Advanced imaging for patient selection in mechanical thrombectomy is not widely available.
To compare the clinical outcomes of patients selected for mechanical thrombectomy by noncontrast computed ...tomography (CT) vs those selected by computed tomography perfusion (CTP) or magnetic resonance imaging (MRI) in the extended time window.
This multinational cohort study included consecutive patients with proximal anterior circulation occlusion stroke presenting within 6 to 24 hours of time last seen well from January 2014 to December 2020. This study was conducted at 15 sites across 5 countries in Europe and North America. The duration of follow-up was 90 days from stroke onset.
Computed tomography with Alberta Stroke Program Early CT Score, CTP, or MRI.
The primary end point was the distribution of modified Rankin Scale (mRS) scores at 90 days (ordinal shift). Secondary outcomes included the rates of 90-day functional independence (mRS scores of 0-2), symptomatic intracranial hemorrhage, and 90-day mortality.
Of 2304 patients screened for eligibility, 1604 patients were included, with a median (IQR) age of 70 (59-80) years; 848 (52.9%) were women. A total of 534 patients were selected to undergo mechanical thrombectomy by CT, 752 by CTP, and 318 by MRI. After adjustment of confounders, there was no difference in 90-day ordinal mRS shift between patients selected by CT vs CTP (adjusted odds ratio aOR, 0.95 95% CI, 0.77-1.17; P = .64) or CT vs MRI (aOR, 0.95 95% CI, 0.8-1.13; P = .55). The rates of 90-day functional independence (mRS scores 0-2 vs 3-6) were similar between patients selected by CT vs CTP (aOR, 0.90 95% CI, 0.7-1.16; P = .42) but lower in patients selected by MRI than CT (aOR, 0.79 95% CI, 0.64-0.98; P = .03). Successful reperfusion was more common in the CT and CTP groups compared with the MRI group (474 88.9% and 670 89.5% vs 250 78.9%; P < .001). No significant differences in symptomatic intracranial hemorrhage (CT, 42 8.1%; CTP, 43 5.8%; MRI, 15 4.7%; P = .11) or 90-day mortality (CT, 125 23.4%; CTP, 159 21.1%; MRI, 62 19.5%; P = .38) were observed.
In patients undergoing proximal anterior circulation mechanical thrombectomy in the extended time window, there were no significant differences in the clinical outcomes of patients selected with noncontrast CT compared with those selected with CTP or MRI. These findings have the potential to widen the indication for treating patients in the extended window using a simpler and more widespread noncontrast CT-only paradigm.
Percutaneous mechanical thrombectomy is commonly used to treat acute thrombotic syndromes. AngioJet (AJ) forcibly sprays fibrinolytics to fragment and aspirate thrombus. It is known to cause ...hemolysis and gross hematuria, yet potential consequences to renal function after AJ remain unstudied. We sought to determine the risk of acute kidney injury (AKI) after AJ when compared with other lysis techniques.
We retrospectively reviewed patients treated with thrombolysis over 5 years. We identified those treated with AJ or catheter-directed thrombolysis (CDT). Demographics, indications, procedures, and laboratory values within 3 days were recorded. AKI was defined as an increase >25% above the baseline creatinine within 72 hr of the procedure. IN total, 102 patients (52 AJ, 50 CDT) had no statistical difference in mean age (50 and 51), indication (arterial thrombosis 65% and 88%), or baseline creatinine (0.9 and 1.0 mg/dL), respectively. AKI occurred in 15 (29%) patients treated with AJ versus 4 (8%) of CDT (P = 0.007). Similar numbers of AJ and CDT patients underwent additional open surgical procedures (21% and 30%, respectively, P = not significant). Multivariable analysis demonstrated that the odds of AKI were only increased by AJ (odds ratio OR 8.2, 95% confidence interval CI 1.98-34.17, P = 0.004), open surgery (OR 5.4, 95% CI 1.43-20.17, P = 0.013), or a >10% drop in hematocrit (OR 4.0, 95% CI 1.15-14.25, P = 0.03).
In our observational study, AJ is an independent risk factor for AKI. Concomitant open surgery and drop in hematocrit also raise the odds of AKI. Renal injury after AJ is under-reported in the literature, and may be related to hemolysis from the device.
Background
We investigated the prevalence and mechanisms of neurological deterioration after endovascular thrombectomy.
Methods
Between January 2011 and October 2017, acute ischemic stroke patients ...treated by endovascular thrombectomy in a tertiary university hospital were included. Early neurological deterioration (END) was defined as an increase of 2 or more National Institute of Health Stroke Scale (NIHSS) compared to the best neurological status after stroke within 7 days. The END mechanism was categorized into ischemia progression, symptomatic hemorrhage, and brain edema.
