TREVO stent-retriever mechanical thrombectomy for acute ischemic stroke secondary to large vessel occlusion registry

Factors and outcomes associated with National Institutes of Health stroke scale scores in acute ischemic stroke patients undergoing thrombectomy in United States

BACKGROUND AND PURPOSE

The National Institutes of Health Stroke Scale (NIHSS) is the standard for assessing neurological deficits in acute ischemic stroke patients undergoing thrombectomy. However, data on NIHSS scores in patients undergoing thrombectomy at national-level studies in the United States are lacking.

METHODS

Acute ischemic stroke patients admitted between 2018 and 2021 were identified using ICD-10-CM codes from the Nationwide In-patient Sample, with NIHSS scores categorized into specific strata (0-9, 10-19, 20-29, 30-42). We analyzed the effect of NIHSS scores on in-hospital mortality, routine discharge without palliative care (based on discharge disposition), and length and costs of hospitalization after adjusting for potential confounders.

RESULTS

The NIHSS score strata among 108,990 acute ischemic stroke patients undergoing thrombectomy were: NIHSS score 0-9 (29.6 %), 10-19 (40.6 %), 20-29 (26.4 %), and 30-42 (3.4 %). Patients in the Midwest and West regions (adjusted odds ratio [adjusted OR] = 1.51, p = 0.002 and adjusted OR = 1.63, p < 0.001, respectively), those treated in rural hospitals (adjusted OR = 1.35, p = 0.009) and those who were self-pay (adjusted OR = 1.51, p = 0.048) had higher odds of being in higher NIHSS score strata. Patients in higher NIHSS score strata (NIHSS score 10-19, 20-29, and 30-42 had significantly lower odds of discharge home without palliative care (adjusted OR= 0.50, 0.32, and 0.22 respectively, all p < 0.001) and higher odds of in-hospital mortality (adjusted OR = 1.51, 2.30, and 3.80 respectively, all p < 0.001) compared to those in NIHSS score strata of 0-9. Patients in higher NIHSS score strata had significantly higher hospital stays and higher hospitalization costs.

CONCLUSIONS

We provide a comprehensive national-level analysis of NIHSS scores in acute ischemic stroke patients undergoing thrombectomy which may assist in understanding variations in outcomes and resource utilizations in United States.

National trends in patient characteristics, interventional techniques and outcomes of endovascular treatment for acute ischaemic stroke: Final results of the MR CLEAN Registry (2014-2018)

INTRODUCTION

Endovascular thrombectomy (EVT) procedures and workflow have evolved over the years. We examined trends in patient characteristics, EVT techniques and outcomes over 5 years in the Netherlands.

PATIENTS AND METHODS

Data from the MR CLEAN Registry (2014-2018) were analysed, including patients treated with EVT for anterior circulation acute ischaemic stroke (AIS). Patients were grouped by year of inclusion except for the linear regression analysis where the inclusion date was used. Baseline predicted probability of poor outcome (modified Rankin Scale (mRS) score 3-6) was calculated using a validated prediction model. Primary outcome was mRS score at 90 days. Secondary outcomes included workflow times, EVT techniques, successful reperfusion (eTICI ⩾ 2B) and symptomatic intracranial haemorrhage (sICH). Time trends were analysed using multivariable regression models (adjusted common odds ratios (acOR) per year).

RESULTS

5193 patients were included. Median age increased (from 66 in 2014 to 74 years in 2018 [p < 0.001]). Proportion of patients with pre-stroke dependence (mRS ⩾ 3) increased from 2014 through 2018 (9% to 16%, p < 0.001). Baseline predicted probability of poor outcome did not change (60% vs 66%, p = 0.06). Over time, functional outcomes improved (acOR 1.14 per year, 95%CI: 1.09-1.20); mortality decreased (aOR 0.88 per year, 95%CI: 0.83-0.94). EVT under local anaesthesia increased (from 46% in 2014 to 70% in 2018; aOR 1.15, 95%CI: 1.10-1.22), as did use of direct aspiration (13%-36%; aOR 1.43, 95%CI: 1.35-1.53). Successful reperfusion became more frequent (aOR 1.32 per year, 95%CI: 1.25-1.40), despite needing more attempts (1 in 2014 vs 2 in 2018, aOR 0.93 per year, 95%CI: 0.89-0.98). Incidence of sICH remained unchanged (5% vs 5%, aOR 0.99 per year, 95%CI: 0.89-1.09). Time from emergency room to groin puncture reduced by 7 min per year (95%CI: 5-8).

DISCUSSION AND CONCLUSION

Enhanced workflow and increased EVT experience may have led to shorter time to treatment and more frequent successful reperfusion, with better functional outcomes over 5 years, despite treating older, more dependent patients.

Effectiveness and safety of the Trevo® Retriever for mechanical thrombectomy in Chinese patients with acute ischemic stroke: Trevo Retriever China Registry

BACKGROUND

To quantify the effectiveness and safety of the Trevo® Retriever for endovascular treatment of acute ischemic stroke (AIS) patients in China.

METHODS

Trevo Retriever Registry (China) was a prospective, multicenter, non-comparative, open-label study of patients with AIS treated with the Trevo Retriever. The primary outcome was the proportion of patients achieving an expanded Thrombolysis in Cerebral Infarction (eTICI) score ≥2b at the end of endovascular treatment. Secondary outcomes included first-pass eTICI score ≥2b and 90-day modified Rankin Scale (mRS) score ≤2.

RESULTS

The Trevo Retriever Registry (China) enrolled and followed 201 patients (62.1 ± 12.5 years-old; 70.6% male) at 11 centers. The pre-procedure NIHSS score and ASPECTS were 16 (interquartile range (IQR), 13-21) and 7 (IQR, 6-9), respectively, and 188 (93.5%) patients had an mRS score of 0 prior to the stroke. The main stroke etiology was large artery atherosclerosis, accounting for 71.6% (144/201) of patients. Post-procedure eTICI ≥2b was 98.4% (187/190). First-pass eTICI ≥2b was 74.7% (136/182). The 90-day good outcome (mRS ≤2) rate was 73.6% (148/201). The 90-day all-cause mortality was 5.5% (11/201). Neurological deterioration at 24 h post-procedure was observed in 7.7% (15/195) patients. Embolism in a new territory was seen in one patient (0.5%). Two (1.0%) procedure-related adverse events (AEs) occurred, which were intra-procedure cerebral artery embolism. No Trevo related AEs occurred.

CONCLUSIONS

This real-world study of the Trevo Retriever in China demonstrated a high rate of revascularization and first-pass success that resulted in an overall high good function outcome rate and low mortality.

Comparison of combined intravenous and intra-arterial thrombolysis with intravenous thrombolysis alone in stroke patients undergoing mechanical thrombectomy: a propensity-matched analysis

BACKGROUND

A combination of intravenous (IVT) or intra-arterial (IAT) thrombolysis with mechanical thrombectomy (MT) for acute ischemic stroke due to large vessel occlusion (AIS-LVO) has been investigated. However, there is limited data on patients who receive both IVT and IAT compared with IVT alone before MT.

METHODS

STAR data from 2013 to 2023 was utilized. We performed propensity score matching between the two groups. The primary outcomes were symptomatic intracranial hemorrhage (sICH) and 90-day modified Rankin Scale (mRS) score 0-2. Secondary outcomes included successful recanalization (modified treatment in cerebral infarction (mTICI) ≥2B, ≥2C), early neurological improvement, any intracranial hemorrhage (ICH), and 90-day mortality.

RESULTS

A total of 2454 AIS-LVO patients were included. Propensity matching yielded 190 well-matched patients in each group. No significant differences were observed between the groups in either ICH or sICH (odds ratio (OR): 0.80, 95% confidence interval (CI) 0.51-1.24, P=0.37; OR: 0.60, 95% CI 0.29 to 1.24, P=0.21, respectively). Rates of successful recanalization and early neurological improvement (ENI) were significantly lower in MT+IVT + IAT. mRS 0-1 and mortality were not significantly different between the two groups. However, the MT+IVT + IAT group demonstrated superior rates of good functional outcomes (90-day mRS 0-1) compared with patients in the MT+IVT group who had mTICI ≤2B, (OR: 2.18, 95% CI 1.05 to 3.99, P=0.04).

CONCLUSION

The combined use of IAT and IVT thrombolysis in AIS-LVO patients undergoing MT is safe. Although the MT+IVT+ IAT group demonstrated lower rates of recanalization and early neurological improvement, long-term functional outcomes were favorable in this group suggesting a potential delayed benefit of IAT.

Thrombectomy for Anterior Circulation Stroke with a Hybrid Cell Design Stent Retriever: A Multicenter Registry

Objective

Thrombectomy is the standard recanalization treatment for acute ischemic stroke (AIS) due to large vessel occlusions (LVO). However, thrombectomy was validated using a few brands of devices. New types of thrombectomy devices have been developed, and assessing their safety and efficacy is essential. This study aimed to evaluate the safety and efficacy of thrombectomy with the Aperio Hybrid stent retriever (Acandis, Pforzheim, Germany) in the treatment of patients with AIS due to anterior circulation LVO.

Methods

This was a multicenter registry of thrombectomy in the treatment of stroke due to anterior circulation LVO. Between January 2022 and January 2024, a total of 128 patients were included.

Results

The mean procedure time was 62 minutes. The rates of the main outcomes were recanalization (extended treatment in cerebral ischemia 2b-3) 102/128 (79.7%), symptomatic intracranial hemorrhage 9/128 (7.0%), good clinical outcome (modified Rankin Scale = 0-2) 67/128 (52.3%), and mortality 24/128 (18.7%) at 3 months.

Conclusion

This study showed that, in a multicenter real-life scenario, the Aperio hybrid stent retriever was safe and effective for thrombectomy of anterior circulation strokes. The outcomes of this study were similar to those of previous large thrombectomy studies.

The safety and efficacy of NeVa mechanical thrombectomy device in acute ischemic stroke: A systematic review and meta-analysis

BACKGROUND

Recent favorable cohort studies on endovascular therapy for ischemic stroke have predominantly utilized NeVa thrombectomy (NeVaTM) stent retrievers. We carried out a systematic review and meta-analysis to investigate the efficacy and safety of this second-generation stent retriever in acute ischemic stroke patients.

METHOD

We conducted the study according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The electronic databases of PubMed, Embase, and Scopus were searched until 26 November 2023 and was updated on August 1, 2024.

