Mechanical Thrombectomy in Patients With Milder Strokes and Large Vessel Occlusions A Multicenter Matched Analysis

Background and Purpose-We aimed to describe the safety and efficacy of immediate mechanical thrombectomy (MT) in patients with large vessel occlusions and low National Institutes of Health Stroke Scale (NIHSS) versus best medical management. Methods-Patients from prospectively collected databases of 6 international comprehensive stroke centers with large vessel occlusions (distal intracranial internal carotid, middle cerebral artery-M1 and M2 segments, or basilar artery with or without tandem occlusions) and NIHSS 0 to 5 were identified and divided into 2 groups for analysis: immediate MT or initial best medical management which included rescue MT after neurological deterioration (best medical management-MT). Uni- and multivariate analyses and patient-level matching for age, baseline NIHSS, and occlusion site were performed to compare baseline and outcome variables across the 2 groups. The primary outcome was defined as good outcome (modified Rankin Scale score, 0-2) at day 90. Safety outcome was symptomatic intracranial hemorrhage as defined by the ECASS (European Cooperative Acute Stroke Study) II and mortality at day 90. Results: Compared with best medical management-MT (n=220), patients with immediate MT (n=80) were younger (65.3 +/- 13.5 versus 69.5 +/- 14.1;P=0.021), had more often atrial fibrillation (44.8% versus 28.2%;P=0.012), higher baseline NIHSS (4, 0-5 versus 3, 0-5;P=0.005), higher Alberta Stroke Program Early CT Score (10, 7-10 versus 10, 5-10;P=0.023), more middle cerebral artery-M1, and less middle cerebral artery-M2 (41.3% versus 21.9% and 28.8% versus 49.3%;P=0.016) occlusions. The adjusted odds ratio for good outcome was 3.1 (95% CI, 1.4-6.9) favoring immediate MT. In the matched analysis, there was a 14.4% absolute difference in good outcome (84.4% versus 70.1%;P=0.03) at day 90 favoring immediate MT. There were no safety concerns. Conclusions: Our retrospective, pilot analysis suggests that immediate thrombectomy in large vessel occlusions patients with low NIHSS on presentation may be safe and has the potential to result in improved outcomes. Randomized clinical trials are warranted to establish the optimal management for this patient population

First clinical multicenter experience with the new Scepter Mini microballoon catheter

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Order of Treatment Matters in Ischemic Stroke: Mechanical Thrombectomy First, Then Carotid Artery Stenting for Tandem Lesions of the Anterior Circulation

Background: One endovascular treatment option of acute ischemic stroke due to tandem occlusion (TO) comprises intracranial thrombectomy and acute extracranial carotid artery stenting (CAS). In this setting, the order of treatment may impact the clinical outcome in this stroke subtype. Methods: Retrospective analysis was performed on data prospectively collected in 4 international stroke centers between 2013 and 2017. One hundred sixty-five patients with anterior TO were treated by endovascular therapy. Clinical and procedural data were evaluated. Favorable clinical outcome was defined as modified Rankin Scale (mRS) = 2 at 90 days. Propensity score matching was performed for different treatment strategies. Results: Patients' mean age was 65 +/- 11 years and 118 were male (69%). The median admission National Institutes of Health Stroke Scale was 15 (interquartile range 8). In 59% of the patients (n = 101), the antegrade strategy (first stenting, then thrombectomy) was -performed, in 41% (n = 70) retrograde treatment (first thrombectomy, then stenting). Successful reperfusion (mTICI = 2b) was achieved in 128 patients (75%). Fifty-nine patients (39%) showed a favorable clinical outcome after 90 days. After propensity score matching, data of 100 patients could be analyzed. Analysis revealed that the retrograde strategy yielded a significantly higher rate of successful reperfusion compared to the antegrade strategy (92 vs. 56%; p < 0.001). The rate of favorable clinical outcome after 90 days (mRS = 2) was consistently higher (44 vs. 30%; p < 0.05) in the retrograde strategy group. Conclusion: Mechanical thrombectomy prior to acute CAS in TO is a predictive factor for favorable clinical outcome at 90 days. (c) 2018 S. Karger AG, Base

Automated Perfusion Calculations vs. Visual Scoring of Collaterals and CBV-ASPECTS Has the Machine Surpassed the Eye?

