Large vessel occlusion stroke due to underlying intracranial atherosclerotic disease (ICAD-LVO) is prevalent in 10 to 30% of LVOs depending on patient factors such as vascular risk factors, race and ...ethnicity, and age. Patients with ICAD-LVO derive similar functional outcome benefit from endovascular thrombectomy as other mechanisms of LVO, but up to half of ICAD-LVO patients reocclude after revascularization. Therefore, early identification and treatment planning for ICAD-LVO are important given the unique considerations before, during, and after endovascular thrombectomy. In this review of ICAD-LVO, we propose a multistep approach to ICAD-LVO identification, pretreatment and endovascular thrombectomy considerations, adjunctive medications, and medical management. There have been no large-scale randomized controlled trials dedicated to studying ICAD-LVO, therefore this review focuses on observational studies.
OBJECTIVE
The objective of this study was to investigate the incidence and predictors of first-pass effect (FPE) and to compare the clinical outcomes among FPE, multiple-pass effect, and incomplete ...reperfusion (ICR) in acute anterior circulation large vessel occlusion.
METHODS
Patients from the ANGEL-ACT (Endovascular Treatment Key Technique and Emergency Workflow Improvement of Acute Ischemic Stroke) registry were included. FPE was defined as complete reperfusion after a single pass of the thrombectomy device without rescue treatment. MPE was defined as complete reperfusion after ≥ 2 passes of the thrombectomy device. ICR was defined as a modified Thrombolysis in Cerebral Infarction score of 2b independent of the number of passes. Multivariable analyses were used to determine predictors of FPE and to compare the following outcomes: functional independence, mortality within 90 days, intraprocedural complications, and intracranial hemorrhage (ICH) among FPE, MPE, and ICR.
RESULTS
There were 1139 patients, of whom 307 (27.0%) achieved FPE. FPE was related to occlusion location (M1 vs internal carotid artery ICA, adjusted OR aOR 1.57, 95% CI 1.15–2.15, p = 0.004; M2/anterior cerebral artery vs ICA, aOR 2.06, 95% CI 1.32–3.22, p = 0.002) and negatively associated with underlying intracranial atherosclerosis disease (ICAD) (aOR 0.33, 95% CI 0.23–0.49, p < 0.001). Patients with FPE had a higher rate of functional independence (52.7% of FPE patients vs 45.6% of MPE patients and 37.1% of ICR patients, p = 0.002; MPE vs FPE, aOR 0.69, 95% CI 0.51–0.95, p = 0.023; ICR vs FPE, aOR 0.45, 95% CI 0.31–0.66, p < 0.001), lower rate of intraprocedural complications (4.2% vs 18.1% and 21.2%, p < 0.001; MPE vs FPE, aOR 6.23, 95% CI 3.36–11.54, p < 0.001; ICR vs FPE, aOR 7.70, 95% CI 3.97–14.94, p < 0.001), and lower rate of ICH within 24 hours (18.3% vs 27.9% and 26.9%, p = 0.009; MPE vs FPE, aOR 1.97, 95% CI 1.35–2.86, p < 0.001; ICR vs FPE, aOR 2.03, 95% CI 1.30–3.16, p = 0.002) than those with MPE and ICR.
CONCLUSIONS
FPE was achieved at a rate of 27.0% and associated with functional independence, decreased intraprocedural complications, and ICH. Non-ICA occlusion and underlying ICAD were predictors of FPE.
Despite preventing disability in 12·5–50% of patients, about half of patients treated with mechanical thrombectomy have disability or die after the procedure.1 Blood pressure management after ...mechanical thrombectomy is a proposed strategy to improve outcomes of patients based on observational studies reporting worse functional outcomes with higher post-mechanical thrombectomy blood pressure.2,3 A previous randomised trial showed no improvement in the incidence of intracerebral haemorrhage after mechanical thrombectomy when a lower systolic blood pressure target was used;4 however, the trial was underpowered to test superiority of this target for the improvement of functional outcomes. ...should post-mechanical thrombectomy blood pressure management be individualised according to the cause of stroke, recanalisation status, and baseline blood pressure control? In addition to the results of ENCHANTED-2, ongoing studies (NCT04205305, NCT04116112, NCT04775147) are expected to advance this knowledge. ...these results are available, patients should expect their clinical team to take an individualised approach to blood pressure management after endovascular thrombectomy.
Intracranial endovascular interventions provide effective and minimally invasive treatment of a broad spectrum of diseases. This area of expertise has continued to gain both wider application and ...greater depth as new and better techniques are developed and as landmark clinical studies are performed to guide their use. Some of the greatest advances since the last American Heart Association scientific statement on this topic have been made in the treatment of ischemic stroke from large intracranial vessel occlusion, with more effective devices and large randomized clinical trials showing striking therapeutic benefit. The treatment of cerebral aneurysms has also seen substantial evolution, increasing the number of aneurysms that can be treated successfully with minimally invasive therapy. Endovascular therapies for such other diseases as arteriovenous malformations, dural arteriovenous fistulas, idiopathic intracranial hypertension, venous thrombosis, and neoplasms continue to improve. The purpose of the present document is to review current information on the efficacy and safety of procedures used for intracranial endovascular interventional treatment of cerebrovascular diseases and to summarize key aspects of best practice.
