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  • 1
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    Online Resource
    Trial of Endovascular Thrombectomy for Large Ischemic Strokes
    Massachusetts Medical Society ; 2023
    In:  New England Journal of Medicine Vol. 388, No. 14 ( 2023-04-06), p. 1259-1271
    Details
    In: New England Journal of Medicine, Massachusetts Medical Society, Vol. 388, No. 14 ( 2023-04-06), p. 1259-1271
    Type of Medium: Online Resource
    ISSN: 0028-4793 , 1533-4406
    URL: Article
    DOI: 10.1056/NEJMoa2214403
    RVK:
    XA 10000
    Language: English
    Publisher: Massachusetts Medical Society
    Publication Date: 2023
    detail.hit.zdb_id: 1468837-2
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  • 2
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    Abstract 42: The Effect Of Anesthesia On Thrombectomy Outcomes Is Modified By Collateral Flow: Pooled Patient Level Analysis From EXTEND-IA, EXTEND-IA TNK Part I And II, And SELECT
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Stroke Vol. 53, No. Suppl_1 ( 2022-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 53, No. Suppl_1 ( 2022-02)
    Abstract: Background: The effect of anesthesia choice on endovascular thrombectomy (EVT) outcomes is unclear. Collateral status on perfusion imaging may help identify the optimal anesthesia choice. Methods: In a pooled patient level analysis of EXTEND-IA, EXTEND-IA TNK, EXTEND-IA TNK part II and SELECT, EVT Functional outcomes (mRS distribution) were compared between general anesthesia (GA) vs non-general anesthesia (non-GA). Further, we assessed the impact of collateral flow on perfusion imaging evaluated by hypoperfusion intensity ratio (HIR) - Tmax10 sec/Tmax6 sec) on the association between anesthesia type and EVT outcomes. Results: Of 731 treated with EVT, 305 (42%) received GA and 426 (58%) non-GA. The baseline characteristics were similar, except for presentation NIHSS (median [IQR] GA 18 [13-22] , non-GA 16[11-20], p 〈 0.001) and ischemic core volume (GA 14.1mL [3-37] vs non-GA 9mL [0-31] , p=0.002). GA was associated with longer LKW to arterial access (203min [158-267] vs 186min [138-252] , p=0.002), but similar procedural time (36min [23-59] vs 34min [22-54] , p=0.36). Non-GA was independently associated with improved functional outcomes (adj cOR 1.42, 95%CI 1.05-1.93, p=0.024) and lower mortality (17% vs 11.3%, p=0.025). Patients with poor collaterals (HIR≥0.4) had improved functional outcomes with non-GA (adj cOR 1.53, 95%CI 1.02-2.29, p=0.038), while no difference was observed in those with good collaterals-HIR 〈 0.4 (adj cOR 1.38, 95% CI 0.84-2.27, p=0.21). Conclusion: GA was associated with worse functional outcomes after EVT, particularly in patients with poor collaterals. These findings have implications for randomized trials of GA vs non-GA.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.53.suppl_1.42
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
    detail.hit.zdb_id: 1467823-8
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  • 3
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    Abstract P481: Time to Reperfusion Determines Clinical Outcomes Independent of Post Thrombectomy Infarct Volume
    Ovid Technologies (Wolters Kluwer Health) ; 2021
    In:  Stroke Vol. 52, No. Suppl_1 ( 2021-03)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 52, No. Suppl_1 ( 2021-03)
    Abstract: Introduction: Late time window thrombectomy trials demonstrated that good functional outcomes can be achieved up to 24 hours from stroke onset in Slow Progressors (small infarct volume and large penumbral volume). In this study, we aim to investigate whether early ( 〈 6 hours) recanalization leads to superior functional outcomes compared to delayed recanalization ( 〉 6 hours) amongst patients with similar 24-hour infarct volumes post thrombectomy. Methods: We performed a retrospective analysis of a prospectively maintained LVO stroke thrombectomy database across 3 comprehensive stroke centers. Demographic, clinical, radiological, and outcomes data were analyzed. Inclusion criteria were witnessed onset anterior circulation LVO [internal carotid or middle cerebral artery M1] strokes with a good baseline mRS score (0-1) having achieved success recanalization [mTICI 2b-3] and 24-hour infarct volume of ≤10 ml on CT head or MRI. Univariate and multivariate analysis of the impact of time to recanalization on clinical outcomes was performed. Results: Of the 499 LVO strokes undergoing thrombectomy, 30% (148) met inclusion criteria. Mean age was 70 ±14 and median NIHSS score was 17 (14-21). Early recanalization ( 〈 6h) was achieved in 65% (96) of patients. Baseline demographic (age: 73 vs 74, p=0.80) and clinical characteristics (NIHSS:16.5 vs 17, p=0.52; 24-h infarct volume: 4.4 vs 4.2 ml, p=0.60) were comparable between early versus late recanalization patients. Rates of early clinical improvement (24-h NIHSS 〈 6) (71% vs 39%, p=0.0007) and mRS 0-2 at 90 days (68% vs 48%, p=0.019) were higher in early recanalizers compared to late recanalizers. Multivariate analysis including age, NIHSS, time to recanalization, and 24-hour infarct volume identified early recanalization as an independent predictor of mRS 0-2 at 90 days (OR-2.41 95% CI 1.89-4.50). Every 1-hour increase in time to recanalization decreased the odds of 90-day mRS 0-2 by 2.2%. Conclusion: Among patients with similar 24-hour infarct volume post thrombectomy (≤10 ml), shorter time to successful recanalization is associated with significantly higher rates of early clinical improvement and mRS 0-2 at 90 days. Increased penumbral ischemic time may have an impact on outcomes post stroke thrombectomy.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.52.suppl_1.P481
