scholarly journals Evidence-Based Updates to Thrombectomy: Targets, New Techniques, and Devices

2021 ◽  
Vol 12 ◽  
Author(s):  
Leonard L. L. Yeo ◽  
Mingxue Jing ◽  
Pervinder Bhogal ◽  
Tianming Tu ◽  
Anil Gopinathan ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Standard Of Care ◽  
Late Presentation ◽  
Vessel Occlusion ◽  
New Techniques ◽  
Endovascular Thrombectomy ◽  
Stent Retrievers ◽  
Tandem Lesions ◽  
Novel Devices ◽  
Improve Patient

Endovascular thrombectomy (EVT) has been validated in several randomized controlled trials in recent years for its efficacy in the treatment of acute ischemic strokes (AIS) and is now the standard of care according to international guidelines. However, in about 20% of EVT procedures, recanalization is not achieved, and over 50% of patients who undergo EVT still do not have good functional outcome. In this article, we provide an extensive review of the latest evidence and developments in the field of EVT, with particular focus on the factors that improve patient outcomes. These factors include new and adjunctive techniques such as combination of direct aspiration and stent retriever, intra-arterial urokinase or 2b/3a inhibitors, rescue stenting, as well as novel devices including balloon guide catheters and the newer generations of aspiration catheters and stent retrievers. We also examined the latest notion of using first-pass effect (FPE) as the target to achieve during EVT, which has been associated with an improved functional outcome. While the field of EVT has been rapidly evolving, further research is required in specific AIS patient populations such as those with large ischemic core, late presentation beyond 24 h, posterior circulation strokes, and with distal medium vessel occlusion or tandem lesions to better assess its efficacy and safety.

Abstract MP33: Association Between Neurologic Outcomes and Temporal Profile of Systolic Blood Pressure Variability After Endovascular Thrombectomy

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Ayush Prasad ◽  
Jessica Kobsa ◽  
Sreeja Kodali ◽  
Cindy Khanh Nguyen ◽  
Darko Quispe Orozco ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Standard Deviation ◽  
Systolic Blood Pressure ◽  
Functional Outcome ◽  
Blood Pressure Variability ◽  
Treatment Strategies ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Increased Risk ◽  
Systolic Blood Pressure Variability

Introduction: Higher systolic blood pressure variability (BPV) after endovascular thrombectomy (EVT) has been associated with an increased risk of hemorrhagic transformation and worse functional outcomes. However, the time-varying behavior of BPV after EVT and its effects on functional outcome have not been well characterized. Methods: We analyzed data from an international cohort of patients with acute large-vessel occlusion stroke who underwent EVT at 11 centers across North America, Europe, and Asia. Repeated time-stamped blood pressure data were recorded for the first 72 hours after thrombectomy. Parameters of BPV were calculated in 12-hour epochs using five established methodologies: standard deviation (SD), coefficient of variation (CV), average real variability (ARV), successive variation (SV), and residual SD (rSD). Patients’ overall mean BPV was then used to assign patients into tertiles for regression analysis: low BPV, intermediate BPV, and high BPV. Functional outcome was measured with the modified Rankin Scale (mRS) at 90 days. Results: Of the 1,791 patients (age 69 ± 14, NIHSS 15 ± 6) included in our analysis, 1,085 (60.6%) had a poor 90-day outcome (mRS >3). Patients with poor outcome had significantly higher systolic BPV (p<0.05) measured as standard deviation (SBP SD) at each epoch (Figure 1B). Compared to patients with low BPV, those in the highest tertile group had significantly greater odds of a poor functional outcome after adjusting for age, sex, hypertension, NIHSS, ASPECT, tPA, time to reperfusion, and TICI score (OR 1.5; 95% CI 1.2-2; p=0.001). Patients in the highest tertile of BPV demonstrated time-dependent variability with the highest SBP SD during the first 24 hours after thrombectomy (Figure 1A). Conclusions: Higher BPV measured by SBP SD appears to be associated with poor 90-day outcome in EVT-treated stroke patients. Early treatment strategies targeting early high BPV warrant further prospective investigation.

