Article

Comparison of Solitaire thrombectomy and Penumbra suction thrombectomy in patients with acute ischemic stroke caused by basilar artery occlusion

November 2014
Journal of Neurointerventional Surgery 8(1)

November 2014
8(1)

DOI:10.1136/neurintsurg-2014-011472

Source
PubMed

Authors:

Seungnam Son

Gyeongsang National University

Min-Kyun Oh

Show all 10 authorsHide

Acute ischemic stroke (AIS) caused by basilar artery occlusion (BAO) is a very severe neurological disease with a high mortality rate and poor clinical outcomes. In this study, we compared our experience of mechanical thrombectomy using the Solitaire stent (Solitaire thrombectomy) and manual aspiration thrombectomy using the Penumbra reperfusion catheter (Penumbra suction thrombectomy) in patients with AIS caused by BAO. Between March 2011 and December 2011, 13 patients received Solitaire thrombectomy. In January 2012, the Korean Food and Drug Administration banned the use of the Solitaire stent as a thrombectomy device, and a further 18 patients received Penumbra suction thrombectomy until December 2013. We compared parameters between patients treated with each device. Successful recanalization rates (Thrombolysis in Cerebral Infarction (TICI) score ≥2b: 84.6% vs 100%, p=0.168) and clinical outcomes (judged by the modified Rankin Scale scores recorded at 3 months: 3.6±2.6 vs 3.2±2.6, p=0.726) were not significantly different between the two groups. However, complete recanalization rates (TICI score of 3: 23.1% vs 72.2%, p=0.015) and total procedure times (101.9±41.4 vs 62.3±34.8 min, p=0.044) were significantly higher, and shorter, respectively, in patients treated by Penumbra suction thrombectomy. The two thrombectomy devices were associated with similar recanalization rates and clinical outcomes in patients with AIS caused by BAO. However, Penumbra suction thrombectomy seemed to allow more rapid and complete recanalization than Solitaire thrombectomy. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Influence of renal impairment on neurologic outcomes following mechanical thrombectomy in acute vertebrobasilar stroke

Article

Full-text available

Apr 2022
NEURORADIOLOGY

PurposeRenal impairment (RI) has been regarded as a risk factor for unfavorable neurologic outcomes after mechanical thrombectomy (MT) in acute ischemic stroke. However, most of the previous studies were conducted on patients with anterior circulation stroke. Accordingly, the influence of RI on MT outcomes has not been well elucidated in detail in acute vertebrobasilar stroke.Methods Consecutive stroke patients with MT due to acute vertebrobasilar artery occlusion between March 2015 and December 2020 at four institutions were included. Multivariable logistic regression analysis was conducted to assess the associations between RI and outcomes and mortality at 3 months, and the development of intracerebral hemorrhage (ICH) after the procedure. Additionally, the multivariable Cox proportional hazards model was performed to determine the influence of RI on survival probability after patient discharge.ResultsA total of 110 patients were included in the final analysis. The presence of RI (OR = 0.268, 95% CI: 0.077–0.935), National Institute of Health Stroke Scale scores (OR = 0.849, 95% CI: 0.791–0.910), and puncture-to-recanalization time (OR = 0.981, 95% CI: 0.966–0.997) were related to outcomes. There was no significant association between RI and 3-month mortality or ICH. The cumulative survival probability after adjusting for relevant risk factors demonstrated that RI remained significantly associated with poorer survival after MT compared to patients without RI (HR = 2.111, 95% CI: 0.919–4.847).ConclusionRI was an independent risk factor for poor 3-month neurologic outcomes and survival probability after MT in patients with acute vertebrobasilar stroke.

Efficacy and safety of direct aspiration first pass technique versus stent-retriever thrombectomy in acute basilar artery occlusion—a retrospective single center experience

Article

Full-text available

Mar 2017
NEURORADIOLOGY

IntroductionThe study aimed to compare efficacy and safety of aspiration thrombectomy (AT) to stentriever thrombectomy (SRT) in patients with basilar artery (BA) occlusion (BAO). Methods We retrospectively included patients with the following characteristics: acute BAO or occlusion of the intracranial vertebral artery (ICVA) and endovascular therapy (EVT) with stentriever (SRT) or aspiration thrombectomy (AT). Additional extra- but not intracranial EVT and intravenous thrombolysis (IVT) were allowed. ResultsBetween January 2013 and April 2016, 33 patients fulfilled the criteria (13 treated with SRT, 20 with AT). Prior to EVT, 23 (70%) patients received IVT. The proximal intracranial occlusion was ICVA in 2 patients, proximal BA in 5 patients, middle BA in 20 patients, and distal BA in 6 patients. Mean time to treatment was 334 min (95% CI 276–391 min). Procedure duration differed significantly (p = 0.002) as follows: 97 min with SRT (95% CI 69–124 min) and 55 min with AT (95% CI 43–66 min). Recanalization (arterial occlusive lesion (AOL) 2/3) was achieved in 26 patients (79%). Complete recanalization (AOL 3) happened more often with AT (75% (95% CI 65–85%)) compared to SRT (46% (95% CI 32–60%)). Conversion rate 6% (two patients). Hemorrhages occurred in 12 (36%) patients, periprocedural complications in eight (three dissections, five embolizations to new territory) (no group difference). Ten patients (30%) had a favorable outcome (mRS ≤3) at discharge; mortality rate was 24% (eight deaths) (no group difference). Conclusion In primarily embolic BAO, aspiration thrombectomy was faster, effective and not detrimental to outcome as compared to stentriever thrombectomy. Thus, it may be justified to use aspiration thrombectomy as first-line treatment in these patients.

Endovascular treatment of acute basilar artery occlusion: A systematic review and meta‐analysis of first‐line stent retriever versus direct aspiration

Article

Full-text available

Jul 2023

Background The best choice between first‐line aspiration and stent retriever for acute basilar artery occlusion remains controversial. This study aims to perform a systematic review and meta‐analysis comparing the stent retriever and direct aspiration about reported recanalization rates and periprocedural complications. Method PubMed, Embase, Web of Science, Cochrane, and Clinical Trials were searched for the studies evaluating the efficacy and safety of first‐line aspiration versus stent retriever for acute basilar artery occlusion. A standard software program (Stata Corporation) was used for end‐point analyses. Statistical significance was defined as a p ‐value less than .05. Results A total of 11 studies were involved in the current study, including 1014 patients. Regarding postoperative recanalization, the pooled analysis identified a significant difference in successful recanalization (odds ratio [OR] = 1.642; 95% confidence interval (95% CI): 1.099–2.453; p = .015) and complete recanalization (OR = 3.525; 95% CI: 1.306–2.872; p = .001) between the two groups in favor of the first‐line aspiration. Concerning the complications, the first‐line aspiration could achieve a lower rate of total complication (OR = .359; 95% CI: .229–.563; p < .001) and hemorrhagic complication (OR = .446, 95% CI: .259–.769; p = .004) than stent retriever. No significant difference was observed in postoperative mortality (OR = .966; p = .880), subarachnoid hematoma (OR = .171; p = .094), and parenchymal hematoma (OR = .799; p = .720). In addition, the pooled results revealed a significant difference in procedure duration between the two groups in favor of aspiration (WMD = −27.630, 95% CI: −50.958 to −4.302; p = .020). However, there was no significant difference in favorable outcome (OR = 1.149; p = .352) and rescue therapy (OR = 1.440; p = .409) between the two groups. Conclusion Given that the first‐line aspiration was associated with a higher rate of postoperative recanalization, a lower risk of postoperative complication, and a faster duration of the procedure, these findings support the aspiration may be more secure than a stent retriever.

Aspiration versus stent retriever for posterior circulation stroke: A meta‐analysis

Article

Full-text available

Dec 2022
CNS NEUROSCI THER

Aims New thrombectomy strategies have emerged recently. Differences between posterior circulation stroke management via aspiration and stent retriever remain to be evaluated. We compared the safety and efficacy of aspiration and stent retriever in treating posterior circulation stroke. Methods Three databases (PubMed, Embase, and Cochrane Library) were systematically searched for studies comparing aspiration and stent retriever in patients with posterior circulation stroke. The modified Newcastle‐Ottawa scale was used to assess the risk of bias. A random‐effects model was used. Results Fifteen cohort studies with 1451 patients were included. Pooled results showed a significant difference in total complication (odds ratio [OR] 0.48, 95% confidence interval [CI] [0.30, 0.76], p = 0.002). successful recanalization (1.85, [1.30, 2.64], p = 0.0006), favorable outcome (1.30, [1.02, 1.67], p = 0.04), procedure duration (−22.10, [−43.32, −0.88], p = 0.04), complete recanalization (4.96, [1.06, 23.16], p = 0.009), and first‐pass effect (2.59, [1.55, 4.32], p = 0.0003) between the aspiration and stent retriever groups, and in favor of aspiration. There was no significant difference in the outcomes of rescue therapy (1.42, [0.66, 3.05], p = 0.37) between the two groups. Conclusion Patients with posterior circulation stroke receiving treatment with aspiration achieved better recanalization, first‐pass effect, and shorter procedure time. Aspiration may be more secure than a stent retriever.

Values of Baseline Posterior Circulation Acute Stroke Prognosis Early Computed Tomography Score for Treatment Decision of Acute Basilar Artery Occlusion

Article

Full-text available

Feb 2021

Background and Purpose This study aimed to analyze the impact of baseline posterior circulation Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS) on the efficacy and safety of endovascular therapy (EVT) for patients with acute basilar artery occlusion. Methods The BASILAR was a nationwide prospective registry of consecutive patients with a symptomatic and radiologically confirmed acute basilar artery occlusion within 24 hours of symptom onset. We estimated the effect of standard medical therapy alone (SMT group) versus SMT plus EVT (EVT group) for patients with documented pc-ASPECTS on noncontrast CT, both as a categorical (0–4 versus 5–7 versus 8–10) and as a continuous variable. The primary outcomes included favorable functional outcomes (modified Rankin Scale ≤3) at 90 days and mortality within 90 days. Results In total, 823 cases were included: 468 with pc-ASPECTS 8 to 10 (SMT: 71; EVT: 397), 317 with pc-ASPECTS 5 to 7 (SMT: 85; EVT: 232), and 38 with pc-ASPECTS 0 to 4 (SMT: 13; EVT: 25). EVT was associated with higher rate of favorable outcomes (adjusted relative risk with 95% CI, 4.35 [1.30–14.48] and 3.20 [1.68–6.09]; respectively) and lower mortality (60.8% versus 77.6%, P =0.005 and 35.0% versus 66.2%, P< 0.001; respectively) than SMT in the pc-ASPECTS 5 to 7 and 8 to 10 subgroups. Continuous benefit curves also showed the superior efficacy and safety of EVT over SMT in patients with pc-ASPECTS ≥5. Furthermore, the prognostic effect of onset to puncture time on favorable outcome with EVT was not significant after adjustment for pc-ASPECTS (adjusted odds ratio, 0.98 [95% CI, 0.94–1.02]). Conclusions Patients of basilar artery occlusion with pc-ASPECTS ≥5 could benefit from EVT. The baseline pc-ASPECTS appears more important for decision making and predicting prognosis than time to EVT. REGISTRATION URL: http://www.chictr.org.cn . Unique identifier: ChiCTR1800014759.

Effect of manual aspiration thrombectomy using large-bore aspiration catheter for acute basilar artery occlusion: comparison with a stent retriever system

Article

Full-text available

Nov 2020
BMC NEUROL

Background A large-bore aspiration catheter can be employed for recanalization of acute basilar artery occlusion. Here we compare the results of mechanical thrombectomy using a stent retriever (SR) and manual aspiration thrombectomy (MAT) using a large-bore aspiration catheter system as a first-line recanalization method in acute basilar artery occlusion (BAO). Methods The records of 50 patients with acute BAO who underwent mechanical thrombectomy were retrospectively reviewed. Patients were assigned to one of two groups based on the first-line recanalization method. The treatment and clinical outcomes were compared. Results Sixteen (32%) patients were treated with MAT with a large-bore aspiration catheter and 34 (68%) with a SR as the first-line treatment method. The MAT group had a shorter procedure time (28 vs. 65 min; p = 0.001), higher rate of first-pass recanalization (68.8% vs. 38.2%, p = 0.044), and lower median number of passes (1 vs 2; p = 0.008) when compared with the SR group. There was no significant difference in the incidence of any hemorrhagic complication (6.3% vs. 8.8%; p = 0.754) between the groups. However, there were four cases of procedure-related subarachnoid hemorrhage (SAH) in the SR group and one death occurred due to massive hemorrhage. Conclusions Selection of MAT using a large-bore aspiration catheter for acute BAO may be a safe and effective first-line treatment method with higher first-pass recanalization rate and shorter procedure time than SR.

Frontline Contact Aspiration Treatment for Emergent Large Vessel Occlusion: A Review Focused on Practical Techniques

Article

Full-text available

Jan 2019

Endovascular thrombectomy (EVT) as the standard care for acute stroke due to large vessel occlusion has recently been validated through several randomized controlled trials (RCTs). Contact aspiration (CA) and stent retriever (SR) are the two major EVT methods currently used. Because the RCTs have mostly evaluated SR devices, there was a demand to test CA in relation to SR as a frontline EVT treatment method. Recently, the Contact Aspiration vs Stent Retriever for Successful Recanalization (ASTER) study, the first RCT to compare CA and SR, demonstrated similar efficacy between them as a frontline EVT for patients with large vessel occlusions. This facilitates further investigation to confirm better frontline EVT for patients with acute stroke. In this review, we discuss past and recent developments in CA techniques, focusing on related literature. Additionally, we describe practical skills to overcome technical difficulties that can be encountered during the CA procedure. Finally, we review the evolution of device technologies, including a newer version of using a large-bore aspiration catheter.

First-Line A Direct Aspiration First-Pass Technique vs. First-Line Stent Retriever for Acute Ischemic Stroke Therapy: A Meta-Analysis

Article

Full-text available

Sep 2018

Background: Recent trials have proved the efficacy of mechanical thrombectomy over medical treatment for patients with acute ischemic stroke, with the balance of equivalent rates of adverse events. Stent retrievers were applied predominantly in most trials; however, the role of other thrombectomy devices has not been well validated. A direct aspiration first-pass technique (ADAPT) is proposed to be a faster thrombectomy technique than the stent retriever technique. This meta-analysis investigated and compared the efficacy and adverse events of first-line ADAPT with those of first-line stent retrievers in patients with acute ischemic stroke. Methods: A structured search was conducted comprehensively. A total of 1623 papers were found, and 4 articles were included in our meta-analysis. The Critical Appraisal Skills Programme tools were applied to evaluate the quality of studies. The primary outcome was defined as the proportion of patients with the Thrombolysis in Cerebral Ischemia (TICI) scale of 2b/3 at the end of all procedures. Secondary outcomes were the proportion of patients with functional independence (modified Rankin scale of 0–2) at the third month, the proportion of patients with the Thrombolysis in Cerebral Ischemia (TICI) scale of 2b/3 by primary chosen device, and the proportion of patients who received rescue therapies. Safety outcomes were the symptomatic intracranial hemorrhage (sICH) rate and the mortality rate within 3 months. Results: One randomized controlled trial, one prospective cohort study, and two retrospective cohort studies were included. No significant difference between these 2 strategies of management were observed in the primary outcome (TICI scale at the end of all procedures, odds ratio [OR] = 0.78), two secondary outcomes (functional independence at the third month, OR = 1.16; TICI scale by primary chosen device, OR = 1.25), and all safety outcomes (sICH rate, OR = 1.56; mortality rate, OR = 0.91). The proportion of patients who received rescue therapies was higher in the first-line ADAPT group (OR = 0.64). Conclusions: Among first-line thrombectomy devices for patients with ischemic stroke, ADAPT with the latest thrombosuction system was as efficient and safe as stent retrievers.

