In patients with ischemic stroke, randomized trials showed a better functional outcome after endovascular therapy with new-generation thrombectomy devices compared with medical treatment, including ...intravenous thrombolysis. However, effects on mortality and the generalizability of results to routine clinical practice are uncertain.
In a prospective observational register-based study patients with ischemic stroke treated either with thrombectomy, intravenous thrombolysis, or their combination were included. Primary outcome was the modified Rankin scale score (0 no symptoms to 6 death) at 3 months. Ordinal logistic regression was used to estimate the common odds ratio as treatment effects (shift analysis). Propensity score matching was applied to compare patients treated either with intravenous thrombolysis alone or with intravenous thrombolysis plus thrombectomy.
Among 2650 recruited patients, 1543 received intravenous thrombolysis, 504 underwent thrombectomy, and 603 received intravenous thrombolysis in combination with thrombectomy. Later time-to-treatment was associated with worse outcomes among patients treated with thrombectomy plus thrombolysis. In 241 pairs of propensity score-matched patients with a proximal intracranial occlusion, thrombectomy plus thrombolysis was associated with improved functional outcome (common odds ratio, 1.84; 95% confidence interval, 1.32-2.57), and reduced mortality (15% versus 33%; P<0.0001) compared with intravenous thrombolysis alone. Results were similar in various sensitivity analyses accounting for missing outcome data and different analytic methods.
Results from this large prospective registry show that also in routine clinical care thrombectomy plus thrombolysis compared with thrombolysis alone improved functional outcome and reduced mortality in patients with ischemic stroke. Earlier treatment was associated with better outcomes.
Acute ischemic stroke and large vessel occlusion can be concurrent with the coronavirus disease 2019 (COVID-19) infection. Outcomes after mechanical thrombectomy (MT) for large vessel occlusion in ...patients with COVID-19 are substantially unknown. Our aim was to study early outcomes after MT in patients with COVID-19.
Multicenter, European, cohort study involving 34 stroke centers in France, Italy, Spain, and Belgium. Data were collected between March 1, 2020 and May 5, 2020. Consecutive laboratory-confirmed COVID-19 cases with large vessel occlusion, who were treated with MT, were included. Primary investigated outcome: 30-day mortality.
early neurological improvement (National Institutes of Health Stroke Scale improvement ≥8 points or 24 hours National Institutes of Health Stroke Scale 0-1), successful reperfusion (modified Thrombolysis in Cerebral Infarction grade ≥2b), and symptomatic intracranial hemorrhage.
We evaluated 93 patients with COVID-19 with large vessel occlusion who underwent MT (median age, 71 years interquartile range, 59-79; 63 men 67.7%). Median pretreatment National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score were 17 (interquartile range, 11-21) and 8 (interquartile range, 7-9), respectively. Anterior circulation acute ischemic stroke represented 93.5% of cases. The rate modified Thrombolysis in Cerebral Infarction 2b to 3 was 79.6% (74 patients 95% CI, 71.3-87.8). Thirty-day mortality was 29% (27 patients 95% CI, 20-39.4). Early neurological improvement was 19.5% (17 patients 95% CI, 11.8-29.5), and symptomatic intracranial hemorrhage was 5.4% (5 patients 95% CI, 1.7-12.1). Patients who died at 30 days exhibited significantly lower lymphocyte count, higher levels of aspartate, and LDH (lactate dehydrogenase). After adjustment for age, initial National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and successful reperfusion, these biological markers remained associated with increased odds of 30-day mortality (adjusted odds ratio of 2.70 95% CI, 1.21-5.98 per SD-log decrease in lymphocyte count, 2.66 95% CI, 1.22-5.77 per SD-log increase in aspartate, and 4.30 95% CI, 1.43-12.91 per SD-log increase in LDH).
The 29% rate of 30-day mortality after MT among patients with COVID-19 is not negligible. Abnormalities of lymphocyte count, LDH and aspartate may depict a patient's profiles with poorer outcomes after MT. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT04406090.
A large-bore aspiration catheter can be employed for recanalization of acute basilar artery occlusion. Here we compare the results of mechanical thrombectomy using a stent retriever (SR) and manual ...aspiration thrombectomy (MAT) using a large-bore aspiration catheter system as a first-line recanalization method in acute basilar artery occlusion (BAO).
