IntroductionCharacteristics of clots from stroke patients have gained a lot of interest in recent years as they could provide insights to improve the endovascular and medical management of ischemic ...stroke. Histology have been used to quantify the clot compositions, but analysis of clot structural pattern has been limited to qualitative description.MethodsFrom the STRIP (stroke thromboembolism registry of imaging and pathology) registry, we analyzed clots from 157 passes retrieved by mechanical thrombectomy from stroke cases where TICI 2c/3 was achieved. The clots were stained with Martius Scarlet Blue. To quantify the clot heterogeneity, we developed an algorithm to automatically segment scanned images into uniform grids and calculate the composition within each grid. Using the variance of compositions across neighboring grids, we proposed and implemented a formula to calculate the spatial heterogeneity index (SPI) value. To validate the clinical significance, we compared the clot SPI and clot compositions (red blood cells, fibrin, platelets, white blood cells) between cases with first pass effect (FPE) and cases without. SPI values of clots from cases with different etiologies, thrombectomy techniques, and tPA admission were also compared.ResultsThe average SPI value was 0.040 (SD 0.019) with a large range (0.001-0.091) with a grid size of 0.3 mm. For cases with FPE (n = 107), SPI was significantly smaller (0.038 vs 0.044, p =0.05) compared to those without (n = 50). In comparison, none of the clot compositions was significantly different between cases with FPE and cases without. There was no significant difference in heterogeneity for clots from cases with different etiologies or retrieved with different thrombectomy techniques. Admission of tPA didn’t change the clot heterogeneity either.ConclusionSPI is a useful measure of clot structural heterogeneity and could provide more insights to improve the thrombectomy outcome compared to clot compositions.Disclosures Y. Liu: None. W. Brinjikji: None. M. Abbasi: None. D. Dai: None. J. Arturo Larco: None. D. Kallmes: None. L. Savastano: None.
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
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
BackgroundMechanical thrombectomy (MT) indications for acute stroke treatment have expanded in the last few years to include medium vessel occlusions. However, limited data is available about the ...safety and efficacy of MT in the distal anterior cerebral artery (ACA) segments (A2/A3). This study aims to assess the feasibility and outcomes of MT in stroke patients presenting with acute A2 and A3 occlusions in a large multicenter registry.MethodsThis is a retrospective analysis from the Stroke Thrombectomy and Aneurysm registry (STAR) which maintains data from 40 stroke centers in the United States, Europe, Asia, and South America. We included patients who presented with A2/A3 occlusions and were treated with MT using second generation thrombectomy devices between January 1, 2014, and December 31, 2020. Primary outcome of this analysis was the final modified treatment in cerebral infarction (mTICI) score. Other endpoints included the modified Rankin Scale (mRS) score at 90 days and the rate of symptomatic intracranial hemorrhage (sICH).ResultsWe identified 27 patients who met the inclusion criteria. Median age was 61 (IQR 53-81) years, 15 (55.6%) were female, and 14 (51.9%) were white. A2 segment occlusion was seen in 20 (74.1%) patients and A3 segment in 7 (25.9%) patients. Fourteen (51.9%) in patients received intravenous tissue plasminogen activator (tPA) prior to MT. Regarding MT technique used, contact aspiration first line (ADAPT) was used in 14 (51.9%) patients, stent retriever first-line was used in 4 (14.8%) patients, and a combination of both techniques was used in 9 (33.3%). Intraarterial tPA was used in 6 (22.2%) patients. Final mTICI ≥ 2B was recorded in 20 (74.1%) patients (13 48.1% had mTICI of 2C or 3). Periprocedural complications were seen in 4 (14.8%) patients and sICH occurred in 1 (3.7%) patient. At 90 days, 17 (63%) patients achieved functional independence (mRS 0-2).ConclusionIn this multicenter study, MT for distal ACA occlusions in the A2/A3 segments seem to be feasible and associated with low complication and symptomatic hemorrhage rates. Future studies are needed to compare the functional outcome of MT versus medical management for stroke patients presenting with A2/A3 occlusions.Disclosures D. Pullmann: None. E. Almallouhi: None. S. Al Kasab: None. A. Alawieh: None. R. Chalhoub: None. R. Starke: None. R. De Leacy: None. D. Raper: None. A. Rai: None. T. Dumont: None. S. Wolfe: None. P. Jabbour: None. C. Ogilvy: None. M. Park: None. M. Levitt: None. A. Polifka: None. R. Crowley: None. A. Arthur: None. J. Osbun: None. R. Crosa: None. I. Maier: None. J. Kim: None. W. Casagrande: None. A. Shaban: None. J. Grossberg: None. S. Chowdhry: None. M. Mokin: None. C. Matouk: None. I. Fragata: None. S. Webb: None. A. Yoo: None. J. Mascitelli: None. M. Psychogios: None. M. Azab: None. A. Spiotta: 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.
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.
BackgroundWe report our initial experience with a new stent retriever for mechanical thrombectomy of large- and medium vessel occlusions.MethodsWe pooled data of four high-volume European stroke ...centers over the time period from October 2020 to February 2021. Patients were included in our study if the Trevo NXT stent retriever was used as first-line device. Primary endpoints were first-pass near-complete or complete reperfusion, defined as mTICI score of ≥2c. Secondary endpoints were final reperfusion, National Institutes of Health Stroke Scale (NIHSS) at 24 hours and discharge, device malfunctions, complications during the procedure and subjective ratings of the interventionalists regarding device functionality.ResultsEighty patients (39 women, mean age 74±14 years) were eligible for our study. Median NIHSS at admission was 15 (IQR, 8–19) and median Alberta Stroke Program Early CT Score at baseline 9 (IQR, 8–10). In 74 (93%) patients a primary combined approach was used as first-line technique. First-pass near-complete reperfusion was achieved in 43 (54%) and first-pass complete reperfusion in 34 (43%) patients. Final near-complete reperfusion was achieved in 66 (83%) patients after a median of 1.5 (1–3) passes, while final successful reperfusion was observed in 96% of our cases. We observed no device malfunctions. Median NIHSS at discharge was 2 (IQR, 0–5) and 3 patients (4%) suffered a symptomatic intracranial hemorrhage.ConclusionsBased on our initial data, we conclude that the Trevo NXT is an effective and safe tool for mechanical thrombectomy especially when used for combined approaches.DisclosureNothing to disclose
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.
Stroke in the Young: a Global Update Hathidara, Mausaminben Y.; Saini, Vasu; Malik, Amer M.
Current neurology and neuroscience reports,
11/2019, Letnik:
19, Številka:
11
Journal Article
Recenzirano
Odprti dostop
Purpose of Review
We aim to evaluate the epidemiology, racial and gender disparity, etiology, and treatment of stroke in the younger population.
Recent Findings
The younger age group without vascular ...risk factors exhibits an increased prevalence of cardio-embolism in context of patent foramen ovale/atrial septal aneurysm strokes, from other determined etiology of non-atherosclerotic vasculopathy including dissection, inherited or acquired thrombophilia, and other unusual causes of stroke. Ethnic disparities also exist in certain populations.
Summary
The prevalence of stroke in the young is increasing due to several factors. Since stroke is often disabling, this trend poses an enormous threat to socioeconomic stability especially in developing countries. In young patients with an absence of conventional vascular risk factors and negative preliminary stroke work-up, clinicians must consider less common causes of stroke in this population. There is prime opportunity for future investigations as there is currently a lack of evidence-based management guidelines for these uncommon etiologies based on research completed to date.
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