Selected patients with large vessel occlusion (LVO) strokes can benefit from endovascular therapy (EVT). However, the effectiveness of EVT is largely dependent on how quickly the patient receives ...treatment. Recent technological developments have led to the first neurointerventional treatments using robotic assistance, opening up the possibility of performing remote stroke interventions. Existing telestroke networks provide acute stroke care, including remote administration of intravenous thrombolysis (IVT). Therefore, the introduction of remote EVT in distant stroke centers requires an adaptation of the existing telestroke networks. The aim of this work was to propose a framework for centers that are potential candidates for telerobotics according to the resources currently available in these centers.
In this paper, we highlight the future challenges for including remote robotics in telestroke networks. A literature review provides potential solutions.
Existing telestroke networks need to determine which centers to prioritize for remote robotic technologies based on objective criteria and cost-effectiveness analysis. Organizational challenges include regional coordination and specific protocols. Technological challenges mainly concern telecommunication networks.
Specific adaptations will be necessary if regional telestroke networks are to include remote robotics. Some of these can already be put in place, which could greatly help the future implementation of the technology.
Background The association between time to reperfusion and clinical outcome is well known in anterior circulation strokes, whereas the impact of main time metrics remains unknown in posterior ...circulation strokes. We investigated the clinical effect of different time intervals from symptom onset to reperfusion on the 90-day clinical outcome in acute ischemic stroke patients with basilar artery occlusion, and especially in the subset population presenting a low stroke volume on baseline diffusion-weighted imaging. Methods and Results We studied patients included in the prospective, multicenter, observational ETIS (Endovascular Treatment in Ischemic Stroke) registry who had had basal artery occlusion and had achieved successful reperfusion (modified Thrombolysis In Cerebral Infarction 2b-3). Three time intervals (onset to reperfusion, onset to imaging, and imaging to reperfusion) were considered in all patients and separately in patients with pc- ASPECTS (posterior-circulation Alberta Stroke Program Early Computed Tomography Score) <8 and ≥8 on baseline diffusion-weighted imaging. The primary end point was good outcome defined as 90-day modified Rankin Scale scores of 0 to 2. Among the 95 included patients, 38 (40%) achieved a good outcome. In all patients, no significant association was found between the different time intervals and outcome. In patients evaluated with diffusion-weighted imaging (n=61) at baseline, a significant negative association was found between imaging-to-reperfusion time for patients with pc- ASPECTS <8 (adjusted odds ratio=0.4 per 30-minute increase; 95% CI 0.18-0.85; P=0.02) compared with those with pc- ASPECTS ≥8. Conclusions In patients with basilar artery occlusion and pc- ASPECTS <8 at baseline diffusion-weighted imaging, clinical outcome is highly dependent on the time from imaging to reperfusion, which suggests that rapid endovascular reperfusion should be performed after imaging in these patients.
Endovascular treatment (EVT) for basilar artery occlusions (BAO) is associated with a higher rate of futile recanalization compared with anterior circulation procedures. We aimed to identify the ...incidence and predictors of poor clinical outcome despite successful reperfusion in current clinical practice.
We used data from the ETIS (Endovascular Treatment in Ischemic Stroke) registry, a prospective multicenter observational registry of stroke treated with EVT in France. Patients undergoing EVT for acute BAO from January 2014 to May 2019 successfully treated within 8 hours from onset were included. Predictors of 90-day poor outcome (modified Rankin Scale (mRS) 4-6) were researched within patients with successful (modified Thrombolysis In Cerebral Infarction (mTICI 2b-3)) and excellent (mTICI 2c-3) reperfusion.
Among 242 patients treated within 8 hours, successful reperfusion was achieved in 195 (80.5%) and excellent reperfusion in 120 (49.5%). Poor outcome was observed in 107 (54.8%) and 60 (50%) patients, respectively. In patients with successful early reperfusion, age, higher initial National Institutes of Health Stroke Scale (NIHSS) score, lower posterior circulation Alberta Stroke Programme Early CT Score (pc-ASPECTS), and absence of prior intravenous thrombolysis were independent predictors of poor outcome. The only treatment factor with an independent predictive value was first-pass mTICI 2b-3 reperfusion (adjusted OR 0.13, 95% CI 0.05 to 0.37, p<0.001). In patients with excellent early reperfusion, independent predictors were age, initial NIHSS score, first-pass mTICI 2c-3 reperfusion, and hemorrhagic transformation on post-interventional imaging.
