In this multicenter study, we sought to evaluate comparative safety and efficacy of combined IV thrombolysis (IVT) and mechanical thrombectomy (MT) vs direct MT in emergent large vessel occlusion ...(ELVO) patients.
Consecutive ELVO patients treated with MT at 6 high-volume endovascular centers were evaluated. Standard safety and efficacy outcomes (successful reperfusion modified Thrombolysis in Cerebral Infarction IIb/III, functional independence FI modified Rankin Scale (mRS) score of 0-2 at 3 months, favorable functional outcome mRS of 0-1 at 3 months, functional improvement mRS shift by 1-point decrease in mRS score) were compared between patients who underwent combined IVT and MT vs MT alone. Additional propensity score-matched analyses were performed.
A total of 292 and 277 patients were treated with combination therapy and direct MT, respectively. The combination therapy group had greater functional improvement (
= 0.037) at 3 months. After propensity score matching, 104 patients in the direct MT group were matched to 208 patients in the combination therapy group. IVT pretreatment was independently (
< 0.05) associated with higher odds of FI (odds ratio OR 1.75; 95% confidence interval CI 1.02-2.99) and functional improvement (common OR 1.64; 95% CI 1.05-2.56). Combination therapy was independently (
< 0.05) related to lower likelihood of 3-month mortality (0.50; 95% CI 0.26-0.96).
This observational study provides preliminary evidence that IVT pretreatment may improve outcomes in ELVO patients treated with MT. The question of the potential effect of IVT on ELVO patients treated with MT should be addressed with a randomized controlled trial.
This study provides Class III evidence that for stroke patients with emergent large vessel occlusion, combined IVT and MT is superior to direct MT in improving functional outcomes.
Background and purpose
A direct aspiration first pass technique (ADAPT), involving the first‐line use of a large‐bore distal aspiration catheter, is a new strategy in the mechanical thrombectomy of ...acute ischemic stroke caused by large‐vessel occlusion. However, its impact on reperfusion rates, clinical outcomes and complication rates has not been fully examined.
Methods
We conducted a systematic review of the literature searching multiple databases for reports on thrombectomy of acute stroke with ADAPT and performed meta‐analyses of clinical and radiographic outcomes.
Results
We selected 16 articles that included a total of 1378 patients treated with ADAPT. The mean admission National Institutes of Health Stroke Scale score was 17 and pre‐treatment intravenous thrombolysis was used in 51% of cases. The successful recanalization (thrombolysis in cerebral ischemia 2b‐3) rate was 66% 95% confidence interval (CI), 59–72% with ADAPT and a rescue stent retriever was used in 31% of cases (95% CI, 24–37%) yielding an overall thrombolysis in cerebral ischemia 2b‐3 rate of 89% (95% CI, 85–92%). We found a pooled estimate of 50% (95% CI, 45–54%) for functional independence (modified Rankin Scale score 0–2) at 90 days, 15% (95% CI, 10–21%) for mortality within 90 days and 5% (95% CI, 3–7%) for symptomatic intracranial hemorrhage.
Conclusions
ADAPT therapy is associated with similar reperfusion rates, clinical outcomes and complication rates compared with thrombectomy with stent retrievers. However, the major limitations of current evidence (i.e. retrospective studies and selection bias) indicate a need for adequately powered, multicenter randomized controlled trials to determine the best strategy.
Acute ischemic stroke is a leading cause of death and disability worldwide. Several recent clinical trials have shown that endovascular treatment improves clinical outcomes among patients with acute ...ischemic stroke.
To provide an overall and precise estimate of the efficacy of endovascular treatment predominantly using second-generation mechanical thrombectomy devices (stent-retriever devices) compared to medical management on clinical and functional outcomes among patients with acute ischemic stroke.
MEDLINE, EMBASE, Cochrane Collaboration Central Register of Controlled Clinical Trials, Web of Science, and NIH ClinicalTrials.gov were searched through November 2015.
Searches returned 3,045 articles. After removal of duplicates, two authors independently screened titles and abstracts to assess eligibility of 2,495 potentially relevant publications. From these, 38 full-text publications were more closely assessed. Finally, 5 randomized controlled trials of endovascular treatment with predominant use of retrievable stents were selected.
Three authors independently extracted information on participant and trial characteristics and clinical events using a standardized protocol. Random effects models were used to pool endovascular treatment effects across outcomes.
The primary outcome was better functional outcome as measured on the modified Rankin Scale at 90 days of follow-up. Secondary outcomes included all-cause mortality and symptomatic intra-cerebral hemorrhage.
