Safety and Outcomes of Thrombectomy in Ischemic Stroke With vs Without Intravenous Thrombolysis

Neurology ◽  
2021 ◽  
pp. 10.1212/WNL.0000000000012327
Author(s):  
Niaz Ahmed ◽  
Michael Mazya ◽  
Ana Paiva Nunes ◽  
Tiago Moreira ◽  
Jyrki P. Ollikainen ◽  
...  
Keyword(s):  
Cerebral Artery ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Artery Occlusion ◽  
Large Artery ◽  
Anterior Circulation ◽  
Stroke Disability ◽  
Artery First ◽  
Symptomatic Intracranial Hemorrhage ◽  
Residual Confounding

Objective:To test the hypothesis that intravenous thrombolysis (IVT) treatment prior to endovascular thrombectomy (EVT) is associated with better outcomes in patients with anterior circulation large artery occlusion (LAO) stroke, we examined a large real-world database, the SITS-International Stroke Thrombectomy Register (SITS-ISTR).Methods:We identified centers recording ≥10 consecutive patients in the SITS-ISTR, with at least 70% available modified Rankin Scale (mRS) scores at 3 months during 2014-19. We defined LAO as intracranial internal carotid artery, first and second segment of middle cerebral artery and first segment of anterior cerebral artery. Main outcomes were functional independence (mRS 0-2) and death at 3 months and symptomatic intracranial hemorrhage (SICH) per modified SITS-MOST. We performed propensity score matched (PSM) and multivariable logistic regression analyses.Results:Of 6350 patients from 42 centers, 3944 (62.1%) received IVT. IVT+EVT treated patients had less frequent atrial fibrillation, ongoing anticoagulation, previous stroke, heart failure and pre-stroke disability. PSM analysis showed that IVT+EVT patients had a higher rate of functional independence than EVT alone patients (46.4% vs. 40.3%, p<0.001) and a lower rate of death at 3 months (20.3% vs. 23.3%, p=0.035). SICH rates (3.5% vs. 3.0%, p= 0.42) were similar in both groups. Multivariate adjustment yielded results consistent with PSM.Interpretation:Pretreatment with IVT was associated with favorable outcomes in EVT-treated LAO stroke in the SITS Thrombectomy Registry. These findings, while indicative of international routine clinical practice, are limited by observational design, unmeasured confounding and possible residual confounding by indication.Classification of Evidence:This study provides Class II evidence that IVT prior to EVT increases the probability of functional independence at 3 months compared to EVT alone.

scholarly journals Impact of eloquent motor cortex-tissue reperfusion beyond the traditional thrombolysis in cerebral infarction (TICI) scoring after thrombectomy

2020 ◽  
pp. neurintsurg-2020-016834
Author(s):  
Radoslav Raychev ◽  
Hamidreza Saber ◽  
Jeffrey L Saver ◽  
Jason D Hinman ◽  
Scott Brown ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Motor Cortex ◽  
Cerebral Infarction ◽  
Cerebral Artery ◽  
Primary Motor Cortex ◽  
Anterior Circulation ◽  
Endovascular Thrombectomy ◽  
Stroke Disability ◽  
Symptomatic Intracranial Hemorrhage ◽  
The Impact

BackgroundTargeted eloquence-based tissue reperfusion within the primary motor cortex may have a differential effect on disability as compared with traditional volume-based (thrombolysis in cerebral infarction, TICI) reperfusion after endovascular thrombectomy (EVT) in the setting of acute ischemic stroke (AIS).MethodsWe explored the impact of eloquent reperfusion (ER) within primary motor cortex (PMC) on clinical outcome (modified Rankin Scale, mRS) in AIS patients undergoing EVT. ER-PMC was defined as presence of flow on final digital subtraction angiography (DSA) within four main cortical branches, supplying the PMC (middle cerebral artery (MCA) – precentral, central, postcentral; anterior cerebral artery (ACA) – medial frontal branch arising from callosomarginal or pericallosal arteries) and graded as absent (0), partial (1), and complete (2). Prospectively collected data from two centers were analyzed. Multivariate analysis was conducted to assess the impact of ER-PMC on 90-day disability (mRS) among patients with anterior circulation occlusion who achieved partial reperfusion (TICI 2a and 2b).ResultsAmong the 125 patients who met the study criteria, ER-PMC distribution was: absent (0) in 19/125 (15.2%); partial (1) in 52/125 (41.6%), and complete (2) in 54/125 (43.2%). TICI 2b was achieved in 102/125 (81.6%) and ER-PMC was substantially higher in those patients (P<0.001). In multivariate analysis, in addition to age and symptomatic intracranial hemorrhage, ER-PMC had a profound independent impact on 90-day disability (OR 6.10, P=0.001 for ER-PMC 1 vs 0 and OR 9.87, P<0.001 for ER-PMC 2 vs 0), while the extent of total partial reperfusion (TICI 2b vs 2a) was not related to 90-day mRS.ConclusionsEloquent PMC-tissue reperfusion is a key determinant of functional outcome, with a greater impact than volume-based (TICI) degree of partial reperfusion alone. PMC-targeted revascularization among patients with partial reperfusion may further diminish post-stroke disability after EVT.

