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ENDOVASCULAR TREATMENT FOR M3 OCCLUSIONS
Abstract
Background and Aims
Endovascular treatment (ET) has become most well-proven beneficial treatment for the M1-2 occlusions of the middle cerebral artery (1-3). Mortality and disability rates are high if large vessel occlusions are not treated (4). Even if these rates are lower in M3 occlusions, the important branch blockages can end with disability. Small vessels occlusions are difficult to detect and treatment for endovascular interventions. There are few studies on the effectiveness of endovascular treatment for M3 occlusions (5,6). In this study, our aim to assess the feasibility, safety, and preliminary efficacy of endovascular therapy for M3 occlusions.
Methods
This study was conducted a retrospective analysis of a prospectively collected database in two- centers for acute ischemic stroke of anterior system between July 2015 and April 2020. Middle cerebral artery is divided into the sections according to the course and angle of the middle cerebral artery. M3 (opercular) segment of the middle cerebral artery is after the circular sulcus of the insula.
Results
The complete or near complete reperfusion (mTICI 2b-3) of m3 occlusion was achieved in 15 cases (38.5%). The complete (mTICI 3) reperfusion was achieved in 24 cases (61.5%). The complete or near complete reperfusion (mTICI 2b-3) of the other anterior circulation occlusion was achieved in 129 cases (65.9%) while the complete (mTICI 3) reperfusion was achieved in 50 cases (27%).
Conclusions
This retrospective study demonstrates the ability of endovascularly treatment of M3 occlusions as effective, reliable and cost-effective.
UTILIZATION AND OUTCOMES OF ENDOVASCULAR THROMBECTOMY IN PATIENTS 80 YEARS AND OLDER
Abstract
Background and Aims
Patients aged 80 and over were often excluded or under-represented in pivotal endovascular thrombectomy (EVT) trials. Accordingly, trends in frequency, outcomes, and disparities of EVT use merit close analysis.
Methods
From a pool of 2.4 million AIS cases in the Get With The Guidelines-Stroke US nationwide registry from April 2012 to June 2019, we identified patients potentially eligible for EVT treatment (i.e., arrived≤6h, NIHSS≥6). We compared EVT use and outcomes between those ages ≥80y vs <80y.
Results
Among 42,422 patients arriving ≤6h and receiving EVT at 614 sites, 12,768 (30.1%) were age ≥80. EVT rates in these potentially EVT-eligible very old patients increased substantially during the study period, from 3.3% in early 2012 to 20.8% in early 2019. This increase paralleled that in younger patients so that, by study period end, the relative rate of EVT in ≥80y vs <80y had risen to 0.76. Older patients had poorer outcomes at discharge compared with younger patients, including discharge to home: 12.5% versus 31.1%, aOR 0.43 (95%CI 0.40-0.46), functional independence (mRS 0-2): 10.9% vs 26.6%, aOR 0.45 (0.41-0.49), and inpatient death/hospice, 34.5% vs 16.1%, aOR 2.22 (2.09-2.36). However, symptomatic intracranial hemorrhage rates did not differ, 6.9% vs 6.5%, aOR 1.04 (0.94-1.14).
Conclusions
Use of EVT among the very old has increased dramatically, though rates remain lower than in younger patients. Although favorable functional outcomes at discharge are lower and combined mortality/discharge to hospice higher in the oldest old, the risk of symptomatic intracranial hemorrhage is not increased.
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.
MECHANICAL THROMBECTOMY FOR BASILAR ARTERY OCCLUSION STROKE: ANALYSIS OF THE GERMAN STROKE REGISTRY-ENDOVASCULAR TREATMENT (GSR-ET)
Abstract
Background and Aims
Stroke due to basilar artery occlusion (BAO) causes the most severe strokes with poor prognosis. Data regarding efficacy of mechanical thrombectomy (MT) in BAO are sparse.
Methods
Patients enrolled between 06/2015 and 12/2019 in the German Stroke Registry-Endovascular Treatment (GSR-ET) were analyzed. The GSR-ET is an independent, prospective, multicenter, observational registry with 25 participating stroke centers in Germany enrolling patients treated with MT. Primary outcomes were successful reperfusion (mTICI score of 2b-3) and good functional outcome at 3-months (mRS of 0-2).
Results
640 (9.6%) of the 6635 patients in the GSR were strokes due to BAO. Successful reperfusion was observed in 86.6%. At 3 months follow-up, 31% of patients showed a good functional outcome, mortality was 39%. Analysis of mTICI3 vs. mTICI2b showed considerable better outcomes (good outcome in 38.9% vs. 24.4% p=0.005, see Figure 1). Strongest predictor for good functional outcome were IVT treatment (OR 3.04, 95% CI 1.76-5.23) and successful reperfusion (OR 4.92, 95% CI 1.15-21.11), while the effect of the time between symptom onset and start of reperfusion seems to be low (see Figure 2).
