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 Endovascular thrombectomy without versus with intravenous thrombolysis in acute ischemic stroke: a non-inferiority meta-analysis of randomized clinical trials

2021 ◽  
pp. neurintsurg-2021-017667
Author(s):  
Chun-Hsien Lin ◽  
Jeffrey L Saver ◽  
Bruce Ovbiagele ◽  
Wen-Yi Huang ◽  
Meng Lee
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Randomized Trials ◽  
Randomized Clinical Trials ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Risk Difference ◽  
Endovascular Thrombectomy ◽  
Symptomatic Intracranial Hemorrhage

ObjectiveTo conduct a meta-analysis of randomized trials to comprehensively compare the effect of endovascular thrombectomy (EVT) versus intravenous thrombolysis (IVT) plus EVT on functional independence (modified Rankin Scale (mRS) 0–2) after acute ischemic stroke due to large vessel occlusions (AIS-LVO).MethodsWe searched Pubmed, EMBASE, CENTRAL, and clinicaltrials.gov from January 2000 to February 2021 and abstracts presented at the International Stroke Conference in March 2021 to identify trials comparing EVT alone versus IVT plus EVT in AIS-LVO. Five non-inferiority margins established in the literature were assessed: −15%, −10%, −6.5%, −5%, and −1.3% for the risk difference for functional independence at 90 days.ResultsFour trials met the selection criteria, enrolling 1633 individuals, with 817 participants randomly assigned to EVT alone and 816 to IVT plus EVT. Crude cumulative rates of 90-day functional independence were 46.0% with EVT alone versus 45.5% with IVT plus EVT. Pooled results showed the risk difference of functional independence was 1% (95% CI −4% to 5%) between EVT alone versus IVT plus EVT. The lower 95% CI bound of −4% fell within the non-inferiority margins of −15%, −10%, −6.5%, and −5%, but not −1.3%. Pooled results also showed the risk difference between EVT alone versus IVT plus EVT was 1% (95% CI −3% to 5%) for mRS 0–1, and 1% (95% CI −1% to 3%) for symptomatic intracranial hemorrhage.ConclusionsThis meta-analysis suggests that EVT alone is non-inferior to IVT plus EVT for several, but not the most stringent, non-inferiority margins.

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 Efficacy and Safety of Endovascular Treatment for Acute Large-Vessel Ischemic Stroke Beyond 6 h After Symptom Onset: A Meta-Analysis

2021 ◽  
Vol 12 ◽  
Author(s):  
Ye Zhongxing ◽  
Liu Zhiqiang ◽  
Wang Jiangjie ◽  
Chen Qing ◽  
Zhang Jinfeng ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Symptom Onset ◽  
Meta Analysis ◽  
Evaluation Criteria ◽  
Functional Independence ◽  
Similar Proportion ◽  
Efficacy And Safety ◽  
Endovascular Thrombectomy ◽  
Significant Difference ◽  
Symptomatic Intracranial Hemorrhage

Background: There is considerable evidence on the benefits of endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) within 6 h after symptom onset. However, uncertainties remain regarding EVT efficacy beyond 6 h after symptom onset. We undertook a meta-analysis to assess the efficacy and safety of EVT in patients with AIS &gt;6 h after symptom onset.Methods: We searched PubMed, EMBASE, and Chinese Biomedical through July 2019. We included studies involving early (≤6 h) vs. delayed (&gt;6 h) EVT in selected patients with AIS, based on radiological evaluation criteria. Functional independence, successful recanalization, mortality, and symptomatic intracranial hemorrhage (sICH) rates were assessed.Results: Eight articles, with 3,265 patients who had undergone early EVT and 1,078 patients who had received delayed EVT, were included in the meta-analysis. Patients treated with early EVT showed a similar proportion of functional independence at 90 days [odds ratio (OR) = 1.14, 95% confidence interval (CI) = 0.926–1.397, P = 0.219; I2 = 36.2%, P = 0.128] as those treated with delayed EVT. Delayed EVT was also associated with no significant difference in mortality (OR = 1.015, 95% CI = 0.852–1.209; P = 0.871; I2 = 0.0%, P = 0.527), successful recanalization (OR = 1.255, 95% CI = 0.923–1.705; P = 0.147; I2 = 60.5%, P = 0.009), and sICH (OR = 0.976, 95% CI = 0.737–1.293; P = 0.871; I2 = 0.0%, P = 0.742) rates compared with early EVT.Conclusions: Among selected patients with AIS, delayed EVT showed comparable outcomes in functional independence, recanalization, mortality, and sICH rates compared with early EVT.

