Combined technique as first approach in mechanical thrombectomy: Efficacy and safety of REACT catheter combined with stent retriever

Acute stroke; Endovascular treatment; Mechanical thrombectomyAccidente cerebrovascular agudo; Tratamiento endovascular; Trombectomía mecánicaAccident cerebrovascular agut; Tractament endovascular; Trombectomia mecànicaIntroduction Mechanical thrombectomy (MT) with combined treatment including both a stent retriever and distal aspiration catheter may improve recanalization rates in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Here, we evaluated the effectiveness and safety of the REACT aspiration catheter used with a stent retriever. Methods This prospective study included consecutive adult patients who underwent MT with a combined technique using REACT 68 and/or 71 between June 2020 and July 2021. The primary endpoints were final and first pass mTICI 2b-3 and mTICI 2c-3 recanalization. Analysis was performed after first pass and after each attempt. Secondary safety outcomes included procedural complications, symptomatic intracranial hemorrhage (sICH) at 24 h, in-hospital mortality, and 90-day functional independence (modified Rankin Scale [mRS] 0–2). Results A total of 102 patients were included (median age 78; IQR: 73–87; 50.0% female). At baseline, median NIHSS score was 19 (IQR: 11–21), and ASPECTS was 9 (IQR: 8–10). Final mTICI 2b-3 recanalization was achieved in 91 (89.2%) patients and mTICI 2c-3 was achieved in 66 (64.7%). At first pass, mTICI 2b-3 was achieved in 55 (53.9%) patients, and mTICI 2c-3 in 37 (36.3%). The rate of procedural complications was 3.9% (4/102), sICH was 6.8% (7/102), in-hospital mortality was 12.7% (13/102), and 90-day functional independence was 35.6% (36/102). Conclusion A combined MT technique using a stent retriever and REACT catheter resulted in a high rate of successful recanalization and first pass recanalization in a sample of consecutive patients with AIS due to LVO in clinical use

Headache : A striking prodromal and persistent symptom, predictive of COVID-19 clinical evolution

To define headache characteristics and evolution in relation to COVID-19 and its inflammatory response. This is a prospective study, comparing clinical data and inflammatory biomarkers of COVID-19 patients with and without headache, recruited at the Emergency Room. We compared baseline with 6-week follow-up to evaluate disease evolution. Of 130 patients, 74.6% (97/130) had headache. In all, 24.7% (24/97) of patients had severe pain with migraine-like features. Patients with headache had more anosmia/ageusia (54.6% vs. 18.2%; p < 0.0001). Clinical duration of COVID-19 was shorter in the headache group (23.9 ± 11.6 vs. 31.2 ± 12.0 days; p = 0.028). In the headache group, IL-6 levels were lower at the ER (22.9 (57.5) vs. 57.0 (78.6) pg/mL; p = 0.036) and more stable during hospitalisation. After 6 weeks, of 74 followed-up patients with headache, 37.8% (28/74) had ongoing headache. Of these, 50% (14/28) had no previous headache history. Headache was the prodromal symptom of COVID-19 in 21.4% (6/28) of patients with persistent headache (p = 0.010). Headache associated with COVID-19 is a frequent symptom, predictive of a shorter COVID-19 clinical course. Disabling headache can persist after COVID-19 resolution. Pathophysiologically, its migraine-like features may reflect an activation of the trigeminovascular system by inflammation or direct involvement of SARS-CoV-2, a hypothesis supported by concomitant anosmia

Clinico-radiological features of intracranial atherosclerosis-related large vessel occlusion prior to endovascular treatment

