Manual Aspiration Thrombectomy Using Penumbra Catheter in Patients with Acute M2 Occlusion : A Single-Center Analysis

ObjectiveThe efficacy and safety of manual aspiration thrombectomy using Penumbra in an acute occlusion of large intracranial arteries has been proven in many previous studies. Our study aimed to retrospectively assess the efficacy and safety of manual aspiration thrombectomy using Penumbra in patients with small vessel occlusions (M2 segment of the MCA).MethodsWe conducted a retrospective review of 32 patients who underwent manual aspiration thrombectomy using the Penumbra 4 MAX Reperfusion Catheter for treatment of an M2 occlusion between January 2013 and November 2014. We evaluated immediate angiographic results and clinical outcomes through review of patient electronic medical records.ResultsThere were slightly more men in this study (M : F=18 : 14) and the median age was 72.5 (age range : 41–90). The rate of successful recanalization (TICI grade ≥2b) was 84% (27/32). NIHSS at discharge and favorable clinical outcomes at 3 months were significantly improved than baseline. Median initial NIHSS score was 10 (range : 4–25) and was 4 (range : 0–14) at discharge. Favorable clinical outcomes (mRS score ≤2 at 3 months) were seen in 25 out of 32 patients (78%). There were no procedure-related symptomatic intracerebral hemorrhages. One patient expired after discharge due to a cardiac problem.ConclusionManual aspiration thrombectomy might be safe and is capable of achieving a high rate of successful recanalization and favorable clinical outcomes in patients with distal cerebral vessel occlusion (M2).     

Trevo支架与Solitaire支架对急性缺血性脑卒中的血管再通疗效比较

目的 比较Trevo支架和Soliatire支架对急性缺血性脑卒中(acute ischemic stroke,AIS)机械取栓术中血管再通及术后并发症的影响。方法 回顾性纳入200例在本院接受支架取栓术的AIS患者,根据选用的支架类型将患者分为Solitaire支架组(102例)和Trevo支架组(98例); 以NIHSS评分和改良Rankin量表(mRS)评估患者的神经功能预后; 以脑梗死溶栓分级(thrombolysis in cerebral infarction,TICI)评估血管再灌注情况,比较患者术后并发症的发生率,并通过logistics回归分析确定影响并发症发生及血管再通的独立危险因素。结果 Trevo组的30d NIHSS评分显著低于Solitaire组[3(0～13)vs 6(0～17),P<0.05],且90d的mRS评分也显著低于Solitaire组[2(0～5)vs 3(0～6),P<0.05],但2组术后脑卒中进展、远端血栓或栓子形成、术后出血、死亡等并发症发生率无明显差异(P>0.05)。与Solitaire支架组比较,Trevo支架组的取栓时间更短[51(30～165)min vs 70(27～160)min,P<0.05]、取栓次数更少[2.1(1～6)次 vs 2.9(1～8)次,P<0.05]、取栓1次成功率更高(40.8% vs 27.5%,P<0.05)、TICI达2b或3级的血管再通率更高(89.8% vs 79.4,P<0.05)。发病到治疗时间≥360 min是影响术后并发症发生的独立危险因素(OR=1.084,95% CI=1.041～1.223,P=0.029),而血管再通TICI达2b或3级是预防术后并发症的独立保护性因素(OR=0.858,95% CI=0.761～0.977,P=0.016)。使用Trevo支架是促进血管再通的独立保护性因素(OR=0.722,95% CI=0.541～0.928,P=0.018,而取栓次数≥2次则是影响血管再通的独立危险因素(OR=1.460,95% CI=1.248～2.303,P=0.015)。结论 与Solitaire支架比较,Trevo支架能够减少AIS患者的取栓次数、缩短取栓时间,并提高闭塞血管的再通率和促进神经功能恢复。     

First-pass effect in posterior acute ischemic stroke undergoing endovascular thrombectomy: A systematic review and meta-analysis