SOFIA catheter for direct aspiration of large vessel occlusion stroke: A single-center cohort and meta-analysis

2021 ◽  
pp. 159101992110053
Author(s):  
Federico Bolognini ◽  
Pablo A Lebedinsky ◽  
Mariano Musacchio ◽  
Mariette Delaitre ◽  
Abdoulaye M Traoré ◽  
...  
Keyword(s):  
Rescue Therapy ◽  
Meta Analysis ◽  
Functional Independence ◽  
Large Vessel ◽  
Study Cohort ◽  
Large Vessel Occlusion ◽  
First Line ◽  
Vessel Occlusion ◽  
Global Rate ◽  
Symptomatic Intracranial Hemorrhage

Background and Purpose Direct aspiration (DA) using large-bore distal aspiration catheters is an established strategy for the endovascular thrombectomy (EVT) of large-vessel occlusion stroke (LVOS). However, the performance of individual catheters like SOFIA has yet to be examined. Methods We present a cohort of 144 consecutive patients treated with first-line DA and SOFIA 6 F Plus catheter for LVOS. We also conducted a systematic review of the literature searching multiple databases for reports on thrombectomy with DA and SOFIA catheters and performed a meta-analysis of recanalization, safety, and clinical outcomes. Results In the study cohort a successful recanalization (mTICI 2b-3) rate of 75.7% was achieved with DA alone, the global rate for functional independence (90-day mRS 0-2) was 40.3%. For the metanalysis we selected nine articles that included a total of 758 patients treated with first-line thrombectomy with the SOFIA catheters. The mTICI 2b-3 rate was 71.6% (95%CI, 66.3-76.5%) while a rescue stent-retriever was used in 24.1% (95%CI, 17.7-31.9%) of cases. The overall mTICI2b-3 rate after DA and rescue therapy was 88.9% (95%CI, 82.6-93.1%). We found a pooled estimate of 45.6% (95%CI, 38.6-52.8%) for functional independence, a mortality within 90 days of 19% (95%CI, 14.1-25.0%) and a rate of 5.8% (95%CI, 4.2-8.0%) of symptomatic intracranial hemorrhage. Conclusion The DA approach for LVOS with the SOFIA catheters is highly effective with an efficacy and safety profile comparable to those found in contemporary thrombectomy trials and observational studies that use other devices or approaches.

Successful mechanical thrombectomy in acute ischemic stroke: revascularization grade and functional independence

2022 ◽  
pp. neurintsurg-2021-018436
Author(s):  
Sherief Ghozy ◽  
Salah Eddine Oussama Kacimi ◽  
Ahmed Y Azzam ◽  
Ramadan Abdelmoez Farahat ◽  
Abdelaziz Abdelaal ◽  
...  
Keyword(s):  
Systematic Review ◽  
Functional Outcomes ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Functional Independence ◽  
Complete Revascularization ◽  
Modified Rankin Scale ◽  
Technical Success ◽  
Endovascular Thrombectomy ◽  
Quantitative Synthesis

Most studies define the technical success of endovascular thrombectomy (EVT) as a Thrombolysis in Cerebral Infarction (TICI) revascularization grade of 2b or higher. However, growing evidence suggests that TICI 3 is the best angiographic predictor of improved functional outcomes. To assess the association between successful TICI revascularization grades and functional independence at 90 days, we performed a systematic review and network meta-analysis of thrombectomy studies that reported TICI scores and functional outcomes, measured by the modified Rankin Scale, using the semi-automated AutoLit software platform. Forty studies with 8691 patients were included in the quantitative synthesis. Across TICI, modified TICI (mTICI), and expanded TICI (eTICI), the highest rate of good functional outcomes was observed in patients with TICI 3 recanalization, followed by those with TICI 2c and TICI 2b recanalization, respectively. Rates of good functional outcomes were similar among patients with either TICI 2c or TICI 3 grades. On further sensitivity analysis of the eTICI scale, the rates of good functional outcomes were equivalent between eTICI 2b50 and eTICI 2b67 (OR 0.81, 95% CI 0.52 to 1.25). We conclude that near complete or complete revascularization (TICI 2c/3) is associated with higher rates of functional outcomes after EVT.

