In vitro testing of a funnel-shaped tip catheter model to decrease clot migration during mechanical thrombectomy.
Tanyildizi Yasemin,Payne Emily,Gerber Tiemo,Seidman Larissa,Heimann Axel,Kempski Oliver,Leithner Doris,Garcia-Bardon Andreas,Kloeckner Roman,Hahn Felix,Keric Naureen,Masomi-Bornwasser Julia,Brockmann Marc A,Kirschner Stefanie
One limitation of mechanical thrombectomy (MT) is clot migration during procedure. This might be caused by abruption of the trapped thrombus at the distal access catheter (DAC) tip during stent-retriever retraction due to the cylindrical shaped tip of the DAC. Aiming to solve this problem, this study evaluates the proof-of-concept of a new designed funnel-shaped tip, in an experimental in vitro setting. Two catheter models, one with a funnel-shaped tip and one with a cylindrical-shaped tip, were compared in an experimental setup. For MT a self-made vessel model and thrombi generated from pig's blood were used. MT was performed 20 times for each device using two different stent-retrievers, 10 times respectively. For the funnel-shaped model: for both stent-retrievers (Trevo XP ProVue 3/20 mm; Trevo XP ProVue 4/20 mm) MT was successful at first pass in 9/10 (90%), respectively. For the cylindrical-shaped model: MT was successful at first pass in 5/10 (50%) with the smaller stent-retriever and in 6/10 (60%) with the larger stent-retriever. The experiments show a better recanalization rate for funnel-shaped tips, than for cylindrical-shaped tips. These results are indicating a good feasibility for this new approach, thus the development of a prototype catheter seems reasonable.
Intentional Stent Stenosis to Prevent Hyperperfusion Syndrome after Carotid Artery Stenting for Extremely High-Grade Stenosis.
Mori T,Yoshioka K,Tanno Y,Kasakura S
AJNR. American journal of neuroradiology
BACKGROUND AND PURPOSE:Intracranial hemorrhage due to hyperperfusion syndrome is a severe carotid artery stent placement complication of extremely high-grade stenosis, causing hemodynamic insufficiency. To prevent hyperperfusion syndrome, we attempted intentional residual stent stenosis and implemented "gentle" carotid artery stent placement, defined as carotid artery stent placement using a closed-cell stent coupled with slight balloon predilation, without balloon postdilation. Gradual stent expansion was expected. We investigated the incidence of hyperperfusion syndrome and long-term outcomes after gentle carotid artery stent placement. MATERIALS AND METHODS:We included patients who underwent carotid artery stent placement for extremely high-grade stenosis from January 2015 to March 2019. We defined extremely high-grade stenosis as carotid stenosis with conventional angiographic "slow flow" and a reduced MCA signal intensity on MRA. A reduced MCA signal intensity was defined as MCA with a relative signal intensity of <0.9 in the ipsilateral compared with the contralateral MCA. We evaluated the stent diameter, CBF on SPECT, hyperperfusion syndrome, and intracranial hemorrhage. We defined hyperperfusion syndrome as a triad of ipsilateral headache, seizure, and hemiparesis. RESULTS:Twenty-eight of the 191 patients met our inclusion criteria. After carotid artery stent placement, their median minimal stent diameter was 2.9 mm, which expanded to 3.9 mm at 4 months. Neither cerebral hyperperfusion syndrome nor intracranial hemorrhage occurred. CONCLUSIONS:The gentle carotid artery stent placement strategy for intentional residual stent stenosis may prevent hyperperfusion syndrome in high-risk patients. Stents spontaneously dilated in 4 months.
Stent-unsheathed effect predicts acute distal middle cerebral artery atherosclerotic disease-related occlusion.
Chen Wen-Huo,Yi Ting-Yu,Zhan A-Lai,Wu Yan-Min,Lu Yan-Yu,Li Yi-Min,Pan Zhi-Nan,Lin Ding-Lai,Lin Xiao-Hui
Journal of the neurological sciences
BACKGROUND:The differentiation of intracranial atherosclerosis (ICAS) and embolism is important. OBJECTIVE:In cases of ICAS, we observe a phenomenon that we call the "post-stent-deployment effect"; that is, all major branches are clearly visible beyond the occlusion segment when the stent is deployed at the site of occlusion. Our objective is to evaluates whether this post-stent-deployment effect can be used to differentiate ICAS from embolism in the distal M1 segment occlusion. METHODS:We conduct a retrospective study which reviewed consecutive patients with acute distal M1 segment and in whom recanalization was achieved by endovascular treatment. The post-stent-deployment effect was assessed in these patients. The sensitivity, specificity, positive predictive values (PPV), and accuracy of the post-stent-deployment effect for prediction of ICAS were assessed. RESULTS:From January 2015 to July 2018, a total of 80 patients were evaluated. The post-stent-deployment effect was more frequently observed in patients with ICAS than in those with embolism (100% vs 15.0%, P < .001). For identifying ICAS in distal M1 segment, the sensitivity, specificity, PPV, and accuracy of the post-stent-deployment effect were 100%, 85.0%, 69.0%, and 88.7%, respectively. CONCLUSION:Our study finds that the sensitivity and accuracy of the post-stent-deployment effect in predicting distal M1 segment ICAS occlusion in patients with acute symptoms was high, and it may be useful in identifying ICAS lesion.
Is Histologic Thrombus Composition in Acute Stroke Linked to Stroke Etiology or to Interventional Parameters?
Goebel J,Gaida B-J,Wanke I,Kleinschnitz C,Koehrmann M,Forsting M,Moenninghoff C,Radbruch A,Junker A
AJNR. American journal of neuroradiology
BACKGROUND AND PURPOSE:Detailed insight into the composition of thrombi retrieved from patients with ischemic stroke by mechanical thrombectomy might improve pathophysiologic understanding and therapy. Thus, this study searched for links between histologic thrombus composition and stroke subtypes and mechanical thrombectomy results. MATERIALS AND METHODS:Thrombi from 85 patients who had undergone mechanical thrombectomy for acute ischemic stroke between December 2016 and March 2018 were studied retrospectively. Thrombi were examined histologically. Preinterventional imaging features, stroke subtypes, and interventional parameters were re-analyzed. Statistical analysis was performed with the Kruskal-Wallis test, Mann-Whitney test, or Spearman correlation as appropriate. RESULTS:Cardioembolic thrombi had a higher percentage of macrophages and a tendency toward more platelets than thrombi of large-artery atherosclerotic stenosis ( = .021 and .003) or the embolic stroke of undetermined source ( = .037 and .099) subtype. Thrombi prone to fragmentation required the combined use of contact aspiration and stent retrieval ( = .021) and were associated with an increased number of retrieving maneuvers ( = .001), longer procedural times ( = .001), and a higher lymphocyte content ( = .035). CONCLUSIONS:We interpreted the higher macrophage and platelet content in cardioembolic thrombi compared with large-artery atherosclerotic stenosis or embolic stroke of undetermined source thrombi as an indication that the latter type might be derived from an atherosclerotic plaque rather than from an undetermined cardiac source. The extent of thrombus fragmentation was associated with a more challenging mechanical thrombectomy and a higher lymphocyte content of the thrombi. Thus, thrombus fragmentation not only might be caused by the recanalization procedure but also might be a feature of a lymphocyte-rich, difficult-to-retrieve subgroup of thrombi.
Fast Stent Retrieval Improves Recanalization Rates of Thrombectomy: Experimental Study on Different Thrombi.
Soize S,Pierot L,Mirza M,Gunning G,Gilvarry M,Gawlitza M,Vivien D,Zuber M,Touzé E
AJNR. American journal of neuroradiology
BACKGROUND AND PURPOSE:About 20% of patients with acute ischemic stroke due to large-artery occlusion do not achieve recanalization with mechanical thrombectomy. We aimed to determine whether the speed of retrieval of the stent retriever influences the efficacy in removing different clot types. MATERIALS AND METHODS:Sixty mechanical thrombectomies were performed using an in vitro pulsatile cerebrovascular circulation model with controlled pressure and flow rate. Experiments were dichotomized into fast and slow retrieval using a wedging technique, in which the stent retriever and distal catheter are retrieved together. We used 3 different clot types: erythrocyte-rich, fibrin-rich, and friable clots. Primary end points were complete (TICI 3) and successful (TICI 2b-3) recanalizations. Secondary measures were distal and new territory embolizations. RESULTS:Fast retrieval was more frequently associated with complete (RR = 1.83; 95% CI, 1.12-2.99) and successful recanalization (RR = 1.50; 95% CI, 1.03-2.19) than slow retrieval, without a difference in distal embolization (RR = 0.75; 95% CI, 0.29-1.90). There were no emboli in a new territory. The advantage of fast retrieval over slow retrieval differed according to the clot composition, with a stronger effect with fibrin-rich clots with regard to complete (RR = 4.00; 95% CI, 1.11-14.35; int .04) and successful (int.10) recanalization. CONCLUSIONS:In our experimental model, a fast removal improved recanalization rates of mechanical thrombectomy, especially in the case of fibrin-rich clots. An in vivo confirmation is warranted to see whether our findings can have an impact in clinical practice.
Efficacy of beveled tip aspiration catheter in mechanical thrombectomy for acute ischemic stroke.
Vargas Jan,Blalock Jonathan,Venkatraman Anand,Anagnostakou Vania,King Robert M,Ewing Joseph A,Gounis Matthew J,Turner Raymond D,Chaudry Imran,Turk Aquilla
Journal of neurointerventional surgery
BACKGROUND:Direct aspiration thrombectomy techniques use large bore aspiration catheters for mechanical thrombectomy. Several aspiration catheters are now available. We report a bench top exploration of a novel beveled tip catheter and our experience in treating large vessel occlusions (LVOs) using next-generation aspiration catheters. METHODS:A retrospective analysis from a prospectively maintained database comparing the bevel shaped tip aspiration catheter versus non-beveled tip catheters was performed. Patient demographics, periprocedural metrics, and discharge and 90-day modified Rankin Scale (mRS) scores were collected. Patients were divided into two groups based on which aspiration catheter was used. RESULTS:Our data showed no significant difference in age, gender, IV tissue plasminogen activator administration, admission NIH Stroke Scale score, baseline mRS, or LVO location between the beveled tip and flat tip groups. With the beveled tip, Thrombolysis in Cerebral Infarction (TICI) 2C or better recanalization was more frequent overall (93.2% vs 74.2%, p=0.017), stent retriever usage was lower (9.1% vs 29%, p=0.024), and patients had lower mRS on discharge (median 3 vs 4, p<0.001) and at 90 days (median 2 vs 4, p=0.008). CONCLUSION:Patients who underwent mechanical thrombectomy with the beveled tip catheter had a higher proportion of TICI 2C or better and had a significantly lower mRS score on discharge and at 90 days.
Tandem stents thrombectomy as a rescue treatment for refractory large vessel occlusions.
Xu Haowen,Peng Shanling,Quan Tao,Yuan Yongjie,Wang Zibo,Fu Xiaojie,Han Kaihao,Liu Guo,Guan Sheng,Li Panxing
Journal of neurointerventional surgery
BACKGROUND:Mechanical thrombectomy with a stent retriever (SR) and/or aspiration is the 'gold standard' for the treatment of acute ischemic stroke due to large vessel occlusion (LVO). However, sometimes clots may not be retrievable with a single SR alone or combined with aspiration. OBJECTIVE:To assess the safety and efficacy of a novel tandem stents thrombectomy (TST) technique as a rescue treatment for acute LVO that is refractory to conventional attempts. METHODS:All patients treated with the TST technique as rescue treatment after failure of conventional attempts were retrospectively reviewed. The postprocedural angiographic and clinical outcome, including modified Thrombolysis in Cerebral infarction (mTICI) grade, National Institutes of Health Stroke Scale (NIHSS) score, and modified Rankin Scale (mRS) score, was assessed. RESULTS:Nine patients (mean age, 65.2 years; median NIHSS score 18) with middle cerebral artery M1 segment (n=6) and terminal internal carotid artery (n=3) occlusions were included in the study. The TST technique was performed as a rescue treatment after unsuccessful stent thrombectomy alone (four cases) and stent thrombectomy plus aspiration (five cases). Successful recanalization (mTICI 2b/3) was achieved in all patients. No procedure-related complications occurred except reversible vasospasms were observed in three patients and one patient developed hemorrhage transformation after the procedure, but was asymptomatic. Three patients had good clinical outcome (mRS score 0-2 at 90 days). Two patients (22.2%) died. CONCLUSIONS:The TST technique seems to be a safe and effective rescue treatment for acute LVO that is refractory to conventional attempts.
The relationship between first pass recanalization of stent-retriever-based thrombectomy and neutrophil to lymphocyte ratio in middle cerebral artery occlusions.
The International journal of neuroscience
BACKGROUND:Inflammatory response plays an important role in the process of ischemic stroke. Rapid, sustained and complete reperfusion is the most important modifiable prognostic factor for a favorable clinical outcome in patients receiving endovascular treatment (EVT). The studies related to the clot contents regarding the high level of leukocyte clots that are difficult to recanalize are quite remarkable. We aimed to investigate the relationship between Neutrophil to lymphocyte ratio and recanalization at the first pass thrombectomy. METHODS:Study was conducted from February 2015 to December 2018. Patients with stroke were treated with mechanical thrombectomy. The normality of distribution of continuous variables was tested by Shapiro-Wilk test. The Mann-Whitney test and Chi-square test was used to assess relations between variables. ROC curve analysis was performed to determine the cut-off value for NLR. RESULTS:There were 84 patients included the study, the mean age 62.8 ± 12.9; 61.9% (52/84) that were female; median (IQR 25-75) NIHSS 16 (14-19) treated with stent-retriever-based thrombectomy. The distribution of NLR was skewed ( value for 1-sample Kolmogorov-Smirnov test: <0.001). In terms of recanalization outcomes, the patients with NLR < 3.51 showed a significantly higher rates of successful recanalization (AUC = 0.671 ± 0.06; = 0.005). CONCLUSION:This study demonstrates that higher admission NLR values are independent predictors of unsuccessful recanalization first pass in MCA M1 occlusion of stroke patients treated with mechanical stent-retriever-based thrombectomy. Future large cohort and structural analysis of thrombi studies are needed to further explore the role of NLR as a prognostic neuroinflammatory biomarker for successful recanalization in EVT of stroke.