ObjectivesFirst-pass effect (FPE) has been shown to be a predictor of favorable clinical outcomes following endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) in the anterior circulation. Literature regarding FPE for posterior circulation AIS is sparse; we conducted a systematic review and meta-analysis to explore FPE in posterior circulation stroke undergoing EVT.Materials and MethodsWe conducted a systematic review of the English literature in PubMed, Embase, Scopus, and Web of Science. FPE was defined as thrombolysis in cerebral infarction (TICI) 2c-3 and modified FPE (mFPE) was defined as TICI 2b-3 in one pass. Definitions of non-FPE and non-mFPE varied among studies. The primary outcome of interest was modified Rankin Scale (mRS) 0-2. Secondary outcomes of interest were mRS 0-3, symptomatic intracranial hemorrhage (sICH), and mortality. We calculated odds ratios (OR) and corresponding 95% confidence intervals (CI). Heterogeneity was assessed with Q statistic and I² test.ResultsSeven studies with 417 patients in the mFPE group, 942 in the non-mFPE group, 545 in the FPE group, and 1023 in the non-FPE group were included. Overall, FPE was associated with greater rates of 90-day mRS 0-2 (OR= 2.78, 95% CI= 2.11-3.65; P-value< 0.001) and mRS 0-3 (OR= 2.67, 95% CI= 1.98-3.60; P-value< 0.001); however, there was significant heterogeneity among studies for both mRS 0-2 (I²= 69%; P-value< 0.001) and mRS 0-3 (I²= 69%; P-value< 0.001). FPE and non-FPE were associated with similar rates of sICH (OR= 0.65, 95% CI= 0.40-1.07; P-value= 0.09), and no heterogeneity was observed (I²= 0%; P-value= 0.95). FPE was associated with lower rates of mortality (OR= 0.44, 95% CI= 0.33-0.58; P-value< 0.001), although heterogeneity was observed (I²= 58%; P-value= 0.01).ConclusionsFPE is associated with favorable clinical outcomes in patients undergoing EVT for posterior circulation AIS. Future studies should work to further quantify the impact of FPE on outcomes in the posterior circulation.     

Mechanical thrombectomy with a novel device: initial clinical experience with the ANA thrombectomy device

IntroductionThe ANA? (Anaconda Biomed) thrombectomy system is a novel stroke thrombectomy device comprising a self-expanding funnel designed to reduce clot fragmentation by locally restricting flow while becoming as wide as the lodging artery. Once deployed, ANA allows distal aspiration in combination with a stentretriever (SR) to mobilize the clot into the funnel where it remains copped during extraction. We investigate safety and efficacy of ANA? in a first-in-man study.MethodsProspective data was collected on 35 consecutive patients treated as first line with ANA? at a single centre. Outcome measures included per-pass reperfusion scores, symptomatic intracerebral hemorrhage (sICH), NIHSS at day 5, and mRS at 90 days.ResultsMedian NIHSS was 12(9?18). Sites of primary occlusion were: 5 ICA, 15 M1-MCA, 15 M2-MCA. Primary performance endpoint, mTICI 2b-3 within 3 passes without rescue therapy was achieved in 91.4% (n = 32) of patients; rate of complete recanalization (mTICI 2c-3) was 65.7%. First pass complete recanalization rate was 42.9%, and median number of ANA passes 1(IQR: 1?2). In 17.1% (n = 6) rescue treatment was used; median number of rescue passes was 2(1–7), leading to a final mTICI2b-3rate of 94.3% (n = 33). There were no device related serious adverse events, and rate of sICH was 5.7% (n = 2). At 5 days median NIHSS was 1 (IQR 1?6) and 90 days mRS 0?2 was achieved in 60% of patients.ConclusionsIn this initial clinical experience, the ANA? device achieved a high rate of complete recanalization with a good safety profile and favourable 90 days clinical outcomes.     

Extended Time Window Mechanical Thrombectomy for Acute Stroke in Brazil

BackgroundMechanical thrombectomy (MT) is the standard of care for acute ischemic stroke (AIS) caused by large vessel occlusion of the anterior circulation within 6 hours of symptoms onset and can be performed with an extended window up to 24 hours in selected patients. Nevertheless, the outcomes of MT with extended window are unknown in developing countries.ObjectiveExplore the safety and efficacy of MT for AIS performed beyond 6 hours from symptoms onset in Brazil.MethodsWe reviewed data from AIS patients treated with MT beyond 6 hours of stroke onset, from 2015 to 2018 in a Brazilian public hospital. Patients had an occlusion of the intracranial internal carotid artery and/or proximal segment of the middle cerebral artery. CT Perfusion mismatch was evaluated using the RAPID® software. We evaluated the modified Rankin scale (mRS) and mortality at 90 days, and rate of symptomatic intracranial hemorrhage (sICH).ResultsFifty-four patients were included, with a mean age of 65.6 ± 16.1 years, 55.6% were male, and the median NIHSS score at presentation was 17. Successful recanalization (TICI 2b to 3) was obtained in 92.6% of patients and sICH rate was 11.1%. Overall, 34% of the patients had a good outcome (mRS ≤2) at 90 days and the mortality rate was 20.3%.ConclusionOur study, the first series of MT for AIS treated with extended window reported in Latin America, shows that MT can be performed with safety and lead to adequate functional outcomes in this context. Further studies should explore the barriers to broad implementation of MT for AIS in Latin America.     