Early successful reperfusion with EVT occurred in 80.5% of patients, and the only treatment-related factor predictive of clinical outcome was first pass mTICI 2b-3 reperfusion. Further research is warranted to identify the optimal techniques and devices associated with first pass reperfusion in the posterior circulation.
Assisted coiling with stents or balloons enables a higher percentage of complete occlusions of saccular unruptured intracranial aneurysms to be achieved with a reasonable complication rate. The aim ...of this study was to compare stent-assisted coiling and the balloon remodeling technique in terms of efficacy, stability, and safety for the treatment of comparable unruptured saccular intracranial aneurysms.
268 patients with 286 saccular unruptured wide-necked intracranial aneurysms were treated at our institution with stent- or balloon-assisted coiling and retrospectively reviewed. Statistical analysis was performed to assess significant differences between the two groups.
The rate of complete occlusion at the end of the procedure was higher with stent-assisted coiling than with balloon-assisted coiling (86.8% vs 78%) and the same results were also observed after 6 months (92.1% vs 77.6%; p=0.05). About 50% of major recurrences occurred in large to giant aneurysms (p<0.001). The overall complication rate was similar in the stent-assisted and balloon-assisted groups (10.3% vs 9.3%). Independently of the technique, a higher complication rate was observed with bifurcational aneurysms, particularly in the middle cerebral artery (p=0.016).
Stent-assisted coiling achieved better results in terms of complete occlusion and stability than balloon-assisted coiling with a lower rate of recurrence without being associated with a higher risk of intraprocedural complications. Bifurcational and large to giant aneurysms were associated with higher complication rates and higher recurrence rates, respectively, and still represent a challenge for both techniques.
Mechanical thrombectomy (MT) is currently the gold standard treatment for ischemic stroke due to large vessel occlusion (LVO). However, the evidence of clinical usefulness of MT in posterior ...circulation LVO (pc-LVO) is still doubtful compared to the anterior circulation, especially in patients with mild neurological symptoms. The database of 10 high-volume stroke centers in Europe, including a period of three year and a half, was screened for patients with an acute basilar artery occlusion or a single dominant vertebral artery occlusion ("functional" BAO) presenting with a NIHSS ≤10, and with at least 3 months follow-up. A total of 63 patients were included. Multivariate analysis demonstrated that female gender (adjusted OR 0.04; 95% CI 0-0.84;
= 0.04) and combined technique (adj OR 0.001; 95% CI 0-0.81;
= 0.04) were predictors of worse outcome. Higher pc-ASPECTS (adj OR 4.75; 95% CI 1.33-16.94;
= 0.02) and higher Delta NIHSS (adj OR 2.06; 95% CI 1.16-3.65;
= 0.01) were predictors of better outcome. Delta NIHSS was the main predictor of good outcome at 90 days in patients with posterior circulation LVO presenting with NIHSS score ≤ 10.
Background The CATCHVIEW device (Balt) is a last‐generation stent retriever designed for endovascular therapy. We aimed to compare the CATCHVIEW device with standard stent retrievers (SSRs) using ...propensity score methods and assess the noninferiority of CATCHVIEW versus SSRs. Methods We used the ETIS (Endovascular Treatment in Ischemic Stroke) multicenter (13 centers), prospective registry to compare clinical and radiological data of patients treated with CATCHVIEW or SSRs as a first‐line strategy. Procedural outcomes (successful, near‐perfect, perfect reperfusion after first‐line strategy, and at the end of endovascular therapy), clinical outcomes (modified Rankin Scale at 90 days), and safety outcomes (symptomatic intracranial hemorrhage, mortality at 90 days) were compared after propensity score matching. Noninferiority of CATCHVIEW was established if the prespecified lower bound of the 95% CI was >−10%. Results From March 2017 to March 2020, 171 patients treated first‐line by CATCHVIEW were matched to 617 patients treated first‐line by an SSR. In the propensity score–matched cohort, successful reperfusion after first‐line strategy was achieved in 73.9% and 76.2% in the CATCHVIEW and SSR groups, respectively (absolute difference, −2.3%; 1‐sided 95% CI, −7.0% to ∞ ), demonstrating noninferiority of CATCHVIEW versus SSR. CATCHVIEW was associated with better near‐perfect (matched relative risk, 1.15; 95% CI, 1.00–1.31) and perfect (matched relative risk, 1.26; 95% CI, 1.07–1.47) reperfusion rates at the end of endovascular therapy and favorable 90‐day outcomes (matched relative risk, 1.27; 95% CI, 1.03–1.55). Safety outcomes were comparable. Conclusions In this propensity score–matched cohort, we demonstrated the noninferiority of CATCHVIEW compared with SSR, as the first‐line strategy for successful reperfusion. CATCHVIEW achieved higher reperfusion rates at the end of endovascular therapy and higher rates of favorable outcomes at 90 days.