Initial factors affecting the clinical outcome after successful recanalization via MR-based mechanical thrombectomy in patients with acute ischemic stroke due to basilar artery occlusion

Article

Sep 2015
J Neurointerv Surg

Background and purpose: To determine the initial factors, including patient characteristics, stroke etiology and severity, time factors, and imaging findings, that could affect the clinical outcome of patients with acute ischemic stroke (AIS) caused by basilar artery occlusion (BAO) where successful recanalization was achieved via mechanical thrombectomy. Methods: Between March 2011 and December 2014, 35 patients with AIS caused by BAO received MRI/MR angiography-based mechanical thrombectomies, and recanalization was achieved with a Thrombolysis In Cerebral Infarction score of >2b. The patients were divided into a good outcome group (n=19), defined as those with a modified Rankin Scale (mRS) score of 0-2 at 3 months after stroke onset, and a poor outcome group (n=16), defined as a mRS score of 3-6. The differences between the groups were analyzed. Results: Initial National Institutes of Health Stroke Scale (NIHSS) score (good vs poor: 17.9±8.9 vs 27.6±8.5, p=0.003), posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) based on initial diffusion-weighted images (DWI) (good vs poor: 7.8±1.6 vs 5.4±1.8, p=0.001), pc-ASPECTS based on contrast staining on the post-thrombectomy control CT (good vs poor: 9.2±1.5 vs 6.3±2.2, p<0.001), and presence of contrast staining in the brainstem on that CT (good vs poor: 15.8% vs 81.6%, p<0.001) were significantly different between the groups. Conclusions: Patients with AIS caused by BAO with a lower initial NIHSS score, fewer lesions on initial DWI, and less contrast staining on the post-thrombectomy control CT have higher probabilities of a good clinical outcome after successful recanalization via a mechanical thrombectomy.

Therapeutic management of ischemic stroke

Article

Full-text available

Nov 2023
N Schmied Arch Pharmacol

Stroke is the third leading cause of years lost due to disability and the second-largest cause of mortality worldwide. Most occurrences of stroke are brought on by the sudden occlusion of an artery (ischemic stroke), but sometimes they are brought on by bleeding into brain tissue after a blood vessel has ruptured (hemorrhagic stroke). Alteplase is the only therapy the American Food and Drug Administration has approved for ischemic stroke under the thrombolysis category. Current views as well as relevant clinical research on the diagnosis, assessment, and management of stroke are reviewed to suggest appropriate treatment strategies. We searched PubMed and Google Scholar for the available therapeutic regimes in the past, present, and future. With the advent of endovascular therapy in 2015 and intravenous thrombolysis in 1995, the therapeutic options for ischemic stroke have expanded significantly. A novel approach such as vagus nerve stimulation could be life-changing for many stroke patients. Therapeutic hypothermia, the process of cooling the body or brain to preserve organ integrity, is one of the most potent neuroprotectants in both clinical and preclinical contexts. The rapid intervention has been linked to more favorable clinical results. This study focuses on the pathogenesis of stroke, as well as its recent advancements, future prospects, and potential therapeutic targets in stroke therapy. Graphical Abstract

Network meta-analysis of first-line thrombectomy strategy for acute posterior circulation strokes: a preliminary evaluation for combined approach

Article

Full-text available

Nov 2023

Objective Thrombectomy may provide superior results compared to best medical care for acute posterior circulation strokes (PCS). Contact aspiration (CA), stent retriever (SR), and combined SR + CA (SRA) are commonly employed as first-line techniques. However, the optimal strategy and the role of SRA remain uncertain. Methods Systematic searching was conducted in three databases (PubMed, Embase, and Cochrane). Network meta-analyzes were performed using random-effects models. The reperfusion and clinical outcomes were compared. Pooled outcomes were presented as odds ratios (OR) with 95% confidence intervals (CI). Rankograms with surface under the cumulative ranking curve (SUCRA) were calculated. Results Seventeen studies were included, involving a total of 645 patients who received first-line CA, 850 patients who received SR, and 166 patients who received SRA. Regarding final recanalization outcomes, both first-line SRA (OR = 3.2, 95%CI 1.4–11.0) and CA (OR = 2.1, 95%CI 1.3–3.7) demonstrated superiority over SR in achieving successful reperfusion [modified Thrombolysis In Cerebral Infarction (mTICI) 2b-3], with values of SUCRA 91.1, 58.5, and 0.4%, respectively. In addition, first-line SRA showed an advantage in achieving final mTICI 2c/3 compared to CA (OR = 3.6, 95%CI 0.99–16.0) and SR (OR = 6.4, 95%CI 1.3–35.0), with SUCRA value of 98.0, 44.7, and 7.2%, respectively. Regarding reperfusion outcome after the first pass, SRA also achieved a higher rate of mTICI 3 than SR (OR = 4.1, 95%CI 1.3–14.0), while CA did not (SUCRA 97.4, 4.6, 48.0%). In terms of safety outcomes, first-line CA was associated with a lower incidence of symptomatic intracranial hemorrhage (sICH) compared to SR (OR = 0.38, 95%CI 0.1–1.0), whereas the SRA technique did not (SUCRA 15.6, 78.6, 55.9%). Regarding clinical prognosis, first-line CA achieved a higher proportion of functional independence (modified Rankin Scale (mRS) 0–2) at 90 days than SR (OR = 1.4, 95%CI 1.1–1.9), whereas SRA did not (SUCRA 90.5, 17.4, 42.1%). Conclusion For acute PCS, a first-line CA strategy yielded better results in terms of final successful reperfusion and 90-day functional independence compared to SR. As the combined technique, first-line SRA was associated with superior first-pass and final reperfusion outcomes compared to SR. However, no significant difference was observed in functional independence achieved by first-line SRA compared to the other two strategies. Further high-quality studies are warranted.

Analysis and Structure Optimization of Scissor-Type Micro-Stirrer with the Most Effective Output Performance for Thrombus Dissolution in Interventional Therapy

Article

Full-text available

Jan 2023

Compared with thrombus dissolution using only thrombolytic agents, an advanced therapy of direct stirring of the blood clot can yield shorter recanalization time and higher recanalization velocity. Our previous research presented the design of a novel micro-stirrer, which can convert longitudinal vibration into transverse vibration and eventually generate opposite transverse vibration at the end-effort, like a scissor, for efficient blood clot stirring and thrombus dissolution acceleration. Transverse vibration is the most effective movement to dissolve thrombi. However, the small size of blood vessels has strict limits, which will greatly affect the output transverse vibration. Therefore, to improve the output performance of the micro-stirrer in curved and narrow vascular spaces, the analysis and structure optimization of the micro-stirrer is expected to increase the vibration mode conversion efficiency from longitudinal to transverse mode. The design concept and theoretical analysis of the micro-stirrer are presented in detail. Aiming to obtain the optimal structure parameters of the micro-stirrer, the mathematical model is established and analyzed. Next, a series of finite element models involving important structure parameters are designed and investigated. Finally, the optimal structure parameters are obtained, and the stirring effect in a blood vessel is verified by simulation and experiment.

Safety and efficacy of aspiration thrombectomy versus stent retriever thrombectomy for acute ischaemic stroke: a systematic review and meta-analysis

Article

Full-text available

Jul 2022
WIDEOCHIRURGIA TEC M

Introduction: Although aspiration thrombectomy has shown comparable safety and efficacy to stent retriever thrombectomy for acute ischaemic stroke (AIS), the use of aspiration thrombectomy as first-line endovascular treatment for AIS remains controversial. Aim: To perform a systematic evaluation of the safety and efficacy of aspiration thrombectomy versus stent retriever thrombectomy in the treatment of AIS. Material and methods: We searched the online databases PubMed, Embase, Cochrane Library, and SinoMed to collect randomized controlled trials and retrospective studies concerning the treatment of AIS with aspiration thrombectomy and stent retriever thrombectomy. Primary outcomes included 90-day all-cause mortality, a 90-day mRS scores of 0-2, intracranial haemorrhage, and successful recanalization rate. The Jadad scale and the MINORS evaluation items were used to evaluate study quality, and RevMan 5.2 was used to conduct a meta-analysis. Any differential effects in rates between the two strategies were assessed using a random effect model. Results: A total of 15 articles were found, including 2 randomized controlled trials and 13 retrospective studies. It showed that aspiration thrombectomy and stent retriever thrombectomy had similar results in terms of 90-day all-cause mortality (p = 0.88), 90-day mRS scores 0-2 (p = 0.29), and intracranial haemorrhage (p = 0.47). And in terms of successful recanalization rates, the aspiration thrombectomy group had better outcomes than the stent retriever thrombectomy group (p = 0.0003). The heterogeneity of 90-day all-cause mortality (I2 = 0%), 90-day mRS scores of 0-2 (I2 = 6%), intracranial haemorrhage (I2 = 21%), and successful recanalization rate (I2 = 0%) were less than 30%. Conclusions: Both aspiration thrombectomy and stent thrombectomy can be used as the first line of intravascular treatment for AIS.

Comparative study on treatment of acute cerebral infarction between mechanical thrombectomy by micro catheter and thrombectomy by Solitaire AB stent

Article

Full-text available

Feb 2022

Background: Acute cerebral artery occlusion is a common disease with high morbidity and mortality. At present, the commonly used mechanical thrombectomy schemes are mechanical thrombectomy and stent thrombectomy. However, the clinical differences between the two methods is not fully understood. The present study aimed to evaluate the clinical effectiveness of Solitaire AB stent thrombectomy for acute cerebral infarction (ACI). Methods: A retrospective study was carried out in 96 ACI patients admitted to our department from January 2017 to January 2020. According to the treatment they received, they were divided into group A (conventional microcatheter mechanical thrombectomy, n = 48) and group B (Solitaire AB stent thrombectomy, n = 48). All patients were followed up for 3 months. Their pre- and post-operative nerve function indices were compared between the 2 groups. The therapeutic effects were evaluated by thrombolysis in cerebral infarction scale system, Glasgow coma scale (GCS), National Institutes of Health Stroke Scale (NIHSS), and modified Rankin scale statistics. Results: Two groups of patients with NIHSS scores postoperative 3 and 30 days decreased significantly compared with preoperation. NIHSS score of group A 3 and 30 days postoperation was significantly higher than group B (P < .05). Two groups of patients with GCS scores postoperative 3 and 30 days increased significantly compared with preoperation. GCS score of group A 3 and 30 days postoperation was significantly lower than group B (P < .05). Group B with vascular recanalization ratio postoperative 30 days was higher than group A, however with no significant differences (P > .05). Moreover, group B with outcomes (modified Rankin scale score ≤2 points) postoperative 3 months was better than group A, however with no significant differences (P > .05). Conclusion: Solitaire AB stent embolectomy shows similar efficacy as mechanical thrombectomy in the treatment of ACI patients.

Frontline thrombectomy strategy and outcome in acute basilar artery occlusion

Article

Jan 2022

Background Novel thrombectomy strategies emanate expeditiously day-by-day counting on access system, clot retriever device, proximity to and integration with the thrombus, and microcatheter disengagement. Nonetheless, the relationship between native thrombectomy strategies and revascularization success remains to be evaluated in basilar artery occlusion (BAO). Purpose To compare the safety and efficacy profile of key frontline thrombectomy strategies in BAO. Methods Retrospective analyses of prospectively maintained stroke registries at two comprehensive stroke centers were performed between January 2015 and December 2019. Patients with BAO selected after MR imaging were categorized into three groups based on the frontline thrombectomy strategy (contact aspiration (CA), stent retriever (SR), or combined (SR+CA)). Patients who experienced failure of clot retrieval followed by an interchanging strategy were categorized as a fourth (switch) group. Clinicoradiological features and procedural variables were compared. The primary outcome measure was the rate of complete revascularization (modified Thrombolysis in Cerebral Infarction (mTICI) grade 2c–3). Favorable outcome was defined as a 90 day modified Rankin Scale score of 0–2. Results Of 1823 patients, we included 128 (33 underwent CA, 35 SR, 35 SR +CA, and 25 switch techniques). Complete revascularization was achieved in 83/140 (59%) primarily analyzed patients. SR +CA was associated with higher odds of complete revascularization (adjusted OR 3.04, 95% CI 1.077 to 8.593, p=0.04) which was an independent predictor of favorable outcome (adjusted OR 2.73. 95% CI 1.152 to 6.458, p=0.02). No significant differences were observed for symptomatic intracranial hemorrhage, functional outcome, or mortality rate. Conclusion Among BAO patients, the combined technique effectively contributed to complete revascularization that showed a 90 day favorable outcome with an equivalent complication rate after thrombectomy.

Added Value of Rescue Devices in Intra-Arterial Thrombectomy: When Should We Apply Them?

Article

Full-text available

Aug 2021

Introduction: Recent trials have demonstrated the superior efficacy of mechanical thrombectomy over other medical treatments for acute ischemic stroke; however, not every large vessel occlusion (LVO) can be recanalized using a single thrombectomy device. Rescue devices were proved to increase the reperfusion rate, but the efficacy is unclear. Objective: In this retrospective study, we evaluated the efficacy of rescue therapy in different locations of LVO. Methods: We analyzed the outcomes of mechanical thrombectomy from a prospective registry of consecutive 82 patients in Taipei Medical University Hospital. The reperfusion rate and the functional outcome were compared in patients who received first-line therapy only and patients who need rescue therapy. Results: An 84.1% reperfusion rate was achieved in our cohort. We applied first-line stent retriever (SR) treatment in 6 patients, among which 4 (66.6%) achieved successful reperfusion. We applied a direct-aspiration first-pass technique (ADAPT) as the first-line treatment in 76 patients, among which 46 (60.5%) achieved successful reperfusion. Successful reperfusion could not be achieved in 30 cases (39.5%); therefore, we applied a second-line rescue SR for 28 patients, and reperfusion was established in 18 (64.3%) of them. These results revealed that the LVO in anterior circulation has a higher chance to respond to SR rescue therapy than posterior circulation lesions (68 vs. 33.3%, P < 0.001). Patients who received only first-line therapy exhibited significantly better functional outcomes than those who were also treated with rescue SR therapy (41.2 vs. 16.7%, P = 0.001). In addition, patients with LVO in the anterior circulation were found to have a higher probability of achieving functional independence than patients with posterior circulation lesions (10.7 vs. 0.0%, P < 0.001). The adjusted multivariate analysis revealed that successful reperfusion and treatment type (first-line or rescue therapy) were significantly related to a modified Rankin Scale (mRS) score at 90 days. Conclusion: This study reveals that rescue SR therapy improves the reperfusion rate. Patients who require rescue SR therapy have a lower likelihood of functional independence. LVO in the anterior circulation responds better to rescue SR therapy and results in better functional outcomes than posterior circulation lesions.

A direct aspiration first-pass technique (ADAPT) versus stent retriever for acute ischemic stroke (AIS): a systematic review and meta-analysis

Article

Full-text available

Dec 2021
J NEUROL

Background and purpose There is an ongoing debate about whether a direct aspiration first-pass technique (ADAPT) or stent retriever should be used as the first-pass mechanical thrombectomy device for patients with acute ischemic stroke (AIS). This meta-analysis aimed to compare the safety and efficacy of ADAPT versus stent retriever in patients with AIS. Methods Structured searches on the PubMed, Embase, and Cochrane Library databases were conducted through July 2020. The primary outcomes of this study were: successful and complete recanalization; excellent and favorable outcomes; all-cause mortality at 90 days; and symptomatic intracerebral hemorrhage (sICH). The secondary outcomes of this study were: successful recanalization by primary chosen device; additional therapy; occurrence of emboli in a new territory; hemorrhagic complication; hemorrhagic infarction; parenchymatous hematoma; and subarachnoid hemorrhage. The odds ratios (ORs) with 95% confidence intervals (CIs) of the primary and secondary outcomes were calculated using a random-effects model. I² statistics were used to assess the heterogeneity for each outcome among the included studies. Results Finally, 20 studies with a total of 6311 patients were included in our meta-analysis. There were no significant differences between the ADAPT group and the stent retriever group of the primary and secondary outcomes except additional therapy. Our pooled results indicated that patients in the ADAPT group needed more additional therapy than those in the stent retriever group (OR 2.24, 95% CI 1.41–3.57). Conclusion In conclusion, our meta-analysis showed similar clinical outcomes of ADAPT and stent retriever. However, patients in the ADAPT group had higher additional therapy rates than those in the stent retriever group. Due to several inevitable limitations of this meta-analysis, more large-scale randomized controlled trials are required to further investigate this topic.