Mechanical thrombectomy in patients with proximal occlusions and low NIHSS: Results from a large prospective registry

BackgroundMechanical thrombectomy is now standard of care for treatment of acute ischemic stroke secondary to large vessel occlusion in the setting of high NIHSS. We analysed a large nationwide registry focusing on patients with large vessel occlusion and low NIHSS on admission to evaluate the efficacy and safety of thrombectomy in this patient populationMethods2826 patients treated with mechanical thrombectomy were included in a multicentre registry from January 1, 2011 to December 31, 2015. We included patients with large vessel occlusion and NIHSS ≤ 6 on admission. Baseline characteristics, imaging, clinical outcome, procedure adverse events and positive and negative outcome predictors were analysed.Results134 patients were included. 90/134 had an anterior circulation and 44 a posterior circulation stroke. One patient died before treatment. Successful revascularization (mTICI 2b-3) was achieved in 73.7% (98/133) of the patients. Intraprocedural adverse event was observed in 3% (4/133) of cases. Symptomatic intracranial haemorrhage rate was 5.3% (7/133). At three months, 70.9% (95/134) of the patients had mRS score 0-2, 15.7% (21/134) mRS 3-5 and 13.4% (18/134) mRS 6. Age and successful recanalization were significant predictors of a good clinical outcome on both univariate (p= 0.005 and p=0.007) and multivariable (p=0.0018 and p=0.009 [nat log]) analysis. Absence of vessel recanalization and symptomatic intracranial hemorrhage were independent predictors of poor outcome (p=0.021) .ConclusionsOur study suggests that patients with large vessel occlusion and low NIHSS score on admission can benefit from mechanical thrombectomy. Randomized trials are warranted.     

Thrombectomy or intravenous thrombolysis in patients with NIHSS of 5 or less?

Background and purposeTo compare outcomes of minor stroke patients with intracranial vessel occlusions (IVO) underwent mechanical thrombectomy (MT) versus those treated with intravenous thrombolysis alone (IVT).MethodsWe retrospectively reviewed two large prospective stroke databases from two European centers searching for patients admitted with minor stroke (i.e. NIHSS Score░≤░5), baseline mRS░=░0 and occlusion of the M1–M2 segment of the middle cerebral artery (MCA). Groups receiving (A) IVT alone and (B) MT+/-IVT were compared. Primary outcome measures were MT safety, successful recanalization rate (mTICI 2b-3) and NIHSS shift (discharge NIHSS minus admission NIHSS); secondary outcomes included discharge rates and excellent outcome (mRS 0-1) at 3 months. Univariate and multivariate analyses were performed.ResultsThirty-two patients were enrolled in Group B (19░MT alone; 13 MT░+░IVT) and 24 in Group A. Successful recanalization (mTICI 2b-3) was obtained in 100% of cases in Group B vs 38% in Group A. Symptomatic hemorrhagic transformation rate did not differ between the two groups. Multivariate analysis reported MT as the only predictor of early (<░12░h) favorable NIHSS shift and lower NIHSS at discharge. Moreover, discharge at home and excellent outcome at 3-month follow-up were statistically associated with MT.ConclusionsMT in patients with minor strokes and intracranial vessel occlusion (IVO) is safe and can determine a rapid improvement of NIHSS Score. MT seems also associated with a higher rate of patients discharged at home after hospitalization and better clinical outcome at 3-month follow-up. Larger randomized trials are warranted to confirm these results.     

