Repeated Endovascular Thrombectomy in Patients With Acute Ischemic Stroke

Reocclusion after successful endovascular treatment in acute ischemic stroke: systematic review and meta-analysis

BACKGROUND

Endovascular treatment (EVT) is the standard of care for selected patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO).

OBJECTIVE

To systematically review the available data on: (1) incidence, predictors, and outcomes of patients with reocclusion after successful EVT for AIS and, (2) the characteristics, complications, and outcomes of patients with reocclusion treated with repeated EVT (rEVT) within 30 days of the first procedure.

METHODS

PubMed was searched (between January 2012 and April 2021) to identify studies reporting reocclusion following successful EVT (Thrombolysis in Cerebral Infarction ≥2b) in patients with AIS due to LVO. Pooled incidence of reocclusion per 100 patients with successful recanalization following EVT was calculated using a random-effects model with Freeman-Tukey double arcsine transformation. Extracted incidences of reocclusion according to etiology and use of intravenous thrombolysis were pooled using random-effects meta-analytic models.

RESULTS

A total of 840 studies was identified and seven studies qualified for the quantitative analysis, which described 91 same-vessel reocclusions occurring within the first 7 days after treatment among 2067 patients (4.9%; 95% CI 3% to 7%, I2=70.2%). Large vessel atherosclerosis was associated with an increased risk of reocclusion (OR=3.44, 95% CI 1.12 to 10.61, I2=50%). We identified 90 patients treated with rEVT for recurrent LVO, described in five studies. The rates of procedural complications, mortality, and unfavorable functional outcome at 3 months were 18.0%, 18.9%, and 60.3%, respectively.

CONCLUSION

In cohorts of patients with AIS due to LVO, 5% of patients experienced reocclusion within 7 days after successful EVT. Repeated EVT can be a safe and effective treatment for selected patients with reocclusion.

The relationship between antiplatelet therapies and the outcome of endovascular treatment for acute ischemic stroke

PURPOSE

We conducted this study to investigate the safety and efficacy of antiplatelet therapies (APT) for acute ischemic patients received endovascular treatment (EVT).

METHODS

The population of our study was derived from a nationwide multicentered registry conducted by 111 centers in China. Patients were divided to groups of no APT, single APT (SAPT) or dual APT (DAPT) according to the APT received at 24 h after EVT. The primary outcome was 90-day functional independence, and the safety outcomes included the symptomatic intracranial hemorrhage (sICH), any type of intracranial hemorrhage, and all-caused death within 90 days. Patient characteristics, procedural data, and outcomes were analyzed.

RESULTS

A total of 1679 patients were included in this study, 71.42% of whom received oral APT at 24 h after EVT, and the initial time was 20.53(13.94-27.17) hours after recanalization or the end of procedure. 90-day functional independence was significantly more observed in patients with DAPT (54.02% vs. 33.64%; adjusted odds ratio [OR] 1.940, 95% CI 1.444-2.606), but not in SAPT (40.75% vs. 33.64%; adjusted OR 1.280, 95% CI 0.907-1.804) compared with patients without APT. APT increased the risk of sICH (1.14% vs. 0, p = 0.036). Both the application of DAPT (adjusted OR 0.264, 95% CI 0.178-0.392, p < 0.001) and SAPT (adjusted OR 0.341, 95% CI 0.213-0.545, p < 0.001) could reduce the 90-day mortality.

CONCLUSIONS

In this uncontrolled series of patients APT at 24 h after EVT showed improvement of the patients' functional independence and reduction of mortality, even though the rate of sICH was increased, especially in the DAPT-group.

Laterality of previous stoke affects endovascular thrombectomy outcomes

BACKGROUND

Investigations into the effect of previous stroke on thrombectomy outcomes have yielded conflicting results, and are limited by small sample sizes. We present the results of a large single center retrospective study aimed at investigating the effect of chronic stroke laterality on thrombectomy outcomes.

