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Introduction by the Convenors
THE IMPACT OF THE TREATING INTERVENTIONIST’S EXPERIENCE ON THE PERFORMANCE OF ENDOVASCULAR THROMBECTOMY IN ACUTE ISCHEMIC STROKE: RESULTS FROM THE MR CLEAN REGISTRY.
Abstract
Group Name
On behalf of the MR CLEAN Registry investigators.
Background And Aims
It’s unclear whether a relation exists between interventionist’s experience and recanalization or clinical outcomes in endovascular thrombectomy (EVT) for acute ischemic stroke. We aimed to investigate this relationship in a large nationwide registry of patients treated with EVT.
Methods
We used data from 2,700 patients, included in the MR CLEAN Registry (2014-2017). Interventionist’s experience was defined as the total number of patients treated before the current intervention (EXPno) and the number of patients treated in the previous year (EXPfreq). Experience was obtained from MR CLEAN pre-trial, trial, and Registry data. Outcomes were NIHSS 24-48h post-EVT, recanalization (eTICI≥2B), and procedure time. We used linear and binary multilevel models with the interventionist as a random intercept.
Results
EXPno was only associated with NIHSS score 24-48h post-EVT in univariate analysis (β -0.014, 95%CI: -0.025 to -0.003). EXPfreq was significantly associated with a decreased NIHSS score (adjusted(a)β:-0.05, 95%CI: -0.07 to -0.02). EXPno and EXPfreq both showed increased probabilities for recanalization (respectively aOR:1.01, 95%CI:1.00 to 1.01, and aOR:1.02, 95%CI:1.01 to 1.03). Both EXPno and EXPfreq were significantly associated with shorter procedure times (respectively aβ:-0.13 95%CI:-0.18 to -0.08, and aβ:-0.31, 95%CI:-0.43 to -0.18).
Conclusions
In this observational study, the interventionist’s experience, especially the number of patients treated in the previous year was associated with short-term neurological outcomes, recanalization, and procedure time. For every 22 procedures more per interventionist per year, the chance of recanalization was 1.5 times higher, NIHSS scores decreased by 1 point, and procedure times decreased by 7 minutes.
Trial Registration Number
Not applicable
BLOOD PRESSURE AFTER ENDOVASCULAR THROMBECTOMY AND OUTCOMES IN ACUTE ISCHEMIC STROKE PATIENTS: A SYSTEMATIC REVIEW AND INDIVIDUAL PATIENT DATA META-ANALYSIS
Abstract
Background And Aims
In this systematic review and individual patient data meta-analysis we aim to explore the association between blood pressure (BP) levels after endovascular thrombectomy (EVT) and the clinical outcomes of acute ischemic stroke (AIS) patients with large vessel occlusion (LVO).
Methods
A study was eligible if it enrolled AIS patients older than 18 years, with an LVO treated with either successful or unsuccessful EVT, and provided either individual or mean 24-hour systolic BP values after the end of the EVT procedure. Individual patient data from all studies were analyzed using a generalized linear mixed-effects model.
Results
A total of 5874 patients (mean age: 69±14 years, 50% women, median NIHSS on admission:16) from 7 published studies were included. Increasing mean systolic BP levels per 10 mm Hg during the first 24 hours after the end of the EVT were associated with a lower odds of functional improvement (unadjusted common OR=0.82, 95%CI:0.80-0.85; adjusted common OR=0.88, 95%CI:0.84-0.93) and modified Ranking Scale score≤2 (unadjusted OR=0.82, 95%CI:0.79-0.85; adjusted OR=0.87, 95%CI:0.82-0.93), and a higher odds of all-cause mortality (unadjusted OR=1.18, 95%CI:1.13-1.24; adjusted OR=1.15, 95%CI:1.06-1.23) at 3 months. Higher 24-hour mean systolic BP levels were also associated with an increased likelihood of early neurological deterioration (unadjusted OR=1.14, 95%CI:1.07-1.21; adjusted OR=1.14, 95%CI:1.03-1.24) and a higher odds of symptomatic intracranial hemorrhage (unadjusted OR=1.20, 95%CI:1.09-1.29; adjusted OR=1.20, 95%CI:1.03-1.38) after EVT.
Conclusions
Increased mean systolic BP levels in the first 24 hours after EVT are independently associated with a higher odds of symptomatic intracranial hemorrhage, early neurological deterioration, three-month mortality, and worse three-month functional outcomes.
PREDICTORS OF OUTCOME AFTER THROMBECTOMY IN STROKE PATIENTS WITH MODERATE OR SEVERE BASELINE DISABILITY: A MULTICENTRE RETROSPECTIVE COHORT STUDY.
Abstract
Group Name
on behalf of the MonSTer Collaborators and the ETIS registry Collaborators
Background And Aims
Patients with pre-stroke disability, defined as a modified Rankin Scale (mRS) ≥3 were excluded from most trials of endovascular thrombectomy (EVT) for acute stroke. We sought to evaluate the prognostic factors associated with favorable outcome in stroke patients with known disability undergoing EVT, and the impact of successful reperfusion.