Effectiveness of Anchoring with Balloon Guide Catheter and Stent Retriever in Difficult Mechanical Thrombectomy for Large Vessel Occlusion

ObjectiveA distal navigation of a large bore aspiration catheter during mechanical thrombectomy (MT) is important. However, delivering a large bore aspiration catheter is difficult to a tortuous or atherosclerotic artery. We report the experience of anchoring with balloon guide catheter (BGC) and stent retriever to facilitate the passage of an aspiration catheter in MT. MethodsWhen navigating an aspiration catheter failed with a conventional co-axial microcatheter delivery, an anchoring technique was used. Two types of anchoring technique were applied to facilitate distal navigation of a large bore aspiration catheter during MT. First, a passage of aspiration catheter was attempted with a proximal BGC anchoring technique. If this technique also failed, another anchoring technique with distal stent retriever was tried. Consecutive patients who underwent MT with an anchoring technique were identified. Details of procedure, radiologic outcomes, and safety variables were evaluated. ResultsA total of 67 patients underwent MT with an anchoring technique. Initial trial of aspiration catheter passage with proximal BGC anchoring technique was successful for 35 patients (52.2%) and the second trial with distal stent retriever anchoring was successful for 32 patients (47.8%). Overall, navigation of a large bore aspiration catheter was successful for all patients (100%) without any procedure related complications. ConclusionOur study showed the usefulness of anchoring technique with proximal BGC and distal stent retriever during MT, especially in those with an unfavorable anatomical structure. This technique could be an alternative option for delivering an of aspiration catheter to a distal location.     

Effect of race/ethnicity on arterial recanalization following intravenous thrombolysis in acute ischemic stroke patients

IntroductionSeveral reports have identified that clinical outcomes such as death or disability in acute ischemic stroke (AIS) patients following intravenous (IV) tissue plasminogen activator (tPA) treatment can vary according to race and ethnicities. We determined the effect of race/ethnicity on rates of arterial recanalization in AIS patients with large vessel occlusion (LVO) after IV tPA.MethodsWe analyzed 234 patients with LVO detected on computed tomographic angiography (CTA) who received IV tPA and subsequently underwent angiography for potential thrombectomy. The primary occlusion sites on CTA and digital subtracted angiography (DSA) were compared and a score was given to the level of recanalization with values ranging from 1 (complete recanalization), 2 (partial recanalization), or 3 (no recanalization).The effect of race/ethnicity were assessed for predicting vessel recanalization using the covariates of age, gender, time since stroke onset, tPA dose received, NIHSS (National Institute of Health Stroke Scale) score at baseline, and location of the occlusion, using logistic regression analysis.ResultsFive patients (2.1%) were Hispanic or Latino, 8 (3.4%) Asian, 24 (10.3%) African American, and 197 (84.2%) White. A total of 50% had a distal ICA/proximal M1 occlusion, 20% distal M1 occlusion, and 16% single M2 occlusion. At the primary occlusion site, 44 (18.8%) had complete recanalization on post IV tPA angiogram, 17 (7.3%) had partial recanalization, and 165 (70.5%) had no recanalization. We did not find any association between race/ethnicity and vessel recanalization post IV tPA (Nonwhite combined [OR=1.49, p=0.351]; Asian [OR=1.460, p=0.650]; African American [OR=1.508, p=0.415]; White [OR=0.672, p=0.351]; ethnicity (Hispanic or Latino) [OR= 1.008, p=0.374]); Occlusion location (OR=0.189, p<0.001). Final TICI scores and mRS at 90 days were similar among the different groups.ConclusionApproximately 19% of patients had complete recanalization after IV tPA, but race and ethnicity did not seem to have an effect on arterial recanalization. Arterial recanalization was only affected by location of occlusion.     

急性缺血性脑卒中血管内治疗21例临床分析

目的探讨急性缺血性脑卒中血管内治疗的方法、疗效和安全性。方法回顾性分析血管内治疗的大血管闭塞的急性缺血性脑卒中患者21例。10例为阿替普酶静脉溶栓后桥接血管内治疗,11例直接行血管内治疗。其中机械取栓12例,机械取栓+支架植入3例,单纯颈动脉支架植入3例,机械取栓+动脉溶栓1例,机械取栓+动脉溶栓+支架植入1例,单纯动脉溶栓1例。评估术中mTICI再通等级、并发症及术后随访第90天m RS评分,分析疗效与安全性。结果21例患者前循环卒中18例,后循环卒中3例。NIHSS评分平均15. 81±6. 44分。20例患者术后血管再通达mTICI 2 b-3级。术中并发出血1例,术后大量颅内出血1例,无症状少量颅内出血4例。术后高灌注综合征8例,其中4例行去骨瓣减压术,最终死亡5例(23. 81%)。术后随访第90天mRS评分0～2分8例。结论经充分评估并及时采取适宜的单一或多种血管内治疗方法对于大血管闭塞导致的急性缺血性脑卒中患者安全有效。     