RESULTS

This meta-analysis systematically investigated 11 studies with a total of 805 patients suffering from ischemic stroke. The mean age of participants across the studies ranged from 65 to 77 years with a male preponderance of 50.16 %. While ten studies reported on the etiology of strokes, some studies reported the risk factors such as hypertension, dyslipidemia, diabetes, history of coronary artery disease, and previous stroke. The results of our study indicate that the all-hemorrhagic complications rate was 0.32 (95 %CI: 0.18-0.45), while the complete arterial recanalization rate was 0.76 [95 %CI: 0.49-1.04]. The overall recanalization rate was found to be 0.97 [95 %CI: 0.94-1.00]. Moreover, the postoperative hemorrhage rate was 0.28 [95 %CI: 0.14-0.41], while the repeated re-thrombosis rate was 0.01 [95 %CI: -0.01-0.03]. Lastly, the vasospasm rate was calculated to be 0.09 [95 %CI: -0.03-0.21].

CONCLUSION

NeVa™ is a safe option capable of achieving a high rate of recanalization and functional independence.

ABBREVIATIONS

PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PROSPERO, International Prospective Register of Systematic Reviews; NeVa™, NeVa Thrombectomy; ICH, Intracranial Hemorrhage; mTICI, modified Thrombolysis in Cerebral Infarction; mRS, modified Rankin Scale; ACA, Anterior Cerebral Artery; MCA, Middle Cerebral Artery; PCA, Posterior Cerebral Artery; ICA, Internal Carotid Artery; NIHSS, National Institutes of Health Stroke Scale.

A direct aspiration first-pass technique (ADAPT) for acute ischemic stroke thrombectomy: Indications, technique, and emerging devices

To date, the use of the most suitable first-pass technique for Mechanical Thrombectomy is still debated. In last years, several observational studies have suggested noninferiority or superiority of A Direct Aspiration first-Pass Technique (ADAPT) technique to achieve better reperfusion in comparison to stent retriever. While ASA/AHA 2018 guidelines recommend that patients with AIS should receive Mechanical Thrombectomy with a stent retriever, last European Stroke Organization guidelines report no evidence that stent retriever compared with contact aspiration could improve reperfusion rate. ADAPT is based on aspiration alone as the primary mechanism of thrombectomy and, if initially unsuccessful, then incorporating adjunctive alternatives. ADAPT improvement is also related to last generation of aspiration catheters. The purpose of this review is to report ADAPT principles, technique, efficacy, and safety as first-line treatment for acute ischemic stroke with the latest generation of reperfusion devices.

Stent Retriever AssIsted Lysis Technique with Tirofiban: A Potential Bailout Alternative to Angioplasty and Stenting

BACKGROUND AND PURPOSE

Angioplasty and stent placement have been described as a bailout technique in individuals with failed thrombectomy. We aimed to investigate Stent retriever AssIsted Lysis (SAIL) with tirofiban before angioplasty and stent placement.

MATERIALS AND METHODS

Patients from 2 comprehensive stroke centers were reviewed (2020-2023). We included patients with failed thrombectomy and/or underlying intracranial stenosis who received SAIL with tirofiban before the intended angioplasty and stent placement. SAIL consisted of deploying a stent retriever through the occluding lesion to create a bypass channel and infuse 10 mL of tirofiban for 10 minutes either intra-arterially or IV. The stent retriever was re-sheathed before retrieval. The primary end points were successful reperfusion (expanded TICI 2b-3) and symptomatic intracerebral hemorrhage. Additional end points included 90-day mRS 0-2 and mortality.

RESULTS

After a median of 3 (interquartile range, 2-4) passes, 44 patients received the SAIL bridging protocol with tirofiban, and later they were considered potential candidates for angioplasty and stent placement bailout (43.2%, intra-arterial SAIL). Post-SAIL successful reperfusion was obtained in 79.5%. A notable residual stenosis (>50%) after successful SAIL was observed in 45.7%. No significant differences were detected according to post-SAIL: successful reperfusion (intra-arterial SAIL, 80.0% versus IV-SAIL, 78.9%; P = .932), significant stenosis (33.3% versus 55.0%; P = .203), early symptomatic re-occlusion (0% versus 8.0%; P = .207), or symptomatic intracerebral hemorrhage (5.3% versus 8.0%; P = .721). Rescue angioplasty and stent placement were finally performed in 15 (34.1%) patients (intra-arterial SAIL 21.0% versus IV-SAIL 44%; P = .112). At 90 days, mRS 0-2 (intra-arterial SAIL 50.0% versus IV-SAIL 43.5%; P = .086) and mortality (26.3% versus 12.0%; P = .223) were also similar.

CONCLUSIONS

In patients with stroke in which angioplasty and stent placement are considered, SAIL with tirofiban, either intra-arterial or IV, seems to safely induce sustained recanalization, offering a potential alternative to definitive angioplasty and stent placement.

Evolution and advances in endovascular mechanical thrombectomy of cerebral venous sinus thrombosis

Cerebral venous sinus thrombosis (CVST) is a rare type of stroke and standard treatment involves anticoagulation. However, for some special CVST patients who are ineligible for anticoagulation or refractory to conservative treatment, endovascular treatment (EVT) may be an effective option. Mechanical thrombectomy (MT) is a commonly used treatment. Compared with anticoagulation treatment alone, MT may result in additional procedure-related complications, however, many studies have shown that it has a high rate of vessel recanalization and lower incidence of related complications in arterial large vessel occlusion stroke. In addition, the applicability of MT in children, patients with deep cerebral thrombosis, and patients with bleeding before treatment has been reported. MT combined with intravascular thrombolysis (IVT) and other multimodal therapeutic strategies, also has a good curative effect, and further research is needed to compare and optimize different treatment strategies. Owing to the low incidence of CVST, randomized controlled clinical trials with a large sample size to explore the safety and effectiveness of MT are scarce. In addition, devices specifically designed for cerebral venous sinus and effective endovascular therapies are currently not well-established. This article summarizes different endovascular instruments and multimodal therapies for cerebral venous thrombosis. We also discuss the limitations, prospects, prognostic factors, and applications in special cases of interventional thrombectomy.

Endovascular thrombectomy in patients with anterior circulation stroke: an emulated real-world comparison

BACKGROUND

Endovascular thrombectomy (EVT) has been proven effective in anterior circulation stroke due to large vessel occlusion (LVO). However, translation from randomized clinical trials (RCTs) with highly selected patients to real-world requires confirmation, particularly to identify associations outside of strict selection criteria.

AIMS

This study aims to compare functional outcomes after EVT in real-world with those reported in RCTs, and to identify associations with functional outcome after EVT outside RCT-criteria.

METHODS

This study analyzed longitudinal German real-world data from the Stroke Research Consortium in Northern Bavaria (STAMINA) cohort from January, 2015 to June, 2019. We conducted a trial emulation, comparing patients with anterior circulation stroke and LVO meeting selection criteria for RCTs investigating EVT (1) predominantly within 6 hours with those from HERMES meta-analysis, and (2) within 6-24 hours with those from AURORA meta-analysis. We (3) analyzed treatment effects of EVT and association with functional outcome in patients treated outside RCT criteria.

RESULTS

Of 598 patients, 281 (47.0%) met RCT-criteria for treatment within 6 hours (hereinafter STAMINA-HERMES), 74 (12.4%) met RCT-criteria for treatment within 6-24 hours (STAMINA-AURORA), and 277 (46.3%) patients received EVT outside RCT-criteria. We observed no difference in rates of functional independence or mortality, comparing STAMINA-HERMES with HERMES meta-analysis (mRS 0-1: n=120/281 [43%] vs. 291/633 [46%], p=0.36; mortality: n=34/281 [12%] vs. 97/633 [15%], p=0.20), and STAMINA-AURORA with AURORA meta-analysis (mRS 0-1: n=26/74 [35%] vs. 122/266 [46%], p=0.10, mortality: n=10/74 [14%] vs. 45/266 [17%], p=0.48). Patients treated outside RCT-criteria had worse outcome (mRS 0-1: n=38/277 [14%], mortality: n=90/277 [32%], both p<0.001); possibly driven by pre-existing functional dependence (n=172/277 [62%]). Compared to matched controls, EVT outside of RCT-criteria was associated with lower mortality (absolute treatment effect: -14%, 95% Confidence Interval [CI] -23 to -5, p<0.01), but not with recovery to functional independence or premorbid functional status (treatment effect: 4%, CI -4 to 11, p=0.34), which was associated with lower NIHSS (Odds ratio [OR] 0.86, CI 0.80-0.92, p<0.001) and age (OR 0.95, CI 0.93-0.98, p=0.002).

CONCLUSIONS

Translation of EVT outcomes reported in RCTs into real-world is possible, however, almost half of patients did not meet trial criteria. Identification of patients who functionally benefit from frequently performed EVT outside RCT-criteria requires further investigation.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT04357899.

A prospective, multicentre, registry study of RECO in the endovascular treatment of acute ischaemic stroke

The RECO is a novel endovascular treatment (EVT) device that adjusts the distance between two mesh segments to axially hold the thrombus. We organized this postmarket study to assess the safety and performance of RECO in acute ischaemic stroke (AIS) patients with large vessel occlusion (LVO). This was a single-arm prospective multicentre study that enrolled patients as first-line patients treated with RECO at 9 stroke centres. The primary outcome measures included functional independence at 90 days (mRS 0-2), symptomatic intracranial haemorrhage (sICH), time from puncture to recanalization and time from symptom onset to recanalization. The secondary outcome measures were a modified thrombolysis in cerebral infarction (mTICI) score of 2b or 3 after the first attempt and at the end of the procedure and the all-cause mortality rate within 90 days. From May 22, 2020, to July 30, 2022, a total of 268 consecutive patients were enrolled in the registry. The median puncture-to-recanalization time was 64 (IQR, 45-92), and the symptom onset-to-recanalization time was 328 min (IQR, 228-469). RECO achieved successful reperfusion (mTICI 2b-3) after the first pass in 133 of 268 patients (49.6%). At the end of the operation, 96.6% of the patients reached mTICI 2b-3, and 97.4% of the patients ultimately achieved successful reperfusion. Sixteen (7.2%) patients had sICH. A total of 132 (49.3%) patients achieved functional independence at 90 days, and the all-cause mortality rate within 90 days was 17.5%. In this clinical experience, the RECO device achieved a high rate of complete recanalization with a good safety profile and favourable 90-day clinical outcomes.Clinical trial registration: URL: https://www.clinicaltrials.gov/ ; Unique identifier: NCT04840719.