METHODS

A prospectively maintained database was queried for all thrombectomy cases conducted between December 2014 and January 2020, and patient imaging was prospectively reviewed for evidence of prior supratentorial infarction. Procedural, clinical, and demographic characteristics were recorded, and good clinical outcome was defined as a 90 day modified Rankin Scale (mRS) score of <2 or mRS score unchanged if baseline was >2.

RESULTS

The final analysis cohort included 555 patients, 79 of whom were found to have radiographic evidence of prior chronic infarcts. On univariate analysis, patients with any chronic supratentorial infarct achieved a lower rate of good clinical outcome than patients with no chronic infarct (22.8% vs 41.0%, p=0.0021). With regard to subgroups, this difference remained only in patients with ipsilateral (14.3%, p=0.0018) and bilateral (11.8%, p=0.015) lesions. Patients with chronic contralateral supratentorial infarcts were no less likely to achieve good outcomes (40.7%, p=0.98). After multivariate regression controlling for age, sex, and baseline mRS, chronic ipsilateral infarcts (OR 0.22, CI 0.07 to 0.67) and chronic bilateral infarcts (OR 0.19, CI 0.04 to 0.85) were the only independent predictors of poor outcome in endovascular thrombectomy patients.

CONCLUSIONS

In this single center retrospective study of thrombectomy patients with chronic supratentorial infarcts, the laterality of the previous stroke significantly affected the likelihood of good clinical outcomes.

Repeated mechanical thrombectomy for recurrent large vessel occlusion: A systematic review and meta-analysis

BACKGROUND

Mechanical thrombectomy (MT) is the standard treatment for acute large vessel occlusion (LVO). Recurrent LVO can still occur in patients who already underwent MT for the first LVO. This study aimed to evaluate the efficacy of repeating MT for recurrent LVO.

METHODS

This meta-analysis of the available literature was conducted to summarize the current evidence regarding repeated MT outcomes in patients with recurrent LVO. All studies with ≥ 1 outcomes of interest were included. The Newcastle-Ottawa Scale (NOS) was used for risk of bias assessment.

RESULTS

Twenty studies, 10 observational (n = 21,251 patients) and 10 case reports (n = 10 patients), were included. 266 patients (62.78% females) with recurrent LVO were identified, with an overall prevalence of 1.6% and a mean age of 65.67 ± 16.23 years. Cardio-embolism was the most common mechanism in both times, with a median of 15 days between the first and second LVOs. Compared with pre-intervention, the first and second MTs significantly reduced the National Institute of Health Stroke Scale (NIHSS) score, (mean difference (MD) = -8.91) and (MD = -5.97) respectively, with a significant difference (p = 0.001). The rate of favorable outcome (modified Rankin scale (mRS) score 0-3) was 82.6% and 59.2% after the first and second MTs respectively, with a significant difference (p < 0.001).

CONCLUSION

In properly selected recurrent LVO patients, repeated MT is efficacious and safe. A prior MT procedure should not discourage aggressive treatment as many patients may achieve favorable outcomes.

Astrocytic p75NTR expression provoked by ischemic stroke exacerbates the blood-brain barrier disruption

The disruption of the blood-brain barrier (BBB) plays a critical role in the pathology of ischemic stroke. p75 neurotrophin receptor (p75NTR ) contributes to the disruption of the blood-retinal barrier in retinal ischemia. However, whether p75NTR influences the BBB permeability after acute cerebral ischemia remains unknown. The present study investigated the role and underlying mechanism of p75NTR on BBB integrity in an ischemic stroke mouse model, middle cerebral artery occlusion (MCAO). After 24 h of MCAO, astrocytes and endothelial cells in the infarct-affected brain area up-regulated p75NTR . Genetic p75NTR knockdown (p75NTR+/- ) or pharmacological inhibition of p75NTR using LM11A-31, a selective inhibitor of p75NTR , both attenuated brain damage and BBB leakage in MCAO mice. Astrocyte-specific conditional knockdown of p75NTR mediated with an adeno-associated virus significantly ameliorated BBB disruption and brain tissue damage, as well as the neurological functions after stroke. Further molecular biological examinations indicated that astrocytic p75NTR activated NF-κB and HIF-1α signals, which upregulated the expression of MMP-9 and vascular endothelial growth factor (VEGF), subsequently leading to tight junction degradation after ischemia. As a result, increased leukocyte infiltration and microglia activation exacerbated brain injury after stroke. Overall, our results provide novel insight into the role of astrocytic p75NTR in BBB disruption after acute cerebral ischemia. The p75NTR may therefore be a potential therapeutic target for the treatment of ischemic stroke.