Abstract TP124: 90-Day Disability Outcomes and Stroke Etiology: An ALIAS 2 Secondary Analysis

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Eric D Goldstein ◽  
Vivek K Reddy ◽  
Stephanie Lyden ◽  
Jennifer J Majersik ◽  
Adam de Havenon
Keyword(s):  
Univariate Analysis ◽  
Secondary Analysis ◽  
Large Artery ◽  
Logistic Regression Models ◽  
Stroke Etiology ◽  
Disability Outcome ◽  
Toast Classification ◽  
Iv Tpa ◽  
Toast Criteria

Background: Acute ischemic stroke (AIS) treatment remains a leading cause of global morbidity and mortality despite advancements in therapeutic options. Cardioembolic AIS had previously been associated with the greatest long-term disability and mortality. Our aim is to provide an updated perspective of 90-day disability outcomes with regard to stroke etiology. Methods: This is a secondary analysis of the ALIAS 2 trial. The primary outcome was the 90-day mRS. Stroke etiology was defined based on TOAST criteria. Spearman’s Rho is used to determine correlation between etiology and mRS. Univariate and multivariate logistic regression models are fit to a binary stratification of our outcome (mRS 0-1 vs 2-6). Results: A total of 776 patients were enrolled between 2009 and 2012 with a mean (SD) age of 64.7 (12.7) years. The median (IQR) NIHSS was 11 (8, 17) with 55.3% being male, 76.7% white, and 89.7% having received IV TPA. Large artery atherosclerosis (LAA) (201/776, 25.9%), cardioembolism (271/776, 34.9%) and cryptogenic (196/776, 25.3%) were the most common AIS etiologies. The 90-day mRS had significant differences by TOAST category (rho = 0.013, p<0.001). Individuals with LAA had the highest mean 90-day mRS (Figure 1). LAA was associated with lower odds of good outcome in both univariate analysis (OR 0.68, 95% CI 0.48-0.96) and in a multivariate model (OR 0.66, 95% CI 0.45-0.97) adjusted for age, NIHSS, diabetes, hypertension, hyperlipidemia, sex, white race and administration of IV TPA. Conclusion: Our secondary analysis revealed that AIS with a NIHSS greater than 8 of LAA origin purported a worse 90-day disability outcome. This data may serve to remind clinicians that AIS from LAA may yield comparable or greater disability than cardioembolic AIS. Figure 1: Mean 90-day disability outcome based on TOAST classification. LAA purported worse mean disability outcomes compared to other grouped etiologies.

EXPRESS: Impact of renal impairment on short-term outcomes following endovascular thrombectomy for acute ischemic stroke: A systematic review and meta-analysis

2021 ◽  
pp. 174749302110473
Author(s):  
Jin Pyeong Jeon ◽  
Chih-Hao Chen ◽  
Fon-Yih Tsuang ◽  
Jianming Liu ◽  
Michael D Hill ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Renal Impairment ◽  
Acute Ischemic Stroke ◽  
Meta Analysis ◽  
Functional Independence ◽  
Continuous Variable ◽  
Endovascular Thrombectomy ◽  
Symptomatic Intracerebral Hemorrhage ◽  
The Impact

Background. The impact of renal impairment (RI) on the outcomes of patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT) was relatively limited and contradictory. We performed a systematic review and meta-analysis to investigate this. Aims. We registered a protocol on September 2020 and searched MEDLINE, EMBASE, and Google Scholar accordingly. RI was defined as an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2. Predefined outcomes included functional independence (defined as a modified Rankin Scale of 0, 1, or 2) at 3 months, successful reperfusion, mortality, and symptomatic intracerebral hemorrhage (sICH). Summary of review. Eleven studies involving 3453 patients were included. For the unadjusted outcomes, RI was associated with fewer functional independence (odds ratio (OR), 0.49; 95% confidence interval (CI), 0.39–0.62) and higher mortality (OR, 2.55; 95% CI, 2.03–3.21). RI was not associated with successful reperfusion (OR, 0.80; 95% CI 0.63–1.00) and sICH (OR, 1.41; 95% CI, 0.95–2.10). For the adjusted outcomes, results derived from a multivariate meta-analysis were consistent with the respective unadjusted outcomes: functional independence (OR, 0.59; 95% CI, 0.45–0.77), mortality (OR, 2.23, 95% CI, 1.45–3.43), and sICH (OR, 1.34; 95% CI, 0.85–2.10). Conclusions. We presented the first systematic review to demonstrate that RI is associated with fewer functional independence and higher mortality. Future EVT studies should publish complete renal eGFR data to facilitate prognostic studies and permit eGFR to be analyzed in a continuous variable. Systematic Review Registration: PROSPERO CRD42020191309

Thrombectomy for acute ischemic stroke in nonagenarians compared with octogenarians

