Abstract P490: Influence of Balloon Guide Catheter Use on Procedural & Clinical Outcomes in the Escape-NA1 Trial

Purpose: We assessed whether balloon guide catheter (BGC) use during endovascular thrombectomy (EVT) influences procedural and clinical outcomes in the ESCAPE-NA1 trial. Methods: ESCAPE-NA1 was an international multicenter trial that randomized large vessel occlusion stroke patients who underwent endovascular thrombectomy (EVT) to receive Nerinetide vs. placebo. Information on EVT techniques and devices was extracted from angiographic images and procedure report forms. Effect estimates of BGC use on angiographic and clinical outcomes were obtained with logistic regression with adjustment for age, ASPECTS, baseline NIHSS, occlusion site, alteplase and study drug treatment. Results: Detailed information on EVT devices and technique was available for 891/1105 (80.6%) patients. A BGC was used in 599/891 patients (67.2%). BGC use was most common with a retrievable stent use (with or without distal access catheter) as the first-line approach (in 252/266 cases [94.7%] vs. combined approach (both aspiration and SR): 288/414 [69.6%], vs. contact aspiration: 37/159 cases [23.3%]). Overall, eTICI 2b/3 rates with vs. without BGC did not differ significantly (525/598 [87.8%] vs. 260/292 [89.0%]), but eTICI 2c/3 rates were significantly higher when a BGC was used (304/598 [50.8%] vs. 126/292 [43.2%], adjusted OR 1.39 [95%CI 1.05 - 1.9]). Good outcomes (mRS 0-2) were not associated with BGC use (adjusted OR 1.07 [95%CI 0.78 - 1.48]). Conclusion: BGC use was associated with a greater proportion of near-complete reperfusion, while there was no significant association with clinical outcomes.

Abstract WP35: Thrombectomy Techniques and Patient Characteristics Associated With Complete TICI 3 Reperfusion After Stroke Thrombectomy

Introduction: Prior randomized trials have defined substantial reperfusion for stroke thrombectomy as TICI 2b or TICI 3. However, recent data suggest that complete TICI 3 reperfusion results in more favorable patient outcomes than partial reperfusion with TICI 2b. We have multiple effective techniques for thrombectomy, but it is not clear which are most likely to achieve TICI 3 rather than TICI 2b reperfuson. Methods: Retrospective data from 15 hospitals were used for patients age 18 or over discharged from January 2014 to May 2019 with a primary or secondary diagnosis of ischemic stroke who received a thrombectomy and achieved TICI reperfusion grade of 2b or 3. Primary outcome was TICI grade 3, defined as complete reperfusion, versus TICI 2b. Multivariate logistic regression was conducted to determine if procedure technique (retrievable stent only, distal aspiration only or a combination approach with both) was associated with achieving TICI 3 versus 2b adjusting for sex, age ≥70 vs ≤69, race/ethnicity, history of chronic renal insufficiency or diabetes, history or newly diagnosed atrial fibrillation or flutter, previous anticoagulation medication. Interaction effects between technique and clinical variables were also tested. Results: The analysis included 787 patients, 67.9% (n=534) TICI 3 and 32.1% (n=253) TICI 2b. While, main effect of procedure technique was not a significant predictor of achieving TICI 3 (p=.451), interaction effects showed superiority of the combination approach in several patient populations. Specifically, the combined approach increased the likelihood of TICI 3 compared to stent retrieval alone for older patients (Adjusted Odds Ratio (AOR) =1.79, p=.007), those with a history of diabetes (AOR=1.56, p=.045) and Asian patients (AOR=4.41, p=.010). Among AFIB/flutter patients, the combined approach also increased the odds of complete reperfusion compared to stent retriever alone (AOR=1.76, p=.005) or distal aspiration alone (AOR=1.38, p=.034). Conclusion: The combined approach of retrievable stent and distal aspiration was a significant predictor of achieving TICI 3 in certain patient subgroups including patients who were older, Asian, had a history of diabetes or history of or current AFIB/flutter.