Thrombectomy is a cost-saving procedure up to 24 h after onset

INTRODUCTION AND AIM

The treatment of ischemic stroke due to large-vessel occlusion has been revolutionized by mechanical thrombectomy (MT), as multiple trials have consistently shown improved functional outcomes compared to standard medical management both in the early and late time windows after symptom onset. However, MT is an interventional procedure that is more costly than best supportive care (BSC).

METHODS

We set out to study the cost-utility and budget impact of MT + BSC versus BSC alone for large-vessel occlusion using a combined decision tree and Markov model. The analysis was conducted from a Belgian payer perspective over a lifetime horizon, and health states were defined by the modified Rankin Scale (mRS). The treatment effect of MT + BSC combined clinical outcomes from all published early and late treatment window studies showing improved mRS after 90 days. Resource use and utilities were informed by an observational Belgian study of 569 stroke patients. Long-term mRS transitions were sourced from the Oxford Vascular study.

RESULTS

MT + BSC generated 1.31 additional quality-adjusted life years and resulted in cost savings of €10,216 per patient over lifetime. Deterministic sensitivity analyses demonstrated dominance of MT over a wide range of parameter inputs. In a Belgian setting, adding MT to BSC within an early time window for 1575 eligible stroke patients every year produced cost savings between €6.3 million (year 1) and €14.6 million (year 5), or a total cost saving of €56.2 million over 5 years.

CONCLUSION

Mechanical thrombectomy is a highly cost-effective treatment for ischemic stroke patients, providing quality-adjusted survival at lower health care cost, both when given in an early time window, as well as in a late time window.

[A case of recurrent cerebral embolism associated with Lambl's excrescence]

A 75-year-old female had a history of prior ischemic stroke with aphasia and right hemiplegia. Magnetic resonance angiography showed left internal carotid artery occlusion. She was successfully treated with intravenous recombinant tissue plasminogen activator (IV t-PA) and underwent endovascular thrombectomy (EVT). She was diagnosed with cardioembolic stroke due to the presence of atrial fibrillation and mitral valve stenosis, and warfarin was administered. However, she experienced large vessel occlusion twice within 2 years. Upon further analysis, transesophageal echocardiography revealed a mobile hyperechoic structure on the aortic valve, which was assumed to be an embolic source. Thus, we decided to perform mitral and aortic valve replacement. The excised aortic valve structure was suggested to be an example of Lambl's excrescence, histopathologically. After surgery, the patient had no recurrence for 3 years. Several cases of ischemic stroke associated with Lambl's excrescence have been reported, but definitive guidelines for managing patients with Lambl's excrescence do not currently exist. Surgical intervention for Lambl's excrescence with recurrent ischemic events may be important for preventing further recurrence.

Repeated Mechanical Endovascular Thrombectomy for Recurrent Large Vessel Occlusion: A Multicenter Experience

BACKGROUND AND PURPOSE

Mechanical thrombectomy (MT) is now the standard of care for large vessel occlusion (LVO) stroke. However, little is known about the frequency and outcomes of repeat MT (rMT) for patients with recurrent LVO.

METHODS

This is a retrospective multicenter cohort of patients who underwent rMT at 6 tertiary institutions in the United States between March 2016 and March 2020. Procedural, imaging, and outcome data were evaluated. Outcome at discharge was evaluated using the modified Rankin Scale.

