The aim of the current study was to explore the whole‐brain dynamic functional connectivity patterns in acute ischemic stroke (AIS) patients and their relation to short and long‐term stroke severity. ...We investigated resting‐state functional MRI‐based dynamic functional connectivity of 41 AIS patients two to five days after symptom onset. Re‐occurring dynamic connectivity configurations were obtained using a sliding window approach and k‐means clustering. We evaluated differences in dynamic patterns between three NIHSS‐stroke severity defined groups (mildly, moderately, and severely affected patients). Furthermore, we built Bayesian hierarchical models to evaluate the predictive capacity of dynamic connectivity and examine the interrelation with clinical measures, such as white matter hyperintensity lesions. Finally, we established correlation analyses between dynamic connectivity and AIS severity as well as 90‐day neurological recovery (ΔNIHSS). We identified three distinct dynamic connectivity configurations acutely post‐stroke. More severely affected patients spent significantly more time in a configuration that was characterized by particularly strong connectivity and isolated processing of functional brain domains (three‐level ANOVA: p < .05, post hoc t tests: p < .05, FDR‐corrected). Configuration‐specific time estimates possessed predictive capacity of stroke severity in addition to the one of clinical measures. Recovery, as indexed by the realized change of the NIHSS over time, was significantly linked to the dynamic connectivity between bilateral intraparietal lobule and left angular gyrus (Pearson's r = −.68, p = .003, FDR‐corrected). Our findings demonstrate transiently increased isolated information processing in multiple functional domains in case of severe AIS. Dynamic connectivity involving default mode network components significantly correlated with recovery in the first 3 months poststroke.
By employing dynamic functional connectivity analyses, Bonkhoff et al. demonstrate that severe acute ischemic stroke is linked to transiently increased isolated information processing in multiple functional domains. Additionally, they show that dynamic connectivity involving default mode network components significantly correlates with recovery in the first three months poststroke.
Background
The Indian data concerning the endovascular mechanical thrombectomy (MT) in acute ischemic strokes (AIS) with large vessel occlusion (LVO) is still scarce and evolving. Tenecteplase (TNK) ...has been recently approved for intravenous stroke thrombolysis prior to the MT.
Methods
This study is a single-center retrospective study. We performed data analysis of the AIS patients who consecutively presented during the study period with LVO and underwent thrombectomy. Procedural success was defined by the post-thrombectomy angiographic picture of grades 2b and 3 on modified Thrombolysis in Cerebral Infarction (mTICI) scale. Primary efficacy outcome was defined as an improvement of ≥4 points in National Institute of Health Stroke Scale (NIHSS) score at 24 h. Secondary efficacy outcome was based on modified Rankin Scale (mRS) score at 90 days. We also performed a comparative analysis of TNK and alteplase subgroups.
Results
Successful recanalization (mTICI 2b/3) was achieved in 65 (86.67%) patients. There was a significant mean difference between the NIHSS scores on admission and at 24 h (P < .001). Likewise, mRS score at 3 months also showed a significant mean difference as compared to baseline (P < .001). A faster recanalization was observed in those who were thrombolyzed with TNK, needed fewer number of passes, and if the procedure was performed under conscious sedation.
Conclusion
This study further strengthens the Indian data on efficacy and safety of MT in LVO ischemic strokes. Besides, whether the observation of TNK resulting in a faster revascularization is due to some factors unaccounted in our study, or an actual effect on thrombus due to a high fibrin specificity, needs to be tested further in larger randomized studies with matched sample sizes.