Thrombectomy Technique Predicts Outcome in Posterior Circulation Stroke-Insights from the STAR Collaboration.
Alawieh Ali M,Eid Maya,Anadani Mohammad,Sattur Mithun,Maier Ilko L,Feng Wuwei,Goyal Nitin,Starke Robert M,Rai Ansaar,Fargen Kyle M,Psychogios Marios-Nikos,De Leacy Reade,Grossberg Jonathan A,Keyrouz Salah G,Dumont Travis M,Kan Peter,Lena Jonathan,Liman Jan,Arthur Adam S,Elijovich Lucas,Mccarthy David J,Saini Vasu,Wolfe Stacey Q,Mocco J,Fifi Johanna T,Nascimento Fábio A,Giles James A,Allen Michelle,Crosa Roberto,Fox W Christopher,Gory Benjamin,Spiotta Alejandro M
BACKGROUND:Randomized controlled trials evaluating mechanical thrombectomy (MT) for acute ischemic stroke predominantly studied anterior circulation patients. Both procedural and clinical predictors of outcome in posterior circulation patients have not been evaluated in large cohort studies. OBJECTIVE:To investigate technical and clinical predictors of functional independence after posterior circulation MT while comparing different frontline thrombectomy techniques. METHODS:In a retrospective multicenter international study of 3045 patients undergoing MT for stroke between 06/2014 and 12/2018, 345 patients had posterior circulation strokes. MT was performed using aspiration, stent retriever, or combined approach. Functional outcomes were assessed using the 90-d modified Rankin score dichotomized into good (0-2) and poor outcomes (3-6). RESULTS:We included 2700 patients with anterior circulation and 345 patients with posterior circulation strokes. Posterior patients (age: 60 ± 14, 46% females) presented with mainly basilar occlusion (80%) and were treated using contact aspiration or ADAPT (39%), stent retriever (31%) or combined approach (19%). Compared to anterior strokes, posterior strokes had delayed treatment (500 vs 340 min, P < .001), higher national institute of health stroke scale (NIHSS) (17.1 vs 15.7, P < .01) and lower rates of good outcomes (31% vs 43%, P < .01). In posterior MT, diabetes (OR = 0.28, 95%CI: 0.12-0.65), admission NIHSS (OR = 0.9, 95%CI: 0.86-0.94), and use of stent retriever (OR = 0.26, 95%CI: 0.11-0.62) or combined approach (OR = 0.35, 95%CI: 0.12-1.01) vs ADAPT were associated with lower odds of good outcome. Stent retriever use was associated with lower odds of good outcomes compared to ADAPT even when including patients with only basilar occlusion or with successful recanalization only. CONCLUSION:Despite similar safety profiles, use of ADAPT is associated with higher rates of functional independence after posterior circulation thrombectomy compared to stent retriever or combined approach in large "real-world" retrospective study.
First pass effect with contact aspiration and stent retrievers in the Aspiration versus Stent Retriever (ASTER) trial.
Ducroux Célina,Piotin Michel,Gory Benjamin,Labreuche Julien,Blanc Raphael,Ben Maacha Malek,Lapergue Bertrand,Fahed Robert,
Journal of neurointerventional surgery
BACKGROUND:The 'first pass effect' (FPE), which was originally described with stent retrievers, designates a (near-)complete revascularization obtained after a single device pass with no rescue therapy, and is associated with improved clinical outcome and decreased mortality. OBJECTIVE:We report the rate and benefits of FPE in the Aspiration versus Stent Retriever (ASTER) trial. MATERIALS AND METHODS:ASTER is a randomized trial comparing angiographic revascularization with the stent retriever (SR) and contact aspiration (CA) thrombectomy techniques, assessed by an external core laboratory using the modified Thrombolysis in Cerebral Infarction (mTICI) scale. Rates of FPE (defined by mTICI 2c/3 after a single pass with no rescue therapy) were compared between patients treated with SR and CA techniques. Outcomes were compared between FPE-SR and FPE-CA patients, and between FPE and non-FPE patients. RESULTS:FPE was achieved in 97/336 patients (28.9%), with no significant difference between SR and CA (respectively 53/169 patients (31.3%) vs 44/167 patients (26.3%), adjusted RR for CA versus SR 0.84, 95% CI 0.54 to 1.31; p=0.44). After prespecified adjustment for allocated arm and randomization stratification factors, FPE in patients was associated with a significantly improved clinical outcome and a decreased mortality, and a significantly lower rate of hemorrhagic transformation and procedural complications than in non-FPE patients. CONCLUSION:In the ASTER trial, similar rates of FPE were achieved with SR and CA, and FPE was associated with a significantly improved outcome. New techniques and devices to improve the rate of FPE are warranted. TRIAL REGISTRATION NUMBER:Unique identifier: NCT02523261.
Hyperdense vessel sign as a potential guide for the choice of stent retriever versus contact aspiration as first-line thrombectomy strategy.
Mohammaden Mahmoud H,Haussen Diogo C,Perry da Camara Catarina,Pisani Leonardo,Olive Gadea Marta,Al-Bayati Alhamza R,Liberato Bernardo,Rangaraju Srikant,Frankel Michael R,Nogueira Raul G
Journal of neurointerventional surgery
BACKGROUND:The first-pass effect (FPE) has emerged as a key metric for efficacy in mechanical thrombectomy (MT). The hyperdense vessel sign (HDVS) on non-contrast head CT (NCCT) indicates a higher clot content of red blood cells. OBJECTIVE:To assess whether the HDVS could serve as an imaging biomarker for guiding first-line device selection in MT. METHODS:A prospective MT database was reviewed for consecutive patients with anterior circulation large vessel occlusion stroke who underwent thrombectomy with stent retriever (SR) or contact aspiration (CA) as first-line therapy between January 2012 and November 2018. Pretreatment NCCT scans were evaluated for the presence of HDVS. The primary outcome was FPE (modified Thrombolysis in Cerebral Infarction score 2c/3). The primary analysis was the interaction between HDVS and thrombectomy modality on FPE. Secondary analyses aimed to evaluate the predictors of FPE. RESULTS:A total of 779 patients qualified for the analysis. HDVS and FPE were reported in 473 (60.7%) and 286 (36.7%) patients, respectively. The presence of HDVS significantly modified the effect of thrombectomy modality on FPE (p=0.01), with patients with HDVS having a significantly higher rate of FPE with a SR (41.3% vs 22.2%, p=0.001; adjusted OR 2.11 (95% CI 1.20 to 3.70), p=0.009) and non-HDVS patients having a numerically better response to CA (41.4% vs 33.9%, p=0.28; adjusted OR 0.58 (95% CI 0.311 to 1.084), p=0.088). Age (OR 1.01 (95% CI 1.00 to 1.02), p=0.04) and balloon guide catheter (OR 2.08 (95% CI 1.24 to 3.47), p=0.005) were independent predictors of FPE in the overall population. CONCLUSION:Our data suggest that patients with HDVS may have a better response to SRs than CA for the FPE. Larger confirmatory prospective studies are warranted.
Direct thromboaspiration efficacy for mechanical thrombectomy is related to the angle of interaction between the aspiration catheter and the clot.
Bernava Gianmarco,Rosi Andrea,Boto José,Brina Olivier,Kulcsar Zsolt,Czarnetzki Christoph,Carrera Emmanuel,Schaller Karl,Lovblad Karl-Olof,Machi Paolo
Journal of neurointerventional surgery
BACKGROUND:Direct thromboaspiration has been reported as an effective mechanical treatment for acute ischemic stroke. We aimed to determine whether the angle of interaction between the aspiration catheter and the clot affects the success of clot removal in ischemic stroke patients with large vessel occlusion in the anterior and posterior circulation. METHODS:All patients treated at our institution by direct thromboaspiration as a firstline technique between January 2016 and December 2017 were enrolled in the study. We retrospectively reviewed baseline and procedural characteristics, the angle of interaction formed between the aspiration catheter and the clot, the modified Thrombolysis in Cerebral Infarction score, and the 3 month modified Rankin Scale score. RESULTS:85 patients underwent direct thromboaspiration as the firstline treatment during the study period. 100 direct thromboaspiration passes were performed. An angle of interaction of ≥125.5° significantly influenced the success of clot removal (P<0.001) with good sensitivity and specificity, in particular for occlusion of the middle cerebral and basilar artery. The combination of aspiration with a stent retriever based thrombectomy was a valid rescue treatment in cases of standalone direct thromboaspiration failure. CONCLUSIONS:In our series, an angle of interaction between the aspiration catheter and the clot of ≥125.5° was significantly associated with successful clot removal. The prediction of the angle of interaction on pretreatment imaging may help operators to select the most adequate mechanical thrombectomy technique on a case by case basis.
Influence of vessel morphology and variations on technical and clinical success in mechanical thrombectomy: -In vivo and in vitro analyses.
Hopf-Jensen Silke,Marques Joana,Lehrke Stephanie,Preiß Michael,Müller-Hülsbeck Stefan
Journal of neuroradiology = Journal de neuroradiologie
PURPOSE:To determine the impact of vessel variation and anatomical features on technical and clinical success. MATERIALS AND METHODS:In vitro blood clots (n=100) were introduced into a silicon carotid-T flow model of 2, 3 or 4mm. The ICA/M1angle varied at 45°, 90°, 135° and 180°. Peripheral embolism was measured. In vivo 50 pat. (73.5 yrs.,±15) with MCA occlusion were examined for siphon variation, ICA morphology, vessel diameter and angles. The patients were divided according to the clinical success (mRS): group A: mRS≤2 after 90 day and group B: mRS≥3. Furthermore the technical success (TICI) and number of retrieval (n) were analysed. RESULTS:In vitro with larger vessel diameter the migrated thrombus load decreased (P=.001). The steeper the M1/ICA angles, the higher thrombus weighs (180°: 2.94mg; 135°: 6.32mg; 90°: 8.65mg, 45°: 10.69mg; P<.001). In vivo patients with mRS≤2 had significantly lower NIHSS (16.5 vs 20, P=.009) and higher ASPECTS (9 vs 6, P<.05). TICI≥2b was more often achieved (86.6 vs 40% P=.002). The procedure time was lower (45 vs. 80min, P<.05) with smaller number of retrieval (1.5 vs 4, P<05). Proximal ICA stenosis offers a trend to unfavourable outcome (P=.073). Siphon variation "D" is associated with less retrieval manoeuvre. CONCLUSION:While in vitro there is a close correlation between embolism and vascular anatomy, in vivo carotid artery stenosis and siphon variation influence clinical and technical success.
Novel Technique for Detection of Actual Position of Clot During Endovascular Clot Retrieval: Assessment of Microcatheter Withdrawing Angiography.
Ohshima Tomotaka,Niwa Aichi,Kawaguchi Reo,Matsuo Naoki,Miyachi Shigeru
BACKGROUND:When endovascular clot retrievals are performed using a stent retriever and/or an aspiration catheter, identifying the accurate position of a clot is extremely important for a successful immediate recanalization. Herein, we report a new technique called microcatheter withdrawing angiography, which facilitates the identification of the precise position of a clot. The negative shadow appearance of the clot on angiography was referred to as the actual crab claw sign. METHODS:When a 0.027-inch microcatheter penetrated the clot after inserting a 0.014-inch microwire, selective angiography was conducted using the microcatheter. Simultaneously, the microcatheter was slowly withdrawn with continuous contrast media injection, while the microwire was kept in the distal vessel. The precise position of the clot was found, which was referred to as the actual crab claw sign. Next, we conducted in vitro and in vivo analyses. RESULTS:The actual crab claw sign could be identified in the vascular model and in actual clinical settings. Therefore the sweet spot of the stent retriever could be set over the clot, and an accurate contact aspiration could be performed using an aspirator. CONCLUSIONS:Microcatheter withdrawing angiography can help identify the actual crab claw sign. This technique has a higher success rate and faster recanalization than conventional strategy, particularly in challenging cases of unsuccessful recanalization during the first attempt.
Clot perviousness is associated with first pass success of aspiration thrombectomy in the COMPASS trial.
Mokin Maxim,Waqas Muhammad,Fifi Johanna,De Leacy Reade,Fiorella David,Levy Elad I,Snyder Kenneth,Hanel Ricardo,Woodward Keith,Chaudry Imran,Rai Ansaar T,Frei Donald,Delgado Almandoz Josser E,Kelly Michael,Arthur Adam S,Baxter Blaise W,English Joey,Linfante Italo,Fargen Kyle M,Turk Aquilla,Siddiqui Adnan H,Mocco J
Journal of neurointerventional surgery
BACKGROUND:Clot density (Hounsfield units, HU) and perviousness (post-contrast increase in the HU of clot) are thought to be associated with clot composition. We evaluate whether these imaging characteristics were associated with angiographic outcomes of aspiration and stent retriever thrombectomy in COMPASS: a trial of aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion. METHODS:Clot density and perviousness were measured by two independent operators who were blind to all the final angiographic and clinical outcomes. The association of clot density and perviousness with the Thrombolysis In Cerebral Infarction (TICI) scale after first pass was assessed using univariate and multivariate analysis. RESULTS:Among all patients enrolled in COMPASS, 165 were eligible for the post-hoc analysis (81 patients in the aspiration first and 84 in the stent retriever first groups). Overall mean perviousness of clot was significantly higher in patient with mTICI 2b-3 after first pass (28.6±22.9 vs 20.3±19.2, p=0.017). Mean perviousness among patients who achieved TICI 2c/3 versus TICI 2b versus TICI 0-2a in the aspiration first group varied significantly (32.6±26.1, 35.3±24.4, and 17.7±13.1, p=0.013). The association of perviousness with first pass success was not significant in the stent retriever group. Using multivariate analysis, high perviousness (defined as cut-off >27.6) was an independent predictor of TICI 2b-3 (OR 3.82, 95% CI 1.10 to 13.19; p=0.034). CONCLUSIONS:Clot perviousness is associated with first pass angiographic success in patients treated with the aspiration first approach for thrombectomy.