Outcomes of Mechanical Thrombectomy in Patients with Large Diffusion-Weighted Imaging Lesions

ObjectiveDespite many advancements in endovascular treatment, the benefits of mechanical thrombectomy (MT) in patients with large infarctions remain uncertain due to hemorrhagic complications. Therefore, we aimed to investigate the efficacy and safety of recanalization via MT within 6 hours after stroke in patients with large cerebral infarction volumes (>70 mL). MethodsWe retrospectively reviewed the medical data of 30 patients with large lesions on initial diffusion-weighted imaging (>70 mL) who underwent MT at our institution within 6 hours after stroke onset. Baseline data, recanalization rate, and 3-month clinical outcomes were analyzed. Successful recanalization was defined as a modified treatment in cerebral ischemia score of 2b or 3. ResultsThe recanalization rate was 63.3%, and symptomatic intracerebral hemorrhage occurred in six patients (20%). The proportion of patients with modified Rankin Scale (mRS) scores of 0–3 was significantly higher in the recanalization group than in the non-recanalization group (47.4% vs. 9.1%, p=0.049). The mortality rate was higher in the non-recanalization group, this difference was not significant (15.8% vs. 36.4%, p=0.372). In the analysis of 3-month clinical outcomes, only successful recanalization was significantly associated with mRS scores of 0–3 (90% vs. 50%, p=0.049). The odds ratio of recanalization for favorable outcomes (mRS 0–3) was 9.00 (95% confidence interval, 0.95–84.90; p=0.055). ConclusionDespite the risk of symptomatic intracerebral hemorrhage, successful recanalization via MT 6 hours after stroke may improve clinical outcomes in patients with large vessel occlusion.     

Familiarization with Contact Aspiration using Non-Penetrating of the Thrombus (CANP) Technique as the Initial Procedure for Acute Ischemic Stroke

ObjectivesThis study aimed to prove the safety and efficacy of the contact aspiration using non-penetrating of thrombus (CANP) technique for the initial procedure for acute ischemic stroke and to increase operator familiarization with the technical aspects of the CANP technique.Materials and MethodsA total of 103 patients with large-vessel stroke who were treated using thrombectomy alone at our institution between April 2019 and March 2021 were included in this study. CANP technique was performed using a large lumen catheter (inner diameter, ≥0.060 in.) without penetrating a thrombus. Results of the CANP technique, including the procedure time; first-pass effect (FPE); angiographical recanalization; functional independence; thrombus migration; and intracerebral hemorrhage (ICH) were compared with combined technique.ResultsA total of 77 patients (74.8%) were scheduled to undergo the CANP technique for initial procedure, and 50 (64.9%) attempted the CANP technique. Of 50 patients with CANP technique, 33 (66.0%) achieved angiographically good recanalization using CANP technique alone. FPE was achieved in 31 patients (62.0%) in CANP technique group; the rate of FPE was significantly higher (p = 0.008). Asymptomatic ICH were significantly smaller in the CANP technique group (p = 0.008). The median interval of only the CANP technique was 20 (IQR, 16–29.5) min for groin puncture to final recanalization, and was significantly faster (p < 0.001).ConclusionsCANP technique was safe with low risk of hemorrhagic complication and effective for the initial procedure of acute ischemic stroke.     

Outcomes of Mechanical Thrombectomy for Ischemic Stroke in Nonagenarians: A 10-Year Institutional Experience

