Background and Purpose: The rationale for recanalization therapy in acute ischemic stroke (AIS) is to preserve brain through penumbral salvage and thus improve clinical outcomes. We sought to determine relationship between recanalization, clinical outcomes, and final infarct volumes in AIS patients presenting with middle cerebral artery (MCA) occlusion who underwent endovascular therapy and post procedure Magnetic Resonance Imaging (MRI). Methods: We identified 201 patients with MCA occlusion. Patients with other occlusive lesions were excluded. Baseline clinical/radiological characteristics, procedural outcomes (including Thrombolysis in Myocardial Infarction -TIMI scores), clinical outcome scores (modified Rankin scores - mRS), and final infarct volumes on Diffusion Weighted Imaging (DWI) were retrospectively analyzed from a prospectively collected database. Favorable outcome is defined as 90-day mRS≤2. Results: Successful recanalization (TIMI grade 2/3) was achieved in 83% and favorable outcomes in 46% of cases. Mean infarct volume was 69.5 ml in recanalized vs. 129.6 ml in non-recanalized patients (p<0.01) and 40.4 ml in patients with favorable outcomes vs. 111.8 ml in patients with unfavorable outcomes (p<0.01). In multivariate analysis TIMI ≥ 2, baseline NIHSS, ASPECTS scores and age were identified as independent predictors of outcome. However, when infarct volumes were included in analysis only final infarct volume and age remained significantly associated. Conclusions: Successful recanalization leads to improved functional outcomes through a reduction in final infarct volumes. In our series, age and final infarct volume but not recanalization was found to be independent predictors of outcome, supporting the use of final infarct volume as surrogate marker of outcome in acute stroke trials.
Importance: Clinical trials focusing on new mechanical thrombectomy (MT) technologies have been typically single-arm studies using historical comparison data to determine the safety and efficacy of the novel device. To date, there has not been a contemporaneous prospective, randomized, controlled study comparing standard to newer designed stent-retrievers. Objective: To evaluate the safety and efficacy of the pRESET (phenox Ltd) compared to the Solitaire (Medtronic Corp) thrombectomy devices in the treatment of large vessel occlusion strokes (LVOS). Methods: Multicenter, prospective, randomized, open-label, blinded endpoint, core lab adjudicated, non-inferiority trial that enrolled 340 patients from October 2019 to February 2022 across 19 US & 5 German sites. Patients aged ≥ 18 years with either anterior or posterior circulation LVOS were included up to 8 hours after symptom onset. Patients were randomly assigned in a 1:1 ratio to either pRESET or Solitaire for the first three device passes.The Primary Endpoint was the proportion of patients achieving a modified Rankin Scale score of 0-2, analyzed by intent to treat with a non-inferiority margin of 0.125 based on the lower bound 95% Confidence Interval. The Primary Safety Endpoint was the proportion of subjects with device- or procedure-related symptomatic intracerebral hemorrhage at 24 (-8/+12) hours as per the SITS-MOST criteria. Secondary Outcome Measures included the rates of (1) Successful Revascularization (defined as expanded Thrombolysis in Cerebrovascular Infarction [eTICI] ≥2b50 ≤3 passes of the assigned device; (2) eTICI ≥2c following the first pass of the assigned device; (3) 90-day mortality and (4) Distribution of 90-day mRS across the entire spectrum of disability (ordinal shift). Results: The study database was locked in August 2022. The analysis is ongoing and the final results will be presented at the 2023 International Stroke Conference. Conclusions and Relevance: PROST is the first randomized clinical trial aiming to compare a novel versus an established stent-retriever technology, establishing a new scientific benchmark for stroke device trials. (ClinicalTrials.gov: NCT03994822).
