scholarly journals Expanding indications for endovascular thrombectomy-how to leave no patient behind

2021 ◽  
Vol 14 ◽  
pp. 175628642199890
Author(s):  
Peter B. Sporns ◽  
Jens Fiehler ◽  
Johanna Ospel ◽  
Apostolos Safouris ◽  
Uta Hanning ◽  
...  
Keyword(s):  
Pediatric Patients ◽  
Time Window ◽  
Current Knowledge ◽  
Intravenous Thrombolysis ◽  
Standard Of Care ◽  
Primary Therapy ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Current Guidelines ◽  
Distal Vessel

Endovascular thrombectomy (EVT) has become standard of care for large vessel occlusion strokes but current guidelines exclude a large proportion of patients from this highly effective treatment. This review therefore focuses on expanding indications for EVT in several borderline indications such as patients in the extended time window, patients with extensive signs of infarction on admission imaging, elderly patients and patients with pre-existing deficits. It also discusses the current knowledge on intravenous thrombolysis as an adjunct to EVT and EVT as primary therapy for distal vessel occlusions, for tandem occlusions, for basilar artery occlusions and in pediatric patients. We provide clear recommendations based on current guidelines and further literature.

scholarly journals Mobile Interventional Stroke Teams Improve Outcomes in the Early Time Window for Large Vessel Occlusion Stroke

Stroke ◽  
2021 ◽  
Author(s):  
Jacob R. Morey ◽  
Xiangnan Zhang ◽  
Naoum Fares Marayati ◽  
Stavros Matsoukas ◽  
Emily Fiano ◽  
...  
Keyword(s):  
Scale Score ◽  
Time Window ◽  
Early Time ◽  
National Institutes Of Health ◽  
Large Vessel ◽  
Late Time ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy

Background and Purpose: Endovascular thrombectomy for large vessel occlusion stroke is a time-sensitive intervention. The use of a Mobile Interventional Stroke Team (MIST) traveling to Thrombectomy Capable Stroke Centers to perform endovascular thrombectomy has been shown to be significantly faster with improved discharge outcomes, as compared with the drip-and-ship (DS) model. The effect of the MIST model stratified by time of presentation has yet to be studied. We hypothesize that patients who present in the early window (last known well of ≤6 hours) will have better clinical outcomes in the MIST model. Methods: The NYC MIST Trial and a prospectively collected stroke database were assessed for patients undergoing endovascular thrombectomy from January 2017 to February 2020. Patients presenting in early and late time windows were analyzed separately. The primary end point was the proportion with a good outcome (modified Rankin Scale score of 0–2) at 90 days. Secondary end points included discharge National Institutes of Health Stroke Scale and modified Rankin Scale. Results: Among 561 cases, 226 patients fit inclusion criteria and were categorized into MIST and DS cohorts. Exclusion criteria included a baseline modified Rankin Scale score of >2, inpatient status, or fluctuating exams. In the early window, 54% (40/74) had a good 90-day outcome in the MIST model, as compared with 28% (24/86) in the DS model ( P <0.01). In the late window, outcomes were similar (35% versus 41%; P =0.77). The median National Institutes of Health Stroke Scale at discharge was 5.0 and 12.0 in the early window ( P <0.01) and 5.0 and 11.0 in the late window ( P =0.11) in the MIST and DS models, respectively. The early window discharge modified Rankin Scale was significantly better in the MIST model ( P <0.01) and similar in the late window ( P =0.41). Conclusions: The MIST model in the early time window results in better 90-day outcomes compared with the DS model. This may be due to the MIST capturing high-risk fast progressors at an earlier time point. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03048292.

scholarly journals Stroke Care During the First and the Second Waves of the COVID-19 Pandemic in a Community Hospital

2021 ◽  
Vol 12 ◽  
Author(s):  
Piotr Sobolewski ◽  
Wiktor Szczuchniak ◽  
Danuta Grzesiak-Witek ◽  
Jacek Wilczyński ◽  
Karol Paciura ◽  
...  
Keyword(s):  
Retrospective Study ◽  
Stroke Unit ◽  
Community Hospital ◽  
Intravenous Thrombolysis ◽  
Stroke Care ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Staff Members ◽  
Second Wave