Recent single-center series and meta-analyses suggest that mechanical thrombectomy (MT) without prior intravenous thrombolysis (IVT) might be equally effective to bridging therapy. We analyzed, ...within the Endovascular Treatment in Ischemic Stroke (ETIS) prospective observational registry, the angiographic and clinical outcomes after IVT+MT versus MT alone.
From December 2012 to December 2016, a total of 1,507 consecutive patients with a proximal arterial occlusion of the anterior circulation were treated by MT. Of these, 975 (64.7%) received prior IVT. Immediate angiographic and clinical outcomes at 90 days (modified Rankin Scale mRS) were compared between the two groups while checking for propensity score, matched-propensity score and by inverse probability of treatment weighting (IPTW) propensity score method.
Favorable outcome (mRS 0 to 2) was more frequently achieved after IVT+MT (n=523, 53.6%) than after MT alone (n=222, 41.8%) with an unadjusted odds ratio (OR) for bridging therapy of 1.61 (95% confidence interval CI, 1. 29 to 2.01). This difference remained not significant in matched-propensity score cohort (OR, 1.21; 95% CI, 0.90 to 1.63) although it remained according to adjusted propensity score (OR, 1.31; 95% CI, 1.02 to 1.68) and IPTW (OR, 1.37; 95% CI, 1.09 to 1.73) analyses. A significant difference was found in terms of excellent outcome (mRS 0 to 1) (adjusted OR, 1.63; 95% CI, 1.25 to 2.11) and successful reperfusion (adjusted OR, 1.58; 95% CI, 1.33 to 2.15). No differences in intracerebral hemorrhage or in allcause mortality within 90 days were found between groups.
s IVT prior to MT is associated with increased excellent outcome and successful reperfusion rates. These findings support the use of bridging therapy.
The benefits of mechanical thrombectomy (MT) for patients with acute ischemic stroke (AIS) and a large ischemic core (LIC) at presentation are uncertain. We aimed to obtain up-to-date aggregate ...estimates of the outcomes following MT in patients with volumetrically assessed LIC. We conducted a Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA)-conformed, PROSPERO-registered, systematic review and meta-analysis of studies that included patients with AIS and a baseline LIC treated with MT, reported ischemic core volume quantitatively, and included patients with a LIC defined as a core volume ≥50 mL. The search was restricted to studies published between January 2015 and June 2020. Random-effects-meta-analysis was used to assess the effect of MT on 90-day unfavorable outcome (i.e., modified Rankin Scale mRS 3–6), mortality, and symptomatic intracranial hemorrhage (sICH) occurrence. Sensitivity analyses were performed for imaging-modality (computed tomography-perfusion or magnetic resonance-diffusion weighted imaging) and LIC-definition (≥50 or ≥70 mL). We analyzed 10 studies (954 patients), including six (682 patients) with a control group, allowing to compare 332 patients with MT to 350 who received best-medical-management alone. Overall, after MT the rate of patients with mRS 3–6 at 90 days was 74% (99% confidence interval CI, 67 to 84; Z-value=7.04; I2=92.3%) and the rate of 90-day mortality was 36% (99% CI, 33 to 40; Z-value=–7.07; I2=74.5). Receiving MT was associated with a significant decrease in mRS 3–6 odds ratio (OR) 0.19 (99% CI, 0.11 to 0.33; P<0.01; Z-value=–5.92; I2=62.56) and in mortality OR 0.60 (99% CI, 0.34 to 1.06; P=0.02; Z-value=–2.30; I2=58.72). Treatment group did not influence the proportion of patients experiencing sICH, OR 0.96 (99% CI, 0.2 to 1.49; P=0.54; Z-value=–0.63; I2=64.74). Neither imaging modality for core assessment, nor LIC definition influenced the aggregated outcomes. Using aggregate estimates, MT appeared to decrease the risk of unfavorable functional outcome in patients with a LIC assessed volumetrically at baseline.
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