Abstract WP8: Procedural Times and First Pass Tici-3 With Direct Aspiration vs Retrievable Stents vs for Treatment of Large Vessel Occlusion Stroke: A Systematic Review and Meta-Analysis

Introduction: Randomized trials of direct aspiration (ADAPT) vs retrievable stent (RS) did not show a difference in 90-day outcomes. We searched existing literature for differences in reperfusion times and success between the two techniques. Methods: We performed a systematic review to identify relevant articles in electronic databases and references. Studies comparing ADAPT vs RS and reporting the procedural details and outcomes were included. Random-effect meta-analysis was performed to compare the procedural duration and outcomes. Results: We screened 8578 abstracts and 864 full-text articles. Analysis of 16 studies (2182 ADAPT and 2786 RS patients) reveals no difference in procedural time (D=-5.37 min shorter with ADAPT, 95% CI -19.78 to 9.04; p=0.46), successful reperfusion rate defined as TICI 2b or higher (OR=1.38 in favour of RS, 95% CI 0.98 to 1.96; p=0.07), first pass TICI3 rates (OR=1.29 in favour of RS, 95% CI 0.92 to 1.82; p=0.14) and number of device passes (OR=0.03, 95% CI -0.18 to 0.24; p=0.79). Good functional outcome was also similar (OR=0.89, 95% CI 0.78 to 1.02; p=0.08), as mortality (RR=1.07, 95% CI 0.95 to 1.2; p=0.28), and ICH (RR=1.23, 95% CI 0.99 to 1.52; p=0.06) Conclusions: Existing endovascular techniques appear equally efficient in current literature. Fig. 1. OR forest plot of for successful reperfusion. Fig. 2. Mean D forest plot for groin to reperfusion time.

The neuroprotective mechanisms of ginkgolides and bilobalide in cerebral ischemic injury: a literature review

The incidence and mortality of strokes have increased over the past three decades in China. Ischemic strokes can cause a sequence of detrimental events in patients, including increased permeability and dysfunction of the blood-brain barrier, brain edema, metabolic disturbance, endoplasmic reticulum stress, autophagy, oxidative stress, inflammation, neuron death and apoptosis, and cognitive impairment. Thrombolysis using recombinant tissue plasminogen activator (rtPA) and mechanical embolectomy with a retrievable stent are two recognized strategies to achieve reperfusion after a stroke. Nevertheless, rtPA has a narrow therapeutic timeframe, and mechanical embolectomy has limited rates of good neurological outcomes. EGb761 is a standardized and extensively studied extract of Ginkgo biloba leaves. The ginkgolides and bilobalide that constitute a critical part of EGb761 have demonstrated protective properties towards cerebral injury. Ginkgolides include Ginkgolide A (GA), Ginkgolide B (GB), Ginkgolide C (GC), Ginkgolide J (GJ), Ginkgolide K (GK), Ginkgolide L (GL), and Ginkgolide M (GM). This review seeks to elucidate the neuroprotective effects and mechanisms of ginkgolides, especially GA and GB, and bilobalide in cerebral injury following ischemic strokes.

Endovascular management of acute postprocedural flow diverting stent thrombosis

IntroductionPostprocedural thrombosis is a rare complication after flow diverting stent (FD) implantation for aneurysm treatment with few reported cases in the literature. Management strategies and outcomes associated with this complication have not been reported.MethodsA multicenter retrospective series of cases of acute postprocedural FD thrombosis were compiled and prevalence was calculated based on procedural volumes over a 7 year period. Acute postprocedural FD thrombosis was defined as the development of neurologic deficit with angiographic imaging demonstrating acute thrombus within the index FD stent at least 2 hours following completion of the implantation procedure.ResultsA total of 10 cases of postprocedural thrombosis were identified at five participating centers among a total of 768 patients treated (prevalence 1.3%). Thrombosis occurred a median of 5.5 days after implantation (range 0–83 days). 9/10 patients underwent emergent angiography with intent to perform endovascular reperfusion. A variety of different endovascular treatments were used, including aspiration thrombectomy, retrievable stent thrombectomy, balloon angioplasty, and intra-arterial thrombolytic infusion, without any procedural complications. There were no instances of FD migration, stent kinking, or aneurysm rupture. 90% of patients achieved Thrombolysis in Cerebral Infarction 2B or greater revascularization. Favorable clinical outcomes (modified Rankin Scale score of 0–2) at 3 months were achieved in 88% of patients.ConclusionAcute postprocedural thrombosis of an FD is a rare complication that occurs in approximately 1–2% of patients after aneurysm treatment. Patients presenting with acute postprocedural FD thrombosis should be aggressively managed using large vessel occlusion thrombectomy techniques, as good angiographic and clinical outcomes are possible.