BACKGROUND: Most stroke patients present to small community hospitals without established stroke pathways or interventional stroke treatment capability. The advent of 2 way audiovisual telestroke systems gives such patients the opportunity to be assessed rapidly by stroke neurologists. Patients who are not candidates for systemic IV tPA or have failed thrombolytic treatment can be identified and transferred to a comprehensive stroke center for potential endovascular treatment. We compared the clinical outcomes of patients undergoing endovascular stroke treatment at University of Pittsburgh Medical Center triaged either through telestroke or non-telestroke means. METHODS: Prospective data including demographics, co-morbidities, baseline Alberta Stroke Program Early CT (ASPECT) and National Institute of Health Stroke Scale (NIHSS) score, intervention modality (pharmacological, mechanical or both), time to treatment, clinical outcome, and hemorrhage and mortality rates were compared. Favorable outcome was defined as modified rankin score (mRS) of 2 or less. RESULTS: Between 3/2007 and 5/2011, thirty four patients underwent endovascular stroke treatment following telestroke evaluation versus 354 patients who were triaged through other means. Baseline characteristics were similar between the groups. Time to endovascular treatment (595 vs. 767 minutes; p = 0.5), pretreatment with systemic tPA (51.6 vs. 56.9%, p=0.6), recanalization (TIMI ≥ 2; 91.2% vs. 84.8%; p = 0.31), favorable outcome (modified rankin score ≤ 2; 50% vs. 40.4%; p = 0.29) and mortality rates (28.1% vs. 34.9%, p=0.44) were comparable. Multivariate logistic regression model identified young age (OR 0.91, CI 0.88-0.95, p<0.01), successful recanalization (OR 3.3, CI 1.8-6.2, p<0.01), and baseline ASPECT score (OR 6.5, CI 2.4-17.4, p<0.01) as predictors of favorable outcome. CONCLUSION: The results of this study suggest that telestroke guided endovascular stroke treatment is feasible and the outcomes are similar to those patients who were triaged by traditional means. Future randomized studies which specifically compare triage via telemedicine vs. telephone or direct emergency department presentation are needed to substantiate these findings.
Background and Purpose: Final infarct volume has previously been shown to be a major predictor of outcome after endovascular therapy for middle cerebral artery (MCA) occlusion. However, the importance of specific location of infarct within the MCA territory has not been described. We sought to assess the predictive value of specific topographic regions as predictors of outcomes in a homogeneous cohort of patients treated with endovascular therapy of M1 occlusive disease who underwent post procedure MRI. Methods: A retrospective review of our prospectively maintained single center endovascular database was performed. Automated software was used to measure infarct volume and the DWI ASPECT score was assessed by visual inspection using standard templates. Univariate and multivariate analysis was performed to determine predictors of favorable outcomes using each of the 10 regions as part of the ASPECT score as well as total ASPECT score. Results: 100 patients were identified. 56% were female. Median age was 70. Successful recanalization was achieved with TIMI 2/3 flow in 87% of patients and TICI 2B/3 in 61% of patients. Good outcomes (mRS 0-2 at 3 months) in 46% of patients. There was no difference between outcomes based on the hemisphere involved. Median final infarct on DWI MRI at 24 hours was 39 cc. Median ASPECT score was 6. In multivariate analysis, strong predictors of good outcomes included: age (OR 0.88, 95% CI 0.8-0.96, p=0.006), serum glucose on admission (OR 0.98, 95% CI 0.97-1, p=0.046) and ASPECT score on MRI (OR 0.7, 95% CI 0.03-1.05, p=0.03). There was a high correlation between the volume of infarct and ASPECT score on the post recanalization MRI (Spearman’s rho of -0.76). Conclusions: Quantitative (automated software) and semi-quantitative (ASPECT score values) measurements of infarct size are highly predictive of outcomes after recanalization therapy in middle cerebral artery infarcts. No single topographic region or combination of regions is predictive of outcome, whereas total ASPECT scores are highly predictive. These data support the role of post procedural MRI in guiding prognosis after anterior circulation infarct.
A 60-year-old woman on venlafaxine presented with headache and left-sided weakness 1 month after undergoing right common carotid artery stenting. Catheter-based angiogram identified new irregularities of the right anterior cerebral and right middle cerebral artery (figure, A–C). Investigations for vasculitis, including CSF studies, were unremarkable. The vessel irregularities and symptoms improved after administration of intra-arterial verapamil (figure, D–F). Unilateral reversible cerebral vasoconstriction syndrome has previously been described after carotid endarterectomy. The mechanism is unclear; however, it may be due to disturbance of cerebral autoregulation.1,2 Concomitant use of a serotonin and norepinephrine reuptake inhibitor may have been a predisposing factor.