BackgroundNonagenarians have been underrepresented in stroke trials that established endovascular treatment as the standard for acute ischemic stroke (AIS). Evidence remains inconclusive regarding the efficacy of thrombectomy in this population.ObjectivesTo report our experience with thrombectomy in nonagenarians with stroke, and to identify predictors of mortality. We further investigated the effects of first-pass reperfusion and the addition of intravenous thrombolysis (IVT) on achieving better outcomes.Materials and methodsData was collected for consecutively treated patients at three affiliated comprehensive stroke centers from 2010 to 2021. We included patients ≥90 years-old with AIS secondary to large vessel occlusion. Bivariate analyses were performed using the Mann-Whitney U test for continuous variables, and χ² and Fisher's exact tests, respectively, for nominal and ordinal variables.ResultsThirty-two nonagenarians underwent thrombectomy, of whom 25 (81%) had prestroke mRS ≤2. Thrombectomies were performed using stents (2, 6.7%), aspiration (8, 26.7%), or a combination of both (20, 66.7%). Successful recanalization was achieved in 97%. Procedural complications occurred in 2 (6.3%) and intracranial hemorrhage in 3 (9.4%). Sixteen patients (50%) were discharged home or to rehabilitation, 9 (28.2%) to nursing home or hospice, and 7 (21.9%) died during hospitalization. Only 2 (6%) patients had mRS ≤2 at discharge. No independent predictors of in-hospital mortality were identified, and neither first-pass reperfusion nor the addition of IVT correlated with improvement in clinical outcome.ConclusionsAlthough thrombectomy is safe for nonagenarian stroke and can achieve excellent recanalization, high mortality and poor functional status remain high given the advanced age and frailty of this population.     

Impact of age on mechanical thrombectomy and clinical outcome in patients with acute ischemic stroke

Background and purposeMechanical thrombectomy is less effective in patients aged 80 years or older. Our goal was to better understand the impact of age in general on recanalization rates and clinical outcome.MethodsWe performed a retrospective analysis of our prospective database of adult patients with acute ischemic stroke due to large vessel occlusions, who had undergone mechanical thrombectomy between 2019 and mid-2021. The cohort was categorized into five age groups: 18 – 49, 50 – 59, 60 – 69, 70 – 79 and ≥ 80 years. Our primary outcome measure was clinical outcome at three months after mechanical thrombectomy, measured by the mRS score. Secondary outcomes were procedure times and rates of successful recanalization, defined by mTICI ≥ 2b.ResultsData of 264 patients were analyzed. There were no significant differences in procedure times (p = 0.46) or in rates of successful recanalization (p = 0.49) between age groups. There was a significant association of age and mRS score at three months (p < 0.0001): From youngest to oldest group, odds of functional independence (mRS ≤ 2) decreased (80.0% vs. 21.3%) and odds of death (mRS 6) increased (13.3% vs. 57.3%). Increasing age was significantly associated with lower rates of functional independence (OR 0.93; [95% CI 0.90 – 0.95]), higher rates of care dependency (OR 1.04; [95% CI 1.01 – 1.07]) and higher mortality rates (OR 1.06; [95% CI 1.04 – 1.09]).ConclusionHigher age had no significant impact on recanalization times or recanalization rates but was strongly associated with worse clinical outcome after mechanical thrombectomy.     

Mechanical thrombectomy of M2 occlusions with distal access catheters using ADAPT

Background and purposeThe direct aspiration first pass technique (ADAPT) using distal access catheters (DAC) has proven to be an effective and safe endovascular treatment strategy of acute ischemic stroke with large vessel occlusions (LVO). However, data about direct aspiration using DAC in M2 segment occlusions is limited.We assess the safety and efficacy of DACs in acute M2 occlusions using ADAPT with large bore (5 French /6 French) aspiration catheters as the primary method for endovascular recanalization.Materials and methodsFrom January 2017 to July 2018, 52 patients with an acute ischemic stroke due to M2 occlusions underwent mechanical thrombectomy using ADAPT with DACs (SOFIA 5 French/Catalyst 6) as frontline therapy. Patient demographics, technical parameters and outcome data were recorded.ResultsMedian National Institutes of Health Strokes Scale (NIHSS) Score was 12 at admission. Successful revascularization to mTICI 2b-3 with ADAPT alone was achieved in 45 of 52 patients (86.5%) with mTICI 3 achieved in 32 patients (61.5%). Additional stent retrievers were used in 6 patients and led to an overall successful revascularisation of 92.3% (48/52). Median NIHSS at discharge was 4. 29 of 52 (55.8%) patients had a modified Rankin Scale (mRS) Score 0–2 at three months. Symptomatic intracranial hemorrhage did not occur.ConclusionDACs can safely be used for mechanical thrombectomy of acute M2 occlusions by the ADAPT approach. Their use alone can be a high efficacious treatment of distal intracranial thromboembolic occlusions.     