Objective: The coronavirus disease 2019 (COVID-19) infection may alter a stroke course; thus, we compared stroke course during subsequent pandemic waves in a stroke unit (SU) from a hospital located in a rural area.Methods: A retrospective study included all patients consecutively admitted to the SU between March 15 and May 31, 2020 (“first wave”), and between September 15 and November 30, 2020 (“second wave”). We compared demographic and clinical data, treatments, and outcomes of patients between the first and the second waves of the pandemic and between subjects with and without COVID-19.Results: During the “first wave,” 1.4% of 71 patients were hospitalized due to stroke/TIA, and 41.8% of 91 during the “second wave” were infected with SARS-CoV-2 (p &lt; 0.001). During the “second wave,” more SU staff members were infected with COVID-19 than during the “first wave” (45.6 vs. 8.7%, p &lt; 0.001). Nevertheless, more patients underwent intravenous thrombolysis (26.4 vs. 9.9%, p &lt; 0.008) and endovascular thrombectomy (5.3 vs. 0.0%, p &lt; 0.001) during the second than the first wave. Large vessel occlusion (LVO) (OR 8.74; 95% CI 1.60–47.82; p = 0.012) and higher 30-day mortality (OR 6.01; 95% CI 1.04–34.78; p = 0.045) were associated with patients infected with COVID-19. No differences regarding proportions between ischemic and hemorrhagic strokes and TIAs between both waves or subgroups with and without COVID-19 existed.Conclusion: Despite the greater COVID-19 infection rate among both SU patients and staff during the “second wave” of the pandemic, a higher percentage of reperfusion procedures has been performed then. COVID-19 infection was associated with a higher rate of the LVO and 30-day mortality.

Abstract TMP13: Tenecteplase versus Alteplase Before Endovascular Therapy in Basilar Artery Occlusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Fana Alemseged ◽  
Volker Puetz ◽  
Gregoire Boulouis ◽  
Alessandro Rocco ◽  
Timothy Kleinig ◽  
...  
Keyword(s):  
Basilar Artery ◽  
Endovascular Therapy ◽  
Primary Outcome ◽  
Intravenous Thrombolysis ◽  
Artery Occlusion ◽  
Basilar Artery Occlusion ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Randomized Controlled ◽  
Repeat Imaging

Background: Tenecteplase (TNK) is a genetically modified variant of alteplase with greater fibrin specificity and longer half-life than alteplase. The recent Tenecteplase versus Alteplase before Endovascular Therapy for Ischemic Stroke (EXTEND-IA TNK) trial demonstrated that increased reperfusion with TNK compared to alteplase prior to endovascular thrombectomy (EVT) in large vessel occlusion ischaemic strokes. However, only 6 patients with basilar artery occlusion (BAO) were included. We aimed to investigate the efficacy of TNK versus alteplase before EVT in patients with basilar artery occlusion (BAO). Methods: Clinical and procedural data of consecutive BAO diagnosed on CT Angiography or MR Angiography from the multisite international Basilar Artery Treatment and MANagement (BATMAN) collaboration were retrospectively analysed. The primary outcome was reperfusion of greater than 50% of the involved ischemic territory or absence of retrievable thrombus at the time of the initial angiographic assessment. Results: We included 119 BAO patients treated with intravenous thrombolysis prior to EVT; mean age 68 (SD 14), median NIHSS 16 (IQR 7-32). Eleven patients were treated with TNK (0.25mg/kg or 0.4mg/kg) and 108 with alteplase (0.9mg/kg). Overall, 113 patients had catheter angiography or early repeat imaging after thrombolysis. Reperfusion of greater than 50% of the ischemic territory or absence of retrievable thrombus occurred in 4/11 (36%) of patients treated with TNK vs 8/102 (8%) treated with alteplase (p=0.02). Onset-to-needle time did not differ between the two groups (p=0.4). Needle-to-groin-puncture time was 61 (IQR 33-100) mins in patients reperfused with TNK vs 111 (IQR 86-198) mins in patients reperfused with alteplase (p=0.048). Overall, the rate of symptomatic haemorrhage was 3/119 (2.5%). No differences were found in the rate of symptomatic intracranial haemorrhage (p=0.3) between the two thrombolytic agents. Conclusions: Despite shorter needle-to-groin-puncture times, tenecteplase was associated with an increased rate of reperfusion in comparison with alteplase before EVT in BAO. Randomized controlled trials to compare tenecteplase with alteplase in BAO patients before endovascular thrombectomy are warranted.

