Intraarterial urokinase for thrombus migration after mechanical thrombectomy for large vessel ischemic stroke

2021 ◽  
pp. 159101992110694
Author(s):  
Hiroaki Neki ◽  
Takehiro Katano ◽  
Takuma Maeda ◽  
Aoto Shibata ◽  
Hiroyuki Komine ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Functional Independence ◽  
Large Vessel ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Procedure Time ◽  
Vessel Occlusion ◽  
The Uk ◽  
Ultimate Purpose

Background Achieving rapid and complete reperfusion is the ultimate purpose for ischemic stroke with large vessel occlusion (LVO). Although mechanical thrombectomy (MT) had been a proverbially important procedure, medium vessel occlusion (MeVO) with thrombus migration can sporadically occur after MT. Moreover, the safe and effective approach for such had been unknown. We reported thrombolysis with intraarterial urokinase for MeVO with thrombus migration after MT. Methods We included 122 patients who were treated by MT with LVO stroke at our institution between April 2019 and March 2021. Of 26 patients (21.3%) who developed MeVO with thrombus migration after MT, 11 (9.0%) underwent additional MT (MT group) and 15 (12.3%) received intraarterial urokinase (UK group). The procedure time; angiographically modified Treatment in Cerebral Ischemia Scale (mTICI); functional independence, which was defined as modified Rankin Scale 0–2, on day 30 or upon discharge; and symptomatic and asymptomatic intracerebral hemorrhage (ICH) were compared between the UK and MT groups. Results The procedure time, mTICI, and asymptomatic ICH did not significantly differ between the groups. In the UK group, 8 of 15 (53.3%) patients obtained functional independence, and the functional independence rate was significantly higher in the UK group than in the MT group ( p < 0.05). Symptomatic ICH did not occur in the UK group, and its incidence was significantly smaller than that in the MT group ( p < 0.05). Conclusion The results of this study suggest that intraarterial urokinase for MeVO with thrombus migration after MT may safely improve angiographic reperfusion.

First Experience of Mechanical Thrombectomy Outcomes Without Bridging Technique: A 3-Year Retrospective Analysis

2019 ◽  
Vol 2 (2) ◽  
pp. 105-110
Author(s):  
Saima Ahmad ◽  
Umair Rashid Chaudhry ◽  
Ossama Yassin Mansour
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Retrospective Analysis ◽  
Mechanical Thrombectomy ◽  
Stent Retriever ◽  
Large Vessel ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Bridging Technique

Introduction: Mechanical thrombectomy has become the cornerstone and standard of care for acute stroke patients. Early reperfusion in patients experiencing acute ischemic stroke is the most important factor. The motivation behind this investigation is to display the aftereffects of mechanical thrombectomy in patients with large vessel occlusion in anterior and posterior circulation and to demonstrate that it lessens the level of handicap 3 months post stroke. Methods: A retrospective analysis was conducted of patients who presented with acute ischemic stroke at our center from 2015 to 2018 and received mechanical thrombectomy using combined manual aspiration with a stent retriever and with large bore catheters without the bridging technique. Result factors including recanalization rate and modified Rankin Scale at 90 days post procedure were assessed. An aggregate of 30 patients were included. Results: About 30 patients presented at the institute and met the inclusion criteria for the study. Successful recanalization (the Thrombolysis in Cerebral Infarction Score [TICI 2B]) was accomplished in 90% of patients, TICI 3 score was accomplished in 56% of the patients. 67% of the patients had good modified Rankin Scale score 0-2 result at 90 days. There were 3 symptomatic hemorrhages and 3 procedure and comorbidity-related deaths (10%). Conclusion: Mechanical thrombectomy using combined manual aspiration with a stent retriever and with large bore catheters alone without the bridging technique is an effective and safe procedure for endovascular revascularization of large vessel occlusion presenting with acute ischemic stroke.

scholarly journals Mismatch Profile Influences Outcome After Mechanical Thrombectomy

Stroke ◽  
2021 ◽  
Vol 52 (1) ◽  
pp. 232-240
Author(s):  
Jean-Marc Olivot ◽  
Jean-François Albucher ◽  
Adrien Guenego ◽  
Claire Thalamas ◽  
Michael Mlynash ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Clinical Response ◽  
Functional Recovery ◽  
Perfusion Imaging ◽  
Mechanical Thrombectomy ◽  
Large Vessel ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion

