Factores asociados a resultados funcionales en pacientes con ictus isquémico tratados con trombolisis endovenosa en un hospital del Perú.

Objective: To describe the treatment of acute ischemic strokes with intravenous rtPA and determine the factors associated with the functional outcomes of patients treated with thrombolysis in a Peruvian hospital. Material and Methods: A prospective, longitudinal cohort study of patients with ischemic stroke who received rtPA over a period of 3 years was performed. The association of demographic and clinical data with functional status was assessed 3 months after the intervention. Simple and multivariate Poisson regression models were performed to evaluate associations with functional prognosis, and Relative Risk (RR) with a 95% confidence interval (CI) was used as a measure of association. Results: During the study period, 74 patients (1.19% of the total) received IV thrombolysis, and 68.18% of them achieved functional independence (mRS 0-2) at 90 days. We found a mortality of 6%, an intracerebral hemorrhage (ICH) rate of 3%. Glycemia >140 mg/dl (OR 5.12; 1.31-20.02; p = 0.019), and posterior circulation infarcts (OR 7.47; 1.01-55.15; p = 0,04) were associated with an increased risk of functional dependency. Conclusions: In the studied cohort, most of the patients who underwent thrombolytic therapy achieved a functional independence at 3 months. Hyperglycemia (>140gr/dl) and vertebro-basilar infarcts were associated with an increased risk of functional dependenceObjetivo: Describir el tratamiento del ictus isquémico agudo con reperfusión endovenosa y determinar los factores asociados al rendimiento funcional de pacientes sometidos a trombolisis en un hospital peruano. Material y Métodos: Estudio prospectivo y longitudinal de una cohorte de pacientes con ictus isquémico que recibieron rtPA en un periodo de 3 años. Se evaluó la relación entre datos demográficos y clínicos y el estado funcional a los 3 meses de la intervención. La asociación del pronóstico funcional se valoró mediante el modelo de regresión simple y multivariado de Poisson, y el Riesgo Relativo (RR) con un intervalo de confianza (IC) al 95%, como medida de asociación. Resultados. Durante el periodo del estudio, 74 pacientes (1.19% del total) recibieron el tratamiento. El  68,18% logró independencia funcional (mRS 0-2) a los 90 días. La mortalidad fue de 6 % y un 3% mostró hemorragia intracerebral (HIC). Glicemia >140 mg/dl (OR 5,12; 1,31-20,02; p=0,019) e infarto de tipo posterior (OR 7,47; 1,01-55,15; p =0,04) se asociaron a un mayor riesgo de dependencia funcional. Conclusiones: En la cohorte estudiada, la mayoría de los pacientes alcanzaron independencia funcional a los 3 meses de tratamiento trombolítico. La hiperglicemia (>140gr/dl) y el infarto vertebro-basilar se asociaron con un mayor riesgo de dependencia funcional

Safety and efficacy of balloon-mounted stent in the treatment of symptomatic intracranial atherosclerotic disease: a multicenter experience

Background Randomized clinical trials have failed to prove that the safety and efficacy of endovascular treatment for symptomatic intracranial atherosclerotic disease (ICAD) is better than that of medical management. A recent study using a self-expandable stent showed acceptable lower rates of periprocedural complications. Objective To study the safety and efficacy of a balloon-mounted stent (BMS) in the treatment of symptomatic ICAD. Methods Prospectively maintained databases from 15 neuroendovascular centers between 2010 and 2020 were reviewed. Patients were included if they had severe symptomatic intracranial stenosis in the target artery, medical management had failed, and they underwent intracranial stenting with BMS after 24 hours of the qualifying event. The primary outcome was the occurrence of stroke and mortality within 72 hours after the procedure. Secondary outcomes were the occurrence of stroke, transient ischemic attacks (TIAs), and mortality on long-term follow-up. Results A total of 232 patients were eligible for the analysis (mean age 62.8 years, 34.1% female). The intracranial stenotic lesions were located in the anterior circulation in 135 (58.2%) cases. Recurrent stroke was the qualifying event in 165 (71.1%) while recurrent TIA was identified in 67 (28.9%) cases. The median (IQR) time from the qualifying event to stenting was 5 (2–20.75) days. Strokes were reported in 13 (5.6%) patients within 72 hours of the procedure; 9 (3.9%) ischemic and 4 (1.7%) hemorrhagic, and mortality in 2 (0.9%) cases. Among 189 patients with median follow-up time 6 (3–14.5) months, 12 (6.3%) had TIA and 7 (3.7%) had strokes. Three patients (1.6%) died from causes not related to stroke. Conclusion Our study has shown that BMS may be a safe and effective treatment for medically refractory symptomatic ICAD. Additional prospective randomized clinical trials are warranted