RESULTS

Of 3059 patients treated with MT during the study period, 56 (1.8%) underwent at least 1 rMT. Fifty-four (96%) patients were analyzed; median age was 64 years. The median time interval between index MT and rMT was 2 days; 35 of 54 patients (65%) experienced recurrent LVO during the index hospitalization. The mechanism of stroke was cardioembolism in 30 patients (56%), intracranial atherosclerosis in 4 patients (7%), extracranial atherosclerosis in 2 patients (4%), and other causes in 18 patients (33%). A final TICI recanalization score of 2b or 3 was achieved in all 54 patients during index MT (100%) and in 51 of 54 patients (94%) during rMT. Thirty-two of 54 patients (59%) experienced recurrent LVO of a previously treated artery, mostly the pretreated left MCA (23 patients, 73%). Fifty of the 54 patients (93%) had a documented discharge modified Rankin Scale after rMT: 15 (30%) had minimal or no disability (modified Rankin Scale score ≤2), 25 (50%) had moderate to severe disability (modified Rankin Scale score 3-5), and 10 (20%) died.

CONCLUSIONS

Almost 2% of patients treated with MT experience recurrent LVO, usually of a previously treated artery during the same hospitalization. Repeat MT seems to be safe and effective for attaining vessel recanalization, and good outcome can be expected in 30% of patients.

Early recurrent ischemic events after mechanical thrombectomy: effect of post-treatment intracranial hemorrhage

OBJECTIVE

Patients with intracranial hemorrhages (ICH) after mechanical thrombectomy (MT) may have a higher risk of early recurrent embolism (ERE) because of delayed initiation of anticoagulants. We assessed the rate of ischemic events in the early period after MT and the association with post-MT ICH.

METHODS

Patients who underwent MT in our institute were retrospectively reviewed. ERE was defined as recurrent ischemic stroke and systemic embolism within 14 days after MT. The association between ERE and parenchymal hematoma (PH) was assessed. Multivariable regression analysis and inverse probability of treatment weighting was used to adjust for differences in baseline characteristics between patients with and without PH.

RESULTS

A total of 307 patients (median age, 78 years; female, 47%; median baseline National Institutes of Health Stroke Scale score, 19) were included. ERE was observed in 12 of 307 patients (8 strokes, 4 systemic embolisms; 3.9%). Median time from MT to ERE was 6.5 days (IQR, 3-8 days). PH occurred in 21 patients (6.8%). Median time from MT to initiating oral anticoagulants was longer in patients with PH (8 days) than in those without (3 days) (p < 0.01). In both unweighted and weighted multivariable analysis, PH was significantly associated with an increased risk of ERE (unweighted odds ratio, 10.60; 95% CI, 2.66-42.23; weighted odds ratio, 12.34; 95% CI, 2.49-61.07).

CONCLUSIONS

ERE occurred in about 4% of patients after MT. PH after MT was associated with delayed initiation of oral anticoagulants and an increased risk of recurrent ischemic events.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov . Unique identifier: NCT02251665.

Intracranial Bleeding After Reperfusion Therapy in Acute Ischemic Stroke

Intracranial hemorrhage is one of the most feared complications following brain infarct. Ischemic tissues have a natural tendency to bleed. Moreover, the first recanalization trials using intravenous thrombolysis have shown an increase in mild to severe intracranial hemorrhage. Symptomatic intracerebral hemorrhage is strongly associated with poor outcomes and is an important factor in recanalization decisions. Stroke physicians have to weigh the potential benefit of recanalization therapies, first, with different risks of intracranial hemorrhage described in randomized controlled trials, and second with numerous risk markers that have been found to be associated with intracranial hemorrhage in retrospective series. These decisions have become quite complex with different intravenous thrombolytics and mechanical thrombectomy. This review aims to outline some elements of the pathophysiological mechanisms and classifications, describe most of the risk factors identified for each reperfusion therapy, and finally suggest future research directions that could help physicians dealing with these complications.

