scholarly journals Collateral Circulation Augmentation and Neuroprotection as Adjuvant to Mechanical Thrombectomy in Acute Ischemic Stroke

Neurology ◽  
2021 ◽  
Vol 97 (20 Supplement 2) ◽  
pp. S178-S184
Author(s):  
Shashvat M. Desai ◽  
Ruchira M. Jha ◽  
Italo Linfante
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Collateral Circulation ◽  
Mechanical Thrombectomy ◽  
Cell Structure ◽  
Neuronal Loss ◽  
Functional Independence ◽  
Complication Rates ◽  
Vessel Occlusion ◽  
Ischemic Core

Purpose of the ReviewMechanical thrombectomy (MT)–mediated endovascular recanalization has dramatically transformed treatment and outcomes after acute ischemic stroke caused by a large vessel occlusion (LVO). Current guidelines recommend MT up to 24 hours from stroke onset in carefully selected patients based on favorable clinical and imaging parameters. Despite optimal patient selection and low complication rates with current recanalization technology, approximately 1 in 2 patients with LVO stroke do not achieve functional independence at 3 months. This ceiling effect of MT efficacy may be explained by ischemic core expansion into the ischemic penumbra before recanalization and neuronal loss occurring after recanalization. Factors affecting the efficacy of MT, or the degree of irreversible injury, include time from symptom onset to recanalization, collateral circulation status, and differences in neuronal vulnerability. The purpose of this brief review is to discuss potential targets for neuroprotection, present and future potential pharmacologic and nonpharmacologic agents, and the data available in the literature.Recent FindingsIn experimental ischemia models, several authors reported that pharmacologic and nonpharmacologic agents are able to slow the progression of ischemic core expansion. However, in the era of unsuccessful recanalization of the occluded artery, several neuroprotective agents that were promising in the preclinical stage failed phase II/III clinical trials.SummaryProviding neuroprotection before and after recanalization of an LVO may play an important role in improving outcomes in the era of MT. Neuroprotection is classically defined as a process that results in the salvage, recovery, or regeneration of neuronal (and other supporting CNS cell) structure or function. The advent of successful recanalization of acute LVO by MT in the majority of patients may spur the growth of effective neuroprotection.

scholarly journals Frontline ADAPT therapy to treat patients with symptomatic M2 and M3 occlusions in acute ischemic stroke: initial experience with the Penumbra ACE and 3MAX reperfusion system

2017 ◽  
Vol 10 (5) ◽  
pp. 434-439 ◽  
Author(s):  
Jens Altenbernd ◽  
Oliver Kuhnt ◽  
Svenja Hennigs ◽  
Ruediger Hilker ◽  
Christian Loehr
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Functional Independence ◽  
National Institutes Of Health ◽  
Complication Rates ◽  
Vessel Occlusion ◽  
First Pass ◽  
Symptomatic Intracranial Hemorrhage ◽  
Distal Vessel

BackgroundAfter a series of positive studies for mechanical thrombectomy in large vessel occlusion acute ischemic stroke, the question remains, can symptomatic patients with distal vessel occlusion benefit from mechanical thrombectomy?PurposeTo assess the safety and efficacy of the 3MAX reperfusion system as frontline therapy for M2 and M3 occlusions.MethodsThis study retrospectively collected data on 58 patients treated for M2 and M3 occlusions between January and September 2016. Of these 58 patients, 31 had an isolated M2 or M3 occlusion. Eligible patients were treated with 3MAX by adirect first pass aspiration (ADAPT) technique within 6 hours following stroke onset. Effectiveness was defined by functional independence (90-day modified Rankin Scale core 0–2) and revascularization to modified Thrombolysis in Cerebral Infarction (mTICI) 2b–3 scores adjudicated by a core laboratory, while complication rates were used to determine safety of the device and the procedure.ResultsPatients with an isolated M2 or M3 occlusion had a mean age of 68.6±13.3 years (range 18–90 years), a median National Institutes of Health Stroke Score of 15 (IQR 9–19), and ASPECTS score of 9 (IQR 8–10). After intervention, 100% (31/31) of patients were revascularized to mTICI 2b–3; 77.4% (24/31) of patients showed revascularization to mTICI 3. Aspiration alone led to revascularization in 83.9% (26/31) of patients. At 90 days, 96.8% (30/31) of patients had achieved functional independence. The incidence of symptomatic intracranial hemorrhage was 0% (0/31).ConclusionsResults suggest that the 3MAX reperfusion system is safe and effective in achieving successful revascularization and functional independence for patients with acute ischemic stroke secondary to M2 and M3 occlusions using ADAPT, either as frontline monotherapy, or in combination with adjunctive devices.