Primary stentriever versus combined stentriever plus aspiration thrombectomy approaches: in vitro stroke model comparison.
Mokin Maxim,Ionita Ciprian N,Nagesh Swetadri Vasan Setlur,Rudin Stephen,Levy Elad I,Siddiqui Adnan H
Journal of neurointerventional surgery
BACKGROUND:Artificial stroke models can be used for testing various thrombectomy devices. OBJECTIVE:To determine the value of combined stentriever-aspiration thrombectomy compared with the stentriever-alone approach. METHODS:We designed an in vitro model of the intracranial circulation with a focus on the middle cerebral artery (MCA) that closely resembles the human intracranial circulation. After introducing fresh clot in the MCA, we used conventional biplane angiography and microangiographic fluoroscopy to compare recanalization rates and occurrence of emboli in new, unaffected territory for thrombectomy approaches in which a stentriever (Solitaire flow restoration stentriever, Covidien) was used alone or in combination with continuous manual aspiration through a Navien catheter (Covidien). RESULTS:In a total of 22 experiments (11 for each approach), successful clot delivery to the MCA was achieved in all cases. Successful angiographic recanalization (thrombolysis in cerebral infarction score of 2b-3) was achieved more frequently with the combined stentriever-aspiration approach than with the stentriever-alone approach (in 10 vs 4 experiments, p=0.023). Emboli in new territory occurred in three experiments with the stentriever-alone approach, and none were seen with the combined approach (p=0.21). CONCLUSIONS:The combined stentriever-aspiration approach to thrombectomy leads to better angiographic recanalization rates than use of the stentriever alone. Further experiments are needed to test the value of balloon-guide catheters and aspiration performed using other types of catheters and modes of aspiration.
In vitro experiments of cerebral blood flow during aspiration thrombectomy: potential effects on cerebral perfusion pressure and collateral flow.
Lally Frank,Soorani Mitra,Woo Timothy,Nayak Sanjeev,Jadun Changez,Yang Ying,McCrudden John,Naire Shailesh,Grunwald Iris,Roffe Christine
Journal of neurointerventional surgery
BACKGROUND:Mechanical thrombectomy with stent retriever devices is associated with significantly better outcomes than thrombolysis alone in the treatment of acute ischemic stroke. Thrombus aspiration achieves high patency rates, but clinical outcomes are variable. The aim of this study was to examine the effect of different suction conditions on perfusate flow during aspiration thrombectomy. METHODS:A computational fluid dynamics model of an aspiration device within a patent and occluded blood vessel was used to simulate flow characteristics using fluid flow solver software. A physical particulate flow model of a patent vessel and a vessel occluded by thrombus was then used to visualize flow direction and measure flow rates with the aspiration catheter placed 1-10 mm proximal of the thrombus, and recorded on video. RESULTS:The mathematical model predicted that, in a patent vessel, perfusate is drawn from upstream of the catheter tip while, in an occluded system, perfusate is drawn from the vessel proximal to the device tip with no traction on the occlusion distal of the tip. The in vitro experiments confirmed the predictions of this model. In the occluded vessel aspiration had no effect on the thrombus unless the tip of the catheter was in direct contact with the thrombus. CONCLUSIONS:These experiments suggest that aspiration is only effective if the catheter tip is in direct contact with the thrombus. If the catheter tip is not in contact with the thrombus, aspirate is drawn from the vessels proximal of the occlusion. This could affect collateral flow in vivo.
Numerical modelling of blood clot extraction by aspiration thrombectomy. Evaluation of aspiration catheter geometry.
Talayero Carlos,Romero Gregorio,Pearce Gillian,Wong Julian
Journal of biomechanics
Aspiration thrombectomy is one of the most effective systems for blood clot removal and vessel recanalization. We present the results of a study involving the modelling and extraction of blood clots in the arteries of the human body using the following computer tools: Bond-Graph methodology for the fluid domain and Multi-Body Simulation for the mechanical domain. The modelling for the mechanical domain focuses on the clot and the distal end section of an aspiration device. Our final model considers an elastic characterization of the blood clot with progressive detachment from the vessel wall. We conclude that the results of such modelling could potentially improve the effectiveness of blood clot removal by reducing the risk of clot fragmentation. Such modelling could also potentially provide an adjunct technique in improving recanalization of arteries over a range of given parameters (mechanical properties of the vessel, mechanical properties of the blood clot, blood clot length, suction pressure, catheter - clot distance, catheter shape, catheter diameter and vessel occlusion).
Impact of Thrombus Length on Outcomes After Intra-Arterial Aspiration Thrombectomy in the THERAPY Trial.
Yoo Albert J,Khatri Pooja,Mocco J,Zaidat Osama O,Gupta Rishi,Frei Donald,Lopes Demetrius,Shownkeen Harish,Berkhemer Olvert A,Meyer Denise,Hak Susana S,Kuo Sophia S,Buell Hope,Bose Arani,Sit Siu Po,von Kummer Rüdiger,
BACKGROUND AND PURPOSE:Increasing thrombus length (TL) impedes recanalization after intravenous (IV) thrombolysis. We sought to determine whether the clinical benefit of aspiration thrombectomy relative to IV r-tPA (recombinant tissue-type plasminogen activator) may be greater at longer TL. METHODS:THERAPY was a randomized trial of aspiration thrombectomy plus IV r-tPA versus IV r-tPA alone in large-vessel stroke patients with prospective TL measurement ≥8 mm. In this post hoc study, we evaluated the association of TL with trial end points and potential endovascular treatment effect, using univariate, multivariable, and multiplicative interaction analyses. RESULTS:TL data were available for all 108 patients (28% internal carotid artery, 62% M1, and 10% M2). Median TL was 14.0 mm (interquartile range, 9.7-19.5 mm). Longer TL was associated with worse outcome (90-day modified Rankin Scale score: odds ratio, 1.24 per 5-mm TL increment; 95% confidence interval, 1.04-1.52; =0.02), even after adjusting for key outcome predictors (adjusted =0.004). Longer TL was also associated with more serious adverse events (adjusted =0.01), more symptomatic hemorrhages (adjusted =0.03), and increased mortality (adjusted =0.01). No significant relationship was observed between TL and angiographic reperfusion (modified thrombolysis in cerebral ischemia 2b-3), but greater TL was associated with longer endovascular procedural times (ρ=0.36; =0.045). Increasing TL was associated with greater aspiration thrombectomy treatment effect (interaction term =0.03). This might be related to a potentially stronger adverse effect of increasing TL on 90-day modified Rankin Scale for patients treated with IV r-tPA (ρ=0.39; =0.01) compared with intra-arterial therapy (ρ=0.20; =0.165). CONCLUSIONS:Ischemic stroke patients with longer symptomatic thrombi have worse 90-day clinical outcomes but may have a greater relative benefit of aspiration thrombectomy over IV r-tPA alone. CLINICAL TRIAL REGISTRATION:URL: http://www.clinicaltrials.gov. Unique identifier: NCT01429350.
Mechanical thrombectomy of right internal carotid artery terminus occlusion using the ADAPT technique: impact of aspiration on parent vessel.
Dossani Rimal Hanif,Tso Michael K,Waqas Muhammad,Rai Hamid H,Rajah Gary B,Siddiqui Adnan H
Journal of neurointerventional surgery
The impact of ADAPT-"a direct aspiration first pass technique"-on intracranial vasculature is not well understood, since the change of arterial diameter is often not visible during aspiration. We present a unique case in which the impact of aspiration on the parent vessel was visualized due to a previously deployed Neuroform Atlas stent and a Pipeline embolization device. The patient presented with right internal carotid artery occlusion. An aspiration catheter was advanced over the microcatheter system and corked into the clot, located within the stents in proximal M1. The stents were seen to collapse both during electronic pump and hand aspiration with no evidence of stent migration. This demonstrates that it is crucial to engage the clot interface with the tip of the aspiration catheter while performing ADAPT. Placing the aspiration catheter remote from the clot may result in collapse of the artery proximal to the clot with subsequent ADAPT failure.(video 1) neurintsurg;12/11/1148/V1F1V1video 1.
Optimizing endovascular stroke treatment: removing the microcatheter before clot retrieval with stent-retrievers increases aspiration flow.
Nikoubashman Omid,Alt Jan Patrick,Nikoubashman Arash,Büsen Martin,Heringer Sarah,Brockmann Carolin,Brockmann Marc-Alexander,Müller Marguerite,Reich Arno,Wiesmann Martin
Journal of neurointerventional surgery
BACKGROUND:Flow control during endovascular stroke treatment with stent-retrievers is crucial for successful revascularization. The standard technique recommended by stent-retriever manufacturers implies obstruction of the respective access catheter by the microcatheter, through which the stent-retriever is delivered. This, in turn, results in reduced aspiration during thrombectomy. In order to maximize aspiration, we fully retract the microcatheter out of the access catheter before thrombectomy-an approach we term the 'bare wire thrombectomy' (BWT) technique. We verified the improved throughput with systematic in vitro studies and assessed the clinical effectiveness and safety of this method. METHODS:We compared aspiration flow of water through various access catheters (5-8 F) with a Rebar microcatheter (0.18 inch and 0.27 inch) and a Trevo stent-retriever using the standard technique and the BWT technique in vitro. We also retrospectively analyzed 302 retrieval maneuvers in 117 patients who received endovascular treatment with a stent-retriever between February 2010 and April 2015. RESULTS:In the in vitro experiment, removal of the microcatheter in all tested settings resulted in significantly increased aspiration flow through the access catheter (p<0.001). This effect was particularly pronounced in access catheters with a diameter of ≤7 F. In the clinical study, the revascularization rate (Thrombolysis In Cerebral Infarction ≥2b) was 91%. There were no complications associated with the BWT technique in 302 retrieval maneuvers. CONCLUSIONS:The BWT technique results in improved aspiration flow rates compared with the standard deployment technique. Our clinical data show that the BWT technique is effective and safe.
Postoperative hyperglycemia predicts symptomatic intracranial hemorrhage after endovascular treatment in patients with acute anterior circulation large artery occlusion.
Li Fangfang,Ren Yi,Cui Xiuying,Liu Ping,Chen Fei,Zhao Haiping,Han Ziping,Huang Yuyou,Ma Qingfeng,Luo Yumin
Journal of the neurological sciences
INTRODUCTION:Acute phase hyperglycemia is independently associated with an increased risk of death and symptomatic intracranial hemorrhage (sICH) in stroke patients treated with intravenous thrombolysis. Whether postoperative hyperglycemia is an independent predictor of sICH after endovascular therapy remains unknown. Here, we assessed whether hyperglycemia after endovascular therapy can predict sICH. METHODS:Consecutive acute ischemic stroke patients who were treated with mechanical thrombectomy with or without subsequent stent implantation were analyzed. The primary outcome was the occurrence of sICH within the first 7 days after endovascular treatment. The second outcome was other forms of hemorrhagic transformation (HT), including parenchymal hematoma (PH) and parenchymal hematoma type 2 (PH-2). RESULTS:One hundred and fifty-six patients were included. Fifteen patients (9.62%) developed sICH after endovascular therapy. After adjusting for potential confounding factors, postoperative glucose values were independently associated with sICH after endovascular therapy. Furthermore, adding postoperative glucose values to conventional risk factors led to a substantial reclassification for sICH following endovascular therapy (net reclassification improvement = 28.1%; p = .014). Moreover, postoperative glucose values were found to be risk factors for PH-2. CONCLUSIONS:We found that postoperative glucose values might be an independent risk factor for sICH in patients with anterior circulation large vessel occlusion who are treated with mechanical thrombectomy. Adding postoperative glucose values to conventional risk factors could improve risk stratification for sICH following endovascular therapy.
Impacts of in-hospital workflow on functional outcome in stroke patients treated with endovascular thrombectomy.
Yang Dong,Zi Wenjie,Wang Huaiming,Hao Yonggang,Zhou Zhiming,Lin Min,Zhang Meng,Xiong Yunyun,Xu Gelin,Liu Xinfeng,
Journal of thrombosis and thrombolysis
High-performance in-hospital workflow may save time and improve the efficacy of thrombectomy in patients with acute ischemic stroke. However, the optimal in-hospital workflow is far from being formulated, and the current models varied distinctly among centers. This study aimed to evaluate the impacts of in-hospital workflow on functional outcomes after thrombectomy. Patients were enrolled from a multi-center registry program in China. Based on in-hospital managing procedure and personnel involved, two workflow models, neurologist-dominant and non-neurologist-dominant, were identified in the participating centers. Favorable outcome was defined as a mRS score of ≤ 2 at 90 days of stroke onset. After patients being matched with propensity score matching (PSM) method, ratios of favorable outcomes and symptomatic intracerebral hemorrhage (sICH) were compared between patients with different workflow models. Of the 632 enrolled patients, 543 (85.9%) were treated with neurologist-dominant and 89 (14.1%) with non-neurologist-dominant model. 88 patients with neurologist-dominant model and 88 patients with non-neurologist-dominant model were matched with PSM. For the matched patients, no significant differences concerning the ratios of successful recanalization (92.0% vs 87.5%, P = 0.45), sICH (17.0% vs 14.8%, P = 0.85), favorable outcome (42.0% vs 42.0%, P = 1.00) were detected between patients with neurologist-dominant model and those with non-neurologist-dominant model. Patients with neurologist-dominant model had shorter door to puncture time (124 (86-172) vs 156 (120-215), P = 0.005), fewer passes of retriever (2 (1-3) vs 2 (1-4), P = 0.04), lower rate of > 3 passes (11.4% vs 28.4%, P = 0.004), and lower incidence of asymptomatic intracerebral hemorrhage rate (27.3% vs 43.2%, P = 0.045). Although the neurologist-dominant model may decrease in-hospital delay and risk of asymptomatic intracerebral hemorrhage, workflow models may not influence the functional outcome significantly after thrombectomy in patients with acute ischemic stroke.
Prognostic Significance of Various Inflammation-Based Scores in Patients with Mechanical Thrombectomy for Acute Ischemic Stroke.