Results
A total of 125 acute ischemic stroke patients received endovascular thrombectomy. Neurological deterioration was detected in 44 patients, and 38 cases (86.4% of END) occurred within 72 h. The END mechanism included 20 ischemia progression, 16 brain edema and 8 hemorrhagic transformation cases. Multivariable logistic regression analysis revealed that the patients who experienced END were more likely to have poor functional outcome defined as modified Rankin scale 3–6 at 90 days than neurologically stable patients (odds ratio (OR) = 4.06, confidence interval (CI) = 1.39–11.9). The risk factor of END due to ischemia progression was stroke subtype of large artery atherosclerosis (OR = 6.28, CI = 1.79–22.0). Successful recanalization (OR = 0.11, CI = 0.03–0.39) and NIHSS after endovascular thrombectomy (OR = 1.15 per one-point increase, CI = 1.06–1.24) were significantly associated with END due to hemorrhage or brain edema.
Conclusion
Neurological deterioration frequently occurs after endovascular thrombectomy, and the risk factors of END differ according to the mechanism of END.
The benefit of mechanical thrombectomy added to intravenous thrombolysis (IVT) in patients with acute ischemic stroke has been largely demonstrated. However, evidence of the economic incentive of ...this strategy is still limited, especially in the context of a randomized controlled trial. We aimed to analyze whether mechanical thrombectomy combined with IVT (IVMT) is cost-effective when compared with IVT alone.
Individual-level cost and outcome data were collected in the THRACE randomized controlled trial (Thrombectomie des Artères Cerébrales) including patients with acute ischemic stroke. Patients were assigned to receive IVT or IVMT. The primary outcomes were modified Rankin Scale score of functional independence at 90 days (score 0-2) and the EuroQol-5D quality-of-life score at 1 year.
Treating acute ischemic stroke with IVMT (n=200) versus IVT (n=202) increased the rate of functional independence by 10.9% (53.0% versus 42.1%;
=0.028), at an increased cost of $2116 (€1909), with no significant difference in mortality (12% versus 13%;
=0.70) or symptomatic intracranial hemorrhage (2% versus 2%;
=0.71). The cost per one averted case of disability was estimated at $19 379 (€17 480). The incremental cost per one quality-adjusted life year gained was $14 881 (€13 423). On sensitivity analysis, the probability of cost-effectiveness with IVMT was 84.1% in terms of cases of averted disability and 92.2% in terms of quality-adjusted life years.
Based on randomized trial data, this study demonstrates that IVMT used to treat acute ischemic stroke is cost-effective when compared with IVT alone.
URL: http://www.clinicaltrials.gov. Unique identifier: NCT01062698.
Aim
Stroke treatment is a time-critical condition. Understanding the impact of timing and types of treatment on patient outcomes can help develop and optimize stroke management strategies. The study ...aimed to analyse the effect of different time intervals and mechanical thrombectomy methods on outcomes of stroke patients in Kazakhstan.
Methods
The patient data, including demographic information, clinical characteristics, and specific time intervals from stroke onset to hospital admission, stroke onset to surgery initiation, and hospital admission to surgery initiation were collected. A total
of 100 patients were analysed. Patients’ neurological status was evaluated using the National Institutes of Health Stroke Scale (NIHSS), Modified Rankin Scale (mRS), and Glasgow Coma Scale (GCS) before and after the surgical treatment.
Results
Most patients had concomitant arterial hypertension, and almost 25 % had diabetes mellitus. The average time from stroke onset to hospital admission was 123.2±7.6 minutes, and from hospital admission to surgery initiation, it was 134.7±13.1 minutes. A shorter duration from the onset of stroke to hospitalization and surgery was associated with better clinical outcomes. Our results demonstrated a statistically significant decrease in NIHSS, mRS after surgical treatment compared to baseline. The association between the extended time from stroke onset to hospitalization and
reduced survival rates was observed.
Conclusion
Our findings indicate the essential role of timely intervention in managing stroke patients, as well as the need for a
comprehensive and patient-centred approach to stroke care.
The time from arterial puncture to successful recanalization is an important milestone toward timely recanalization. With the significant improvement in recanalization rates by using thrombectomy ...devices, procedural time to recanalization is becoming a determinant factor in choosing among available devices. We aimed to assess the impact of time to recanalization on the outcome of intra-arterial stroke therapies.
We conducted a meta-analysis of studies reporting procedural times in patients with stroke treated with the MD, PS, and RS.