Abstract TMP7: Blood Pressure Goal Post Mechanical Yhrombectomy for Anterior and Posterior Circulation Stroke: A Multicenter Registry Study

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Ming Yang ◽  
Xiaochuan Huo ◽  
Ning Ma ◽  
Feng Gao ◽  
Dapeng Mo ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Clinical Outcomes ◽  
Functional Independence ◽  
Artery Occlusion ◽  
Posterior Circulation ◽  
Blood Pressure Goal ◽  
Large Artery ◽  
Registry Study ◽  
Anterior Circulation ◽  
Posterior Circulation Stroke

Background and Purpose: The effect of blood pressure (BP) within 24 hours post-mechanical thrombectomy (MT) accounts on clinical outcomes for patients with successful reperfusion. We aimed to investigate the relationship between BP during 24 hours post-MT with clinical outcomes individually for anterior circulation stroke (ACS) or posterior circulation stroke (PCS) patients Method: Patients with successful recanalization and a full record of systolic BP (SBP) and diastolic BP (DBP) every two hours within 24 hours post-MT were included from the ANGEL study, a multi-centric, prospective registry study of endovascular treatment owing to proximal large-artery occlusion from June 2015 to December 2017. We divided patients into three groups based on maximum SBP: <140 (intensive), 140-160 (moderate) and <180 mmHg (permissive). Clinical outcomes included functional independence (modified Rankin Scale score 0-2), mortality at 90 days follow up and intracerebral hemorrhage (ICH). Results: 355 eligible patients were enrolled in this study. There were 162, 124, and 69 patients in the intensive, moderate, and permissive group, respectively. A 10mmHg increase of maximum SBP during the first 24 hours post-MT was independently associated with a lower likelihood of functional independence (OR=0.84 [0.75-0.94], p=0.001) at 90 days after adjusting for potential confounders. As to ACS, intensive SBP management was associated with higher odds of 90-day functional independence (OR=0.38 [0.18-0.79], p=0.010), compared with permissive SBP group. As to PCS, moderate SBP management was associated with lower odds of 90-day mortality, either compared with permissive or intensive SBP group. Conclusion: Higher maximum SBP post-MT was independently associated with a higher risk of poor clinical outcomes. Intensive SBP control may be more reasonable for patients with ACS, while moderate SBP is more beneficial for PCS. Although more randomized trials are needed.

NCCT and CTA-based imaging protocol for endovascular treatment selection in late presenting or wake-up strokes

2018 ◽  
Vol 11 (2) ◽  
pp. 200-203 ◽  
Author(s):  
Telma Santos ◽  
Andreia Carvalho ◽  
André Almeida Cunha ◽  
Marta Rodrigues ◽  
Tiago Gregório ◽  
...  
Keyword(s):  
Observational Study ◽  
Endovascular Treatment ◽  
Time Window ◽  
Functional Independence ◽  
Large Artery ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Imaging Protocol ◽  
Procedural Complications ◽  
Symptomatic Intracranial Hemorrhage

IntroductionRecently, the benefit of selecting patients for endovascular treatment (EVT) beyond the 6-hour time window using a tissue-based approach was demonstrated in two randomized trials. The optimal imaging protocol for selecting patients is under debate, and it is still unknown if a simpler and faster protocol may adequately select patients with wake-up stroke (WUS) and late-presenting stroke (LPS) for EVT.ObjectiveTo compare outcomes of patients submitted to EVT presenting within 6 hours of symptom onset or 6–24 hours after last seen well, selected using non-contrast computed tomography (NCCT) and CT angiography (CTA).MethodsAn observational study was performed, which included consecutive patients with anterior circulation ischemic stroke with large vessel occlusion treated with EVT. Patients presenting within 6 hours were treated if their NIH Stroke Scale (NIHSS) score was ≥6 and Alberta Stroke Program Early CT score (ASPECTS) was ≥6, while patients presenting with WUS or 6–24 hours after last seen well (WUS/LPS) were treated if their NIHSSscore was ≥12 and ASPECTS was ≥7.Results249 patients were included, 63 of whom were in the WUS/LPS group. Baseline characteristics were similar between groups, except for longer symptom-recanalization time, lower admission NIHSS (16 vs 17, P=0.038), more frequent tandem occlusions (25.4% vs 11.8%, P=0.010), and large artery atherosclerosis etiology (22.2% vs 11.8%, P=0.043) in the WUS/LPS group. No differences in symptomatic intracranial hemorrhage, peri-procedural complications or mortality were found between groups. Three-month functional independence was similar in both groups (65.1% in WUS/LPS vs 57.0% in ≤6 hours, P=0.259) and no differences were found after adjustment for confounders.ConclusionsThis real-world observational study suggests that EVT may be safe and effective in patients with WUS and LPS selected using clinical-core mismatch (high NIHSS/high ASPECTS in NCCT).