Prognostic Determinants of Anterior Large Vessel Occlusion in Acute Stroke in Elderly Patients

This study investigated prognostic factors in elderly patients (80 years and older) undergoing mechanical thrombectomy (MT) for anterior circulation large vessel occlusion (LVO) in acute stroke treatment. Of 59 cases, 47.5% achieved a favorable outcome (mRS ≤ 3) at three months, with a mortality rate of 20.3%. Factors associated with better outcomes included younger age, lower admission National Institute of Health Stroke Scale (NIHSS) scores, lower N-terminal pro-brain natriuretic peptide (NT-proBNP) and D-dimer levels, the presence of the first pass effect (FPE), and successful recanalization. However, logistic regression showed that only lower admission NIHSS scores were significantly correlated with favorable outcomes. In addition, this study suggests that lower admission NT-proBNP and D-dimer levels could potentially serve as prognostic indicators for elderly LVO patients undergoing MT.

Evaluation of effectiveness and safety of the multizone NeVaTM stent retriever for mechanical thrombectomy in ischemic stroke

PURPOSE

This study aimed to evaluate the effectiveness and safety of the NeVaTM stent retriever as first- and second-line device for mechanical thrombectomy in acute ischemic stroke.

METHODS

In this retrospective single-center study, all consecutive patients that underwent mechanical thrombectomy with NeVaTM stent retriever as first- or second-line device due to intracranial vessel occlusion with acute ischemic stroke between March and November 2022 were included.

RESULTS

Thirty-nine patients (m=18, f=21) with a mean age of 69.9 ± 13.3 years were treated with the NeVaTM stent retriever. NeVaTM stent retriever was used as first-line device in 24 (61.5%) of patients and in 15 (38.5%) as second-line device. First-pass rate (≥mTICI 2c) of NeVaTM stent retriever was both 66.7% when used as first- or second-line device. Final recanalization rate including rescue strategies was 92.3% for ≥mTICI2c and 94.9% for ≥mTICI2b. No device-related minor or major adverse events were observed. A hemorrhage was detected in 33.3% of patients at 24h post-thrombectomy dual-energy CT, of which none was classified as symptomatic intracerebral hemorrhage. NIHSS and mRS improved significantly at discharge compared to admission (p<0.05).

CONCLUSION

The NeVaTM stent retriever has a high effectivity and good safety profile as first- and second-line device for mechanical thrombectomy in acute ischemic stroke.

Mechanical thrombectomy with a new intermediate balloon catheter combining the BGC and DAC features: Initial clinical experience with the iNedit device

INTRODUCTION

The iNedit balloon distal access catheter is a novel thrombectomy device. It has an inner diameter of 0.058″, proximal outer diameter of 2.13 mm, and distal outer diameter of 1.67mm. It is compatible with a 0.088″ guide catheter and includes a balloon located 5 cm from the catheter tip, enabling proximal flow restriction and combined therapy with stent retrievers. We investigate the appraisal of the use, safety, and efficacy of the iNedit catheter in the first-in-human study.

METHODS

In the preliminary cases that demanded training on the product previous to a multicentric study, prospective data were collected on 22 consecutive patients treated with the iNedit catheter to perform thrombectomy for acute ischemic stroke due to large vessel occlusion within 24 h. The outcome measures consisted of several evaluations of user experience rated on a 5-point scale ranging from 1 (bad) to 5 (excellent), as well as assessments of procedural safety outcomes such as artery perforation and arterial occlusion, procedural efficacy outcomes including first-pass effect (Thrombolysis In Cerebral Infarction [TICI] 2c/3) and final recanalization (TICI 2b/3), and clinical efficacy outcomes such as a 3-month 0-2 modified Rankin Scale (mRS).

RESULTS

The mean age was 72 ± 12 years old; median National Institute Health Stroke Scale was 17 (11-19). Sites of primary occlusion were: 2 internal carotid artery, 12 M1-MCA, 7 M2-MCA, and one P1. Median score evaluation of the appraisal of use was 4- IQR [4-5]. The median number of passes was 1 [IQR 1-2]. First pass complete recanalization rate was 50% and the final recanalization rate was 94.45%. No artery perforation and arterial occlusion. Good functional outcome mRS 0-2 was achieved in 50% of patients.

CONCLUSIONS

In this initial clinical experience, iNedit device achieved a high rate of first-pass effect and final recanalization rate with no safety concerns, thus favoring a high percentage of good clinical outcomes.

Association Between Intravenous Thrombolysis and Clinical Outcomes Among Patients With Ischemic Stroke and Unsuccessful Mechanical Reperfusion

Importance

Clinical evidence of the potential treatment benefit of intravenous thrombolysis preceding unsuccessful mechanical thrombectomy (MT) is scarce.

Objective

To determine whether intravenous thrombolysis (IVT) prior to unsuccessful MT improves functional outcomes in patients with acute ischemic stroke.

Design, Setting, and Participants

Patients were enrolled in this retrospective cohort study from the prospective, observational, multicenter German Stroke Registry-Endovascular Treatment between May 1, 2015, and December 31, 2021. This study compared IVT plus MT vs MT alone in patients with acute ischemic stroke due to anterior circulation large-vessel occlusion in whom mechanical reperfusion was unsuccessful. Unsuccessful mechanical reperfusion was defined as failed (final modified Thrombolysis in Cerebral Infarction grade of 0 or 1) or partial (grade 2a). Patients meeting the inclusion criteria were matched by treatment group using 1:1 propensity score matching.

Interventions

Mechanical thrombectomy with or without IVT.

Main Outcomes and Measures

Primary outcome was functional independence at 90 days, defined as a modified Rankin Scale score of 0 to 2. Safety outcomes were the occurrence of symptomatic intracranial hemorrhage and death.

Results

After matching, 746 patients were compared by treatment arms (median age, 78 [IQR, 68-84] years; 438 women [58.7%]). The proportion of patients who were functionally independent at 90 days was 68 of 373 (18.2%) in the IVT plus MT and 42 of 373 (11.3%) in the MT alone group (adjusted odds ratio [AOR], 2.63 [95% CI, 1.41-5.11]; P = .003). There was a shift toward better functional outcomes on the modified Rankin Scale favoring IVT plus MT (adjusted common OR, 1.98 [95% CI, 1.35-2.92]; P < .001). The treatment benefit of IVT was greater in patients with partial reperfusion compared with failed reperfusion. There was no difference in symptomatic intracranial hemorrhages between treatment groups (AOR, 0.71 [95% CI, 0.29-1.81]; P = .45), while the death rate was lower after IVT plus MT (AOR, 0.54 [95% CI, 0.34-0.86]; P = .01).

Conclusions and Relevance

These findings suggest that prior IVT was safe and improved functional outcomes at 90 days. Partial reperfusion was associated with a greater treatment benefit of IVT, indicating a positive interaction between IVT and MT. These results support current guidelines that all eligible patients with stroke should receive IVT before MT and add a new perspective to the debate on noninferiority of combined stroke treatment.

Operator assessment versus core laboratory adjudication of recanalization following endovascular treatment of acute ischemic stroke: a systematic review and meta-analysis

BACKGROUND

Successful recanalization after endovascular thrombectomy serves as the primary endpoint in clinical trials and is a crucial predictor of long-term outcomes. Radiographic outcomes for various interventions have been shown to vary based on the type of interpreter, including the site interventionalist compared with an independent reader.

OBJECTIVE

To compare angiographic outcomes in stroke thrombectomy procedures based on the type of reader.

METHODS

A systematic literature search was conducted in Medline, EMBASE, Scopus, and Web-of-Science through February 2022. We included primary studies that reported core laboratory-read and operator angiographic outcomes after mechanical thrombectomy for ischemic stroke. Furthermore, study-defined successful recanalization data were collected.

RESULTS

Eight studies were included with 4797 patients, 51.2% of whom were male. Four thousand, four hundred and thirty-one patients had core readings, and 4211 had operator readings. Study-defined successful recanalization was significantly higher for operator (84%, 3543/4211) examinations than for core laboratory-read (78.4%, 3476/4431) examinations (p<0.001; OR=1.462, 95% CI 1.175 to 1.819). The modified Thrombolysis in Cerebral Infarction (mTICI) scale score of ≥2 b was higher for operator (85%, 3341/3929) examinations than for core laboratory-read (78.6%, 3107/3952) examinations (p<0.001; OR=1.349, 95% CI 1.071 to 1.701). mTICI 3 was significantly higher for operator (54.6%, 1000/1832) examinations than for core laboratory-read (39.9%, 731/1832) examinations (p<0.001; OR=1.823, 95% CI 1.598 to 2.081).

CONCLUSION

Operator angiographic reads are statistically significantly higher than core laboratory-read readings following stroke thrombectomy, especially for complete recanalization. These differences should be considered when interpreting reports of angiographic outcomes after thrombectomy.

Periprocedure Management of Blood Pressure After Acute Ischemic Stroke

The management of acute ischemic stroke primarily revolves around the timely restoration of blood flow (recanalization/reperfusion) in the occluded vessel and maintenance of cerebral perfusion through collaterals before reperfusion. Mechanical thrombectomy is the most effective treatment for acute ischemic stroke due to large vessel occlusions in appropriately selected patients. Judicious management of blood pressure before, during, and after mechanical thrombectomy is critical to ensure good outcomes by preventing progression of cerebral ischemia as well hemorrhagic conversion, in addition to optimizing systemic perfusion. While direct evidence to support specific hemodynamic targets around mechanical thrombectomy is limited, there is increasing interest in this area. Newer approaches to blood pressure management utilizing individualized cerebral autoregulation-based targets are being explored. Early efforts at utilizing machine learning to predict blood pressure treatment thresholds and therapies also seem promising; this focused review aims to provide an update on recent evidence around periprocedural blood pressure management after acute ischemic stroke, highlighting its implications for clinical practice while identifying gaps in current literature.

Timing and causes of death after endovascular thrombectomy in patients with acute ischemic stroke

Introduction:

Endovascular thrombectomy (EVT) increases the chance of good functional outcome after ischemic stroke caused by a large vessel occlusion, but the risk of death in the first 90 days is still considerable. We assessed the causes, timing and risk factors of death after EVT to aid future studies aiming to reduce mortality.

