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Endovascular thrombectomy (EVT) has been validated in several randomized controlled trials in recent years for its efficacy in the treatment of acute ischemic strokes (AIS) and is now the standard of care according to international guidelines. However, in about 20% of EVT procedures, recanalization is not achieved, and over 50% of patients who unde...
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Background
Carotid tandem lesions ((TL) ⩾70% stenosis or occlusion) account for 15–20% of acute stroke with large vessel occlusion.
Aims
We investigated the safety and efficacy of intravenous tenecteplase (0.25 mg/kg) versus intravenous alteplase (0.9 mg/kg) in patients with carotid TL.
Methods
This is a substudy of the alteplase compared with th...
Background
Despite thrombectomy having become the standard of care for large‐vessel occlusion strokes, acute endovascular management in tandem occlusions, especially of the cervical internal carotid artery lesion, remains uncertain. We aimed to compare efficacy and safety of acute carotid artery stenting to balloon angioplasty alone on treating the...
Mechanical thrombectomy is currently the gold standard treatment of large vessel occlusions, especially in anterior circulation acute ischemic stroke. At the same time, the problem of tandem occlusions seems especially important since most of the major clinical mechanical thrombectomy studies did not specifically evaluate patients with concomitant...
Purpose
The aim of this study is to test the prognostic value of a diffusion-weighted imaging (DWI) score in acute basilar artery occlusion (ABAO) with successful recanalization.
Methods
The DWI-based pons-midbrain and thalamus (PMT) score was developed to assess posterior circulation infarcts. We test its prognostic value and compare it with othe...
Background and Purpose— The relationship between heart rate and the prognosis of patients with large vessel occlusion strokes treated with mechanical thrombectomy (MT) is not well established. This study aimed to evaluate the association of mean heart rate and heart rate variability with the clinical outcomes after MT therapy.
Methods— Acute ischem...
Citations
... R ecent advancements in technique and expertise in endovascular therapy (EVT) enable a high rate of near-complete or complete reperfusion, which, in turn, is associated with higher rates of functional independence in patients with acute ischemic stroke secondary to large vessel occlusion. 1 However, only between 32.4% and 56.7% of patients achieve functional independence after EVT despite effective reperfusion. 2 Previous data have shown that ischemic core volume (ICV) evaluated by computed tomography perfusion (CTP) or diffusion-weighted imaging has strong prognostic value on functional outcomes in patients who underwent EVT, independent of reperfusion status. 3 However, CTP adds time, contrast, and radiation to hyperacute stroke care, and magnetic resonance imaging is not routinely available at many centers. ...
BACKGROUND
Early ischemic change and collateral extent are colinear with ischemic core volume (ICV). We investigated the relationship between a combined score using the Alberta Stroke Program Early Computed Tomography Score and multiphase computed tomography angiography (mCTA) collateral extent, named mCTA-ACE score, on functional outcomes in endovascular therapy–treated patients.
METHODS
We performed a post hoc analysis of a subset of endovascular therapy–treated patients from the Alteplase Compared to Tenecteplase trial which was conducted between December 2019 and January 2022 at 22 centers across Canada. Ten-point mCTA collateral corresponding to M2 to M6 regions of the Alberta Stroke Program Early Computed Tomography Score grid was evaluated as 0 (poor), 1 (moderate), or 2 (normal) and additively combined with the 10-point Alberta Stroke Program Early Computed Tomography Score to produce a 20-point mCTA-ACE score. We investigated the association of mCTA-ACE score with modified Rankin Scale score ≤2 and return to prestroke level of function at 90 to 120 days using mixed-effects logistic regression. In the subset of patients who underwent baseline computed tomography perfusion imaging, we compared the mCTA-ACE score and ICV for outcome prediction.