The records of 50 patients with acute BAO who underwent mechanical thrombectomy were retrospectively reviewed. Patients were assigned to one of two groups based on the first-line recanalization method. The treatment and clinical outcomes were compared.
Sixteen (32%) patients were treated with MAT with a large-bore aspiration catheter and 34 (68%) with a SR as the first-line treatment method. The MAT group had a shorter procedure time (28 vs. 65 min; p = 0.001), higher rate of first-pass recanalization (68.8% vs. 38.2%, p = 0.044), and lower median number of passes (1 vs 2; p = 0.008) when compared with the SR group. There was no significant difference in the incidence of any hemorrhagic complication (6.3% vs. 8.8%; p = 0.754) between the groups. However, there were four cases of procedure-related subarachnoid hemorrhage (SAH) in the SR group and one death occurred due to massive hemorrhage.
Selection of MAT using a large-bore aspiration catheter for acute BAO may be a safe and effective first-line treatment method with higher first-pass recanalization rate and shorter procedure time than SR.
Background and purpose
The clinical benefit of endovascular stroke therapy has been demonstrated in several prospective randomized trials. However, in a relevant percentage of patients, mechanical ...thrombectomy bears the risk of causing new infarction in initially unaffected vascular territories through thrombus fragmentation and migration of clot debris. The goal of this study was to evaluate the use of the balloon guide catheter (BGC) to effectively achieve flow arrest and thrombus aspiration during the intervention to avoid distal embolization.
Methods
A retrospective study was performed in 139 patients between October 2010 and May 2016 to analyze occlusions in the middle cerebral artery (MCA) or internal carotid artery (ICA) by using a stent retriever with a BGC (
n
= 73) or a non-BGC (
n
= 66). The following data were collected: patient age and gender, along with history of diabetes mellitus, hypertension, atrial fibrillation, smoking, obesity, dyslipidemia, and previous ischemic stroke. Data on procedure time, number of passes, and angiographic findings were also collected. The final reperfusion score was rated based on the Thrombolysis in Cerebral Infarction (TICI) grading scale. Successful recanalization was defined as TICI 3 or 2b.
Results
A total of 139 patients underwent mechanical thrombectomy with the stent retriever. Of the 139 patients, 73 (52.5%) underwent placement of a BGC. The mean age was 65.8 ± 13.5 years, and the median National Institutes of Health Stroke Scale (NIHSS) score was 11. The average initial NIHSS score was lower in the BGC group compared with the non-BGC group (mean, 11.2 ± 5.6 vs. 13.2 ± 5.6;
P
= 0.03). Patients with BGC had fewer incidences of previous ischemic stroke (12.3% vs. 28.8%;
P
= 0.01). The numbers of passes were similar between the two groups. The procedure time (99 ± 49.4 min vs. 124 ± 72.2 min;
P
= 0.02) and the time from onset of symptoms to procedure end (302 ± 102 min vs. 357.2 ± 136.1 min;
P
= 0.009) were shorter in the BGC group. TICI 3 or 2b recanalization scores were higher in the BGC group compared to the non-BGC group 63/73, 86.3% vs. 48/66, 72.7%; odds ratio (OR), 0.6; 95% confidence interval (CI), 0.2–1.4;
P
= 0.04. Importantly, distal embolization was less frequent in the BGC group (5/73, 6.8% vs. 21/66, 31.8%; OR, 6.3; 95% CI, 2.2–18.0;
P
< 0.001).
Conclusions
The risk of distal embolization was significantly decreased with the use of a BGC.
The aim of this guideline is to provide a focused update of the current recommendations for the endovascular treatment of acute ischemic stroke. When there is overlap, the recommendations made here ...supersede those of previous guidelines.
This focused update analyzes results from 8 randomized, clinical trials of endovascular treatment and other relevant data published since 2013. It is not intended to be a complete literature review from the date of the previous guideline publication but rather to include pivotal new evidence that justifies changes in current recommendations. Members of the writing committee were appointed by the American Heart Association/American Stroke Association Stroke Council's Scientific Statement Oversight Committee and the American Heart Association/American Stroke Association Manuscript Oversight Committee. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Statement Oversight Committee and Stroke Council Leadership Committee.