Patients and methods:

We used data from the MR CLEAN Registry, a prospective, multicenter, observational cohort study of patients treated with EVT in the Netherlands between March 2014, and November 2017. We assessed causes and timing of death and risk factors for death in the first 90 days after treatment. Causes and timing of death were determined by reviewing serious adverse event forms, discharge letters, or other written clinical information. Risk factors for death were determined with multivariable logistic regression.

Results:

Of 3180 patients treated with EVT, 863 (27.1%) died in the first 90 days. The most common causes of death were pneumonia (215 patients, 26.2%), intracranial hemorrhage (142 patients, 17.3%), withdrawal of life-sustaining treatment because of the initial stroke (110 patients, 13.4%) and space-occupying edema (101 patients, 12.3%). In total, 448 patients (52% of all deaths) died in the first week, with intracranial hemorrhage as most frequent cause. The strongest risk factors for death were hyperglycemia and functional dependency before the stroke and severe neurological deficit at 24–48 h after treatment.

Discussion and conclusion:

When EVT fails to decrease the initial neurological deficit, strategies to prevent complications like pneumonia and intracranial hemorrhage after EVT could improve survival, as these are often the cause of death.

Safety and Efficacy of the Novel Low-Profile APERIO Hybrid17 for a Treatment of Proximal and Distal Vessel Occlusion in Acute Ischemic Stroke: A Multi-Center Experience

OBJECTIVE

To report our initial experience with the novel low-profile APERIO Hybrid17 Thrombectomy Device (AP17) for proximal and distal vessel occlusions in acute ischemic stroke.

METHODS

A multicentric retrospective analysis of patients treated with the AP17 was performed. The primary effectiveness endpoint was first-pass TICI ≥2b (Thrombolysis in cerebral infarction scale). The primary safety endpoint was the occurrence of hemorrhagic complications. Further outcome measures were number of passes, device-related complications, and 3-month functional outcome.

RESULTS

The AP17 was used in 71 patients (mean age: 73 years) with a median baseline National Institutes of Health Stroke Scale score of 9. Treated vessels were the carotid-T in 8 cases (11%), the M1-segment in 16 (23%), the M2-segment in 29 (41%), the anterior cerebral artery in 3 (4%), and basilar/posterior cerebral arteries in 15 (21%). The rates of first-pass and final TICI ≥2b were 75.6% and 92.7%, retrospectively, with a mean number of passes of 3 ± 2. Final TICI ≥2b rates were comparable between large and medium vessel occlusions. Symptomatic intracranial hemorrhages were recorded in 2 cases (2.8%). At 3-month clinical follow-up, a modified Rankin scale score ≤2 was achieved in 69.0% (29/42). The all-cause mortality at discharge was 17.4%.

CONCLUSIONS

The AP17 was associated with a reasonable safety and efficacy profile for both proximal and distal vessel occlusions. These results may contribute to establish mechanical thrombectomy for distal occlusions.

Effect of Standardized Perioperative Management on EEG Indexes and Nerve and Limb Functions of Patients with Acute Cerebral Infarction Undergoing Mechanical Thrombectomy

Objective

To explore the application value of standardized perioperative management in mechanical thrombectomy for acute cerebral infarction.

Methods

98 patients with acute cerebral infarction admitted to our hospital from January 2019 to January 2022 were selected as the study sample in this study, and all patients were given the standardized perioperative management. According to the interventional methods, they were divided into the thrombolytic treatment group (arteriovenous combined thrombolysis, n = 49) and mechanical thrombectomy group (mechanical thrombectomy, n = 49) to compare the nerve function, limb function, thrombolysis in myocardial infarction (TIMI) flow grade, symptomatic intracranial hemorrhage within 24 hours, acute vascular reocclusion, and the death status within 1 year and incidence of adverse events in 90 days of the two groups after treatment.

Results

After treatment, the values of brain symmetry index (BSI) and power ratio indices (DTABR) in the two groups were obviously lower than those before treatment (P < 0.05), and the values of BSI and DTABR in the mechanical thrombectomy group were lower than those in the thrombolytic treatment group (P < 0.05). According to the statistical data of National Institutes of Health Stroke Scale (NIHSS) score in patients, the NIHSS scores of the two groups after treatment were visibly decreased (P < 0.05), while the NIHSS score in the mechanical thrombectomy group after treatment was lower than that in the thrombolytic treatment group (P < 0.05). The proportion of modified Rankin scale (mRS) score < 3 in the mechanical thrombectomy group was distinctly higher than that in the thrombolytic treatment group (P < 0.05). The proportion of TIMI flow grade ≥ 2 in the mechanical thrombectomy group was significantly higher than that in the thrombolytic treatment group (P < 0.05). The rate of symptomatic intracranial hemorrhage within 24 hours in the mechanical thrombectomy group was lower than that in the thrombolytic treatment group (P < 0.05), with the indistinctive difference between the two groups (P > 0.05). The incidence of acute vascular reocclusion in the mechanical thrombectomy group was markedly lower than that in the thrombolytic treatment group (P < 0.05). There was no significant difference in 1-year mortality between the two groups (P > 0.05). In the mechanical thrombectomy group, there were 1 case of gingiva bleeding, 1 case of hemorrhinia, and 2 cases of recurrent cerebral infarction in 90 days, with a total of 4 cases (8.16%), while in the thrombolytic treatment group, there were 4 cases of gingiva bleeding, 4 cases of hemorrhinia, and 15 cases of recurrent cerebral infarction in 90 days, with a total of 23 cases (46.94%), indicating that the incidence of adverse events in 90 days in the mechanical thrombectomy group was significantly lower than that in the thrombolytic treatment group (P < 0.05).

Conclusion

The standardized perioperative management is effective in patients with acute cerebral infarction who were treated with arteriovenous combined thrombolysis or mechanical thrombectomy, which can improve the neurological function and physical function of patients. However, the mechanical thrombectomy has a better improvement effect on the neurological function and physical function of patients, with the relatively better safety, thrombolytic effect, and long-term prognosis.

Safety of Sheathless Transradial Balloon Guide Catheter Placement for Acute Stroke Thrombectomy

BACKGROUND

Transradial access has been described for mechanical thrombectomy in acute stroke, and proximal balloon occlusion has been shown to improve recanalization and outcomes. However, sheathed access requires a larger total catheter diameter at the access site. We aimed to characterize the safety of sheathless transradial balloon guide catheter use in acute stroke intervention.

METHODS

Consecutive patients who underwent sheathless right-sided transradial access for thrombectomy with a balloon guide catheter were identified in a prospectively collected dataset from 2019 to 2021. Demographics, procedure details, and short-term outcomes were collected and reported with descriptive statistics.

RESULTS

A total of 48 patients (20 women) with a mean age of 72.3 years were identified. Of patients, 56.3% had occlusions in the left-sided circulation; 35 (72.9%) had M1 occlusions, 7 (14.6%) had M2 occlusions, and 6 (12.5%) had internal carotid artery occlusions. Tissue plasminogen activator was administered to 16 (33.3%) patients. Five (10.4%) patients underwent intraprocedural carotid stenting. The cohort had successful reperfusion after a median of 1 (interquartile range: 1, 2) pass. Median time from access to recanalization was 31 (interquartile range: 25, 53) minutes. A postprocedural Thrombolysis In Cerebral Infarction score of ≥2b was achieved in 46 (95.8%) patients. Five patients had wrist access site hematomas. All hematomas resolved with warm compresses, and no further intervention was required.

CONCLUSIONS

Sheathless radial access using a balloon guide catheter may be safely performed for acute ischemic stroke with excellent radiographic outcomes. Further investigation is warranted to evaluate the comparative effectiveness of sheathless compared with sheathed transradial balloon guide access.

Reduction in Door-to-Groin Puncture Time for Endovascular Treatment in Acute Ischemic Stroke Patients With Large Vessel Occlusion

Background The outcome of mechanical thrombectomy for large vessel occlusion (LVO) in patients with acute ischemic stroke (AIS) is time-dependent. In the current stroke workflow, the pre-hospital delay is one of the most common reasons for an increase in door-to-groin puncture time (DGPT). In the present study, we sought to compare the difference in (DGPT) before and after the implementation of the Ventura Emergent Large Vessel Occlusion Score (VES) protocol for LVO. Methods VES was implemented in the Ventura County of California by Emergency Medical Services (EMS). We performed a retrospective analysis to compare DGPT of patients undergoing endovascular treatment (EVT) pre- and post-VES implementation. Mean and standard deviation was reported for the continuous variable 'time for intra-arterial (IA) treatment' in minutes. The Mann-Whitney test was used for the comparison of the variable between the two groups. analyses were performed using SAS v9.4 (SAS Institute Inc., Cary, NC) with a significant p-value of ≤0.05. Results A total of 304 (males: 142 and females: 162) patients were alerted of the stroke code by the EMS. VES was positive in 139 patients. Of these, 64 (46%) were males and 75 (54%) were females. VES score of 1, 2, 3, and 4 were recorded in 57 (41%), 44 (31.6%), 31 (22.3%), and 7 (5%) patients, respectively. A total of 48 VES-positive patients underwent EVT. There were 62 patients who underwent EVT before the implementation of the VES protocol. The mean DGPT for the EVT among post-VES patients was 65 minutes, which was significantly (p=0.0009) shorter than the mean DGPT of 109 minutes among pre-VES patients. Conclusion VES is a simplified and effective tool for identifying LVO in the field. Implementation of VES showed significantly reduced DGPT in LVO patients.

Related Factors of Cerebral Hemorrhage after Cerebral Infarction and the Effect of Atorvastatin Combined with Intensive Nursing Care

Background

Cerebral infarction is a common neurological disease with high incidence, which is the main factor causing death and disability in adults in China. Cerebral hemorrhage transformation is a common clinical complication. High NIHSS score at admission, atrial fibrillation, and small artery occlusion cerebral infarction can increase the risk of cerebral infarction complicated with hemorrhage transformation.

Aim

To explore the related factors of cerebral hemorrhage transformation after cerebral infarction and the value of atorvastatin calcium tablets combined with early intensive care measures.

Methods

In this study, a case-control study was conducted. Sixty patients with hemorrhagic transformation after cerebral infarction admitted to the Department of Neurology of our hospital from January 2017 to June 2021 were selected as the observation group, and 90 patients with cerebral infarction without hemorrhagic transformation during the same period were selected as the control group. The risk factors of hemorrhagic transformation after cerebral infarction were analyzed.