RESULTS
Among 1577 intention-to-treat population in the trial, 368 (23%; 179 men; median age, 73 years) were included, with Alberta Stroke Program Early Computed Tomography Score, mCTA collateral, and combination of both (mCTA-ACE score: median [interquartile range], 8 [7–10], 9 [8–10], and 17 [16–19], respectively). The probability of modified Rankin scale score ≤2 and return to prestroke level of function increased for each 1-point increase in mCTA-ACE score (odds ratio, 1.16 [95% CI, 1.06–1.28] and 1.22 [95% CI, 1.06–1.40], respectively). Among 173 patients in whom computed tomography perfusion data was assessable, the mCTA-ACE score was inversely correlated with ICV (ρ=−0.46; P <0.01). The mCTA-ACE score was comparable to ICV to predict a modified Rankin scale score ≤2 and return to prestroke level of function (C statistics 0.71 versus 0.69 and 0.68 versus 0.64, respectively).
CONCLUSIONS
The mCTA-ACE score had a significant positive association with functional outcomes after endovascular therapy and had a similar predictive performance as ICV.
... Mechanical thrombectomy (MT), a procedure to remove the occluding clot, has become a gold standard treatment for ischemic stroke caused by LVO [4,5]. The most common MT methods involve the use of an aspiration catheter, stent retriever, or a combination of both [6]. While these techniques have demonstrated high rates of successful recanalization [7], achieving successful reperfusion with a single pass-deemed the "first-pass effect"-is associated with improved clinical outcomes and fewer procedure-related complications [8][9][10]. ...
... Indications for MT were determined according to the American Heart Association / American Stroke Association guidelines, and the procedure was performed after informed consent was obtained from each patient or the patient's family [5]. The devices used were FDA-approved and commonly available devices, and the treatment strategy was determined by the neuroendovascular physicians [6]. ...
Background
Mechanical thrombectomy (MT) has become the gold standard care for treating acute ischemic stroke (AIS) due to large vessel occlusion. Emerging evidence suggests that understanding the composition of clots prior to intervention could be useful for the selection of neuroendovascular techniques, potentially improving the efficacy of treatments. However, current imaging modalities lack the ability to distinguish clot composition accurately and reliably. Since water content can influence signal intensity on CT and MRI scans, its assessment may provide indirect clues about clot composition. This study aimed to elucidate the correlation between water content and clot composition using human clots retrieved from stroke patients and experimentally generated ovine clots.
Materials and methods
This study involved an analysis of ten clots retrieved from patients with AIS undergoing MT. Additionally, we created ten red blood cells (RBC)-rich and ten fibrin-rich ovine blood clots, which were placed in a human intracranial vascular model under realistic flow conditions. The water content and compositions of these clots were evaluated, and linear regression analyses were performed to determine the relationship between clot composition and water content.
Results
The regression analysis in human stroke clots revealed a significant negative association between RBC concentration and water content. We also observed a positive correlation between water content and both fibrin and platelets in ovine blood clots.
Conclusion
... During the past few years, LVO treatment improved by implementing better EVT-devices and more precise neuroimaging algorithms, by increasing expertise, and by extending the time-window from symptom onset for eligible patients for EVT [21,22]. Yet, there is still a notable number of patients who despite EVT develop LHI [23]. ...
Background
Despite benefits of endovascular treatment (EVT) for large vessel occlusion (LVO) ischemic stroke, space-occupying brain edema (BE) represents a detrimental complication. In critical-care settings, CT-imaging is needed for monitoring these patients. Yet, bed-side techniques with the potential to predict whether patients develop BE or not would facilitate a time- and cost-efficient patient care. We assessed clinical significance of automated pupillometry in the follow-up of patients undergoing EVT.
Methods
From 10/2018 to 10/2021, neurocritical-care-unit patients were retrospectively enrolled after EVT of anterior circulation LVO. We monitored parameters of pupillary reactivity [light-reflex-latency (Lat), constriction- and redilation-velocities (CV, DV), percentage-change-of-apertures (per-change); NeurOptics-pupilometer®] up to every hour on day 1–3 of ICU stay. BE was defined as midline shift ≥ 5 mm on follow-up imaging 3–5 days after EVT. We calculated mean values of intra-individual differences between successive pairs of parameters (mean-deltas), determined best discriminative cut-off values for BE development (ROC-analyses), and evaluated prognostic performance of pupillometry for BE development (sensitivity/specificity/positive-/negative-predictive-values).