scholarly journals Association of Venous Outflow Profiles and Successful Vessel Reperfusion After Thrombectomy

Neurology ◽  
2021 ◽  
pp. 10.1212/WNL.0000000000012106
Author(s):  
Tobias Djamsched Faizy ◽  
Reza Kabiri ◽  
Soren Christensen ◽  
Michael Mlynash ◽  
Gabriella Kuraitis ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Tissue Perfusion ◽  
Secondary Outcome ◽  
Multivariable Logistic Regression Analysis ◽  
Venous Outflow ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Cortical Vein ◽  
Good Functional Outcome ◽  
Pre Treatment

Objective:Robust arterial collaterals are associated with successful reperfusion after thrombectomy treatment of acute ischemic stroke due to large vessel occlusion (AIS-LVO). Excellent venous outflow (VO) reflects excellent tissue perfusion and collateral status in AIS-LVO patients. To determine whether favorable VO profiles assessed on pre-treatment CT angiography (CTA) images correlate with successful vessel reperfusion after thrombectomy in AIS-LVO patients.Methods:Multicenter retrospective cohort study of consecutive AIS-LVO patients treated by thrombectomy. Baseline CTA was used to assess collateral status (Tan scale) and VO using the cortical vein opacification score (COVES). Favorable VO was defined as COVES ≥3. Primary outcome was excellent vessel reperfusion status (modified Thrombolysis In Cerebral Infarction [TICI] 2c-3). Secondary outcome was good functional outcome defined as 0-2 on the Modified Ranking Scale (mRS) after 90 days.Results:565 patients met inclusion criteria. Multivariable logistic regression analysis showed that favorable VO (OR= 2.10 [95% CI 1.39-3.16]; p<0.001) was associated with excellent vessel reperfusion during thrombectomy, regardless of good CTA collateral status (OR= 0.87 [95%CI 0.58-1.34]; p=0.48). A favorable VO profile (OR= 8.9 [95%CI 5.3-14.9]; p<0.001) and excellent vessel reperfusion status (OR = 2.7 [95%CI 1.7-4.4]; p<0.001) were independently associated with good functional outcome adjusted for age, sex, glucose, tPA administration, good CTA collateral status and presentation NIHSS.Conclusion:A favorable VO profile is associated with reperfusion success and good functional outcomes in patients with AIS-LVO treated by endovascular thrombectomy.

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.

scholarly journals Significant aortic stenosis associated with poorer functional outcomes in patients with acute ischaemic stroke undergoing endovascular therapy

2020 ◽  
Vol 26 (6) ◽  
pp. 793-799
Author(s):  
Nicholas JH Ngiam ◽  
Benjamin YQ Tan ◽  
Ching-Hui Sia ◽  
Bernard PL Chan ◽  
Gopinathan Anil ◽  
...  
Keyword(s):  
Aortic Stenosis ◽  
Ischaemic Stroke ◽  
Functional Outcome ◽  
Acute Ischaemic Stroke ◽  
Functional Outcomes ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy

Background and aim Bi-directional feedback mechanisms exist between the heart and brain, which have been implicated in heart failure. We postulate that aortic stenosis may alter cerebral haemodynamics and influence functional outcomes after endovascular thrombectomy for acute ischaemic stroke. We compared clinical characteristics, echocardiographic profile and outcomes in patients with or without aortic stenosis that underwent endovascular thrombectomy for large vessel occlusion acute ischaemic stroke. Methods Consecutive acute ischaemic stroke patients with anterior and posterior circulation large vessel occlusion (internal carotid artery, middle cerebral artery and basilar artery) who underwent endovascular thrombectomy were studied. Patients were divided into those with significant aortic stenosis (aortic valve area <1.5 cm2) and without. Univariate and multivariate analyses were employed to compare and determine predictors of functional outcomes measured by modified Rankin scale at three months. Results We identified 26 (8.5%) patients with significant aortic stenosis. These patients were older (median age 76 (interquartile range 68–84) vs. 67 (interquartile range 56–75) years, p = 0.001), but similar in terms of medical comorbidities and echocardiographic profile. Rates of successful recanalisation (73.1% vs. 78.0%), symptomatic intracranial haemorrhage (7.7% and 7.9%) and mortality (11.5% vs. 12.6%) were similar. Significant aortic stenosis was independently associated with poorer functional outcome (modified Rankin scale >2) at three months (adjusted odds ratio 2.7, 95% confidence interval 1.1–7.5, p = 0.048), after adjusting for age, door-to-puncture times, stroke severity and rates of successful recanalisation. Conclusion In acute ischaemic stroke patients managed with endovascular thrombectomy, significant aortic stenosis is associated with poor functional outcome despite comparable recanalisation rates. Larger cohort studies are needed to explore this relationship further.