Results

The results of logistic regression model showed that the increased National Institutes of Health Stroke Scale (NIHSS) score at admission, hypertension, atrial fibrillation, TOAST classification of small artery occlusion, and large infarction lesions were the risk factors for hemorrhagic transformation in patients with cerebral infarction (P < 0.05). After 2 weeks and 4 weeks of treatment, the NIHSS scores of the intervention group were lower than those of the conventional group (P < 0.05). NIHSS scores of the two groups after treatment were significantly lower than those before treatment (P < 0.05). After three months of treatment, the patients in the intervention group with GOS score of 5 points accounted for 16.67%, and the patients with GOS score of 4 points accounted for 56.67%. The patients in the conventional group with GOS score of 5 points accounted for 6.67%, and the patients with GOS score of 4 points accounted for 33.33%. The prognosis of the intervention group was better than that of the conventional group on the whole (P < 0.05).

Conclusion

Patients with hypertension, large infarction lesions, high NIHSS score at admission, atrial fibrillation, and small artery occlusion cerebral infarction can increase the risk of bleeding transformation in patients with cerebral infarction. For patients with bleeding transformation, atorvastatin calcium tablets combined with early intensive nursing intervention has a certain value for improving the prognosis of patients.

Technical note and first results on JET 7 thromboaspiration device for T-ICA occlusions

Background

To describe technical features and initial results of a novel large-bore reperfusion catheter as first thromboaspiration approach for endovascular stroke treatment in terminal internal carotid artery (T-ICA) occlusions.

Methods

All patients treated with A Direct Aspiration first-Pass Technique (ADAPT) using JET 7 “Standard Tip” Penumbra Reperfusion catheter for acute T-ICA occlusion were retrospectively included in the study. Baseline data, puncture to recanalization time, number of attempts, switch to second device/technique rate and successful recanalization rate were assessed. Successful recanalization was defined by a thrombolysis in cerebral infarction (TICI) score ≥ 2b and favorable functional outcome was defined according to modified Rankin scale (score, 0–2). Catheter specifics and thromboaspiration reperfusion technique with JET 7 were reported.

Results

A total of 21 patients who underwent ADAPT with JET 7 Reperfusion catheter were enrolled for the final analysis. ADAPT was performed as first approach in all cases (100%). First attempt successful recanalization (eTICI ≥2b) was obtained in 90,5% of cases. Mean puncture to recanalization time was 16 minutes. Final successful recanalization was reached in 96.5%. Functional independence at 90 was achieved in 57,1% cases. Symptomatic intracranial hemorrhage occurred in one patient within 24 h.

Conclusion

The large-bore JET 7 reperfusion catheter could be considered as first-line in patients with acute T-ICA occlusion, allowing rapid recanalization and low rate of rescue therapy with stent retriver. Further series and/or trial evaluation are required to confirm our results.

A fully radiopaque hybrid stent retriever versus a precursor device: Outcome, efficacy, and safety in large vessel stroke

BACKGROUND AND PURPOSE

The aim of this multicenter study was to compare the clinical outcome, safety, and efficacy of the full-length radiopaque Aperio Hybrid stent retriever (APH) with the precursor Aperio thrombectomy device (AP).

METHODS

Multicentric retrospective analysis of patients with stroke, treated with the APH and AP due to an acute ischemic stroke by large vessel occlusions in the anterior or posterior circulation, was performed. We focused on the comparison of favorable clinical outcome (modified Rankin Scale, 0-2) after 3 months, favorable reperfusion rates (thrombolysis in cerebral infarction scale ≥ 2b), and the complication rate.

RESULTS

A total of 51 patients (female: n = 33, 64.7%, mean age 73 ± 16 years) with a median baseline National Institutes of Health Stroke Scale: 15 were treated with the APH or AP. Favorable outcome in patients treated with APH was excellent (44.0%) and comparable to the AP (36.8%). The rate of final favorable reperfusion for both devices was outstanding (APH 31/31 and AP 20/20). The overall complication rate for the APH was slightly higher compared to the AP (32.3%/15.0%). Symptomatic intracranial hemorrhage was recorded in 0 of 51 cases. The all-cause mortality rate at 90 days was 20.0% for the APH and comparable for the AP (21.1%).

CONCLUSIONS

Comparable clinical outcome, efficacy, and safety of the AP and the recently introduced APH were demonstrated. Both devices appeared feasible, efficient, and safe with regard to endovascular treatment in large vessel occlusion.

Safety and Effectiveness of the New Generation APERIO® Hybrid Stent-retriever Device in Large Vessel Occlusion Stroke

BACKGROUND

It is unknown whether technological advancement of stent-retriever devices influences typical observational indicators of safety or effectiveness.

METHODS

Observational retrospective study of APERIO® (AP) vs. new generation APERIO® Hybrid (APH) (Acandis®, Pforzheim, Germany) stent-retriever device (01/2019-09/2020) for mechanical thrombectomy (MT) in large vessel occlusion (LVO) stroke. Primary effectiveness endpoint was successful recanalization eTICI (expanded Thrombolysis In Cerebral Ischemia) ≥ 2b67, primary safety endpoint was occurrence of hemorrhagic complications after MT. Secondary outcome measures were time from groin puncture to first pass and successful reperfusion, and the total number of passes needed to achieve the final recanalization result.

RESULTS

A total of 298 patients with LVO stroke who were treated by MT matched the inclusion criteria: 148 patients (49.7%) treated with AP vs. 150 patients (50.3%) treated with new generation APH. Successful recanalization was not statistically different between both groups: 75.7% for AP vs. 79.3% for APH; p = 0.450. Postinterventional hemorrhagic complications and particularly subarachnoid hemorrhage as the entity possibly associated with stent-retriever device type was significantly less frequent in the group treated with the APH: 29.7% for AP and 16.0% for APH; p = 0.005; however, rates of symptomatic hemorrhage with clinical deterioration and in domo mortality were not statistically different. Neither the median number of stent-retriever passages needed to achieve final recanalization, time from groin puncture to first pass, time from groin puncture to final recanalization nor the number of cases in which successful recanalization could only be achieved by using a different stent-retriever as bail-out device differed between both groups.

CONCLUSION

In the specific example of the APERIO® stent-retriever device, we observed that further technological developments of the new generation device were not associated with disadvantages with respect to typical observational indicators of safety or effectiveness.

Outcomes of Stroke Thrombectomy Performed by Interventional Radiologists vs Neurointerventional Physicians

PURPOSE

To test the hypothesis that interventional radiologists (IR) have outcomes for endovascular stroke thrombectomy (EVT) similar to Neurointerventional (NI) physicians and could be used to improve availability of thrombectomy.

MATERIALS AND METHODS

Eight hospitals providing EVT performed by IR and NI in the same institution submitted sequential retrospective data limited to the era of modern devices. Good clinical outcome (90 day modified Rankin score 0-2) and successful revascularization (modified Thrombolysis in Cerebral Infarction score > 2b) were compared between specialties, adjusted for treating hospital, patient age, stroke severity, Alberta Stroke Program Early CT Score (ASPECTS), time from symptom onset to door, and clot location. Propensity score matching was used to compare outcomes. A total of 1009 patients were entered (622 treated by IR and 387 treated by NI).

RESULTS

Median stroke onset to puncture was 245 vs 253 minutes (p=.49), technically successful revascularization was 81.8% vs 82.4% (p=.81), and good clinical outcome was 45.5% vs 50.1% (p=.16), respectively. After adjusting, physician specialty was not a significant predictor of good clinical outcome (odds ratio 1.028 [95% CI 0.760-1.390]; p=.86). After matching, mRS 0-2 was 47.7% for IR and 51.1% for NI (p=0.366).

CONCLUSION

There was no significant difference in successful revascularization and good clinical outcomes between IR and NI physicians. Outcomes by IR were similar to NI outcomes from previously published trials and registries. This may be useful to address coverage and access to stroke interventions.

Clinical protocol of the ischemic stroke patients treatment

Today in Ukraine there is no single standardized protocol for the treatment of patients in the acute period of ischemic stroke using modern methods of diagnosis and treatment, which include thrombolytic therapy and endovascular treatment. This protocol was created and implemented in Scientific-practical Center of endovascular neuroradiology, NAMS of Ukraine and is based on the latest recommendations of AHA/ASA and ESO, as well as registers of patients with ischemic stroke. The main purpose of this publication is the creation and implementation of «instructions» for the diagnosis and selection of objective tactics for treating patients in the acute period of ischemic stroke.

Dose-Response Relationship and Threshold Drug Dosage Identification for a Novel Hybrid Mechanical-Thrombolytic System with an Ultra-Low Dose Patch

Introduction

Ischemic stroke treatment has advanced in the last two decades and intravenous thrombolysis is now considered the standard of care for selected patients. Recanalization can also be achieved by mechanical endovascular treatment for patients with large vessel occlusions. Complicating treatment-related symptomatic intracerebral hemorrhage and prolonged needle-to-recanalization times have been identified as major determinants of poor three-month functional outcomes. A hybrid mechanical-thrombolytic system with a patch imbued with an ultra-low dose of thrombolytic agents loaded onto a stent-retriever has been developed.

Methods

In this study, the in situ dose-response relationship of the thrombolytic patch imbued with up to 1000 IU of urokinase plasminogen activator (uPA) was quantified using Raman spectroscopy.

Results

Thrombi of up to 400 μm thickness dissolved within 15 min when patches imbued with < 1% of the conventional thrombolysis therapy dosage were applied. The results demonstrated that low-dose thrombolytic patches can dissolve normal clots compressed in the blood vessel in a short time. 500 IU is the threshold uPA dosage in the thrombolytic patch that most effectively dissolves the clots.

Conclusion

This study suggests that a novel endovascular stent-retriever loaded with an ultra-low drug dose fibrinolytic patch may be a suitable treatment for patients who are ineligible for conventional thrombolytic therapy.

Global Epidemiology of Stroke and Access to Acute Ischemic Stroke Interventions

PURPOSE OF THE REVIEW

To provide an up-to-date review of the incidence of stroke and large vessel occlusion (LVO) around the globe, as well as the eligibility and access to IV thrombolysis (IVT) and mechanical thrombectomy (MT) worldwide.

RECENT FINDINGS

Randomized clinical trials have established MT with or without IVT as the usual care for patients with LVO stroke for up to 24 hours from symptom onset. Eligibility for IVT has extended beyond 4.5 hours based on permissible imaging criteria. With these advances in the last 5 years, there has been a notable increase in the population of patients eligible for acute stroke interventions. However, access to acute stroke care and utilization of MT or IVT is lagging in these patients.