Results
3241 pupillary assessments of 122 patients [67 women, 73 years (61.0–85.0)] were included. 13/122 patients developed BE. Patients with BE had significantly lower CVs, DVs, and smaller per-changes than patients without BE. On day 1 after EVT mean-deltas of CV, DV, and per-changes were significantly lower in patients with than without BE. Positive-predictive-values of calculated thresholds to discriminate both groups were considerably low, yet, we found high negative-predictive-values for CV, DV, per-changes, and mean-deltas (max.: 98.4%).
Conclusion
Our data suggest associations between noninvasively detected changes in pupillary reactivity and BE early after LVO-EVT. Pupillometry may identify patients who are unlikely to develop BE and may not need repetitive follow-up-imaging or rescue-therapy.
... Stent retriever and clot aspiration are the 2 most used EVT techniques, with continued improvements leading to reperfusion rates exceeding 90% in LVO thrombectomy. 51 Stent retrievers are inserted within the thrombus and re-establish blood flow once expanded, while simultaneously binding the thrombus. Subsequent stent retrieval extracts the clot. ...
... 54 These patients have an especially higher risk of recurrent stroke and often have acute vessel re-occlusion despite repeat recanalization during EVT. 51,54 The Wingspan stent (Stryker) was the first selfexpanding stent designed specifically for ICAD and is the only FDA-approved stent for symptomatic ICAD. 55 A few trials have evaluated the role of stent placement versus aggressive medical therapy in preventing recurrent strokes in this cohort. ...
... 82 This finding has increasingly led to comparison of catheter performance in terms of achieving a first-pass effect mTICI$ 2b. 51 The use of balloonguided catheters during EVT is also being explored to reduce the chances of clot fragmentation and distal embolization. 83 In terms of thrombolytic therapies, the Norwegian Tenecteplase Stroke Trial 2 (NOR-TEST 2, NCT03854500) is evaluating TNK within 4.5 hours of stroke onset. ...
The management of acute ischemic stroke has undergone a paradigm shift in the past decade. This has been spearheaded by the emergence of endovascular thrombectomy, along with advances in medical therapy, imaging, and other facets of stroke care. Herein, we present an updated review of the various stroke trials that have impacted and continue to transform stroke management. It is critical for the radiologist to stay abreast of the ongoing developments to provide meaningful input and remain a useful part of the stroke team.
... Final reperfusion status is a key factor influencing clinical outcomes of patients that have a large-vessel occlusion treated with MT. 4 Thus, successful reperfusion is the goal of MT. 18 Complete reperfusion increases the likelihood of functional independence at 90 days by 15%-20% over incomplete reperfusion. 13 Although reperfusion of injured brain tissue provides an impetus for the development of post thrombolysis hemorrhagic transformation, 24 pre-MT IVT may also help to resolve embolisms of distal vessels, improve perfusion, and reduce the final volume of injured brain tissue. ...
Aims
Although intravenous thrombolysis (IVT) has not shown confirmative effects on the outcomes of patients receiving successful thrombectomy, it might influence the outcomes of a subset of these patients. This study aims to evaluate whether the effects of IVT depend on final reperfusion grade in patients with successful thrombectomy.
Methods
This is a single‐center, retrospective analysis of patients with an acute anterior circulation large‐vessel occlusion and a successful thrombectomy between January 2020 and June 2022. Final reperfusion grade was evaluated by the modified Thrombolysis in Cerebral Infarction (mTICI) score, which was dichotomized into incomplete (mTICI 2b) and complete (mTICI 3) reperfusion. The primary outcome was functional independence (90‐day modified Rankin Scale score 0–2). Safety outcomes were 24‐h symptomatic intracranial hemorrhage and 90‐day all‐cause mortality. Multivariable logistic regression analyses were used to assess the interactions between IVT treatment and final reperfusion grade on outcomes.
