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Group Name

on behalf of the MR CLEAN-NO IV Investigators

Background And Aims

We assessed whether the treatment effect of intravenous thrombolysis with alteplase (IVT) prior to endovascular treatment (EVT) on outcome is modified by first-line EVT technique (stent-retriever with or without aspiration versus aspiration alone) during EVT.

Methods

We included data from all patients who underwent EVT with a thrombectomy attempt from MR CLEAN-NO IV, a randomized trial of IVT followed by EVT versus EVT alone in patients presenting directly to EVT-capable centers. Primary outcome was the modified Rankin scale score at 90 days. We used mixed model ordinal regression with a multiplicative interaction term to assess if the treatment effect of IVT is modified by first-line EVT technique.

Results

Of 473 included patients, 102 (21.6%) were treated with aspiration only as first-line EVT technique. Overall, functional outcome was similar for patients treated with aspiration versus stent-retriever (acOR 1.06,95%CI 0.68–1.67) and for patients treated with IVT followed by EVT versus EVT alone (acOR 0.82,95%CI 0.59–1.14). We observed a significant interaction between the treatment effect of IVT treatment and first-line EVT technique (p=0.03). Patients treated with aspiration alone had worse functional outcomes without IVT (acOR 0.44,95%CI 0.21–0.91,figure 1). In the stent-retriever group, functional outcome was not significantly different between patients treated with or without IVT (acOR 1.07,95%CI 0.74–1.56).

Conclusions

In MR CLEAN-NO IV, the treatment effect of IVT seems to be modified by first-line EVT technique. Patients treated with aspiration alone as first-line EVT technique had worse outcomes without IVT in this study. No such effect was seen in patients treated with stent-retrievers as first-line technique.

Trial Registration Number

ISRCTN80619088

Group Name

on behalf the TETRIS Investigators

Background And Aims

In clinical trials, intravenous thrombolysis (IVT) with tenecteplase improved recanalization before mechanical thrombectomy (MT) patients with large vessel occlusion acute ischemic strokes (LVO-AIS) compared with alteplase. In this study we investigated in routine care the efficacy and safety of IVT with tenecteplase prior to MT in patients with LVO-AIS, either transferred after IVT (drip-and-ship) or who underwent MT on site (mothership).

Methods

We retrospectively analyzed clinical and procedural data of patients treated with 0.25 mg/kg tenecteplase within 270 minutes of LVO-AIS who underwent a brain angiography. The main outcome was 3-month functional independence (mRS score ≤ 2). Recanalization (mTICI score 2b-3), was evaluated before (pre-MT) and after MT (final).

Results

We included 590 patients (median age 75 years [IQR 61-84]; 316 women [54%]; median NIHSS score 16 [IQR 10-19]), of which 522 (88%) were treated under the drip-and-ship paradigm. Functional independence occurred in 47% (n = 268/572; 95%CI 42.7-51.0) of patients. Pre-MT recanalization occurred in 121 patients (20.5%; 95%CI 17.3-24.0), at a similar rate across treatment paradigms (mothership, n = 17/68 [25%]; drip-and-ship, n = 104/522 [20%]; p = .34) despite a shorter median IVT-to-puncture time in mothership patients (38 [IQR 23-55] vs 89 [IQR 71-110] minutes; p < .001). Final recanalization was achieved in 496 patients (84%; 95%CI 80.9-86.9). Symptomatic intracerebral hemorrhage occurred in 14 patients (2%; 95%CI 1.4-4.1).

Conclusions

Tenecteplase before MT is safe, effective and achieves a fast recanalization in everyday practice under drip-and-ship and mothership treatment paradigms, in line with published results. These findings should encourage its wider use in bridging therapy.

Trial Registration Number

Not applicable

Group Name

The Investigators of the Swiss Stroke Registry

Background And Aims

There are few data about efficacy of endovascular treatment (EVT) and bridging therapy of acute ischaemic stroke (AIS) due to isolated posterior cerebral artery occlusion (PCAO). We aimed to verify the functional outcome and safety of AIS patients with PCAO, treated with EVT or EVT + IVT (bridging), compared to IVT alone.

Methods

Multicenter retrospective analysis of data from the Swiss Stroke Registry. Primary endpoint was favourable functional outcome (mRS 0-1) at 3 months. Secondary outcomes were independence (mRS 0-2), mortality and symptomatic intracerebral haemorrhage (ICH). EVT and IVT patients were matched 1:1 by using propensity scores. Differences in outcomes were examined using multivariate logistic models.