Aspiration Thrombectomy for Posterior Circulation Stroke: A Systematic Review and Meta-Analysis

Article

Full-text available

Apr 2020

Purpose: This study aims to analyze the efficacy of aspiration thrombectomy for large vessel occlusion of the posterior circulation, with an emphasis on comparison with stent retriever thrombectomy. Methods: A systematic review and meta-analysis were performed to analyze the outcomes of aspiration thrombectomy for acute posterior circulation stroke. For those studies that included data for both aspiration and stent-retriever thrombectomy, we additionally performed a second meta-analysis comparing their outcomes against each other. Results: A total of 17 articles were included. For the primary outcomes, the weighted pooled rate of mortality was 26.71% (95% confidence interval [CI] 19.35%-34.71%), modified Ranking Score (mRS) 0-2 at 3 months was 36.71 (95% CI 32.02%-41.52%), and successful recanalization 89.26% (95% CI 83.12%-94.31%). Primary stent retriever thrombectomy was inferior to primary aspiration thrombectomy for the outcomes of successful recanalization (odds ratio [OR] 0.57, 95% CI 0.36-0.91, P = 0.018), complete recanalization (OR 0.65, 95% CI 0.42-0.1.00, P = 0.048), procedure time (mean difference 28.17, 95% CI 9.47-46.87), and rate of embolization to new territory (OR 5.01, 95% CI 1.20-20.87, P = 0.027). No significant difference was seen for other outcomes. Further subgroup analysis suggests that for the outcome of recanalization, this may be dependent on the availability of second-line stent retriever thrombectomy. Limitations: The included studies were observational in nature. There was unresolved heterogeneity in some of the outcomes. Conclusions: There was no statistically significant difference seen for the primary outcomes of mortality and favorable outcome (mRS score 0-2) at 3 months. While superior rates of successful recanalization, complete recanalization, faster procedural time, and improved safety profile for primary aspiration thrombectomy were seen compared to primary stent retriever thrombectomy, this did not translate into superior clinical outcomes.

Thrombectomy in acute vertebrobasilar occlusion: a single-centre experience

Article

Full-text available

Jun 2020
NEURORADIOLOGY

PurposeAcute vertebrobasilar occlusion (VBO) has a grave clinical course; however, thrombectomy in VBO patients has rarely been reported. We retrospectively evaluated the clinical and radiological outcomes of thrombectomy in VBO patients.Methods From March 2010 to December 2017, 38 patients with 40 acute VBOs underwent thrombectomy at our hospital. Thrombectomy was performed using catheter aspiration (n = 11, 26.8%) or a stent retriever (n = 29, 70.7%).ResultsGood clinical outcomes (3-month modified Rankin scale (mRS) of 2 or lower) were achieved in 9 cases (22.5%), and successful recanalization (thrombolysis in cerebral infarction (TICI) grade of 2b or 3) was achieved in 35 cases (87.5%). Good clinical outcomes were significantly related to aetiologies other than atherosclerosis (p = 0.020) and lower National Institutes of Health Stroke Scale (NIHSS) scores on admission (p = 0.025). The clinical and radiological outcomes did not differ significantly between catheter aspiration and stent retriever thrombectomy (p = 1.000 and p = 0.603, respectively); however, stent retriever thrombectomy had a shorter procedure time than catheter aspiration (59.7 ± 31.2 vs. 84.5 ± 35.1 min, p = 0.037).Conclusion In our series, good clinical outcomes were associated with a lower NIHSS score on admission and stroke aetiologies other than atherosclerosis. The two thrombectomy modalities showed similar clinical and radiological outcomes. However, stent retrievers seemed to allow more rapid recanalization than catheter aspiration in VBO.

Endovascular Thrombectomy for Acute Basilar Artery Occlusion: A Multicenter Retrospective Observational Study

Article

Full-text available

Jul 2018

Background: Despite the recent acceptance of thrombectomy as the standard of care in patients with acute anterior circulation stroke, the benefits of thrombectomy remain uncertain for patients with acute basilar artery occlusion (BAO). This study aimed to evaluate the effectiveness and safety of thrombectomy and to identify predictors of outcomes in a large cohort of patients with acute BAO. Methods and results: This study included 212 consecutive patients with acute BAO who underwent either stent-retriever or contact aspiration thrombectomy as the first-line approach between January 2011 and August 2017 at 3 stroke centers. Clinical and radiologic data were prospectively collected and stored in a database at each center. Multivariable ordinal logistic regression was performed to assess the association between each characteristic and 90-day modified Rankin scale scores. Reperfusion was successful in 91.5% (194/212) of patients; 44.8% (95/212) of patients achieved 90-day modified Rankin scale 0 to 2. The symptomatic hemorrhage rate was 1.9% (4/212) and mortality was 16% (34/212). In a multivariable ordinal regression, younger age, lower National Institute of Health stroke scale on admission, and absence of diabetes mellitus and parenchymal hematoma were significantly associated with a favorable shift in the overall distribution of 90-day modified Rankin scale scores. Treatment outcomes were similar between patients who received stent-retriever thrombectomy and contact aspiration thrombectomy as the first-line technique. Conclusions: Endovascular thrombectomy was effective and safe for treating patients with acute BAO. Age, the baseline National Institute of Health stroke scale, diabetes mellitus, and parenchymal hematoma were associated with better outcomes. This study showed no superiority of the stent-retriever over the aspiration thrombectomy for treating acute BAO.

Mechanical thrombectomy in basilar artery occlusion: influence of reperfusion on clinical outcome and impact of the first-line strategy (ADAPT vs stent retriever)

Article

Jan 2018
J NEUROSURG

OBJECTIVE Several randomized trials have been focused on patients with anterior circulation stroke, whereas few data on posterior circulation stroke are available. Thus, new mechanical thrombectomy (MT) strategies, including a direct-aspiration first-pass technique (ADAPT), remain to be evaluated in basilar artery occlusion (BAO) patients. The authors here assessed the influence of reperfusion on outcome in BAO patients and examined whether ADAPT improves the reperfusion rate compared with stent retriever devices.METHODS Three comprehensive stroke centers prospectively collected individual data from BAO patients treated with MT. Baseline characteristics as well as radiographic and clinical outcomes were compared between the 2 MT strategies. The primary outcome measure was the rate of successful reperfusion, defined as a modified Thrombolysis in Cerebral Infarction (mTICI) grade of 2b-3. Favorable outcome was defined as a 90-day modified Rankin Scale score of 0-2.RESULTSAmong the 100 adult patients included in the study, 46 were treated with first-line ADAPT (median age 61 years, IQR 53-71 years; stent-retriever rescue therapy was secondarily used in 12 [26.1%]) and 54 were treated with a primary stent retriever (median age 67 years, IQR 53-78 years). There was no difference in baseline characteristics between the 2 treatment groups, except for the rate of diabetes (19.6% vs 5.7%, respectively, p = 0.035). Successful reperfusion was achieved in 79% of the overall study sample. Overall, the rate of favorable outcome was 36.8% and 90-day all-cause mortality was 44.2%. Successful reperfusion positively impacted favorable outcome (OR 4.57, 95% CI 1.24-16.87, p = 0.023). A nonsignificant trend toward a higher successful reperfusion rate (unadjusted OR 2.56, 95% CI 0.90-7.29, p = 0.071) and a significantly higher rate of complete reperfusion (mTICI grade 3; unadjusted OR 2.59, 95% CI 1.14-5.86, p = 0.021) was found in the ADAPT group. The procedure duration was also significantly lower in the ADAPT group (median 45 minutes, IQR 34 to 62 minutes vs 56 minutes, IQR 40 to 90 minutes; p = 0.05), as was the rate of periprocedural complications (4.3% vs 25.9%, p = 0.003). Symptomatic intracranial hemorrhage (0.0% vs 4.0%, p = 0.51) and 90-day all-cause mortality (46.7% vs 42.0%, p = 0.65) were similar in the 2 groups.CONCLUSIONS Among BAO patients, successful reperfusion is a strong predictor of a 90-day favorable outcome, and the choice of ADAPT as the first-line strategy achieves a significantly higher rate of complete reperfusion with a shorter procedure duration.

The direct first pass aspiration technique in the treatment of acute ischemic stroke resulting from large vessel occlusions

Article

Full-text available

Jul 2017

Methods Recanalization was assessed using the modified thrombolysis in cerebral infarction (mTICI) score. Neurological outcomes were assessed using the National Institutes of Health Stroke Scale and modified Rankin Scale. Results Fifteen patients were evaluated. The mTICI score was 2b-3 in 80%, and it was 3 in 60% of patients. No intracranial hemorrhage was seen. At three months, modified Rankin Scale scores ≤ 2 were observed in 60% of patients and the mortality rate was 13.3%. Conclusions The ADAPT appears to be a safe, effective, and fast recanalization strategy for treatment of acute ischemic stroke resulting from large vessel occlusions.

Forced Arterial Suction Thrombectomy Using Distal Access Catheter in Acute Ischemic Stroke

Article

Full-text available

Mar 2017

Historical innovations in mechanical thrombectomy devices and strategies for ischemic stroke have resulted in improved angiographic outcomes and better clinical outcomes. Various devices have been used, but the two most common approaches are aspiration thrombectomy and stent-retrieval thrombectomy. Aspiration thrombectomy has advanced from the traditional Penumbra system to forced arterial suction thrombectomy and a direct aspiration first-pass technique. Newer generation aspiration catheters with flexible distal tips and a larger bore have demonstrated faster and better recanalization relative to older devices. Recently, several species of distal access catheters have similar structural characteristics to the Penumbra reperfusion catheter. Therefore, we used the distal access catheter for forced arterial suction thrombectomy in three patients with acute ischemic stroke. In each case, we achieved fast and complete recanalization without significant complications. Forced arterial suction thrombectomy using a distal access catheter might provide another option for mechanical thrombectomy in patients with acute ischemic stroke.

Pseudoaneurysm Formation after Repetitive Suction Thrombectomy Using a Penumbra Suction Catheter

Article

Full-text available

Sep 2016

With the recent advent of suction catheters, the use of manual aspiration thrombectomy (MAT) for patients with acute ischemic stroke with large vessel occlusion has increased. Although contrast leakage and subarachnoid hemorrhage have been reported during MAT procedures, pseudoaneurysm formation due to vessel injury by suction catheters has not been. We discuss the case of a 60-year-old woman who presented to our emergency room with dysarthria and left-sided weakness. She underwent suction thrombectomy 5 times for acute middle cerebral artery occlusion and significant contrast leakage occurred during the procedure. On follow-up angiogram on post-operative day 15, we noticed a pseudoaneurysm, which was treated with detachable coil embolization. Surgeons who perform suction thrombectomy should keep in mind the possibility of vessel injury that results in the formation of a pseudoaneurysm, especially at the branching site or tortuous segments.

A Comparison between Mechanical Thrombectomy and Intra-arterial Fibrinolysis in Acute Basilar Artery Occlusion: Single Center Experiences

Article

Full-text available

May 2016

Background and purpose: Recent advances in intra-arterial techniques and thrombectomy devices lead to high rate of recanalization. However, little is known regarding the effect of the evolvement of endovascular revascularization therapy (ERT) in acute basilar artery occlusion (BAO). We compared the outcome of endovascular mechanical thrombectomy (EMT) versus intra-arterial fibrinolysis (IAF)-based ERT in patients with acute BAO. Methods: After retrospectively reviewed a registry of consecutive patients with acute ischemic stroke who underwent ERT from September 2003 to February 2015, 57 patients with acute BAO within 12 hours from stroke onset were enrolled. They were categorized as an IAF group (n=24) and EMT group (n=33) according to the primary technical option. We compared the procedural and clinical outcomes between the groups. Results: The time from groin puncture to recanalization was significantly shorter in the EMT group than in the IAF group (48.5 [25.3 to 87.8] vs. 92 [44 to 179] minutes; P=0.02) The rate of complete recanalization was significantly higher in the EMT group than in the IAF group (87.9% vs 41.7%; P<0.01). The good outcome of the modified Rankin Scale score≤2 at 3 months was more frequent in the EMT group than in the IAF group, but it was not statistically significant (39.4% vs 16.7%; P=0.06). Conclusions: EMT-based ERT in patients with acute BAO is superior to IAF-based ERT in terms of the reduction of time from groin puncture to recanalization and the improvement of the rate of complete recanalization.

Outcomes of endovascular treatment of basilar artery occlusion in the stent retriever era: A systematic review and meta-analysis

Article

Full-text available

Mar 2016

Background: Stent retriever thrombectomy has recently been found to be effective for anterior circulation strokes, but its efficacy for basilar artery occlusion (BAO) is unclear. Objective: To carry out a systematic review and meta-analysis to analyze the available evidence for the use of stent retrievers for BAO. Methods: Two independent reviewers searched six databases for studies reporting outcomes following endovascular treatment for BAO. Results: A total of 17 articles (6 prospective and 11 retrospective) were included. The weighted mean age of patients was 67 years (range 59-82) and 59% were male. Thrombolytic drugs were administered intravenously and intra-arterially in 46% (range 0-88%) and 38% (range 0-90%) of patients, respectively. Weighted pooled estimates of successful recanalization (TICI 2b-3) and good outcome (modified Rankin Scale ≤2) were 80.0% (95% CI 70.7% to 88.0%; I(2)=80.28%; p<0.001) and 42.8% (95% CI 34.0% to 51.8%; I(2)=61.83%; p=0.002), respectively. Pooled mortality was 29.4% (95% CI 23.9% to 35.3%; I(2)=37.01%; p=0.087). Incidence of procedure-related complications and symptomatic hemorrhage was 10.0% (95% CI 3.7% to 18.3%; I(2)=61.05%; p=0.017) and 6.8% (95% CI 3.5% to 10.8%; I(2)=37.99%; p=0.08), respectively. Conclusions: Stent retriever thrombectomy achieves a high rate of recanalization and functional independence while being relatively safe for patients with BAO. Future prospective studies with long-term follow-up are warranted.

Basilar Occlusion Syndromes: An Update

Article

Jul 2015

Basilar artery occlusions (BAOs) are a subset of posterior circulation strokes. Particular issues relevant to BAOs include variable and stuttering symptoms at onset resulting in delays in diagnosis, high morbidity and mortality, and uncertain best management. Despite better imaging techniques, diagnosis, and therefore treatment, is often delayed. We will present the most common signs and symptoms of posterior circulation strokes. Data on optimal treatment strategies are gathered from multiple case series, registries, and one randomized trial, which was stopped early. Possible etiologies of BAOs, acute, and subacute treatment strategies and special topics in neuroimaging of the posterior fossa are discussed. This review may be helpful to neurohospitalists who are managing patients with acute stroke as well as emergency room physicians and neurologists.

Predictors of Outcome after Direct Aspiration of Basilar Artery Occlusion

Article

Full-text available

Mar 2024

Background: Basilar artery occlusion (BAO) is a serious disease with a poor prognosis if left untreated. Endovascular therapy (EVT) is the most effective treatment that is able to reduce mortality and disability. Treatment results are influenced by a wide range of factors that have not been clearly identified. In the present study, direct aspiration was chosen as a first-line treatment. The safety and effectiveness of direct aspiration in BAO were determined, and factors affecting patient outcomes were identified. Methodology: Data for patients with BAO treated between November 2013 and December 2021 were evaluated using a database. The association between clinical and procedural parameters and functional outcome was assessed. Results: A total of 89 patients with BAO were identified. Full recanalization was achieved in 69.7% of cases and partial recanalization in 19.1%. Intracranial hemorrhage was detected in 11 (12.4%) patients, of which, eight (9.0%) patients experienced symptomatic intracranial hemorrhage. Patients with good outcomes presented with milder strokes (mean NIHSS score of 12.58 vs. 24.00, p < 0.001), had higher collateral scores (6.79 vs. 5.88, p = 0.016), more often achieved complete recanalization (87.9% vs. 58.9%, p = 0.009), and more often experienced early neurological improvement (66.7% vs. 26.8%, p < 0.001). On the contrary, patients with worse outcomes had higher serum glucose levels (p = 0.05), occlusion of the middle portion of the basilar artery (MAB) (30.3% vs. 53.6%, p = 0.033), longer thrombus lengths (10.51 vs. 16.48 mm, p = 0.046), and intracranial hemorrhage (p = 0.035). Conclusions: The present study results suggest that direct aspiration is a safe and effective treatment for patients with BAO. We identified several factors affecting the patients’ outcome.