Purpose Use of automated perfusion software has gained importance for imaging of stroke patients for mechanical thrombectomy (MT). We aim to compare four perfusion software packages: 1) with respect to their association with 3-month functional outcome after successful reperfusion with MT in comparison to visual Cerebral Blood Volume - Alberta Stroke Program Early CT Score (CBV-ASPECTS) and collateral scoring and 2) with respect to their agreement in estimation of core and penumbra volume. Methods This retrospective, multicenter cohort study (2015-2019) analyzed data from 8 centers. We included patients who were functionally independent before and underwent successful MT of the middle cerebral artery. Primary outcome measurements were the relationship of core and penumbra volume calculated by each software, qualitative assessment of collaterals and CBV-APECTS with 3-month functional outcome and disability (modified Rankin scale >2). Quantitative differences between perfusion software measurements were also assessed. Results A total of 215 patients (57% women, median age 77 years) from 8 centers fulfilled the inclusion criteria. Multivariable analyses showed a significant association of RAPID core (common odds ratio, cOR 1.02; p = 0.015), CBV-ASPECTS (cOR 0.78; p = 0.007) and collaterals (cOR 0.78; p = 0.001) with 3-month functional outcome (shift analysis), while RAPID core (OR 1.02; p = 0.018), CBV-ASPECTS (OR 0.77; p = 0.024), collaterals (OR 0.78; p = 0.007) and OLEA core (OR 1.02; p = 0.029) were significantly associated with 3-month functional disability. Mean differences on core estimates between VEOcore and RAPID were 13.4 ml, between syngo.via and RAPID 30.0 ml and between OLEA and RAPID -3.2 ml. Conclusion Collateral scoring, CBV-ASPECTS and RAPID were independently associated with functional outcome at 90 days. Core and Penumbra estimates using automated software packages varied significantly and should therefore be used with caution

CLinical EValuation of WEB 17 device in intracranial aneuRysms (CLEVER) : procedural, 30-day and 1-year safety results for ruptured and unruptured aneurysms

BackgroundIntrasaccular flow disruption is an endovascular approach for the treatment of wide-neck aneurysms and, more specifically, wide-neck bifurcation aneurysms, which are challenging to treat with previously developed technologies. The Woven EndoBridge (WEB) device has demonstrated its efficacy and safety, for both unruptured and ruptured aneurysms.MethodsThe CLEVER study was an observational, multicenter, prospective study conducted in 17 European investigational sites using the WEB 17 device, for the treatment of ruptured and unruptured aneurysms. The study objective was to provide safety and efficacy data on the WEB 17 device in the treatment of wide-neck bifurcation aneurysms. Imaging results were assessed independently by a Corelab and adverse events adjudicated by a Clinical Event Adjudicator. This analysis reports procedural results and safety at 30 days and 12 months.ResultsA total of 163 patients (mean age 58.1 years; 68.1% women) with 103 unruptured aneurysms and 60 ruptured aneurysms were enrolled. Most aneurysms were located on the anterior communicating artery (ACom) (37.4%) or the middle cerebral artery (MCA) bifurcation (30.1%). Aneurysm widths ranged from 2.0-9.2 mm, and the mean sac width was 5.0 mm. The WEB procedure was successfully completed in 163 patients (100%). At the 12-month follow-up, major stroke events occurred in 3 of 163 patients (1.8%), and no device-related mortality was observed.ConclusionEndovascular treatment of ruptured and unruptured wide-neck bifurcation aneurysms using WEB 17 is safe, with a low complication rate and no device-related mortality. In particular, none of the ruptured aneurysms bled again up to 1 year of follow-up.Trial registration numberNCT03844334.Peer reviewe

Comparison of PED and FRED flow diverters for posterior circulation aneurysms: a propensity score matched cohort study

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First-Line Stent Retriever Versus Contact Aspiration or Combined Technique for Endovascular Therapy of Posterior Cerebral Artery Occlusion Stroke : The PLATO Study