Abstract P488: The Impact of First Pass Effect on Acute Ischemic Stroke Clinical Outcomes: Why We Need to Continue to Improve Mechanical Thrombectomy?

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Ameer E Hassan ◽  
Mahmoud Dibas ◽  
Amr Ehab El-Qushayri ◽  
Sherief Ghozy ◽  
Adam A Dmytriw ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Clinical Outcomes ◽  
Mechanical Thrombectomy ◽  
Functional Independence ◽  
Vessel Occlusion ◽  
First Pass Effect ◽  
Improved Outcomes ◽  
First Pass ◽  
The Impact

Background: Mechanical thrombectomy (MT) has significantly improved outcomes of acute ischemic stroke (AIS) patients due to large vessel occlusion (LVO). The first-pass effect (FPE), defined as achieving complete reperfusion (mTICI3/2c) with a single pass, was reported to be associated with higher functional independence rates following EVT and has been emphasized as an important procedural target. We compared MT outcomes in patients who achieved FPE to those who did not in a real world large database. Method: A retrospective analysis of LVO pts who underwent MT from a single center prospectively collected database. Patients were stratified into those who achieved FPE and non-FPE. The primary outcome (discharge and 90 day mRS 0-2) and safety (sICH, mortality and neuro-worsening) were compared between the two groups. Results: Of 580 pts, 261 (45%) achieved FPE and 319 (55%) were non-FPE. Mean age was (70 vs 71, p=0.051) and mean initial NIHSS (16 vs 17, p=0.23) and IV tPA rates (37% bs 36%, p=0.9) were similar between the two groups. Other baseline characteristics were similar. Non-FPE pts required more stenting (15% vs 25%, p=0.003), and angioplasty (19% vs 29%, p=0.01). The FPE group had significantly more instances of discharge (33% vs 17%, p<0.001), and 90-day mRS score 0-2 (29% vs 20%, p<0.001), respectively. Additionally, the FPE group had a significant lower mean discharge NIHSS score (12 vs 17, p<0.001). FPE group had better safety outcomes with lower mortality (14.2% vs 21.6%, p=0.03), sICH (5.7% vs 13.5, p=0.004), and neurological worsening (71.3% vs 78.4%, p=0.02), compared to the non-FPE group. Conclusion: Patients with first pass complete or near complete reperfusion with MT had higher functional independence rates, reduced mortality, symptomatic hemorrhage and neurological worsening. Improvement in MT devices and techniques is vital to increase first pass effect and improve clinical outcomes.

Abstract WP25: The Impact of Body Mass Index on Outcomes of Mechanical Thrombectomy for Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Stephanie Chen ◽  
David McCarthy ◽  
Vasu Saini ◽  
Marie Brunet ◽  
Eric Peterson ◽  
...  
Keyword(s):  
Body Mass Index ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Body Mass ◽  
Linear Correlation ◽  
Mechanical Thrombectomy ◽  
Functional Independence ◽  
Normal Weight ◽  
Vessel Occlusion ◽  
The Impact

Background: Obesity is an established risk factor for acute ischemic stroke (AIS), but its impact on clinical outcomes and mortality after AIS remains controversial. In this study, we evaluate the association of body mass index (BMI) on outcomes after mechanical thrombectomy (MT) for large vessel occlusion acute ischemic stroke (LVOS). Methods: We reviewed our prospective MT database for LVOS between 2015 and 2018. BMI was analyzed as a continuous and categorical variable with underweight BMI <18.5, normal BMI 18.5-24.9, overweight BMI 25-29.9, and obese BMI>30. Multivariate analysis was used to determine predictors of outcome. Results: 335 patients underwent MT with 7 (2.1%) patients classified as underweight, 107 (31.9%) normal, 141 (42.1%) overweight, and 80 (23.9%) obese. Compared to normal weight (reference), obese patients had higher rates of hypertension and hyperlipidemia, while underweight patients had higher rates of previous stroke and presentation NIHSS. The time from symptom onset to puncture, procedural techniques, and reperfusion success (>TICI 2b) was not significantly different between BMI categories. There was a significant inverse linear correlation between BMI and symptomatic hemorrhagic. In patients with successful reperfusion (>TICI 2b), there was also a significant bell-shaped relationship between BMI and functional independence (mRS < 3) with both low and high BMIs associated with worse outcomes. In patients without post-procedural symptomatic hemorrhage, there was a significant linear correlation between BMI and inpatient mortality. Conclusion: In LVOS patients treated with MT, BMI is inversely related with post-procedural symptomatic hemorrhage. Yet in those whom reperfusion is achieved, both lower and higher than normal BMI were associated with worse functional outcomes. Thus, the obesity paradox does not appear to pertain to mechanical thrombectomy, although larger prospective studies are necessary.