Hyperperfusion after Endovascular Reperfusion Therapy for Acute Ischemic Stroke

Background and purpose: Patients with acute ischemic stroke (AIS) may display prolonged neurological deficits and conscious disturbance even after successful endovascular thrombectomy. We hypothesized that hemodynamic change after reperfusion might influence outcomes. This study investigated the factors causing hyperperfusion and outcomes. Methods: We retrospectively analyzed 27 patients with AIS who underwent successful acute revascularization (TICI: Thrombolysis in Cerebral Infarction 2b?+?3). Changes of the neurological status were precisely assessed by using the National Institutes of Health Stroke Scale (NIHSS). Ischemic lesions were scored by MRI with diffusion-weighted imaging (DWI), and blood flow in the middle cerebral artery territory was assessed by MRI with arterial spin labeling. Univariate analysis was performed to investigate correlations between hyperperfusion and demographic factors or the functional prognosis. Results: Thirteen of the 27 (48%) patients developed hyperperfusion after reperfusion. A significant correlation was seen between hyperperfusion and the improvement of NIHSS at 24 hours (P < .0001), the duration of disturbance of consciousness (days) (P < .0001), DWI-ASPECTS (P = .001), hemorrhagic transformation (P = .007), and mRS less than or equal to 2 at 90 days (P = .007). Conclusions: The present findings suggested that some patients with AIS will develop hyperperfusion after successful acute revascularization. The status of hyperperfusion could prolong conscious disturbance and affect outcomes. Since the mechanism of hyperperfusion after revascularization depends on stroke etiology, diagnosing the type of ischemic stroke in the acute stage is important for managing postoperative treatment.     

Acute Treatment of Isolated Posterior Cerebral Artery Occlusion: Single Center Experience

Background and objectivesRandomized trials for mechanical thrombectomy (MT) excluded patients with ischemic strokes due to isolated posterior cerebral artery occlusion (IPCAO), and there is no evidence for best acute treatment strategy in these patients. We aimed to assess the effectiveness and safety of MT in acute IPCAO.MethodsWe retrospectively analyzed consecutive patients with acute stroke due to IPCAO submitted to MT and/or intravenous thrombolysis (IVT), between 2015-2019. Effectiveness outcomes (recanalization rate, first-pass effect, NIHSS 24h improvement and 3-month Modified Ranking Scale - mRS) and safety outcomes (complications, symptomatic intracranial hemorrhage (SICH) and 3-month mortality) were described and compared between groups.ResultsA total of 38 patients were included, 25 underwent MT and 13 had IVT alone. Successful and complete recanalization were achieved in 68% and 52% of MT patients, respectively. NIHSS improvement at 24h was found in 56% of MT patients versus 30.8% of patients submitted to IVT alone (OR [95% CI]=2.86 [0.69-11.82]) and excellent functional outcome at 3 months (mRS≤1) was achieved in 54.2% of MT patients versus 38.5% in the IVT group (OR [95% CI]=1.60 [0.41-6.32]). Complications occurred in 3 (12%) procedures and there were no SICH. Mortality at 3 months was 20% in the MT group and 15.4% in patients submitted to IVT alone.ConclusionsOur results reflect a real-world scenario in a single center and seem to support the recently growing literature showing that MT is a feasible and safe treatment in IPCAO, with favorable effectiveness.     

Clinical predictors for favorable outcomes from endovascular recanalization in wake-up stroke

Background and purposePatients who have acute stroke symptoms present on awakening are ineligible for standard intravenous thrombolysis due to the unclear onset time of symptoms. Some of these wake-up stroke (WUS) patients may benefit from endovascular recanalization. This study aimed to evaluate clinical predictors of outcomes from endovascular recanalization in WUS patients.MethodsForty-one WUS patients with internal carotid (ICA) or middle cerebral artery (MCA) occlusion treated with endovascular recanalization were reviewed. Regression analysis was performed to measure clinical predictors of outcomes from endovascular recanalization in WUS patients.ResultsThe mean initial NIHSS score was 16.41 ± 4.96 (5–24). The mean symptom recognition-to-door time (SRDT) was 108.85 ± 65.80 (19–230) min. Successful recanalization (TICI 2b-3) was achieved in 29 patients (70.7%). Thirty-four patients improved on NIHSS (amount 7.59 ± 4.84, range; 1–17) at 7 days after recanalization. At 90 days after recanalization, a mRS of ≤2 was achieved in 19 patients (46.3%) and a mRS of ≤3 was achieved in 24 patients (58.5%). No symptomatic intracerebral hemorrhage occurred. Multivariate regression analysis identified SRDT (P = 0.019), successful recanalization (P = 0.005), and hypertension (P = 0.013) were factors associated with an improvement of the NIHSS score. For a good functional outcome at 90 days, SRDT (P = 0.036) and initial NIHSS score (P = 0.016) were found to be significant predictors.ConclusionsThe results of this study suggest that the SRDT is an independent predictor of both an improvement of NIHSS score and a good functional outcome in endovascular recanalization for WUS patients.     

