Association of intravenous thrombolysis and pre-interventional reperfusion: a post hoc analysis of the SWIFT DIRECT trial.

BACKGROUND A potential benefit of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) is pre-interventional reperfusion. Currently, there are few data on the occurrence of pre-interventional reperfusion in patients randomized to IVT or no IVT before MT. METHODS SWIFT DIRECT (Solitaire With the Intention For Thrombectomy Plus Intravenous t-PA vs DIRECT Solitaire Stent-retriever Thrombectomy in Acute Anterior Circulation Stroke) was a randomized controlled trial including acute ischemic stroke IVT eligible patients being directly admitted to a comprehensive stroke center, with allocation to IVT with MT versus MT alone. The primary endpoint of this analysis was the occurrence of pre-interventional reperfusion, defined as a pre-interventional expanded Thrombolysis in Cerebral Infarction score of ≥2a. The effect of IVT and potential treatment effect heterogeneity were analyzed using logistic regression analyses. RESULTS Of 396 patients, pre-interventional reperfusion occurred in 20 (10.0%) patients randomized to IVT with MT, and in 7 (3.6%) patients randomized to MT alone. Receiving IVT favored the occurrence of pre-interventional reperfusion (adjusted OR 2.91, 95% CI 1.23 to 6.87). There was no IVT treatment effect heterogeneity on the occurrence of pre-interventional reperfusion with different strata of Randomization-to-Groin-Puncture time (p for interaction=0.33), although the effect tended to be stronger in patients with a Randomization-to-Groin-Puncture time >28 min (adjusted OR 4.65, 95% CI 1.16 to 18.68). There were no significant differences in rates of functional outcomes between patients with and without pre-interventional reperfusion. CONCLUSION Even for patients with proximal large vessel occlusions and direct access to MT, IVT resulted in an absolute increase of 6% in rates of pre-interventional reperfusion. The influence of time strata on the occurrence of pre-interventional reperfusion should be studied further in an individual patient data meta-analysis of comparable trials. TRIAL REGISTRATION NUMBER clinicaltrials.gov NCT03192332

Functional aplasia of the contralateral A1 segment influences clinical outcome in patients with occlusion of the distal internal carotid artery

Background: The importance of an A1 aplasia remains unclear in stroke patients. In this work, we analyze the impact of an A1 aplasia contralateral to an acute occlusion of the distal internal carotid artery (ICA) on clinical outcomes. Methods: We conducted a retrospective study of consecutive stroke patients treated with mechanical thrombectomy at 12 tertiary care centers between January 2015 and February 2021 due to an occlusion of the distal ICA. Functional A1 aplasia was defined as the absence of A1 or hypoplastic A1 (>50% reduction to the contralateral site). Functional independence was measured by the modified Rankin Scale (mRS ≤ 2). Results: In total, 81 out of 1068 (8%) patients had functional A1 aplasia contralateral to distal ICA occlusion. Patients with functional contralateral A1 aplasia were more severely affected on admission (median NIHSS 18, IQR 15–23 vs. 17, IQR 13–21; aOR: 0.672, 95% CI: 0.448–1.007, p = 0.054) and post-interventional ischemic damage was larger (median ASPECTS 5, IQR 1–7, vs. 6, IQR 3–8; aOR: 1.817, 95% CI: 1.184–2.789, p = 0.006). Infarction occurred more often within the ipsilateral ACA territory (20/76, 26% vs. 110/961, 11%; aOR: 2.482, 95% CI: 1.389–4.437, p = 0.002) and both ACA territories (8/76, 11% vs. 5/961, 1%; aOR: 17.968, 95% CI: 4.979–64.847, p ≤ 0.001). Functional contralateral A1 aplasia was associated with a lower rate of functional independence at discharge (6/81, 8% vs. 194/965, 20%; aOR: 2.579, 95% CI: 1.086–6.122, p = 0.032) and after 90 days (5/55, 9% vs. 170/723, 24%; aOR: 2.664, 95% CI: 1.031–6.883, p = 0.043). Conclusions: A functional A1 aplasia contralateral to a distal ICA occlusion is associated with a poorer clinical outcome

Acute Basilar Artery Occlusion with Underlying High-Grade Basilar Artery Stenosis: Multimodal Endovascular Therapy in a Series of Seven Patients

Acute basilar artery occlusion is associated with high rates of major morbidity and mortality. In rare cases, the underlying pathology is a high-grade stenosis of the basilar artery. We report on a series of seven cases with occluded high-grade basilar artery stenosis who received endovascular therapy at our center. Our prospective database since October 2009 until September 2013 was screened for patients with acute basilar artery occlusion and underlying high-grade stenosis who underwent endovascular therapy. Case files were retrospectively reviewed for clinical, outcome, and technical data. Seven patients were identified who suffered from an acute basilar artery occlusion based on a high-grade stenosis between October 2009 and September 2013. These patients were treated with an acute stenting of the basilar artery with or without a preceding mechanical thrombectomy. Median age was 75 (53-83) years; median prethrombectomy National Institute of Health Stroke scale score was 19 (7-28). A successful recanalization result defined as modified Thrombolysis In Cerebral Infarction grade 2b or higher was achieved in all cases. Two of the seven patients had a procedural complication consisting of a vessel dissection after angioplasty. A good clinical outcome according to the Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT) study criteria was achieved in three of the seven patients. One patient died during hospitalization in the acute phase. Mechanical thrombectomy combined with acute stenting of the basilar artery is technically feasible and may be an effective therapeutic option in the rare case of an acutely occluded high-grade stenosis of the basilar artery in patients with an otherwise poor prognosis

WEB as part of a multimodality treatment in complex, large, and partially thrombosed intracranial aneurysms: a single-center observational study of technical success, safety, and recurrence

Introduction Complex, large, wide-neck aneurysms, but particularly partially thrombosed intracranial aneurysms (PTIAs), have a greater tendency to recanalize after coil occlusion. The Woven Endovascular Bridge (WEB) combines shape memory wires braided to a relatively uniform, dense surface, which may limit its compaction and its incorporation into an existing aneurysm clot and may thus reduce PTIA recurrence. Objective To carry out a retrospective analysis of our experience with the WEB as part of a complex treatment in conjunction with other implants to assess the efficacy and safety of this technique. Methods Among 43 aneurysms treated with the WEB in our center, eight complex, large, wide-neck aneurysms were treated in conjunction with other implants (additional WEBs, coils, stents, flow diverters). Six of these eight aneurysms were PTIAs. All patients were followed up by DSA between 3 1/2 and 38 months. Results All eight (100%) of the complex, large, wide-neck aneurysms were treated successfully and without periprocedural adverse events (0%). At follow-up, the two non-thrombosed aneurysms were completely occluded, but all six PTIAs recurred (75%) and were re-treated. There was no morbidity or mortality in these eight patients. Conclusions Treatment of large, complex aneurysms with the WEB in conjunction with other implants was technically successful and safe but did not prevent recurrence of partially thrombosed aneurysms in our center. PTIA re-treatment was possible and not limited by the previously placed WEB