Repeated Mechanical Endovascular Thrombectomy for Recurrent Large Vessel Occlusion: A Multicenter Experience

BACKGROUND AND PURPOSE: Mechanical thrombectomy (MT) is now the standard of care for large vessel occlusion (LVO) stroke. However, little is known about the frequency and outcomes of repeat MT (rMT) for patients with recurrent LVO. METHODS: This is a retrospective multicenter cohort of patients who underwent rMT at 6 tertiary institutions in the United States between March 2016 and March 2020. Procedural, imaging, and outcome data were evaluated. Outcome at discharge was evaluated using the modified Rankin Scale. RESULTS: Of 3059 patients treated with MT during the study period, 56 (1.8%) underwent at least 1 rMT. Fifty-four (96%) patients were analyzed; median age was 64 years. The median time interval between index MT and rMT was 2 days; 35 of 54 patients (65%) experienced recurrent LVO during the index hospitalization. The mechanism of stroke was cardioembolism in 30 patients (56%), intracranial atherosclerosis in 4 patients (7%), extracranial atherosclerosis in 2 patients (4%), and other causes in 18 patients (33%). A final TICI recanalization score of 2b or 3 was achieved in all 54 patients during index MT (100%) and in 51 of 54 patients (94%) during rMT. Thirty-two of 54 patients (59%) experienced recurrent LVO of a previously treated artery, mostly the pretreated left MCA (23 patients, 73%). Fifty of the 54 patients (93%) had a documented discharge modified Rankin Scale after rMT: 15 (30%) had minimal or no disability (modified Rankin Scale score ≤2), 25 (50%) had moderate to severe disability (modified Rankin Scale score 3-5), and 10 (20%) died. CONCLUSIONS: Almost 2% of patients treated with MT experience recurrent LVO, usually of a previously treated artery during the same hospitalization. Repeat MT seems to be safe and effective for attaining vessel recanalization, and good outcome can be expected in 30% of patients

Abstract 1122‐000227: Stenting Versus Medical Treatment for Chronic Internal Carotid Artery Occlusions: A Systematic Review and Meta‐analysis

Introduction: Chronic internal carotid occlusion is responsible for 10–15% ischemic strokes or transit ischemic attacks (TIA). Subsequent ipsilateral ischemic stroke rate is 5.9% per year. However, this risk can increase up to 23% in two years in a subgroup of patients with poor collaterals regardless of medical therapy with antiplatelet or anticoagulant agents. Prevention of subsequent stroke in patients with carotid artery occlusion remains a difficult challenge. Carotid artery stenting (CAS) has recently been considered in its management. However, there is ambiguity on its safety. We aim to evaluate the safety and feasibility of CAS and compared it with medical management. Methods: We performed a systematic review and meta‐analysis to compare long‐term outcome (stroke recurrence) of current carotid occlusion treatments (CAS vs medical therapy). Two independent reviewers performed the screening, data extraction, and quality assessment. A random effects model was used for analysis. Results: A total of 5720 studies were screened. Of these, 11 studies were included in our systematic review and meta‐analysis of proportions. The CAS group has lower proportions of recurrent strokes (5% vs 30%,) after 30 days than medical therapy alone. Additionally, the proportion of periprocedural intracranial hemorrhage was 4.4% (95% CI 2.5 to 6.8) in the CAS group. Conclusions: CAS of the chronically occluded cervical ICA seems to be a safe procedure with lower rates of recurrent stroke in clinical follow up. Future randomized studies are warranted to guide the optimal management of this complex disease

