Charles B. Majoie (Netherlands)
Amsterdam UMC, University of Amsterdam Department of Radiology and Nuclear MedicineAuthor Of 5 Presentations
BEYOND ETICI 2B REPERFUSION: VALUE OF ADDITIONAL PASSES TO ACHIEVE COMPLETE REPERFUSION
Abstract
Background and Aims
Currently, it is unclear whether during endovascular treatment (EVT) for acute ischemic stroke, an extra pass should be undertaken to achieve more complete reperfusion after expanded Treatment In Cerebral Ischemia (eTICI) 2B is already achieved. We aimed to compare outcomes of single-pass good reperfusion (eTICI 2B) with multi-pass (near-)complete reperfusion (eTICI 2C-3) in daily clinical practice.
Methods
We included MR CLEAN Registry patients with M1 occlusions in whom EVT was ended either after achieving eTICI 2B in a single pass or after achieving eTICI 2C/3 in multiple passes. Regression models were used to investigate the association between single-pass eTICI 2B versus multi-pass eTICI 2C/3 with 24-hour National Institutes of Health Stroke Scale (NIHSS) score and 90-day functional outcome (modified Rankin Scale [mRS]).
Results
In 114 (28%) patients, eTICI 2B was achieved after a single pass; in 292 (72%) patients eTICI2C/3 was achieved after multiple passes. Patients with single-pass eTICI 2B showed lower 24-hour NIHSS scores (-19% [95% CI -33 to -1%]) and better functional outcomes (acOR 1.32 [95 % CI 0.93-1.87]) than patients with eTICI 2C/3 after ≥3 passes (Figure 1). No significant difference in functional outcomes was found between single-pass eTICI 2B and eTICI 2C/3 in two passes.
Conclusions
Our results do not provide arguments to continue an EVT procedure when eTICI 2B is reached after one pass, but further research is necessary to investigate the per-pass effect in relation to reperfusion and functional outcome.
DIRECT MECHANICAL THROMBECTOMY VERSUS BRIDGING THERAPY FOR ACUTE ISCHAEMIC STROKE–A CUMULATIVE STUDY-LEVEL META-ANALYSIS OF THE DIRECT-MT, MRCLEAN-NOIV, DEVT, SKIP AND SWIFT-DIRECT RCTS: PLACEHOLDER ABSTRACT
Abstract
Background and Aims
Whether direct mechanical thrombectomy (MT) in acute ischaemic stroke patients with large vessel occlusion (LVO) is equally effective as intravenous thrombolysis (IVT) with alteplase followed by MT remains a matter of debate. Primary aim of this study was to test non-inferiority of direct mechanical thrombectomy using summary estimates of study-level aggregate data of all randomized controlled trials evaluating direct MT vs IVT followed by MT. Secondary aims included superiority testing of IVT followed by MT versus direct MT and presentation of relevant secondary outcomes.
Methods
We performed a PROSPERO registered, prespecified, systematic review of electronic databases (Web of Science, PubMed, Embase) and meta-analysis with data presentation adherent to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Random effects models were used to pool the study-level data. The primary outcome used for non-inferiority and superiority testing was good functional outcome at 90 days (mRS≤2). The non-inferiority margin was prespecified. Secondary outcomes included excellent functional outcome (mRS≤1), mortality, symptomatic intracranial haemorrhage (sICH), successful reperfusion (TICI≥2b) and procedure-related complications. Five RCTs comprising 2043 patients (xy dMT, yx bridging therapy) were included.
Results
To be determined.
Conclusions
To be determined.
ASSOCIATION OF THROMBUS DENSITY IN PATIENTS WITH M1 OCCLUSIONS WITH OUTCOME
Abstract
Background and Aims
The association of thrombus density with reperfusion and functional outcome remains conflicted in acute ischemic stroke. We evaluated if hyperdense thrombi were associated with reperfusion and functional outcome after endovascular treatment (EVT).
Methods
Thrombus imaging characteristics were measured in patients with M1 occlusions included in the MR CLEAN Registry. Thrombus density was measured on thin-slice (<2.5 mm) non-contrast computed tomography. Based on median density across the dataset, hyperdense thrombi were defined as thrombi >50 Hounsfield Units (HU). Regression models were used to investigate the association between hyperdense thrombi, successful reperfusion (expanded Treatment In Cerebral Ischemia (eTICI) score 2B-3), and favorable and excellent functional outcome (modified Rankin Scale (mRS) of 0-2 and 0-1, respectively) at 90 days. We adjusted for age, gender, baseline National Institutes of Health Stroke Scale, prestroke mRS, clot burden score, intravenous alteplase treatment (IVT) and carotid tandem lesions. Subgroup analyses were performed in patients treated with or without IVT prior to EVT.