scholarly journals Outcomes of Endovascular Thrombectomy with and without Thrombolysis for Acute Large Artery Ischaemic Stroke at a Tertiary Stroke Centre

2017 ◽  
Vol 7 (2) ◽  
pp. 95-102 ◽  
Author(s):  
Chee-Keong Wee ◽  
William McAuliffe ◽  
Constantine C. Phatouros ◽  
Timothy J. Phillips ◽  
David Blacker ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Functional Outcome ◽  
Acute Ischaemic Stroke ◽  
Controlled Trial ◽  
Group Versus ◽  
Large Artery ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Neurological Improvement

Background and Purpose: Endovascular thrombectomy (EVT) improves the functional outcome when added to best medical therapy, including alteplase, in patients with acute ischaemic stroke secondary to large vessel occlusion (LVO) in the anterior circulation. However, the evidence for EVT in alteplase-ineligible patients is less compelling. It is also uncertain whether alteplase is necessary in patients with successful recanalization by EVT, as the treatment effect of EVT may be so powerful that bridging alteplase may not add to efficacy and may compromise safety by increasing bleeding risks. We aimed to survey the proportion of patients suitable for EVT who are alteplase-ineligible and to compare the safety and effectiveness of standard care of acute large artery ischaemic stroke by EVT plus thrombolysis with that of EVT alone in a tertiary hospital clinical stroke service. Methods: We performed a retrospective analysis of acute ischaemic stroke patients treated with EVT at our centre between October 2013 and April 2016, based on a registry with prospective and consecutive patient collection. Individual patient records were retrieved for review. Significant early neurological improvement was defined as a NIHSS score of 0–1, or a decrease from baseline of ≤8, at 24 h after stroke onset. Results: Fifty patients with acute ischaemic stroke secondary to LVO in the anterior circulation received EVT in this period, of whom 21 (42%) received concurrent alteplase and 29 (58%) EVT alone. The 2 groups had similar baseline characteristics and similar outcomes. Significant neurological improvement at 24 h occurred in 47.6% of the patients with EVT and bridging alteplase and in 51.7% of the patients with EVT alone (p = 0.774). Mortality during acute hospitalization was 20% for the bridging alteplase group versus 7.1% for EVT alone (p = 0.184). Intracranial haemorrhage rates were 14.3% for bridging alteplase versus 20.7% for EVT alone (p = 0.716). Local complications, groin haematoma (23.8 vs. 10.3%) and groin pseudoaneurysms (4.8 vs. 0%) (p = 0.170), were not significantly different. Conclusion: Our study highlights the relatively large proportion of patients suitable for EVT who have a contraindication to alteplase and raises the hypothesis that adding alteplase to successful EVT may not be necessary to optimize functional outcome. The results are consistent with observational data from other endovascular centres and support a randomised controlled trial of EVT versus EVT with bridging alteplase.

scholarly journals Endovascular Acute Ischemic Stroke Treatment with FlowGate Balloon Guide Catheter: A Single-Center Observational Study of FlowGate Balloon Guide Catheter Use

2018 ◽  
Vol 7 (6) ◽  
pp. 327-333 ◽  
Author(s):  
Mohamed S. Teleb
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Standard Of Care ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
Guide Catheter ◽  
Stent Retrievers ◽  
Number Of Passes ◽  
Single Center Observational Study