The identification of large vessel occlusion with underlying intracranial atherosclerotic disease (ICAS-LVO) before endovascular treatment (EVT) continues to be a challenge. We aimed to analyze baseline clinical-radiological features associated with ICAS-LVO that could lead to a prompt identification. We performed a retrospective cross-sectional study of consecutive patients with stroke treated with EVT from January 2020 to April 2022. We included anterior LVO involving intracranial internal carotid artery and middle cerebral artery. We analyzed baseline clinical and radiological variables associated with ICAS-LVO and evaluated the diagnostic value of a multivariate logistic regression model to identify ICAS-LVO before EVT. ICAS-LVO was defined as presence of angiographic residual stenosis or a trend to re-occlusion during EVT procedure. A total of 338 patients were included in the study. Of them, 28 patients (8.3%) presented with ICAS-LVO. After adjusting for confounders, absence of atrial fibrillation (OR 9.33, 95% CI 1.11-78.42; p = 0.040), lower hypoperfusion intensity ratio (HIR [Tmax > 10 s/Tmax > 6 s ratio], (OR 0.69, 95% CI 0.50-0.95; p = 0.025), symptomatic intracranial artery calcification (IAC, OR.15, 95% CI 1.64-26.42, p = 0.006), a more proximal occlusion (ICA, MCA-M1: OR 4.00, 95% CI 1.23-13.03; p = 0.021), and smoking (OR 2.91, 95% CI 1.08-7.90; p = 0.035) were associated with ICAS-LVO. The clinico-radiological model showed an overall well capability to identify ICAS-LVO (AUC = 0.88, 95% CI 0.83-0.94; p < 0.001). In conclusion, a combination of clinical and radiological features available before EVT can help to identify an ICAS-LVO. This approach could be useful to perform a rapid assessment of underlying etiology and suggest specific pathophysiology-based measures. Prospective studies are needed to validate these findings in other populations

Complete Sudden Recanalization: There Is Hope Beyond the First Pass Effect

Background In the endovascular treatment of stroke, achieving complete recanalization in a minimum number of attempts is the main procedural objective. We aimed to explore the effect of the per pass recanalization pattern in patients with final complete recanalization. Methods We analyzed all patients admitted in our center from 2014 to 2022 with a terminal internal carotid artery or M1‐middle cerebral artery occlusion who received endovascular treatment and achieved complete recanalization (expanded thrombolysis in cerebral infarction 2c–3) in our center. Complete sudden recanalization (cSR) was considered when expanded thrombolysis in cerebral infarction improved from 0–1 to 2c–3 in a single pass as opposed to complete progressive recanalization when partial recanalization (2a or 2b) was observed after interim passes. Results Among the 400 included patients with final complete recanalization, 301 (75%) showed a cSR pattern. There were no differences in baseline demographic characteristics between patients with cSR and complete progressive recanalization, including intravenous tissue plasminogen activator treatment (42.2% versus 44.4%; P=0.69). The rate of terminal carotid artery occlusion (28.6% versus 44.4%; P=0.003), median number of passes (1 [interquartile range 1—2] versus 2 [2–3]; P2 passes: 63.6%; P=0.825). Conclusion Among stroke patients with a large vessel occlusion, the cSR pattern predicted favorable outcome independently of the number of thrombectomy passes

Abstract 268: Validation of an automated method to assess 24‐hour infarct volume in stroke patients

Introduction In stroke patients, accurate infarct volume assessment at 24 hours typically requires manual segmentation of lesions that often are not well defined. We aimed to validate an automated machine learning algorithm (MethinksFIV) specifically trained to automatically segment and measure subacute infarcts on non‐contrast CT (NCCT) scans. Methods We retrospectively studied stroke patients with a large vessel occlusion prospectively admitted to a comprehensive stroke center. The final infarct volume was segmented on the 24h NCCT manually (man‐FIV) and with the automated method (auto‐FIV). Both measurements were correlated with clinical outcomes. Results We included 346 patients. On 24h‐NCCT median auto‐FIV was lower than man‐FIV (8.6 ml [2.3‐40.7] vs. 16.9 ml [1.1‐70.8], p2 at three months (OR: 1.02 95%CI 1.01‐1.13, p=0.002) than manual segmentation (OR=1.01, 95%CI 1.00‐1.01, p=0.01). In a multivariable analysis, only auto‐FIV remained a significant predictor of mRS>2 at three months (aOR: 1.03 95% CI 1.01‐1.05, p=0.004). Conclusion An automated method to measure subacute infarct volumes in stroke patients is accurate and correlates well with further clinical outcomes. The method appears to outperform manual segmentation and may be used to facilitate infarct characterization in large clinical trials