Background The optimal reperfusion technique in patients with isolated posterior cerebral artery (PCA) occlusion is uncertain. We compared clinical and technical outcomes with first-line stent retriever (SR), contact aspiration (CA), or combined techniques in patients with isolated PCA occlusion. Methods This international case-control study was conducted at 30 sites in Europe and North America and included consecutive patients with isolated PCA occlusion presenting within 24 hours of time last seen well from January 2015 to August 2022. The primary outcome was the first-pass effect (FPE), defined as expanded Treatment in Cerebral Infarction (TICI) 2c/3 on the first pass. Patients treated with SR, CA, or combined technique were compared with multivariable logistic regression. Results There were 326 patients who met inclusion criteria, 56.1% male, median age 75 (interquartile range 65-82) years, and median National Institutes of Health Stroke Scale score 8 (5-12). Occlusion segments were PCA-P1 (53.1%), P2 (40.5%), and other (6.4%). Intravenous thrombolysis was administered in 39.6%. First-line technique was SR, CA, and combined technique in 43 (13.2%), 106 (32.5%), and 177 (54.3%) patients, respectively; FPE was achieved in 62.8%, 42.5%, and 39.6%, respectively. FPE was lower in patients treated with first-line CA or combined technique compared with SR (CA versus SR: adjusted odds ratio 0.45 [0.19-1.06]; P=0.07; combined versus SR: adjusted odds ratio 0.35 [0.016-0.80]; P=0.01). There were lower odds of functional independence (modified Rankin scale score 0-2) in the first-line CA versus SR alone group (adjusted odds ratio 0.52 [0.28-0.95]; P=0.04). FPE was associated with higher rates of favorable outcomes (modified Rankin scale score 0-2: 58% versus 43.4%; P=0.01; modified Rankin scale score 0-1: 36.6% versus 25.8%; P=0.05). Overall, symptomatic intracranial hemorrhage was present in 5.6% (18/326) and mortality in 10.9% (35/326) without difference between first-line technique. Conclusion In patients with isolated PCA occlusion, SR was associated with a higher rate of FPE compared with CA or combined techniques with no difference in final successful reperfusion. Functional independence at 90 days was more likely with first-line SR compared with CA. FPE was associated with better 90-day clinical outcomes.Peer reviewe

Simulation-Based Training of the Rapid Evaluation and Management of Acute Stroke (STREAM)-A Prospective Single-Arm Multicenter Trial

Introduction: Acute stroke care delivered by interdisciplinary teams is time-sensitive. Simulation-based team training is a promising tool to improve team performance in medical operations. It has the potential to improve process times, team communication, patient safety, and staff satisfaction. We aim to assess whether a multi-level approach consisting of a stringent workflow revision based on peer-to-peer review and 2-3 one-day in situ simulation trainings can improve acute stroke care processing times in high volume neurocenters within a 6 months period. Methods and Analysis: The trial is being carried out in a pre-test-post-test design at 7 tertiary care university hospital neurocenters in Germany. The intervention is directed at the interdisciplinary multiprofessional stroke teams. Before and after the intervention, process times of all direct-to-center stroke patients receiving IV thrombolysis (IVT) and/or endovascular therapy (EVT) will be recorded. The primary outcome measure will be the door-to-needle time of all consecutive stroke patients directly admitted to the neurocenters who receive IVT. Secondary outcome measures will be intervention-related process times of the fraction of patients undergoing EVT and effects on team communication, perceived patient safety, and staff satisfaction via a staff questionnaire. Interventions: We are applying a multi-level intervention in cooperation with three STREAM multipliers from each center. First step is a central meeting of the multipliers at the sponsor's institution with the purposes of algorithm review in a peer-to-peer process that is recorded in a protocol and an introduction to the principles of simulation training and debriefing as well as crew resource management and team communication. Thereafter, the multipliers cooperate with the stroke team trainers from the sponsor's institution to plan and execute 2-3 one-day simulation courses in situ in the emergency department and CT room of the trial centers whereupon they receive teaching materials to perpetuate the trainings