Subarachnoid hyperdensity is commonly seen on postoperative computed tomography scans within 24 h after mechanical thrombectomy. The impact on patients' outcomes remains uncertain. We present a real-world experience evaluating periprocedural factors associated with the development of subarachnoid hemorrhage (SAH) and its impact on outcomes of patients with acute stroke undergoing mechanical thrombectomy.A single-center, retrospective analysis was performed between January 2016 and August 2021, including all consecutive patients who underwent thrombectomy. Our study aimed to evaluate periprocedural factors associated with subarachnoid hemorrhage within 24 h of the intervention, and the potential impact on patients' outcome.Of 781 patients, 44 patients (5.63%) demonstrated pure SAH within 24 h of the intervention. Patients from the SAH group were more likely to have tandem occlusion (15.9% vs. 5.2%, p = .003), aspiration using reperfusion pump system (81.4% vs. 66.8%, p = .047), intraoperative complications (9.1% vs. 0.9%; p < .001), longer puncture-to-recanalization times (45 min vs 29 min, p = .042) and a higher median number of passes to achieve recanalization (1 vs. 3, p = .002). There was no statistically significant difference in the long-term functional outcome between the groups.We suggest that dual-energy computed tomography could better distinguish between blood and pure contrast stagnation. Still, SAH was not associated with an unfavorable outcome in stroke patients undergoing thrombectomy.
Benalia, Victor H. C. MD; Cortez, Gustavo M. MD; Robinson, Michael MD; Guy, Elleree D. PAC, ANVP; Aghaebrahim, Amin MD; Sauvageau, Eric MD; Hanel, Ricardo A. MD, PhD Author Information
In patients undergoing acute neurointervention, thromboembolic complications are the most common procedure related morbidity, in special when endoluminal prosthesis (stents/flow diverters) are needed. Dual-antiplatelet therapy (DAPT) has been used in order to prevent these events. Cangrelor is a potent, intravenous, P2Y12-receptor antagonist presented as an alternative to oral antiplatelet agents, with a rapid onset and offset. We aimed to evaluate the safety and effectiveness of cangrelor in patients with acute neurologic ischemic disease and intracranial aneurysms that underwent endovascular intervention.
Materials and Methods
We conducted a multicenter retrospective review of patients who underwent acute neurological intervention and had cangrelor as part of their optimal treatment. Patients from four comprehensive interventional neurovascular centers were included and allocated into two groups: (1) Acute ischemic (acute stroke and/or symptomatic atherosclerotic disease) and Aneurysms (ruptured and unruptured). Clinical presentation, laboratorial data, and outcomes were analyzed with an emphasis on periprocedural thromboembolic and hemorrhagic complications.
Results
A total of 66 patients were included, 42 of whom were allocated in the ischemic group and 24 in the aneurysm group. In the acute ischemic group, median NIHSS was 15.5 (IQR, 8.25–21], and the majority of patients underwent mechanical thrombectomy (73%) associated with either rescue intracranial stenting (61.3%) or carotid stenting (35.4%). The overall periprocedural complication in this group was 9.5%, corresponding to 3 (7.1%) postoperative symptomatic intracranial hemorrhages (sICH) and 1 (2.3%) intraoperative thromboembolic event. At discharge, a favorable outcome (mRS 0–2) was noted in 47.6%, and 1 (2.4%) patient died after the progression of a sizeable infarct. In the aneurysm group, 66.7% were ruptured, and the most common treatment modality was flow diverter (66.7%). Although overall periprocedural complication was noted in 3 cases (12.5%), only one complication (4.2%) had occurred during or after cangrelor infusion. It consisted of a sICH in previously ruptured aneurysm. The other two complications occurred before cangrelor infusion, being 1 sICH and 1 thromboembolic event. At discharge, a favorable outcome (mRS 0–2) was seen in 66.7%, and mortality was 8.3%, related to the ruptured aneurysms that progressed with sICH. When both groups were divided according to cangrelor infusion duration, there was no significant difference in the number of complications in patients receiving either short (median of 2h hours) or prolonged (median of 24 hours) infusion.