Repeated Endovascular Thrombectomy in Patients with Acute Ischemic Stroke in a Single Center

BACKGROUND

Patients with acute ischemic stroke treated with endovascular thrombectomy may be treated with repeat endovascular thrombectomy (rEVT) in case of recurrent large vessel occlusion (LVO). The purpose of this study is to report the frequency, timing, and outcomes of rEVT in a single center.

MATERIALS AND METHODS

We retrospectively reviewed our databases for anterior or posterior circulation rEVT cases. Patient characteristics, procedural data, and functional outcomes (modified Rankin scale at 90 days) were analyzed. Early and late recurrence of stroke was divided at 30 days.

RESULTS

Of 1025 patients treated between January 2011 and January 2020, 23 (2.2%) underwent rEVT. The median time between the first and second procedure was 185 days; 7 (30.4%) patients were re-treated within 30 days. Eleven patients (47.8%) had different occlusion sites between the two procedures. Good clinical outcome of patients with late ipsilateral recurrence was significantly higher than that of patients with late contralateral recurrence (83.3% vs. 16.7, p = 0.027). Overall good functional outcome after the second procedure was 43.5% (10/23). Overall good functional outcome of early and late recurrence groups were similar (57.1% vs. 37.5%, p = 0.650). One patient died due to an underlying cardiac problem.

CONCLUSION

rEVT can be performed in patients with recurrent stroke of LVO. Ipsilateral recurrence of stroke was associated with good clinical outcome after rEVT.

Early recurrence of ischemic stroke in patients receiving endovascular thrombectomy

BACKGROUND/PURPOSE

Endovascular thrombectomy (EVT) is effective in treating acute ischemic stroke associated with large vessel occlusion. Early recurrence of ischemic stroke (ERIS) after EVT, however, is a devastating event and could worsen the condition of patient. Current study aimed to investigate the prevalence and risk factors of ERIS after EVT.

METHODS

The medical records of all patients receiving EVT at a single medical center were reviewed and analyzed. ERIS was defined as presentation of newly developed neurological deficits in previously recanalized vascular territory or another vascular territory that was not initially involved within 30 days of the index stroke.

RESULTS

From January 2015 to September 2018, a total of 200 patients (71.6 ± 12.3 years, male 49%) had received EVT and 17 patients (8.5%) developed ERIS. Presence of valvular heart disease was the only clinical factor associated with ERIS (OR: 4.26, 95% CI: 1.16-17.7). Patients with ERIS had significantly worse modified Rankin scale at 3 months (common OR: 3.11, 95% CI: 1.18-8.73) and were independently associated with mortality (OR: 7.73, 95% CI: 2.00-30.6). Ten of 17 patients with ERIS had received repeated EVT and all achieved good recanalization without procedure-related complications or symptomatic intracerebral hemorrhage.

CONCLUSION

ERIS in patients receiving EVT was not rare, especially in those with valvular heart disease, and was associated with worse outcome. Nevertheless, they could be safely treated by repeated EVT.

Multiple Thrombectomies in the Same Patient within One Month: Case Report of a Patient with Trousseau Syndrome and Acute Ischemic Stroke

BACKGROUND AND IMPORTANCE

Since Trousseau's initial publication, the development of thromboembolic events related to malignancy has been well established. The pathophysiology of this is understood to be through activation of the coagulation cascade through neoplastic cells themselves or the therapy initiated (chemotherapy or surgery). To date, there have been a variety of studies, such as the OASIS-CANCER trial, which highlight the relationship of hypercoagulability to ischemic stroke. Despite these efforts, clear evidence is lacking for the utilization of antiplatelet or anticoagulation therapy in the secondary prevention of stroke following mechanical thrombectomy in patients with suspected or confirmed malignancy.