scholarly journals Challenging the Ischemic Core Concept in Acute Ischemic Stroke Imaging

Stroke ◽  
2020 ◽  
Vol 51 (10) ◽  
pp. 3147-3155 ◽  
Author(s):  
Mayank Goyal ◽  
Johanna M. Ospel ◽  
Bijoy Menon ◽  
Mohammed Almekhlafi ◽  
Mahesh Jayaraman ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Neuronal Loss ◽  
Treatment Decision ◽  
Stroke Care ◽  
Core Concept ◽  
Vessel Occlusion ◽  
Ischemic Core

Endovascular treatment is a highly effective therapy for acute ischemic stroke due to large vessel occlusion and has recently revolutionized stroke care. Oftentimes, ischemic core extent on baseline imaging is used to determine endovascular treatment-eligibility. There are, however, 3 fundamental issues with the core concept: First, computed tomography and magnetic resonance imaging, which are mostly used in the acute stroke setting, are not able to precisely determine whether and to what extent brain tissue is infarcted (core) or still viable, due to variability in tissue vulnerability, the phenomenon of selective neuronal loss and lack of a reliable gold standard. Second, treatment decision-making in acute stroke is multifactorial, and as such, the relative importance of single variables, including imaging factors, is reduced. Third, there are often discrepancies between core volume and clinical outcome. This review will address the uncertainty in terminology and proposes a direction towards more clarity. This theoretical exercise needs empirical data that clarify the definitions further and prove its value.

Mechanical thrombectomy for acute ischemic stroke with occlusion of the M2 segment of the middle cerebral artery: a meta-analysis

2017 ◽  
Vol 10 (7) ◽  
pp. 620-624 ◽  
Author(s):  
Hamidreza Saber ◽  
Sandra Narayanan ◽  
Mohan Palla ◽  
Jeffrey L Saver ◽  
Raul G Nogueira ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Cerebral Artery ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Functional Independence ◽  
Vessel Occlusion ◽  
Increased Risk ◽  
Significant Difference

BackgroundEndovascular thrombectomy has demonstrated benefit for patients with acute ischemic stroke from proximal large vessel occlusion. However, limited evidence is available from recent randomized trials on the role of thrombectomy for M2 segment occlusions of the middle cerebral artery (MCA).MethodsWe conducted a systematic review and meta-analysis to investigate clinical and radiographic outcomes, rates of hemorrhagic complications, and mortality after M2 occlusion thrombectomy using modern devices, and compared these outcomes against patients with M1 occlusions. Recanalization was defined as Thrombolysis in Cerebral Infarction (TICI) 2b/3 or modified TICI 2b/3.ResultsA total of 12 studies with 1080 patients with M2 thrombectomy were included in our analysis. Functional independence (modified Rankin Scale 0–2) rate was 59% (95% CI 54% to 64%). Mortality and symptomatic intracranial hemorrhage rates were 16% (95% CI 11% to 23%) and 10% (95% CI 6% to 16%), respectively. Recanalization rates were 81% (95% CI 79% to 84%), and were equally comparable for stent-retriever versus aspiration (OR 1.05; 95% CI 0.91 to 1.21). Successful M2 recanalization was associated with greater rates of favorable outcome (OR 4.22; 95% CI 1.96 to 9.1) compared with poor M2 recanalization (TICI 0–2a). There was no significant difference in recanalization rates for M2 versus M1 thrombectomy (OR 1.05; 95% CI 0.77 to 1.42).ConclusionsThis meta-analysis suggests that mechanical thrombectomy for M2 occlusions that can be safely accessed is associated with high functional independence and recanalization rates, but may be associated with an increased risk of hemorrhage.

A multicenter study of the safety and effectiveness of mechanical thrombectomy for patients with acute ischemic stroke not meeting top-tier evidence criteria

2017 ◽  
Vol 10 (1) ◽  
pp. 10-16 ◽  
Author(s):  
Nitin Goyal ◽  
Georgios Tsivgoulis ◽  
Donald Frei ◽  
Aquilla Turk ◽  
Blaise Baxter ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Standard Of Care ◽  
High Volume ◽  
Functional Independence ◽  
Functional Improvement ◽  
Complication Rates ◽  
Logistic Regression Models ◽  
Symptomatic Intracerebral Hemorrhage