SUMMARY

Stroke is the second leading cause of both disability and death worldwide, with the highest burden of the disease shared by low- and middle-income countries. In 2016, there were 13.7 million new incident strokes globally; ≈87% of these were ischemic strokes and by conservative estimation about 10%-20% of these account for LVO. Fewer than 5% of patients with acute ischemic stroke received IVT globally in the eligible therapeutic time window and fewer than 100,000 MTs were performed worldwide in 2016. This highlights the large gap among eligible patients and the low utilization rates of these advances across the globe. Multiple global initiatives are underway to investigate interventions to improve systems of care and bridge this gap.

Food and Drug Association Approval Process for Devices Used in Endovascular Treatment of Stroke

PURPOSE OF THE REVIEW

This article reviews the Food and Drug Administration's (FDA's) process for approval of new medical devices and describes the evolution of endovascular devices used for the treatment of acute ischemic stroke.

RECENT FINDINGS

Several recent studies have established the benefit of endovascular treatment of acute ischemic stroke from emergent large vessel occlusion. This has led to endovascular treatment becoming the usual care in acute stroke management and has generated greater-than-ever interest in the development of newer and more effective devices.

SUMMARY

In the United States, the FDA is the regulatory authority that is empowered with the approval and monitoring of new medical devices for widespread use in the population. The FDA categorizes medical devices into 3 classes based mainly on their potential risks to patients and/or users; class I devices pose the least risk and have the least stringent approval process, while class III devices pose the highest risk and undergo the most stringent and time-consuming approval process. There are 4 main pathways to approval: premarket notification, also known as the 510(k) pathway; premarket approval (PMA), de novo, and Humanitarian Device Exemption pathway. These pathways are described in detail in the article. The FDA also mandates postmarketing surveillance to identify any untoward and unexpected long-term complications.

Prestroke Disability and Outcome After Thrombectomy for Emergent Anterior Circulation Large Vessel Occlusion Stroke

BACKGROUND AND OBJECTIVES

To determine the impact of endovascular therapy for large vessel occlusion stroke in patients with vs those without premorbid disability.

METHODS

We performed a post hoc analysis of the TREVO Stent-Retriever Acute Stroke (TRACK) Registry, which collected data on 634 consecutive patients with stroke treated with the Trevo device as first-line endovascular thrombectomy (EVT) at 23 centers in the United States. We included patients with internal carotid or middle cerebral (M1/M2 segment) artery occlusions, and the study exposure was patient- or caregiver-reported premorbid modified Rank Scale (mRS) score ≥2 (premorbid disability [PD]) vs premorbid mRS score of 0 to 1 (no PD [NPD]). The primary outcome was no accumulated disability, defined as no increase in 90-day mRS score from the patient's premorbid mRS score.

RESULTS

Of the 634 patients in TRACK, 407 patients were included in our cohort, of whom 53 (13.0%) had PD. The primary outcome of no accumulated disability was achieved in 37.7% (20 of 53) of patients with PD and 16.7% (59 of 354) of patients with NPD (p < 0.001), while death occurred in 39.6% (21 of 53) and 14.1% (50 of 354) (p < 0.001), respectively. The adjusted odds ratio of no accumulated disability for patients with PD was 5.2 (95% confidence interval [CI] 2.4-11.4, p < 0.001) compared to patients with NPD. However, the adjusted odds ratio for death in patients with PD was 2.90 (95% CI 1.38-6.09, p = 0.005).

DISCUSSION

In this study of patients with anterior circulation acute ischemic stroke treated with EVT, we found that PD was associated with a higher probability of not accumulating further disability compared to patients with NPD but also with higher probability of death.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that in anterior circulation acute ischemic stroke treated with EVT, patients with PD compared to those without disability were more likely not to accumulate more disability but were more likely to die.

Frequency, Characteristics, and Outcomes of Endovascular Thrombectomy in Patients With Stroke Beyond 6 Hours of Onset in US Clinical Practice

BACKGROUND AND PURPOSE

In 2018, 2 randomized controlled trials showed the benefit of endovascular thrombectomy (EVT) in acute ischemic stroke patients treated 6 to 24 hours from last known well using imaging-guided selection. However, little is known about outcomes in contemporary nontrial settings. We assessed the frequency of EVT and outcomes beyond 6 hours in the US Get With The Guidelines-Stroke clinical registry.

METHODS

We analyzed all acute ischemic stroke patients treated with EVT between January 1, 2009 and October, 1, 2018, at Get With The Guidelines-Stroke hospitals in the United States. We assessed trends over time in frequency of EVT beyond 6 hours, compared patient characteristics and outcomes between those treated within versus beyond 6 hours, and evaluated the associations between EVT time and outcomes.

RESULTS

We identified 53 702 patients at 697 sites treated with EVT during the study period. Treatment after 6 hours from last known well occurred in 17 720 (33%) of all 53 702 EVT cases (median 4.7 hours, interquartile range, 3.3-7 hours). The proportion of EVT cases treated after 6 hours from last known well varied widely across sites (median 30%, interquartile range, 24%-38%). Compared with patients treated within 6 hours, those treated beyond six hours were younger, less likely to have atrial fibrillation, less likely to arrive by ambulance, had lower stroke severity, were less likely to be anticoagulated, and more likely to be treated at centers with higher EVT volumes. After adjusting for patient and hospital characteristics, patients receiving EVT beyond 6 hours had less favorable in-hospital mortality, ambulation at discharge, and discharge disposition compared to those treated within 6 hours.

CONCLUSIONS

EVT is frequently performed for patients with ischemic stroke after 6 hours from last known well, accounting for one-third of cases nationally, and adjusted functional outcomes at discharge are worse in these patients compared to those treated with EVT within 6 hours. Further efforts are needed for optimal EVT outcomes in clinical practice settings.

Efficacy and Safety of a Novel Thrombectomy Device in Patients With Acute Ischemic Stroke: A Randomized Controlled Trial

Purpose: The Tonbridge stent is a novel retriever with several design improvements which aim to achieve promising flow reperfusion in the treatment of acute ischemic stroke (AIS). We conducted a randomized controlled, multicenter, non-inferiority trial to compare the safety and efficacy of the Tonbridge stent with the Solitaire FR. Methods: AIS patients aged 18-85 years with large vessel occlusion in anterior circulation who could undergo puncture within 6 h of symptom onset were included. Randomization was performed on a 1:1 ratio to thrombectomy with either the Tonbridge stent or the Solitaire FR. The primary efficacy endpoint was successful reperfusion using a modified thrombolysis in cerebral infarction score (mTICI) of 2b/3. Safety outcomes were symptomatic intracranial hemorrhage (sICH) within 24 ± 6 h and all-cause mortality within 90 days. A clinically relevant non-inferiority margin of 12% was chosen as the acceptable difference between groups. Secondary endpoints included time from groin puncture to reperfusion, National Institutes of Health Stroke Scale (NIHSS) score at 24 h and at 7 days, and a modified Rankin Scale (mRS) score of 0-2 at 90 days. Results: A total of 220 patients were enrolled; 104 patients underwent thrombectomy with the Tonbridge stent and 104 were treated with the Solitaire FR. In all test group patients, the Tonbridge was used as a single retriever without rescuing by other thrombectomy devices. Angioplasty with balloon and/or stent was performed in 26 patients in the Tonbridge group and 16 patients in the Solitaire group (p = 0.084). Before angioplasty, 86.5% of those in the Tonbridge group and 81.7% of those in the Solitaire group reached successful reperfusion (p = 0.343). Finally, more patients in the Tonbridge group achieved successful reperfusion (92.3 vs. 84.6%, 95% CI of difference value 0.9-16.7%, p < 0.0001). There were no significant differences on sICH within 24 ± 6 h between the two groups. All-cause mortality within 90 days was 13.5% in the Tonbridge group and 16.3% in the Solitaire group (p = 0.559). We noted no significant differences between groups on the NIHSS at either 24 h or 7 days and the mRS of 0-2 at 90 days. Conclusion: The trial indicated that the Tonbridge stent was non-inferior to the Solitaire FR within 6 h of symptom onset in cases of large vessel occlusion stroke. Clinical Trial Registration:ClinicalTrials.gov, number: NCT03210623.

Analysis of 565 thrombectomies for anterior circulation stroke: A Brazilian registry

INTRODUCTION

The benefits of mechanical thrombectomy in the treatment of patients with acute stroke due to large vessel occlusions (LVOs) have been extensively demonstrated by randomized trials and registries in developed countries. However, data on thrombectomy outside controlled trials are scarce in developing countries. The aim of this study was to assess the safety and efficacy, and to investigate the predictors for good and poor outcomes of thrombectomy for treatment of AIS due to anterior circulation LVOs in Brazil.

MATERIALS AND METHODS

This was a single center registry of thrombectomy in the treatment of stroke caused by anterior circulation LVOs. Between 2011 and 2019, a total of 565 patients were included.

RESULTS

the mean baseline NIHSS score on admission was 17.2. The average baseline ASPECTS was 8, and 91.0% of patients scored ≥6. Half of the patients received intravenous thrombolysis. The mean time from symptom onset to arterial puncture was 296.4 minutes. The mean procedure time was 61.4 minutes. The rates of the main outcomes were recanalization (TICI 2b-3) 85.6%, symptomatic intracranial hemorrhage (sICH) 8,1%, good clinical outcome (mRS=0-2) 43,5%, and mortality 22.1% at three months.

CONCLUSIONS

This study demonstrates the efficacy and safety of mechanical thrombectomy for treatment of patients with AIS of the anterior circulation in real-life conditions under limited facilities and resources. The results of the present study were relatively similar to those of large trials and population registers of developed countries.

Cyclical aspiration using a novel mechanical thrombectomy device is associated with a high TICI 3 first pass effect in large-vessel strokes

Background and Purpose

Complete reperfusion (TICI 3) after the first thrombectomy attempt or first pass effect (FPE) is associated with best clinical outcomes in large‐vessel occlusion (LVO) acute ischemic stroke. While endovascular therapy techniques have improved substantially, FPE remains low (24–30%), and new methods to improve reperfusion efficiency are needed.

Methods

In a prospective observational cohort study, 40 consecutive patients underwent cyclical aspiration thrombectomy using CLEAR^TM Aspiration System (Insera Therapeutics Inc., Dallas, TX). Primary outcome included FPE with complete/near‐complete reperfusion (TICI 2c/3 FPE). Secondary outcomes included early neurological improvement measured by the National Institute of Health Stroke Scale (NIHSS), safety outcomes, and functional outcomes using modified Rankin Scale (mRS). Outcomes were compared against published historical controls.