CLINICAL PRESENTATION

A 71-year-old female with a history of immune thrombocytopenia, diabetes mellitus, and hypertension who was undergoing an evaluation for a lung nodule, later determined to be adenocarcinoma of the lung, underwent three successful mechanical thrombectomies for acute ischemic stroke with large vessel occlusion over a one month period. This patient had improved National Institutes of Health Stroke Scale (NIHSS) scores following each of her thrombectomies. However, her history of immune thrombocytopenia and underlying malignancy complicated her discharge medication regimen following each of her thrombectomies and may have contributed to her repeat strokes.

CONCLUSION

Clear guidance is lacking regarding the utilization of antiplatelet and anticoagulation therapy in patients with suspected or confirmed malignancy following mechanical thrombectomy. Review of the literature suggests that controlling a patient's hypercoagulability may lead to improved clinical outcomes, but further clinical trials are warranted.

Repeated mechanical thrombectomy in short-term large vessel occlusion recurrence: multicenter study and systematic review of the literature

BACKGROUND

Data on the frequency and outcome of repeated mechanical thrombectomy (MT) in patients with short-term re-occlusion of intracranial vessels is limited. Addressing this subject, we report our multicenter experience with a systematic review of the literature.

METHODS

A retrospective analysis was conducted of consecutive acute stroke patients treated with MT repeatedly within 30 days at 10 tertiary care centers between January 2007 and January 2020. Baseline demographics, etiology of stroke, angiographic outcome and clinical outcome evaluated by the modified Rankin Scale (mRS) at 90 days were noted. Additionally, a systematic review of reports with repeated MT due to large vessel occlusion (LVO) recurrence was performed.

RESULTS

We identified 30 out of 7844 (0.4%) patients who received two thrombectomy procedures within 30 days due to recurrent LVO. Through systematic review, three publications of 28 participants met the criteria for inclusion. Combined, a total of 58 participants were analyzed: cardioembolic events were the most common etiology for the first (65.5%) and second LVO (60.3%), respectively. Median baseline NIHSS (National Institutes of Health Stroke Scale) was 13 (IQR 8-16) before the first MT and 15 (IQR 11-19) before the second MT (p=0.031). Successful reperfusion was achieved in 91.4% after the first MT and in 86.2% patients after the second MT (p=0.377). The rate of functional independence (mRS 0-2) was 46% at 90 days after the second procedure.

CONCLUSION

Repeated MT in short-term recurrent LVO is a rarity but appears to be safe and effective. The second thrombectomy should be pursued with the same extensive effort as the first procedure as these patients may achieve similar good outcomes.

Endovascular treatment of acute ischemic stroke in patients with recurrent intracranial large vessel occlusion

BACKGROUND

Data on the treatment with recurrent mechanical thrombectomy of patients with acute ischemic stroke with recurrent large vessel occlusion are limited. We report our experience with recurrent mechanical thrombectomy for recurrent large vessel occlusion.

METHODS

During the period between May 2013 and August 2018, data on patients with recurrent large vessel occlusion were collected. Baseline clinical characteristics, recanalization technique, recanalization rates and clinical outcomes of patients with recurrent large vessel occlusion treated with mechanical thrombectomy were analyzed. Patients with recurrent large vessel occlusion treated with mechanical thrombectomy were compared with patients who underwent single mechanical thrombectomy.

RESULTS

During the study period, 7 of 474 patients (1.5%) were treated with mechanical thrombectomy for recurrent large vessel occlusion. The mean age of these patients was 64.4 (±7.9) years, and the mean time interval between thrombectomies was 47 (±48) h. The median baseline National Institutes of Health Stroke Scale (NIHSS) was 12 (range 5-24) before the first and 20 (range 3-34) before the second procedure; the mean NIHSS at discharge was 5 (range 2-25). Good clinical outcome after repeated mechanical thrombectomy defined as modified Rankin scale of 0-2 was achieved in 29% of patients at three months of follow-up.

CONCLUSIONS

Repeat mechanical thrombectomy is a rare procedure, but appears to be a feasible, safe and effective treatment option in patients with acute ischemic stroke and early recurrent large vessel occlusion.