BackgroundWhile mechanical thrombectomy (MT) has become the standard of care for patients with acute ischemic stroke (AIS) with emergent large-vessel occlusions (ELVO), recently published guidelines appropriately award top-tier evidence to the same selective criteria that were employed in completed clinical trials. We sought to evaluate the safety and effectiveness of MT in patients with AIS with ELVO who do not meet top-tier evidence criteria (TTEC).MethodsWe conducted an observational study on consecutive patients with AIS with ELVO who underwent MT at six high-volume endovascular centers. Standard safety outcomes (3-month mortality, symptomatic intracranial hemorrhage) and effectiveness outcomes (3-month functional independence: modified Rankin Scale scores of 0–2) were compared between patients meeting and failing TTEC.ResultsThe sample consisted of 349 (60%) controls fulfilling TTEC and 234 (40%) non-TTEC patients. Control patients meeting TTEC for MT tended to have higher functional independence rates at 3 months (47% vs 39%; p=0.055), while the rates of symptomatic intracerebral hemorrhage (sICH) were similar (9%) in both groups (p=0.983). In multivariable logistic regression models, adherence to TTEC for MT was not independently related to any safety outcome (sICH: OR 0.71, 95% CI 0.30 to 1.68, p=0.434; 3-month mortality: OR 1.27, 95% CI 0.69 to 2.33, p=0.448) or effectiveness outcome (3-month functional independence: OR 0.81, 95% CI 0.48 to 1.37, p=0.434; 3-month functional improvement: OR 0.73, 95% CI 0.48 to 1.11, p=0.138) after adjusting for potential confounders.ConclusionsApproximately 40% of patients with AIS with ELVO offered MT do not fulfill TTEC for MT. Patients who did not meet TTEC had high rates of good clinical outcome and low complication rates.

Abstract WP3: Occluded Vessel Location is a Predictor of Clinical Outcome in the Natural History of Acute Ischemic Stroke From Large Vessel Occlusion Eligible for Mechanical Thrombectomy

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Iris Grunwald ◽  
Mary Sneade ◽  
Birgit Bock ◽  
Vallabh Janardhan ◽  
Lynne Ammar ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Natural History ◽  
Acute Ischemic Stroke ◽  
Basilar Artery ◽  
Mechanical Thrombectomy ◽  
Functional Independence ◽  
Multicenter Studies ◽  
Vessel Occlusion ◽  
Serious Adverse Events ◽  
History Of

Purpose: The preponderance of evidence suggests that target vessel locations (TVL) are important predictors of outcomes in acute ischemic stroke (AIS). However, few studies have examined in detail their correlation in the natural history of a cohort of patients with ICA, M1 and M2 vessel occlusions who are eligible for, but untreated with, mechanical thrombectomy. Hypothesis: We hypothesize that, similar to the broader stroke cohort, there is a correlation between TVL and outcomes. Methods: The SOS and FIRST trials were prospective, multicenter studies evaluating the natural history of a stroke cohort eligible for mechanical thrombectomy but did not receive the treatment. Enrolled patients presented with symptoms of AIS due to LVO and were refractory or ineligible for rtPA treatment. Functional independence was defined as a mRS score 0-2 at 90 days. Incidence of death, intracranial hemorrhage (ICH), serious adverse events (SAEs), and mortality were assessed for association with TVL. Results: A total of 238 patients (median age: 71) met study criteria. Occlusions were reported in the ICA (32.5%), M1 (54.4%), M2 (8.9%), and basilar artery (1.7%). At 90 days, 9.2% of ICA, 12.1% of MCA M1, 25.0% of MCA M2, and 0.0% of basilar artery patients achieved functional independence as defined by a mRS score of 0-2. Although the rate of SAEs was similar between ICA (83.3%), M1 (81.4%), and basilar artery (75%), the rate was lowered in patients with M2 occlusion (61.9%, p<0.05). There were also significantly fewer mortalities associated with occlusion of the M1 (27.4%, p<0.01) and M2 (10.0%, p<0.01) when compared to ICA occlusions (40.8%). Conclusion: Similar to the broader patients with AIS, there is a significant correlation between TVL and outcomes in patients with LVO eligible for mechanical thrombectomy. Although occlusion of smaller vessels (i.e. M2) predicts better functional outcome, 75% of patients will not reach functional independence.

scholarly journals Subarachnoid Hemorrhage in Mechanical Thrombectomy for Acute Ischemic Stroke: Analysis of the STRATIS Registry, Systematic Review, and Meta-Analysis