scholarly journals ENDOVASCULARAPPROACHES TOACUTE ISCHEMIC STROKE- INDIAN PERSPECTIVE

2020 ◽  
Vol 7 (3) ◽  
pp. 7-14
Author(s):  
Pramod Dhonde ◽  
N. Kadam
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intravenous Thrombolysis ◽  
Artery Occlusion ◽  
Review Literature ◽  
Large Artery ◽  
Stroke Event ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Indian Perspective

Aim: To review literature about endovascular approaches to acute ischemic stroke and provide Indian perspective about managing these cases. Brief Summary: In acute ischemic stroke cases, intravenous thrombolysis (IVT) with altepase within 4.5 hours has been the standard of care. Due to certain limitations of IVT, in pooled patientlevel data from 5 trials (HERMES [Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials], which included the 5 trials MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND-IA), mechanical thrombectomy (MT) is indicated for patients with acute ischemic stroke due to a large artery occlusion (LVO) in the anterior circulation who can be treated within 24 hours of the time last known to be well (ie, at neurologic baseline), regardless of whether they received intravenous alteplase for the same ischemic stroke event. The maximum benefit can be achieved within 6 hours of onset of symptoms. There are studies suggesting the benefit of MT in posterior circulation stroke as well as in distal arteries. We are going to review the methodology of endovascular techniques in brief alongwith Indian perspective on feasibility of this treatment approach in AIS. Conclusion: Mechnicalthrombectomy is certainly an effective modality of treatment in large vessel occlusion in anterior circulation within 24 hours. More awareness regarding the approach in India, can reduce the stroke morbidity and mortality in many of the cases in future

scholarly journals Stroke Etiology and Outcomes after Endovascular Thrombectomy: Results from the SITS Registry and a Meta-Analysis

2021 ◽  
Vol 23 (3) ◽  
pp. 388-400
Author(s):  
Marius Matusevicius ◽  
Charith Cooray ◽  
Viiu-Marika Rand ◽  
Ana Paiva Nunes ◽  
Tiago Moreira ◽  
...  
Keyword(s):  
Meta Analysis ◽  
Functional Independence ◽  
Artery Occlusion ◽  
Aggregate Data ◽  
Large Artery ◽  
Endovascular Thrombectomy ◽  
Logistic Regression Models ◽  
Risk Of Death ◽  
Stroke Etiology ◽  
Symptomatic Intracranial Hemorrhage

Background and Purpose The influence of stroke etiology on outcomes after endovascular thrombectomy (EVT) is not well understood. We aimed to investigate whether stroke etiology subgrouped as large artery atherosclerosis (LAA) and cardiac embolism (CE) influences outcomes in large artery occlusion (LAO) treated by EVT.Methods We included EVT treated LAO stroke patients registered in the Safe Implementation of Treatment in Stroke (SITS) thrombectomy register between January 1, 2014 and September 3, 2019. Primary outcome was successful reperfusion (modified Treatment in Cerebral Infarction 2b-3). Secondary outcomes were symptomatic intracranial hemorrhage (SICH), 3-month functional independence (modified Ranking Scale 0–2) and death. Multivariable logistic regression models were used for comparisons. In addition, a meta-analysis of aggregate data from the current literature was conducted (PROSPERO, ID 167447).Results Of 7,543 patients, 1,903 (25.2%) had LAA, 3,214 (42.6%) CE, and 2,426 (32.2%) unknown, other, or multiple etiologies. LAA patients were younger (66 vs. 74, P<0.001) and had lower National Institutes of Health Stroke Scale score at baseline (15 vs. 16, P<0.001) than CE patients. Multivariable analyses showed that LAA patients had lower odds of successful reperfusion (odds ratio [OR], 0.70; 95% confidence interval [CI], 0.57 to 0.86) and functional independence (OR, 0.74; 95% CI, 0.63 to 0.85), higher risk of death (OR, 1.44; 95% CI, 1.21 to 1.71), but no difference in SICH (OR, 1.09; 95% CI, 0.71 to 1.66) compared to CE patients. The systematic review found 25 studies matching the criteria. The meta-analysis did not find any difference between etiologies. Conclusions From the SITS thrombectomy register, we observed a lower chance of reperfusion and worse outcomes after thrombectomy in patients with LAA compared to CE etiology, despite more favorable baseline characteristics. In contrast, the meta-analysis did not find any difference between etiologies with aggregate data.