Clinico-radiological features of intracranial atherosclerosis-related large vessel occlusion prior to endovascular treatment

Abstract The identification of large vessel occlusion with underlying intracranial atherosclerotic disease (ICAS-LVO) before endovascular treatment (EVT) continues to be a challenge. We aimed to analyze baseline clinical-radiological features associated with ICAS-LVO that could lead to a prompt identification. We performed a retrospective cross-sectional study of consecutive patients with stroke treated with EVT from January 2020 to April 2022. We included anterior LVO involving intracranial internal carotid artery and middle cerebral artery. We analyzed baseline clinical and radiological variables associated with ICAS-LVO and evaluated the diagnostic value of a multivariate logistic regression model to identify ICAS-LVO before EVT. ICAS-LVO was defined as presence of angiographic residual stenosis or a trend to re-occlusion during EVT procedure. A total of 338 patients were included in the study. Of them, 28 patients (8.3%) presented with ICAS-LVO. After adjusting for confounders, absence of atrial fibrillation (OR 9.33, 95% CI 1.11–78.42; p = 0.040), lower hypoperfusion intensity ratio (HIR [Tmax > 10 s/Tmax > 6 s ratio], (OR 0.69, 95% CI 0.50–0.95; p = 0.025), symptomatic intracranial artery calcification (IAC, OR .15, 95% CI 1.64–26.42, p = 0.006), a more proximal occlusion (ICA, MCA-M1: OR 4.00, 95% CI 1.23–13.03; p = 0.021), and smoking (OR 2.91, 95% CI 1.08–7.90; p = 0.035) were associated with ICAS-LVO. The clinico-radiological model showed an overall well capability to identify ICAS-LVO (AUC = 0.88, 95% CI 0.83–0.94; p < 0.001). In conclusion, a combination of clinical and radiological features available before EVT can help to identify an ICAS-LVO. This approach could be useful to perform a rapid assessment of underlying etiology and suggest specific pathophysiology-based measures. Prospective studies are needed to validate these findings in other populations

Abstract 233: First‐line Techniques for Endovascular Therapy of Primary Distal medium Vessel Occlusion Stroke: A Matched Analysis