Endovascular therapy of acute vertebrobasilar occlusions: influence of first-line strategy in the Endovascular Treatment in Ischemic Stroke (ETIS) Registry

Article

Feb 2024

Background The choice of the first-line technique in vertebrobasilar occlusions (VBOs) remains challenging. We aimed to report outcomes in a large cohort of patients and to compare the efficacy and safety of contact aspiration (CA) and combined technique (CoT) as a first-line endovascular technique in patients with acute VBOs. Methods We retrospectively analyzed clinical and neuroradiological data of patients with VBOs from the prospective, multicenter, observational Endovascular Treatment in Ischemic Stroke (ETIS) Registry in France between January 2015 and August 2023. The primary outcome was the first pass effect (FPE) rate, whereas modified Thrombolysis In Cerebral Infarction (mTICI) 2b-3 and 2c-3, number of passes, need for rescue strategy, modified Rankin Scale (mRS) 0–2, mortality, and symptomatic intracranial hemorrhage (sICH) were secondary outcomes. We performed univariate and multivariate analyses to investigate differences between the two groups. Results Among the 583 included patients (mean age 66.2 years, median National Institutes of Health Stroke Scale (NIHSS) 13, median posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) 8), 393 were treated with CA alone and 190 with CoT. Procedures performed with CA were shorter compared with CoT (28 vs 47 min, P<0.0001); however, no differences were observed in terms of FPE (CA 43.3% vs CoT 38.4%, P=0.99), and successful final recanalization (mTICI 2b-3, CA 92.4% vs CoT 91.8%, P=0.74) did not differ between the two groups. Functional independence and sICH rates were also similar, whereas mortality was significantly lower in the CA group (34.5% vs 42.9%; OR 1.79, 95% CI 1.03 to 3.11). Conclusions We observed no differences in FPE, mTICI 2b-3, sICH, and functional independence between the two study groups. First-line CA was associated with shorter procedures and lower mortality rates than CoT.

Endovascular thrombectomy or bridging therapy in minor ischemic stroke with large vessel occlusion

Article

Sep 2022
THROMB RES

Background Whether direct endovascular thrombectomy (EVT) is non-inferior to bridging therapy (intravenous thrombolysis [IVT] followed by EVT) in minor acute ischemic stroke due to large vessel occlusions (AIS-LVO) is not clear. Therefore, this study aimed to assess whether direct EVT is non-inferior to bridging therapy in minor AIS-LVO. Methods 903 patients with acute ischemic stroke due to large vessel occlusion and National Institutes of Health Stroke Scale (NIHSS) score <6 receiving EVT treatment were enrolled at Bigdata Observatory Platform for Stroke of China in China from January 1, 2019, to December 31, 2020, with final follow-up on March 31, 2021. The primary efficacy endpoint was a favorable outcome defined as a modified Rankin Scale score of 0 to 2 at three months. In addition, there were three prespecified secondary efficacy endpoints, including symptomatic intracerebral hemorrhage (ICH), in-hospital mortality, and mortality by month 3. Results A total of 662 patients treated with direct EVT (age 65.9 ± 10.5 years, 71.5 % male, NIHSS score 2.4 [standard deviation {SD}. 1.8]) were compared to 241 bridging-treated patients (age 65.7 ± 10.8, 75.9 % female, NIHSS score 2.5 [1.8]). The rate of symptomatic ICH in the EVT group was lower than in the bridging group (4.2 % vs. 8.3 %; P = 0.02). The in-hospital mortality was not different between the two groups (EVT vs. bridging group: adjusted hazard ratio {HR}, 0.9 [95 % confidence interval {CI}, 0.5 to 1.9]; P = 0.93). There was no significant difference in 3-month poor functional outcome rate (EVT vs. bridging group: 17.1 % vs. 16.2 % [absolute difference, 0.9 % {95 % CI, −0.8 % to 2.4 %}, P = 0.75; adjusted hazard ratio {HR}, 1.0 {95 % CI, 0.6 to 1.7}, P = 0.83]) and mortality rate (13.0 % vs. 11.2 % [absolute difference, 1.5 % {95 % CI, −3.9 % to 6.8 %}, P = 0.47; adjusted HR, 1.1 {95 % CI, 0.8 to 1.9}, P = 0.55]) between those two groups. Conclusion Among patients with minor AIS-LVO, direct EVT, compared with bridging therapy, met the prespecified statistical threshold for noninferiority for the 3-month prognosis.

Aspiration versus Stent Retriever Thrombectomy in Posterior Circulation Stroke: A Systematic Review and Meta-Analysis

Article

Aug 2022

Introduction: The management of posterior circulation stroke is primarily carried out by endovascular approaches including aspiration or stent retrevier thrombectomy. Existing reviews have attempted to comparatively evaluate their efficacy in terms of morbidity and mortality-related outcomes, however, with several limitations. Therefore, in this review, we attempt to address the gap in the existing literature by evaluating the comparative impact of stent retriever-based and aspiration-based thrombectomy interventions in posterior circulation stroke patients on the following parameters: overall procedure duration, recanalization time, rescue therapy usage, complication risk, and mortality risk. Methods: A systematic search of the academic literature was performed according to PRISMA guidelines across five databases. We conducted a random-effect meta-analysis to evaluate comparative outcomes, including procedural duration, time to recanalization, risk of complications, use of rescue therapy, and risk of mortality in patients with posterior circulation stroke undergoing stent retriever- and aspiration-based thrombectomies. We also performed comparative subgroup analyses to evaluate differences in outcomes between contact and manual aspiration interventions. Results: From 963 studies, we found nine eligible studies containing data on 840 patients. Meta-analysis revealed a large-to-medium size positive effect for stent retriever-based thrombectomy on overall procedure duration and recanalization compared to aspiration-based thrombectomy. Additional analysis revealed higher risk of complications and mortality in posterior circulation stroke patients undergoing stent retriever-based thrombectomy as compared to aspiration-based thrombectomy. We also observed that the use of rescue therapy was elevated in patients undergoing aspiration-based thrombectomy compared to stent retriever-based thrombectomy. Conclusion: This study provides preliminary evidence for improved morbidity and mortality outcomes in posterior circulation stroke patients undergoing aspiration-based thrombectomies as compared to stent retriever-based thrombectomy. The study also provides evidence for improved endovascular outcomes for patients undergoing aspiration-based thrombectomies. The findings from this study can have implications in developing awareness among neurosurgeons for stratifying patients to manage posterior circulation stroke according to the risks associated with aspiration and stent retriever-based thrombectomies.

Should the direct aspiration first pass technique be advocated over the stent-retriever technique for acute ischemic stroke? A systematic review and meta-analysis of 7692 patients

Article

Full-text available

Dec 2021

Background The present meta-analysis aimed to synthesize evidence from all published studies with head-to-head data on the outcomes of a direct aspiration first pass technique (ADAPT) and the stent-retriever (SR) in acute ischemic stroke (AIS) patients. Methods We searched PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials from inception to March 2021 for relevant clinical trials and observational studies. Eligible studies were identified, and all relevant outcomes were pooled in the meta-analysis random-effects model of DerSimonian-Laird. Results Thirty studies were included in the meta-analysis with a total of 7868 patients. Compared with the SR, the ADAPT provides slightly higher rates of successful recanalization (RR 1.06, 95% CI [1.02 to 1.10]) and complete recanalization (RR 1.20, 95% CI [1.01 to 1.43]) but with more need for rescue therapy (RR 1.81, 95% CI [1.29 to 2.54]). There were no significant differences between the two techniques in terms of mortality at discharge, mortality at 90 days, change in the National Institutes of Health Stroke Scale score, the favorable outcome (modified Rankin scale (mRS) of 0-2), time to the groin puncture, or frequency of complications as intracerebral hemorrhage (ICH), symptomatic intracranial hemorrhage (sICH), embolus in a new territory (ENT), hemorrhagic infarction, parenchymal hematoma, subarachnoid hemorrhage, or procedural complications (all P > 0.05). Conclusion Current evidence supports the use of the ADAPT technique to achieve successful and complete recanalization while considering the higher need for rescue therapy in some patients.

First Line Stent Retriever vs Direct Aspiration for Acute Basilar Artery Occlusions: a systematic review and meta-analysis

Article

Nov 2021

Background Mechanical thrombectomy (MT) for anterior circulation stroke has been proven to be highly effective. In comparison, MT for basilar artery occlusion (BAO) continues to lack definitive evidence of efficacy. The main MT modalities are stent retriever (SR) and direct aspiration (DA). Several studies have recently been published comparing the two approaches. Objective To directly compare and synthesize safety and efficacy outcomes with SR versus DA for acute BAO. Methods A systematic review and meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results Overall, eight studies comprising 693 patients with BAO were included (SR: 457; DA: 236). The SR group was associated with statistically significant lower odds of modified Thrombolysis in Cerebral Infarction (mTICI)2b/3 (OR: 0.54; 95%CI: 0.31-0.94) and mTICI3 (OR: 0.47; 95%CI: 0.23-0.95) compared to DA. Favorable outcome rates, were similar between the two groups (OR:0.83; 95%CI: 0.60-1.16). The rates of symptomatic ICH (sICH) (OR: 3.57; 95%CI: 0.75-16.95), subarachnoid hemorrhage (SAH) (OR:4.71; 95%CI: 0.82-26.90) and vessel perforation (OR: 2.64; 95%CI:0.43-16.33) were higher in the SR group, but statistical significance was not reached. The rates of 90-day mortality were similar between the two groups (OR:1.07; 95%CI: 0.67-1.70). Procedure duration was significantly shorter when DA was used compared to SR (Weighted mean difference: 26.10 minutes; 95% CI:13.28-38.92). Conclusions SR is associated with statistically significant lower odds of mTICI 2b/3 and mTICI 3 recanalization rates compared to DA. SR appears to be associated with a higher complication rates but significance was not reached.

A Direct Aspiration First Pass Technique for Vertebra-Basilar Occlusion: A Retrospective Comparison to Stent Retriever

Article

Nov 2021
J Stroke Cerebrovasc Dis

Objectives This study aimed to assess the clinical usefulness of a direct aspiration first pass technique as a first-line strategy for mechanical thrombectomy in posterior circulation. Materials and methods We examined 34 consecutive patients treated with mechanical thrombectomy for acute vertebrobasilar artery occlusion. Procedural and clinical outcomes were assessed and compared between patients treated with a direct aspiration first pass technique first-line strategy (ADAPT group) and stent retriever system first-line strategy (stent retriever group). Results Overall, successful reperfusion, complete reperfusion, and first-pass effects were achieved in 94.1%, 61.8%, and 50% of patients with acute ischemic stroke in vertebra-basilar artery occlusion treated with mechanical thrombectomy, respectively. The ADAPT group required a significantly shorter procedural time (p=.015) and fewer attempts (p=.0498) to achieve successful recanalization than the stent retriever group. The ADAPT group also tended to show better recanalization rates and first-pass effects than the stent retriever group. The rates of favorable outcomes seemed to be better, although insignificant, in the ADAPT group than in the stent retriever group (52.2% vs. 27.3%, p=.217). However, a significant correlation between the time required for reperfusion and clinical outcome was detected, and this will serve as the rationale for encouraging a direct aspiration first pass technique as a first-line strategy in the acute vertebra-basilar artery. Conclusions The a direct aspiration first pass technique first-line strategy for mechanical thrombectomy in posterior circulation may achieve successful recanalization with fewer attempts and shorter durations than the stent retriever first-line strategy.

First-line contact aspiration versus first-line stent retriever for acute posterior circulation strokes: An updated meta-analysis

Article

May 2021

Background Both stent retriever (SR) and contact aspiration (CA) are widely used as first-line strategies for acute posterior circulation strokes (PCS). However, it is still unclear how CA and SR compare as the first-line treatment of acute PCS. Several new studies have been published recently, so we aimed to perform an updated meta-analysis. Methods The meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement. Random-effects models were performed to pool the outcomes and the value of I ² was calculated to assess the heterogeneity. Results Ten observational studies with 1189 patients were included, among whom 492 received first-line CA and 697 received first-line SR. The pooled results revealed that first-line CA could achieve a significantly higher proportion of modified Thrombolysis In Cerebral Infarction (mTICI) 2b/3 (OR 1.90, 95% CI 1.33 to 2.71, I ² =0%), mTICI 3 (OR 1.95, 95% CI 1.15 to 3.31, I ² =59.6%), first-pass effect (OR 2.91, 95% CI 1.51 to 5.58, I ² =0%), lower incidence of new-territory embolic events (OR 0.20, 95% CI 0.05 to 0.83, I ² =0%), and shorter procedure time (mean difference −29.4 min, 95% CI −46.8 to −12.0 min, I ² =62.8%) compared with first-line SR. At 90-day follow-up, patients subjected to first-line CA showed a higher functional independence (modified Rankin Scale score 0–2; OR 1.38, 95% CI 1.01 to 1.87, I ² =23.5%) and a lower mortality (OR 0.71, 95% CI 0.50 to 1.00, p=0.050, I ² =0%) than those subjected to first-line SR. Conclusions This meta-analysis suggests that the first-line CA strategy could achieve better recanalization and clinical outcomes for acute PCS than first-line SR. Limited by the quality of included studies, this conclusion should be drawn with caution.

Clot Meniscus Sign: An Angiographic Clue for Choosing between Stent Retriever and Contact Aspiration in Acute Basilar Artery Occlusion

Article

Feb 2021

Background and purpose: The efficacy of mechanical thrombectomy methods may differ depending on the characteristics of the occlusion. The purpose of this study was to compare the recanalization efficacy and treatment outcome of a stent retriever versus contact aspiration in patients with acute basilar artery occlusion according to the angiographic characteristics of the occlusion. Materials and methods: One hundred sixty-one patients with acute basilar artery occlusion who underwent mechanical thrombectomy were retrospectively analyzed. A stent retriever was compared with contact aspiration thrombectomy according to the clot meniscus sign, defined as a meniscoid/tram-track-like sidewall contrast opacification of the thrombus. A propensity score matching analysis was performed. Clinical/angiographic characteristics and treatment and clinical outcomes were compared. Results: Overall, a stent retriever (n = 118) and contact aspiration (n = 43) did not show significant differences in the successful recanalization (82.2% versus 86.0%) and good clinical outcome rates (32.2% versus 39.5%). In patients with the positive meniscus sign, contact aspiration was associated with shorter procedural time (44 versus 26 minutes, P = .018), a lower number of passes (2 versus 1, P = .041), a higher complete recanalization rate (58.8% versus 85.7%, P = .021), and a higher rate of first-pass effect (27.9% versus 53.6%, P = .031) compared with a stent retriever. After propensity score matching, contact aspiration was associated with higher complete recanalization rates (59.3% versus 85.7%, P = .033). No significant differences in the outcomes were noted between a stent retriever and contact aspiration in patients negative for the meniscus sign. Conclusions: The efficacy of the mechanical thrombectomy techniques may differ according to the angiographic characteristics of occlusion in patients with basilar artery occlusion. Contact aspiration may be more effective in terms of recanalization compared with a stent retriever in patients with the clot meniscus sign.