We identified 16 eligible studies: 4 on the MD (n = 357), 8 on the PS (n = 455), and 4 on RS (n = 113). Merci device studies described total procedural duration, while PS and RS studies described puncture-to-recanalization times. With a random-effects model, mean procedural duration for the MD was 120 minutes (95% CI, 105.7-134.2 minutes). Mean puncture to recanalization time for the PS was 64.6 minutes (95% CI, 44.4-84.8 minutes) and 54.7 minutes for RS (95% CI, 47.3-62.2 minutes). Successful recanalization was achieved in 211 of 357 patients (59.1%) in the MD studies (95% CI, 49.3-77.7), 394 of 455 (86.6%) in the PS studies (95% CI, 84.1-93.8), and 105 of 113 (92.9%) in the RS studies (95% CI, 90.9-99.9). Functional independence (mRS ≤2) was achieved in 31.5% of patients in the MD studies, 36.6% in the PS studies, and 46.9% in the RS studies.
The use of the PS and RS was associated with comparable procedural time to recanalization. Available data did not allow this parameter to be determined for trials using the MD. Retrievable stents achieved the highest rate of successful recanalization and functional outcome and the lowest mortality.
A direct aspiration first pass technique (ADAPT) has been reported to be fast, safe, and effective for the treatment of acute ischemic stroke. The aim of this study is to determine the preoperative ...factors that affect success of the aspiration component of the technique in ischemic stroke patients with large vessel occlusion in the anterior circulation.
We enrolled all 347 consecutive patients with anterior circulation acute ischemic stroke admitted for mechanical thrombectomy at our institution from August 2013 to October 2015 and treated by ADAPT for the endovascular treatment of stroke. Baseline and procedural characteristics, modified thrombolysis in cerebral infarction scores, and 3-month modified Rankin Scale were captured and analyzed.
Among the 347 patients (occlusion sites: middle cerebral artery=200, 58%; internal carotid artery Siphon=89, 25%; Tandem=58, 17%), aspiration component led to successful reperfusion (modified thrombolysis in cerebral infarction 2b/3 scores) in 55.6% (193/347 patients), stent retrievers were required in 40%, and a total successful final reperfusion rate of 83% (288/347) was achieved. Overall, procedural complications occurred in 13.3% of patients (48/347). Modified Rankin Scale score of 0 to 2 at 90 days was reported in 45% (144/323). Only 2 factors positively influenced the success of the aspiration component: an isolated middle cerebral artery occlusion (
<0.001) and a shorter time from stroke onset to clot contact (
=0.018).
In this large retrospective study, ADAPT was shown to be safe and effective for anterior circulation acute ischemic stroke with a final successful reperfusion achieved in 83%. The site of arterial occlusion and delay of the procedure were predictors for reperfusion.
URL: http://www.clinicaltrials.gov. Unique identifier: NCT02523261, NCT02678169, and NCT02466893.
Background
Most disabling strokes are due to a blockage of a large artery in the brain by a blood clot. Prompt removal of the clot with intra‐arterial thrombolytic drugs or mechanical devices, or ...both, can restore blood flow before major brain damage has occurred, leading to improved recovery. However, these so‐called endovascular interventions can cause bleeding in the brain. This is a review of randomised controlled trials of endovascular thrombectomy or intra‐arterial thrombolysis, or both, for acute ischaemic stroke.
Objectives
To assess whether endovascular thrombectomy or intra‐arterial interventions, or both, plus medical treatment are superior to medical treatment alone in people with acute ischaemic stroke.
Search methods
We searched the Trials Registers of the Cochrane Stroke Group and Cochrane Vascular Group (last searched 1 September 2020), CENTRAL (the Cochrane Library, 1 September 2020), MEDLINE (May 2010 to 1 September 2020), and Embase (May 2010 to 1 September 2020). We also searched trials registers, screened reference lists, and contacted researchers.
Selection criteria
Randomised controlled trials (RCTs) of any endovascular intervention plus medical treatment compared with medical treatment alone in people with definite ischaemic stroke.
Data collection and analysis
Two review authors (MBR and MJ) applied the inclusion criteria, extracted data, and assessed trial quality. Two review authors (MBR and HL) assessed risk of bias, and the certainty of the evidence using GRADE. We obtained both published and unpublished data if available. Our primary outcome was favourable functional outcome at the end of the scheduled follow‐up period, defined as a modified Rankin Scale score of 0 to 2. Eighteen trials (i.e. all but one included trial) reported their outcome at 90 days. Secondary outcomes were death from all causes at in the acute phase and by the end of follow‐up, symptomatic intracranial haemorrhage in the acute phase and by the end of follow‐up, neurological status at the end of follow‐up, and degree of recanalisation.