Abstract WP280: A Potential Scoring System to Predict Infarct Progression During Inter Facility Transfer of Patients for Endovascular Thrombectomy Evaluation

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Sujan Teegala Reddy ◽  
Elliott Friedman ◽  
Tzu-Ching Wu ◽  
Xu Zhang ◽  
Jing Zhang ◽  
...  
Keyword(s):  
Systems Of Care ◽  
Youden Index ◽  
Coefficient Estimates ◽  
Anterior Circulation ◽  
Eligibility Criteria ◽  
Vessel Occlusion ◽  
Hub And Spoke ◽  
Endovascular Thrombectomy ◽  
Stroke Systems Of Care ◽  
Current Guidelines

Introduction: Current guidelines recommend CT ASPECTS≥6 as eligibility criteria for endovascular thrombectomy (EVT), a proven therapy for anterior circulation large vessel occlusion (ACLVO). Infarct progression during inter-facility transfer can render many patients ineligible for EVT. We developed a score utilizing clinical and imaging variables to predict infarct progression. Methods: Patients with ACLVO transferred from a referring hospital (RH) to our EVT capable center between August 2015 and December 2018 were reviewed. Significant predictors (p<0.10) of infarct progression, defined as CT ASPECTS of ≥6 at RH to <6 at hub, were identified using a logistic regression model. Regression coefficient estimates were used to score selected variables. The optimal cut-point was selected based on evaluated Youden index. Results: A total of 132 patients were analyzed. Score ranged from 0 to theoretical limit 18 (table 1): CTA collateral score (2/3/4=0, 0/1=3), Clot location (not ICA/M2=0, M2=2, ICA/M1=3), NIHSS (0-14=0, ≥15=5), use of antiplatelet by history (Yes=0, No=3), CT ASPECTS at RH (10=0, 6-9=2). Patients with score of ≥10.0 were more likely to have infarct progression (OR=22.15, 95% CI 4.99 - 98.35, p<0.001). Conclusions: Our score utilizing clinical and imaging variables provides information on which patients with ACLVO may undergo infarct progression during inter-facility transfer. We plan to externally validate our findings in another hub and spoke network. This score may potentially aid decisions to develop stroke systems of care to triage patients with ACLVO within hub and spoke networks.

Endovascular thrombectomy in pediatric patients with large vessel occlusion

2019 ◽  
Vol 11 (7) ◽  
pp. 729-732 ◽  
Author(s):  
Hazem Shoirah ◽  
Hussain Shallwani ◽  
Adnan H Siddiqui ◽  
Elad I Levy ◽  
Cynthia L Kenmuir ◽  
...  
Keyword(s):  
Pediatric Patients ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Transfemoral Approach ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Neurological Outcomes ◽  
First Pass ◽  
Procedural Complications ◽  
The Mean

BackgroundPediatric acute ischemic stroke with underlying large vessel occlusion is a rare disease with significant morbidity and mortality. There is a paucity of data about the safety and outcomes of endovascular thrombectomy in these cases, especially with modern devices.MethodsWe conducted a retrospective review of all pediatric stroke patients who underwent endovascular thrombectomy in nine US tertiary centers between 2008 and 2017.ResultsNineteen patients (63.2% male) with a mean (SD) age of 10.9(6) years and weight 44.6 (30.8) kg were included. Mean (SD) NIH Stroke Scale (NIHSS) score at presentation was 13.9 (5.7). CT-based assessment was obtained in 88.2% of the patients and 58.8% of the patients had perfusion-based assessment. All procedures were performed via the transfemoral approach. The first-pass device was stentriever in 52.6% of cases and aspiration in 36.8%. Successful revascularization was achieved in 89.5% of the patients after a mean (SD) of 2.2 (1.5) passes, with a mean (SD) groin puncture to recanalization time of 48.7 (37.3) min (median 41.5). The mean (SD) reduction in NIHSS from admission to discharge was 10.2 (6.2). A good neurological outcome was achieved in 89.5% of the patients. One patient had post-revascularization seizure, but no other procedural complications or mortality occurred.ConclusionsEndovascular thrombectomy is safe and feasible in selected pediatric patients. Technical and neurological outcomes were comparable to adult literature with no safety concerns with the use of standard adult devices in patients as young as 18 months. This large series adds to the growing literature but further studies are warranted.

Onset to Reperfusion Time Was Not Important in Mechanical Thrombectomy for Elderly Patients: A Retrospective Multicenter Study in Tama Area, Tokyo

2018 ◽  
Vol 46 (1-2) ◽  
pp. 89-96 ◽  
Author(s):  
Satoshi Koizumi ◽  
Takahiro Ota ◽  
Keigo Shigeta ◽  
Tatsuo Amano ◽  
Masayuki Ueda ◽  
...  
Keyword(s):  
Elderly Patients ◽  
Scale Score ◽  
Mechanical Thrombectomy ◽  
Treatment Strategies ◽  
Onset Time ◽  
Standard Of Care ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Factors Affecting ◽  
Good Outcome