ObjectiveWhile there is class I evidence for mechanical thrombectomy for anterior circulation large vessel occlusion (LVO) stroke; no high-class evidence exists for the posterior circulation. ...Multiple retrospective case studies have assessed thrombectomy for posterior circulation LVO but incorporated data before 2015. The authors sought to explore outcomes of post-2015 posterior LVO mechanical thrombectomy.MethodsAcute ischemic stroke patients who underwent mechanical thrombectomy for anterior and posterior large vessel occlusion (LVO) stroke between 02/2016 and 08/2020 from two comprehensive stroke centers were reviewed. Anterior and posterior LVO strokes were compared. Predictors for a favorable outcome (mRS 0-2), death (mRS 6), and futile revascularization (mRS 4-6 despite TICI 2b/3 revascularization) for posterior LVO were analyzed.ResultsCollectively, 813 LVO thrombectomy cases were analyzed, and 77/813 (9.5%) were located in the posterior circulation. While favorable 90-day functional outcome rates did not differ between anterior and posterior LVO, death was significantly more frequent among posterior LVO cases. Posterior, compared to anterior location, independently predicted death in multivariable analysis. In the posterior LVO subgroup, a primary aspiration technique and successful revascularization TICI 2b/3 irrespective of time to the intervention was independently associated with achieving a favorable outcome and preventing death. Higher risk of futile revascularization, however, was independently associated with treatment beyond the six-hour time window.ConclusionPosterior circulation LVO mechanical thrombectomy appears safe and effective in judiciously selected patients. The use of a primary aspiration technique and achieving successful revascularization appear fundamental.Disclosures P. Hendrix: None. M. Killer-Oberpfalzer: None. E. Broussalis: None. I. Melamed: None. S. Pikija: None. C. Hecker: None. O. Goren: None. R. Zand: None. C. Schirmer: None. E. Trinka: None. C. Griessenauer: None.
BackgroundMedium-vessel occlusions (MeVOs) account for 25%-40% of all acute ischemic stroke (AIS) cases. With peri-procedural embolization occurring in up to 9% of all EVT cases, secondary MeVOs are ...of particular interest to neurointerventionalists. There is currently no reliable evidence regarding whether EVT is safe and effective for MeVO strokes. We sought to gain insight into the current management approaches regarding EVT in AIS caused by secondary MeVOs.MethodsWe conducted an international case-based survey (MeVO-Finding Rationales and Objectifying New Targets for IntervEntional Revascularization in Stroke; MeVO-FRONTIERS) among stroke physicians to gain insight into the current management approaches regarding EVT in AIS caused by secondary MeVOs. Survey participants were presented three cases involving secondary MeVO, each consisting of three case-vignettes with differences in the neurological status of the described patient (improvement, no change, unable to assess due to general anaesthesia). Univariate and multivariate logistic regression analyses clustered by respondent identity were performed to assess factors influencing the decision to treat.Results366 physicians (56 women, 308 men, 2 of undisclosed gender) of different specialities from 44 countries completed the survey for a total of 3294 responses. The majority of physicians (54.1%, 1782/3294) were in favor of EVT. Participants were more likely to treat patients if the occlusion site was in the anterior M2/3 (74.3%; risk ratio RR 2.62, 95%CI:2.27-3.03) and A3 (59.7%; RR 2.11, 95%CI:1.83-2.42) segments, compared to those in the M3/4 segment (28.3%; reference). An improvement in neurological status led to a significant decrease in the likelihood to pursue EVT compared to patients whose neurological deficit remained unchanged (49.9% versus 57% responses in favor of EVT, respectively; RR 0.88, 95%CI:0.83-0.92). Interventionalists and more experienced physicians were more likely to treat secondary MeVOs.ConclusionOur findings suggest that physician’s willingness to treat secondary MeVOs endovascularly is limited and varies per occlusion location and change in neurological status. More evidence on the safety and efficacy of EVT for secondary MeVO stroke is needed.Disclosures P. Cimflova: None. R. McDonough: None. M. Kappelhof: None. J. Ospel: None. N. Singh: None. N. Kashani: None. A. Demchuk: None. B. Menon: None. M. Chen: 2; C; Medtronic, Genentech, Stryker, Microvention, Cerenovus, Penumbra. N. Sakai: None. J. Fiehler: None. M. Goyal: 2; C; Mentice, Medtronic, Microvention, Stryker.