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
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  • 4
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    Abstract 24: Primary Results Of The Preset For Occlusive Stroke Treatment (prost) Randomized Clinical Trial
    Ovid Technologies (Wolters Kluwer Health) ; 2023
    In:  Stroke Vol. 54, No. Suppl_1 ( 2023-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 54, No. Suppl_1 ( 2023-02)
    Abstract: Importance: Clinical trials focusing on new mechanical thrombectomy (MT) technologies have been typically single-arm studies using historical comparison data to determine the safety and efficacy of the novel device. To date, there has not been a contemporaneous prospective, randomized, controlled study comparing standard to newer designed stent-retrievers. Objective: To evaluate the safety and efficacy of the pRESET (phenox Ltd) compared to the Solitaire (Medtronic Corp) thrombectomy devices in the treatment of large vessel occlusion strokes (LVOS). Methods: Multicenter, prospective, randomized, open-label, blinded endpoint, core lab adjudicated, non-inferiority trial that enrolled 340 patients from October 2019 to February 2022 across 19 US & 5 German sites. Patients aged ≥ 18 years with either anterior or posterior circulation LVOS were included up to 8 hours after symptom onset. Patients were randomly assigned in a 1:1 ratio to either pRESET or Solitaire for the first three device passes.The Primary Endpoint was the proportion of patients achieving a modified Rankin Scale score of 0-2, analyzed by intent to treat with a non-inferiority margin of 0.125 based on the lower bound 95% Confidence Interval. The Primary Safety Endpoint was the proportion of subjects with device- or procedure-related symptomatic intracerebral hemorrhage at 24 (-8/+12) hours as per the SITS-MOST criteria. Secondary Outcome Measures included the rates of (1) Successful Revascularization (defined as expanded Thrombolysis in Cerebrovascular Infarction [eTICI] ≥2b50 ≤3 passes of the assigned device; (2) eTICI ≥2c following the first pass of the assigned device; (3) 90-day mortality and (4) Distribution of 90-day mRS across the entire spectrum of disability (ordinal shift). Results: The study database was locked in August 2022. The analysis is ongoing and the final results will be presented at the 2023 International Stroke Conference. Conclusions and Relevance: PROST is the first randomized clinical trial aiming to compare a novel versus an established stent-retriever technology, establishing a new scientific benchmark for stroke device trials. (ClinicalTrials.gov: NCT03994822).
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.54.suppl_1.24
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2023
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  • 5
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    Endovascular Thrombectomy Versus Medical Therapy Alone in Patients With Large Core Based on Computed Tomography Perfusion
    Ovid Technologies (Wolters Kluwer Health) ; 2021
    In:  Stroke: Vascular and Interventional Neurology Vol. 1, No. 1 ( 2021-11)
    Details
    In: Stroke: Vascular and Interventional Neurology, Ovid Technologies (Wolters Kluwer Health), Vol. 1, No. 1 ( 2021-11)
    Abstract: Patients presenting with large vessel occlusion and a large ischemic core ( 〉 50 mL) have been consistently undersampled in the major endovascular thrombectomy (ET) trials. As such, equipoise exists as to whether ET is associated with improved outcomes over medical therapy alone in this population. Methods Prospectively collected databases from 4 US centers were reviewed to identify patients with baseline ischemic cores 〉 50 mL based on computed tomography perfusion imaging using RAPID software (iSchemaView), who were treated with ET or medical therapy alone between January 2014 and October 2019. Baseline characteristics, procedural information, and clinical follow‐up data were collected. A matched‐control comparison of these patients was performed. Results A total of 167 patients were included, of whom 92 received medical therapy alone and 75 underwent ET. Seventy‐five pairs were obtained after matching for baseline ischemic core volume, National Institutes of Health Stroke Scale score, and age. Rate of 90‐day good outcome was significantly higher in the ET arm (28.4% versus 4.9%, P =0.002). In univariate analysis of ET patients, the rate of good outcome was significantly higher among patients treated within 〈 6 hours compared with ≥6 hours (44.2% versus 17.4%, P =0.02). Predictors of good outcome included age ( P =0.008), ischemic core volume ( P =0.01), and time from last known well to groin puncture ( P =0.004). Conclusions ET was associated with improved outcomes in patients with large ischemic core based on computed tomography perfusion. This association was more pronounced in patients who present early ( 〈 6 hours from last seen well) with an adequate target mismatch. These results may guide the practice until data from ongoing randomized trials become available.