scholarly journals First-line contact aspiration vs stent-retriever thrombectomy in acute ischemic stroke patients with large-artery occlusion in the anterior circulation: Systematic review and meta-analysis

2019 ◽  
Vol 25 (3) ◽  
pp. 244-253 ◽  
Author(s):  
Marion Boulanger ◽  
Bertrand Lapergue ◽  
Francis Turjman ◽  
Emmanuel Touzé ◽  
René Anxionnat ◽  
...  
Keyword(s):  
Functional Independence ◽  
Artery Occlusion ◽  
Stent Retriever ◽  
Large Artery ◽  
Line Contact ◽  
Efficacy And Safety ◽  
Stroke Patients ◽  
First Line ◽  
Anterior Circulation ◽  
Excellent Outcome

Background In acute ischemic stroke patients with large-artery occlusion, uncertainties remain about whether clinically important outcomes are comparable between first-line contact aspiration and stent-retriever thrombectomy, although two trials have investigated whether one strategy should be preferred over another. Purpose The purpose of this article is to compare the efficacy and safety of first-line contact aspiration and stent-retriever thrombectomy in stroke patients with anterior circulation large-artery occlusion. Methods We undertook a systematic review of studies of patients treated for large-artery occlusion, with the latest devices of either strategy, within six hours of stroke onset. We determined rates of final complete reperfusion (defined as modified Thrombolysis In Cerebral Infarction score = 3), periprocedural complications and 90-day functional independence (defined as modified Rankin Scale (mRS) score 0–2), and excellent outcome (defined as mRS score 0–1) after contact aspiration and after stent-retriever thrombectomy using random-effects meta-analyses. Any differential effects in rates between the two strategies were assessed using random-effects meta-regressions. Results Fifteen studies (1817 patients) were included. There was no difference in rates of final complete reperfusion at the end of all endovascular procedures between contact aspiration and stent retrievers (51.1%, 95% confidence interval (CI) 39.3–62.9; vs 38.3%, 95% CI 28.6–48.0; pint = 0.14), 90-day functional independence (45.0%, 40.7–49.2; vs 52.4%, 47.7–57.1; pint = 0.45) and excellent outcome (32.1%, 25.7–38.5; vs 34.1%, 21.2–46.9; pint = 0.94). Rates of periprocedural complications did not differ between the two strategies. Conclusions Current data suggest no difference in efficacy and safety between first-line contact aspiration and stent-retriever thrombectomy in stroke patients with large-artery occlusion.

scholarly journals Bridging Therapy and Direct Thrombectomy for Acute Ischemic Stroke: A Prospective Cohort Study

2020 ◽  
Vol 3 (2) ◽  
pp. 124-130
Author(s):  
Trung Quoc Nguyen ◽  
Anh Le Tuan Truong ◽  
Hoang Thi Kim Phan ◽  
Duan Duy Nguyen ◽  
Khang Vinh Nguyen ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Therapy Group ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Artery Occlusion ◽  
Large Artery ◽  
Bridging Therapy ◽  
Vessel Occlusion ◽  
Reperfusion Rate

Background: It remains controversial if intravenous thrombolysis (IVT) prior to mechanical thrombectomy (MTE) is superior to MTE alone in patients with acute ischemic stroke caused by large vessel occlusion. We aim to compare functional outcomes, mortality, reperfusion, and intracranial hemorrhage rates in bridging therapy (IVT prior thrombectomy) and MTE alone groups within 6 h from symptom onset. Materials and Methods: Consecutive hospitalized patients (September 2017 and July 2018) with acute large artery occlusion within the anterior cerebral circulation eligible for MTE with or without prior IVT were included. A modified Rankin Scale score of 0 to 2 was considered as good functional outcome at 90 days. Successful reperfusion was defined as a Thrombolysis in Cerebral Infarction scale of 2b to 3. Results: Of the 124 patients included, 56 (45.2%) received bridging therapy and 68 (54.8%) received MTE alone. Patients receiving bridging therapy were younger (median, 56 vs 63, P = .045) and had shorter onset-to-groin time (median, 270 vs 370 min, P < .001) than those receiving MTE alone. Successful reperfusion rate was significantly greater in the bridging therapy group (87.5% vs 72.1%, P = 0.03). There were no statistically significant differences between the 2 groups in functional independence (bridging 58.9% vs 75.0%, P = 0.07), mortality at 90 days (bridging 14.3% vs 7.4%, P = 0.22), parenchymal hematoma type 2 (bridging 3.6% vs 2.9%, P > .99), and any hemorrhage (bridging 42.3% vs 26.5%, P = 0.07). Conclusion: Compared to MTE alone, bridging therapy with IVT improved the reperfusion rate but not other outcomes. Further clinical trials are needed to confirm our findings.