BackgroundEndovascular thrombectomy is the gold standard treatment for emergent proximal large vessel occlusion stroke. The safety and efficacy of thrombectomy in distal branch occlusion is not well ...understood. We aimed to evaluate the technical safety and feasibility of thrombectomy in distal vessel occlusion (DVO).MethodsWe performed a retrospective analysis of consecutive acute stroke patients with distal intracranial occlusion (defined as M3, A2 or P2 occlusion) who underwent thrombectomy within 24 hours from the time of last known well. The primary efficacy outcome was successful reperfusion (TICI≥2B). Secondary outcomes included successful recanalization with ≤3 passes. The safety outcome included the rate of subarachnoid hemorrhage (SAH), all intracranial hemorrhages (ICH) and symptomatic ICH (sICH).ResultsTotal of 72 patients with acute DVO treated with thrombectomy were identified. The median (IQR) age was 70 (20), 38% women, and 21% African-American. The site of occlusion included M3 (54%), P2 (28%), and A2 (18%) segments of middle, posterior and anterior cerebral arteries, respectively. Admission NIHSS score median (IQR) was 12 (11), and 90% of the patients had baseline mRS≤ 2. Thirty six percent of the patients had received intravenous thrombolytic therapy. Successful recanalization was achieved in 90% of the patients. Forty six percent of the procedures were performed under general anesthesia. Direct aspiration technique was used in 64% of the patients. The median number of passes was 2, with successful thrombectomy achieved with ≤3 passes in 83% of the patients. ICH was seen in 16% of the patients, including 3 SAH. However, only one patient (1.3%) had sICH. Among 48 patients in whom 90-day outcome data was available, 44% had favorable clinical outcome (mRS≤2).ConclusionThis single center, consecutive real-world experience demonstrates that thrombectomy in DVO stroke patients is safe and leads to high rate of successful recanalization. Further studies are warranted to evaluate the efficacy of thrombectomy in DVO in comparison to best medical management.Disclosures S. Majidi: None. S. Matsoukas: None. R. De Leacy: None. T. Oxley: None. H. Shoirah: None. T. Shigematsu: None. C. Kellner: None. J. Fifi: None. J. Mocco: None.
IntroductionLonger clot dwell times following acute ischemic stroke (AIS) are potentially associated with poorer outcomes in patients treated with aspiration thrombectomy (AT).Aim of the ...StudyEvaluate the safety and efficacy of AT in AIS across differing clot dwell times.MethodsA subset analysis from a global prospective registry of adults with AIS (COMPLETE) was performed to evaluate impact of clot dwell time on functional outcomes following AT with the Penumbra System. Inclusion criteria were M1 occlusion, witnessed stroke, baseline mTICI 0–2a, and onset to puncture time of 0–24 hours.Patients with multiple emboli, proximal stenosis, or tandem lesions were excluded.ResultsAmong 148 patients included (mean age 67.4, 57% female), 67 had clots <=3 hours and 81 had clots >3 hours. Older clots had lower ASPECTS (median 8.0 IQR 6.0, 9.0 versus 9.0 8.0, 10.0 p=0.0003) and higher NIHSS (13.0, 9.0, 18.0 versus 16.0 11.0, 20.0 p=0.0005) at baseline. Older clots required more passes (2.0 1.0, 3.0 versus 1.0 1.0, 2.0, p=0.0066), and time to mTICI 2b-3 reperfusion ( median 27.0 17.0, 42.0 versus 17.0 13.0, 29.0 minutes, p=0.0094). Each hour increase in dwell time reduced odds of functional recovery (90-day mRS 0–2) by 12% (OR 0.88; 95% CI 0.661, 0.989; p=0.0388) with no significant difference in mortality. Older clots were associated with more safety complications and longer hospital stays.ConclusionsPatients with longer clot dwell times were associated with more attempts and longer time to achieve reperfusion, more post-procedure complications, and lower likelihood of functional recovery.DisclosureOsama O. Zaidat: Grant/research support from Genentech, Medtronic Neurovascular, Stryker. Consultant for Codman, Medtronic Neurovascular, National Institutes of Health StrokeNet, Penumbra, Stryker. Honoraria from Codman, Medtronic Neurovascular, Penumbra, Stryker. Serves as an expert witness. Ownership interest in Galaxy Therapeutics, Inc. Johanna T. Fifi: Grant/research support: Microvention, Penumbra, Stryker. Consultant: Microvention, Stryker. Other financial or material support: Ownership interest: Imperative Care. Ameer E. Hassan: Consultant/Speakers bureau: GE Healthcare, Genentech, Medtronic, Microvention, Penumbra, Stryker, Cerenovus, Viz.ai, Balt and Scientia