Background and Purpose: Mechanical thrombectomy (MT) is the recommended treatment for acute ischemic stroke caused by anterior circulation large vessel occlusion. However, despite a high rate of reperfusion, the clinical response to successful MT remains highly variable in the early time window where optimal imaging selection criteria have not been established. We hypothesize that the baseline perfusion imaging profile may help forecast the clinical response to MT in this setting. Methods: We conducted a prospective multicenter cohort study of patients with large vessel occlusion–related acute ischemic stroke treated by MT within 6 hours. Treatment decisions and the modified Rankin Scale evaluation at 3 months were performed blinded to the results of baseline perfusion imaging. Study groups were defined a posteriori based on predefined imaging profiles: target mismatch (TMM; core volume <70 mL/mismatch ratio >1.2 and mismatch volume >10 mL) versus no TMM or mismatch (MM; mismatch ratio >1.2 and volume >10 mL) versus no MM. Functional recovery (modified Rankin Scale, 0–2) at 3 months was compared based on imaging profile at baseline and whether reperfusion (modified Thrombolysis in Cerebral Infarction 2bc3) was achieved. Results: Two hundred eighteen patients (mean age, 71±15 years; median National Institutes of Health Stroke Scale score, 17 [interquartile range, 12–21]) were enrolled. Perfusion imaging profiles were 71% TMM and 82% MM. The rate of functional recovery was 54% overall. Both TMM and MM profiles were independently associated with a higher rate on functional recovery at 3 months Adjusted odds ratios were 3.3 (95% CI, 1.4–7.9) for TMM and 5.9 (95% CI, 1.8–19.6) for MM. Reperfusion (modified Thrombolysis in Cerebral Infarction 2bc3) was achieved in 86% and was more frequent in TMM and MM patients. Reperfusion was associated with a higher rate of functional recovery in MM and TMM patients but not among those with no MM. Conclusions: In this cohort study, about 80% of the patients with a large vessel occlusion–related acute ischemic stroke had evidence of penumbra, regardless of infarction volume. Perfusion imaging profiles predict the clinical response to MT.

Abstract 1122‐000206: Predictors of Hemorrhagic Transformation after Mechanical Thrombectomy in Large Vessel Occlusion Ischemic Stroke

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Vera Sharashidze ◽  
Vasu Saini ◽  
Amer Malik ◽  
Jose Romano
Keyword(s):  
Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Hemorrhagic Transformation ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Procedure Time ◽  
Inpatient Mortality ◽  
Vessel Occlusion ◽  
Symptomatic Intracranial Hemorrhage ◽  
Iv Tpa

Introduction : Stroke is a major cause of morbidity and mortality around the globe. Mechanical thrombectomy (MT) is the standard of care for patients with large vessel occlusion strokes. However, mechanical thrombectomy is associated with a number of complications. Symptomatic intracranial hemorrhage is one of the most feared complications of mechanical thrombectomy. In the pooled analysis of five trials, 4.4% of patients developed symptomatic intracranial hemorrhage. Treating physicians should have a good understanding of the potential complications of MT in order to optimize the safety and benefits of this procedure. Yet, the causes of hemorrhagic transformation are largely unknown and the predictors identified in previous studies vary. The goal of our study is to identify the rate and reliable predictors of radiological hemorrhagic transformation (RHT) and symptomatic hemorrhagic transformation (sICH) post mechanical thrombectomy in large vessel ischemic strokes. Methods : This was a retrospective analysis of consecutive large vessel occlusion acute ischemic stroke patients undergoing mechanical thrombectomy in a comprehensive stroke center (spanning 02/2015 ‐ 09/2018). Outcome measures included radiological hemorrhagic transformation (RHT) and symptomatic hemorrhagic transformation (sICH). sICH was defined as RHT with worsening of 4points in 24–36h NIHSS (ECASS II criteria) and by at least 1point (NINDS criteria).RHT was further classified according to Heidelberg‐bleeding classification as HI1, HI2, PH1, PH2, and SAH. Independent covariates predictive of RHT or symptomatic hemorrhage (sICH) were identified with multivariable logistic regression. Clinical opinion and the existing literature were used to reduce the number of variables collected at baseline to those considered potentially predictive of stroke progression. Results : Out of 341 patients who underwent thrombectomy, 32% had a radiological hemorrhagic transformation. The median age was 71. Smoking, IV tPA, longer procedure time, and lower TICI scores were associated with RHT. On a separate multivariate analysis, coronary artery disease was a separate predictor of hemorrhagic transformation. Patients with RHT had higher inpatient mortality and less mRs < 3 at discharge. Conclusions : RHT is associated with poor functional outcomes and inpatient mortality. Factors such as smoking, IV tPA, longer procedure time, and lower TICI scores were associated with RHT.