2021 ◽  
Vol 12 ◽  
Author(s):  
Hubert Lee ◽  
Ayman M. Qureshi ◽  
Nils H. Mueller-Kronast ◽  
Osama O. Zaidat ◽  
Michael T. Froehler ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Subarachnoid Hemorrhage ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Functional Independence ◽  
Systematic Evaluation ◽  
Vessel Occlusion ◽  
Intravenous Tissue Plasminogen Activator

Background: The indications for mechanical thrombectomy in acute ischemic stroke continue to broaden, leading neurointerventionalists to treat vessel occlusions at increasingly distal locations farther in time from stroke onset. Accessing these smaller vessels raises the concern of iatrogenic subarachnoid hemorrhage (SAH) owing to increasing complexity in device navigation and retrieval. This study aims to determine the prevalence of SAH following mechanical thrombectomy, associated predictors, and resulting functional outcomes using a multicenter registry and compare this with a systematic review and meta-analysis of the literature.Methods: Data from STRATIS (The Systematic Evaluation of Patients Treated with Neurothrombectomy Devices for Acute Ischemic Stroke) registry were analyzed dichotomized by the presence or absence of SAH after thrombectomy. Only patients with 24-h post-procedural neuroimaging were included (n = 841). Multivariable logistic regression was performed to identify significant predictors of SAH. A systematic review and random-effects meta-analysis was also conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) protocol.Results: The prevalence of post-thrombectomy SAH was 5.23% in STRATIS with 15.9% (1.84% overall) experiencing neurological decline. Distal location of vessel occlusion (OR 3.41 [95% CI: 1.75–6.63], p &lt; 0.001) and more than 3 device passes (OR 1.34 [95% CI: 1.09–1.64], p = 0.01) were associated with a higher probability of SAH in contrast to a reduction with administration of intravenous tissue plasminogen activator (tPA) (OR 0.48 [95% CI: 0.26–0.89], p = 0.02). There was a trend toward a higher discharge NIHSS (8.3 ± 8.7 vs. 5.3 ± 6.6, p = 0.07) with a significantly reduced proportion achieving functional independence at 90 days (modified Rankin Score 0–2: 32.5% vs. 57.8%, p = 0.002) in SAH patients. Pooled analysis of 10,126 patients from 6 randomized controlled trials and 64 observational studies demonstrated a prevalence of 5.85% [95% CI: 4.51–7.34%, I2: 85.2%]. Only location of vessel occlusion was significant for increased odds of SAH at distal sites (OR 2.89 [95% CI: 1.14, 7.35]).Conclusions: Iatrogenic SAH related to mechanical thrombectomy is more common with treatment of distally-situated occlusions and multiple device passes. While low in overall prevalence, its effect is not benign with fewer patients reaching post-procedural functional independence, particularly if symptomatic.

Revascularization and functional outcomes after mechanical thrombectomy for acute ischemic stroke in elderly patients

2020 ◽  
Vol 132 (4) ◽  
pp. 1182-1187 ◽  
Author(s):  
Carrie E. Andrews ◽  
Nikolaos Mouchtouris ◽  
Evan M. Fitchett ◽  
Fadi Al Saiegh ◽  
Michael J. Lang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Elderly Patients ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Multivariate Logistic Regression Analysis ◽  
Standard Of Care ◽  
Stroke Severity ◽  
Vessel Occlusion ◽  
Younger Patients ◽  
Success Of Treatment

OBJECTIVEMechanical thrombectomy (MT) is now the standard of care for acute ischemic stroke (AIS) secondary to large-vessel occlusion, but there remains a question of whether elderly patients benefit from this procedure to the same degree as the younger populations enrolled in the seminal trials on MT. The authors compared outcomes after MT of patients 80–89 and ≥ 90 years old with AIS to those of younger patients.METHODSThe authors retrospectively analyzed records of patients undergoing MT at their institution to examine stroke severity, comorbid conditions, medical management, recanalization results, and clinical outcomes. Univariate and multivariate logistic regression analysis were used to compare patients < 80 years, 80–89 years, and ≥ 90 years old.RESULTSAll groups had similar rates of comorbid disease and tissue plasminogen activator (tPA) administration, and stroke severity did not differ significantly between groups. Elderly patients had equivalent recanalization outcomes, with similar rates of readmission, 30-day mortality, and hospital-associated complications. These patients were more likely to have poor clinical outcome on discharge, as defined by a modified Rankin Scale (mRS) score of 3–6, but this difference was not significant when controlled for stroke severity, tPA administration, and recanalization results.CONCLUSIONSOctogenarians, nonagenarians, and centenarians with AIS have similar rates of mortality, hospital readmission, and hospital-associated complications as younger patients after MT. Elderly patients also have the capacity to achieve good functional outcome after MT, but this potential is moderated by stroke severity and success of treatment.

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