BackgroundThe availability of advanced large-bore diameter aspiration catheters has improved recanalization rates and time. We report a prospectively collected clinical experience with a simple ...technique: SNACE (Sofia Non-wire Aspiration Contrast Enhancement) as the primary method for vessel recanalization.Methods38 prospective patients with ELVO at four institutions were included in the study. The SNACE technique was utilized in all patients. Procedural and clinical data were analyzed.ResultsThe SNACE approach using SOFIA 6 Plus Catheter was successful in achieving Thrombolysis in Cerebral Infarction (TICI) 2b or 3 revascularizations in 88% of cases. The first Pass effect was obtained in 75%. The average time from groin puncture to at least TICI 2b recanalization was 17 min. National Institutes of Health Stroke Scale (NIHSS) score average at the onset of 16 and improved to a median NIHSS score at discharge of 5.5. We did not find intraprocedural complications and two symptomatic intracerebral hemorrhages were recorded postoperatively.DiscussionThe SNACE technique is a simple, fast, safe, and effective method that has reduced the requirements to multiple passes and avoiding the use of expensive materials to reach the occlusion site. SNACE is a replicable approach without additional training requirements.ReferencesGory B, Armoiry X, Sivan-Hoffmann R, Piotin M, Mazighi M, Lapergue B, et al. A direct aspiration first pass technique for acute stroke therapy: a systematic review and meta-analysis. Eur J Neurol 2018 Feb 1;25(2):284–92.Blanc R, Redjem H, Ciccio G, Smajda S, Desilles JP, Orng E, et al. Predictors of the aspiration component success of a direct aspiration first pass technique (ADAPT) for the endovascular treatment of stroke reperfusion strategy in anterior circulation acute stroke. Stroke 2017 Jun 1;48(6):1588–93.DisclosureBoris pabon proctorship con MEDTRONIC, Microvention Consultant MIVI
Achieving substantial reperfusion in the first pass is a strong predictor of clinical outcomes. Its role in preventing symptomatic ICH (sICH) is incompletely characterized.We assess the association ...of increasing number of passes with sICH using a large multicenter, prospectively collected international registry with core-lab adjudicated blinded imaging endpoints.We analyzed all patients receiving EVT for LVO in the COMPLETE (Penumbra, Inc) registry. SICH at 24 hours was defined as greater than four-point increase in NIHSS associated with ICH after review by two independent physicians. Multivariable analysis adjusted for age, NIHSS, occlusion location, and ASPECTS were used to assess the likelihood of developing sICH.Among 650 patients included in the analysis, median age was 70 IQR 60–79 and 54% were female. Average number of passes was 1.5. First pass mTICI 2b-3 was achieved in 55.5% (358/645) while 32.2% (208/645) required two or greater attempts. SICH occurred in 25 (3.8%) and PH-2 in 20 (3.1%). We identified an increased likelihood of sICH with increasing number of attempts to achieve TICI 2b or greater (3 vs 1 pass, OR = 3.98 95% CI, 1.05–15.0, and 4 vs 1 pass, OR = 5.04 95% CI, 1.35–18.8). Failure to achieve mTICI 2b or greater (79/645) was associated with increased incidence of sICH compared to first pass reperfusion (OR = 4.66, CI 95%, 1.43–15.1).Achieving substantial reperfusion with the fewest number of thrombectomy attempts was associated with decreasing likelihood of sICH.ReferencesZaidat OO, Castonguay AC, Linfante I, et al. First pass effect: a new measure for stroke thrombectomy devices. Stroke 2018;49(3):660–666. doi:10.1161/STROKEAHA.117.020315Maros ME, Brekenfeld C, Broocks G, et al. Number of retrieval attempts rather than procedure time is associated with risk of symptomatic intracranial hemorrhage. Stroke 2021;52(5):1580–1588. doi:10.1161/STROKEAHA.120.031242DisclosureAll COMPLETE trial investigators received support from Penumbra Inc