Abstract P500: Outcomes of Mechanical Thrombectomy in Patients With Low Aspects: Insights From Star

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Zachary Hubbard ◽  
Guilherme B Porto ◽  
Sami Al Kasab ◽  
Eyad Almallouhi ◽  
Alejandro M Spiotta ◽  
...  
Keyword(s):  
Logistic Regression Model ◽  
Mechanical Thrombectomy ◽  
Functional Independence ◽  
Large Vessel Occlusion ◽  
Procedure Time ◽  
Large Core ◽  
Common Site ◽  
Vessel Occlusion ◽  
Factors Associated ◽  
Core Infarct

Introduction: Patients with poor baseline images were excluded from most clinical trials so the data about whether these patients could benefit from MT remains unknown. In this study, we aim to investigate the safety and efficacy of MT in patients with large vessel occlusion (LVO) and large core infarct (LCI). Methods: The Stroke Thrombectomy and Aneurysm Registry (STAR) was interrogated. We included thrombectomy patients presenting with LVO within 24 hours and with a LCI as defined by Alberta Stroke Program Early CT Score (ASPECTS) < 6. Patients presenting within 6 hours of last known normal (LKN) were considered in the early window and patients presenting after 6 hours were considered in the late window. 90-day outcomes were assessed. We used a logistic regression model to assess the factors associated with good 90-day outcome in patients in the early and late windows. Results: 144 patients were included in this study (table). Median age was 69 and 92 (64%) patients were treated in the early MT window. ICA was the most common site of occlusion (48.6%) and ADAPT was used in 34.7%. Admission NIHSS was 17.5. Successful recanalization (TICI>2b) was achieved in 84.7% and median procedure time was 54 minutes. sICH hemorrhage was observed in 22 (15.3%). Median mRS was 4 at 90 days. Favorable outcome was observed in 41 patients (28.5%) and mortality occurred in in 59 (41%). There was no difference in 90-day functional outcome between patients in early and late windows. In patients presenting in the early window, age (aOR=0.905, p=0.0002) and baseline NIHSS (aOR=0.909, p=0.0423) were independently associated with 90-day outcome. In patients presenting in the late window, only age (aOR=0.934, p=0.0069) was independently associated with good outcome. Conclusion: More than one in four patients presenting with ASPECTS<6 may achieve functional independence at 90-day following MT. Patient age remains the main predictor of 90-day outcome in patients with low ASPECTS in both late and early windows.

scholarly journals Effect of Statin Administration After Onset of Acute Ischemic Stroke With Large Vessel Occlusion: Insights From RESCUE‐Japan Registry 2

2020 ◽  
Vol 9 (23) ◽  
Author(s):  
Kazutaka Uchida ◽  
Shinichi Yoshimura ◽  
Hirotoshi Imamura ◽  
Nobuyuki Ohara ◽  
Nobuyuki Sakai ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Odds Ratios ◽  
Vessel Occlusion ◽  
Statin Group ◽  
Younger Age

Background Statins have been associated with reduced recurrence and better functional outcomes in patients with acute ischemic stroke. However, the effect of statins in patients with acute large vessel occlusion (LVO) is not well scrutinized. Methods and Results RESCUE (Recovery by Endovascular Salvage for Cerebral Ultra‐Acute Embolism)‐Japan Registry 2, a physician‐initiated registry, enrolled 2420 consecutive patients with acute LVO who were admitted to 46 centers across Japan within 24 hours of onset. We compared patients with and without statin use after acute LVO onset (statin group and nonstatin group, respectively) in terms of the modified Rankin scale at 90 days. We estimated that the odds ratios for the primary outcome was modified Rankin scale and we estimated the odds ratios for a 1‐scale lower modified Rankin scale adjusting for confounders. After excluding 12 patients without LVO and 9 patients without follow‐up, the mean age of 2399 patients was 75.9 years; men accounted for 55% of patients. Statins were administered to 447 (19%) patients after acute LVO onset. Patients in the statin group had more atherothrombotic cerebral infarctions (34.2% versus 12.1%, P <0.0001), younger age (73.4 years versus 76.5 years, P <0.0001), and lower median National Institutes of Health Stroke Scale on admission (14 versus 17, P <0.0001) than the nonstatin group. The adjusted common OR of the statin group for lower modified Rankin scale was 1.29 (95% CI, 1.04–1.37; P =0.02). The mortality at 90 days was lower in the statin group (4.7%) than the nonstatin group (12.5%; P <0.0001). The adjusted OR of the statin group relative to the nonstatin group for mortality was 0.36 (95% CI, 0.21–0.62; P =0.02). Conclusions Statin administration after acute LVO onset is significantly associated with better functional outcome and mortality at 90 days.