Abstract Number ‐ 21: Mechanical Thrombectomy versus Medical Management in Patients with acute LVO and Pre‐morbid Disability: Meta‐analysis

Introduction Actual guidelines offer little guidance for endovascular treatment of patients with acute ischemic stroke (AIS) and pre‐morbid disability (PMD). Often, patients with a mRS >2 are not considered for mechanical thrombectomy (MT) and might not be given the best chance of achieving recovery. Three recent meta‐analysis have showed conflicting results regarding the benefit of MT, while persistently showing a significant increase in mortality. Methods We conducted a systematic search in Embase, Medline, and Web of Science for studies of patients with AIS and PMD who were treated with MT or MM. We included all definitions of PMD, main outcomes were favorable functionality at 90‐days (mRS 0–2 or return to baseline mRS), symptomatic ICH, and mortality. We performed meta‐analyses using a random‐effect model, and I2 to evaluate heterogeneity. Subgroup analyses were used when appropriate. Results 2 studies contained data comparing PMD patients treated with MT versus MM, 14 studies contained data only of patients treated with MT, and 10 only of patients treated with MM; they provided data of 1071 patients in the MT group and 4547 in the MM group. Pooled rates in the MT group were 28% (95% CI 0.24‐0.32) for favorable functionality, 7% (95% CI 0.04‐0.12) for sICH, 43% (95% CI 0.36‐0.51) for 90‐days mortality, 18% (95% CI 0.14‐0.23) for intra‐hospital mortality, and pooled reperfusion rate (mTICI 0–2) of 80% (95% CI 0.72‐0.86). In a meta‐analysis of proportion with the treatments modalities as subgroups, including only studies with a similar definition of PMD, we obtained: for favorable functionality, MT = 26% (95% CI 0.23‐0.30) vs. MM = 35% (95% CI 0.22‐0.51); for sICH, MT = 6% (95% CI 0.05‐0.08) vs. MM = 6% (95% CI 0.05‐0.08); for 90‐days mortality, MT = 48% (95% CI 0.44‐0.52) vs. MM = 34% (95% CI 0.27‐0.41); and for in‐hospital mortality, MT = 18% (95% CI 0.14‐0.23) vs. MM = 22% (95% CI 0.17‐0.28). Additionally, meta‐analysis for 90‐days mortality in MT studies, showed a pooled rate of 49% (95% CI 0.45‐0.53) for the high tPA rate subgroup, and 30% (95% CI 0.19‐0.44) for the low tPA rate subgroup. Conclusions Up to one third of PMD patients who undergo MT might achieve favorable functionality, without increasing the risk of sICH and with rates similar to those obtained with MM. Furthermore, we observed a high 90‐day mortality rate, in both MT and MM groups. In subgroups exploration, there is trend of high tPA rates to be associated with the increased mortality. It is urgent to identify PMD patients who will benefit from MT and factors associated with poor outcomes

Stroke Severity and Early Ischemic Changes Predict Infarct Growth Rate and Clinical Outcomes in Patients With Large‐Vessel Occlusion