Aneurysmal Subarachnoid Hemorrhage Chung, David Y; Abdalkader, Mohamad; Nguyen, Thanh N
Neurologic clinics,
05/2021, Letnik:
39, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Aneurysmal subarachnoid hemorrhage is a neurologic emergency that requires immediate patient stabilization and prompt diagnosis and treatment. Early measures should focus on principles of advanced ...cardiovascular life support. The aneurysm should be evaluated and treated in a comprehensive stroke center by a multidisciplinary team capable of endovascular and, operative approaches. Once the aneurysm is secured, the patient is best managed by a dedicated neurocritical care service to prevent and manage complications, including a syndrome of delayed neurologic decline. The goal of such specialized care is to prevent secondary injury, reduce length of stay, and improve outcomes for survivors of the disease.
This study investigates clinical outcomes after mechanical thrombectomy in adult patients with baseline Alberta Stroke Program Early CT Score (ASPECTS) of 0 to 5.
We included data from the STRATIS ...Registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) from patients who underwent mechanical thrombectomy within 8 hours of symptom onset and had available ASPECTS data adjudicated by an independent core laboratory. Angiographic and clinical outcomes were collected, including successful reperfusion (modified Thrombolysis in Cerebral Infarction ≥2b), functional independence (modified Rankin Scale score 0-2), 90-day mortality, and symptomatic intracranial hemorrhage at 24 hours. Outcomes were stratified by ASPECTS scores and age.
Of the 984 patients enrolled, 763 had available ASPECTS data. Of these patients, 57 had ASPECTS of 0 to 5 with a median age of 63 years (interquartile range, 28-100), whereas 706 patients had ASPECTS of 6 to 10 with a median age of 70 years of age (interquartile range, 19-100). Ten patients had ASPECTS of 0 to 3 and 47 patients had ASPECTS of 4 to 5 at baseline. Successful reperfusion was achieved in 85.5% (47/55) in the ASPECTS of 0 to 5 group. Functional independence was achieved in 28.8% (15/52) in the ASPECTS of 0 to 5 versus 59.7% (388/650) in the 6 to 10 group (
<0.001). Mortality rates were 30.8% (16/52) in the ASPECTS of 0 to 5 and 13.4% (87/650) in the 6 to 10 group (
<0.001). sICH rates were 7.0% (4/57) in the ASPECTS of 0 to 5 and 0.9% (6/682) in the 6 to 10 group (
<0.001). No patients aged >75 years with ASPECTS of 0 to 5 (0/12) achieved functional independence versus 44.8% (13/29) of those age ≤65 (
=0.005).
Patients <65 years of age with large core infarction (ASPECTS 0-5) have better rates of functional independence and lower rates of mortality compared with patients >75 years of age. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02239640.
BACKGROUND:
Endovascular treatment (EVT) for cerebral vein thrombosis (CVT) has not been proven to be more effective than anticoagulation based on recent results of the Thrombolysis or ...Anticoagulation for Cerebral Venous Thrombosis (TO-ACT) randomized clinical trial.
OBJECTIVE:
To compare outcomes of EVT vs medical management in CVT.
METHODS:
We compared EVT vs medical management in a retrospective multinational cohort of consecutive patients with CVT across 4 countries (USA, Italy, Switzerland, and New Zealand) and 27 sites (2015-2020), using propensity score matching (PSM) and inverse probability treatment weighting (IPTW), and meta-analyzed these results with the TO-ACT trial. The primary outcome was excellent functional outcome (modified Rankin Scale mRS 0-1) at 90 days.
RESULTS:
Of the 987 patients, the mean age was 45.7 ± 16.9 years and 79 (8%) underwent EVT. With PSM (n = 124), there were no major differences in clinical or imaging features between groups other than a higher proportion of female patients receiving EVT (81% vs 65%,
P
= .04). There was no difference in the primary outcome with PSM (odds ratio OR 1.48, 95% CI, 0.55-3.96) or IPTW (OR 1.02, 95% CI, 0.34-3.06). EVT was associated with a higher 90-day shift in modified Rankin Scale (OR 2.00, 95% CI, 1.01-3.98) and mortality with IPTW (OR 4.60, 95% CI, 1.10-19.23) but no other differences in secondary outcomes with PSM or IPTW. A meta-analysis of primary and secondary outcomes from TO-ACT and PSM patients from anticoagulation in the treatment of cerebral venous thrombosis also showed no significant association with EVT in primary or secondary outcomes.
CONCLUSION:
In this large observational cohort, there was no evidence of benefit with EVT for CVT. These findings corroborate the results from the TO-ACT trial.
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