Background The best management of basilar artery occlusion (BAO) remains uncertain. The BASICS (Basilar Artery International Cooperation Study) and the BEST (Basilar Artery Occlusion Endovascular ...Intervention Versus Standard Medical Treatment) trials reported neutral results. We sought to understand physicians’ approaches to BAOs and whether further BAO randomized controlled trials were warranted. Methods We conducted an online international survey from January to March 2022 to stroke neurologists and neurointerventionalists. Survey questions were designed to examine clinical and imaging parameters under which clinicians would offer (or rescind) a patient with BAO to endovascular therapy (EVT) or best medical management versus enrollment into a randomized clinical trial. Results Of >3002 invited participants, 1245 responded (41.4% response rate) from 73 countries, including 54.7% stroke neurologists and 43.6% neurointerventionalists. More than 95% of respondents would offer EVT to patients with BAO, albeit in various clinical circumstances. There were 70.0% of respondents who indicated that the BASICS and BEST trials did not change their practice. Only 22.1% of respondents would perform EVT according to anterior circulation occlusion criteria. The selection of patients for BAO EVT by clinical severity, timing, and imaging modality differed according to geography, specialty, and country income level. Over 80% of respondents agreed that further randomized clinical trials for BAO were warranted. Moreover, 45.6% of respondents indicated they would find it acceptable to enroll all trial‐eligible patients into the medical arm of a BAO trial, whereas 26.3% would not enroll. Conclusion Most stroke physicians continue to believe in the efficacy of EVT in selected patients with BAO in spite of BEST and BASICS. There is no consensus on which selection criteria to use, and few clinicians would use anterior circulation occlusion criteria for BAOs. Further randomized clinical trials for BAO are warranted.
More than 800,000 people in North America suffer a stroke each year, with ischemic stroke making up the majority of these cases. The outcomes of ischemic stroke range from complete functional and ...cognitive recovery to severe disability and death; outcome is strongly associated with timely reperfusion treatment. Historically, ischemic stroke has been treated with intravenous thrombolytic agents with moderate success. However, five recently published positive trials have established the efficacy of endovascular treatment in acute ischemic stroke. In this review, we will discuss the history of stroke treatments moving from various intravenous thrombolytic drugs to intra-arterial thrombolysis, early mechanical thrombectomy devices, and finally modern endovascular devices. Early endovascular therapy failures, recent successes, and implications for current ischemic stroke management and future research directions are discussed.
Stentrievers have resulted in faster recanalization times in patients with acute ischemic stroke. Nonetheless, when strokes occur during evenings and weekends, delays are introduced in achieving this ...goal. We assessed the feasibility of achieving fast and successful endovascular reperfusion in patients with stroke treated during evenings and weekends and whether this has an impact on the outcome.
A retrospective review was performed of a longitudinal database of patients with acute anterior ischemic stroke treated with endovascular therapy in a comprehensive stroke center between January 2011 and December 2012. The imaging to reperfusion time was defined as the time from completion of the unenhanced CT scan to the time of angiographic successful reperfusion (TICI 2b-3). This time interval was compared between patients treated during working hours (Monday to Friday 07:00-18:00 h) and those treated in the evening outside these hours and at weekends. The 24-h NIH Stroke Scale score and 90-day favorable outcome score (modified Rankin scale ≤2) were compared between the two groups.
In a cohort of 110 patients, 56 (50.9%) were treated on evenings and weekends. The median imaging to reperfusion time in these patients was 111 min compared with 90 min during working hours (p=0.019). The proportion of patients with successful reperfusion (TICI 2b or 3) during the evenings and weekends was 82.1% compared with 76.7% during working hours (p=0.4). The proportion of patients with a 90-day favorable outcome was not significantly different in the two groups (64.3% in those treated during evenings and weekends vs 52.1% in working hours, p=0.2).
Some delays were encountered during evenings and weekend hours. Despite that, it was feasible to achieve a relatively short imaging to reperfusion times during these hours, in comparison to existing literature. A target universal time metric is needed to assess the timeliness of endovascular therapy in stroke centers.
The overwhelming benefit demonstrated in the four recent randomized trials comparing intra-arterial therapies to medical management alone will have a transformative effect on the emergent management ...of strokes throughout the world. New generation neurothrombectomy devices were critical to trial success, but not the sole driver of patient outcomes in these trials. Patients in the positive trials were treated at hospitals with complex, efficient, resource-rich, team-based stroke systems in place. To ensure attainment of trial results in actual practice, patients should receive treatment at facilities certified as having the resources, personnel, organization, and continuous quality improvement processes characteristic of trial centers. It is our hope that, through greater education initiatives, robust resource investment, and developing quality-based certification processes, the results demonstrated by these trials may be extrapolated to greater numbers of centers – in turn allowing greater access for patients to high-quality, advanced stroke care.
Connecting different items and devices over the internet is a novel and fascinating idea in wireless communication. Despite the widespread use of WSNs, energy usage still remains a challenge. Energy ...management is vital to ensuring an efficient and economical deployment of WSNs. This study presents a life prolonging clustering mechanism entitled Regional Stable Election Protocol (R-SEP) for WSNs which aims at energy management as a major concern. An evaluation of the R-SEP was conducted and the approach greatly enhances energy efficiency, network lifetime, and throughput. An analysis of results was conducted against the LEACH and Z-SEP protocols. R-SEP shows an improvement in many aspects when energy efficiency and performance of WSNs is concerned.
The advent of stentrievers provided momentum for endovascular stroke therapy. Hopes were dampened after three randomized trials showed no clear benefit of endovascular therapy. This review discusses ...the results of these trials results and shortcomings. A detailed discussion will follow on the design, conduct and analysis of current and future endovascular stroke trials. Steps to improve the workflow of acute stroke cases from the time they enter the emergency department until endovascular reperfusion is achieved can significantly shorten the time from onset to successful reperfusion. These factors in addition to using novel approaches to analyze data and minimize delays caused by the consent process are perceived to be sufficient to demonstrate the efficacy of endovascular stroke therapy.
Introduction
Quicker recanalization results in better clinical outcomes in patients with acute ischemic strokes. We describe our experience with the use of a self-expanding, fully retrievable stent ...in acute intracranial occlusions.
Methods
Patients who underwent intra-arterial procedures with a self-expanding, fully retrievable stent for acute ischemic strokes at our center in 2009 were included in this study. The primary outcome was recanalization Thrombolysis in Myocardial Infarction (TIMI) grade 2/3 at end of procedure. Secondary endpoints were procedural interval times, incidence of vasospasm, rupture of vessels, device-related complications, groin complications, postprocedural intracerebral hemorrhage (ICH) on noncontrast CT, and all-cause mortality.
Results
Fourteen patients (mean age 62.1 years, range 34–81 years; six males) were included in the study. Sites of occlusion are as follows: M1 middle cerebral artery (MCA,
n
= 8), M2 MCA (
n
= 1), proximal basilar artery (
n
= 1), and distal basilar artery (
n
= 4). An additional device or technique was used in 9 of 14 patients prior to the use of the retrievable stent. Twelve out of 14 (85.7%) achieved TIMI 2–3 recanalization with 4 of 14 (28.6%) achieving TIMI 3. Eight of 14 (57.1%) patients had modified Rankin Scale (0–2) at 3 months or discharge. ICH on follow-up CT was noted in 28.6% (4 of 14) of patients. All-cause mortality was 2 of 14 (14.3%).
Conclusion
Use of a novel self-expanding, fully retrievable stent resulted in fast and very high recanalization rates in acute ischemic strokes with intravascular occlusions.
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