Background The infarct growth rate (IGR) measures ischemic stroke progression and varies among patients. Clinicoradiological phenotypes of IGR are poorly understood. We evaluated the association of presentation stroke severity and early ischemic changes with infarct progression in patients who underwent successful thrombectomy. Methods This is a retrospective cohort observational study of consecutive endovascular therapy patients with anterior circulation large‐vessel occlusion strokes and successful reperfusion (modified Thrombolysis in Cerebral Ischemia≥2b) from 2 comprehensive stroke centers. National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT [Computed Tomography] Score (ASPECTS) were scored at admission. IGR was defined as the final infarct volume after endovascular therapy divided by the time from stroke onset to successful reperfusion. We used the Youden J index to identify the optimal IGR cutoff to stratify fast and slow progressors. A multivariate logistic regression was used to identify variables associated with a fast IGR and clinical outcomes. Results A total of 212 patients were included in the study. The optimal IGR threshold was 3.2 mL/h, and 135 patients (63.6%) were classified as fast progressors. Presentation National Institutes of Health Stroke Scale score (odds ratio [OR], 1.12; 95% CI, 1.06–1.19) and ASPECTS (OR, 0.56; 95% CI, 0.41–0.73) were accurate predictors of a fast IGR after adjusting for significant confounders. For each 1‐point increase in National Institutes of Health Stroke Scale score at admission, the likelihood of being a fast progressor increased by 12%; for each 1‐point increase in ASPECTS, the likelihood of being a fast progressor decreased by 44%. In the early window (≤6 hours), all patients with ASPECTS <7 were identified as fast progressors. Conclusions This study shows that National Institutes of Health Stroke Scale score and ASPECTS at presentation could predict fast versus slow IGR in patients receiving endovascular therapy

Angiography suite cone-beam CT perfusion for selection of thrombectomy patients: A pilot study

Background and purpose: The availability of cone-beam CT perfusion (CBCTP) in angiography suites may improve large-vessel occlusion (LVO) triage and reduce reperfusion times for patients presenting during extended time window. We aim to evaluate the perfusion maps correlation and agreement between multidetector CT perfusion (MDCTP) and CBCTP when obtained sequentially in patients undergoing endovascular therapy. Methods: This is a prospective, pilot, single-arm interventional cohort study of consecutive patients with anterior circulation LVO. All patients underwent MDCTP and CBCTP prior to endovascular therapy, generating cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time-to-maximum/time to peak contrast concentration maps. We compared the two imaging modalities using three different methods: (1) six regions of interest (ROIs) placed in the anterior circulation territory; (2) ROIs placed in all 10 Alberta Stroke Program Early CT Score regions; and (3) ROI drawn around the entire ischemic area. ROI ratios (unaffected/affected area) were compared for all sequences in each method. We used the intraclass correlation coefficient to calculate the correlation between the studies. Bland-Altman plots were also created to measure the degree of agreement. Finally, a sensitivity analysis was done comparing both modalities in patients with low infarct growth rate. Results: Fourteen patients were included (median age 81 years [74-87], 50% males, median National Institutes of Health Stroke Scale 19 [14-22]). Median time between studies was 42 minutes (interquartile range 29-61). Independently of the method used, we found moderate to excellent correlation in CBF, CBV, and MTT between modalities. CBF correlation further improved in patients with low infarct growth. Conclusion: These results demonstrate promising accuracy of CBCTP in evaluating ischemic tissue in patients presenting with LVO ischemic stroke

Mechanical Thrombectomy Access for All? Challenges in Increasing Endovascular Treatment for Acute Ischemic Stroke in the United States

Mechanical thrombectomy (MT) is the most effective treatment for selected patients with an acute ischemic stroke due to emergent large vessel occlusions (LVOs). There is an urgent need to identify and address challenges in access to MT to maximize the numbers of patients who can benefit from this treatment. Barriers in access to MT include delays in evaluation and accurate diagnosis of LVO leading to inappropriate triage, logistical delays related to availability of facilities and trained interventionalists, and financial hurdles that affect treatment reimbursement. Collection of regional data related to these barriers is critical to better understand current access gaps and a measurable access score to thrombectomy could be useful to plan local public health intervention

Direct Transfer to Angiosuite Triage Strategy for Patients Undergoing Mechanical Thrombectomy in a Rural Setting