Background: Mechanical thrombectomy (MT) has become the standard of care for acute ischemic stroke with large vessel occlusion; however, evidence remains insufficient for MT for elderly patients, especially with respect to factors affecting their outcomes. Methods: This study was a retrospective analysis of a multicenter registry of MT, called Tama Registry of Acute Endovascular Thrombectomy. Patients were divided by their age into 2 groups: Nonelderly (NE; < 80) and elderly (E; ≥80). Factors related to a good outcome (modified Rankin scale score ≤2) were examined in each group. Onset to reperfusion time (OTR) was stratified into 4 categories: category 1, 0 – ≤180 min; category 2, > 180 – ≤360 min; category 3, > 360 min or onset time not identified; and category 4, effective recanalization not achievable. Results: 143 NE patients and 78 E patients were included in this study. The E group had less chance of achieving a good outcome (NE group 51%, E group 35%; p = 0.024). In the NE group, lower OTR category was an independent prognostic factor for good outcome (p = 0.037, OR = 1.09). However, in the E group, OTR category was not a significant predictor on multivariate analysis. Instead, effective recanalization (p = 0.0081, OR 1.40) and lower National Institute of Health Stroke Scale score at presentation (p = 0.0032, OR 1.02) were the independent predictors. Conclusions: In MT for elderly patients, effective recanalization improved the patients’ outcome but OTR affected less. Further studies are warranted to establish the appropriate patient selection and treatment strategies.

Abstract 130: Is Intravenous Thrombolysis Far From Obsolete in the Era of Endovascular Thrombectomy? A Hint From a Meta-analysis of Randomized Clinical Trials

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Georgios Tsivgoulis ◽  
Aristeidis H Katsanos ◽  
Dimitris Mavridis ◽  
Anne W Alexandrov ◽  
Georgios Magoufis ◽  
...  
Keyword(s):  
Randomized Clinical Trials ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Bridging Therapy ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Systemic Thrombolysis ◽  
Shift Analysis ◽  
Ordinal Logistic Regression Analysis

Background & Purpose: Current AHA recommendations advocate that pretreatment with intravenous thrombolysis (IVT) should first be offered to all eligible acute ischemic stroke (AIS) patients with emergent large vessel occlusion (ELVO) before an endovascular thrombectomy (ET) procedure. Nevertheless, recent single-center observational studies question the utility of IVT pretreatment in ELVO patients eligible for systemic thrombolysis and advocate ET monotherapy. We sought to evaluate the comparative efficacy between ET and bridging therapy (IVT&ET) in AIS due to ELVO. Methods: We performed mixed-effects subgroup analyses, according to IVT pretreatment status of both functional independence [modified Rankin Scale (mRS) of 0-2)] and death/dependency (mRS of 5-6) at 90 days using available RCTs that evaluated the safety and efficacy of ET with stent-retrievers in comparison to standard therapy. We additionally performed an ordinal logistic regression analysis of individual patient data on the distribution of 3-month mRS scores (shift analysis) between the two groups. Results: We identified 7 eligible RCTs including 1764 ELVO patients (53% men), and 108 patients randomized to ET without IVT pretreatment. Patients receiving bridging therapy (BT) had lower rates (p=0.041) of 90-day death/dependency (19%, 95%CI: 14%-25%) compared to patients receiving only ET (31%, 95%CI: 21%-43%; Figure). Similarly, shift-analysis favored a trend for BT over ET in terms of better 90-day functional outcome (common OR=0.78, 95%CI: 0.53-1.10; p=0.155). Conclusion: Our findings indicate that pretreatment with IVT prior ET in ELVO patients may be associated with lower rates of three-month death/dependency and a trend towards more favorable functional outcomes. Until the results from head-to-head RCTs comparing BT to ET monotherapy become available, our findings support AHA guidelines recommending delivery of tPA to appropriate ELVO candidates undergoing ET.

Abstract TP28: Intravenous Thrombolysis is Associated With Better Functional Outcomes in Endovascular Thrombectomy Patients Requiring Multiple-Passes to Achieve Reperfusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Christopher Blair ◽  
Cecilia Cappelen-Smith ◽  
Dennis Cordato ◽  
Leon Edwards ◽  
Amer Mitchelle ◽  
...  
Keyword(s):  
Functional Outcomes ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Independent Effect ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Multiple Pass ◽  
First Pass