Oh Shin Woo,Yi Ho Jun,Lee Dong Hoon,Sung Jae Hoon
BACKGROUND:The objective of this study was to assess the relationship between inflammation-based scores and prognosis of patients who had undergone mechanical thrombectomy (MT) for large artery occlusion. METHODS:A total of 411 patients were enrolled and inflammation-based scores, such as neutrophil/lymphocyte ratio (NLR), lymphocyte/monocyte ratio (LMR), and monocyte/high-density lipoprotein cholesterol ratio (MHR) were calculated based on laboratory data. Prognoses were evaluated with unfavorable outcome (modified Rankin Scale score of 3-6), symptomatic intracranial hemorrhage, hemorrhagic transformation of infarct, and mortality. Multivariate analyses were performed to explore the relationships of inflammation-based scores with various clinical outcomes. RESULTS:Patients with unfavorable outcome showed higher mean NLR and MHR but lower mean LMR than those with favorable outcome (NLR, 7.32 vs. 3.78, P ≤ 0.001; MHR, 1.42 vs. 1.15, P = 0.012; LMR, 2.76 vs. 3.70, P = 0.003). In multivariate analysis, higher NLR (≥5.1) (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.04-2.12; P = 0.014) and higher MHR (≥1.4) (OR, 1.32; 95% CI, 1.10-1.74; P = 0.028), lower LMR (<2.5) (OR, 1.28; 95% CI, 1.08-1.58; P = 0.032) were independently associated with unfavorable outcome. CONCLUSIONS:After MT, higher NLR, higher MHR, and lower LMR were found in patients with unfavorable outcome. Inflammation-based scores, such as NLR, LMR, and MHR, might be independent factors that can predict outcomes in patients with MT.
Thrombectomy vs medical management in low NIHSS acute anterior circulation stroke.
OBJECTIVE:To undertake an effectiveness and safety analysis of EVT in patients with LVO and NIH Stroke Scale (NIHSS) score ≤6 using datasets of multicenter and multinational nature. METHODS:We pooled patients with anterior circulation occlusion from 3 prospective international cohorts. Patients were eligible if presentation occurred within 12 hours from last known well and baseline NIHSS ≤6. Primary outcome was modified Rankin Scale (mRS) score 0-1 at 90 days. Secondary outcomes included neurologic deterioration at 24 hours (change in NIHSS of ≥2 points), mRS 0-2 at 90 days, and 90-day all-cause mortality. We used propensity score matching to adjust for nonrandomized treatment allocation. RESULTS:Among 236 patients who fit inclusion criteria, 139 received EVT and 97 received medical management. Compared to medical management, the EVT group was younger (65 vs 72 years; < 0.001), had more proximal occlusions ( < 0.001), and less frequently received concurrent IV thrombolysis (57.7% vs 71.2%; = 0.04). After propensity score matching, clinical outcomes between the 2 groups were not significantly different. EVT patients had an 8.6% (95% confidence interval [CI] -8.8% to 26.1%) higher rate of excellent 90-day outcome, despite a 22.3% (95% CI, 3.0%-41.6%) higher risk of neurologic deterioration at 24 hours. CONCLUSIONS:EVT for LVO in patients with low NIHSS score was associated with increased risk of neurologic deterioration at 24 hours. However, both EVT and medical management resulted in similar proportions of excellent clinical outcomes at 90 days. CLASSIFICATION OF EVIDENCE:This study provides Class III evidence that for patients with acute anterior circulation ischemic strokes and LVO with NIHSS < 6, EVT and medical management result in similar outcomes at 90 days.
Glycosylated Hemoglobin A1c Predicts Intracerebral Hemorrhage with Acute Ischemic Stroke Post-Mechanical Thrombectomy.
Sun Chenghe,Wu Chuanjie,Zhao Wenbo,Wu Longfei,Wu Di,Li Weili,Wei Dongmei,Ma Qingfeng,Chen Hong,Ji Xunming
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
BACKGROUND:Intracerebral hemorrhage, including symptomatic intracerebral hemorrhage, is a serious post-mechanical thrombectomy complication in patients with acute ischemic stroke. We aimed to determine whether glycosylated hemoglobin A1c parameters could predict intracerebral hemorrhage in this patient population. METHODS:We enrolled patients with acute occlusion of the internal carotid artery or proximal middle cerebral artery and who had undergone mechanical thrombectomy. According to the glycosylated hemoglobin A1c level (%) assessed during the hospital stay, the patients were divided into two groups: > 6.5% and ≤ 6.5%. Intracerebral hemorrhage was evaluated and classified based on cranial computed tomography scans obtained within 24-48 h or when neurological conditions worsened. We assessed the outcome at the end of 90 days using the modified Rankin Scale scores. RESULTS:Among 202 patients, 86 (42.6%) suffered intracerebral hemorrhage, while 25 (12.4%) had symptomatic intracerebral hemorrhage; 35.6% of the patients had a favorable outcome (modified Rankin Scale scores 0-2). Multivariable analysis demonstrated an association of glycosylated hemoglobin A1c > 6.5% with intracerebral hemorrhage. Furthermore, glycosylated hemoglobin A1c > 6.5% was independently associated with symptomatic intracerebral hemorrhage (OR, 2.136; 95% CI, 1.279-3.567; P = 0.004). In addition, glycosylated hemoglobin A1c > 6.5% was significantly associated with increased mortality (OR, 1.511; 95% CI, 1.042-2.191; P = 0.029) and negatively associated with favorable outcome (OR, 0.480; 95% CI, 0.296-0.781; P = 0.003) at 90 days. CONCLUSIONS:Glycosylated hemoglobin A1c is an independent predictor of intracerebral hemorrhage (specifically, symptomatic intracerebral hemorrhage) in patients with acute ischemic stroke treated with mechanical thrombectomy. Further studies are needed to validate these findings.
Stress hyperglycemia is predictive of worse outcome in patients with acute ischemic stroke undergoing intravenous thrombolysis.
Merlino Giovanni,Smeralda Carmelo,Gigli Gian Luigi,Lorenzut Simone,Pez Sara,Surcinelli Andrea,Marini Alessandro,Valente Mariarosaria
Journal of thrombosis and thrombolysis
No study investigated the possible detrimental effect of stress hyperglycemia on patients affected acute ischemic stroke (AIS) undergoing intravenous thrombolysis (IVT). A new index, the glucose-to-glycated hemoglobin ratio (GAR), has been developed for assessing stress hyperglycemia. We retrospectively analyzed data from a prospectively collected database of consecutive patients admitted to the Udine University Hospital with AIS that were treated with IVT from January 2015 to December 2019. Four hundred and fourteen consecutive patients with AIS undergoing IVT entered the study. The patients were then stratified into four groups by quartiles of GAR (Q1-Q4). The higher GAR index was, the more severe stress hyperglycemia was considered. Prevalence of 3 months poor outcome (37.7% for Q1, 34% for Q2, 46.9% for Q3, and 66.7% for Q4, p for trend = 0.001), 3 months mortality (10.5% for Q1, 7.5% for Q2, 11.2% for Q3, and 27.1% for Q4, p for trend = 0.001), and symptomatic intracranial hemorrhage (0.9% for Q1, 0.9% for Q2, 5.1% for Q3, and 17.7% for Q4, p for trend = 0.001) was significant different among the four groups. AIS patients with severe stress hyperglycemia had a significantly increased risk of 3 months poor outcome (OR 2.43, 95% CI 1.14-5.22, p = 0.02), 3 months mortality (OR 2.38, 95% CI 1.01-5.60, p = 0.04), and symptomatic intracranial hemorrhage (OR 16.76, 95% CI 2.09-134.58, p = 0.008) after IVT. In conclusion, we demonstrated that stress hyperglycemia, as measured by the GAR index, is associated to worse outcome in AIS patients undergoing IVT.
Association Between Low Blood Pressure and Clinical Outcomes in Patients With Acute Ischemic Stroke.
Verschoof Merelijne A,Groot Adrien E,Vermeij Jan-Dirk,Westendorp Willeke F,van den Berg Sophie A,Nederkoorn Paul J,van de Beek Diederik,Coutinho Jonathan M
Background and Purpose- Low blood pressure is uncommon in patients with acute ischemic stroke (AIS). We assessed the association between baseline low blood pressure and outcomes in patients with AIS. Methods- Post hoc analysis of the PASS (Preventive Antibiotics in Stroke Study). We compared patients with AIS and low (<10th percentile) baseline systolic blood pressure (SBP) to patients with normal SBP (≥10th percentile <185 mm Hg). The first SBP measured at the Emergency Department was used. Outcomes included in-hospital mortality, major complications <7 days of stroke onset, and functional outcome at 90 days (modified Rankin scale score). We used regression analysis to calculate (common) odds ratios and adjusted for predefined prognostic factors. Results- Two thousand one hundred twenty-four out of 2538 patients had AIS. The cutoff for low SBP was 130 mm Hg (n=212; range, 70-129 mm Hg). One thousand four hundred forty patients had a normal SBP (range, 130-184 mm Hg). Low SBP was associated with an increased risk of in-hospital mortality (8.0% versus 4.2%; adjusted odds ratio [aOR], 1.58; 95% CI, 1.13-2.21) and complications (16.0% versus 6.5%; aOR, 2.56; 95% CI, 1.60-4.10). Specifically, heart failure (2.4% versus 0.1%; aOR, 17.85; 95% CI, 3.36-94.86), gastrointestinal bleeding (1.9% versus 0.1%; aOR, 26.04; 95% CI, 2.83-239.30), and sepsis (3.3% versus 0.5%; aOR, 5.53; 95% CI, 1.84-16.67) were more common in patients with low SBP. Functional outcome at 90 days did not differ (shift towards worse outcome: adjusted common odds ratio, 1.24; 95% CI, 0.95-1.61). Conclusions- Whether it is cause or consequence, low SBP at presentation in patients with AIS was associated with an increased risk of in-hospital mortality and complications, specifically heart failure, gastrointestinal bleeding, and sepsis. Clinicians should be vigilant for potentially treatable complications. Clinical Trial Registration- URL: https://www.controlled-trials.com. Unique identifier: ISRCTN66140176.
A high neutrophil-to-lymphocyte ratio predicts hemorrhagic transformation of large atherosclerotic infarction in patients with acute ischemic stroke.
Zhang Wen-Bo,Zeng Ya-Ying,Wang Fang,Cheng Lin,Tang Wen-Jie,Wang Xiao-Qiang
Increasing evidence suggests that inflammation is associated with the development of acute ischemic stroke (AIS). The neutrophil-to-lymphocyte ratio (N/L) is an important marker of inflammation and is highly correlated with mortality in stroke patients in recent studies. The N/L of patients who experience hemorrhagic transformation (HT) after AIS is know, but any relationship between N/L and large artery atherosclerosis (LAA) remains unclear, this is our present topic. We enrolled 185 patients with LAA-type HT in the development cohort from a prospective, consecutive, hospital-based stroke registry to this end. We matched these patients to 213 LAA patients who did not develop HT as controls. The incidence of HT after LAA was significantly greater (P<0.01) in patients with higher N/L. We developed a predictive nomogram (incorporating age, systolic blood pressure, the National Institutes of Health Stroke Scale, and the N/L) for LAA patients. The predictive power was good (area under the curve, AUC: 0.832, 95%CI: 0.791-0.872). Our findings were further validated in a validation cohort of 202 patients with AIS attributable to LAA (AUC:0.836, 95%CI:0.781-0.891). In summary, a high N/L is associated with an increased risk for HT after LAA.
Lymphocyte-to-monocyte ratio and risk of hemorrhagic transformation in patients with acute ischemic stroke.
Song Quhong,Pan Ruosu,Jin Yuxi,Wang Yanan,Cheng Yajun,Liu Junfeng,Wu Bo,Liu Ming
Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology
BACKGROUND:Hemorrhagic transformation (HT) is a common complication of acute ischemic stroke (AIS), and inflammation has been found to play an important role in the occurrence of HT. We aimed to investigate the impact of lymphocyte-to-monocyte ratio (LMR), a maker of inflammatory status, on HT in patients with AIS. METHODS:Consecutive AIS patients within 7 days from stroke onset were enrolled between January 2016 and October 2017. LMR was calculated according to lymphocyte and monocyte counts obtained within 24 h on admission. Patients were categorized into three groups according to LMR tertiles. HT was detected by follow-up computed tomography (CT) or magnetic resonance imaging (MRI) during hospitalization. The multivariate logistic analysis was used to evaluate the independent relationship between LMR and HT. RESULTS:A total of 1005 patients were finally included. HT was observed in 99 (9.9%) patients, with 51 (5.1%) hemorrhagic infarction (HI) and 48 (4.8%) parenchymal hematoma (PH). After adjustment for potential confounders, the odds ratio (OR) of HT was 0.523 (95% confidence interval [CI] 0.293-0.936, P = 0.029) for the highest LMR tertile compared with the lowest tertile. Multiple-adjusted spline regression model showed a nonlinear approximately L-shaped relationship between LMR levels and HT (P for nonlinear trend = 0.030). There was no significant association of baseline LMR with PH (OR 0.562, 95% CI 0.249-1.268, P = 0.165). CONCLUSION:Lower LMR was independently related to higher risk of HT in patients with AIS. Admission LMR may be used as one of the predictors for HT. Further prospective multicenter studies are needed to validate our findings.
Combined prognostic significance of D-dimer level and platelet count in acute ischemic stroke.
