THE CHANGE OF TRIAGE SIGNIFICANTLY SHORTENS PREHOSPITAL TIME INTERVAL FOR MECHANICAL THROMBECTOMY CANDIDATES

Introduction : The value of intravenous thrombolysis (IVT) in patients eligible for mechanical thrombectomy (MT) remains unclear. We hypothesized that pre‐treatment with and/or ongoing IVT may facilitate reperfusion of distal vessel occlusion after incomplete MT. We evaluated this potential association using follow‐up perfusion imaging. Methods : Retrospective observational analysis of our institution`s stroke registry included patients with incomplete reperfusion after MT, admitted between February 1, 2015 and December 8, 2020. Delayed reperfusion (DR) was defined as the absence of a persistent perfusion deficit on contrast‐enhanced perfusion imaging ⁓24h±12h after the intervention. The association between baseline parameters and the occurrence of DR was evaluated using a logistic regression analyses. To account for possible time‐dependent associations of IVT with DR, additional stratification sets were made based on different time windows between IVT start time and final angiography runs. Results : Among the 378 included patients (median age 73.5, 50.8% female), DR occurred in 226 (59.8%). Atrial fibrillation (aOR 2.53 [95% CI 1.34 ‐ 4.90]), eTICI score (aOR 3.79 [95% CI 2.71 ‐ 5.48] per TICI grade increase), and intervention‐to‐follow‐up time (aOR 1.08 [95% CI 1.04 ‐ 1.13] per hour delay) were associated with DR. Dichotomized IVT strata showed no association with DR (aOR 0.75 [95% CI 0.42 ‐ 1.33]), whereas shorter intervals between IVT start and end of the procedure showed a borderline significant association with DR (OR 2.24 [95% CI 0.98 ‐ 5.43, and OR 2.07 [95% 1.06 – 4.31], for 80 and 100 minutes respectively). Patients with DR had higher rates of functional independence (modified Rankin scale 0–2 at 90 days, DR: 63.3% vs PPD: 38.8%; p<0.01) and longer survival time (at 3 years, DR: 69.2% vs PPD: 45.8%; p = 0.001). Conclusions : There is weak evidence that IVT may favor DR after incomplete MT if the time interval between IVT administration and end of the procedure is short. In general, perfusion follow‐up imaging may constitute a suitable surrogate parameter for evaluating medical rescue strategies after incomplete MT, because a considerable proportion of patients do not experience DR, and there seems to be a close correlation with clinical outcomes.

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Impact of early division of the middle cerebral artery on outcome following mechanical thrombectomy

Interventional Neuroradiology ◽

10.1177/1591019920920987 ◽

2020 ◽

Vol 26 (4) ◽

pp. 389-395

Author(s):

Hanna Styczen ◽

Volker Maus ◽

Amélie C Hesse ◽

Lukas Goertz ◽

Sebastian Fischer ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Intracranial Hemorrhage ◽

Cerebral Artery ◽

Mechanical Thrombectomy ◽

Tertiary Care ◽

Time Interval ◽

Large Artery ◽

Vessel Occlusion ◽

Symptomatic Intracranial Hemorrhage ◽

Tertiary Care Centers

Background Mechanical thrombectomy has become the standard care for acute ischemic stroke caused by large vessel occlusion. However, complete reperfusion cannot be achieved in all cases, and several factors influencing the results of mechanical thrombectomy have been investigated. Among others, a tortuous anatomy is associated with lower rates of complete reperfusion. We aimed to investigate whether an early division of the middle cerebral artery has an impact on reperfusion results in mechanical thrombectomy. Methods Retrospective review of consecutive patients with M1 occlusion treated endovascularly between January 2016 and December 2019 at three tertiary care centers. The study group was dichotomized based on the length of the M1 segment. Early division of the middle cerebral artery was defined as a maximum length of 10 mm of the M1 segment. Primary endpoints were first-pass mTICI scores of 3, ≥2c, and ≥2b. Secondary endpoints contained final reperfusion, number of device-passes, time interval from groin puncture to reperfusion, rate of postinterventional symptomatic intracranial hemorrhage, and frequency of emboli of new territory. Results Among 284 included patients, 70 presented with an early division of the M1 segment (25%). Reperfusion results did not differ significantly between early and late division of M1. A higher rate of symptomatic intracranial hemorrhage was found in the group with an early M1 division treated with aspiration only (14.3% vs. 0%; p = 0.013). Patients with late M1 division had a significantly higher rate of large artery sclerosis (19.2% vs. 8.6%, p = 0.039). Conclusion The anatomic variant of an early division of the middle cerebral artery was not a predictor for incomplete reperfusion.