IntroductionEmerging data show an association between increased mechanical thrombectomy (MT) passes and poor outcomes in ischemic stroke. Clots that require ≥3 passes are more often tough, ...fibrin-rich thrombi than those retrieved within two passes.AimsTo assess the clinical and economic burden of number of MT passes, we evaluated the odds of achieving successful reperfusion and functional independence in first pass, or 2–3 passes, compared to ≥4 passes.MethodsA retrospective observational study was conducted on 857 cases treated with MT from the Irish National Thrombectomy database. Outcomes were 90-day functional independence (mRS 0–2) and successful reperfusion (mTICI 2b-3) stratified by number of passes (1; 2–3; and ≥4) with multivariable regression to adjust for confounding variables. A decision-tree economic model was informed by 90-day mRS: independent (0–2), dependent (3–5), or dead, with literature-derived annual healthcare costs by mRS.ResultsThe odds of achieving successful reperfusion were significantly higher for 1 vs. ≥4 passes (OR 7.19, p<0.001); and for 2–3 vs. ≥4 passes (OR 3.19, p<0.001). The odds of functional independence were significantly higher for 1 vs. ≥4 passes (OR 2.51, p<0.001); and trended higher for 2–3 vs. ≥4 passes (OR 1.49, p=0.199). Patients treated with 1 pass had the lowest annual healthcare costs ($20,910); 2–3 passes ($21,999) ≥4 passes ($25,904).ConclusionOdds of achieving good outcomes decline with MT passes, while care costs increase. Thrombectomy devices that improve interaction with tough clots for rapid and complete retrieval in fewer passes may improve clinical and economic outcomes.ReferencesYoo AJ. Journal of Stroke 2017;19(2):121.Douglas A. JNIS 2020;12(6):557–562.Liebeskind DS. Stroke 2011;42(5):1237–1243.Abbasi M. Interventional Neuroradiology 2021;202115910199211009119.Siddiqui AH. Stroke 2021;52(Suppl_1):AP14–AP14.García-Tornel Á. Stroke 2019;50(7):1781–1788.Shireman TI. Stroke 2017;48(2):379–387.DisclosureDr. Jack Alderson, Radiology, Beaumont Hospital. Prof. Dr. John Thornton, Neuroradiology, Beaumont Hospital. Consultancy for Johnson & Johnson, Perfuze and Microvention. Shareholder Perfuze. Cindy Tong and Shelly Ikeme are employees of Johnson & Johnson. Heather Cameron is an employee of EVERSANA, a consultant for Johnson & Johnson. This research is funded by Cerenovus – a company of Johnson & Johnson
IntroductionNimbus was developed for difficult to remove white clots that account for a substantial percentage of technical failure in mechanical thrombectomy (MT). The device aims at engaging tough ...clots through unique architecture of a proximal spiral portion followed by a distal regular mesh.AimTo evaluate the retrieval rate, and composition, of clot deemed challenging to remove, using Nimbus in a clinical setting.MethodsConsecutive Nimbus cases from 2 high volume stroke centers were retrospectively analyzed. Clots from 1 center were sent to a central lab for composition analysis including Martius Scarlet Blue staining.ResultsNimbus was used as 1st and 2nd line device in 5 and 30 patients, respectively. The main reason for using Nimbus (30/35) was failure of standard MT techniques with a mean 2.9 number of passes (maximum 6). In non-Nimbus passes, the rate of any clot retrieval was 35.5%, compared to 89.2% in Nimbus passes. With Nimbus, mTICI≥2b was achieved in 68.6% (24/35) cases with a mean 1.8 passes (mean 4.7 total number passes with all devices). Final mTICI≥2b with all devices was 77.1% (27/35). In successful cases (mTICI≥2b), Nimbus was used in the last pass in 88.9% (24/27) cases.Clot specimens from 16 cases underwent composition analysis. Fibrin and platelets represented 30.2% and 29.3% of clot components; 34.6% were red blood cells.ConclusionsNimbus is effective in removing tough clots markedly rich in fibrin and platelets in challenging real world situations.ReferenceJens Fiehler. Failed thrombectomy in acute ischemic stroke: return of the stent? Stroke 2018;49:811–812. https://doi.org/10.1161/STROKEAHA.118.020541DisclosureThis series has emanated from research supported in part by a grant from Science Foundation Ireland (SFI) and the European Regional Development Fund (ERDF) under grant number 13/RC/2073_P2. It is the independent clinical practice of the authors. Cerenovus provided support for post hoc data collection and analysis.
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