Rescue stenting after the failure of mechanical thrombectomy to treat acute intracranial atherosclerotic occlusion

Determinants of day-1 stent patency following rescue intracranial stenting in failed intracranial thrombectomy

IntroductionThis study aimed to identify factors affecting stent patency in patients treated with rescue intracranial stenting (RIS) for a refractory intracranial occlusion following mechanical thrombectomy (MT), focusing on antithrombotic regimens, and types of devices used.Material and methodsData from 14 university hospitals spanning from 2015 to 2021 were utilized, concentrating on patients who underwent MT in the anterior circulation. The primary outcome was stent patency on follow-up imaging at day 1.ResultsThroughout the study period, a total of 101 patients received RIS at 14 centers for refractory anterior large vessel occlusion (LVO). Amongst the 101 implanted stents, 18 were coronary and 83 were neuro-stents. Seventy-six patients were given a double antiplatelet (AP) regimen following stent implantation. After adjustment on LVO level (M1 vs. carotid), sex, susceptibility vessel sign, number of stent passes, follow-up AP, and coronary versus neuro-stent usage, the presence of follow-up dual antiplatelet regimen was independently linked to stent patency on follow-up imaging (p = .0016). The type of stent and other factors were not.ConclusionOur study shows that in patients treated with RIS in the context of failed MT, starting dual antiplatelet therapy is independently associated with stent patency on follow-up imaging at day 1. In this large series, we have not found evidence supporting the superiority of a specific class of antiplatelet drugs or a stent category, especially coronary versus neuro-stents. These results may inform the design of future clinical trials.

Mechanical thrombectomy for AIS from large vessel occlusion - current trends and future perspectives

Stroke is found to be one of the global top causes of mortality and the major factor in years of life with a handicap (DALYs). Ischemic strokes contributed to nearly 70% of all strokes worldwide. For endovascular thrombectomy in acute ischemic stroke with large vessel obstruction (AIS-LVO), using stent retrievers and/or reperfusion catheters has become the gold standard of therapy. The methodology involved keyword-based search in databases like PubMed, Embase, and Google Scholar for recent publications on mechanical thrombectomy (MT), AIS, large vessel occlusion (Large Vessel Occlusion (LVO)), screening relevant articles, retrieving full texts, and synthesizing key findings on procedural advancements, patient selection, COVID-19 (coronavirus disease 2019) impact, delay effects, effectiveness, clinical outcomes, and future perspectives. Only people with substantial cerebral artery obstruction may do well from MT. This includes the distal carotid artery and the proximal middle cerebral artery (segment M1). The size of a blocked vessel and NIHSS (National Institute of Health Stroke Scale) score are directly connected. Both the 2018 and 2019 versions of the AHA/ASA (American Heart Association/American Stroke Association) Guidelines for the Early Management of Patients with Acute Ischemic Stroke contained the recommendations that cases with AIS-LVO get endovascular therapy when administered during the time frame of 0-6 h after onset (Grade IA evidence). It is questionable whether this group of patients can be managed without the need for intravenous tissue plasminogen activator at the onset. When functional independence [modified Rankin Scale (mRS) score 2] was present at long-term follow-up, the endovascular intervention was favored. Tenecteplase, which differs from alteplase in terms of genetic variation, has a greater half-life and a higher level of fibrin selectivity, enabling bolus infusion. Studies have also demonstrated its efficacy and safety, as well as its long-term cost-effectiveness.