Main results
We included 19 studies with a total of 3793 participants. The majority of participants had large artery occlusion in the anterior circulation, and were treated within six hours of symptom onset with endovascular thrombectomy. Treatment increased the chance of achieving a good functional outcome, defined as a modified Rankin Scale score of 0 to 2: risk ratio (RR) 1.50 (95% confidence interval (CI) 1.37 to 1.63; 3715 participants, 18 RCTs; high‐certainty evidence). Treatment also reduced the risk of death at end of follow‐up: RR 0.85 (95% CI 0.75 to 0.97; 3793 participants, 19 RCTs; high‐certainty evidence) without increasing the risk of symptomatic intracranial haemorrhage in the acute phase: RR 1.46 (95% CI 0.91 to 2.36; 1559 participants, 6 RCTs; high‐certainty evidence) or by end of follow‐up: RR 1.05 (95% CI 0.72 to 1.52; 1752 participants, 10 RCTs; high‐certainty evidence); however, the wide confidence intervals preclude any firm conclusion. Neurological recovery to National Institutes of Health Stroke Scale (NIHSS) score 0 to 1 and degree of recanalisation rates were better in the treatment group: RR 2.03 (95% CI 1.21 to 3.40; 334 participants, 3 RCTs; moderate‐certainty evidence) and RR 8.25 (95% CI 1.63 to 41.90; 198 participants, 2 RCTs; moderate‐certainty evidence), respectively.
Authors' conclusions
In individuals with acute ischaemic stroke due to large artery occlusion in the anterior circulation, endovascular thrombectomy can increase the chance of survival with a good functional outcome without increasing the risk of intracerebral haemorrhage or death.
Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common and potentially fatal disease.
To summarize the advances in diagnosis and treatment of VTE ...of the past 5 years.
A systematic search was conducted in EMBASE Classic, EMBASE, Ovid MEDLINE, and other nonindexed citations using broad terms for diagnosis and treatment of VTE to find systematic reviews and meta-analyses, randomized trials, and prospective cohort studies published between January 1, 2013, and July 31, 2018. The 10th edition of the American College of Chest Physicians Antithrombotic Therapy Guidelines was screened to identify additional studies. Screening of titles, abstracts, and, subsequently, full-text articles was performed in duplicate, as well as data extraction and risk-of-bias assessment of the included articles.
Thirty-two articles were included in this review. The application of an age-adjusted D-dimer threshold in patients with suspected PE has increased the number of patients in whom imaging can be withheld. The Pulmonary Embolism Rule-Out Criteria safely exclude PE when the pretest probability is low. The introduction of direct oral anticoagulants has allowed for a simplified treatment of VTE with a lower risk of bleeding regardless of etiology or extent of the VTE (except for massive PE) and has made extended secondary prevention more acceptable. Thrombolysis is best reserved for patients with massive PE or those with DVT and threatened limb loss. Insertion of inferior vena cava filters should be avoided unless anticoagulation is absolutely contraindicated in patients with recent acute VTE. Graduated compression stockings are no longer recommended to treat DVT but may be used when acute or chronic symptoms are present. Anticoagulation may no longer be indicated for patients with isolated distal DVT at low risk of recurrence.
Over the past 5 years, substantial progress has been made in VTE management, allowing for diagnostic and therapeutic strategies tailored to individual patient characteristics, preferences, and values.
The article "Update on Treatment of Acute Ischemic Stroke" by Dr Rabinstein was first published in the February 2017 Cerebrovascular Disease issue of Continuum: Lifelong Learning in Neurology as ..."Treatment of Acute Ischemic Stroke" and has been updated by Dr Rabinstein for this issue at the request of the Editor-in-Chief.
PURPOSE OF REVIEWThis article provides an update on the state of the art of the treatment of acute ischemic stroke with particular emphasis on the indications for reperfusion therapy.RECENT FINDINGSIn addition to the previously established indications for intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rtPA) within 4.5 hours of stroke symptom onset and endovascular therapy with mechanical thrombectomy for patients with large artery occlusion who can be treated within 6 hours of symptom onset, recent randomized controlled trials have now established new indications for emergency reperfusion in patients with wake-up stroke or delayed presentation (up to 24 hours from last known well in the case of mechanical thrombectomy). Identification of patients who may benefit from acute reperfusion therapy within this extended time window requires screening with perfusion brain imaging or, in the case of IV thrombolysis for wake-up strokes, emergency brain MRI. Collateral status and time to reperfusion remain the primary determinants of outcome.SUMMARYTimely successful reperfusion is the most effective treatment for patients with acute ischemic stroke. Recent evidence supports the expansion of the time window for reperfusion treatment in carefully selected patients.
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