Methods
Consecutive acute stroke patients with pre-stroke disability, undergoing EVT, were collected between 2016 to 2019 from a Canadian cohort and a multicentric French cohort (ETIS registry). Baseline characteristics, 90-day functional outcomes, mortality and intracerebral hemorrhage rates were collected. Favorable outcome was defined as an mRS equal to or better than pre-stroke mRS. Patients achieving successful reperfusion (modified Thrombolysis in Cerebral Infarction score of 2b/3) were then compared with patients without successful reperfusion to determine if successful EVT was associated with better functional outcomes.
Results
A total of 322 patients with a pre-stroke mRS ≥3 were treated with EVT in 8 comprehensive stroke centers. Ninety-six patients (30.5%) had a favorable outcome and 146 (46.3%) died. Patients with successful reperfusion had a higher proportion of favorable 90-day mRS (p=0.005) and a lower mortality (42.3% versus 66.7%, P=0.002) than patients without successful reperfusion There was no difference in ICH rates between patients with and without successful reperfusion.
Conclusions
Among stroke patients with baseline disability treated with EVT, stability or improvement in mRS was seen in almost one-third of patients. Successful reperfusion is associated with a greater proportion of favorable functional outcome and lower mortality; EVT should therefore not be withheld from patients with known disability.
Trial Registration Number
Not applicable
INCIDENCE OF EARLY NEUROLOGICAL DETERIORATION AND THE EFFECTIVENESS OF ENDOVASCULAR RECANALIZATION IN PATIENTS WITH LVO AND LOW NIHSS
Abstract
Group Name
the Clinical Research Collaboration for Stroke in Korea investigators
Background And Aims
The natural history and effect of endovascular treatment (EVT) in patients with acute LVO and low NIHSS score (<6 points) is unclear.
Methods
Based on a prospective, multicentre, national acute stroke registry, 1083 patients with LVO and low NIHSS scores presenting ≤24 hours from last known well (LKW) were recruited, with imaging assessed in a core lab. Early neurological deterioration (END) was defined as an increase of total NIHSS score ≥2 or any worsening of the NIHSS consciousness or motor subscores. Significant hemorrhage was defined as PH2 hemorrhagic transformation or remote hemorrhage.
Results
Incident END occurred in 207 (19%) patients after a median 24.5 hours [IQR, 13.5-41.9 hours] after LKW (incidence rate, 1.41 [95% CI, 1.23-1.62] per 100 person-hour), 85% ≤48 hours (Figure A). END was associated with extracranial ICA (adjusted OR 1.72 [95% CI, 1.09-2.73]) or tandem occlusions (aOR 2.79 [1.57-4.95]), higher NIHSS scores (aOR 1.12 per 1-point [1.02-1.23] and history of hypertension (aOR 1.49 [1.03-2.14]). EVT was performed in 149 (14%) patients after a median 5.9 [3.6-12.3] hours after LKW. In a propensity score-matched analysis, EVT was not associated with mRS 0-1 three months after stroke (OR 0.99 [0.63-1.54]; Figure B) but increased the risk of significant hemorrhage (OR, 4.51 [1.59-12.80]; Figure C). Stroke etiology, baseline occlusion location, and END impacted the efficacy of EVT.
Conclusions
The use of EVT in patients with acute LVO and low NIHSS scores may require an assessment of individual risks of early deterioration, hemorrhagic complication and expected benefit.
Trial Registration Number
Not applicable
MACHINE LEARNING-BASED ASSESSMENT OF THE BENEFIT OF THROMBECTOMY FOR ACUTE ISCHEMIC STROKE IN REAL-WORLD AND RCT DATA IDENTIFIES POTENTIAL TREATMENT TARGET GROUPS
Abstract
Group Name
on behalf of the GSR investigators and the VISTA-Endovascular Collaborators
Background And Aims
Whether endovascular thrombectomy (EVT) improves functional outcome in patients that do not comply with inclusion criteria of randomized controlled trials (RCT) from large-vessel occlusion (LVO) stroke but that are considered for EVT in clinical practice, is uncertain. We aimed to identify patients with LVO stroke underrepresented in RCTs who might also benefit from EVT.
Methods
We used level of reperfusion as a graded treatment marker and its value for prediction of functional independence in a machine learning model to assess treatment benefit in real-world (N=5,235, German-Stroke-Registry) and RCT data (N=1,488, Virtual-International-Stroke-Trials-Archive). We further analyzed the influence of patient characteristics on clinical outcome.
Results
In real-world data, leading predictors of functional independence were NIHSS upon admission, age, and pre-stroke mRS; while in RCT data, leading predictors were NIHSS and onset-to-puncture time. The importance of reperfusion level for outcome prediction in an RCT-like real-world cohort was similar compared to EVT treatment allocation for outcome prediction in RCT data and was considerably higher compared to an unselected real-world population. The importance of reperfusion level was magnified in patient groups underrepresented in RCTs, including patients with lower NIHSS scores (0-10), M2 occlusions, longer onset-to-puncture times, and lower ASPECTS (0-5 and 6-8). Reperfusion level was equally important in patients with vertebrobasilar as with anterior LVO stroke.
Conclusions
The importance of reperfusion level for outcome prediction identifies patients who likely benefit from EVT, including vertebrobasilar stroke patients and among patients underrepresented in RCTs patients with low NIHSS scores, low ASPECTS, and M2 occlusions.
Trial Registration Number
Not applicable