Liu Yue,Li Fang,Sun Hongwei,Sun Yanyan,Sun Hongwei,Zhai Yun,Yang Fan,Wang Jiamin,Feng Anqi,Zhao Jingbo,Tang Ying
BACKGROUND:D-dimer level and platelet count (PC) have been reported separately as significant independent predictors of Acute Ischemic Stroke (AIS). Here, we aimed to investigate the combined prognostic value of abnormal D-dimer level and PC as defined for specific in-hospital and long-term outcomes in AIS patients. METHODS:A total of 1468 patients admitted for ischemic stroke within 24 h of symptom onset from April 1, 2016 to November 31, 2019 at the Department of Neurology, the First Affiliated Hospital of Harbin Medical University were included in the final analysis. Eligible subjects were divided into four groups in terms of their levels of D-dimer and PC: DD-PC- (normal D-dimer level and normal PC), DD-PC+ (normal D-dimer level and abnormal PC), DD+PC- (higher D-dimer level and normal PC), and DD+PC+ (higher D-dimer level and abnormal PC). Logistic regression model and multinomial logit model were used to estimate the combined effect of D-dimer level and PC on in-hospital outcomes including discharge outcome and early neurological changes, and poor outcomes at 3, 6 and 12 months. RESULTS:DD+PC+ was found to be associated with the risk of in-hospital mortality (adjusted odds ratio [OR], 6.904; 95% confidence interval [CI], 2.781-17.144) and 3-month mortality (adjusted OR, 5.455; 95% CI, 2.019-14.743) compared with DD-PC-. Combination of the two indicators significantly improved the independent predictive value for functional outcomes, including early neurological deterioration (END) (OR, 3.622; 95% CI, 1.732-7.573) with threshold of at least 4-point increase on NIHSS, discharge outcome (OR, 2.713; 95% CI, 1.421-5.177); mRS of 0-1 point (OR, 0.409; 95% CI, 0.211-0.792), mRS of 0-2 points (OR, 0.234; 95% CI, 0.118, 0.461), and higher mRS-shift (OR, 2.379; 95% CI, 1.237-4.576) at 3 months; unfavorable outcome at 3 months (OR, 4.280; 95% CI, 2.169-8.446), 6 months (OR, 3.297; 95% CI, 1.452-7.488) and 12 months (OR, 4.157; 95% CI, 1.598-10.816). While comparatively weaker statistical significance was shown in DD+PC- and no correlation was found between adverse outcomes and DD-PC+. Similarly, patients with abnormal D-dimer level and PC were less likely to reach the status of stable or improving. CONCLUSIONS:Combination of D-dimer level and PC may have more significant prognostic value on END, in-hospital mortality, discharge outcome, and long-term outcomes than either index of D-dimer level or PC alone in AIS patients.
Chronic Cortical Cerebral Microinfarcts Slow Down Cognitive Recovery After Acute Ischemic Stroke.
Sagnier Sharmila,Okubo Gosuke,Catheline Gwenaëlle,Munsch Fanny,Bigourdan Antoine,Debruxelles Sabrina,Poli Mathilde,Olindo Stéphane,Renou Pauline,Rouanet François,Dousset Vincent,Tourdias Thomas,Sibon Igor
Background and Purpose- Cortical cerebral microinfarcts (CMIs) have been associated with vascular dementia and Alzheimer disease. The aim of the present study was to evaluate the role of cortical CMI detected on 3T magnetic resonance imaging, on the evolution of cognition during the year following an acute ischemic stroke. Methods- We conducted a prospective and monocentric study, including patients diagnosed for a supratentorial ischemic stroke with a National Institutes of Health Stroke Scale score ≥1, without prestroke dementia or neurological disability. Cortical CMIs were assessed on a brain 3T magnetic resonance imaging realized at baseline, as well as markers of small vessel disease, stroke characteristics, and hippocampal atrophy. Cognitive assessment was performed at 3 time points (baseline, 3 months, and 1 year) using the Montreal Cognitive Assessment, the Isaacs set test, and the Zazzo's cancellation task. Generalized linear mixed models were performed to evaluate the relationships between the number of cortical CMI and changes in cognitive scores over 1 year. Results- Among 199 patients (65±13 years old, 68% men), 88 (44%) had at least one cortical CMI. Hypertension was the main predictor of a higher cortical CMI load (B=0.58, P=0.005). The number of cortical CMI was associated with an increase time at the Zazzo's cancellation task over 1 year (B=3.84, P=0.01), regardless of the other magnetic resonance imaging markers, stroke severity, and demographic factors. Conclusions- Cortical CMIs are additional magnetic resonance imaging markers of poorer processing speed after ischemic stroke. These results indicate that a high load of cortical CMI in patients with stroke can be considered as a cerebral frailty condition which counteracts to the recovery process, suggesting a reduced brain plasticity among these patients.
The association between computed tomography angiography timing and workflow times in patients with acute ischemic stroke.
Dessens Femke M,Groot Adrien E,van der Veen Bas,Treurniet Kilian M,Majoie Charles Blm,Driessen-Waaijer Annet,Weinstein Henry C,Roos Yvo Bwem,Van den Berg-Vos Renske M,Coutinho Jonathan M,van Schaik Sander M
International journal of stroke : official journal of the International Stroke Society
BACKGROUND:In most hospitals, computed tomography angiography (CTA) is nowadays routinely performed in patients with acute ischemic stroke. However, it is unclear whether CTA is best performed before or after start of intravenous thrombolysis (IVT), since acquisition of CTA before IVT may prolong door-to-needle times, while acquisition after IVT may prolong door-to-groin times in patients undergoing endovascular treatment. METHODS:We performed a before-versus-after study (CTA following IVT, period I and CTA prior to IVT, period II), consisting of two periods of one year each. This study is based on a prospective registry of consecutive patients treated with IVT in two collaborating high-volume stroke centers; one primary stroke center and one comprehensive stroke center. The primary outcome was door-to-needle times. Secondary outcomes included door-to-groin times. Quantile regression analyses were performed to evaluate the association between timing of CTA and workflow times, adjusted for prognostic factors. RESULTS:A total of 519 patients received IVT during the study period (246 in period I, 273 in period II). In the adjusted analysis, we found a nonsignificant 1.13 min median difference in door-to-needle times (95% confidence interval: 1.03-3.29). Door-to-groin times was significantly shorter in period II in both unadjusted and adjusted analysis with the latter showing a 19.16 min median difference (95% confidence interval: 3.08-35.24). CONCLUSIONS:CTA acquisition prior to start of IVT did not adversely affect door-to-needle times. However, a significantly shorter door-to-groin times was observed in endovascular treatment eligible patients. Performing CTA prior to start of IVT seems the preferred strategy.
Presentation outside office hours does not negatively influence treatment times for reperfusion therapy for acute ischemic stroke.
Groot A E,de Bruin H,Nguyen T T M,Kappelhof M,de Beer F,Visser M C,Zwetsloot C P,Halkes P H A,de Kruijk J,van der Meulen W D M,van der Ree T C,Kwa V I H,van Schaik S M,Hani L,van den Berg R,Sprengers M E S,Roosendaal S D,Emmer B J,Nederkoorn P J,Majoie C B L M,Roos Y B W E M,Coutinho J M
Journal of neurology
BACKGROUND:Treatment outside office hours has been associated with increased workflow times for intravenous thrombolysis (IVT) in acute ischemic stroke (AIS). Limited data suggest that this "off-hours effect" also exists for endovascular treatment (EVT). We investigated this phenomenon in a well-organized acute stroke care region in the Netherlands. METHODS:Retrospective, observational cohort study of consecutive patients with AIS who received reperfusion therapy in the Greater Amsterdam Area, consisting of 14 primary stroke centers and 1 comprehensive stroke center (IVT: 2009-2015, EVT: 2014-2017). Office hours were defined as presentation during weekdays between 8 AM and 5 PM, excluding National Festive days. Primary outcome was door-to-treatment time (door-to-needle [DNT] for IVT, door-to-groin [DGT] for EVT). For DGT, we used the door time of the first hospital. Other outcomes were in-hospital mortality, modified Rankin Scale (mRS) score at 90 days and symptomatic intracranial hemorrhage (sICH). We performed multivariable linear and logistic regression analyses and used multiple imputation to account for missing values. RESULTS:In total, 59% (2450/4161) and 61% (239/395) of patients treated with IVT and EVT, respectively, presented outside office hours. Median DNT was minimally longer outside office hours (32 vs. 30 min, p = 0.024, adjusted difference 2.5 min, 95% CI 0.7-4.2). Presentation outside office hours was not associated with a longer DGT (median 130 min for both groups, adjusted difference 7.0 min, 95% CI - 4.2 to 18.1). Clinical outcome and sICH rate also did not differ. CONCLUSION:Presentation outside office hours did not lead to clinically relevant treatment delays for reperfusion therapy in patients with AIS.
Low Serum Magnesium Levels Are Associated With Hemorrhagic Transformation After Thrombolysis in Acute Ischemic Stroke.
Cheng Zicheng,Huang Xiaoyan,Muse Farah Mohamed,Xia Lingfan,Zhan Zhenxiang,Lin Xianda,Cao Yungang,Han Zhao
Frontiers in neurology
In patients with acute ischemic stroke, hemorrhagic transformation is a major complication after intravenous thrombolysis. This study aimed to investigate the relationship between serum magnesium levels and hemorrhagic transformation (HT) after thrombolytic therapy. We retrospectively analyzed data from 242 patients who received thrombolytic therapy at the Second Affiliated Hospital of the Wenzhou Medical University in China. Baseline serum magnesium levels were measured before intravenous thrombolysis, and the occurrence of HT was evaluated using computed tomography images reviewed within 24-36 h after therapy. The relationship between serum magnesium levels and HT was examined using multivariate logistic regression, subgroup analysis, and restricted cubic spline models. Of the 242 included patients, 43 (17.8%) developed HT. Patients with HT had significant lower serum magnesium levels than those without HT (0.81 ± 0.08 vs. 0.85 ± 0.08 mmol/L, = 0.007). Multivariable logistic regression analysis indicated that patients with higher serum magnesium levels had lower risk of HT (OR per 0.1-mmol/L increase 0.43, 95% CI 0.27-0.73, = 0.002). However, this association did not persist when baseline levels of serum magnesium were higher than the median value (0.85 mmol/L) in subgroup analysis (OR per 0.1-mmol/L increase 0.58, 95% CI 0.14-2.51, = 0.47). This threshold effect was also observed in the restricted cubic spline model when serum magnesium levels were above 0.88 mmol/L. No association between symptomatic HT and serum magnesium levels was observed in our study (OR per 0.1-mmol/L increase 0.52, 95% CI 0.25-1.11, = 0.092). Lower serum magnesium levels in patients with ischemic stroke are associated with an increased risk of HT after intravenous thrombolysis, but perhaps only when serum magnesium is below a certain minimal concentration.
Subtypes of anterior circulation large artery occlusions with acute brain ischemic stroke.
Zhang Kun,Li Tong,Tian Jing,Li Peifang,Fu Baosheng,Yang Xiaoli,Liu Luji,Zhao Yanying,Lu Honglin,Zhao Pandi,Bu Kailin,Li Zhongzhong,Yuan Si,Wang Qisong,Zhang Yingzhen,Guo Li,Liu Xiaoyun
Anterior circulation large artery occlusion (AC-LAO) related acute ischemic stroke (AIS) is particularly common in clinics in China. We retrospectively analyzed 787 consecutively hospitalized AIS patients with AC-LAO in Hebei Province, China. AC-LAO was defined as a complete occlusion of at least one intracranial internal carotid artery (ICA) or middle cerebral artery (MCA) based on computed tomography or magnetic resonance angiography. Among eight subtypes of AC-LAO, unilateral MCA occlusion is the most common one (49.8%, n = 392), while bilateral ICA/unilateral MCA occlusion is the least (0.3%, n = 2). Compared with unilateral MCA and unilateral ICA occlusion, patients with tandem ICA/MCA and bilateral ICA/MCA occlusion had poor outcomes after suffering AIS. Age (OR 1.022; 95%CI, 1.007 to 1.036) was an independent risk factor for single artery progressed to multiple artery occlusion, while ApoA1 (OR 0.453; 95% CI, 0.235 to 0.953) was a protective factor. Patients with unilateral MCA occlusion were prone to artery-to-artery embolism infarction subtype, unilateral ICA occlusion group were the most vulnerable to hypoperfusion/impaired emboli clearance subtype. Our results suggested various AC-LAO subtypes have different clinical characteristics and prognosis and were prone to different subtypes of infarction. Customized preventive measures based on AC-LAO subtypes may be more targeted preventions of stroke recurrences for AIS patients and could improve their prognoses.
High Neutrophil-to-Platelet Ratio Is Associated With Hemorrhagic Transformation in Patients With Acute Ischemic Stroke.
He Weilei,Ruan Yiting,Yuan Chengxiang,Cheng Qianqian,Cheng Haoran,Zeng Yaying,Chen Yunbin,Huang Guiqian,Chen Huijun,He Jincai
Frontiers in neurology
Hemorrhagic transformation (HT) is a complication that may cause neurological deterioration in patients with acute ischemic stroke. Both neutrophil and platelet have been associated with the stroke progression. The aim of this study was to explore the relationship between neutrophil-to-platelet ratio (NPR) and HT after acute ischemic stroke. A total of 279 stroke patients with HT were consecutively recruited. HT was diagnosed using magnetic resonance imaging (MRI) or computed tomography (CT) and classified into hemorrhagic infarction (HI) and parenchymal hematoma (PH). Blood samples for neutrophil and platelet counts were obtained at admission. Meanwhile, 270 age- and gender-matched controls without HT were included for comparison. Among the patients with HT, 131 patients had PH and 148 patients had HI. NPR was higher in patients with PH than those with HI or non-HT [36.8 (23.7-49.2) vs. 26.6 (17.9-38.3) vs. 19.1 (14.8-24.8), < 0.001]. After adjustment for potential confounders, high NPR remained independently associated with the increased risk of HT (OR = 2.000, 95% CI: 1.041-3.843, = 0.037). NPR (>39.9) was independently associated with PH (OR = 2.641, 95% CI: 1.308-5.342, = 0.007). High NPR was associated with the increased risk of HT especially PH in patients with acute ischemic stroke.
Public health and cost consequences of time delays to thrombectomy for acute ischemic stroke.
