Logistical and financial obstacles for endovascular therapy of acute stroke implementation

After publication of the recent positive randomized clinical endovascular trials, several questions and obstacles for wide spread implementation remain. We address specific issues namely efficacy, safety, logistics, timing, sedation, numbers, imaging, manpower, centers, geographics, and economical aspects of endovascular therapy. As we move forward, a high degree of collaboration will be crucial to implement a therapy with established overwhelming treatment efficacy for severe acute stroke patients.

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Abstract 180: The Growth Rate of Early DWI Lesions is Highly Variable and Associated with Penumbral Salvage and Clinical Outcomes Following Endovascular Reperfusion

Stroke ◽

10.1161/str.44.suppl_1.a180 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Hayley M Wheeler ◽

Michael Mlynash ◽

Manabu Inoue ◽

Aaryani Tipirneni ◽

John Liggins ◽

...

Keyword(s):

Growth Rate ◽

Acute Stroke ◽

Clinical Outcomes ◽

Endovascular Therapy ◽

Symptom Onset ◽

Growth Rates ◽

Initial Growth ◽

Stroke Patients ◽

Final Volume ◽

Favorable Clinical Response

Background: The degree of variability in the rate of early DWI expansion has not been well characterized. We hypothesized that Target Mismatch patients with slowly expanding DWI lesions have more penumbral salvage and better clinical outcomes following endovascular reperfusion than Target Mismatch patients with rapidly expanding DWI lesions. Methods: This substudy of DEFUSE 2 included all patients with a clearly established time of symptom onset. The initial DWI growth rate was determined from the baseline scan by assuming a volume 0 ml just prior to symptom onset. Target Mismatch patients who achieved reperfusion (>50% reduction in PWI after endovascular therapy), were categorized into tertiles according to their initial DWI growth rates. For each tertile, penumbral salvage (comparison of final volume to the volume of PWI (Tmax > 6 sec)/ DWI mismatch prior to endovascular therapy), favorable clinical response, and good functional outcome (see figure for definitions) were calculated. We also compared the growth rate in patients with the Target mismatch vs. Malignant Profile. Results: 64 patients were eligible for this study. Target mismatch patients (n=44) had initial growth rates (range 0 to 43 ml/hr, median of 3 ml/hr) that were significantly less than the growth rates in Malignant profile (n=7) patients (12 to 92 ml/hr, median 39 ml/hr; p < 0.001). In Target mismatch patients who achieved reperfusion (n=30), slower early DWI growth rates were associated with better clinical outcomes (p<0.05) and a trend toward more penumbral salvage (n=27, p=0.137). Conclusions: The growth rate of early DWI lesions in acute stroke patients is highly variable; Malignant profile patients have higher growth rates than other MRI profiles. Among Target Mismatch patients, a slower rate of DWI growth is associated with a greater degree of penumbral salvage and improved clinical outcomes following endovascular reperfusion.

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Different Levels of Ventilation Are a Plausible Explanation for Different Outcomes of Acute Stroke Patients Undergoing Endovascular Therapy

Anesthesiology ◽

10.1097/aln.0b013e318262567a ◽

2012 ◽

Vol 117 (3) ◽

pp. 683-683

Author(s):

E. Lynne Williams

Keyword(s):

Acute Stroke ◽

Endovascular Therapy ◽

Stroke Patients ◽

Different Levels

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Abstract W P11: A Clinical Scale to Predict Futile Arterial Recanalization in Acute Stroke Patients with Anterior Circulation Arterial Occlusion Treated with Endovascular Therapies.

Stroke ◽

10.1161/str.45.suppl_1.wp11 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Natalia Perez de la Ossa ◽

Maria Hernández-Pérez ◽

Monica Millán ◽

Meritxell Gomis ◽

Elena López-Cancio ◽

...