Background A direct admission to angiosuite (DAA) strategy in transfer patients with large vessel occlusion (LVO) is considered to decrease stroke time metrics and benefit functional outcomes. However, feasibility and effectiveness of DAA have not been established in rural settings. Fast door‐to‐reperfusion times and high‐quality reperfusion are key predictors of outcome in patients with LVO. To reduce treatment times in transferred patients with suspected LVO, we initiated a DAA triage protocol in 2017. Methods We conducted a nested interventional cohort study of adult patients with anterior LVO from January 2015 to August 2019 transferred to our center from an outside hospital. Patients were divided into DAA for mechanical thrombectomy (MT) and patients directly admitted to the emergency department (DAED). DAED was subdivided into patients undergoing MT and patients who did not. Workflow times and clinical and radiographic outcomes were analyzed. Results Forty‐five DAA patients and 241 DAED patients (DAED patients undergoing MT=134 patients and DAED patients not undergoing MT=107 patients) were identified. DAA patients had significantly shorter median door‐to‐arterial‐puncture times (15 versus 71 minutes) and puncture‐to‐recanalization times (27 versus 42.5 minutes). At discharge, DAA patients had a significant decrease in median admission National Institutes of Health Stroke Scale (NIHSS) score (ΔNIHSS score 10 versus 4; P=0.02), and higher rate of dramatic clinical improvement (ΔNIHSS score >10; 48.9% versus 23.5%; P<0.001). Both groups had comparable rates of functional independence (modified Rankin Scale; mRS 0–2; 36.1% versus 29.2%; P=0.52), and mortality at 90 days (P=0.63). When mortality was excluded, DAA patients showed a significant proportion of excellent functional outcome (mRS 0–1; 50% versus 26%) before (P=0.04) and after (P=0.02) adjusting for confounders. Conclusions DAA is feasible and can safely reduce reperfusion times in transferred patients with LVO to MT centers in a rural setting. Reducing workflow times may impact the functional recovery of patients undergoing MT

Flow Diverter Performance for the Treatment of Intracranial Aneurysms: An International Multicenter Comparative Study

Background Current evidence comparing flow diverters (FDs) for the treatment of intracranial aneurysms is limited to single‐arm head‐to‐head retrospective and prospective studies. Herein, we aimed to compare the efficacy and safety of four FDs for the treatment of intracranial aneurysms. Methods We performed a retrospective, multicenter international cohort study of adult patients treated with FDs (Pipeline embolization device, Surpass Streamline, Flow Redirection Endoluminal Device, and Silk) for intracranial aneurysms between 2015 and 2021. Efficacy was determined by aneurysm occlusion at final follow‐up. Safety was determined by ischemic/hemorrhagic events and mortality. Secondary safety was assessed by technical complications. A mixed‐effect multivariable ordinal and logistic regression were performed to evaluate variables that predicted the outcomes of interest. Results We included 235 patients with 274 aneurysms. Treatment was performed with either the Pipeline embolization device (92), Surpass Streamline (56), Flow Redirection Endoluminal Device (47), and Silk (40). Median age was 57 (47–65) years. Most patients were asymptomatic (76%), and 8% had previous rupture. Most aneurysms were saccular (85%) and anterior (94%). The Pipeline embolization device subgroup had the largest aneurysms (6 mm, P=0.005). Median follow‐up time was 9 (6–14) months. Final overall complete occlusion was 72% without significant differences between FDs (P=0.5). Total ischemic (5%) and hemorrhagic (3%) events were also similar (P=0.1 and P=0.06). One patient expired (0.4%, P=0.6). In multivariable analysis, device diameter predicted aneurysm persistence and ≥50% in‐stent stenosis predicted ischemic/hemorrhagic complications. Conclusions Our findings comparing 4commonly used FDs in a heterogeneous population with mainly small‐sized aneurysms confirmed a similar safety and efficacy profile between devices