Five trials representing 1,287 patients were included. Overall, patients randomized to endovascular therapy experienced 2.22 times greater odds of better functional outcome compared to those randomized to medical management (95% CI, 1.66 to 2.98; P < 0.0001). Endovascular therapy was not associated with mortality OR (95% CI), 0.78 (0.54, 1.12); P = 0.1056 or symptomatic intracerebral hemorrhage OR (95% CI), 1.19 (0.69, 2.05); P = 0.5348. Meta-regression analysis suggested that shorter times from stroke onset to groin puncture and from stroke onset to reperfusion result in better functional outcomes in ischemic stroke patients (P = 0.0077 and P = 0.0089). There were no significant differences in the beneficial effects of endovascular treatment on functional outcomes across categories of gender, age, stroke severity, ischemic changes on computed tomography, or intravenous tissue plasminogen activator administration.
This meta-analysis demonstrated superior functional outcomes in subjects receiving endovascular treatment compared to medical management. Further, this analysis showed that acute ischemic stroke patients may receive enhanced functional benefit from earlier endovascular treatment.
Whether bridging strategiesintravenous thrombolysis (IVT) + mechanical thrombectomy (MT) are superior to mechanical thrombectomy alone for large vessel occlusion(LVO) is still uncertain. A systematic ...review and meta-analysis was conducted to investigate and evaluate comparative efficacy and safety of bridging strategies vs direct MT in patients with LVO.
The PubMed, EMBASE and Cochrane library databases were searched to evaluate the efficacy and safety of bridging strategies with direct MT in LVO. Functional independence, mortality, symptomatic intracranial hemorrhage (sICH) and successful recanalization were assessed. The risk ratio (RR) and its 95% confidence interval (CI) were calculated.
The proportion of patients who received MT + IVT was significantly higher in functional independence and successful recanalization rate than MT alone patients. However, pooled results showed that the mortality of patients who received MT + IVT was significantly lower than that of MT alone patients. Moreover, no significant differences were observed in the incidence of sICH between the 2 groups.
The findings of our meta-analysis confirmed that bridging strategies improved functional outcomes, successful recanalization rate and reduced mortality rates. Moreover, the incidence of sICH showed no differences between the bridging strategies and MT alone treatments. However, the conduct of high-quality randomized clinical trials that directly compare both strategies is warranted.
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.
Stent-supported aneurysm coiling has been utilized with increasing frequency over the past few years, particularly for addressing treatment of complex and wide-neck aneurysms. A sizable body of ...literature describing various experiences with stent-supported coiling now exists. The purpose of this research was to carry out a comprehensive literature survey of stent-supported aneurysm coiling.
A survey of papers reporting results with stent-assisted aneurysm coiling through January 2011 was conducted to identify the prevalence of stent-related and other complications, occlusion rates, and clinical and angiographic follow-up data.
Thirty-nine articles with 1517 patients met inclusion criteria for initial analysis, follow-up analysis, or both. Overall, 9% of cases were confounded by a technical stent-related issue, including 4% failure of deployment. The overall procedure complication rate was 19%, with periprocedural mortality of 2.1%. Approximately 45% of aneurysms were completely occluded at first treatment session, increasing to 61% on follow-up. Approximately 3.5% in-stent stenosis and 0.6% stent occlusion were observed at angiographic follow-up. Delayed stroke or transient ischemic attack was reported in 3% of subjects. Within a subset of articles, the incidence of stent-related issues in the first 10 patients was significantly higher than in subsequent subjects, supporting the notion of a procedural "learning curve."
In experienced hands, the morbidity of stent-supported coiling is somewhat higher compared with "traditional" coiling. As might be expected, execution of the procedure appears improved with experience. Complete occlusion rates remain somewhat low. More and longer term angiographic follow-up information is needed to understand delayed stent-related issues and to better define the durability of treatment.
After the many positive results in thrombectomy trials in ischemic stroke of the anterior circulation, the question arises whether these positive results also apply to the patient with basilar artery ...occlusion (BAO).
To report up-to-date outcome data of intra-arterial (IA) treatment in patients with BAO and to evaluate the influence of collateral circulation on outcome.
Single-center retrospective case series of 38 consecutive patients with BAO who underwent IA treatment between 2006 and 2015 at a comprehensive stroke center.
Intra-arterial treatment by mechanical thrombectomy and/or IA thrombolysis.
Adequate recanalization was defined as a score of 2b or 3 on the Thrombolysis in Cerebral Infarction score. Favorable outcome was defined as a modified Rankin Scale of 0 to 3 at first follow-up. Imaging data on the patency of the vertebral arteries and posterior communicating arteries, as well as the presence of cerebellar arterial anastomosis, were recorded and posttreatment imaging results were reviewed.