Background: Treatment of large vessel occlusion acute ischemic stroke with mechanical thrombectomy has become the standard of care after recent clinical trials. However, the degree of recanalization with stent retrievers remains very important in overall outcomes. We sought to review the utility of a new balloon guide catheter (BGC) in improving the degree of recanalization in conjunction with mechanical thrombectomy. Methods: The medical records of a prospectively collected endovascular ischemic stroke database were reviewed. All consecutive strokes when a FlowGate BGC was used with a thrombectomy stent retriever were identified. Use of a FlowGate BGC, number of passes, final Thrombolysis in Cerebral Infarction (TICI) score, trackability, and use of adjunct devices were all collected and analyzed. Results: Use of a FlowGate BGC resulted in 64% (33/52) first-pass effect (FPE) of TICI 2b/3, and specifically 46% (24/52) TICI 3 FPE (true FPE). A total of 52/62 (84%) of thrombectomy cases were treated with BGCs. In the remaining 10, the BGC was not inflated or used due to the clot not being visualized or the lesions being distal and BGC use thus not deemed appropriate. Adjunct use of an aspiration catheter was seen in 12% (6/52) of cases. The overall success with FlowGate BGCs with one or more passes of TICI 2b/3 was 94% (49/52). Trackability was achieved in 92% (57/62) of cases. Conclusions: Use of the FlowGate BGC as an adjunct to mechanical thrombectomy was associated with good FPE and an overall recanalization of TICI 2b/3 of 94%.

Abstract TMP89: Impaired Cerebral Autoregulation Increases Risk of Worse Outcome After Endovascular Thrombectomy in Stroke Patients With High Blood Pressure Variability

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Cindy Khanh Nguyen ◽  
Andrew Silverman ◽  
Anson Wang ◽  
Sreeja Kodali ◽  
Sumita Strander ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Functional Outcome ◽  
Near Infrared ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Mean Values ◽  
Monitoring Time ◽  
Increased Risk ◽  
The Mean

Introduction: Both increased blood pressure (BP) variability and impaired autoregulation have been associated with increased risk of poor outcome after endovascular thrombectomy (EVT). The combined effect of these two variables, however, has not yet been elucidated. We hypothesized that the detrimental effects of high BP variability may be amplified by impaired autoregulation. Methods: We prospectively enrolled patients with large-vessel occlusion (LVO) stroke undergoing EVT. Autoregulatory function was continuously measured for up to 48 hours post-EVT by interrogating changes in near-infrared spectroscopy-derived tissue oxygenation (a cerebral blood flow surrogate) in response to changes in BP (Fig. 1A). BP variability was assessed using the standard deviation of the mean. Values were averaged for the entire recording period and dichotomized based on the median. Functional outcome was assessed using the modified Rankin scale (mRS) at 90 days. We examined the association between BP variability, autoregulatory function, and outcome using ordinal logistic regression, adjusting for age and admission NIHSS. Results: Ninety-five patients (mean age 71, NIHSS 14, monitoring time 28±18 hours) were included. BP variability (p=0.043) and autoregulation (p=0.04) were each independently associated with functional outcome. Among patients with high BP variability, worse autoregulation was independently associated with higher (worse) mRS scores at 90 days (OR 3.9, 95% CI 1.1-14.5, p=0.036; Fig. 1B). The proportion of favorable outcome was highest among patients with low BP variability and better autoregulation, and lowest among those with high BP variability and worse autoregulation (p=0.073; Fig. 1C). Conclusion: For LVO stroke patients with high BP variability after EVT, worse functional outcome may be exacerbated by impaired autoregulation. These results suggest that autoregulatory status should be considered in the management of BP after EVT.