Brain Atrophy and Leukoaraiosis Correlate with Futile Stroke Thrombectomy

IntroductionAlthough mechanical thrombectomy (MT) is a proven therapy for acute large vessel occlusion strokes, futile recanalization in the elderly is common and costly. Strategies to minimize futile recanalization may reduce unnecessary thrombectomy transfers and procedures. We evaluated whether a simple and rapid visual assessment of brain atrophy and leukoaraiosis on a plain head CT correlates with futile stroke recanalization in the elderly.MethodsConsecutive stroke patients admitted for thrombectomy, older than 65 years of age, all with TICI 2b/3 recanalization rates were retrospectively studied from multiple comprehensive stroke centers. Brain atrophy and leukoaraiosis were visually analyzed from pre-intervention plain head CTs using a simplified scheme based on validated scales. Baseline demographics were collected and the primary outcome measure was 90-day modified Rankin score (mRS). Cochran-Armitage trend test was applied in analyzing the association of the severity of brain atrophy and leukoaraiosis with 90-day mRS.ResultsBetween 2017 and 2019, 175 patients > 65 years who underwent thrombectomy with TICI 2b/3 recanalization from two comprehensive stroke centers were evaluated. The median age was 77 years. IV-tPA was given in 59% of patients, average initial NIHSS was 19, average baseline mRS was 0.77 and median time to recanalization was 300 minutes. Age and severity of atrophy/leukoaraiosis was categorized into three groups of increasing severity and associated with 90 day mRS 0-3 rates of 62%, 49% and 41% (p=0.037) respectively.ConclusionsA simplified, visual assessment of the degree of brain atrophy and leukoaraiosis measured on plain head CT correlates with futile recanalization in patients age >65 years. Although additional validation is needed, these findings suggest that brain atrophy and leukoaraiosis may have value as a surrogate marker of prestroke functional status. In doing so, simplified visual plain head CT grading scales may minimize elderly futile recanalization.     

Effects of and prognostic factors affecting endovascular mechanical thrombectomy of acute vertebrobasilar artery occlusion

PurposeTo investigate the clinical outcome and factors affecting the prognosis of endovascular mechanical thrombectomy of acute vertebrobasilar artery occlusion.Materials and methodsEighty-three patients with acute vertebrobasilar artery occlusion were treated with endovascular mechanical thrombectomy, and the recanalization rate, clinical outcomes at three months, modified DWI-PC-ASPECTS, and MRA-BATMAN scores were analyzed.ResultsFollowing acute mechanical thrombectomy, the TICI 2B-3 score was achieved in all patients (100%). At three-month evaluation, 56 (67.5%) patients had good prognosis with the mRS score of 0–2, including 13 (23.2%) patients who had arterial occlusion caused by emboli and 43 (76.8%) who had atherosclerotic stenosis. In analyzing factors affecting the prognosis, a significant difference (P < 0.05) existed between patients with good (mRS 0–2) and poor (mRS 3–6) prognosis in the NIHSS (17.3 vs. 31.2, P = 0.000001), modified DWI-PC-ASPECTS (10.4 vs. 7.8, P = 0.021), and MRA-BATMAN (6.3 vs. 4.6, P = 0.003) scores. Univariate Logistic regression analysis demonstrated NIHS score ≥ 21, modified DWI-PC-ASPECTS score ≤ 8.5, and MRA-BATMAN score ≤ 6.5 to be the risk factors for poor prognosis. Multivariate Logistic regression analysis revealed NIHSS score ≥ 21 as an independent risk factor for poor prognosis.ConclusionEndovascular mechanical thrombectomy is safe and effective in recanalizing occluded vertebrobasilar artery occlusion, and NIHS score ≥ 21, modified DWI-PC-ASPECTS score ≤ 8.5, and MRA-BATMAN score ≤ 6.5 are the risk factors for poor prognosis.