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Intracranial mechanical thrombectomy of large vessel occlusions in the posterior circulation using SAVE

10.21203/rs.2.9281/v1 ◽

2019 ◽

Author(s):

Volker Maus ◽

Hanna Styczen ◽

Jan Liman ◽

Ilko Maier ◽

Alex Brehm ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Posterior Circulation ◽

Large Vessel ◽

Time Interval ◽

Anterior Circulation ◽

Primary Endpoints ◽

First Pass ◽

Secondary Endpoints ◽

Symptomatic Intracranial Hemorrhage ◽

Number Of Passes

Abstract Background Mechanical thrombectomy (MT) using stent retriever assisted vacuum-locked extraction (SAVE) is a promising method for anterior circulation strokes. We present our experience with SAVE for large vessel occlusions (LVO) of the posterior circulation. Methods We retrospectively analyzed 66 consecutive MT patients suffering from LVO of the posterior circulation. Primary endpoints were first-pass and overall complete/near complete reperfusion, defined as a modified thrombolysis in cerebral infarction (mTICI) score of 2c and 3. Secondary endpoints contained number of passes, time interval from groin puncture to reperfusion and rate of postinterventional symptomatic intracranial hemorrhage (sICH). Results Median age was 75 years (interquartile range (IQR) 54 – 81 years). Baseline median National Institutes of Health stroke scale (NIHSS) was 13 (IQR 8 – 21). Fifty-five (83%) patients had LVO of the basilar artery and 11 (17%) of the posterior cerebral artery. Eighteen (27%) patients were treated with SAVE and 21 (32%) with aspiration only. First pass mTICI2c or 3 and overall mTICI2c or 3 were documented in 11/18 (61%) and 14/18 (78%) with SAVE and in 4/21 (19%) and 13/21 (33%) with aspiration only. Median attempt was 1 (IQR 1 – 2) with SAVE and 2 (IQR 1 – 4) with aspiration (p=0.0249). Median groin to reperfusion time did not differ significantly between groups. The rate of sICH was 5% without any complications in the SAVE cohort. Conclusion Mechanical thrombectomy of posterior large vessel occlusions with SAVE is feasible, safe, and effective with high rates of near-complete and complete reperfusion.

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Importance of Prehospital Time Interval for Risk Assessment in Acute Heart Failure Patients

Journal of Cardiac Failure ◽

10.1016/j.cardfail.2013.08.215 ◽

2013 ◽

Vol 19 (10) ◽

pp. S144-S145

Author(s):

Jun Makino

Keyword(s):

Heart Failure ◽

Risk Assessment ◽

Acute Heart Failure ◽

Time Interval ◽

Heart Failure Patients ◽

Prehospital Time

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Intracranial mechanical thrombectomy of large vessel occlusions in the posterior circulation using SAVE

10.21203/rs.2.9281/v3 ◽

2019 ◽

Author(s):

Volker Maus ◽

Hanna Styczen ◽

Jan Liman ◽

Ilko Maier ◽

Alex Brehm ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Posterior Circulation ◽

Large Vessel ◽

Time Interval ◽

Anterior Circulation ◽

Primary Endpoints ◽

First Pass ◽

Secondary Endpoints ◽

Symptomatic Intracranial Hemorrhage ◽

Number Of Passes

Abstract Background Mechanical thrombectomy (MT) using stent retriever assisted vacuum-locked extraction (SAVE) is a promising method for anterior circulation strokes. We present our experience with SAVE for large vessel occlusions (LVO) of the posterior circulation. Methods We retrospectively analyzed 66 consecutive MT patients suffering from LVO of the posterior circulation. Primary endpoints were first-pass and overall complete/near complete reperfusion, defined as a modified thrombolysis in cerebral infarction (mTICI) score of 2c and 3. Secondary endpoints contained number of passes, time interval from groin puncture to reperfusion and rate of postinterventional symptomatic intracranial hemorrhage (sICH). Results Median age was 75 years (interquartile range (IQR) 54 – 81 years). Baseline median National Institutes of Health stroke scale (NIHSS) was 13 (IQR 8 – 21). Fifty-five (83%) patients had LVO of the basilar artery and 11 (17%) of the posterior cerebral artery. Eighteen (27%) patients were treated with SAVE and 21 (32%) with aspiration only. First pass mTICI2c or 3 and overall mTICI2c or 3 were documented in 11/18 (61%) and 14/18 (78%) with SAVE and in 4/21 (19%) and 13/21 (33%) with aspiration only. Median attempt was 1 (IQR 1 – 2) with SAVE and 2 (IQR 1 – 4) with aspiration (p=0.0249). Median groin to reperfusion time did not differ significantly between groups. The rate of sICH was 5% without any complications in the SAVE cohort. Conclusion Mechanical thrombectomy of posterior large vessel occlusions with SAVE is feasible, safe, and effective with high rates of near-complete and complete reperfusion.

