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

Treatment of a middle cerebral artery bifurcation aneurysm with the novel Contour Neurovascular System compatible with 0.021″ catheters

Background: For wide-necked intracranial aneurysms, endo-saccular flow disruption can be a viable alternative to coiling or flow diverters. The Contour Neurovascular System is an intrasaccular flow diverter device targeting the neck of the aneurysm. Until now, the system had to be delivered through a 0.02700 microcatheter. We report the first implantation and follow-up of the novel Contour 021 system compatible with 0.02100 microcatheters. Case presentation: A 54-year-old male patient presented with an unruptured right middle cerebral artery aneurysm at the right temporopolar branch. Existing medication included apixaban. An arteriogram showed a broad-based aneurysm. Due to its asymmetric geometry, neither the Woven EndoBridge nor stent-assisted coil embolisation were regarded as promising treatment strategies. To uphold the option of different treatment options, prasugrel 10 mg was initiated before treatment. Implantation was performed under general anaesthesia via femoral artery puncture. A 0.02100 HeadwayTM catheter was used for accessing the aneurysm. The Contour device was oversized to the equatorial plane. Deployment was successful with only one attempt without the need for re-sheathing. Follow-up catheter angiography was performed after three months, showing complete occlusion of the aneurysm. No procedure-related complications occurred. Conclusion: The 0.021 design of the Contour enlarges the subgroup of patients that can be treated with endo-saccular devices and will enable treatment of smaller and more distal aneurysms.Transformationsvertra

Complications Associated with Cerebral Aneurysm Morphology in Balloon-Assisted Coil Embolization of Ruptured and Unruptured Aneurysms-a Single-Center Analysis of 116 Consecutive Cases

BACKGROUND: We investigated the complication rates of balloon-assisted coil embolization of ruptured and unruptured cerebral aneurysms dependent on their morphologic characteristics in angiography. METHODS: The study was a single-center retrospective analysis of all consecutive endovascular balloon-assisted coiling interventions performed between April 2008 and December 2013. Data were extracted from a prospective database on an intention-to-treat basis. We described the clinical (Hunt & Hess score, modified Rankin scale) and technical results (Raymond Roy aneurysm occlusion scale) and analyzed the rate of periprocedural complications with regard to aneurysm subgroups of bifurcation aneurysms versus sidewall aneurysms. RESULTS: There were 116 interventions performed on 108 patients (mean age: 51.7 +/- 11.1 years), with 70/116 emergency procedures (60%), 36/116 elective procedures (31%), and 10/116 elective procedures on recurrent aneurysms (9%). The balloon was used in 108/116 cases (93%). Among the cases, 76/116 were bifurcation aneurysms and 40/116 were sidewall aneurysms. Periprocedural complications, such as rerupture, thrombus formation, distal embolism, coil-loop protrusion, and coil migration, occurred in 26/116 cases (22%). Complications occurred significantly more often in ruptured than unruptured bifurcation aneurysms (23 vs. 3 events, P < 0.05). There was a significantly higher rate of complications in bifurcation aneurysms compared with sidewall aneurysms (17% vs. 3%, P = 0.03). Six periprocedural complications were associated with a permanent neurologic deficit (6% of cases), all of which occurred in the subgroup of acutely ruptured aneurysms. CONCLUSION: The risk of periprocedural complications in balloon-assisted coil embolization of ruptured and unruptured cerebral aneurysms is linked to the morphologic presentation of the aneurysm; the complication rate was significantly higher in bifurcation aneurysms

Direct aspiration first pass technique for the treatment of acute ischemic stroke: initial experience at a European stroke center

Introduction Over the past decade, endovascular techniques for the treatment of acute ischemic stroke have emerged significantly. However, revascularization rates are limited at approximately 80%, and mechanical thrombectomy procedures still last about 1h. Therefore, we investigated the novel direct aspiration first pass technique for its efficacy and safety. Methods Our neurointerventional database was screened for patients who received mechanical thrombectomy for acute ischemic stroke using the Penumbra 5MAX ACE aspiration catheter on an intention to treat basis between November 2013 and June 2014. Procedural data, including modified Thrombolysis in Cerebral Infarction (mTICI) score, procedural timings, and complications, as well as clinical data at admission and discharge, were analyzed. Results 54 patients received mechanical thrombectomy using the 5MAX ACE. Median age was 69 (39-94) years (54% were men). Baseline National Institutes of Health Stroke Scale (NIHSS) score was 15 (2-27) and 44/54 (81%) patients received intravenous thrombolysis. Vessel occlusion sites were 91% anterior circulation and 9% posterior circulation. A successful revascularization result (mTICI 2b) was achieved in 93% of cases whereas direct aspiration alone was successful in 30/54 (56%) cases; among these, median time from groin puncture to revascularization was 30min (9-113). Symptomatic intracranial hemorrhage occurred in 2/54 (4%) patients, and embolization to new territories in 3/54 (6%). Median NIHSS at discharge was 6 (0-24); 46% of patients were independent at discharge. Conclusions The direct aspiration first pass technique proofed to be fast, effective, and safe. Promising revascularization results can be achieved quickly in more than 50% of patients using this technique as the firstline option. Nevertheless, stent retrievers are still warranted in approximately 40% of cases to achieve a favorable revascularization result

Stenting of the cervical internal carotid artery in acute stroke management: The Karolinska experience

Background: Emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy is a routine procedure. Yet, precise indications and clinical safety in this setting remains controversial. Present data for mechanical thrombectomy include few studies with acute stenting of tandem occlusions. We evaluated the feasibility, safety and clinical outcome of this endovascular treatment in a retrospective analysis of all consecutive cases at a comprehensive stroke centre. Methods: This was a retrospective analysis of all consecutive patients with acute extracranial carotid artery occlusion including acute dissection or high-grade stenosis and concomitant intracranial large-vessel occlusion treated with emergency carotid stenting and intracranial mechanical thrombectomy between November 2007 and May 2015. Results: A total of 63 patients with a median age of 67 years (range 33-84 years) were treated. Of these, 33 (52%) patients had concomitant intravenous thrombolysis with recombinant tissue-type plasminogen activator initially. Median admission National Institutes of Health Stroke Scale was 14 (range 1-29). Median time from stroke onset to recanalization was 408 minutes (range 165-1846 minutes). Procedure time was significantly shorter after intravenous thrombolysis (110 minutes [range 15-202 minutes] vs. 130 minutes [range 60-280 minutes]; p = 0.02). Three (5%) patients experienced post-procedural symptomatic intracerebral haemorrhage. In 55/63 (87%) patients, a score of >= 2b on the Thrombolysis in Cerebral Infarction scale could be achieved. Eight (13%) patients died, five (8%) during the acute phase. A total of 29/63 (46%) patients showed a favourable outcome (modified Rankin Scale score of 0-2) after three months. Conclusions: Our single-centre retrospective analysis of emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy demonstrated high technical success, reasonable clinical outcomes and acceptable rates of symptomatic intracranial haemorrhage in carefully chosen patients which are triaged interdisciplinary based on clinical and computed tomography imaging criteria. This warrants further study in a randomised prospective trial