Keyword(s):

Acute Stroke ◽

Scale Score ◽

Endovascular Therapy ◽

Univariate Analysis ◽

Arterial Occlusion ◽

Stroke Patients ◽

Anterior Circulation ◽

History Of ◽

Stent Retrievers ◽

Arterial Recanalization

Introduction: Futile arterial recanalization (FAR), considered as a lack of functional recovery despite complete recanalization, is observed in up to 30-50% of acute stroke patients treated with endovascular therapy. We aimed to develop a prognostic scale based on baseline clinical and radiological factors to predict FAR. Methods: Prospective analysis of consecutive stroke patients with anterior circulation occlusion treated with endovascular therapy (97% mechanical thrombectomy with stent-retrievers). Complete recanalization was considered as a TICI 2b-3. FAR was defined as a modified Rankin scale >2 at 90 days in patients with complete recanalization. Baseline factors associated with FAR were detected on univariate analysis and were used to compose the predictive scale. Results: From a total of 229 patients with anterior arterial occlusion, 166 (72.5%) achieved complete recanalization. FAR was observed in 80/166 (48.2%). Factors significantly associated with FAR were included to compose the predictive scale as follow: Age (scoring 0 if ≤70 and 1 if >70 years old), history of diabetes mellitus (0 if absent, 1 if present), history of hypertension (0 if absent, 1 if present), NIHSS (1 if NIHSS ≤10, 2 if NIHSS 10-19, 3 if NIHSS>19), ASPECTS (1 if ASPECTS 9-10, 2 if ASPECTS 7-8, 3 if ASPECTS<7) and i.v tPA use (0 if yes, 1 if not). The higher the scale score, the higher the risk of FAR (Figure). The scale showed a good predictive value of FAR (c-statistics 0.71). A scale score <5 was associated with a low rate of FAR (25%) whereas a score >7 increased FAR up to 86%. Conclusion: We developed a simple scale that can easily predict futile arterial recanalization (FAR) in stroke patients with large arterial occlusion treated with endovascular therapies. A larger validation study is necessary to confirm the utility of this predictive scale.

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Abstract TP38: Re-Occlusion During Endovascular Therapy for Acute Stroke Patients With Large Vessel Occlusion

Stroke ◽

10.1161/str.50.suppl_1.tp38 ◽

2019 ◽

Vol 50 (Suppl_1) ◽

Author(s):

Qing Hao ◽

Jacob Morey ◽

Xiangnan Zhang ◽

Emily Chapman ◽

Reade DeLeacy ◽

...

Keyword(s):

Acute Stroke ◽

Endovascular Therapy ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion

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Good recanalization is associated with long term favorable outcomes in acute stroke patients with large vessel occlusion treated with endovascular therapy

Journal of the Neurological Sciences ◽

10.1016/j.jns.2020.117009 ◽

2020 ◽

Vol 416 ◽

pp. 117009

Author(s):

Masafumi Arakawa ◽

Kentaro Suzuki ◽

Akihito Kutsuna ◽

Takehiro Katano ◽

Takuya Kanamaru ◽

...

Keyword(s):

Acute Stroke ◽

Endovascular Therapy ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion

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Does General Anesthesia Compared With Conscious Sedation Result in Better Outcomes in Acute Stroke Patients Undergoing Endovascular Therapy?

The Neurologist ◽

10.1097/nrl.0000000000000318 ◽

2021 ◽

Vol 26 (2) ◽

pp. 47-51

Author(s):

Levi W. Howard ◽

Bart M. Demaerschalk ◽

Brian W. Chong ◽

Bernard R. Bendok ◽

David Gritsch ◽

...

Keyword(s):

Acute Stroke ◽

General Anesthesia ◽

Endovascular Therapy ◽

Conscious Sedation ◽

Stroke Patients

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Abstract TP180: Outcomes in the Elderly Post-Endovascular Therapy in a Community Setting

Stroke ◽

10.1161/str.51.suppl_1.tp180 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Mai N Nguyen-huynh ◽

Janet Alexander ◽

Catherine Lee ◽

Melissa Meighan ◽

Alexander Flint ◽

...