First-Line Contact Aspiration vs Stent Retriever for Proximal Occlusion in Acute Ischemic Stroke: A Systemic Review and Meta-Analysis

Article

Dec 2020
J Stroke Cerebrovasc Dis

Introduction The aim of this systematic review and meta-analysis was to compare the performance of first-line contact aspiration (ASP) and stent retriever (SR) in acute ischemic stroke caused by proximal large vessel occlusion. Methods Cochrane databases, MEDLINE and EMBASE were systematically searched for literatures reporting outcomes on thrombectomy with both first-line aspiration and first-line stent retriever in proximal occlusion. Results Thirteen studies with a total of 1614 patients were included. No differences were identified between the SR and ASP groups in terms of final reperfusion rate (modified thrombolysis in cerebral infarction 2b/3) (OR: 1.54, 95% CI: 0.88–2.70), complete recanalization rate (modified thrombolysis in cerebral infarction 3) (OR: 1.78, 95% CI: 0.58–5.44), and favorable outcomes (modified Rankin scale ≤2) (OR: 1.02, 95% CI: 0.79–1.32). With regard to adverse events, emboli to new territories (OR: 0.81, 95% CI: 0.31–2.14), intracranial hemorrhage (OR: 0.71, 95% CI: 0.40–1.28), 90-days mortality (OR: 1.02, 95% CI: 0.71–1.47) were similar between groups, while symptomatic intracerebral hemorrhage (OR: 0.43 95% CI: 0.21–0.86) was less seen in ASP. Subgroup analysis indicated that ASP was comparable to stent retriever with local aspiration (SRLA) (OR: 1.25 95% CI: 0.25–6.22) and superior to stent retriever alone (OR: 1.85 95% CI: 1.22–2.81). Moreover, in posterior circulation, contact aspiration achieved a significantly higher reperfusion (OR: 1.97 95% CI: 1.03–3.76) compared to stent retriever, and needed relatively less rescue therapies (21.5% vs 29.6%, p < 0.05). Conclusion Our study suggested that contact aspiration might be advantageous over stent retriever alone and more suitable in posterior circulation. While ASP and SRLA thrombectomy were equally effective in achieving good clinical outcomes. However, further studies are needed to confirm these results.

Direct aspiration stroke thrombectomy: A comprehensive review

Article

Jun 2020

Mechanical thrombectomy is now the standard of care for acute ischemic stroke patients with large vessel occlusions, and can be performed with several devices and techniques. One of these techniques, direct aspiration (DA), consists of navigating a large-bore catheter up to the face of the clot and initiating forceful suction. This comprehensive review has three objectives: (1) to describe the direct aspiration technique; (2) to present the available evidence regarding predictive factors of DA success and performance compared with other techniques; and (3) to discuss the forthcoming improvements in distal aspiration.

Thrombectomy Technique Predicts Outcome in Posterior Circulation Stroke-Insights from the STAR Collaboration

Article

May 2020
NEUROSURGERY

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.

Therapy for acute basilar artery occlusion: a systematic review and meta-analysis

Article

Full-text available

Feb 2019

Purpose: This study aims to analyse the efficacy of different treatment methods for acute basilar artery occlusion, with an emphasis placed on evaluating the latest treatment methods. Method: A systematic review and meta-analysis was performed to analyse the current data on the therapies available for treating acute basilar artery occlusion. Results: A total of 102 articles were included. The weighted pooled rate of mortality was 43.16% (95% CI 38.35-48.03%) in the intravenous thrombolysis group, 45.56% (95% CI 39.88-51.28) in the intra-arterial thrombolysis group, and 31.40% (95% CI 28.31-34.56%) for the endovascular thrombectomy group. The weighted pooled rate of Modified Ranking Score (mRS) 0-2 at 3 months was 31.40 (95% CI 28.31-34.56%) in the IVT group, 28.29% (95% CI 23.16-33.69%) in the IAT group, and 35.22% (95% CI 32.39-38.09%) for the EVT group. Meta-analyses were also done for the secondary outcomes of recanalization and symptomatic haemorrhage. There was no difference between stent retriever and thrombo-aspiration thrombectomy on subgroup analysis in both clinical outcome and safety profile. Limitations : The included studies were observational in nature. There was significant heterogeneity in some of the outcomes. Conclusions: Superior outcomes and better recanalization rates for acute basilar occlusion were seen with patients managed with endovascular thrombectomy when compared with either intravenous and/or intraarterial thrombolysis. No superiority of stent‐retrievers over thrombo-aspiration thrombectomy was seen.

Firstline a direct aspiration first pass technique versus firstline stent retriever for acute basilar artery occlusion: a systematic review and meta-analysis

Article

Jan 2019

Introduction Acute basilar artery occlusion (BAO) can result in extremely high disability and mortality. Stent retrievers (SRs) can achieve a high recanalization rate for BAO, therefore improving favorable outcomes. However, the efficacy of a direct aspiration first pass technique (ADAPT) to treat BAO is unclear. Our aim was to compare the efficacy and safety of firstline ADAPT with that of firstline SR for patients with acute BAO. Methods Three databases were systematically searched for literature reporting outcomes on thrombectomy for acute BAO with both firstline ADAPT and firstline SR. The modified Newcastle–Ottawa scale was applied to assess bias risk. The random effects model was used. Results Of 50 articles, 5 cohort studies (2 prospective and 3 retrospective) were included in our research. 193 cases were treated with firstline ADAPT and 283 cases received firstline SR. Successful recanalization rate was significantly higher in the firstline ADAPT group (OR=2.0, 95% CI 1.1 to 3.5). Procedure time (mean difference=−27.6 min, 95% CI −51.0 to −4.3) and the incidence of new territory embolic event (OR=0.2, 95% CI 0.05 to 0.83) was significantly less in the firstline ADAPT group. No significant difference was observed between the firstline ADAPT and firstline SR groups for rate of complete recanalization, rescue therapy, any hemorrhagic complication, favorable outcomes, or mortality at 90 days. Conclusions Our meta-analysis suggested that for patients with acute BAO, firstline ADAPT might achieve higher and faster recanalization, comparable neurological improvement and safety compared with firstline SR. Further studies are needed to confirm these results.

Simulation of Blood Clot Removal by Aspiration Thrombectomy in Cerebral Vessels usingGeometry Optimization of the Aspiration Device

Article

Oct 2018

Thrombectomy by aspiration is one of the most effective systems for vessel recanalization. We present the results of a study on the modelling and elimination of blood clots in the arteries of the human body using Bond-Graph methodology. The modelling focuses on the clot and the distal end section of an aspiration device that improves the effectiveness of the treatment by reducing the risk of breaking the clot. The final model considers an elastic characterization of the blood clot and the possibility of achieving a process of progressive detachment of the clot from the vessel wall. An optimization process based on a design of experiments (DOE) is undertaken. The results show good agreement between the Bond-Graph techniques and the Finite Element Method models considered for validation (Computer Fluid Dynamics and nonlinear mechanics). Physical tests with gelatine also validate the results. We conclude that the proposed geometry will potentially improve the results of recanalization when blood clots are extracted from the arteries for a range of given parameters.

Outcomes of Stent Retriever versus Aspiration-First Thrombectomy in Ischemic Stroke: A Systematic Review and Meta-Analysis

Article

Oct 2018

Background: There is ongoing debate regarding the optimal first-line thrombectomy technique for large-vessel occlusion. Purpose: We performed a systematic review and meta-analysis of comparative studies on stent retriever-first and aspiration-first thrombectomy. Data sources: We searched Ovid MEDLINE, PubMed, and EMBASE from 2009 to February 2018. Study selection: Two reviewers independently selected the studies. The primary end point was successful reperfusion (TICI 2b/3). Data analysis: Random-effects meta-analysis was used for analysis. Data synthesis: Eighteen studies including 2893 patients were included. There was no significant difference in the rate of final successful reperfusion (83.9% versus 83.3%; OR = 0.87; 95% CI, 0.62%-1.27%) or good functional outcome (mRS 0-2) at 90 days (OR = 1.07; 95% CI, 0.80-1.44) between the stent-retriever thrombectomy and aspiration groups. The stent-retriever thrombectomy-first group achieved a statistically significant higher TICI 2b/3 rate after the first-line device than the aspiration-first group (74.9% versus 66.4%; OR = 1.53; 95% CI, 1.14%-2.05%) and resulted in lower use of a rescue device (19.9% versus 32.5%; OR = 0.36; 95% CI, 0.14%-0.90%). The aspiration-first approach resulted in a statistically shorter groin-to-reperfusion time (weighted mean difference, 7.15 minutes; 95% CI, 1.63-12.67 minutes). There was no difference in the number of passes, symptomatic intracerebral hemorrhage, vessel dissection or perforation, and mortality between groups. Limitations: Most of the included studies were nonrandomized. There was significant heterogeneity in some of the outcome variables. Conclusions: Stent-retriever thrombectomy-first and aspiration-first thrombectomy were associated with comparable final reperfusion rates and functional outcome. Stent-retriever thrombectomy was superior in achieving reperfusion as a stand-alone first-line technique, with lower use of rescue devices but a longer groin-to-reperfusion time.

Stroke

Chapter

Jun 2018

In 2015, stroke was the second leading cause of death worldwide, trailed only by ischemic heart disease in global mortality (World Health Organization Global Health Observatory Data. May 2017. http://www.who.int/gho). Recognized symptoms include facial droop, extremity weakness, altered mental status, and aphasia. Strokes can be categorized into ischemic or hemorrhagic based on imaging features. Ischemic strokes of either thrombotic or embolic origin account for nearly 87% of all strokes (Mozaffarian et al. Circulation 131(4):e29–322, 2015). While hemorrhagic strokes are managed medically and/or surgically, the acute ischemic stroke patient may benefit from the administration of intravenous recombinant tissue plasminogen activator (rt-PA) or endovascular therapy within the proper time frame and in the proper clinical setting. This chapter discusses the role of endovascular therapy for treatment of ischemic stroke.

Endovascular Thrombectomy for Acute Ischemic Stroke at Our Institution

Article

Full-text available

Jan 2018

Background and purpose: The usefulness of endovascular thrombectomy for acute ischemic stroke has recently been shown in several randomized control trials. We retrospectively analyzed the efficacy of actions to reduce revascularization and treatment times in elderly patients and assessed the difference in treatment times and recanalization rates using different devices. Object and methods: We reviewed the clinical records of 64 consecutive patients who underwent endovascular thrombectomy for acute ischemic stroke between July 2014 and February 2016. We adopted various approaches to reduce the time to recanalization. Results: A total of 54 cases (85%) had a thrombolysis in cerebral infarction (TICI) score exceeding 2B. The number of cases with a favorable modified Rankin Scale (mRS) score of 0-2 at discharge was 23 (36%), and there were 6 (9%) deaths. We significantly reduced the arrival to puncture time by approximately 40 minutes, from 113.7 to 74.2 minutes, and the prognosis tended to improve. The puncture to recanalization time was the shortest in the stent retriever alone group, and the rate of TICI 3 was high in this group. Conclusions: Adopting various approaches to reduce the recanalization time is important for improving patient prognosis. The prognosis in elderly patients tends to be poor; however, the optimal treatment regimen should not be selected according to age because some elderly cases demonstrated a favorable outcome. The present findings suggest that the use of a stent retriever should be the first choice of treatment for such patients.

Mechanical Thrombectomy for Acute Basilar Artery Occlusion in Early Therapeutic Time Window

Article

Aug 2017

Background: The natural history of basilar artery occlusion (BAO) is devastating, with morbidity rates increasing up to 80%. However, the efficacy of recanalization therapy for BAO has not been established as yet. Objective: We analyzed consecutive cases of BAO treated with mechanical thrombectomy (MT) to evaluate its safety and efficacy and to determine factors associated with the prognosis. Methods: Between October 2011 and September 2016, MT was performed in 34 patients with BAO. MT was performed using the Penumbra system and stent retriever. CT perfusion was used for evaluating patients. Cerebral blood flow (CBF) maps and cerebral blood volume (CBV) maps were evaluated. CBF/CBV mismatch was defined as ≥50% penumbra. Clinical outcomes were correlated with demographic, clinical, and radiographic findings. Results: The median baseline National Institutes of Health Stroke Scale score was 29 (14-33). The recanalization rate (≥thrombolysis in cerebral infarction grades 2b) was 100%. The median onset to recanalization time (OTR) was 197 (160-256) min. Favorable outcomes (modified Rankin Scale ≤2) at 90 days occurred in 56% (n = 19 of 34). The mortality rate at 90 days was 12% (n = 4 of 34). In univariate analysis, intravenous (IV) recombinant tissue-type plasminogen activator (rt-PA) use, and OTR were significantly associated with favorable outcomes. In a multivariate logistic regression model, IV rt-PA use and lower National Institute of Health Stroke Scale score were significantly related to favorable outcomes. Conclusion and Relevance: Multimodal endovascular therapy using the Penumbra system and stent retriever demonstrated a high recanalization rate and favorable outcomes for BAO. Both devices were feasible and effective in the treatment of BAO. An approach combining MT with IV thrombolysis provided a better recanalization rate and more favorable clinical outcomes.

A Direct Aspiration First Pass Technique vs Standard Endovascular Therapy for Acute Stroke: A Systematic Review and Meta-Analysis

Article

Jul 2017

Background: The direct aspiration first pass technique (ADAPT) is a recent endovascular treatment for ischemic stroke due to large vessel occlusion that has been gaining popularity due to the rapidity of the technique and the potential for cost savings in comparison to standard thrombectomy methods such as stent retrievers. However, few studies have directly compared these 2. Objective: To compare ADAPT with stent retrievers for thrombectomy via systematic review and meta-analysis. Methods: Ovid Medline, PubMed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, ACP Journal Club, and Database of Abstracts of Review of Effectiveness limited to English through September 2016 were systematically searched. Eligible studies included those in which patient cohorts underwent ADAPT for acute stroke. Recanalization efficiency, clinical outcomes, and complication rates of ADAPT were compared with the current standard of endovascular thrombectomy techniques. Results: Seventeen studies on ADAPT and 5 randomized controlled trials on endovascular therapy were included. ADAPT achieved higher rates of complete revascularisation (89.4% vs 71.7%, P < .001) but similar clinical outcomes compared to front-line endovascular therapy. Seventy-one point four percent of ADAPT cases were successfully recanalized with aspiration alone, and a trend towards reduced time from groin puncture to recanalization time was noted (44.77 vs 61.46 min, P = .088). Conclusion: The pooled results are comparable with recent randomized studies that demonstrate the benefit of endovascular therapy over intra-arterial medical therapy. Future direct comparative studies and randomized trials are required to confirm the benefit of the ADAPT strategy compared to standard endovascular therapy for acute ischemic stroke.

Rapid Recanalization of Stent Retriever Compared with That of Old-type Aspiration Catheter for Acute Ischemic Stroke

Article

Full-text available

Jun 2017

Objective: In mechanical thrombectomy for acute ischemic stroke, a positive outcome depends on short workflow time and successful recanalization. In this study, we retrospectively compared the recanalization times and rates in our initial experience of mechanical thrombectomy with stent retrievers and the old-type aspiration catheter system. Methods: We retrospectively reviewed patients who underwent mechanical thrombectomy in author's hospital from November 2012 to April 2015, and compared parameters between patients treated with each device. Results: Thirty patients who underwent mechanical thrombectomy in the following order were divided into three chronologically sequential groups (n = 10 patients in each) for evaluating interval trends: the first group of patients underwent thrombectomy using the old aspiration catheter system; second, first stent retrievers; and third, second stent retrievers. Although successful recanalization rates (thrombolysis in cerebral infarction score ≥2b) were not significantly different among the three groups (p = 0.122), puncture-to-recanalization duration or duration of final digital subtraction angiography was significantly longer for patients recanalized using the old aspiration catheter system compared with that of patients recanalized using stent retrievers (143, 59.5, and 51.5 min, respectively; p = 0.004). Conclusion: Although both thrombectomy systems showed no significant differences in successful recanalization rates, the stent system permitted more rapid recanalization than the old aspiration catheter system.

Clinical and Procedural Predictors of Outcomes From the Endovascular Treatment of Posterior Circulation Strokes

Article

Feb 2016
STROKE

Background and purpose: Patients with posterior circulation strokes have been excluded from recent randomized endovascular stroke trials. We reviewed the recent multicenter experience with endovascular treatment of posterior circulation strokes to identify the clinical, radiographic, and procedural predictors of successful recanalization and good neurological outcomes. Methods: We performed a multicenter retrospective analysis of consecutive patients with posterior circulation strokes, who underwent thrombectomy with stent retrievers or primary aspiration thrombectomy (including A Direct Aspiration First Pass Technique [ADAPT] approach). We correlated clinical and radiographic outcomes with demographic, clinical, and technical characteristics. Results: A total of 100 patients were included in the final analysis (mean age, 63.5±14.2 years; mean admission National Institutes of Health Stroke Scale score, 19.2±8.2). Favorable clinical outcome at 3 months (modified Rankin Scale score ≤2) was achieved in 35% of patients. Successful recanalization and shorter time from stroke onset to the start of the procedure were significant predictors of favorable clinical outcome at 90 days. Stent retriever and aspiration thrombectomy as primary treatment approaches showed comparable procedural and clinical outcomes. None of the baseline advanced imaging modalities (magnetic resonance imaging, computed tomographic perfusion, or computed tomography angiography assessment of collaterals) showed superiority in selecting patients for thrombectomy. Conclusions: Time to the start of the procedure is an important predictor of clinical success after thrombectomy in patients with posterior circulation strokes. Both stent retriever and aspiration thrombectomy as primary treatment approaches are effective in achieving successful recanalization.