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Erythrocyte-Rich Thrombus Is Associated with Reduced Number of Maneuvers and Procedure Time in Patients with Acute Ischemic Stroke Undergoing Mechanical Thrombectomy

Cerebrovascular Diseases Extra ◽

10.1159/000486042 ◽

2018 ◽

Vol 8 (1) ◽

pp. 39-49 ◽

Cited By ~ 44

Author(s):

Kota Maekawa ◽

Masunari Shibata ◽

Hideki Nakajima ◽

Akane Mizutani ◽

Yotaro Kitano ◽

...

Keyword(s):

Blood Cells ◽

Mechanical Thrombectomy ◽

Clinical Laboratory ◽

White Blood Cells ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Time Interval ◽

Procedure Time ◽

Vessel Occlusion ◽

Computed Tomography Images

Background: Only few studies have investigated the relationship between the histopathology of retrieved thrombi and clinical outcomes. This study aimed to evaluate thrombus composition and its association with clinical, laboratory, and neurointerventional findings in patients treated by mechanical thrombectomy due to acute large vessel occlusion. Methods: At our institution, 79 patients were treated by mechanical thrombectomy using a stent retriever and/or aspiration catheter between August 2015 and August 2016. The retrieved thrombi were quantitatively analyzed to quantify red blood cells, white blood cells, and fibrin by area. We divided the patients into two groups – a fibrin-rich group and an erythrocyte-rich group – based on the predominant composition in the thrombus. The groups were compared for imaging, clinical, and neurointerventional data. Results: The retrieved thrombi from 43 patients with acute stroke from internal carotid artery, middle cerebral artery, or basilar artery occlusion were histologically analyzed. Erythrocyte-rich thrombi were present in 18 cases, while fibrin-rich thrombi were present in 25 cases. A cardioembolic etiology was significantly more prevalent among the patients with fibrin-rich thrombi than among those with erythrocyte-rich thrombi. Attenuation of thrombus density as shown on computed tomography images was greater in patients with erythrocyte-rich thrombi than in those with fibrin-rich thrombi. All other clinical and laboratory characteristics remained the same. Patients with erythrocyte-rich thrombi had a smaller number of recanalization maneuvers, shorter procedure times, a shorter time interval between arrival and recanalization, and a higher percentage of stent retrievers in the final recanalization procedure. The occluded vessels did not differ significantly. Conclusions: In this study, erythrocyte-rich thrombus was associated with noncardioembolic etiology, higher thrombus density, and reduced procedure time.

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The Relationship between Functional Outcome and Prehospital Time Interval in Patients with Cerebral Infarction

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2017.06.059 ◽

2017 ◽

Vol 26 (12) ◽

pp. 2800-2805 ◽

Cited By ~ 2

Author(s):

Soichiro Seno ◽

Satoshi Tomura ◽

Kenichiro Ono ◽

Shinji Akitomi ◽

Yasumasa Sekine ◽

...

Keyword(s):

Cerebral Infarction ◽

Functional Outcome ◽

Time Interval ◽

Prehospital Time ◽

The Relationship

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Prehospital Management and Fluid Resuscitation in Hypotensive Trauma Patients Admitted to Karolinska University Hospital in Stockholm

Prehospital and Disaster Medicine ◽

10.1017/s1049023x00002582 ◽

2005 ◽

Vol 20 (4) ◽

pp. 228-234 ◽

Cited By ~ 17

Author(s):

Peep Talving ◽

Joakim Pålstedt ◽

Louis Riddez

Keyword(s):