Results

From n=534 patients, 298 met the criteria. Propensity score method matched 81 in each group. Patients with IVT and EVT (of whom 69% had bridging) showed comparable favorable outcome (44% vs 33% respectively; aOR=0.55, 95%CI=0.27-1.13, p=0.104). With both treatments, a substantial proportion of patients was independent at 90 days, and significantly higher in IVT alone (72%) compared to EVT (58%) (aOR 0.30, 95% CI 0.12-0.72, p=0.007). Symptomatic ICH was non-significantly higher in IVT (4.9% vs 1.2%; p=0.211). Mortality at 90 days was comparable between IVT and EVT (7.4% vs 4.9%; p=0.516). No significant differences were documented after stratification for more proximal site of occlusion compared to more distal (P1 vs. P2-P3).

Conclusions

In AIS due to PCAO, EVT and IVT appears similarly effective in terms of favorable outcome. IVT seems superior for reaching independence at 3 months. This aspect should be further investigated in future RCTs.

Trial Registration Number

Not applicable

Background And Aims

Basilar artery occlusion (BAO) is a devastating condition without definitive evidence to guide treatment. The relationship between treatment times with endovascular thrombectomy (EVT) and outcomes for those with BAO has not been well delineated.

Methods

We used prospectively collected data from the Get With The Guidelines-Stroke nationwide US database between January 2015 to December 2019. We included patients with BAO treated with EVT within 24 hours of symptom onset (defined as last known well). Efficacy outcomes were independent ambulation at discharge and discharge home; safety outcomes were in-hospital mortality and symptomatic intracranial hemorrhage (sICH). Multivariable logistic regression analyses were performed to assess the associations of onset-to-EVT time (<=6 vs. >6 hours) with each outcome, adjusting for demographics and baseline clinical characteristics.

Results

Among 3015 patients with BAO who received EVT, mean age was 65.9, 39.3% were women, and median NIHSS was 18. There were significantly higher odds of efficacy outcomes and lower odds of safety outcomes with EVT <=6h versus >6h (Table). Each hour of faster treatment within 6h was associated with 16% reduction in odds of mortality, 21% increase in odds of ambulation at discharge, and 35% increase in odds of discharge home (Figure).

Conclusions

Among patients receiving EVT for BAO, faster treatment from last known well was associated with improved outcomes.

Trial Registration Number

Not applicable

Background And Aims

About 30-60% of patients with basilar artery occlusion (BAO) present with coma, which is often considered as a hallmark of poor prognosis. We asimed to examined factors that will help predicting outcome in patients with BAO being comatose on admission.

Methods

312 patients with angiography-proven BAO were analyzed. Coma was assessed as Glasgow Coma Scale (GCS) of <9 or impaired level of consciousness ascertained in the medical records. Outcome was evaluated with modified Rankin Scale (mRS) over a phone call at three months. 53 patients were excluded due to inadequate data of the level of consciousness.

Results

103/259 (39.8%) of BAO patients presented comatose on admission.

Factors associated with acute coma were higher age, CAD, convulsions, pc-ASPECTS<8, absence of patent posterior collateral vasculature and occlusion over multiple segments of BA. 21/103 (20.4%) of comatose patients had moderate (mRS 0-3) whereas 12/103 (11.7%) had good outcome (mRS 0-2).

Factors associated with moderate outcome in comatose BAO patients were younger age (p=0.010), higher pc-ASPECTS (p=0.027), recanalization (p=0.013) and lacking sICH (p=0.038).

Factors associated with the poorest outcome or death (mRS 5-6) were older age (p=0.001), diabetes (p=0.022), atrial fibrillation (p=0.016), lower GCS (p=0.006), pc-ASPECTS<8 (p=0.003), unsuccessful recanalization (p=0.006) and sICH (p=0.010). Futile recanalization (mRS 4-6) was significantly more common in comatose patients (49.4% vs 18.5%, p<0.001).

Conclusions

One in five BAO patients with acute coma had a favorable outcome. Older patients with cardio- vascular comorbidities and already existing ischemic lesions before reperfusion therapies tended to have poor prognosis, especially if no recanalization is achieved and sICH occurred.

Trial Registration Number

Not applicable

Group Name

on behalfof the Itacat study group

Background And Aims

Our objective is to identify thrombus composition profile associated with successful first pass recanalization (FPR) in mechanical thrombectomy (MT) by its histopathological study.

