2021 ◽  
Author(s):  
Jianan Wang ◽  
Xiaoxian Gong ◽  
Wansi Zhong ◽  
Ying Zhou ◽  
Min Lou
Keyword(s):  
Atrial Fibrillation ◽  
Predictive Value ◽  
Validation Cohort ◽  
Area Under The Curve ◽  
Large Vessel ◽  
Basilar Artery Occlusion ◽  
Youden Index ◽  
Large Vessel Occlusion ◽  
Characteristic Analysis ◽  
Vessel Occlusion

Background Patients with large vessel occlusion stroke (LVOS) need to be rapidly identified and transferred to comprehensive stroke centers. However, current prehospital evaluation and strategies still remain challenging. Methods and Results We retrospectively reviewed our prospectively collected database of patients with acute ischemic stroke (AIS). Based on the items of National Institutes of Health Stroke Scale and medical history that had a strong association with LVOS, we designed the 4‐item Stroke Scale (4I‐SS) and validated it in multi‐centers. The 4I‐SS incorporated gaze, level of consciousness, arm weakness, and atrial fibrillation. Receiver operating characteristic analysis was used to compare the 4I‐SS with previously established prehospital prediction scales. Finally, 1630 and 11 440 patients were included in the derivation and validation cohort, respectively. In the validation cohort, Youden Index, area under the curve, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the 4I‐SS≥4 to predict LVOS were 0.494, 0.800, 0.657, 0.837, 0.600, 0.868, and 0.788, respectively, and that of the 4I‐SS≥7 to predict basilar artery occlusion were 0.200, 0.669, 0.229, 0.971, 0.066, 0.974, and 0.899, respectively. Youden Index and area under the curve were higher than previously published scales for predicting LVOS. Further analysis showed that for predicting whether cardiogenic embolism was the cause, its accuracy was 0.922 when the 4I‐SS score, including atrial fibrillation, was ≥6, and its accuracy of predicting the occluded vessel was intracranial internal carotid artery or M1 segment of the middle cerebral artery when it was ≥7 was 0.590. Conclusions The 4I‐SS is an effective and simple tool that can identify LVOS and its cause. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03317639.

Feasibility and safety of the strategy of first stenting without retrieval using Solitaire FR as a treatment for emergent large-vessel occlusion due to underlying intracranial atherosclerosis

2021 ◽  
pp. 1-9
Author(s):  
Jong-Hoon Kim ◽  
Young-Jin Jung ◽  
Chul-Hoon Chang
Keyword(s):  
Functional Outcomes ◽  
Medical Center ◽  
Large Vessel ◽  
Intracranial Atherosclerosis ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Stent Retrieval ◽  
First Pass ◽  
Solitaire Fr

OBJECTIVEThe optimal treatment for underlying intracranial atherosclerosis (ICAS) in patients with emergent large-vessel occlusion (ELVO) remains unclear. Reocclusion during endovascular treatment (EVT) occurs frequently (57.1%–77.3%) after initial recanalization with stent retriever (SR) thrombectomy in ICAS-related ELVO. This study aimed to compare treatment outcomes of the strategy of first stenting without retrieval (FRESH) using the Solitaire FR versus SR thrombectomy in patients with ICAS-related ELVO.METHODSThe authors retrospectively reviewed consecutive patients with acute ischemic stroke and intracranial ELVO of the anterior circulation who underwent EVT between January 2017 and December 2019 at Yeungnam University Medical Center. Large-vessel occlusion (LVO) of the anterior circulation was classified by etiology as follows: 1) no significant stenosis after recanalization (embolic group) and 2) remnant stenosis > 70% or lesser degree of stenosis with a tendency toward reocclusion and/or flow impairment during EVT (ICAS group). The ICAS group was divided into the SR thrombectomy group (SR thrombectomy) and the FRESH group.RESULTSA total of 105 patients (62 men and 43 women; median age 71 years, IQR 62.5–79 years) were included. The embolic, SR thrombectomy, and FRESH groups comprised 66 (62.9%), 26 (24.7%), and 13 (12.4%) patients, respectively. There were no significant differences between the SR thrombectomy and FRESH groups in symptom onset–to-door time, but puncture-to-recanalization time was significantly shorter in the latter group (39 vs 54 minutes, p = 0.032). There were fewer stent retrieval passes but more first-pass recanalizations in the FRESH group (p < 0.001). Favorable functional outcomes were significantly more frequent in the FRESH group (84.6% vs 42.3%, p = 0.017).CONCLUSIONSThis study’s findings suggest that FRESH, rather than rescue stenting, could be a treatment option for ICAS-related ELVO.

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