ADAPT FAST study: A direct aspiration first pass technique for acute stroke thrombectomy

Article

Full-text available

Feb 2014
J Neurointerv Surg

The development of new revascularization devices has improved recanalization rates and time, but not clinical outcomes. We report a prospectively collected clinical experience with a new technique utilizing a direct aspiration first pass technique with large bore aspiration catheter as the primary method for vessel recanalization. 98 prospectively identified acute ischemic stroke patients with 100 occluded large cerebral vessels at six institutions were included in the study. The ADAPT technique was utilized in all patients. Procedural and clinical data were captured for analysis. The aspiration component of the ADAPT technique alone was successful in achieving Thrombolysis in Cerebral Infarction (TICI) 2b or 3 revascularization in 78% of cases. The additional use of stent retrievers improved the TICI 2b/3 revascularization rate to 95%. The average time from groin puncture to at least TICI 2b recanalization was 37 min. A 5MAX demonstrated similar success to a 5MAX ACE in achieving TICI 2b/3 revascularization alone (75% vs 82%, p=0.43). Patients presented with an admitting median National Institutes of Health Stroke Scale (NIHSS) score of 17.0 (12.0-21.0) and improved to a median NIHSS score at discharge of 7.3 (1.0-11.0). Ninety day functional outcomes were 40% (modified Rankin Scale (mRS) 0-2) and 20% (mRS 6). There were two procedural complications and no symptomatic intracerebral hemorrhages. The ADAPT technique is a fast, safe, simple, and effective method that has facilitated our approach to acute ischemic stroke thrombectomy by utilizing the latest generation of large bore aspiration catheters to achieve previously unparalleled angiographic outcomes.

Comparison of Neurologic and Radiographic Outcomes with Solitaire versus Merci/Penumbra Systems for Acute Stroke Intervention

Article

Full-text available

Jan 2013
BMRI

Background and purpose: The Solitaire Flow Restoration was approved by the FDA in 2012 for mechanical thrombolysis of proximal occlusion of intracranial arteries. To compare the Solitaire FR device and the Merci/Penumbra (previously FDA approved) systems in terms of safety, clinical outcomes, and efficacy including radiographic brain parenchymal salvage. Methods: Thirty-one consecutive patients treated with the Solitaire and 20 patients with comparable baseline characteristics treated with Merci or Penumbra systems were included in the study. Primary outcome measures included recanalization rate and modified Rankin Scale score at followup. Secondary outcomes included length of procedure, incidence of symptomatic intracranial hemorrhage, 90-day mortality, and radiographic analysis of percentage area salvage. Results: Compared with the Merci/Penumbra group, the Solitaire group showed a statistically significant improvement in favorable outcomes (mRS ≤ 2) (69% versus 35%, P = 0.03) and symptomatic ICH rate (0 versus 15%, P = 0.05) with a trend towards higher recanalization rates (93.5% versus 75%, P = 0.096) and shorter length of procedure (58.5 min versus 70.8 min, P = 0.08). Radiographic comparison also showed a significantly larger area of salvage in the Solitaire group (81.9% versus 71.9%, P = 0.05). Conclusion: Our study suggests that the Solitaire system allows faster, safer, and more efficient thrombectomy than Merci or Penumbra systems.

Acute Basilar Artery Occlusion: Outcome of Mechanical Thrombectomy with Solitaire Stent within 8 Hours of Stroke Onset

Article

Full-text available

Dec 2013
AM J NEURORADIOL

Background and purpose: Mechanical thrombectomy with a stent retriever applied shortly after symptom onset could increase good functional outcomes and improve survival in patients with acute basilar artery occlusion, but this has not yet been studied. This study evaluated the efficacy and safety of mechanical thrombectomy with a Solitaire stent within 8 hours of stroke onset in patients with acute basilar artery occlusion. Materials and methods: We analyzed 25 consecutive patients with acute basilar artery occlusion who were treated with mechanical thrombectomy by use of the Solitaire stent within 8 hours of stroke symptom onset. Successful recanalization was defined as TICI grade 2b or 3. Good outcome was defined as mRS score of 0-2 at 3 months. Clinical and radiologic data in patients with good outcomes were compared with those with poor outcomes. Results: Successful recanalization was achieved in 96% (24/25) of patients, and 48% (12/25) of patients had good outcomes. Eighty-eight percent (22/25) of patients survived to 3 months. The median NIHSS score on admission was significantly lower in patients with good outcomes than in those with poor outcomes (9.5 versus 14, P = .005). Procedure-related complications occurred in 2 patients (8%). No symptomatic intracerebral hemorrhages occurred. Conclusions: The current study suggests that mechanical thrombectomy by use of a Solitaire stent within 8 hours of stroke onset increases good outcomes and improves survival in patients with acute basilar artery occlusion.

Mechanical Thrombectomy with Stent Retrievers in Acute Basilar Artery Occlusion

Article

Full-text available

Nov 2013
AM J NEURORADIOL

Background and purpose: Basilar artery occlusion remains one of the most devastating subtypes of ischemic stroke. The prognosis is poor if early recanalization is not achieved. The purpose of this study was to evaluate the safety and technical feasibility of self-expanding retrievable stents in the endovascular treatment of acute basilar artery occlusion. Materials and methods: Twenty-four patients with acute basilar artery occlusion were treated with Solitaire FR or Revive SE devices between December 2009 and May 2012. Additional treatment included intravenous and/or intra-arterial thrombolysis (21/24) and percutaneous transluminal angioplasty/permanent stent placement (7/24). Recanalization was assessed by means of the TICI score. Clinical outcome was determined at discharge (NIHSS), and at 3 months (mRS). Results: Median NIHSS score on admission was 24; median duration of symptoms was 254 minutes. Successful recanalization (TICI 2b +3) by thrombectomy only was achieved in 18 patients (75%). Intracranial stent deployment after thrombectomy caused by underlying atherosclerotic stenosis was performed in 7 patients. If these patients with intracranial stent placement are included, successful recanalization was achieved in 21 of 24 patients (87.5%). NIHSS improvement ≥10 points was reached in 54% of patients (n = 13/24). Mortality during the first 3 months was 29% (7/24). After 3 months, 8 patients (33%) had a favorable clinical outcome (mRS 0-2). Conclusions: In our series, application of self-expanding retrievable stents in acute basilar artery occlusion resulted in a high recanalization rate without procedural complications and good clinical outcome in one-third of patients.

The Penumbra Pivotal Stroke Trial Safety and Effectiveness of a New Generation of Mechanical Devices for Clot Removal in Intracranial Large Vessel Occlusive Disease

Article

Full-text available

Aug 2009

Abstract BACKGROUND AND PURPOSE: The purpose of this clinical evaluation was to assess the safety and effectiveness of the Penumbra System in the revascularization of patients presenting with acute ischemic stroke secondary to intracranial large vessel occlusive disease. METHODS: In this prospective, multicenter, single-arm study, 125 patients with neurological deficits as defined by a National Institutes of Health Stroke Scale score > or =8, presented within 8 hours of symptom onset, and an angiographic occlusion (Thrombolysis In Myocardial Infarction [TIMI] Grade 0 or 1) of a treatable large intracranial vessel were enrolled. Patients who presented within 3 hours from symptom onset had to be ineligible or refractory to recombinant tissue plasminogen activator therapy. All patients were followed clinically for 90 days postprocedure. RESULTS: A total of 125 target vessels in 125 patients were treated by the Penumbra System. Postprocedure, 81.6% of the treated vessels were successfully revascularized to TIMI 2 to 3. There were 18 procedural events reported in 16 patients (12.8%), 3 patients (2.4%) had events that were considered serious. A total of 35 patients (28%) were found to have intracranial hemorrhage on 24-hour CT of which 14 (11.2%) were symptomatic. All cause mortality was 32.8% at 90 days with 25% of the patients achieving a modified Rankin Scale score of < or =2. CONCLUSIONS: These results suggest the Penumbra System allows safe and effective revascularization in patients experiencing ischemic stroke secondary to large vessel occlusive disease who present within 8 hours from symptom onset.

Treatment of Acute Vertebrobasilar Occlusion Using Thrombectomy with Stent Retrievers: Initial Experience with 18 Patients

Article

Full-text available

Nov 2012
AM J NEURORADIOL

Background and purpose: Acute vertebrobasilar occlusion is an ominous disease with few proved effective treatments. Experience with stent retrievers is scarce and limited to combined therapies (stent retrievers associated with previous intravenous fibrinolysis, intra-arterial thrombolysis, or other mechanical devices). We present our experience with 18 patients treated with direct thrombectomy by using stent retrievers. Materials and methods: Eighteen patients with vertebrobasilar occlusion were treated with direct thrombectomy by using stent retrievers at our hospital. The mean age was 67.5 years. Clinical presentation was sudden deterioration in consciousness level in 61.2% and progressive or fluctuating brain stem symptoms in 38.8%. Stroke subtype (TOAST) was atherothrombotic (33.3%), undetermined (33.3%), cardioembolic (27.7%), and of unusual etiology (5.5%). Results: The occlusion site was the vertebral artery in 1 case, proximal basilar artery in 4, middle basilar artery in 6, distal basilar artery in 5, and unilateral posterior cerebral artery in 2 cases. SRs included the Solitaire AB in 8 cases, Solitaire FR in 5 cases, and Trevo Pro in 5 cases. An 8F Merci balloon guide catheter was used in 15 patients, and a Neuron 6F, in 3 patients. Post-clot retrieval definitive intracranial stents were used in 5 patients (27.7%). Postprocedural TICI ≥ 2b was achieved in 17 patients (94.4%). Clinically, 72.2% of patients experienced an improved NIHSS score at discharge, 22.2% died, and in 5.5% the NIHSS scores did not change. The mRS score at 3 months was 0-2 in 9 patients (50%) and 3-5 in 5 patients (27.7%). Conclusions: Thrombectomy with stent retrievers is feasible in the treatment of vertebrobasilar occlusion. These initial results must be confirmed by further prospective studies with a larger number of cases.

Technical Feasibility and Application of Mechanical Thrombectomy with the Solitaire FR Revascularization Device in Acute Basilar Artery Occlusion

Article

Full-text available

Jun 2012
AM J NEURORADIOL

Background and purpose: Acute BAO is a devastating neurological condition associated with a poor clinical outcome and a high mortality rate. Recanalization has been identified as a major prognostic factor for good outcome in BAO. Mechanical thrombectomy using retrievable stents is an emerging treatment option for acute stroke. First clinical trials using stent retrievers have shown promising high recanalization rates. However, these studies mainly included large artery occlusions in the anterior circulation with only a few or single cases of BAO. Therefore, the purpose of this study was to evaluate technical feasibility, safety, and efficacy of mechanical thrombectomy using retrievable stent in the treatment of acute BAO. Materials and methods: Fourteen consecutive patients with BAO undergoing endovascular therapy using retrievable stents (Solitaire FR Revascularization Device) were included. Additional multimodal treatment approaches included thromboaspiration, intravenous and/or intra-arterial thrombolysis, and PTA/ permanent stent placement. Recanalization rates after multimodal therapy and stent retrieval were determined. Clinical outcome and mortality were assessed 3 months after treatment. Results: Median patient age was 64.5 years (range 55-85). Median NIHSS score at presentation was 21 (range 5-36). Overall, successful recanalization (TICI 3 or 2b) was achieved in all patients (TICI 3 in 78.6%, 11/14). In 4 patients (28.6%), insufficient recanalization after stent retrieval was due to an underlying atherosclerotic stenosis. Additional deployment of a permanent intracranial stent was performed in 3 patients (21.4%) and PTA alone in 1 patient (7.1%), resulting in final TICI 3 in 1 patient and TICI 2b in 3 patients. Stent retrieval alone was performed in 4 patients (28.6%). Average number of device passes was 1.3 (range 1-3). Median procedure time to maximal recanalization was 47 minutes (range 10-252). No device-related complications or thromboembolic occlusion of a previously unaffected artery occurred. There was no symptomatic intracranial hemorrhage. At 3 months, good functional outcome (mRS 0-2) was observed in 28.6% (4/14); overall mortality was 35.7% (5/14). Conclusions: A multimodal endovascular approach using retrievable stents in BAO has high recanalization rates, with very low complication rates. Underlying atherothrombotic stenotic lesions of the basilar artery may still necessitate additional permanent stent placement to achieve complete recanalization.

Outcome of forced-suction thrombectomy in acute intracranial internal carotid occlusion

Article

Full-text available

Apr 2012
J Neurointerv Surg

Objectives Ischemic stroke from acute intracranial distal internal carotid artery (ICA) occlusion usually carries a poor prognosis. Despite the intra-arterial revascularization therapies, the results are still unsatisfactory. The aim of this study was to compare the outcomes between two endovascular techniques, the modified Penumbra System (mPS) and mechanical clot disruption (MCD), and to confirm the influence of recanalization on the outcomes. Methods In a retrospective review of 39 consecutive cases of acute distal ICA occlusion, the recanalization rates and functional outcomes at 3 months of the two intra-arterial techniques during two consecutive periods (May 2006 to February 2009: MCD technique (n=19) vs March 2009 to August 2010: mPS technique (n=20)) were compared. Univariate and multivariate analyses were performed to determine the predictors of a favorable functional outcome. Results The rate of successful recanalization (Thrombolysis In Cerebral Infarction score 2 or 3) was significantly higher in the mPS group than in the MCD group (85% (17/20) vs 32% (6/19); p=0.001). Favorable outcomes at 3 months (modified Rankin Scale score 0–2) were achieved in 9/20 and 3/19 in the mPS and MCD groups, respectively (45% vs 16%; p=0.048). Binary logistic regression analysis showed that younger age and successful recanalization were independent predictors of a favorable functional outcome. Conclusions Forced-suction thrombectomy using the mPS technique may be a viable option for acute distal ICA occlusion and could result in more successful recanalization and a more positive clinical outcome.

Cyberknife radiosurgery in treating trigeminal neuralgia

Article

Full-text available

Jan 2012
J Neurointerv Surg

Purpose To assess the short term efficacy of Cyberknife stereotactic radiosurgical treatment of trigeminal neuralgia (TN). Methods 17 consecutive patients with medically or surgically refractory unilateral TN were treated with Cyberknife radiosurgery. Using superimposed CT cisternogram and MR images, the target segment of the trigeminal nerve was consistently defined as a 6 mm length of nerve approximately 2–3 mm distal to the dorsal root entry zone of the brainstem. A radiosurgical rhizotomy was performed with the Cyberknife utilizing a single collimator to deliver an average maximum dose of 73.06 Gy (range 72.91–73.73) to the target. Results Follow-up data were available for 16 of the 17 patients post-treatment (range 1–27 months, average 11.8 months). Overall, 14 of 16 (88%) patients responded favorably with either partial or complete relief of symptomatology. 11 of these patients were successfully free of all pain at some point in their post-treatment course, with seven patients pain free to the last follow-up visit (average 5.0 months, range 1–13 months). Symptoms recurred in four patients, taking place at 3, 7.75, 9 and 18 months after Cyberknife therapy. Only two patients reported side effects. One patient developed a bothersome feathery dysesthesia while the second patient reported a non-bothersome mild jaw hypoesthesia. There were no substantial complications related to stereotactic radiosurgery. Conclusion Cyberknife radiosurgery is a viable treatment alternative in patients with TN with competitive efficacy demonstrated in our group of patients while minimizing adverse effects.