Results
When comparing all 167 patients enrolled in the study, IVT did not influence the extent of functional independence (adjusted OR: 1.38; 95% CI: 0.65–2.95; p = 0.397). The effect of IVT on functional independence depended on final reperfusion grade (p = 0.016). IVT benefited patients with incomplete reperfusion (adjusted OR: 3.70; 95% CI 1.21–11.30; p = 0.022), but not those with complete reperfusion (adjusted OR: 0.48, 95% CI: 0.14–1.59; p = 0.229). IVT was not associated with 24‐h symptomatic intracerebral hemorrhage (p = 0.190) or 90‐day all‐cause mortality (p = 0.545).
Conclusions
The effect of IVT on functional independence depended on final reperfusion grade in patients with successful thrombectomy. IVT appeared to benefit patients with incomplete reperfusion, but not those with complete reperfusion. Because reperfusion grade cannot be determined prior to endovascular treatment, this study argues against withholding IVT in IVT‐eligible patients.
... In the future, the development of more advanced stent systems, especially for the posterior circulation and petrosal internal carotid artery, may decrease bleeding complications and other procedural risks [27]. As more CSCs are being established, nationwide large-datasets and registries can provide more comprehensive and informative data necessary to study the safety and efficacy and long-term outcomes of EVT. ...
Stroke is an urgent public health issue with millions of patients worldwide living with its devastating effects. The advent of thrombolysis and endovascular thrombectomy has transformed the hyperacute care of these patients. However, a significant proportion of patients receiving these therapies still goes on to have unfavorable outcomes and many more remain ineligible for these therapies based on our current guidelines. The future of stroke care will depend on an expansion of the scope of thrombolysis and endovascular thrombectomy to patients outside traditional time windows, more distal occlusions, and large vessel occlusions with mild clinical deficits, for whom clinical trial results have not proven therapeutic efficacy. Novel cytoprotective therapies targeting the ischemic cascade and reperfusion injury therapy, in combination with our existing treatment modalities, should be explored to further improve outcomes for these patients with acute ischemic stroke. In this review, we will review the current status of thrombolysis and thrombectomy, suggest additional data that is needed to enhance these therapies, and discuss how cytoprotection might be combined with thrombectomy.
... Examples of combination techniques include the BAlloon guide with large bore Distal access catheter with Dual Aspiration with Stent retriever as Standard approach (BADDASS) technique [64], the REACT catheter combined with a stent retriever [56], aspiration-retriever technique for stroke (ARTS) [65], a stent retrieving into an aspiration catheter with proximal balloon (ASAP) technique [66], the stent retriever-assisted vacuum-locked extraction (SAVE) approach [67], and PRoximal balloon Occlusion TogEther with direCt Thrombus aspiration during stent retriever thrombectomy (PROTECT PLUS ) [68]. Clinical experience with these techniques suggests they are safe and effective [64,65,[67][68][69]. ...
Stroke is a leading cause of morbidity and mortality. The advent of mechanical thrombectomy has largely improved patient outcomes. This article reviews the features and outcomes associated with aspiration, stent retrievers, and combination catheters used in current practice. There is also a discussion on clinical considerations based on anatomical features and clot composition. The reperfusion grading scale and outcome metrics commonly used following thrombectomy when a patient is still in the hospital are reviewed. Lastly, there are proposed discharge and outpatient follow-up goals in caring for patients hospitalized for a stroke.
... First, the frequency of near-complete or complete reperfusion (eTICI 2c/3) of 37.5% in patients aged ≥75 years might underestimate current reperfusion rates in 2022 with improved technology and operator experience. 45 Second, the HERMES collaboration has a limited number of elderly patients randomized (2 of the 7 trials excluded patients aged ≥81 years) resulting in the wide confidence intervals for all modeling. This limitation is most substantial in modeling accounting simultaneously for age and reperfusion status. ...
Background:
Age and infarct volume are strong predictors of outcome in patients with ischemic stroke who underwent endovascular therapy (EVT). We aimed to investigate the impact of ischemic core volume (ICV) on stroke outcome after EVT in elderly.
Methods:
Using the HERMES (Highly Effective Reperfusion Using Multiple Endovascular Devices) collaboration, a patient-level meta-analysis of 7 randomized trials in which patients were enrolled from December 2010 to April 2015) dataset, we categorized patients into those aged <75 and ≥75 years. ICV was calculated on computed tomography perfusion or magnetic resonance diffusion-weighted imaging. The association between ICV and the benefit of EVT over best medical treatment on outcome (modified Rankin Scale [mRS] at 90 days) and an ICV threshold for high likelihood (≥90%) of very poor outcome (mRS score ≥5) after EVT were investigated.