Kunz Wolfgang G,Hunink Myriam G,Almekhlafi Mohammed A,Menon Bijoy K,Saver Jeffrey L,Dippel Diederik W J,Majoie Charles B L M,Jovin Tudor G,Davalos Antoni,Bracard Serge,Guillemin Francis,Campbell Bruce C V,Mitchell Peter J,White Philip,Muir Keith W,Brown Scott,Demchuk Andrew M,Hill Michael D,Goyal Mayank,
OBJECTIVE:To determine public health and cost consequences of time delays to endovascular thrombectomy (EVT) for patients, health care systems, and society, we estimated quality-adjusted life-years (QALYs) of EVT-treated patients and associated costs based on times to treatment. METHODS:The Markov model analysis was performed from US health care and societal perspectives over a lifetime horizon. Contemporary data from 7 trials within the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials (HERMES) collaboration served as data source. Aside from cumulative lifetime costs, we calculated the net monetary benefit (NMB) to determine the economic value of care. We used a contemporary willingness-to-pay threshold of $100,000 per QALY for NMB calculations. RESULTS:Every 10 minutes of earlier treatment resulted in an average gain of 39 days (95% prediction interval 23-53 days) of disability-free life. Overall, the cumulative lifetime costs for patients with earlier or later treatment were similar. Patients with later treatment had higher morbidity-related costs but over a shorter time span due to their shorter life expectancy, resulting in similar lifetime costs as in patients with early treatment. Regarding the economic value of care, every 10 minutes of earlier treatment increased the NMB by $10,593 (95% prediction interval $5,549-$14,847) and by $10,915 (95% prediction interval $5,928-$15,356) taking health care and societal perspectives, respectively. CONCLUSIONS:Any time delay to EVT reduces QALYs and decreases the economic value of care provided by this intervention. Health care policies to implement efficient prehospital triage and to accelerate in-hospital workflow are urgently needed.
Glycated hemoglobin (HbA1c) and outcome following endovascular thrombectomy for ischemic stroke.
Diprose William K,Wang Michael T M,McFetridge Andrew,Sutcliffe James,Barber P Alan
Journal of neurointerventional surgery
BACKGROUND:In ischemic stroke, increased glycated hemoglobin (HbA1c) and glucose levels are associated with worse outcome following thrombolysis, and possibly, endovascular thrombectomy. OBJECTIVE:To evaluate the association between admission HbA1c and glucose levels and outcome following endovascular thrombectomy. METHODS:Consecutive patients treated with endovascular thrombectomy with admission HbA1c and glucose levels were included. The primary outcome was functional independence, defined as a modified Rankin Scale score of 0-2 at 3 months. Secondary outcomes included successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b-3), early neurological improvement (reduction in National Institutes of Health Stroke Scale (NIHSS) score ≥8 points, or NIHSS score of 0-1 at 24 hours), symptomatic intracerebral hemorrhage (sICH), and mortality at 3 months. RESULTS:223 patients (136 (61%) men; mean±SD age 64.5±14.6) were included. The median (IQR) HbA1c and glucose were 39 (36-45) mmol/mol and 6.9 (5.8-8.4) mmol/L, respectively. Multiple logistic regression analysis demonstrated that increasing HbA1c levels (per 10 mmol/mol) were associated with reduced functional independence (OR=0.76; 95% CI 0.60-0.96; p=0.02), increased sICH (OR=1.33; 95% CI 1.03 to 1.71; p=0.03), and increased mortality (OR=1.26; 95% CI 1.01 to 1.57; p=0.04). There were no significant associations between glucose levels and outcome measures (all p>0.05). CONCLUSIONS:HbA1c levels are an independent predictor of worse outcome following endovascular thrombectomy. The addition of HbA1c to decision-support tools for endovascular thrombectomy should be evaluated in future studies.
Leukocytes, Collateral Circulation, and Reperfusion in Ischemic Stroke Patients Treated With Mechanical Thrombectomy.
Semerano Aurora,Laredo Carlos,Zhao Yashu,Rudilosso Salvatore,Renú Arturo,Llull Laura,Amaro Sergi,Obach Victor,Planas Anna M,Urra Xabier,Chamorro Ángel
Background and Purpose- Peripheral immune cells are activated after stroke and may in turn influence the fate of ischemic brain tissue, thus exerting a dual role in ischemic stroke. We evaluated the contribution of neutrophil and lymphocyte counts to hemorrhagic complications and functional outcome in stroke patients treated with mechanical thrombectomy (MT) with varying degrees of collateral circulation and reperfusion. Methods- We retrospectively analyzed 433 consecutive ischemic stroke patients treated with MT. Neutrophil and lymphocyte counts and the neutrophil-to-lymphocyte ratio (NLR) were collected before MT and 1 day after symptom onset. Outcome measures included categories of hemorrhagic transformation, symptomatic intracerebral hemorrhage, 3-month functional dependence (modified Rankin Scale, 3-6), and mortality. Patients were categorized according to their baseline collateral status and the degree of reperfusion after MT. Results- Neutrophil counts and NLR increased, whereas lymphocyte counts decreased after MT (<0.001), and changes in neutrophils and NLR at day 1 were significantly greater in patients with poor reperfusion. Neutrophil counts and NLR were significantly higher already at admission in patients with poor 3-month outcome. In adjusted analysis, the impact of neutrophilia on poor functional outcome was more substantial in patients with good collaterals achieving successful reperfusion (aOR, 3.09 per quartile; 95% CI, 1.95-4.90), whereas admission lymphopenia (aOR, 4.08 per decreasing quartile; 95% CI, 1.56-10.64) and higher NLR (aOR, 3.76 per quartile; 95% CI, 1.44-9.79) predicted subsequent symptomatic intracerebral hemorrhage in patients with poor collaterals and successful reperfusion. Conclusions- In patients treated with MT, neutrophil and lymphocyte counts are dynamic parameters associated with hemorrhagic complications and long-term outcome. The extent of collateral circulation and the success of brain reperfusion influence the strength of these associations and highlight the dual role of leukocytes in acute stroke.
Cost-utility analysis of mechanical thrombectomy between 6 and 24 hours in acute ischemic stroke.
Pizzo Elena,Dumba Maureen,Lobotesis Kyriakos
International journal of stroke : official journal of the International Stroke Society
BACKGROUND:Recently, two randomized controlled trials demonstrated the benefit of mechanical thrombectomy performed between 6 and 24 h in acute ischemic stroke. The current economic evidence is supporting the intervention only within 6 h, but extended thrombectomy treatment times may result in better long-term outcomes for a larger cohort of patients. AIMS:We compared the cost-utility of mechanical thrombectomy in addition to medical treatment versus medical treatment alone performed beyond 6 h from stroke onset in the UK National Health Service (NHS). METHODS:A cost-utility analysis of mechanical thrombectomy compared to medical treatment was performed using a Markov model that estimates expected costs and quality-adjusted life years (QALYs) over a 20-year time horizon. We present the results of three models using the data from the DEFUSE 3 and DAWN trials and evidence from published sources. RESULTS:Over a 20-year period, the incremental cost per QALY of mechanical thrombectomy was $1564 (£1219) when performed after 12 h from onset, $5253 (£4096) after 16 h and $3712 (£2894) after 24 h. The probabilistic sensitivity analysis demonstrated that thrombectomy had a 99.9% probability of being cost-effective at the minimum willingness to pay for a QALY commonly used in the UK. CONCLUSIONS:The results of this study demonstrate that performing mechanical thrombectomy up to 24 h from acute ischemic stroke symptom onset is still cost-effective, suggesting that this intervention should be implemented by the NHS on the basis of improvement in quality of life as well as economic grounds.
Ultra-early improvement after endovascular thrombectomy and long-term outcome in anterior circulation acute ischemic stroke.
de Campos António Martins,Carvalho Andreia,Rodrigues Marta,Figueiredo Sofia,Gregório Tiago,Costa Henrique,Paredes Ludovina,Cunha André,Castro Sérgio,Ribeiro Manuel,Veloso Miguel,Barros Pedro
Journal of the neurological sciences
BACKGROUND:The use of post-treatment measures after acute ischemic stroke is important to predict good functional outcome. The most studied is 24 h National Institutes of Health Stroke Scale (NIHSS) score and existing literature is scarce regarding the use of earlier indicators, namely NIHSS immediately after endovascular thrombectomy (EVT). We hypothesized that an immediate neurological improvement after EVT, that we called ultra-early neurological improvement (UENI), would be a reliable functional independence predictor in anterior circulation acute ischemic stroke patients. METHODS:We included 296 anterior circulation stroke patients who received EVT at our institution between January 2015 and December 2017. We obtained post-EVT NIHSS score in the angiography room. UUENI was defined as a ≥ 4 point decrease in post-EVT NIHSS score relatively to baseline or post-EVT NIHSS score of 0-1. Patients' functional outcome was assessed using the modified Rankin Scale at 3 months. The ability of UENI to predict good functional outcome was assessed using logistic regression analysis. RESULTS:A total of 155 (52.4%) patients presented UENI. This group of patients achieved a statistically significant higher rate of functional independence (70.3% vs 46.8%, OR crude 2.69, 95% CI 1.67-4.34). After adjusting for potential confounders, the UENI showed to be an independent predictor of good outcome, with UENI patients having 4.61 times the probability of obtaining good outcome compared to patients without UENI. CONCLUSIONS:UENI is useful in outcome prediction in patients with anterior circulation stroke treated with EVT, with the advantage that it can be assessed at an ultra-early stage.
Relationship between blood pressure and outcome changes over time in acute ischemic stroke.
Shin Ji-Ah,Lee Keon-Joo,Lee Ji Sung,Kang Jihoon,Kim Beom Joon,Han Moon-Ku,Kim Jun Yup,Jang Myung Suk,Yang Mi Hwa,Lee Juneyoung,Gorelick Philip B,Bae Hee-Joon
OBJECTIVE:To evaluate whether the relationship between systolic blood pressure (SBP) and stroke outcome varies during the acute stage of ischemic stroke as a function of the elapsed time after stroke onset. METHODS:Patients who were hospitalized due to ischemic stroke within 6 hours of onset were retrospectively analyzed. SBP data were collected at 8 time points (1, 2, 4, 8, 16, 24, 48, and 72 hours after onset). The primary functional outcome measure was a poor outcome, defined as a modified Rankin Scale score of >2 at 3 months after stroke. Linear and quadratic models were constructed at each time point to assess relationships between SBP and outcome. RESULTS:Of the 2,546 patients, 728 (28.6%) had a poor outcome. SBP, as either a linear or quadratic term, had a significant effect on functional outcome, except at 4 hours after onset. For the initial 2 hours after onset, SBP had nonlinear U-shaped relationships with functional outcome, and patients with SBP of approximately 165 mm Hg were the least likely to have a poor outcome. Quadratic models exhibited a significantly better model fit. For 8-24 hours postonset, SBP exhibited linear relationships with functional outcome. For 48-72 hours postonset, SBP exhibited a J-shaped relationship with functional outcome, and the predicted probability of poor outcome was the lowest in patients with SBP of approximately 125 mm Hg. These relationships were relatively consistent across various sensitivity analyses. CONCLUSION:This study revealed that the relationship between SBP and functional outcome may depend on elapsed time from stroke onset.
Endostatin as a novel prognostic biomarker in acute ischemic stroke.
Zhang Chenhuan,Qian Sifan,Zhang Rui,Guo Daoxia,Wang Aili,Peng Yanbo,Peng Hao,Li Qunwei,Ju Zhong,Geng Deqin,Chen Jing,Zhang Yonghong,He Jiang,Zhong Chongke,Xu Tan
BACKGROUND AND AIMS:Endostatin is implicated in the atherosclerosis process and serves as a promising cardiovascular biomarker, while its clinical significance in ischemic stroke patients remains unclear. We aimed to examine the association between endostatin and mortality and disability after ischemic stroke. METHODS:A total of 3463 acute ischemic stroke patients with measured plasma endostatin from the China Antihypertensive Trial in Acute Ischemic Stroke were included in this study. The primary outcome was death or severe disability (modified Rankin scale score of 4-6), and secondary outcomes included death and vascular events. RESULTS:After 3-month follow-up, 402 (11.61%) participants experienced severe disability or died. Compared with the lowest quartile of endostatin, odds ratios or hazard ratios (95% confidence intervals) for the highest quartile were 1.47 (1.04-2.09) for the primary outcome, and 2.36 (1.23-4.54) for death after adjustment for multiple covariates, including age, sex, admission NIH Stroke Scale score and systolic blood pressure. Each 1-SD higher log-transformed endostatin was associated with a 20% (6%-36%) increased risk for primary outcome. Adding plasma endostatin to the basic model constructed with conventional factors significantly improved risk stratification of primary outcome, as observed by the category-free net reclassification index of 20.5% (95% CI 10.1%-30.8%; p < 0.001) and integrated discrimination improvement of 0.3% (95% CI 0.01%-0.6%; p = 0.04). CONCLUSIONS:Increased baseline plasma endostatin levels in acute ischemic stroke were associated with increased risk of mortality and severe disability at 3 months. Plasma endostatin may serve as an important prognostic marker for risk stratification in patients with ischemic stroke.
Intracranial Carotid Artery Calcification and Effect of Endovascular Stroke Treatment.
Compagne Kars C J,Clephas Pascal R D,Majoie Charles B L M,Roos Yvo B W E M,Berkhemer Olvert A,van Oostenbrugge Robert J,van Zwam Wim H,van Es Adriaan C G M,Dippel Diederik W J,van der Lugt Aad,Bos Daniel,
Background and Purpose- Previous studies suggest that intracranial carotid artery calcification (ICAC) volume might influence the clinical outcome of patients after endovascular treatment (EVT) for acute ischemic stroke. Importantly, ICAC can be subtyped into a medial or intimal pattern that may differentially influence the effect of EVT in patients with acute ischemic stroke. Methods- All 500 patients included in the MR CLEAN (Multicenter Randomized Clinical trial of Endovascular treatment for acute ischemic stroke in the Netherlands) were evaluated. Volume (mm) and location pattern (tunica intima or tunica media) of ICAC could be determined on baseline noncontrast computed tomography in 344 patients. Functional outcome at 90 days was assessed with the modified Rankin Scale. Next, we investigated the association of ICAC volume and pattern with functional outcome using adjusted ordinal logistic regression models. Effect modification by EVT was assessed with an interaction term between treatment allocation and ICAC aspect. Results- We found evidence for treatment effect modification by ICAC pattern ( P interaction=0.04). Patients with predominantly medial calcification had better functional outcome with EVT than without this treatment (adjusted common odds ratio, 2.32; 95% CI, 1.23-4.39), but we observed no effect of EVT in patients with predominantly intimal calcifications (adjusted common odds ratio, 0.82; 95% CI, 0.40-1.68). We did not find an association of ICAC volume with functional outcome (adjusted common odds ratio per unit increase ICAC volume 1.01 (95% CI, 0.89-1.13). Moreover, we found no evidence for effect modification by ICAC volume ( P interaction=0.61). Conclusions- The benefit of EVT in acute ischemic stroke patients with a medial calcification pattern is larger than the benefit in patients with an intimal calcification pattern. Clinical Trial Registration- URL: http://www.trialregister.nl . Unique identifier: NTR1804. URL: http://www.isrctn.com . Unique identifier: ISRCTN10888758.