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

Neurosurgery ◽  
2019 ◽  
Vol 86 (6) ◽  
pp. 802-807 ◽  
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) &lt;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 &lt; .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.

scholarly journals Mechanical Thrombectomy in Ischemic Stroke Patients With Alberta Stroke Program Early Computed Tomography Score 0–5

Stroke ◽  
2019 ◽  
Vol 50 (4) ◽  
pp. 880-888 ◽  
Author(s):  
Johannes Kaesmacher ◽  
Panagiotis Chaloulos-Iakovidis ◽  
Leonidas Panos ◽  
Pasquale Mordasini ◽  
Patrik Michel ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Intracerebral Hemorrhage ◽  
Mechanical Thrombectomy ◽  
Functional Independence ◽  
Favorable Outcome ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Symptomatic Intracerebral Hemorrhage

Background and Purpose— If anterior circulation large vessel occlusion acute ischemic stroke patients presenting with ASPECTS 0–5 (Alberta Stroke Program Early CT Score) should be treated with mechanical thrombectomy remains unclear. Purpose of this study was to report on the outcome of patients with ASPECTS 0–5 treated with mechanical thrombectomy and to provide data regarding the effect of successful reperfusion on clinical outcomes and safety measures in these patients. Methods— Multicenter, pooled analysis of 7 institutional prospective registries: Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the SOLITAIRE FR With the Intention for Thrombectomy (Clinical Trial Registration—URL: https://www.clinicaltrials.gov . Unique identifier: NCT03496064). Primary outcome was defined as modified Rankin Scale 0–3 at day 90 (favorable outcome). Secondary outcomes included rates of day 90 modified Rankin Scale 0–2 (functional independence), day 90 mortality and occurrence of symptomatic intracerebral hemorrhage. Multivariable logistic regression analyses were performed to assess the association of successful reperfusion with clinical outcomes. Outputs are displayed as adjusted Odds Ratios (aOR) and 95% CI. Results— Two hundred thirty-seven of 2046 patients included in this registry presented with anterior circulation large vessel occlusion and ASPECTS 0–5. In this subgroup, the overall rates of favorable outcome and mortality at day 90 were 40.1% and 40.9%. Achieving successful reperfusion was independently associated with favorable outcome (aOR, 5.534; 95% CI, 2.363–12.961), functional independence (aOR, 5.583; 95% CI, 1.964–15.873), reduced mortality (aOR, 0.180; 95% CI, 0.083–0.390), and lower rates of symptomatic intracerebral hemorrhage (aOR, 0.235; 95% CI, 0.062–0.887). The mortality-reducing effect remained in patients with ASPECTS 0–4 (aOR, 0.167; 95% CI, 0.056–0.499). Sensitivity analyses did not change the primary results. Conclusions— In patients presenting with ASPECTS 0–5, who were treated with mechanical thrombectomy, successful reperfusion was beneficial without increasing the risk of symptomatic intracerebral hemorrhage. Although the results do not allow for general treatment recommendations, formal testing of mechanical thrombectomy versus best medical treatment in these patients in a randomized controlled trial is warranted.

Presence of the hyperintense acute reperfusion marker on MRI after mechanical thrombectomy for large vessel occlusion is associated with worse early neurological recovery

2016 ◽  
Vol 9 (7) ◽  
pp. 641-643 ◽  
Author(s):  
Rishi Gupta ◽  
Chung-Huan Johnny Sun ◽  
Dustin Rochestie ◽  
Kumiko Owada ◽  
Ahmad Khaldi ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Reperfusion Injury ◽  
Mechanical Thrombectomy ◽  
Binary Logistic Regression ◽  
Functional Independence ◽  
Large Vessel ◽  
Neurological Recovery ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Nihss Score

BackgroundMechanical thrombectomy has become the accepted treatment for large vessel occlusion in acute ischemic stroke. Unfortunately, a large cohort of patients do not achieve functional independence with treatment, even though the results are more robust than with medical management. The hyperintense acute reperfusion marker (HARM) on MRI is an indication of the breakdown of the blood–brain barrier and reperfusion injury.ObjectiveTo examine the hypothesis that the presence of HARM on MRI correlates with worse neurological recovery after reperfusion therapy.MethodsWe retrospectively reviewed 35 consecutive patients who between February 24, 2016 and April 23, 2016 underwent MRI to determine the presence of HARM after thrombectomy for anterior circulation large vessel occlusion. Demographic, radiographic imaging, and outcome data were collected. Univariate and binary logistic regression models were performed to assess predictors for improvement of the National Institutes of Health Stroke Scale (NIHSS) score by ≥8 points at 24 hours.ResultsThe 35 patients studied had an average age of 64±14 years of age with a median NIHSS score of 15 (IQR 9–20). Eighteen patients (51%) were found to have a HARM-positive MRI. In univariate analysis, patients with HARM were older, had lower reperfusion rates and more postprocedural hemorrhages. In binary logistic regression modeling, the absence of HARM was independently associated with a ≥8-point NIHSS score improvement at 24 hours (OR=7.14, 95% CI 1.22 to 41.67).ConclusionsThis preliminary analysis shows that the presence of HARM may be linked to worse neurological recovery 24 hours after thrombectomy. Reperfusion injury may affect the number of patients achieving functional independence after treatment.

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