Keyword(s):

Acute Stroke ◽

Healthcare System ◽

Endovascular Therapy ◽

Community Setting ◽

The Elderly ◽

Study Cohort ◽

Stroke Patients ◽

Vessel Occlusion ◽

Integrated Healthcare ◽

Stroke Treatment

Background: Risks and benefits of thrombectomy in elderly stroke patients remained unclear. We evaluated outcomes in the elderly who underwent endovascular therapy (EST) in a large integrated healthcare system. Methods: In 2016, our integrated healthcare system launched a new standardized acute telestroke care workflow for all 21 stroke centers. It included immediate evaluation by a stroke neurologist via video, expedited IV alteplase treatment, rapid CT angiographic investigation, and expedited transfer and EST for patients with large vessel occlusion (LVO). From January 2016 through December 2018, our study cohort included adult members who had EST within our care system. We compared patient characteristics, door-to-needle (DTN) times, door-to-groin (DTG) times, inpatient and 90-day mortality between those treated with EST aged <80 to those ≥80 years. Multivariable logistic regression model was used to assess whether being ≥80 years was associated with a higher 90-day mortality adjusting for demographics, co-morbidities, and DTG time. Results: There were 291 acute stroke patients who underwent EST [Table]. The older subgroup had a higher percentage of female and higher rates of atrial fibrillation. They were more likely to arrive by EMS, to have a higher initial NIHSS and to have a faster DTN time. Average DTG times and inpatient mortality rates were not different between groups. The elderly had a higher rate of 90-day mortality. In multivariate model, being elderly was associated with higher 90-day mortality (OR=2.56, 95% CI 1.29-5.09, p=0.007). Conclusions: For those who underwent EST in a large community setting with a standardized approach to acute stroke treatment, being elderly was associated with a higher risk of 90-day mortality. Further data analyses are being carried out with additional co-morbidities, inpatient complications, and 90-day functional outcome to better understand outcomes in older patients undergoing EST.

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Duration of symptomatic stroke and successful reperfusion with endovascular thrombectomy for anterior circulation large vessel occlusive stroke

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016961 ◽

2021 ◽

pp. neurintsurg-2020-016961

Author(s):

Adam de Havenon ◽

Matthew D Alexander ◽

Raul G Nogueira ◽

Diogo C Haussen ◽

Alicia C Castonguay ◽

...

Keyword(s):

Logistic Regression ◽

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Large Vessel ◽

Stroke Patients ◽

Anterior Circulation ◽

First Pass ◽

Adjusted Logistic Regression

BackgroundIt has been reported that longer time intervals from stroke onset to endovascular therapy are associated with lower rates of successful reperfusion in acute ischemic stroke patients with large vessel occlusion. However, procedural variables and potential mechanisms of this association have not been fully elucidated.MethodsWe performed a secondary analysis of individual patient data from the North American Solitaire Stent Retriever Acute Stroke (NASA) and Trevo Stent-Retriever Acute Stroke (TRACK) registries. We included patients with occlusion of the internal carotid artery or middle cerebral artery (M1 and M2 segments) who were treated by mechanical thrombectomy within 24 hours of last known normal. The primary outcome was reperfusion, defined as a Thrombolysis In Cerebral Infarction (TICI) score ≥2b. The secondary outcome was reperfusion on the first pass. The primary predictor was duration of symptomatic stroke, defined as time from last known normal to time of final pass. Adjusted logistic regression models were utilized to determine associations between variables and outcome.ResultsWe included 506 patients, of which 401 (79.3%) achieved successful reperfusion (TICI 2b/3). The mean (SD) duration of symptomatic stroke was 6.8 (3.5) hours and in the adjusted logistic regression model the duration of symptomatic stroke was associated with reperfusion (OR 0.90, 95% CI 0.84 to 0.96) and reperfusion on the first pass (OR 0.89, 95% CI 0.83 to 0.95). In that model, the predicted probability of reperfusion was 88% (95% CI 0.83 to 0.92) at 1 hour, 81% (95% CI 0.78 to 0.84) at 6 hours, 70% (95% CI 0.63 to 0.77) at 12 hours, and 42% (95% CI 0.17 to 0.67) at 24 hours (ptrend=0.001). Reperfused patients were significantly younger, more likely to be male, and to have had a balloon guide catheter used during the procedure.ConclusionIn a real-world cohort of acute ischemic stroke patients with anterior circulation occlusion treated with endovascular therapy, longer duration of symptomatic stroke is associated with lower rates of successful reperfusion and reperfusion on the first pass.

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