Methods

Intracranial thrombi obtained with MT were processed for hematoxylin-eosin ( fibrin and hematic proportion) , Immunohistochemistry for T cells ( CD 3, CD 4 and CD8) and platelets ( CD 61 ) analysis . Images were digitalized for quantification of components percentage and cell ratios.

FPR were defined as mTICI 2c or 3 after a single pass of a device . We analyzed the Association between FPR with : Thrombi composition; Demographic parameters ; Intravenous fibrinolysis ; First attempt thrombectomy devices: Direct Aspiration first pass technique ( ADAPT) or Stent retriever or Combination.

Results

Thirty five percent of cases (47/133) achieved FPR. There were no differences in age, gender or use of intravenous fibrinolysis between groups. Regarding clot composition, FPR clots had lower proportion of platelets compared to non-FPR [59.67 %( 36.36-71.40) vs 67.11% (49.19-84.16), p 0.021]. Regarding first-pass strategy, ADAPT (n=19) were associated with higher rates of FPR compared to non–ADAPT strategy (57.9% vs 30.4 %, p=0.019). Multivariate analysis showed the Platelets proportion (OR 0.98; IC 0.96-0.99) and ADAPT strategy (OR 2.90; IC 1.05-7.97) as independent predictors of FPR.

Conclusions

Intracranial thrombus with low platelet percentage and ADAPT strategy were independently associated with successful first pass recanalization . Further research focus on the influence of clot composition with effectiveness of thrombectomy devices is warranted.

Trial Registration Number

Not applicable

Background And Aims

There is limited data on safety and outcomes of endovascular treatment (EVT) in acute ischemic stroke (AIS) patients on oral anticoagulants (OAC).

Methods

We examined patients treated with EVT within 6 hours from 595 American Heart Association Get With The Guidelines-Stroke hospitals in the US between October 2015 and March 2020 and compared outcomes among individuals on no OAC vs. non-vitamin K antagonist (NOACs) vs. warfarin prior to stroke. Information on last dose of NOACs was obtained from a parallel registry, ARAMIS.

Results

Of 36,442 patients, 3727(10.2%) were on NOACs and 3087(8.5%) on warfarin prior to stroke. Compared with no OAC, patients taking NOACs and warfarin were older, had more cardiovascular comorbidities, and had similar door-to-EVT times (median 77 minutes). Table 1 shows the unadjusted and adjusted outcomes for the three groups. In a subset of patients with documented last NOAC dose (n=213), the sICH rate was 3.1% (6/196) with last dose ≤2 day and 0% (0/17) with >2 days.

Table 1:

Conclusions

EVT appears to be well tolerated in AIS patients taking NOACs or warfarin prior to stroke.

Trial Registration Number

Not applicable

Group Name

on behalf of the German Stroke Registry – Endovascular Treatment (GSR-ET) investigators

Background And Aims

Returning to work following ischemic stroke is a major factor for well-being and life-satisfaction in patients of the working age population. We aim to identify potential areas of targeted vocational rehabilitation by determining predictors of (not) returning to paid work in patients with major ischemic stroke due to large vessel occlusion (LVO) treated with mechanical thrombectomy (MT).

Methods

Of all 6635 patients enrolled in the German Stroke Registry Endovascular Treatment (GSR-ET) between June 2015 to December 2019, data of 606 patients of the working population who survived LVO 90 days past MT were compared by employment status at day 90 following MT. Univariate analysis, multiple logistic regression analyses and ROC-analyses were performed to identify predictors of being re-employed three months after MT.

Results

We identified male sex (OR 2.510, 95%CI 1.271-4.955, p=0.008), intravenous thrombolysis (OR 2.446, 95%CI 1.232-4.856, p=0.011), NIHSS 24h after MT (OR 0.762, 95%CI 0.6845-0.848, p<0.001), duration of hospital stay (OR 0.921, 95%CI 0.850-0.998, p=0.043) and excellent functional outcome (mRS 0-1) at 90 day follow-up (OR 14.074, 95%CI 5.543-35.736, p<0.001) being independent predictors of being re-employed three months after MT. At prehospital level, also non-smoking status and atrial fibrillation were positive predictors of re-employment. Multiple regression modelling increased predictive power of re-employment status significantly over prediction by best single functional outcome parameter (NIHSS 24h after MT ≤5) (R² 0.617 vs. 0.432, ROC-AUC 0.916 vs. 0.843, p<0.001).

Conclusions

There is more to re-employment after MT than bare functional outcome. Attention should be paid to possible systemic barriers detaining women from resuming paid work.

Trial Registration Number

URL: http://www.ClinicalTrials.gov. Unique identifier: NCT03356392.