Re: Perez et al 'Intracranial thrombectomy using the Solitaire stent: a historical vignette' Response

Article

Full-text available

Dec 2011
J Neurointerv Surg

The endovascular treatment of acute ischemic stroke has been revolutionized in the past years by the introduction of new devices for mechanical thrombectomy. Several tools were already available in 2008. The majority allowed the recanalization of acutely occluded intracranial arteries with acceptable levels of safety and efficacy, and with occasional failures. On 3 March 2008, a 67-year-old woman was treated 3.5 h after the clinical onset of a right hemispheric stroke due to an embolic middle cerebral artery (MCA) M1 occlusion. The National Institutes of Health Stroke Scale (NIHSS) score prior to treatment was 10. Mechanical thrombectomy with a microbrush yielded a significant amount of thrombotic material without recanalization. Given the urgency of the situation, the uncertain outcome in the case of a persistent occlusion of the right M1 segment and the fact that no other device was available, a Solitaire stent was deployed within the occluded right M1 segment. After several minutes of incubation, the expanded stent was slowly withdrawn under continuous aspiration with instantaneous removal of the entire thrombus and complete recanalization of the right MCA with reperfusion of the whole MCA supply territory. Digital subtraction angiography showed neither peripheral emboli nor vasospasm. The patient made a complete clinical recovery with an NIHSS score of 0 at the 30 day follow-up. The Solitaire stent was initially developed for the endovascular treatment of wide necked intracranial aneurysms but has been demonstrated to be safe and efficacious for intracranial thrombectomy. This was the first successful human clinical use of a Solitaire stent for this purpose and the ignition spark for the development of a whole generation of new devices, now called stent retrievers.

Endovascular therapy for acute basilar artery occlusion: A review of the literature

Article

Full-text available

Jul 2011
J Neurointerv Surg

Basilar artery occlusion is an infrequent form of acute stroke; clinical outcomes are heterogeneous, but the condition can be fatal. There is a lack of randomized controlled trial data in this field. Case series suggest that patients who are recanalized have much better outcomes than those who are not, and it is generally accepted that intra-arterial techniques achieve high rates of recanalization. Controversially, several studies, including a meta-analysis and registry-based investigation, that have compared intravenous thrombolysis (IVT) and intra-arterial treatment suggest similar outcomes. However, there are many potential sources of bias in each of these studies, precluding a firm conclusion. Indeed, there are many confounding factors that can influence the outcome including severity of presentation, site of occlusion, clot load, degree of collateral flow, timing of therapy, agent used for recanalization and dose of thrombolytic agent. Additionally, pretreatment infarct core imaging using diffusion-weighted imaging and the posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) scoring systems have been shown to predict outcome and therefore may be useful in selecting patients for aggressive therapy. Protocols combining intravenous agents such as glycoprotein IIb/IIIa receptor antagonists or thombolytics agents with intra-arterial techniques ('bridging' therapy) have shown encouraging improvements in neurological outcome and survival. Furthermore, initial case series describing the use of mechanical clot extraction devices or aspiration catheters suggest high rates of recanalization. What would be useful is a randomized trial comparing IVT, endovascular approaches and a combined IVT/endovascular approach. However, the small numbers of patients and multiple confounding factors are barriers to the development of such a trial.

Direct Thrombus Retrieval Using the Reperfusion Catheter of the Penumbra System: Forced-Suction Thrombectomy in Acute Ischemic Stroke

Article

Full-text available

Nov 2010
AM J NEURORADIOL

Although the PS has been the most promising mechanical thrombectomy device in terms of recanalization rates, even the PS cannot recanalize all cases of occlusion. Under such circumstances, we simply modified the PS, identified certain advantages, and applied this modification as a primary technique for recanalization. Here we describe and discuss the technical details and results of our preliminary experience. This study included 22 consecutive patients with acute ischemic stroke secondary to large-artery occlusion who underwent modified thrombectomy by using the PS for recanalization. Direct wedging between the tip of the reperfusion catheter and the proximal part of the clot followed by forceful suction by using a 20- or 50-mL syringe is a unique feature of this technique. What is distinctive is that this does not require use of a separator or aspiration pump. All treated vessels (100%) were successfully recanalized. A TICI scale of 2b or 3 was achieved in 81.9% of patients. A 3-month favorable functional outcome (mRS score, 0-2) was achieved in 45.5% of patients. The only procedural complication was a transient dissection of the proximal ICA, which developed while advancing the guide catheter. Forced-suction thrombectomy is a simple modification of the PS. On the basis of our data, this technique allows safe and effective revascularization in acute large-vessel occlusion. Thus, for achieving the best outcome, the modified PS technique is proposed as a viable option for acute stroke management, either by itself or in conjunction with other devices or drugs.

Occurrence and Predictors of Futile Recanalization following Endovascular Treatment among Patients with Acute Ischemic Stroke: A Multicenter Study

Article

Full-text available

Mar 2010
AM J NEURORADIOL

Although recanalization is the goal of thrombolysis, it is well recognized that it fails to improve outcome of acute stroke in a subset of patients. Our aim was to assess the rate of and factors associated with "futile recanalization," defined by absence of clinical benefit from recanalization, following endovascular treatment of acute ischemic stroke. Data from 6 studies of acute ischemic stroke treated with mechanical and/or pharmacologic endovascular treatment were analyzed. "Futile recanalization" was defined by the occurrence of unfavorable outcome (mRS score of > or = 3 at 1-3 months) despite complete angiographic recanalization (Qureshi grade 0 or TIMI grade 3). Complete recanalization was observed in 96 of 270 patients treated with IA thrombolysis. Futile recanalization was observed in 47 (49%). In univariate analysis, patients with futile recanalization were older (73 +/- 11 versus 58 +/- 15 years, P < .0001) and had higher median initial NIHSS scores (19 versus 14, P < .0001), more frequent BA occlusion (17% versus 4%, P = .049), less frequent MCA occlusion (53% versus 76%, P = .032), and a nonsignificantly higher rate of symptomatic hemorrhagic complications (2% versus 9%, P = .2). In logistic regression analysis, futile recanalization was positively associated with age > 70 years (OR, 4.4; 95% CI, 1.9-10.5; P = .0008) and initial NIHSS score 10-19 (OR, 3.8; 95% CI, 1.7-8.4; P = .001), and initial NIHSS score > or = 20 (OR, 64.4; 95% CI, 28.8-144; P < .0001). Futile recanalization is a relatively common occurrence following endovascular treatment, particularly among elderly patients and those with severe neurologic deficits.

Mechanical thrombectomy with the Solitaire AB revascularization device in acute basilar artery occlusion: initial experience

Article

Sep 2013

Objective: To explore and evaluate the efficacy and safety of mechanical thrombectomy with the Solitaire AB Revascularization Device in acute basilar artery occlusion. Methods: Nine patients with basilar artery occlusion were treated with direct thrombectomy by using Solitaire AB stent retrievers between August 2010 and October 2012. Stent angioplasty was performed for patients with serious residual stenosis. Neurologic status was evaluated before and after treatment according to the National Institutes of Health Stroke Scale (NIHSS) and modified Rankin scales (mRs). Neurologic status was evaluated after treatment according to the NIHSS and mRs 6 months after stent placement. Stent patency at follow-up was assessed by MR angiography, or DSA 6 months after stent placement. Results: Successful revascularization was achieved in all patients. Stenting and angioplasty were performed in 6 patients with serious residual stenosis. The complication of cerebral hemorrhage did not occur in any patient. Acute thrombosis happened in one patient one day after procedure. Emergent angiography showed re-occlusion of basilar artery. Intraarterial thrombolytic therapy was given, and reperfusion was achieved, but the patient died 6 days later. One patient developed coma at 4th month of follow-up. MRA showed acute basilar artery occlusion again and magnetic resonance imaging showed extensive ischemic damage of the brainstem. The patient died during the conservative treatment period. The mean NIHSS scores were 2.4 ± 1.2 at discharge. The mRs scores were 0 in 2 patients, 1 in 4 patients, 2 in one patient, and 3 in 1 patient at discharge. Conclusion: Mechanical thrombectomy with the Solitaire AB stent in acute basilar artery occlusion is relatively safe and effective.

Guidelines for the Early Management of Adults With Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists

Article

Apr 2007
STROKE

Purpose: Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included. Methods: Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council's Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years. Results: Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.

Intracerebral hemorrhage after intravenous t-PA therapy for ischemic stroke. The NINDS t-PA Stroke Study Group No authors Stroke 1997 28 2109 2118 10.1161/01.STR.28.11.2109

Article

Nov 1997

T. N. t-P. S. S. Group

Background and Purpose We sought to identify variables associated with intracerebral hemorrhage in patients with acute ischemic stroke who receive tissue plasminogen activator (t-PA). Methods We performed subgroup analyses of data from a randomized, double-blind, placebo-controlled trial of intravenous t-PA administered to stroke patients within 3 hours of onset. Using multivariable regression modeling procedures, we assessed the relationship of baseline and after-treatment variables with symptomatic and asymptomatic intracerebral hemorrhage during the first 36 hours after treatment. Results Overall, t-PA–treated patients had an increase in the absolute risk of symptomatic intracerebral hemorrhage of 6% and a decrease in the absolute risk of 3-month mortality of 4% compared with placebo-treated patients. The only variables independently associated with an increased risk of symptomatic intracerebral hemorrhage in the final multivariable logistic regression model for the 312 t-PA–treated patients were the severity of neurological deficit as measured by the National Institutes of Health Stroke Scale score (five categories; odds ratio [OR], 1.8; 95% confidence interval [CI], 1.2 to 2.9) and brain edema (defined as acute hypodensity) or mass effect by CT before treatment (OR, 7.8; 95% CI, 2.2 to 27.1). This final model correctly predicted those t-PA–treated patients who would or would not have a symptomatic hemorrhage with only 57% efficiency. In the subgroup of patients with a severe neurological deficit, t-PA–treated patients were more likely than placebo-treated patients to have a favorable 3-month outcome (adjusted OR based on multiple outcomes, 4.3; 95% CI, 1.6 to 11.9). These results were similar for the subgroup with edema or mass effect by CT (adjusted OR, 3.4; 95% CI, 0.6 to 20.7). The likelihood of severe disability or death was similar for t-PA–and placebo-treated patients with these two baseline characteristics. Conclusions Despite a higher rate of intracerebral hemorrhage, patients with severe strokes or edema or mass effect on the baseline CT are reasonable candidates for t-PA, if it is administered within 3 hours of onset.

Mechanical thrombectomy with the Solitaire stent: Is there a learning curve in achieving rapid recanalization times?

Article

Oct 2013
J Neurointerv Surg

In acute ischemic stroke, good outcome following successful recanalization is time dependent. In patients undergoing endovascular therapy at our institution, recanalization times with the Solitaire stent were retrospectively evaluated to assess for the presence of a learning curve in achieving rapid recanalization. We reviewed patients who presented to our stroke center and achieved successful recanalization with the Solitaire stent exclusively. Time intervals were calculated (CT to angiography arrival, angiography arrival to groin puncture, groin puncture to first deployment, and deployment to recanalization) from time stamped images and angiography records. Patients were divided into three sequential groups, with overall CT to recanalization time and subdivided time intervals compared. 83 patients were treated with the Solitaire stent from May 2009 to February 2012. Recanalization (Thrombolyis in Cerebral Infarction score 2A) occurred in 75 (90.4%) patients. CT to recanalization demonstrated significant improvement over time, which was greatest between the first 25 and the most recent 25 cases (161-94 min; p<0.01). The maximal contribution to this was from improvements in first stent deployment to recanalization time (p=0.001 between the first and third groups), with modest contributions from moving patients from CT to the angiography suite faster (p=0.02 between the first and third groups) and from groin puncture to first stent deployment (p=0.02 between the first and third groups). There is a learning curve involved in the efficient use of the Solitaire stent in endovascular acute stroke therapy. Along with improvements in patient transfer to angiography and improved efficiency with intracranial access, mastering this device contributed significantly towards reducing recanalization times.

Mechanical thrombectomy with the Solitaire device in acute basilar artery occlusion

Article

May 2013
J Neurointerv Surg

Aims: To evaluate the efficacy and safety of mechanical thrombectomy with the Solitaire FR device in revascularization of patients with acute basilar artery occlusion (ABAO) and to identify the predictive factors for clinical outcome. Methods: This prospective single-center study included 31 patients with acute ischemic stroke attributable to ABAO treated within the first 24 h after onset of symptoms with the Solitaire device. Nineteen patients simultaneously received intravenous thrombolysis. Recanalization rates after stent retrieval were determined and the clinical outcome and mortality rate were assessed 180 days after treatment. Results: The mean ±SD age of the patients was 61±17 years, the median prethrombectomy NIH Stroke Scale score was 38 (IQR 9-38) and the median Glasgow Coma Scale (GCS) score was 7 (IQR 4-14). Successful recanalization (TICI 3 or 2b) was achieved in 23 patients (74%). Five symptomatic intracranial hemorrhages were related to the procedure. Ten symptomatic distal migrations of thrombotic material occurred. A favorable outcome, defined as a modified Rankin Score (mRS) of 0-2, was observed in 35% of patients (11/31). Overall mortality rate was 32% (10/31). In the univariate analysis, elevated baseline glucose (p=0.008) was significantly associated with a poor outcome (mRS >2), whereas a tendency towards significance was observed with age (p=0.06), GCS on admission (p=0.07) and symptom-related lesions on T2 sequences (p=0.10). Patients with successful recanalization tended to have a better outcome (p=0.20). Conclusion: Mechanical thrombectomy with the Solitaire FR device can rapidly and effectively contribute to a high rate of recanalization and improve functional outcome in patients with ABAO and has an acceptable complication rate.

Initial clinical experience with the ADAPT technique: A direct aspiration first pass technique for stroke thrombectomy

Article

Apr 2013
J Neurointerv Surg

Background: The development of new revascularization devices has improved recanalization rates and time but not clinical outcomes. We report our initial results with a new technique utilizing a direct aspiration first pass technique with a large bore aspiration catheter as the primary method for vessel recanalization. Methods: A retrospective evaluation of a prospectively captured database of 37 patients at six institutions was performed on patients where the ADAPT technique was utilized. The data represent the initial experience with this technique. Results: The ADAPT technique alone was successful in 28 of 37 (75%) cases although six cases had large downstream emboli that required additional aspiration. Nine cases required the additional use of a stent retriever and one case required the addition of a Penumbra aspiration separator to achieve recanalization. The average time from groin puncture to at least Thrombolysis in Cerebral Ischemia (TICI) 2b recanalization was 28.1 min, and all cases were successfully revascularized. TICI 3 recanalization was achieved 65% of the time. On average, patients presented with an admitting National Institutes of Health Stroke Scale (NIHSS) score of 16.3 and improved to an NIHSS score of 4.2 by the time of hospital discharge. There was one procedural complication. Discussion: This initial experience highlights the fact that the importance of the technique with which new stroke thrombectomy devices are used may be as crucial as the device itself. The ADAPT technique is a simple and effective approach to acute ischemic stroke thrombectomy. Utilizing the latest generation of large bore aspiration catheters in this fashion has allowed us to achieve excellent clinical and angiographic outcomes.

Recent advances in neuroendovascular therapy

Article

Feb 2013

The field of neurointerventional surgery has grown in recent years. Endovascular therapies for both ischemic stroke and intracranial aneurysms have become important components in the multimodal treatment of these conditions. Familiarity with these treatment options by general neurologists is important for patient care. This article reviews recent trials and devices representing important advances in the field.