Results

Among 38 patients who met criteria for LVO, median age was 75 (range 31–96). FPE was high (TICI 3: 26/38 [68%], TICI 2c/3: 29/38 [76%]). Among anterior circulation strokes, core lab‐adjudicated FPE remained high (TICI 3: 17/29 [59%], TICI 2c/3: 20/29 [69%]), with excellent final successful revascularization results (Final TICI 3: 24/29 [83%], Final TICI 2c/3: 27/29 [93%]). FPE in the CLEAR‐1 cohort was significantly higher compared to FPE using existing devices (meta‐analysis) from historical controls (TICI 2c/3: 76% vs. 28%, p = 0.0001). High rates of early neurological improvement were observed (delta NIHSS≥4: 35/38 [92.1%]; delta NIHSS≥10: 27/38 [71%]). Similarly, high rates of good functional outcomes (mRS 0–2: 32/38 [84%]) and low mortality (2/38 [5%]) were observed.

Conclusion

Cyclical aspiration using the CLEAR^TM Aspiration System is safe, effective, and achieved a high TICI 3 FPE for large‐vessel strokes.

Outcomes of Rescue Endovascular Treatment of Emergent Large Vessel Occlusion in Patients With Underlying Intracranial Atherosclerosis: Insights From STAR

Background

Some emergent large vessel occlusions (ELVOs) are refractory to reperfusion because of underlying intracranial atherosclerosis (ICAS), often requiring rescue therapy (RT) with balloon angioplasty, stenting, or both. In this study, we investigate the safety, efficacy, and long‐term outcomes of RT in the setting of mechanical thrombectomy for ICAS‐related ELVO.

Methods and Results

We queried the databases of 10 thrombectomy‐capable centers in North America and Europe included in STAR (Stroke Thrombectomy and Aneurysm Registry). Patients with ELVO who underwent ICAS‐related RT were included. A matched sample was produced for variables of age, admission National Institute of Health Stroke Scale, Alberta Stroke Program Early CT Score, onset to groin puncture time, occlusion site, and final recanalization. Out of 3025 patients with MT, 182 (6%) patients required RT because of underlying ICAS. Balloon angioplasty was performed on 122 patients, and 117 patients had intracranial stenting. In the matched analysis, 141 patients who received RT matched to a similar number of controls. The number of thrombectomy passes was higher (3 versus 1, P<0.001), and procedural time was longer in the RT group (52 minutes versus 36 minutes, P=0.004). There was a higher rate of symptomatic hemorrhagic transformation in the RT group (7.8% versus 4.3%, P=0.211), however, the difference was not significant. There was no difference in 90‐day modified Rankin scale of 0 to 2 (44% versus 47.5%, P=0.543) between patients in the RT and control groups.

Conclusions

In patients with ELVO with underlying ICAS requiring RT, despite longer procedure time and a more thrombectomy passes, the 90 days favorable outcomes were comparable with patients with embolic ELVO.

Mechanical thrombectomy beyond 6 hours in acute ischaemic stroke with large vessel occlusion in the carotid artery territory: experience at a tertiary hospital

INTRODUCTION

Thrombectomy in the carotid artery territory was recently shown to be effective up to 24 hours after symptoms onset.

METHODS

We conducted a retrospective review of a prospective registry of patients treated at our stroke reference centre between November 2016 and April 2019 in order to assess the safety and effectiveness of mechanical thrombectomy performed beyond 6 hours after symptoms onset in patients with acute ischaemic stroke and large vessel occlusion in the carotid artery territory.

RESULTS

Data were gathered from 59 patients (55.9% women; median age, 71 years). In 33 cases, stroke was detected upon awakening; 57.6% of patients were transferred from another hospital. Median baseline NIHSS score was 16, and median ASPECTS score was 8, with 94.9% of patients presenting > 50% of salvageable tissue. Satisfactory recanalisation was achieved in 88.1% of patients, beyond 24 hours after onset in 5 cases. At 90 days of follow-up, 67.8% were functionally independent; those who were not were older and presented higher prevalence of atrial fibrillation, greater puncture-to-recanalisation time, and higher NIHSS scores, both at baseline and at discharge.

CONCLUSION

In our experience, mechanical thrombectomy beyond 6 hours was associated with good 90-day functional outcomes. Age, NIHSS score, puncture-to-recanalisation time, and presence of atrial fibrillation affected functional prognosis. The efficacy of the treatment beyond 24 hours after onset merits study.

The short- and long-term efficacies of endovascular interventions for the treatment of acute ischemic stroke patients

OBJECTIVE

We aimed to investigate the short- and long-term efficacies of endovascular interventional therapy in acute ischemic stroke (AIS) patients.

METHODS

In this retrospective study, 94 patients with AIS were recruited and divided into a control group (n=51) that was administered intra-arterial thrombolysis and an observation group (n=43) that was administered Solitaire stent thrombectomies. The postoperative recanalization and overall response rates were recorded in both groups. The hemodynamic parameters (high shear viscosity, low shear viscosity, plasma viscosity, and hematocrit), and the C-reactive protein, interleukin 6, and fibrinogen levels were compared between the two groups before and after the treatment. In addition, the National Institutes of Health Stroke Scale and the modified Rankin Scale scores were analyzed before the treatment and at 1 and 3 months after the treatment in both groups. After a 3-year follow-up, a survival analysis was also performed using the Kaplan-Meier survival method.

RESULTS

The overall response and recanalization rates were higher in the observation group than they were in the control group (P<0.05). Before the treatment, there were no significant differences in the hemodynamic parameter, C-reactive protein, interleukin, 6 and fibrinogen levels in the two groups (P>0.05). After the treatment, the above levels in both groups decreased compared to their levels before the treatment, and the observation group had significantly lower levels than the control group (P<0.05). Moreover, no significant differences were seen in National Institutes of Health Stroke Scale and modified Rankin Scale scores between the two groups before the treatment (P>0.05). After the treatment, the above scores were decreased in both groups at 1 and 3 months compared to their pre-treatment levels, and the scores were significantly lower in the observation group than they were in the control group at 1 month after the treatment (P<0.05). After a 3-year follow-up, the Kaplan-Meier survival curves demonstrated that the survival times were significantly longer in the observation group than they were in the control group (P<0.05).

CONCLUSION

Solitaire stent thrombectomy markedly ameliorates neurological deficits in AIS patients, improves their recanalization rated, regulates the inflammatory response and hemodynamics in the lesion areas, thus exerting favorable short- and long-term clinical effects.

A nephroprotective iodinated contrast agent with cardioprotective properties: A pilot study

BACKGROUND AND PURPOSE

Evaluation and treatment of acute ischemic syndromes, in the heart and brain, require vessel visualization by iodinated X-ray contrast agents. However, these contrast agents can induce injury, in both the kidneys and target organs themselves. Sulfobutylether beta cyclodextrin (SBECD) added to iohexol (SBECD-iohexol) (Captisol Enabled-iohexol, Ligand Pharmaceuticals, Inc, San Diego, CA) is currently in clinical trials in cardiovascular procedures, to determine its relative renal safety in high-risk patients. Preclinical studies showed that SBECD-iohexol reduced contrast-induced acute kidney injury in rodent models by blocking apoptosis. The current study was undertaken to determine whether SBECD-iohexol is also cardioprotective, in the male rat ischemia-reperfusion model, compared to iohexol alone.

METHODS

After anesthesia, the left coronary artery was ligated for 30 min and the ligation released and reperfusion followed for 2 h prior to sacrifice. Groups 1-4 were injected in the tail vein 10 min prior to ischemia with: (1) vehicle; (2) iohexol; (3) SBECD; and (4) SBECD-iohexol. Infarct size, hemodynamics, and serum markers were measured.

RESULTS

An eight-fold increase in serum creatine kinase in the iohexol-alone group was observed, compared with no increase in the SBECD-iohexol group. The mean arterial pressure and rate pressure product were depressed in the iohexol-alone group, but not in the SBECD-iohexol group, or controls. No difference in infarct size or serum creatinine among the groups was observed.

CONCLUSION

The results of this study suggest that SBECD-iohexol is superior to iohexol alone, for both the preservation of cardiomyocyte integrity and preservation of myocardial function in myocardial ischemia.

[Thrombectomy in clinical practice-What do we learn from registry studies?]

BACKGROUND

In 2015, randomized controlled trials (RCT) provided high-level evidence for the efficacy of endovascular thrombectomy in selected patients with acute ischemic stroke due to large vessel occlusion of the anterior circulation. Ever since, thrombectomy is strongly recommended for these patients and has been broadly implemented in clinical practice.

OBJECTIVE

To determine whether registry studies depicting real-life data provide additional information beyond RCTs.

MATERIAL AND METHODS

Literature review of RCTs and registry studies related to thrombectomy.

RESULTS

Data from registry studies on thrombectomy are important to 1. evaluate whether RCT results can be directly transferred into clinical practice, 2. comparatively describe the efficacy of thrombectomy in patient groups underrepresented in RCTs, such as older patients, 3. compare device performances and assess technical developments, and 4. determine how treatment processes and outcomes change over time.

CONCLUSION

Beyond RCTs, registry studies are imperative for the continuous analysis and improvement of treatment processes and outcomes as well as technical devices in daily clinical practice.

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

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.

Intra-Arterial Thrombolysis after Unsuccessful Mechanical Thrombectomy in the STRATIS Registry

BACKGROUND AND PURPOSE

Recent data suggest that intra-arterial thrombolytics may be a safe rescue therapy for patients with acute ischemic stroke after unsuccessful mechanical thrombectomy; however, safety and efficacy remain unclear. Here, we evaluate the use of intra-arterial rtPA as a rescue therapy in the Systematic Evaluation of Patients Treated with Neurothrombectomy Devices for Acute Ischemic Stroke (STRATIS) registry.

MATERIALS AND METHODS

STRATIS was a prospective, multicenter, observational study of patients with acute ischemic stroke with large-vessel occlusions treated with the Solitaire stent retriever as the first-line therapy within 8 hours from symptom onset. Clinical and angiographic outcomes were compared in patients having rescue therapy treated with and without intra-arterial rtPA. Unsuccessful mechanical thrombectomy was defined as any use of rescue therapy.