Results
In 434 analyzed patients, hyperdense thrombi were not associated with successful reperfusion (aOR 0.99 [95%CI 0.65-1.51]) or favorable functional outcome (aOR 1.28 [95%CI 0.81-2.01]). Hyperdense thrombi were inversely associated with excellent functional outcome (aOR 0.52 [95%CI 0.32-0.85]). This association was stronger in patients treated with IVT prior to EVT (aOR 0.47 [95%CI 0.26-0.85]) than in EVT only patients (aOR 0.85 [95%CI 0.29-2.52]) (Figure 1).
Conclusions
Hyperdense thrombi were not significantly associated with reperfusion or favorable functional outcome. However, patients with hyperdense thrombi less often achieved excellent functional outcome after EVT.
PRE- AND INTERHOSPITAL WORKFLOW TIMES FOR PATIENTS WITH LARGE VESSEL OCCLUSION STROKE TRANSFERRED FOR ENDOVASCULAR THROMBECTOMY
Abstract
Background and Aims
Patients with large vessel occlusion (LVO) stroke are often initially admitted to a primary stroke center (PSC) and subsequently transferred to a comprehensive stroke center (CSC) for endovascular thrombectomy (EVT). This interhospital transfer delays initiation of EVT. To identify potential workflow improvements, we analyzed pre- and interhospital time metrics for patients with LVO stroke who were transferred from a PSC for EVT.
Methods
We used data from the regional emergency medical services and our EVT registry. We included patients with LVO stroke who were transferred from three nearby PSCs for EVT (2014-2021). The time interval between first alarm and arrival at the CSC (call-to-CSC time) and other time metrics were calculated. We analyzed associations between various clinical and workflow-related factors and call-to-CSC time, using multivariable linear regression.
Results
We included 198 patients with LVO stroke. Mean age was 70 years (±14.9), median baseline NIHSS was 14 (IQR: 9-18), 136/198 (69%) were treated with intravenous thrombolysis, and 135/198 (68%) underwent EVT. Median call-to-CSC time was 162 minutes (IQR: 137-190). In 133/155 (86%) cases, the ambulance for transfer to the CSC was dispatched with the highest level of urgency. This was associated with shorter call-to-CSC time (adjusted β [95% CI]: -27.6 minutes [-51.2 to -3.9]). No clinical characteristics were associated with call-to-CSC time.
Conclusions
In patients transferred from a PSC for EVT, median call-to-CSC time was over 2.5 hours. The highest level of urgency for dispatch of ambulances for EVT transfers should be used, as this clearly decreases time to treatment.
ASSOCIATION BETWEEN THROMBUS CHARACTERISTICS, SUCCESSFUL REPERFUSION AND FUNCTIONAL OUTCOME AFTER ENDOVASCULAR TREATMENT IN PATIENTS WITH POSTERIOR CIRCULATION STROKE.
Abstract
Background and Aims
Thrombus perviousness and length are important thrombus imaging characteristics related to outcome in patients with anterior circulation ischemic stroke. We investigated the association of thrombus characteristics with reperfusion and functional outcome in patients with posterior circulation stroke (PCS) who underwent endovascular treatment (EVT).
Methods
Thrombus imaging characteristics (perviousness, density, and length) were measured in patients with PCS registered in the MR CLEAN Registry between 2014-2018. All characteristics were assessed on thin-slice (<2.5mm) non-contrast computed tomography and computed tomography angiography imaging acquired within 30 minutes from each other. We compared thrombus characteristics in patients with or without excellent reperfusion (expanded Treatment In Cerebral Ischemia (eTICI) score ≥2C) and with or without favorable functional outcome (modified Rankin Scale score (mRS) 0-3) using the Mann-Whitney U-test.
Results
Sixty-six patients were analyzed. Median thrombus perviousness was 7 (IQR -1-21) Hounsfield Units (HU). Median density was 54 (IQR 44-66) HU and median length was 24 (IQR 15-42) mm. No significant between-group differences were found in thrombus characteristics (Table 1).
| eTICI<2C (n=32) | eTICI≥2C (n=29) | p value | mRS 0-3 (n=27) | mRS 4-6 (n=37) | p value | |
| Thrombus imaging characteristics | ||||||
| Length (mm), median (IQR) | 24 (14-49) | 21 (15-29) | 0.45 | 21 (15-29) | 25 (15-48) | 0.24 |
| Perviousness (HU), median (IQR) | 11 (1-21) | 7 (-4-18) | 0.42 | 2 (-2-20) | 10 (1-21) | 0.29 |
| Density (HU), median (IQR) | 55 (47-66) | 51 (43-62) | 0.63 | 55 (43-66) | 50 (44-65) | 0.64 |
Conclusions
In this study of patients with PCS treated with EVT, thrombus imaging characteristics were not associated with reperfusion or functional outcome.