Thrombus Imaging Characteristics and Outcomes in Acute Ischemic Stroke Patients Undergoing Endovascular Treatment.
Dutra Bruna G,Tolhuisen Manon L,Alves Heitor C B R,Treurniet Kilian M,Kappelhof Manon,Yoo Albert J,Jansen Ivo G H,Dippel Diederik W J,van Zwam Wim H,van Oostenbrugge Robert J,da Rocha Antônio J,Lingsma Hester F,van der Lugt Aad,Roos Yvo B W E M,Marquering Henk A,Majoie Charles B L M,
Background and Purpose- Thrombus imaging characteristics have been reported to be useful to predict functional outcome and reperfusion in acute ischemic stroke. However, conflicting data about this subject exist in patients undergoing endovascular treatment. Therefore, we aimed to evaluate whether thrombus imaging characteristics assessed on computed tomography are associated with outcomes in patients with acute ischemic stroke treated by endovascular treatment. Methods- The MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry is an ongoing, prospective, and observational study in all centers performing endovascular treatment in the Netherlands. We evaluated associations of thrombus imaging characteristics with the functional outcome (modified Rankin Scale at 90 days), mortality, reperfusion, duration of endovascular treatment, and symptomatic intracranial hemorrhage using univariable and multivariable regression models. Thrombus characteristics included location, clot burden score (CBS), length, relative and absolute attenuation, perviousness, and distance from the internal carotid artery terminus to the thrombus. All characteristics were assessed on thin-slice (≤2.5 mm) noncontrast computed tomography and computed tomography angiography, acquired within 30 minutes from each other. Results- In total, 408 patients were analyzed. Thrombus with distal location, higher CBS, and shorter length were associated with better functional outcome (adjusted common odds ratio, 3.3; 95% CI, 2.0-5.3 for distal M1 occlusion compared with internal carotid artery occlusion; adjusted common odds ratio, 1.15; 95% CI, 1.07-1.24 per CBS point; and adjusted common odds ratio, 0.96; 95% CI, 0.94-0.99 per mm, respectively) and reduced duration of endovascular procedure (adjusted coefficient B, -14.7; 95% CI, -24.2 to -5.1 for distal M1 occlusion compared with internal carotid artery occlusion; adjusted coefficient B, -8.5; 95% CI, -14.5 to -2.4 per CBS point; and adjusted coefficient B, 7.3; 95% CI, 2.9-11.8 per mm, respectively). Thrombus perviousness was associated with better functional outcome (adjusted common odds ratio, 1.01; 95% CI, 1.00-1.02 per Hounsfield units increase). Distal thrombi were associated with successful reperfusion (adjusted odds ratio, 2.6; 95% CI, 1.4-4.9 for proximal M1 occlusion compared with internal carotid artery occlusion). Conclusions- Distal location, higher CBS, and shorter length are associated with better functional outcome and faster endovascular procedure. Distal thrombus is strongly associated with successful reperfusion, and a pervious thrombus is associated with better functional outcome.
Local Anesthesia Without Sedation During Thrombectomy for Anterior Circulation Stroke Is Associated With Worse Outcome.
Benvegnù Francesco,Richard Sébastien,Marnat Gaultier,Bourcier Romain,Labreuche Julien,Anadani Mohammad,Sibon Igor,Dargazanli Cyril,Arquizan Caroline,Anxionnat René,Audibert Gérard,Zhu François,Mazighi Mikaël,Blanc Raphaël,Lapergue Bertrand,Consoli Arturo,Gory Benjamin,
BACKGROUND AND PURPOSE:The best anesthetic management for mechanical thrombectomy of large vessel occlusion strokes is still uncertain and could impact the quality of reperfusion and clinical outcome. We aimed to compare the efficacy and safety outcomes between local anesthesia (LA) and conscious sedation in a large cohort of acute ischemic stroke patients with anterior circulation large vessel occlusion strokes treated with mechanical thrombectomy in current, everyday clinical practice. METHODS:Patients undergoing mechanical thrombectomy for anterior large vessel occlusion strokes at 4 comprehensive stroke centers in France between January 1, 2018, and December 31, 2018, were pooled from the ongoing prospective multicenter observational Endovascular Treatment in Ischemic Stroke Registry in France. Intention-to-treat and per-protocol analyses were used. RESULTS:Among the included 1034 patients, 762 were included in the conscious sedation group and 272 were included in the LA group. In the propensity score matched cohort, the rate of favorable outcome (90-day modified Rankin Scale score 0-2) was significantly lower in the LA group than in the conscious sedation group (40.0% versus 52.0%, matched relative risk=0.76 [95% CI, 0.60-0.97]), as well as the rate of successful reperfusion (modified Thrombolysis in Cerebral Infarction grade 2b-3; 76.6% versus 87.1%; matched relative risk=0.88 [95% CI, 0.79-0.98]). There was no difference in procedure time between the 2 groups. In the inverse probability of treatment weighting-propensity score-adjusted cohort, similar significant differences were found for favorable outcomes and successful reperfusion. In inverse probability of treatment weighting-propensity score-adjusted cohort, a higher rate of 90-day mortality and a lower parenchymal hematoma were observed after LA. The sensitivity analysis restricted to our per-protocol sample provided similar results in the matched- and inverse probability of treatment weighting-propensity cohorts. CONCLUSIONS:In the Endovascular Treatment in Ischemic Stroke registry mainly included patients in early time window (<6 hours), LA was associated with lower odds of favorable outcome, successful reperfusion, and higher odds of mortality compared with conscious sedation for mechanical thrombectomy of large vessel occlusion.
Cortical Microinfarcts Associated With Worse Outcomes in Patients With Acute Ischemic Stroke Receiving Endovascular Treatment.
Wei Yufei,Pu Yuehua,Pan Yuesong,Nie Ximing,Duan Wanying,Liu Dacheng,Yan Hongyi,Lu Qixuan,Zhang Zhe,Yang Zhonghua,Wen Miao,Gu Weibin,Hou Xinyi,Ma Ning,Leng Xinyi,Miao Zhongrong,Liu Liping,
BACKGROUND AND PURPOSE:We aimed to evaluate the impact of cortical microinfarcts (CMIs) on functional outcome after endovascular treatment in patients with acute ischemic stroke. METHODS:In a multicenter registration study for RESCUE-RE (a registration study for Critical Care of Acute Ischemic Stroke After Recanalization), eligible patients with large vessel occlusion stroke receiving endovascular treatment, who had undergone 3T magnetic resonance imaging on admission or within 24 hours after endovascular treatment were analyzed. We evaluated the presence and numbers of CMIs with assessment of axial T1, T2-weighted images, and fluid-attenuated inversion recovery images. The primary outcome was functional dependence or death defined as modified Rankin Scale scores of 3 to 6 at 90 days. Secondary outcomes included early neurological improvement, any intracranial hemorrhage, symptomatic intracranial hemorrhage, and mortality. We investigated the independent associations of CMIs with the outcomes using multivariable logistic regression in overall patients and in subgroups. RESULTS:Among 414 patients (enrolled from July 2018 to May 2019) included in the analyses, 96 (23.2%) patients had at least one CMI (maximum 6). Patients with CMI(s) were more likely to be functionally dependent or dead at 90 days, compared with those without (55.2% versus 37.4%; <0.01). In multivariable logistic regression analyses, presence of CMI(s) (adjusted odds ratio, 1.78 [95% CI, 1.04-3.07]; =0.04) and multiple CMIs (CMIs ≥2; adjusted odds ratio, 7.41 [95% CI, 2.48-22.17]; <0.001) were independently, significantly associated with the primary outcome. There was no significant difference between subgroups in the associations between CMI presence and the primary outcome. CONCLUSIONS:Acute large vessel occlusion stroke patients receiving endovascular treatment with CMI(s) were more likely to have a poor functional outcome at 90 days, independent of patients' characteristics. Such associations may be dose-dependent. Registration: URL: http://www.chictr.org.cn; Unique identifier: ChiCTR1900022154.
Impact of Initial Imaging Protocol on Likelihood of Endovascular Stroke Therapy.
Lopez-Rivera Victor,Abdelkhaleq Rania,Yamal Jose-Miguel,Singh Noopur,Savitz Sean I,Czap Alexandra L,Alderazi Yazan,Chen Peng R,Grotta James C,Blackburn Spiros,Spiegel Gary,Dannenbaum Mark J,Wu Tzu-Ching,Yoo Albert J,McCullough Louise D,Sheth Sunil A
BACKGROUND AND PURPOSE:Noncontrast head CT and CT perfusion (CTP) are both used to screen for endovascular stroke therapy (EST), but the impact of imaging strategy on likelihood of EST is undetermined. Here, we examine the influence of CTP utilization on likelihood of EST in patients with large vessel occlusion (LVO). METHODS:We identified patients with acute ischemic stroke at 4 comprehensive stroke centers. All 4 hospitals had 24/7 CTP and EST capability and were covered by a single physician group (Neurology, NeuroIntervention, NeuroICU). All centers performed noncontrast head CT and CT angiography in the initial evaluation. One center also performed CTP routinely with high CTP utilization (CTP-H), and the others performed CTP optionally with lower utilization (CTP-L). Primary outcome was likelihood of EST. Multivariable logistic regression was used to determine whether facility type (CTP-H versus CTP-L) was associated with EST adjusting for age, prestroke mRS, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, LVO location, time window, and intravenous tPA (tissue-type plasminogen activator). RESULTS:Among 3107 patients with acute ischemic stroke, 715 had LVO, of which 403 (56%) presented to CTP-H and 312 (44%) presented to CTP-L. CTP utilization among LVO patients was greater at CTP-H centers (72% versus 18%, CTP-H versus CTP-L, <0.01). In univariable analysis, EST rates for patients with LVO were similar between CTP-H versus CTP-L (46% versus 49%). In multivariable analysis, patients with LVO were less likely to undergo EST at CTP-H (odds ratio, 0.59 [0.41-0.85]). This finding was maintained in multiple patient subsets including late time window, anterior circulation LVO, and direct presentation patients. Ninety-day functional independence (odds ratio, 1.04 [0.70-1.54]) was not different, nor were rates of post-EST PH-2 hemorrhage (1% versus 1%). CONCLUSIONS:We identified an increased likelihood for undergoing EST in centers with lower CTP utilization, which was not associated with worse clinical outcomes or increased hemorrhage. These findings suggest under-treatment bias with routine CTP.
IER-SICH Nomogram to Predict Symptomatic Intracerebral Hemorrhage After Thrombectomy for Stroke.
Cappellari Manuel,Mangiafico Salvatore,Saia Valentina,Pracucci Giovanni,Nappini Sergio,Nencini Patrizia,Konda Daniel,Sallustio Fabrizio,Vallone Stefano,Zini Andrea,Bracco Sandra,Tassi Rossana,Bergui Mauro,Cerrato Paolo,Pitrone Antonio,Grillo Francesco,Saletti Andrea,De Vito Alessandro,Gasparotti Roberto,Magoni Mauro,Puglielli Edoardo,Casalena Alfonsina,Causin Francesco,Baracchini Claudio,Castellan Lucio,Malfatto Laura,Menozzi Roberto,Scoditti Umberto,Comelli Chiara,Duc Enrica,Comai Alessio,Franchini Enrica,Cosottini Mirco,Mancuso Michelangelo,Peschillo Simone,De Michele Manuela,Giorgianni Andrea,Delodovici Maria Luisa,Lafe Elvis,Denaro Maria Federica,Burdi Nicola,Internò Saverio,Cavasin Nicola,Critelli Adriana,Chiumarulo Luigi,Petruzzellis Marco,Doddi Marco,Carolei Antonio,Auteri William,Petrone Alfredo,Padolecchia Riccardo,Tassinari Tiziana,Pavia Marco,Invernizzi Paolo,Turcato Gianni,Forlivesi Stefano,Ciceri Elisa Francesca Maria,Bonetti Bruno,Inzitari Domenico,Toni Danilo,
Background and Purpose- As a reliable scoring system to detect the risk of symptomatic intracerebral hemorrhage after thrombectomy for ischemic stroke is not yet available, we developed a nomogram for predicting symptomatic intracerebral hemorrhage in patients with large vessel occlusion in the anterior circulation who received bridging of thrombectomy with intravenous thrombolysis (training set), and to validate the model by using a cohort of patients treated with direct thrombectomy (test set). Methods- We conducted a cohort study on prospectively collected data from 3714 patients enrolled in the IER (Italian Registry of Endovascular Stroke Treatment in Acute Stroke). Symptomatic intracerebral hemorrhage was defined as any type of intracerebral hemorrhage with increase of ≥4 National Institutes of Health Stroke Scale score points from baseline ≤24 hours or death. Based on multivariate logistic models, the nomogram was generated. We assessed the discriminative performance by using the area under the receiver operating characteristic curve. Results- National Institutes of Health Stroke Scale score, onset-to-end procedure time, age, unsuccessful recanalization, and Careggi collateral score composed the IER-SICH nomogram. After removing Careggi collateral score from the first model, a second model including Alberta Stroke Program Early CT Score was developed. The area under the receiver operating characteristic curve of the IER-SICH nomogram was 0.778 in the training set (n=492) and 0.709 in the test set (n=399). The area under the receiver operating characteristic curve of the second model was 0.733 in the training set (n=988) and 0.685 in the test set (n=779). Conclusions- The IER-SICH nomogram is the first model developed and validated for predicting symptomatic intracerebral hemorrhage after thrombectomy. It may provide indications on early identification of patients for more or less postprocedural intensive management.
Brain Atrophy and the Risk of Futile Endovascular Reperfusion in Acute Ischemic Stroke.