2019 ◽  
Vol 12 (3) ◽  
pp. 266-270 ◽  
Author(s):  
Eric S Sussman ◽  
Blake Martin ◽  
Michael Mlynash ◽  
Michael P Marks ◽  
David Marcellus ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Independence ◽  
Inclusion Criteria ◽  
Related Factors ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Improved Outcomes ◽  
Symptomatic Intracranial Hemorrhage ◽  
The Difference

IntroductionMultiple randomized trials have shown that endovascular thrombectomy (EVT) leads to improved outcomes in acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Elderly patients were poorly represented in these trials, and the efficacy of EVT in nonagenarian patients remains uncertain.MethodsWe performed a retrospective cohort study at a single center. Inclusion criteria were: age 80–99, LVO, core infarct <70 mL, and salvageable penumbra. Patients were stratified into octogenarian (80–89) and nonagenarian (90–99) cohorts. The primary outcome was the ordinal score on the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included dichotomized functional outcome (mRS ≤2 vs mRS ≥3), successful revascularization, symptomatic intracranial hemorrhage (ICH), and mortality.Results108 patients met the inclusion criteria, including 79 octogenarians (73%) and 29 nonagenarians (27%). Nonagenarians were more likely to be female (86% vs 58%; p<0.01); there were no other differences between groups in terms of demographics, medical comorbidities, or treatment characteristics. Successful revascularization (TICI 2b–3) was achieved in 79% in both cohorts. Median mRS at 90 days was 5 in octogenarians and 6 in nonagenarians (p=0.09). Functional independence (mRS ≤2) at 90 days was achieved in 12.5% and 19.7% of nonagenarians and octogenarians, respectively (p=0.54). Symptomatic ICH occurred in 21.4% and 6.4% (p=0.03), and 90-day mortality rate was 63% and 40.9% (p=0.07) in nonagenarians and octogenarians, respectively.ConclusionsNonagenarians may be at higher risk of symptomatic ICH than octogenarians, despite similar stroke- and treatment-related factors. While there was a trend towards higher mortality and worse functional outcomes in nonagenarians, the difference was not statistically significant in this relatively small retrospective study.

scholarly journals No Association Between Thrombus Perviousness and Cardioembolic Stroke Etiology in Basilar Artery Occlusion Stroke

2021 ◽  
Vol 12 ◽  
Author(s):  
Anna Kufner ◽  
Matthias Endres ◽  
Michael Scheel ◽  
Christoph Leithner ◽  
Christian H. Nolte ◽  
...  
Keyword(s):  
Basilar Artery ◽  
Binary Logistic Regression ◽  
Artery Occlusion ◽  
Cardioembolic Stroke ◽  
Basilar Artery Occlusion ◽  
Large Artery ◽  
Anterior Circulation ◽  
Stroke Etiology ◽  
Proximal Middle Cerebral Artery

Background: Thrombus perviousness (TP) quantified by thrombus attenuation increase (TAI) assessed on acute non-contrast computed tomography (NCCT) and CT angiography (CTA) may be associated with stroke etiology in anterior circulation ischemic stroke. We investigated whether TP is associated with stroke etiology and recanalization after mechanical thrombectomy in patients with acute basilar artery occlusion (BAO).Methods: Eighty patients with complete BAO and in-house acute imaging from a prospectively maintained database were included. Two raters independently segmented the complete thrombus on co-registered NCCT and CTA to determine TAI in Hounsfield units (HUCTA–HUNCCT); averaged values of the raters were used for analysis. Recanalization to modified treatment in cerebral ischemia (mTICI) score 2b/3 was considered successful, and 90-day modified Rankin Scale score 0–2 was considered favorable.Results: TAI did not differ between patients with different stroke etiologies; median TAI in patients with cardioembolic stroke (n = 36) was −0.47 (interquartile range −4.08 to 7.72), 1.94 (−8.14 to 10.75) in patients with large artery atherosclerosis (LAA; n = 25), and −0.99 (−6.49 to 5.40) in patients with stroke of undetermined origin (n = 17; p = 0.955). Binary logistic regression analyses did not identify TAI as an independent indicator of cardioembolic stroke (adjusted odds ratio [OR] vs. LAA stroke: 1.0 [95% CI: 0.95–1.0], p = 0.751). There was no association with successful recanalization (adjusted OR 1.4 [0.70–2.7], p = 0.345) or favorable outcome (adjusted OR 1.1 [95% CI: 0.94–1.2], p = 0.304).Conclusion: In contrast to proximal middle cerebral artery occlusions, TP in BAO patients is not associated with cardioembolic stroke etiology. Larger confirmatory studies to establish the potential role of TP for clinical applications should focus on patients with anterior circulation stroke.

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