Results:
A total of 899 patients who had baseline ICV data, 247 patients aged ≥75 years, of which 118 were randomized in the EVT arm. Patients aged ≥75 years required smaller ICV to achieve mRS score ≤3 than those aged <75 years in the EVT arm (median 10.7 mL versus 23.9 mL, P<0.001). In patients aged ≥75 years, modeling of outcome in both treatment arms revealed potential loss of effect for EVT at ICV of ≥50 mL or ≥85 mL for achieving mRS score ≤3 or ≤4, respectively. Treatment effect of EVT was significant in ICV <50 mL for mRS ≤3 (odds ratio 2.38, 95% confidence interval 1.35-4.22). ICV ≥132 mL was a threshold for high likelihood of very poor outcome after EVT. However, EVT still predicted at least 30% rate of mRS ≤3 at 150 mL ICV if near-complete or complete reperfusion was achieved.
Conclusions:
Baseline ICV has an impact on stroke outcome after EVT in the elderly, but elderly patients with large ICV may still benefit from EVT if near-complete or complete reperfusion is achieved. Young patients seem to benefit from EVT regardless of ICV status.
... To treat AIS caused by intracranial artery obstruction, multimodal treatments, including IV tissue plasminogen activator (t-PA) injection and endovascular treatment techniques, have been developed. 10 Among several methods of endovascular treatment, MT using aspiration or a stent retriever has been validated in several randomized controlled trials for its effectiveness in treating AIS. It is the standard modality of care according to international guidelines. 1 11 However, even if MT is used, approximately 20% of patients with AIS fail to recanalize and over 50% of patients do not achieve good functional outcomes. ...
Background:
The purpose of this study was to investigate whether the initial DSA appearance of the occlusion during mechanical thrombectomy (MT) can help distinguish the nature of the underlying lesion and predict radiological and clinical outcomes.
Methods:
We retrospectively reviewed cases of patients with acute ischemic stroke who underwent MT for anterior circulation occlusion between March 2017 and February 2020. Underlying intracranial atherosclerotic stenosis (ICAS) was determined based on the presence of fixed stenosis after endovascular treatment. Patients were categorized based on the appearance of the occlusion observed in the initial DSA as tapering sign (+) or (-) groups. We performed 1:2 propensity score matching to establish a proper control group among the tapering sign (-) group. We analyzed and compared baseline characteristics and clinical outcomes between the two groups.
Results:
A total of 293 patients (tapering sign (+), n=47; tapering sign (-), n=246) were included in the analysis. The procedure time of MT was significantly longer for the tapering sign (+) group, and the successful recanalization rate after MT was significantly lower in the tapering sign (+) group than in the tapering sign (-) group. Logistic regression showed that ICAS-related occlusion was strongly associated with a positive angiographic tapering sign, and the angiographic tapering sign was a negative factor for the first-pass effect during MT. However, a 3-month good functional outcome was not significantly associated with the angiographic tapering sign.
Conclusions:
The tapering sign on the initial DSA could be a surrogate marker for ICAS-related occlusion and procedural difficulty. However, its clinical significance remains unclear.
... The advantages of endovascular treatment are beyond doubt, as MTB improves recanalization rates in AIS patients and decreases associated morbidity and mortality 29,30 . It is becoming recognized that the use of stent retrievers is associated with vascular injury [31][32][33][34] . ...
Endovascular treatment with stent retriever thrombectomy is a major advancement in the standard of care in acute ischemic stroke (AIS). The modalities through which thrombi embed along stent retriever following mechanical thrombectomy (MTB) have not yet been elucidated. Using scanning electron microscopy (SEM), we analyzed the appearance of thrombi retrieved by MTB from AIS patients, when embedded into the stent retriever. We observed that the organization and structural compactness vary for compositionally different thrombi. The modalities of attachment onto the stent vary according to thrombus composition and organization.