Evidence-based guidelines are presented for the selection of patients with acute ischemic stroke for endovascular treatment, for the endovascular procedure, and for systems of care to facilitate endovascular treatment.
Certain endovascular procedures have been demonstrated to provide clinical benefit in selected patients with acute ischemic stroke. Systems of care should be organized to facilitate the delivery of this care.
Surgery for renal cell carcinoma (RCC) with inferior vena cava tumor thrombus (TT) remains one of the most complex surgeries performed with high rates of associated complications and perioperative ...mortality. Surgical techniques and neoadjuvant therapies have an important role to play in improving outcomes. This review provides a narrative analysis of recent literature on patients with RCC and TT.
Several imaging techniques are emerging that may improve diagnostic staging of tumor thrombus level. Robotic approaches to surgical resection for all thrombi levels is feasible and safe, while longer term outcomes for higher level thrombi continues to mature. Early data on neoadjuvant immunotherapy and radiotherapy have shown improvements in complication rates and intermediate term oncologic outcomes.
Data suggests that neoadjuvant therapies and minimally invasive techniques may improve outcomes in patients undergoing surgical resection for RCC with tumor thrombus. Larger multiinstitutional series are needed to confirm the benefit of these techniques as well as the durable long term oncologic outcomes.
The single-device simplicity for mechanical thrombectomy (MT) is now challenged by the complementary efficacy of dual-device first-line with a stent retriever and an aspiration catheter.
To compare ...the outcomes after MT initiated with a single device vs dual devices in acute anterior circulation large vessel occlusion.
Patients who underwent MT for acute internal carotid artery (ICA) or M1 occlusion between 2015 and 2020 were retrospectively analyzed. We divided patients into 2 groups: single-device first-line, defined as patients who underwent first-device pass with either a stent retriever or aspiration catheter, and dual-device first-line, defined as first-device pass with both devices.
One hundred forty-one patients were in the single-device group, and 119 were in the dual-device group. In the dual-device group, coiling or kinking of the extracranial ICA was more frequent ( P = .07) and the guide catheters were less frequently navigated to the ICA ( P < .001). 37% of the single-device group was converted to dual-device use. The proportions of mTICI ≥ 2c after the first pass were similar (33% vs 32%. adjusted odds ratio 0.91, 95% CI 0.51-1.62). An mRS score of 0 to 2 at 3 months was achieved similarly (53% vs 48%, P = .46). The total cost for thrombectomy devices was lower in the single-device group ( P < .001).
The proportions of first-pass mTICI ≥ 2c were not different between the 2 groups with similar functional outcomes, although the dual-device group more likely to have unfavorable vascular conditions.
ObjectiveTo compare transradial artery access (TRA) to the gold standard of transfemoral artery access (TFA) in mechanical thrombectomy (MT) for stroke caused by anterior circulation large vessel ...occlusion.MethodsThe clinical outcomes, procedural speed, angiographic efficacy and safety of both techniques were analysed in 375 consecutive cases over an 18-month period in a high volume statewide neurointerventional service.ResultsThere was no significant difference in patient characteristics, stroke parameters, imaging techniques or intracranial techniques. The median time elapsed between CT scanning and reperfusion was 96.5 min (IQR 68–123) in the TFA group and 95 min (IQR 68–123) in the TRA group (p=0.456). Of 336 patients who were independent at presentation 58% (124/214) of the TFA group and 67% (82/122) of the TRA group had a modified Rankin score of 0–2 at 90-day follow-up (p=0.093). Cross-over from radial to femoral was 4.6% (4/130) compared with 1.6% cross-over from femoral to radial (4/245), but did not meet the predetermined level of statistical significance (OR 2.92, 95% CI 0.81 to 10.52), p=0.088) and did not impact median procedural speed. Adequate angiographic reperfusion, first pass reperfusion, embolisation to new territory and symptomatic intracranial haemorrhage were similar in both groups. There was a significant difference in major access site complications requiring an additional procedure. None of the TRA cases had a major access site complication but 6.5% (16/245) of the TFA cases did (p=0.003).ConclusionThis study suggests that using TRA for anterior circulation MT is fast, efficacious, safe and not inferior to the gold standard of TFA.
PDF