Introduction Previous studies did not show a difference in terms of safety and efficacy among first‐line stent retriever (SR), contact aspiration (CA), or combined techniques for proximal large vessel occlusion strokes. However, the optimal reperfusion therapy in patients with primary distal medium vessel occlusion (DMVO) strokes is uncertain. We aimed to compare the clinical and procedural outcomes among first‐line SR, CA and combined techniques in patients with primary DMVO. Methods This is a retrospective analysis of a prospectively maintained database from 14 comprehensive stroke centers in the US and Europe. Patients were included if they had a primary DMVO stroke due to MCA‐M3/M4, ACA‐A1/A2‐3, or PCA‐P1/P2‐3 and underwent mechanical thrombectomy with first‐line SR, CA, or combined technique. The primary outcome was FPE defined as eTICI 2c/3 on the first pass. Secondary outcomes included mFPE defined as eTICI 2b/3 on the first pass, successful reperfusion defined as eTICI 2b/3 at the end of the procedure. Clinical outcomes included 90‐day mRS0‐1 and 90‐day mRS0‐2. Safety measures included procedural complications, symptomatic intracranial hemorrhage (sICH), and 90‐day mortality. The secondary analysis aimed to identify the procedural and clinical outcomes in 3 matched cohorts: (SR vs. CA), (SR vs. combined technique), and (CA vs. combined technique). Results A total of 365 patients were eligible for analysis; 38.1% were female, with a mean age of 69.3 years and a median NIHSS score of 11 [7‐18]. The first‐line SR group consisted of n=74 (20.3%), CA group n=142 (38.9%), and combined technique group n=149 (40.8%). Patients with first‐line SR or combined technique had a lower median NIHSS score, less frequent MCA‐M3 segment occlusion, and less usage of the rescue strategy compared to those with first‐line CA, P<0.05. Patients with first‐line CA had less frequent BGC usage and lower rates of FPE and procedural complications compared to first‐line SR or combined technique, P<0.05. Successful reperfusion at the end of the procedure was similar among the 3 groups (Figure). On multivariable analysis, there was no difference in terms of primary, secondary outcomes, or safety measures among the 3 first‐line techniques, except for higher procedural complications in patients who underwent the first‐line combined technique compared to those with first‐line CA (aOR 3.66, 95% CI [1.25‐10.75], P=0.02). The matched analyses did not show any difference in the primary outcome: (1) (SR, n=54 vs. CA, n=54) FPE; 31.5% vs. 26.9%, P=0.61, aOR 1.33, 95% CI [0.57‐3.11], P=0.52), (2) (SR, n=72 vs. combined technique, n=54) FPE; 37.5% vs. 31.9%, P=0.48, aOR 1.48, 95% CI [0.73‐3.03], P=0.28), and (3) (CA, n=109 vs. combined technique, n=109) FPE; 24.1% vs. 25.7%, P=0.78, aOR 0.94, 95% CI [0.50‐1.74], P=0.84). Similarly, there was no difference in terms of secondary outcomes and safety measures. Conclusion Our study suggests that in patients with primary DMVO, first‐line SR, CA, and combined techniques have a similar rate of FPE with no differences in final reperfusion or clinical outcomes. Randomized clinical trials are warrante

"Insights into vessel perforations during thrombectomy: Characteristics of a severe complication and the effect of thrombolysis"

Thrombectomy complications remain poorly explored. This study aims to characterize periprocedural intracranial vessel perforation including the effect of thrombolysis on patient outcomes.INTRODUCTIONThrombectomy complications remain poorly explored. This study aims to characterize periprocedural intracranial vessel perforation including the effect of thrombolysis on patient outcomes.In this multicenter retrospective cohort study, consecutive patients with vessel perforation during thrombectomy between January 2015 and April 2023 were included. Vessel perforation was defined as active extravasation on digital subtraction angiography. The primary outcome was modified Rankin Scale (mRS) at 90 days. Factors associated with the primary outcome were assessed using proportional odds models.PATIENTS AND METHODSIn this multicenter retrospective cohort study, consecutive patients with vessel perforation during thrombectomy between January 2015 and April 2023 were included. Vessel perforation was defined as active extravasation on digital subtraction angiography. The primary outcome was modified Rankin Scale (mRS) at 90 days. Factors associated with the primary outcome were assessed using proportional odds models.459 patients with vessel perforation were included (mean age 72.5 ± 13.6 years, 59% female, 41% received thrombolysis). Mortality at 90 days was 51.9% and 16.3% of patients reached mRS 0-2 at 90 days. Thrombolysis was not associated with worse outcome at 90 days. Perforation of a large vessel (LV) as opposed to medium/distal vessel perforation was independently associated with worse outcome at 90 days (aOR 1.709, p = 0.04) and LV perforation was associated with poorer survival probability (HR 1.389, p = 0.021). Patients with active bleeding >20 min had worse survival probability, too (HR 1.797, p = 0.009). Thrombolysis was not associated with longer bleeding duration. Bleeding cessation was achieved faster by permanent vessel occlusion compared to temporary measures (median difference: 4 min, p 20 min had worse survival probability, too (HR 1.797, p = 0.009). Thrombolysis was not associated with longer bleeding duration. Bleeding cessation was achieved faster by permanent vessel occlusion compared to temporary measures (median difference: 4 min, p < 0.001).Vessel perforation during thrombectomy is a severe and frequently fatal complication. This study does not suggest that thrombolysis significantly attributes to worse prognosis. Prompt cessation of active bleeding within 20 min is critical, emphasizing the need for interventionalists to be trained in complication management.DISCUSSION AND CONCLUSIONVessel perforation during thrombectomy is a severe and frequently fatal complication. This study does not suggest that thrombolysis significantly attributes to worse prognosis. Prompt cessation of active bleeding within 20 min is critical, emphasizing the need for interventionalists to be trained in complication management

Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection: The STOP-CAD Study.