RESULTS

A total of 212/984 (21.5%) patients received rescue therapy, of which 83 (39.2%) and 129 (60.8%) were in the no intra-arterial rtPA and intra-arterial rtPA groups, respectively. Most occlusions were M1, with 43.4% in the no intra-arterial rtPA group and 55.0% in the intra-arterial rtPA group (P = .12). The median intra-arterial rtPA dose was 4 mg (interquartile range = 2-12 mg). A trend toward higher rates of substantial reperfusion (modified TICI  ≥ 2b) (84.7% versus 73.0%, P = .08), good functional outcome (59.2% versus 46.6%, P = .10), and lower rates of mortality (13.3% versus 23.3%, P = .08) was seen in the intra-arterial rtPA cohort. Rates of symptomatic intracranial hemorrhage did not differ (0% versus 1.6%, P = .54).

CONCLUSIONS

Use of intra-arterial rtPA as a rescue therapy after unsuccessful mechanical thrombectomy was not associated with an increased risk of symptomatic intracranial hemorrhage or mortality. Randomized clinical trials are needed to understand the safety and efficacy of intra-arterial thrombolysis as a rescue therapy after mechanical thrombectomy.

New Class of Radially Adjustable Stentrievers for Acute Ischemic Stroke: Primary Results of the Multicenter TIGER Trial

Supplemental Digital Content is available in the text.

Background and Purpose:

The Tigertriever is a novel, radially adjustable, fully visible, stentriever that permits the operator to align radial expansion with target vessel diameters. This multicenter trial compared the Tigertriever’s effectiveness and safety compared with established stent retrievers.

Methods:

Single arm, prospective, multicenter trial comparing the Tigertriever to efficacy and safety performance goals derived from outcomes in 6 recent pivotal studies evaluating the Solitaire and Trevo stent-retriever devices with a lead-in and a main-study phase. Patients were enrolled if they had acute ischemic stroke with National Institutes of Health Stroke Scale score ≥8 due to large vessel occlusion within 8 hours of onset. The primary efficacy end point was successful reperfusion, defined as core laboratory-adjudicated modified Thrombolysis in Cerebral Ischemia score 2b-3 within 3 passes of the Tigertriever. The primary safety end point was a composite of 90-day all-cause mortality and symptomatic intracranial hemorrhage. Secondary efficacy end points included 3-month good clinical outcome (modified Rankin Scale score 0–2) and first-pass successful reperfusion.

Results:

Between May 2018 and March 2020, 160 patients (43 lead-in, 117 main phase) at 17 centers were enrolled and treated with the Tigertriever. The primary efficacy end point was achieved in 84.6% in the main-study phase group compared with the 63.4% performance goal and the 73.4% historical rate (noninferiority P<0.0001; superiority P<0.01). The first pass successful reperfusion rate was 57.8%. After all interventions, successful reperfusion (modified Thrombolysis in Cerebral Ischemia score ≥2b) was achieved in 95.7% and excellent reperfusion (modified Thrombolysis in Cerebral Ischemia score 2c-3) in 71.8%. The primary safety composite end point rate of mortality and symptomatic intracranial hemorrhage was 18.1% compared with the 30.4% performance goal and the 20.4% historical rate (noninferiority P=0.004; superiority P=0.57). Good clinical outcome was achieved in 58% at 90 days.

Conclusions:

The Tigertriever device was shown to be highly effective and safe compared with Trevo and Solitaire devices to remove thrombus in patients with large-vessel occlusive stroke eligible for mechanical thrombectomy.

Registration:

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03474549.

Balloon guide catheter improvements in thrombectomy outcomes persist despite advances in intracranial aspiration technology

BACKGROUND

First-pass effect (FPE) has been established as a key metric for technical success and strongly correlates with better clinical outcomes. Most data supporting improved outcomes with the use of a balloon guide catheter (BGC) predate the advent of last-generation large-bore intracranial aspiration catheters. We aim to evaluate the impact of BGC in FPE and clinical outcomes in a large cohort of patients treated with contemporary technology.

METHODS

Patients were recruited from the prospectively ongoing ROSSETTI registry. This registry includes all consecutive patients with anterior circulation large-vessel occlusion (LVO) from 10 comprehensive stroke centers in Spain. Demographic, clinical, angiographic, and clinical outcome data were compared between BGC and non-BGC groups. FPE was defined as the achievement of mTICI2c-3 after a single device pass.

RESULTS

426 patients were included out of which 271 (63.62%) used BCG. BGC-treated patients had higher FPE rate (45.8% vs 27.7%; P<0.001), higher final mTICI ≥2 c recanalization rate (76.8% vs 50.3%, respectively; P<0.001), shorter procedural time [median (IQR), 30 (19-58) vs 43 (33-71) min; P<0.001], higher NIHSS difference from admission to 24 hours [median (IQR), 8 (2-12) vs 3 (0-10); P=0.001], and lower mortality rate (17.6% vs 29.8%, P=0.026) compared with non-BGC patients. BGC use was an independent predictor of FPE (OR 2.197, 95% CI 1.436 to 3.361; P<0.001), and excellent clinical outcome at 3 months (OR 0.34, 95% CI 0.17 to 0.68; P=0.002).

CONCLUSIONS

Our results support the benefit of BGC use on angiographic and clinical outcomes in anterior circulation LVO ischemic stroke remain significant even when considering recent improvements in intracranial aspiration technology.

Intra-Arterial Adjunctive Medications for Acute Ischemic Stroke During Mechanical Thrombectomy: A Meta-Analysis

BACKGROUND AND PURPOSE

In patients with acute ischemic stroke with large vessel occlusion, the role of intra-arterial adjunctive medications (IAMs), such as urokinase, tPA (tissue-type plasminogen activator), or glycoprotein IIb/IIIa inhibitors, during mechanical thrombectomy (MT) has not been clearly established. We aim to evaluate the efficacy and safety of concomitant or rescue IAM for acute ischemic stroke with large vessel occlusion patients undergoing MT.

METHODS

We searched Medline, Embase, and Cochrane Stroke Group Trials Register databases from inception until March 13, 2020. We analyzed all studies with patients diagnosed with acute ischemic stroke with large vessel occlusion in the anterior or posterior circulation that provided data for the two treatment arms, (1) MT+IAM and (2) MT only, and also reported on at least one of the following efficacy outcomes, recanalization and 90-day modified Rankin Scale, or safety outcomes, symptomatic intracranial hemorrhage and 90-day mortality. Data were collated in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Sixteen nonrandomized observational studies with a total of 4581 patients were analyzed. MT only was performed in 3233 (70.6%) patients, while 1348 (29.4%) patients were treated with both MT and IAM. As compared with patients treated with MT alone, patients treated with combination therapy (MT+IAM) had a higher likelihood of achieving good functional outcome (risk ratio, 1.13 [95% CI, 1.03-1.24]) and a lower risk of 90-day mortality (risk ratio, 0.82 [95% CI, 0.72-0.94]). There was no significant difference in successful recanalization (risk ratio, 1.02 [95% CI, 0.99-1.06]) and symptomatic intracranial hemorrhage between the two groups (risk ratio, 1.13 [95% CI, 0.87-1.46]).

CONCLUSIONS

In acute ischemic stroke with large vessel occlusion, the use of IAM together with MT may achieve better functional outcomes and lower mortality rates. Randomized controlled trials are warranted to establish the safety and efficacy of IAM as adjunctive treatment to MT.

CTA-Based Patient-Tailored Femoral or Radial Frontline Access Reduces the Rate of Catheterization Failure in Chronic Subdural Hematoma Embolization

BACKGROUND AND PURPOSE

Chronic subdural hematoma embolization, an apparently simple procedure, can prove to be challenging because of the advanced age of the target population. The aim of this study was to compare 2 arterial-access strategies, femoral versus patient-tailored CTA-based frontline access selection, in chronic subdural hematoma embolization procedures.

MATERIALS AND METHODS

This was a monocentric retrospective study. From the March 15, 2018, to the February 14, 2019 (period 1), frontline femoral access was used. Between February 15, 2019, and March 30, 2020 (period 2), the choice of the frontline access, femoral or radial, was based on the CTA recommended as part of the preoperative work-up during both above-mentioned periods. The primary end point was the rate of catheterization failure. The secondary end points were the rate of access site conversion and fluoroscopy duration.

RESULTS

During the study period, 124 patients (with 143 chronic subdural hematomas) underwent an embolization procedure (mean age, 74 [SD, 13] years). Forty-eight chronic subdural hematomas (43 patients) were included during period 1 and were compared with 95 chronic subdural hematomas (81 patients) during period 2. During the first period, 5/48 (10%) chronic subdural hematoma embolizations were aborted due to failed catheterization, significantly more than during period 2 (1/95, 1%; P = .009). The rates of femoral-to-radial (P = .55) and total conversion (P = .86) did not differ between the 2 periods. No significant difference was found regarding the duration of fluoroscopy (P = .62).

CONCLUSIONS

A CTA-based patient-tailored choice of frontline arterial access reduces the rate of catheterization failure in chronic subdural hematoma embolization procedures.

Mechanical thrombectomy beyond 6hours in acute ischaemic stroke with large vessel occlusion in the carotid artery territory: Experience at a tertiary hospital

INTRODUCTION

Thrombectomy in the carotid artery territory was recently shown to be effective up to 24hours after symptoms onset.

METHODS

We conducted a retrospective review of a prospective registry of patients treated at our stroke reference centre between November 2016 and April 2019 in order to assess the safety and effectiveness of mechanical thrombectomy performed beyond 6hours after symptoms onset in patients with acute ischaemic stroke and large vessel occlusion in the carotid artery territory.

RESULTS

Data were gathered from 59 patients (55.9% women; median age, 71 years). In 33 cases, stroke was detected upon awakening; 57.6% of patients were transferred from another hospital. Median baseline NIHSS score was 16, and median ASPECTS score was 8, with 94.9% of patients presenting>50% of salvageable tissue. Satisfactory recanalisation was achieved in 88.1% of patients, beyond 24hours after onset in 5 cases. At 90 days of follow-up, 67.8% were functionally independent; those who were not were older and presented higher prevalence of atrial fibrillation, greater puncture-to-recanalisation time, and higher NIHSS scores, both at baseline and at discharge.

CONCLUSION

In our experience, mechanical thrombectomy beyond 6hours was associated with good 90-day functional outcomes. Age, NIHSS score, puncture-to-recanalisation time, and presence of atrial fibrillation affected functional prognosis. The efficacy of the treatment beyond 24hours after onset merits study.