Pedraza María I,de Lera Mercedes,Bos Daniel,Calleja Ana I,Cortijo Elisa,Gómez-Vicente Beatriz,Reyes Javier,Coco-Martín María Begoña,Calonge Teodoro,Agulla Jesús,Martínez-Pías Enrique,Talavera Blanca,Pérez-Fernández Santiago,Schüller Miguel,Galván Jorge,Castaño Miguel,Martínez-Galdámez Mario,Arenillas Juan F
Background and Purpose- We aimed to evaluate the impact of brain atrophy on long-term clinical outcome in patients with acute ischemic stroke treated with endovascular therapy, and more specifically, to test whether there are interactions between the degree of atrophy and infarct volume, and between atrophy and age, in determining the risk of futile reperfusion. Methods- We studied consecutive patients with acute ischemic stroke with proximal anterior circulation intracranial arterial occlusions treated with endovascular therapy achieving successful arterial recanalization. Brain atrophy was evaluated on baseline computed tomography with the global cortical atrophy scale, and Evans index was calculated to assess subcortical atrophy. Infarct volume was assessed on control computed tomography at 24 hours using the formula for irregular volumes (A×B×C/2). Main outcome variable was futile recanalization, defined by functional dependence (modified Rankin Scale score >2) at 3 months. The predefined interactions of atrophy with age and infarct volume were studied in regression models. Results- From 361 consecutive patients with anterior circulation acute ischemic stroke treated with endovascular therapy, 295 met all inclusion criteria. Futile reperfusion was observed in 144 out of 295 (48.8%) patients. Cortical atrophy affecting parieto-occipital and temporal regions was associated with futile recanalization. Total global cortical atrophy score and Evans index were independently associated with futile recanalization in an adjusted logistic regression. Multivariable adjusted regression models disclosed significant interactions between global cortical atrophy score and infarct volume (odds ratio, 1.003 [95%CI, 1.002-1.004], <0.001) and between global cortical atrophy score and age (odds ratio, 1.001 [95% CI, 1.001-1.002], <0.001) in determining the risk of futile reperfusion. Conclusions- A higher degree of cortical and subcortical brain atrophy is associated with futile endovascular reperfusion in anterior circulation acute ischemic stroke. The impact of brain atrophy on insufficient clinical recovery after endovascular reperfusion appears to be independently amplified by age and by infarct volume.
Refining Stroke and Bleeding Prediction in Atrial Fibrillation by Adding Consecutive Biomarkers to Clinical Risk Scores.
Rivera-Caravaca José Miguel,Marín Francisco,Vilchez Juan Antonio,Gálvez Josefa,Esteve-Pastor María Asunción,Vicente Vicente,Lip Gregory Y H,Roldán Vanessa
Background and Purpose- Current European guidelines for the management of atrial fibrillation suggest using biomarkers to refine the risk stratification process. However, it is unclear whether ≥2 biomarkers incrementally improve risk prediction beyond 1 biomarker alone. We investigated whether the predictive performance of CHADS-VASc and HAS-BLED scores could be enhanced by incrementally adding consecutive different biomarkers in real-world atrial fibrillation patients taking vitamin K antagonists therapy. Methods- We included 940 atrial fibrillation patients stable on vitamin K antagonists (international normalized ratio, 2.0-3.0) for at least the previous 6 months. At inclusion, VWF (von Willebrand factor), high-sensitivity troponin T, NT-proBNP (N-terminal pro-B-type natriuretic peptide), high-sensitivity IL (interleukin)-6, fibrin monomers, and BTP (β-trace protein) concentrations were quantified. During follow-up, all adverse events were recorded, and biomarkers were added to CHADS-VASc and HAS-BLED scores depending on the C index. Results- During 6.5 (4.3-7.9) years, there were 98 ischemic strokes (1.60% per year) and 172 major bleeds (1.60% per year). After the addition of biomarkers, the predictive performance of CHADS-VASc was not significantly increased, although the model with 3 biomarkers (ie, NT-proBNP+BTP+VWF) showed a low gain in sensitivity (integrated discrimination improvement, 2.70%; P<0.001). The predictive performance of HAS-BLED was enhanced in all biomarker-based models, with the best prediction shown by the model with 3 biomarkers (ie, VWF+NT-proBNP+high-sensitivity IL-6; C index, 0.600 [95% CI, 0.561-0.625] versus 0.639 [95% CI, 0.607-0.669]; P=0.025). This model also confirmed an increased sensitivity (integrated discrimination improvement, 5.20%; P<0.001) and positive reclassification (net reclassification improvement, 19.20%; P=0.020). Conclusions- By adding consecutive biomarkers, the predictive ability of CHADS-VASc for ischemic stroke was not increased, whereas the predictive ability of HAS-BLED for major bleeding was only slightly enhanced. The net benefit and clinical usefulness of the biomarker-based models were marginal in comparison to the original scores based on clinical factors.
Acute Kidney Injury after Endovascular Treatment in Patients with Acute Ischemic Stroke.
Yoo Joonsang,Hong Jeong-Ho,Lee Seong-Joon,Kim Yong-Won,Hong Ji Man,Kim Chang-Hyun,Choi Jin Wook,Kang Dong-Hun,Kim Yong-Sun,Hwang Yang-Ha,Lee Jin Soo,Sohn Sung-Il
Journal of clinical medicine
Acute kidney injury (AKI) is often associated with the use of contrast agents. We evaluated the frequency of AKI, factors associated with AKI after endovascular treatment (EVT), and associations with AKI and clinical outcomes. We retrospectively analyzed consecutively enrolled patients with acute ischemic stroke who underwent EVT at three stroke centers in Korea. We compared the characteristics of patients with and without AKI and independent factors associated with AKI after EVT. We also investigated the effects of AKI on functional outcomes and mortality at 3 months. Of the 601 patients analyzed, 59 patients (9.8%) developed AKI and five patients (0.8%) started renal replacement therapy after EVT. In the multivariate analysis, diabetes mellitus (odds ratio (OR), 2.341; 95% CI, 1.283-4.269; = 0.005), the contrast agent dose (OR, 1.107 per 10 mL; 95% CI, 1.032-1.187; = 0.004), and unsuccessful reperfusion (OR, 1.909; 95% CI, 1.019-3.520; = 0.040) were independently associated with AKI. The presence of AKI was associated with a poor functional outcome (OR, 5.145; 95% CI, 2.177-13.850; < 0.001) and mortality (OR, 8.164; 95% CI, 4.046-16.709; < 0.001) at 3 months. AKI may also affect the outcomes of ischemic stroke patients undergoing EVT. When implementing EVT, practitioners should be aware of these risk factors.
Mechanical Thrombectomy in Patients With Ischemic Stroke With Prestroke Disability.
Salwi Sanjana,Cutting Shawna,Salgado Alan D,Espaillat Kiersten,Fusco Matthew R,Froehler Michael T,Chitale Rohan V,Kirshner Howard,Schrag Matthew,Jasne Adam,Burton Tina,MacGrory Brian,Saad Ali,Jayaraman Mahesh V,Madsen Tracy E,Dakay Katarina,McTaggart Ryan,Yaghi Shadi,Khatri Pooja,Mistry Akshitkumar M,Mistry Eva A
Background and Purpose- We aimed to compare functional and procedural outcomes of patients with acute ischemic stroke with none-to-minimal (modified Rankin Scale [mRS] score, 0-1) and moderate (mRS score, 2-3) prestroke disability treated with mechanical thrombectomy. Methods- Consecutive adult patients undergoing mechanical thrombectomy for an anterior circulation stroke were prospectively identified at 2 comprehensive stroke centers from 2012 to 2018. Procedural and 90-day functional outcomes were compared among patients with prestroke mRS scores 0 to 1 and 2 to 3 using χ, logistic, and linear regression tests. Primary outcome and significant differences in secondary outcomes were adjusted for prespecified covariates. Results- Of 919 patients treated with mechanical thrombectomy, 761 were included and 259 (34%) patients had moderate prestroke disability. Ninety-day mRS score 0 to 1 or no worsening of prestroke mRS was observed in 36.7% and 26.7% of patients with no-to-minimal and moderate prestroke disability, respectively (odds ratio, 0.63 [0.45-0.88], =0.008; adjusted odds ratio, 0.90 [0.60-1.35], =0.6). No increase in the disability at 90 days was observed in 22.4% and 26.7%, respectively. Rate of symptomatic intracerebral hemorrhage (7.3% versus 6.2%, =0.65), successful recanalization (86.7% versus 83.8%, =0.33), and median length of hospital stay (5 versus 5 days, =0.06) were not significantly different. Death by 90 days was higher in patients with moderate prestroke disability (14.3% versus 40.3%; odds ratio, 4.06 [2.82-5.86], <0.001; adjusted odds ratio, 2.83 [1.84, 4.37], <0.001). Conclusions- One-third of patients undergoing mechanical thrombectomy had a moderate prestroke disability. There was insufficient evidence that functional and procedural outcomes were different between patients with no-to-minimal and moderate prestroke disability. Patients with prestroke disability were more likely to die by 90 days.
Predictors of 30-day hospital readmission after mechanical thrombectomy for acute ischemic stroke.
Mouchtouris Nikolaos,Al Saiegh Fadi,Valcarcel Breanna,Andrews Carrie E,Fitchett Evan,Nauheim David,Moskal David,Herial Nabeel,Jabbour Pascal,Tjoumakaris Stavropoula I,Sharan Ashwini D,Rosenwasser Robert H,Gooch M Reid
Journal of neurosurgery
OBJECTIVE:The 30-day readmission rate is of increasing interest to hospital administrators and physicians, as it is used to evaluate hospital performance and is associated with increased healthcare expenditures. The estimated yearly cost to Medicare of readmissions is $17.4 billion. The Centers for Medicare and Medicaid Services therefore track unplanned 30-day readmissions and institute penalties against hospitals whose readmission rates exceed disease-specific national standards. One of the most important conditions with potential for improvement in cost-effective care is ischemic stroke, which affects 795,000 people in the United States and is a leading cause of death and disability. Recent widespread adoption of mechanical thrombectomy has revolutionized stroke care, requiring reassessment of readmission causes and costs in this population. METHODS:The authors retrospectively analyzed a prospectively maintained database of stroke patients and identified 561 patients who underwent mechanical thrombectomy between 2010 and 2019 at the authors' institution. Univariate and multivariate analyses were conducted to identify clinical variables and comorbidities related to 30-day readmissions in this patient population. RESULTS:Of the 561 patients, 85.6% (n = 480) survived their admission and were discharged from the hospital to home or rehabilitation, and 8.8% (n = 42/480) were readmitted within 30 days. The median time to readmission was 10.5 days (IQR 6.0-14.3). The most common reasons for readmission were infection (33.3%) and acute cardiac or cerebrovascular events (19% and 20%, respectively). Multivariate analysis showed that hypertension (p = 0.030; OR 2.72) and length of initial hospital stay (p = 0.040; OR 1.032) were significantly correlated with readmission within 30 days, while hemorrhagic conversion (grades 3 and 4) approached significance (p = 0.053; OR 2.23). Other factors, such as unfavorable outcome at discharge, history of coronary artery disease, and discharge destination, did not predict readmission. CONCLUSIONS:The study data demonstrate that hypertension, length of hospital stay, and hemorrhagic conversion were predictors of 30-day hospital readmission in stroke patients after mechanical thrombectomy. Infection was the most common cause of 30-day readmission, followed by cardiac and cerebrovascular diagnoses. These results therefore may serve to identify patients within the stroke population who require increased surveillance following discharge to reduce complications and unplanned readmissions.
2B, 2C, or 3: What Should Be the Angiographic Target for Endovascular Treatment in Ischemic Stroke?
LeCouffe Natalie E,Kappelhof Manon,Treurniet Kilian M,Lingsma Hester F,Zhang Guang,van den Wijngaard Ido R,van Es Adriaan C G M,Emmer Bart J,Majoie Charles B L M,Roos Yvo B W E M,Coutinho Jonathan M,
Background and Purpose- A score of ≥2B on the modified Thrombolysis in Cerebral Infarction scale is generally regarded as successful reperfusion after endovascular treatment for ischemic stroke. The extended Thrombolysis in Cerebral Infarction (eTICI) includes a 2C grade, which indicates near-perfect reperfusion. We investigated how well the respective eTICI scores of 2B, 2C, and 3 correlate with clinical outcome after endovascular treatment. Methods- We used data from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry, a prospective, nationwide registry of endovascular treatment in the Netherlands. We included patients with a proximal intracranial occlusion of the anterior circulation for whom final antero-posterior and lateral digital subtraction angiography imaging was available. Our primary outcome was the distribution on the modified Rankin Scale at 90 days per eTICI grade. We performed (ordinal) logistic regression analyses, using eTICI 2B as reference group, and adjusted for potential confounders. Results- In total, 2807/3637 (77%) patients met the inclusion criteria. Of these, 17% achieved reperfusion grade eTICI 0 to 1, 14% eTICI 2A, 25% eTICI 2B, 12% eTICI 2C, and 32% eTICI 3. Groups differed in terms of age (<0.001) and occlusion location (<0.01). Procedure times decreased with increasing reperfusion grades. We found a positive association between reperfusion grade and functional outcome, which continued to increase after eTICI 2B (adjusted common odds ratio, 1.22 [95% CI, 0.96-1.57] for eTICI 2C versus 2B; adjusted common odds ratio, 1.33 [95% CI, 1.09-1.62] for eTICI 3 versus 2B). Conclusions- Our results indicate a continuous relationship between reperfusion grade and functional outcome, with eTICI 3 leading to the best outcomes. Although this implies that interventionists should aim for the highest possible reperfusion grade, further research on the optimal strategy is necessary.
Predictors of poor clinical outcome despite complete reperfusion in acute ischemic stroke patients.
van Horn Noel,Kniep Helge,Leischner Hannes,McDonough Rosalie,Deb-Chatterji Milani,Broocks Gabriel,Thomalla Goetz,Brekenfeld Caspar,Fiehler Jens,Hanning Uta,Flottmann Fabian
Journal of neurointerventional surgery
BACKGROUND: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. METHODS: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. RESULTS: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. CONCLUSION: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.