Background: Small, randomized trials of cervical artery dissection (CAD) patients showed conflicting results regarding optimal stroke prevention strategies. We aimed to compare outcomes in patients with CAD treated with antiplatelets versus anticoagulation. Methods: This is a multi-center observational retrospective international study (16 countries, 63 sites) that included CAD patients without major trauma. The exposure was antithrombotic treatment type (anticoagulation vs. antiplatelets) and outcomes were subsequent ischemic stroke and major hemorrhage (intracranial or extracranial hemorrhage). We used adjusted Cox regression with Inverse Probability of Treatment Weighting (IPTW) to determine associations between anticoagulation and study outcomes within 30 and 180 days. The main analysis used an "as treated" cross-over approach and only included outcomes occurring on the above treatments. Results: The study included 3,636 patients [402 (11.1%) received exclusively anticoagulation and 2,453 (67.5%) received exclusively antiplatelets]. By day 180, there were 162 new ischemic strokes (4.4%) and 28 major hemorrhages (0.8%); 87.0% of ischemic strokes occurred by day 30. In adjusted Cox regression with IPTW, compared to antiplatelet therapy, anticoagulation was associated with a non-significantly lower risk of subsequent ischemic stroke by day 30 (adjusted HR 0.71 95% CI 0.45-1.12, p=0.145) and by day 180 (adjusted HR 0.80 95% CI 0.28-2.24, p=0.670). Anticoagulation therapy was not associated with a higher risk of major hemorrhage by day 30 (adjusted HR 1.39 95% CI 0.35-5.45, p=0.637) but was by day 180 (adjusted HR 5.56 95% CI 1.53-20.13, p=0.009). In interaction analyses, patients with occlusive dissection had significantly lower ischemic stroke risk with anticoagulation (adjusted HR 0.40 95% CI 0.18-0.88) (Pinteraction=0.009). Conclusions: Our study does not rule out a benefit of anticoagulation in reducing ischemic stroke risk, particularly in patients with occlusive dissection. If anticoagulation is chosen, it seems reasonable to switch to antiplatelet therapy before 180 days to lower the risk of major bleeding. Large prospective studies are needed to validate our findings

The PLATO Mission

International audiencePLATO (PLAnetary Transits and Oscillations of stars) is ESA's M3 mission designed to detect and characterise extrasolar planets and perform asteroseismic monitoring of a large number of stars. PLATO will detect small planets (down to &lt;2 R_(Earth)) around bright stars (&lt;11 mag), including terrestrial planets in the habitable zone of solar-like stars. With the complement of radial velocity observations from the ground, planets will be characterised for their radius, mass, and age with high accuracy (5 %, 10 %, 10 % for an Earth-Sun combination respectively). PLATO will provide us with a large-scale catalogue of well-characterised small planets up to intermediate orbital periods, relevant for a meaningful comparison to planet formation theories and to better understand planet evolution. It will make possible comparative exoplanetology to place our Solar System planets in a broader context. In parallel, PLATO will study (host) stars using asteroseismology, allowing us to determine the stellar properties with high accuracy, substantially enhancing our knowledge of stellar structure and evolution. The payload instrument consists of 26 cameras with 12cm aperture each. For at least four years, the mission will perform high-precision photometric measurements. Here we review the science objectives, present PLATO's target samples and fields, provide an overview of expected core science performance as well as a description of the instrument and the mission profile at the beginning of the serial production of the flight cameras. PLATO is scheduled for a launch date end 2026. This overview therefore provides a summary of the mission to the community in preparation of the upcoming operational phases