Conclusions
Acute reperfusion strategies of BAO are common in daily practice and can be performed safely with high rates of successful reperfusion. Our data suggest that successful, and especially complete reperfusion predicts good outcome, while the time since symptom onset has a low impact. That reinforces the importance of reperfusion success in acute BAO. Future clinical trials should address acute reperfusion strategies of BAO patients.
MINOR STROKES WITH LARGE VESSEL OCCLUSION: A MATCHED ANALYSIS FROM THE GERMAN STROKE REGISTRY-ENDOVASCULAR TREATMENT(GSR-ET) AND THE SAFE IMPLEMENTATION OF THROMBOLYSIS IN STROKE REGISTRY (SITS)
Abstract
Background and Aims
Treatment of large vessel occlusion (LVO) in patients presenting with mild neurological deficits (minor strokes with NIHSS ≤ 5) is still a matter of debate. The main purpose of this study was to compare the outcome of LVO-minor stroke patients treated with intravenous thrombolysis(IVT) plus/minus mechanical thrombectomy(MT).
Methods
GSR-ET and SITS-registry patients enrolled between 06/2015 and 12/2019 were analyzed. Minor stroke patients due to LVO were compared using propensity score matching (PSM). Primary outcomes were the safety, technical and clinical efficacy of IVT plus/minus MT including the technical angiographic outcome parameters (successful reperfusion using the modified Thrombolysis In Cerebral Infarction (mTICI) score of 2b-3) and good functional outcome at 3-months follow-up (modified Rankin Scale (mRS) of 0-2).
Results
Among 6635 GSR-patients, a total of 676 (9.6%) presented with minor strokes. Among these, 272GSR-ET-patients – all IVT-treated (age 68.6±14.0 years, 43.4%female, premorbid mRS (pmRS) 0 (0-0), NIHSS 4 (2-5)) were compared to 272 SITS-patients(69.4±13.7, 43.4% female, pmRS 0 (0-0), NIHSS 4 (2-5)). Successful reperfusion in GSR-ET-patients was achieved in 81.6%. Good functional outcome (67.3% versus 69.5%, p=0.795), mortality (5.1% versus 6.6%, p=0.207) and intracranial hemorrhage (12.5% versus 8.8%, p=0.308) were comparable. After PSM for 624 GSR-ET-patients (IVT-rate 56.7%) and 624 SITS-patients (IVT-rate 100%) independent predictors for good outcome were age, pmRS, NIHSS, IVT-treatment and occurrence of ICH.
Conclusions
Our study demonstrates similar effectiveness of IVT alone compared to MT plus/minus IVT in minor stroke patients. There is an urgent need for randomized controlled trials in this stroke field, including imaging parameters.
SYSTEMIC THROMBOLYSIS IN PATIENTS WITH ACUTE STROKE AND ACTIVE CANCER: A SYSTEMATIC REVIEW AND META-ANALYSIS
Abstract
Background and Aims
Cancer patients frequently have concomitant cerebrovascular diseases, which significantly worsen their prognosis. Prospective studies validating intravenous thrombolysis (IVT) safety profile in patients with acute ischemic stroke and active cancer are still lacking. Our aim was to evaluate efficacy and safety profile of IVT in acute ischemic stroke patients with comorbid active cancer.
Methods
We included in a meta-analysis all relevant published studies including patients with acute ischaemic stroke with or without active cancer, and receiving IVT, according to recommendations for IVT treatment for acute ischaemic stroke. The primary outcomes were all-cause mortality, any intracerebral haemorrhage and functional outcome, reported as modified Rankin Scale (mRS).
Results
Nine studies were included in the meta-analysis. IVT was not associated with a significant increase in the incidence of intracerebral haemorrhage (OR 1.00; 95%CI 0.76 – 1.33; I2 48.07%), nor with a significant increase in death for any cause (OR 1.13; 95%CI 0.90 – 1.43; I2 51.6%); furthermore, IVT did not influence mRS between cancer and non-cance
r stroke patients (OR 1.00; 95%CI 0.58 – 1.71; I2 27.42%).
Conclusions
IVT seems to be safe and effective on patients affected by an ischemic stroke and concomitant cancer. Due to the low overall quality of the evidence, high-quality randomized control trials with adequate sample sizes are needed.
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.