Randomized trials in the late window have demonstrated the efficacy and safety of endovascular thrombectomy in large-vessel occlusions. Patients with M2-segment MCA occlusions were excluded from these trials. We compared outcomes with endovascular thrombectomy in patients with M2-versus-M1 occlusions presenting 6–24 hours after symptom onset.
MATERIALS AND METHODS:
Analyses were on pooled data from studies enrolling patients with stroke treated with endovascular thrombectomy 6–24 hours after symptom onset. We compared 90-day functional independence (mRS ≤ 2), mortality, symptomatic intracranial hemorrhage, and successful reperfusion (expanded TICI = 2b–3) between patients with M2 and M1 occlusions. The benefit of successful reperfusion was then assessed among patients with M2 occlusion.
RESULTS:
Of 461 patients, 367 (79.6%) had M1 occlusions and 94 (20.4%) had M2 occlusions. Patients with M2 occlusions were older and had lower median baseline NIHSS scores. Patients with M2 occlusion were more likely to achieve 90-day functional independence than those with M1 occlusion (adjusted OR = 2.13; 95% CI, 1.25–3.65). There were no significant differences in the proportion of successful reperfusion (82.9% versus 81.1%) or mortality (11.2% versus 17.2%). Symptomatic intracranial hemorrhage risk was lower in patients with M2-versus-M1 occlusions (4.3% versus 12.2%, P = .03). Successful reperfusion was independently associated with functional independence among patients with M2 occlusions (adjusted OR = 2.84; 95% CI, 1.11–7.29).
CONCLUSIONS:
In the late time window, patients with M2 occlusions treated with endovascular thrombectomy achieved better clinical outcomes, similar reperfusion, and lower symptomatic intracranial hemorrhage rates compared with patients with M1 occlusion. These results support the safety and benefit of endovascular thrombectomy in patients with M2 occlusions in the late window.
Good collateral circulation (CC) associates favourable outcomes on acute stroke patients, but which is the best technique to evaluate it is controversial. Single-phase CTA (sCTA) is widely used, but lacks of temporal resolution, and may mislabel CC. We aim to evaluate a new, quick (not post processing), time resolved technique to evaluate CC: multiphase CTA (mCTA). METHODS: Consecutive <4.5h stroke patients evaluated for reperfusion therapies with confirmed M1-MCA or TICA occlusion by sCTA were included. Two more cerebral CTA acquisitions with 10 and 20 seconds delay were performed for mCTA. CC evaluation is described in the Table. sCTA and mCTA were compared as predictors of clinical, radiological and functional endpoints. Recanalization (REC) was assessed by TCD at 24h. RESULTS: 78 patients were included. Mean age: 66.3±13.6y, median NIHSS 17.5 (IQR 6.3), 52 (66.7%) M1- and 26 (33.3%) TICA-occlusions. Mean time from onset to CTA: 2:32±1:31h. On sCTA, 61.8% patients presented good CC whereas on mCTA, 54.7%. Only on mCTA good CC was an independent predictor of low infarct volume at 24h (OR 3.6, CI 95% 1.3-10.5, p=0.017). Moreover, only mCTA-CC status was associated with lower 24h median NIHSS (good CC:5 vs poor CC:17, p<0.001), and 3 months favourable outcome (mRS0-2: good CC 57.1% vs poor CC 11.5%, p<0.001). Association with outcome was especially significant in patients without REC: among poor CC patients, mRS0-2: 0% in non REC Vs 50% in REC (p<0.01). In a logistic regression model including age, NIHSS, ASPECTS and REC, only good CC on mCTA predicted favourable outcome (OR 6.8, CI 95% 1.6-29.2, p=0.009). CONCLUSION: CC evaluation on mCTA improves accuracy of clinical and radiological endpoints as compared with sCTA. Good CC on mCTA is an independent predictor of low infarct volume and good outcome, especially if REC is not achieved.
Endovascular treatment (EVT) for acute ischemic stroke is one of the most efficacious and effective treatments in medicine, yet globally, its implementation remains limited. Patterns of EVT underutilization exist in virtually any health care system and range from a complete lack of access to selective undertreatment of certain patient subgroups. In this review, we outline different patterns of EVT underutilization and possible causes. We discuss common challenges and bottlenecks that are encountered by physicians, patients, and other stakeholders when trying to establish and expand EVT services in different scenarios and possible pathways to overcome these challenges. Lastly, we discuss the importance of implementation research studies, strategic partnerships, and advocacy efforts to mitigate EVT underutilization.
Background: The optimal treatment for stroke patients with tandem cervical carotid occlusion is debated. We analyzed the treatment strategies and outcomes of tandem occlusion patients in the ESCAPE NA1 trial. Methods: ESCAPE NA1 was a multicenter international randomized trial of nerinetide vs. placebo in patients with acute ischemic stroke who underwent EVT. We defined tandem occlusions as complete occlusion of the cervical ICA on catheter angiography. The influence of tandem occlusions on outcome was analyzed using regression modeling with adjustment for age, sex, baseline NIHSS and ASPECTS, occlusion location, thrombolysis and treatment allocation. Results: 115 of 1105 patients (10.4%) had tandem occlusions. 73/115 tandem patients (66.0%) received treatment for the cervical occlusion: 21.9% were stented before thrombectomy, 68.5% were stented after thrombectomy, and 8.2% had angioplasty alone. Successful reperfusion was significantly higher in patients who had thrombectomy first followed by carotid treatment (eTICI 2b-3: 40/40 (100.0%)) or carotid angioplasty before and cervical stent after intracranial thrombectomy (9/10 (90.0%)) compared to carotid intervention before intracranial thrombectomy: (19/23 (82.1%), p=0.016). 90-day mRS 0-2 was achieved in 82/115 patients (71.3%) with tandem occlusions (treated occlusions: 74.0%, untreated: 66.7%) compared to 579/981 (59.5%) patients without tandem occlusions. In adjusted analysis, tandem occlusion was not predictive of outcome. In the subgroup of tandem patients, cervical stent-treatment was nominally associated with better outcomes (OR 2.2, 95% CI 0.5 - 9.2). Conclusion: Cervical carotid stenting may improve outcomes for EVT patients with tandem occlusions, but these results are limited by the sample size and non-randomized selection of patients for stenting.