Solitaire flow restoration device versus the MERCI Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial

Article

Aug 2012
LANCET

The Solitaire Flow Restoration Device is a novel, self-expanding stent retriever designed to yield rapid flow restoration in acute cerebral ischaemia. We compared the efficacy and safety of Solitaire with the standard, predicate mechanical thrombectomy device, the Merci Retrieval System. In this randomised, parallel-group, non-inferiority trial, we enrolled patients from 18 sites (17 in the USA and one in France). Patients were eligible for inclusion if they had acute ischaemic stroke with moderate to severe neurological deficits and were treatable by thrombectomy within 8 h of stroke symptom onset. We used a computer-generated randomisation sequence to randomly allocate patients to receive thrombectomy treatment with either Solitaire or Merci (1:1; block sizes of four and stratified by centre and stroke severity). The primary endpoint was Thrombolysis In Myocardial Ischemia (TIMI) scale 2 or 3 flow in all treatable vessels without symptomatic intracranial haemorrhage, after up to three passes of the assigned device, as assessed by an independent core laboratory, which was masked to study assignment. Primary analysis was done by intention to treat. A prespecified efficacy stopping rule triggered an early halt to the trial. The study is registered with ClinicalTrials.gov, number NCT 01054560. Between February, 2010, and February, 2011, we randomly allocated 58 patients to the Solitaire group and 55 patients to the Merci group. The primary efficacy outcome was achieved more often in the Solitaire group than it was in the Merci group (61%vs 24%; difference 37% [95% CI 19-53], odds ratio [OR] 4·87 [95% CI 2·14-11·10]; p(non-inferiority)<0·0001, p(superiority)=0·0001). More patients had good 3-month neurological outcome with Solitaire than with Merci (58%vs 33%; difference 25% [6-43], OR 2·78 [1·25-6·22]; p(non-inferiority)=0·0001, p(superiority)=0·02). 90-day mortality was lower in the Solitaire group than it was in the Merci group (17 vs 38; difference -21% [-39 to -3], OR 0·34 [0·14-0·81]; p(non-inferiority)=0·0001, p(superiority)=0·02). The Solitaire Flow Restoration Device achieved substantially better angiographic, safety, and clinical outcomes than did the Merci Retrieval System. The Solitaire device might be a future treatment of choice for endovascular recanalisation in acute ischaemic stroke. Covidien/ev3.

Authors' response to Derdeyn CP, Aguilar, et al.

Article

Mar 2012
J Neurointerv Surg

'Racoon eyes' from a stent placement

Article

Mar 2012
J Neurointerv Surg

Gregory Y Chang

Treatment and outcomes of acute basilar artery occlusion in the Basilar Artery International Cooperation Study (BASICS): a prospective registry study

Article

Sep 2009
LANCET NEUROL

Treatment strategies for acute basilar artery occlusion (BAO) are based on case series and data that have been extrapolated from stroke intervention trials in other cerebrovascular territories, and information on the efficacy of different treatments in unselected patients with BAO is scarce. We therefore assessed outcomes and differences in treatment response after BAO. The Basilar Artery International Cooperation Study (BASICS) is a prospective, observational registry of consecutive patients who presented with an acute symptomatic and radiologically confirmed BAO between November 1, 2002, and October 1, 2007. Stroke severity at time of treatment was dichotomised as severe (coma, locked-in state, or tetraplegia) or mild to moderate (any deficit that was less than severe). Outcome was assessed at 1 month. Poor outcome was defined as a modified Rankin scale score of 4 or 5, or death. Patients were divided into three groups according to the treatment they received: antithrombotic treatment only (AT), which comprised antiplatelet drugs or systemic anticoagulation; primary intravenous thrombolysis (IVT), including subsequent intra-arterial thrombolysis; or intra-arterial therapy (IAT), which comprised thrombolysis, mechanical thrombectomy, stenting, or a combination of these approaches. Risk ratios (RR) for treatment effects were adjusted for age, the severity of neurological deficits at the time of treatment, time to treatment, prodromal minor stroke, location of the occlusion, and diabetes. 619 patients were entered in the registry. 27 patients were excluded from the analyses because they did not receive AT, IVT, or IAT, and all had a poor outcome. Of the 592 patients who were analysed, 183 were treated with only AT, 121 with IVT, and 288 with IAT. Overall, 402 (68%) of the analysed patients had a poor outcome. No statistically significant superiority was found for any treatment strategy. Compared with outcome after AT, patients with a mild-to-moderate deficit (n=245) had about the same risk of poor outcome after IVT (adjusted RR 0.94, 95% CI 0.60-1.45) or after IAT (adjusted RR 1.29, 0.97-1.72) but had a worse outcome after IAT compared with IVT (adjusted RR 1.49, 1.00-2.23). Compared with AT, patients with a severe deficit (n=347) had a lower risk of poor outcome after IVT (adjusted RR 0.88, 0.76-1.01) or IAT (adjusted RR 0.94, 0.86-1.02), whereas outcomes were similar after treatment with IAT or IVT (adjusted RR 1.06, 0.91-1.22). Most patients in the BASICS registry received IAT. Our results do not support unequivocal superiority of IAT over IVT, and the efficacy of IAT versus IVT in patients with an acute BAO needs to be assessed in a randomised controlled trial. Department of Neurology, University Medical Center Utrecht.

High-resolution computed tomography of the basilar artery: I. Normal size and position

Article

Jan 1986

Normal high-resolution computed tomographic (CT) scans of 126 patients were reviewed to define the diameter, height of the bifurcation, and transverse position of the normal basilar artery. The mean diameter of the normal basilar artery is 3.17 mm at the level of the pons. In 92% of normal subjects, the basilar bifurcation is located in the interpeduncular cistern adjacent to the dorsum sellae or in the suprasellar cistern below the level of the floor of the third ventricle. In 98% of normal individuals, the basilar artery courses in the midline or in a paramedian position, medial to the lateral margins of the clivus and dorsum sellae.

Trial Design and Reporting Standards for Intra-Arterial Cerebral Thrombolysis for Acute Ischemic Stroke

Article

Aug 2003
STROKE

Background and purpose: The National Institutes of Health (NIH) estimates that stroke costs now exceed 45 billion dollars per year. Stroke is the third leading cause of death and one of the leading causes of adult disability in North America, Europe, and Asia. A number of well-designed randomized stroke trials and case series have now been reported in the literature to evaluate the safety and efficacy of thrombolytic therapy for the treatment of acute ischemic stroke. These stroke trials have included intravenous studies, intra-arterial studies, and combinations of both, as well as use of mechanical devices for removal of thromboemboli and of neuroprotectant drugs, alone or in combination with thrombolytic therapy. At this time, the only therapy demonstrated to improve outcomes from an acute stroke is thrombolysis of the clot responsible for the ischemic event. There is room for improvement in stroke lysis studies. Divergent criteria, with disparate reporting standards and definitions, have made direct comparisons between stroke trials difficult to compare and contrast in terms of overall patient outcomes and efficacy of treatment. There is a need for more uniform definitions of multiple variables such as collateral flow, degree of recanalization, assessment of perfusion, and infarct size. In addition, there are multiple unanswered questions that require further investigation, in particular, questions as to which patients are best treated with thrombolysis. One of the most important predictors of clinical success is time to treatment, with early treatment of <3 hours for intravenous tissue plasminogen activator and <6 hours for intra-arterial thrombolysis demonstrating significant improvement in terms of 90-day clinical outcome and reduced cerebral hemorrhage. It is possible that improved imaging that identifies the ischemic penumbra and distinguishes it from irreversibly infarcted tissue will more accurately select patients for therapy than duration of symptoms. There are additional problems in the assessment of patients eligible for thrombolysis. These include being able to predict whether a particular site of occlusion can be successfully revascularized, predict an individual patient's prognosis and outcome after revascularization, and in particular, to predict the development of intracerebral hemorrhage, with and without clinical deterioration. It is not clear to assume that achieving immediate flow restoration due to thrombolytic therapy implies clinical success and improved outcome. There is no simple correlation between recanalization and observed clinical benefit in all ischemic stroke patients, because other interactive variables, such as collateral circulation, the ischemic penumbra, lesion location and extent, time to treatment, and hemorrhagic conversion, are all interrelated to outcome. Methods: This article was written under the auspices of the Technology Assessment Committees for both the American Society of Interventional and Therapeutic Neuroradiology and the Society of Interventional Radiology. The purpose of this document is to provide guidance for the ongoing study design of trials of intra-arterial cerebral thrombolysis in acute ischemic stroke. It serves as a background for the intra-arterial thrombolytic trials in North America and Europe, discusses limitations of thrombolytic therapy, defines predictors for success, and offers the rationale for the different considerations that might be important during the design of a clinical trial for intra-arterial thrombolysis in acute stroke. Included in this guidance document are suggestions for uniform reporting standards for such trials. These definitions and standards are mainly intended for research trials; however, they should also be helpful in clinical practice and applicable to all publications. This article serves to standardize reporting terminology and includes pretreatment assessment, neurologic evaluation with the NIH Stroke Scale score, imaging evaluation, occlusion sites, perfusion grades, follow-up imaging studies, and neurologic assessments. Moreover, previously used and established definitions for patient selection, outcome assessment, and data analysis are provided, with some possible variations on specific end points. This document is therefore targeted to help an investigator to critically review the scales and scores used previously in stroke trials. This article also seeks to standardize patient selection for treatment based on neurologic condition at presentation, baseline imaging studies, and utilization of standardized inclusion/exclusion criteria. It defines outcomes from therapy in phase I, II, and III studies. Statistical approaches are presented for analyzing outcomes from prospective, randomized trials with both primary and secondary variable analysis. A discussion on techniques for angiography, intra-arterial thrombolysis, anticoagulation, adjuvant therapy, and patient management after therapy is given, as well as recommendations for posttreatment evaluation, duration of follow-up, and reporting of disability outcomes. Imaging assessment before and after treatment is given. In the past, noncontrast CT brain scans were used as the initial screening examination of choice to exclude cerebral hemorrhage. However, it is now possible to quantify the volume of early infarct by using contiguous, discrete (nonhelical) images of 5 mm. In addition, CT angiography by helical scanning and 100 mL of intravenous contrast agent can be used expeditiously to obtain excellent vascular anatomy, define the occlusion site, obtain 2D and 3D reformatted vascular images, grade collateral blood flow, and perform tissue-perfusion studies to define transit times of a contrast bolus through specific tissue beds and regions of interest in the brain. Dynamic CT perfusion scans to assess the whole dynamics of a contrast agent transit curve can now be routinely obtained at many hospitals involved in these studies. The rationale, current status of this technology, and potential use in future clinical trials are given. Many hospitals are also performing MR brain studies at baseline in addition to, or instead of, CT scans. MRI has a high sensitivity and specificity for the diagnosis of ischemic stroke in the first several hours from symptom onset, identifies arterial occlusions, and characterizes ischemic pathology noninvasively. Case series have demonstrated and characterized the early detection of intraparenchymal hemorrhage and subarachnoid hemorrhage by MRI. Echo planar images, used for diffusion MRI and, in particular, perfusion MRI are inherently sensitive for the susceptibility changes caused by intraparenchymal blood products. Consequently, MRI has replaced CT to rule out acute hemorrhage in some centers. The rationale and the potential uses of MR scanning are provided. In addition to established criteria, technology is continuously evolving, and imaging techniques have been introduced that offer new insights into the pathophysiology of acute ischemic stroke. For example, a better patient stratification might be possible if CT and/or MRI brain scans are used not only as exclusion criteria but also to provide individual inclusion and exclusion criteria based on tissue physiology. Imaging techniques might also be used as a surrogate outcome measure in future thrombolytic trials. The context of a controlled study is the best environment to validate emerging imaging and treatment techniques. The final section details reporting standards for complications and adverse outcomes; defines serious adverse events, adverse events, and unanticipated adverse events; and describes severity of complications and their relation to treatment groups. Recommendations are made regarding comparing treatment groups, randomization and blinding, intention-to-treat analysis, quality-of-life analysis, and efficacy analysis. This document concludes with an analysis of general costs associated with therapy, a discussion regarding entry criteria, outcome measures, and the variability of assessment of the different stroke scales currently used in the literature is also featured. Conclusions: In summary, this article serves to provide a more uniform set of criteria for clinical trials and reporting outcomes used in designing stroke trials involving intra-arterial thrombolytic agents, either alone or in combination with other therapies. It is anticipated that by having a more uniform set of reporting standards, more meaningful analysis of the data and the literature will be able to be achieved.

Treatment of vertebrobasilar occlusion by using a coronary waterjet thrombectomy device: A pilot study

Article

Jun 2005

Despite improved patient outcomes because of intraarterial fibrinolysis, vertebrobasilar thromboembolism remains a fatal disease with a death rate of more than 50%. The outcome depends on the success of recanalization. Fibrinolysis achieves recanalization in only 50%-70% of the cases. Therefore, we investigated the feasibility of using a coronary mechanical device to increase the recanalization rate. Twelve patients with acute vertebrobasilar occlusion were included in the pilot study. The older 5F and the new 4F versions of the Possis Angiojet catheter, which use a waterjet to attract, fragment, and extract the thrombus, were used. Inclusion depended on the presence of acute multisegmental intracranial or any extracranial vertebrobasilar occlusion. Exclusion criteria included coma lasting >8 hours and age >80. The Angiojet treatment did not exclude other therapeutic options. The Angiojet catheter accessed the thrombosed site in 10 of 12 patients. Combined treatment with the Angiojet and additional fibrinolysis or angioplasty resulted in a recanalization rate of 100%. Of 37 occluded vertebrobasilar segments, 30 were primarily recanalized with the Angiojet. Three symptomatic and two asymptomatic hemorrhages were detected by CT. Five of the 12 patients died. Fifty percent of all patients obtained a moderate to excellent outcome (Modified Rankin Scale 0-3). Use of the coronary Angiojet in the vertebrobasilar system is feasible. The device has the potential to increase the recanalization rate, especially in cases of extensive thrombosis, and, thus, improve patient outcomes.

The Impact of Recanalization on Ischemic Stroke Outcome: A Meta-Analysis

Article

Apr 2007
STROKE

For a biomarker to serve as an auxiliary or surrogate outcome measure, it must be tightly correlated with and causally related to functional clinical outcome. Vessel recanalization is a potential surrogate outcome marker for functional outcome in trials of thrombolytic and mechanical recanalization therapies in acute stroke, but the correlation of recanalization and clinical outcome has not been previously systematically reviewed. Through Medline search, we identified and abstracted recanalization and outcome data from all articles published between 1985 and 2002 that assessed vessel recanalization, either spontaneous or therapeutically induced, in acute ischemic stroke. Fifty-three studies encompassing 2066 patients reported recanalization rates. Recanalization rates categorized according to intervention were: spontaneous (24.1%), intravenous fibrinolytic (46.2%), intra-arterial fibrinolytic (63.2%), combined intravenous-intra-arterial (67.5%), and mechanical (83.6%). Clinical outcome data categorized by success or failure in achieving recanalization was available from 33 articles encompassing 998 patients. Good functional outcomes at 3 months were more frequent in recanalized versus nonrecanalized patients with odds ratio of 4.43 (95% CI, 3.32 to 5.91). Three-month mortality was reduced in recanalized patients (odds ratio, 0.24; 95% CI, 0.16 to 0.35). Rates of symptomatic hemorrhagic transformation did not differ between the 2 groups (odds ratio, 1.11; 95% CI, 0.71 to 1.74). Formal meta-analysis confirms a strong correlation between recanalization and outcome in acute ischemic stroke. Recanalization is strongly associated with improved functional outcomes and reduced mortality. These findings suggest that recanalization is an appropriate biomarker of therapeutic activity in early phase trials of thrombolytic treatment in acute ischemic stroke.

Vertebrobasilar revascularization rates and outcomes in the MERCI and Multi MERCI trials

Article

Mar 2008

Mortality of 40% to 86% and good outcomes in only 13% to 21% of patients beg for treatment options for basilar occlusion. This study determined outcomes of patients with vertebrobasilar occlusion treated with mechanical embolus removal in cerebral ischemia (MERCI) retriever mechanical thrombectomy. Patients with vertebrobasilar occlusion in the MERCI and Multi-MERCI trials received treatment up to 8 hours after symptom onset. Recanalization was determined after retriever use and adjunctive therapy. Mortality and good outcomes, modified Rankin scale score 0-3, were determined at 90 days in patients who were recanalized and not recanalized. Recanalization occurred in 21 of 27 (78%) patients. Mortality was 44% and good outcomes were seen in 41%. Patients with recanalization tended to have better outcomes than those without. Outcomes in patients with vertebrobasilar occlusions treated with the MERCI retriever compared favorably with natural history reports and tended to be better in those patients with recanalization.

Intracerebral hemorrhage after intravenous t-PA therapy for ischemic stroke

Jan 1997
2109

The NINDS t-PA Stroke Study Group

Comparison of Solitaire thrombectomy and Penumbra suction thrombectomy in patients with acute ischemic stroke caused by basilar artery occlusion

Abstract

No full-text available

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