Introduction: In patients with anterior circulation stroke with large vessel occlusion (LVO), recent data suggest that successful reperfusion (mTICI≥2b) after a single device pass results in more favourable functional outcomes in comparison to patients requiring multiple passes. It is unclear if this effect represents an epiphenomenon or a true independent effect. Methods: A prospectively maintained database of EVT was interrogated for patients presenting with anterior circulation LVO with onset to groin puncture times of ≤ 6 hours from January 2016 to March 2019. Three-month functional outcomes were compared between first-pass reperfusion and multiple-pass reperfusion patients using logistic regression. Results: A total of 169 patients were identified (mean age 71 yrs, 44% female, median NIHSS 17, intravenous thrombolysis (IVT) in 47%). Successful reperfusion (mTICI≥2b) was achieved with the first-pass (FP) in 80 patients (47%) and multiple-passes (MP) in 89 patients (53%). First pass patients had better outcomes when compared to MP patients (mRS 0-2 71% vs 31%, p < 0.001). No difference in functional outcomes was seen between FP patients who received IVT and those that did not (mRS 0-2 68% vs 75%, p = 0.459). Multiple-pass patients who received IVT achieved higher rates of functional independence than those who did not (mRS 0-2 40% vs 27%, p = 0.035). Conclusion: Intravenous thrombolysis may improve functional recovery in EVT patients requiring multiple-passes to achieve reperfusion. Prospective studies should be considered.

'Drip-and-ship' intravenous thrombolysis and outcomes for large vessel occlusion thrombectomy candidates in a hub-and-spoke telestroke model

2021 ◽  
pp. neurintsurg-2021-017819
Author(s):  
Robert W Regenhardt ◽  
Joseph A Rosenthal ◽  
Amine Awad ◽  
Juan Carlos Martinez-Gutierrez ◽  
Neal M Nolan ◽  
...  
Keyword(s):  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Hub And Spoke ◽  
Endovascular Thrombectomy ◽  
Increased Risk ◽  
Intravenous Alteplase ◽  
Model Versus

BackgroundRandomized trials have not demonstrated benefit from intravenous thrombolysis among patients undergoing endovascular thrombectomy (EVT). However, these trials included primarily patients presenting directly to an EVT capable hub center. We sought to study outcomes for EVT candidates who presented to spoke hospitals and were subsequently transferred for EVT consideration, comparing those administered alteplase at spokes (i.e., ‘drip-and-ship’ model) versus those not.MethodsConsecutive EVT candidates presenting to 25 spokes from 2018 to 2020 with pre-transfer CT angiography defined emergent large vessel occlusion and Alberta Stroke Program CT score ≥6 were identified from a prospectively maintained Telestroke database. Outcomes of interest included adequate reperfusion (Thrombolysis in Cerebral Infarction (TICI) 2b–3), intracerebral hemorrhage (ICH), discharge functional independence (modified Rankin Scale (mRS) ≤2), and 90 day functional independence.ResultsAmong 258 patients, median age was 70 years (IQR 60–81), median National Institutes of Health Stroke Scale (NIHSS) score was 13 (6-19), and 50% were women. Ninety-eight (38%) were treated with alteplase at spokes and 113 (44%) underwent EVT at the hub. Spoke alteplase use independently increased the odds of discharge mRS ≤2 (adjusted OR 2.43, 95% CI 1.08 to 5.46, p=0.03) and 90 day mRS ≤2 (adjusted OR 3.45, 95% CI 1.65 to 7.22, p=0.001), even when controlling for last known well, NIHSS, and EVT; it was not associated with an increased risk of ICH (OR 1.04, 95% CI 0.39 to 2.78, p=0.94), and there was a trend toward association with greater TICI 2b–3 (OR 3.59, 95% CI 0.94 to 13.70, p=0.06).ConclusionsIntravenous alteplase at spoke hospitals may improve discharge and 90 day mRS and should not be withheld from EVT eligible patients who first present at alteplase capable spoke hospitals that do not perform EVT. Additional studies are warranted to confirm and further explore these benefits.

Intravenous Thrombolysis in Acute Ischemic Stroke

2018 ◽  
pp. 128-152
Author(s):  
Waldo R. Guerrero ◽  
Edgar A. Samaniego ◽  
Santiago Ortega
Keyword(s):  
Ischemic Stroke ◽  
Clinical Practice ◽  
Acute Ischemic Stroke ◽  
Symptom Onset ◽  
American Heart Association ◽  
American Heart ◽  
Time Window ◽  
Intravenous Thrombolysis ◽  
Heart Association ◽  
Standard Of Care

The only proven therapy for patients with acute ischemic stroke is early recanalization. The use of intravenous thrombolytic alteplase is the standard of care for patients presenting with ischemic stroke within the first 4.5 hours from symptom onset. This chapter reviews the indications and contraindications to alteplase including the 2015 American Heart Association guidelines and their relevance to clinical practice. Furthermore, emerging research and ongoing trials on expanding the time window for intravenous thrombolysis are discussed.

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