Infarct volume is an important predictor of clinical outcome in acute stroke. We hypothesized that the association of infarct volume and clinical outcome changes with the magnitude of infarct size.
MATERIALS AND METHODS:
Data were derived from the Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial, in which patients with acute stroke with large-vessel occlusion were randomized to endovascular treatment plus either nerinetide or a placebo. Infarct volume was manually segmented on 24-hour noncontrast CT or DWI. The relationship between infarct volume and good outcome, defined as mRS 0–2 at 90 days, was plotted. Patients were categorized on the basis of visual grouping at the curve shoulders of the infarct volume/outcome plot. The relationship between infarct volume and adjusted probability of good outcome was fitted with linear or polynomial functions as appropriate in each group.
RESULTS:
We included 1099 individuals in the study. Median infarct volume at 24 hours was 24.9 mL (interquartile range [IQR] = 6.6–92.2 mL). On the basis of the infarct volume/outcome plot, 4 infarct volume groups were defined (IQR = 0–15 mL, 15.1–70 mL, 70.1–200 mL, >200 mL). Proportions of good outcome in the 4 groups were 359/431 (83.3%), 219/337 (65.0%), 71/201 (35.3%), and 16/130 (12.3%), respectively. In small infarcts (IQR = 0–15 mL), no relationship with outcome was appreciated. In patients with intermediate infarct volume (IQR = 15–200 mL), there was progressive importance of volume as an outcome predictor. In infarcts of > 200 mL, outcomes were overall poor.
CONCLUSIONS:
The relationship between infarct volume and clinical outcome varies nonlinearly with the magnitude of infarct size. Infarct volume was linearly associated with decreased chances of achieving good outcome in patients with moderate-to-large infarcts, but not in those with small infarcts. In very large infarcts, a near-deterministic association with poor outcome was seen.
Background The benefit of endovascular treatment (EVT) is highly time-dependent, and treatment delays reduce patients’ chances to achieve a good outcome. In this survey-based study, we aimed to evaluate current in-hospital EVT workflow characteristics across different countries and hospital settings, and to quantify the time-savings that could be achieved by optimizing particular workflow steps. Methods In a multinational survey, neurointerventionalists were asked to provide specific information about EVT workflows in their current working environment. Workflow characteristics were summarized using descriptive statistics and stratified by country and physician characteristics, such as age, career stage, personal and institutional caseload. Results Among 248 respondents from 48 countries, pre-notification of the neurointerventional team was used in 70% of cases. The emergency department (ED) and CT scanner, and the CT scanner and neuroangiography suite, were on different floors in 23% and 38%, respectively. Redundant procedures in the ED were often routinely performed, such as chest x-rays (in 6%). General anesthesia was the most frequently used anesthesia protocol for EVT (42%), and an anesthesiologist was available in 82% for this purpose. 52% of the participants used a pre-prepared EVT kit. Conclusion The current structure of EVT workflows offers possibilities for improvement. While some bottlenecks, such as the spatial department set-up, cannot easily be resolved, pre-notification tools and pre-prepared EVT kits are more straightforward to implement and could help to reduce treatment delays, and thereby improve patient outcomes.
Introduction: There is uncertainty regarding the best transport strategy for ischemic stroke patients with a suspected large vessel occlusion since endovascular therapy (EVT) has become standard of care. Patients can be transported directly to an EVT hospital (mothership), or first to a closer hospital for alteplase and then transferred to the EVT hospital (drip-and-ship). Based on mathematical models, we have developed DESTINE (DEcision Support Tool IN Endovascular therapy), a cloud-based interactive software, which produces visualizations depicting whether drip-and-ship or mothership results in the greatest probability of good outcome. The results are customizable to each system (travel time between treatment centres, treatment efficiency, field population). A novel visualization technique (2-D temporal-spatial visualization) is used to display the model results to the user (Figure). Methods: A usability study was performed with a group of healthcare administrators and clinicians. Users were introduced to the software and asked to perform several tasks and then interpret the results. Users were also asked open-ended questions to help better understand their experience with using a 2-D temporal-spatial diagram. Sessions were screen and audio recorded, audio was transcribed verbatim and analyzed using inductive thematic analysis. Results: 67% of participants were physicians and 33% paramedics, 67% were female and the average age was 40.0 years (SD: 10.54). Some users remarked that once familiarized with the software it was simple to use and the visualizations was clear. Although others felt a video tutorial or reference image would have been helpful. Users also thought the ability to compare two visualizations was beneficial. Several suggestions for improvements were also made. Conclusion: The study results have illuminated that 2-D temporal-spatial visualizations can be used to display the results of a stroke transportation model to end users.
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