Blood Pressure ◽

Fluid Resuscitation ◽

Fluid Therapy ◽

Injury Severity ◽

University Hospital ◽

Time Interval ◽

Trauma Patients ◽

Prehospital Management ◽

Type Of Injury ◽

Prehospital Time

AbstractIntroduction:Few previous studies have been conducted on the prehospital management of hypotensive trauma patients in Stockholm County. The aim of this study was to describe the prehospital management of hypotensive trauma patients admitted to the largest trauma center in Sweden, and to assess whether prehospital trauma life support (PHTLS) guidelines have been implemented regarding prehospital time intervals and fluid therapy. In addition, the effects of the age, type of injury, injury severity, prehospital time interval, blood pressure, and fluid therapy on outcome were investigated.Methods:This is a retrospective, descriptive study on consecutive, hypotensivetrauma patients (systolic blood pressure ≤90 mmHg on the scene of injury) admitted to Karolinska University Hospital in Stockholm, Sweden, during 2001–2003. The reported values are medians with interquartile ranges. Basic demographics, prehospital time intervals and interventions, injury severity scores (ISS), type and volumes of prehospital fluid resuscitation, and 30-day mortality were abstracted. The effects of the patient's age, gender, prehospital time interval, type of injury, injury severity, on-scene and emergency department blood pressure, and resuscitation fluid volumes on mortality were analyzed using the exact logistic regression model.Results:In 102 (71 male) adult patients (age ≥15 years) recruited, the median age was 35.5 years (range: 27–55 years) and 77 patients (75%) had suffered blunt injury. The predominant trauma mechanisms were falls between levels (24%) and motor vehicle crashes (22%) with an ISS of 28.5 (range: 16–50). The on-scene time interval was 19 minutes (range: 12–24 minutes). Fluid therapy was initiated at the scene of injury in the majority of patients (73%) regardless of the type of injury (77 blunt [75%] / 25 penetrating [25%]) or injury severity (ISS: 0–20; 21–40; 41–75). Age (odds ratio (OR) = 1.04), male gender (OR = 3.2), ISS 21–40 (OR = 13.6), and ISS >40 (OR = 43.6) were the significant factors affecting outcome in the exact logistic regression analysis.Conclusion:The time interval at the scene of injury exceeded PHTLS guidelines. The vast majority of the hypotensive trauma patients were fluid-resuscitated on-scene regardless of the type, mechanism, or severity of injury. A predefined fluid resuscitation regimen is not employed in hypotensive trauma victims with different types of injuries. The outcome was worsened by male gender, progressive age, and ISS >20 in the exact multiple regression analysis.

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Intracranial mechanical thrombectomy of large vessel occlusions in the posterior circulation using SAVE

10.21203/rs.2.9281/v2 ◽

2019 ◽

Author(s):

Volker Maus ◽

Hanna Styczen ◽

Jan Liman ◽

Ilko Maier ◽

Alex Brehm ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Posterior Circulation ◽

Large Vessel ◽

Time Interval ◽

Anterior Circulation ◽

Primary Endpoints ◽

First Pass ◽

Secondary Endpoints ◽

Symptomatic Intracranial Hemorrhage ◽

Number Of Passes

Abstract Background Mechanical thrombectomy (MT) using stent retriever assisted vacuum-locked extraction (SAVE) is a promising method for anterior circulation strokes. We present our experience with SAVE for large vessel occlusions (LVO) of the posterior circulation. Methods We retrospectively analyzed 66 consecutive MT patients suffering from LVO of the posterior circulation. Primary endpoints were first-pass and overall complete/near complete reperfusion, defined as a modified thrombolysis in cerebral infarction (mTICI) score of 2c and 3. Secondary endpoints contained number of passes, time interval from groin puncture to reperfusion and rate of postinterventional symptomatic intracranial hemorrhage (sICH). Results Median age was 75 years (interquartile range (IQR) 54 – 81 years). Baseline median National Institutes of Health stroke scale (NIHSS) was 13 (IQR 8 – 21). Fifty-five (83%) patients had LVO of the basilar artery and 11 (17%) of the posterior cerebral artery. Eighteen (27%) patients were treated with SAVE and 21 (32%) with aspiration only. First pass mTICI2c or 3 and overall mTICI2c or 3 were documented in 11/18 (61%) and 14/18 (78%) with SAVE and in 4/21 (19%) and 13/21 (33%) with aspiration only. Median attempt was 1 (IQR 1 – 2) with SAVE and 2 (IQR 1 – 4) with aspiration (p=0.0249). Median groin to reperfusion time did not differ significantly between groups. The rate of sICH was 5% without any complications in the SAVE cohort. Conclusion Mechanical thrombectomy of posterior large vessel occlusions with SAVE is feasible, safe, and effective with high rates of near-complete and complete reperfusion.

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