Of the 38 patients with BAO, mean (SD) age was 58 (16) years, and 21 (55%) were male. Twenty-seven patients (71%) were treated with intravenous thrombolysis before IA therapy. Mechanical thrombectomy was applied to 30 patients, and 7 patients received local urokinase without thrombectomy. The median National Institutes of Health Stroke Scale score was 21 (interquartile range IQR, 15-32) points, and median time to IA treatment was 288 (IQR, 216-380) minutes. Adequate recanalization was achieved in 34 of 38 cases (89%). Functional outcome was favorable in 19 (50%) patients. No association between patent collateral circulation and favorable outcome was found. Symptomatic intracranial hemorrhage occurred in 2 patients (5%).
The proportion of patients reaching a favorable outcome in our study is comparable to the IA-treated group of the MR CLEAN trial and better than the results reported in the BASICS registry, suggesting that IA intervention in patients with BAO is an effective and safe treatment modality in daily clinical practice.
In patients suffering from acute ischemic stroke from large vessel occlusion (LVO), mechanical thrombectomy (MT) often leads to successful reperfusion. Only approximately half of these patients have ...a favorable clinical outcome. Our aim was to determine the prognostic factors associated with poor clinical outcome following complete reperfusion.
Patients treated with MT for LVO from a prospective single-center stroke registry between July 2015 and April 2019 were screened. Complete reperfusion was defined as Thrombolysis in Cerebral Infarction (TICI) grade 3. A modified Rankin scale at 90 days (mRS90) of 3-6 was defined as 'poor outcome'. A logistic regression analysis was performed with poor outcome as a dependent variable, and baseline clinical data, comorbidities, stroke severity, collateral status, and treatment information as independent variables.
123 patients with complete reperfusion (TICI 3) were included in this study. Poor clinical outcome was observed in 67 (54.5%) of these patients. Multivariable logistic regression analysis identified greater age (adjusted OR 1.10, 95% CI 1.04 to 1.17; p=0.001), higher admission National Institutes of Health Stroke Scale (NIHSS) (OR 1.14, 95% CI 1.02 to 1.28; p=0.024), and lower Alberta Stroke Program Early CT Score (ASPECTS) (OR 0.6, 95% CI 0.4 to 0.84; p=0.007) as independent predictors of poor outcome. Poor outcome was independent of collateral score.
Poor clinical outcome is observed in a large proportion of acute ischemic stroke patients treated with MT, despite complete reperfusion. In this study, futile recanalization was shown to occur independently of collateral status, but was associated with increasing age and stroke severity.
Age and stroke severity are inversely correlated with the odds of favorable outcome after ischemic stroke. A previously proposed score for Stroke Prognostication Using Age and NIHSS Stroke Scale ...(SPAN) indicated that SPAN-100-positive patients (ie, age + NIHSS score = 100 or more) do not benefit from IV-tPA. If this finding holds true for endovascular therapy, this score can impact patient selection for such interventions. This study investigated whether a score combining age and NIHSS score can improve patients' selection for endovascular stroke therapy.
The SPAN index was calculated for patients in the prospective Solitaire FR Thrombectomy for Acute Revascularization study: an international single-arm multicenter cohort for anterior circulation stroke treatment by using the Solitaire FR. The proportion with favorable outcome (90-day mRS score ≤2) was compared between SPAN-100-positive versus-negative patients.
Of the 202 patients enrolled, 196 had baseline NIHSS scores. Fifteen (7.7%) patients were SPAN-100-positive. There was no difference in the rate of successful reperfusion (Thrombolysis In Cerebral Infarction 2b or 3) between SPAN-100-positive versus -negative groups (93.3% versus 82.8%, respectively; P = .3). Stroke SPAN-100-positive patients had a significantly lower proportion of favorable clinical outcomes (26.7% versus 60.8% in SPAN-100-negative, P = .01). In a multivariable analysis, SPAN-100-positive status was associated with lower odds of favorable outcome (OR, 0.3; 95% CI, 0.1-0.9; P = .04). A higher baseline Alberta Stroke Program Early CT Score and a short onset to revascularization time also predicted favorable outcome in the multivariable analysis.
A significantly lower proportion of patients with a positive SPAN-100 achieved favorable outcome in this cohort. SPAN-100 was an independent predictor of favorable outcome after adjusting for time to treatment and the extent of preintervention tissue damage according to the Alberta Stroke Program Early CT Score.
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