Conclusion
Cangrelor is a safe alternative in patients requiring immediate intervention with the use of stents and flow diverters. Cangrelor was not associated with increased rates of hemorrhagic complications and also allowed the possibility for a secure transition to long-term DAPT and progression to surgery in the setting of unexpected complications. Ideally, prospective studies with larger samples and comparison with a standard antiplatelet regimen are required to clarify the best protocol, safety profile, and effectiveness of cangrelor in neurologic endovascular interventions, unlikely to happen on our field.
Disclosures
G. Cortez: None. A. Monteiro: None. N. Sourour: None. F. Clarençon: None. M. Elhoray: None. M. Grigoryan: None. S. Mirza: None. G. Dabus: None. I. Linfante: None. Y. Murtaza: None. P. Aguilar-Salinas: None. A. Aghaebrahim: None. E. Sauvageau: None. R. Hanel: 1; C; Chiese USA, Inc. 2; C; Microvention, Codman, Stryker and Medtronic.
Background and Purpose: Octogenerians have consistently been shown to have poor outcomes after endovascular therapy for acute stroke. On the other hand, final infarct volumes are predictive of outcomes. We sought to explore the relationship between final infarct volumes and outcomes in octogenerians with acute stroke due to M1 MCA occlusion treated with endovascular therapy at our institution. Methods: Retrospective analysis of an acute stroke endovascular database was performed. Inclusion criteria were acute M1 MCA occlusion and post procedural MRI allowing for final infarct volume analysis through an automated software application. Results: A total of 219 patients were identified of which 51 (23%) were 80 years or older. Median age in non-octogenerians was 65.5 versus 83 in octogenerians. Females were 51.8% versus 67%, respectively. Median admission NIHSS was 16 versus 17 (p=ns). Median final infarct volume was 43.6 cc vs. 43.3 cc (p=ns). Median time to treatment was 5.6 hours versus 5.5 hours. Successful recanalization rate (TIMI 2/3 flow) was achieved in 139/168 (83%) versus 45/51 (88%) (p=ns). Multivariate analysis, controlling for admission NIHSS score, recanalization and intubation and time from symptom onset to procedure, identified age (OR 0.9, p < 0.0001, 95% CI 0.86-0.93) and final infarct volume (OR 0.98, p < 0.0001, 95% CI 0.97-0.99) as predictors of favorable outcome (mRS 0-2 at 3 months). The rate of favorable outcomes was 89/168 (53%) versus 10/51 (19.6%) (p < 0.0001). Mean final infarct volume in non-octogenerians with good outcome was 40 cc versus 19 cc in octogenerians (p=0.014). In patients with less than 20 cc of final infarct volume, 84% (37 out of 44) of non-octogenerians had a favorable outcome versus 46% (6 out of 7) of octogenerians (p=0.01). Conclusions: Despite similar recanalization rates and final infarct volumes, outcomes after endovascular therapy for MCA occlusions in octogenerians are worse than in non-octogenerians. However, outcomes are strongly related to infarct volumes and consequently nearly half of octogenerians with final infarct volume of <=20 cc had favorable outcomes. A small final infarct volume is best predicted by successful recanalization and high pre-procedural ASPECT scores (9 or 10).
Background: Optimization of workflow and reduction of times are critical in the management of patients with acute ischemic stroke. Strong evidence of thrombectomy is superior to medical therapy alone in the management of selected cases with large vessels occlusion. The role of advanced imaging to select those patients remains uncertain. Other challenge of acute stroke therapy is inter-facility transfer, which may add significant delay to treatment. The use of CT perfusion (CTP) and CT angiography could assist in the selection of the appropriate patient for transfer and could reduce de door to puncture time when done at the referral facility.
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