Large Vessel Occlusion

2016 ◽  
Author(s):  
Ji Y. Chong ◽  
Michael P. Lerario
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Standard Of Care ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Stent Retrievers ◽  
Iv Tpa

Select patients who are not eligible for IV tPA, or who do not recanalize with IV thrombolysis alone, may be treated with acute endovascular therapies within a 6-hour window. Mechanical thrombectomy, with or without intra-arterial tPA, has recently been shown to be effective in treating acute ischemic stroke caused by large vessel occlusion. Intra-arterial therapy using approved stent retrievers has become the standard of care for acute large vessel occlusion.

scholarly journals Impact of the COVID-19-pandemic on thrombectomy services in Germany

2020 ◽  
Vol 2 (1) ◽  
Author(s):  
Steffen Tiedt ◽  
◽  
Felix J. Bode ◽  
Timo Uphaus ◽  
Anna Alegiani ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Functional Outcomes ◽  
Large Cohort ◽  
Large Vessel ◽  
Time Interval ◽  
Large Vessel Occlusion ◽  
Time Intervals ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Interhospital Transfer

Abstract Background The Coronavirus Disease 2019 (COVID-19) pandemic may have altered emergency workflows established to optimize the outcome of patients with large-vessel occlusion (LVO) stroke. Aims We here analyzed workflow time intervals and functional outcomes of LVO patients treated with endovascular thrombectomy (ET) during the COVID-19 pandemic in Germany. Methods We compared the frequency, pre- and intrahospital workflow time intervals, rates of reperfusion, and functional outcome of patients admitted from March 1st to May 31st 2020 with patients admitted during the same time interval in 2019 to 12 university and municipal hospitals across Germany (N = 795). Results The number of LVO patients treated with ET between March to May 2020 was similar when compared to the same interval in 2019. Direct-to-center patients and patients admitted through interhospital transfer in 2020 showed similar pre- and intrahospital workflow time intervals compared to patients admitted in 2019, except for a longer door-to-groin time in patients admitted through interhospital transfer in 2020 (47 min vs 38 min, p = 0.005). Rates of reperfusion were not significantly different between 2020 and 2019. Functional outcome at discharge of LVO patients treated in 2020 was not significantly different compared to patients treated in 2019. Conclusion Pre- and intrahospital workflows, ET efficacy, and functional outcome of LVO patients treated with ET were not affected during the COVID-19 pandemic in our large cohort from centers across Germany.

scholarly journals Equal performance of aspiration and stent retriever thrombectomy in daily stroke treatment

2018 ◽  
Vol 11 (7) ◽  
pp. 631-636
Author(s):  
Marie Louise Elisabeth Bernsen ◽  
Robert-Jan Berend Goldhoorn ◽  
Robert J van Oostenbrugge ◽  
Wim H van Zwam ◽  
Maarten Uyttenboogaart ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Functional Outcome ◽  
Real Life ◽  
Stent Retriever ◽  
Treatment Technique ◽  
Complication Rates ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
Ordinal Logistic Regression Analysis ◽  
Stent Retrievers

BackgroundMechanical thrombectomy with stent retrievers has proved to be safe and effective in endovascular treatment of acute ischemic stroke. Direct aspiration has shown revascularization rates comparable to those of stent retrievers in the recent ASTER and COMPASS trials. However, the efficacy of aspiration in routine clinical practice has not yet been shown.ObjectiveTo show that aspiration has clinical and technical outcomes equal to those of stent retriever thrombectomy in daily clinical practice.MethodsWe analysed data of patients with a large vessel occlusion of the anterior circulation registered in the Dutch MR CLEAN Registry between March 2014 and June 2016. Primary outcome was functional outcome measured with the modified Rankin Scale (mRS) score. Secondary outcomes were reperfusion grade, periprocedural complication rate, and procedure duration. Association of treatment technique with functional outcome was estimated with univariable and multivariable ordinal logistic regression analysis and expressed as a common OR (cOR) for a shift towards better outcome on the mRS.ResultsAs first-line treatment, 207 of 1175 patients (17.6%) were treated with direct aspiration, and 968 (82.4%) by a stent retriever. We observed no differences in functional outcome (adjusted cOR=1.020 (95% CI 0.68 to 1.52)) and periprocedural complications. Successful reperfusion (extended Thrombolysis in Cerebral Infarction ≥2b) was similar. Duration of the procedure was shorter with aspiration (57 min (IQR 35–73) vs 70 min (IQR 47–95), p<0.0001).ConclusionDirect aspiration shows clinical outcomes equal to those of stent retriever thrombectomy in our large multicenter real-life cohort. We found no difference in complication rates and shorter procedure times for aspiration.

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