scholarly journals Pathophysiology of acute middle cerebral artery infarct by multimodal computed tomography: A pilot study in Thai patients

2015 ◽  
Vol 6 (01) ◽  
pp. 059-064 ◽  
Author(s):  
Pornpatr A. Dharmasaroja ◽  
Arvemas Watcharakorn ◽  
Utairat Chaumrattanakul
Keyword(s):  
Computed Tomography ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Intravenous Thrombolysis ◽  
Artery Occlusion ◽  
Anterior Circulation ◽  
Severe Stroke ◽  
Middle Cerebral Artery Infarct ◽  
Multimodal Ct

ABSTRACTMultimodal computed tomography, including non-contrast computed tomography (CT), computed tomography perfusion (CTP) and computed tomography angiography (CTA), has been increasingly used. Aims: The purpose of this study was to study pathophysiology of acute middle cerebral artery infarct using multimodal CT and to evaluate the safety and feasibility of this method in our center. Materials and Methods: Patients who had moderate to severe stroke (NIHSS score > 10), suspected of anterior circulation infarct and presented within 4 hours after stroke onset were prospectively included. Multimodal CTs, using low-osmolar contrast agents, were performed in all patients. Results: Twenty-two patients were included. Mean NIHSS was 16. All patients received intravenous thrombolysis. Favorable outcome was found in nine patients (41%). CTP was unable to identify ischemic lesions in three patients with small subcortical infarct. Most patients (82%) with large middle cerebral artery infarct still had some salvageable brain (penumbra) which partly recovered in a follow-up imaging. Eleven patients (50%) had major artery occlusion. Two patients had creatinine rising within 72 hours. Conclusions: Multimodal CT does provide information about status of major artery and the volume of salvageable/infarct brain tissue and is safely and easily applicable in our center.

Bridging Intravenous Thrombolysis Before Mechanical Thrombectomy for Large Artery Occlusion May be Detrimental with Thrombus Fragmentation

2020 ◽  
Vol 17 (1) ◽  
pp. 18-26 ◽  
Author(s):  
Ho Jun Yi ◽  
Jae Hoon Sung ◽  
Dong Hoon Lee
Keyword(s):  
Clinical Outcome ◽  
Subgroup Analysis ◽  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Artery Occlusion ◽  
Stent Retriever ◽  
Large Artery ◽  
Simultaneous Application

Objective: We investigated whether intravenous thrombolysis (IVT) affected the outcomes and complications of mechanical thrombectomy (MT), specifically focusing on thrombus fragmentation. Methods: The patients who underwent MT for large artery occlusion (LAO) were classified into two groups: MT with prior IVT (MT+IVT) group and MT without prior IVT (MT-IVT) group. The clinical outcome, successful recanalization with other radiological outcomes, and complications were compared, between two groups. Subgroup analysis was also performed for patients with simultaneous application of stent retriever and aspiration. Results: There were no significant differences in clinical outcome and successful recanalization rate, between both groups. However, the ratio of pre- to peri-procedural thrombus fragmentation was significantly higher in the MT+IVT group (14.6% and 16.2%, respectively; P=0.004) compared to the MT-IVT group (5.1% and 6.8%, respectively; P=0.008). The MT+IVT group required more second stent retriever (16.2%), more stent passages (median value = 2), and more occurrence of distal emboli (3.9%) than the MT-IVT group (7.9%, median value = 1, and 8.1%, respectively) (P=0.004, 0.008 and 0.018, respectively). In subgroup analysis, the results were similar to those of the entire patients. Conclusion: Thrombus fragmentation of IVT with t-PA before MT resulted in an increased need for additional rescue therapies, and it could induce more distal emboli. The use of IVT prior to MT does not affect the clinical outcome and successful recanalization, compared with MT without prior IVT. Therefore, we need to reconsider the need for IVT before MT.

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