    Type of Medium: Online Resource
    ISSN: 2694-5746
    URL: Article
    DOI: 10.1161/SVIN.121.000110
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
    detail.hit.zdb_id: 3144224-9
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  • 6
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    Abstract TP352: Work Flow Optimization in Acute Stroke Therapy in a Community Based Comprehensive Stroke Center
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Stroke Vol. 50, No. Suppl_1 ( 2019-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 50, No. Suppl_1 ( 2019-02)
    Abstract: Background and Purpose: In acute stroke therapy, faster reperfusion leads to better outcome. We analyzed optimization steps to reduce treatment delays at a comprehensive stroke center in a non-academic tertiary hospital. Methods: Consecutive patients with ischemic stroke treated with either IV tPA, endovascular therapy or both were analyzed. Patient metrics were divided into two periods: pre-optimization period and post-optimization period. Key interventions of this workflow included: (1) addition of pre notification by EMS to ER and stroke team; (2) dividing stroke alert to level 1 (potential IV/IA candidate) vs. level 2; (3) direct transportation of level 1 stroke patients to brain CT imaging; (4) limitation of non-essential interventions; (5) 24/7 code stroke response by an in house trained vascular midlevel (NP/PA) and vascular neurologist (either in house or through telestroke network);(6) earlier notification of IR team; (7) CT to angiosuite direct transportation for LVO; (8) multidisciplinary monthly meetings to discuss delayed cases. Door to needle time and door to puncture time were used as target metrics in order to measure improvement. Results: A total of 279 patients were identified (101 in the pre-optimization and 178 in the post- optimization periods). No significant differences in any of the patient’s baseline characteristics were documented in the two observation periods. Almost all metrics favored the post-optimization period with a remarkable improvement in door to puncture time (64 (IQR 36-86) vs. 47 (IQR 20-62) min, p=0.002). Although non-statistically significant, we observed an increased percentage of good clinical outcomes in the post-optimization group (60.1% vs 54.8%, p=0.500). Conclusions: For patients undergoing acute reperfusion therapies, significant reductions in workflow time-frames can be achieved after simple optimization steps in a non-academic community based hospital.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.50.suppl_1.TP352
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
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  • 7
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    Abstract WP6: Successful Mechanical Thrombectomy Maybe Associated With Reduced Disability in Patients With Large Core Based on CTP: The Forsaken Cannot be Forgotten
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Stroke Vol. 50, No. Suppl_1 ( 2019-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 50, No. Suppl_1 ( 2019-02)
    Abstract: Background and Purpose: There is disparity on neuroimaging selection for acute stroke thrombectomy. Patients with large core infarcts are often excluded from reperfusion therapies. We aim to assess rates of favorable clinical outcomes in patients with large cores based on CTP (RAPID) and the effect of collaterals in this population. Methods: Retrospective study of patients with ischemic cores greater than 50cc on CTP and a proximal anterior circulation occlusion on computed tomographic angiogram who underwent endovascular thrombectomy. Evaluation period was October 2015 to June 2018 on three comprehensive stroke centers. Baseline characteristics, ASPECTS and collaterals scores were evaluated. Primary endpoint was rate of favorable clinical outcome at 3 months. Results: 45 patients were included in the study. Mean age was 65 ±14.2 years, mean NIHSS score was 20 (10-32) and mean admission infarct volume was 85±31mL (CBF 〈 30%) and Tmax 〉 6 s was 199.5±68mL. The majority of patients presented within 6 hours (82%). Median ASPECTS score was 8 and 33% of patients had a favorable collaterals. Recanalization thrombolysis in cerebral ischemia 2b-3 was 88%. Post-thrombectomy mean infarct volume at 24 to 48 hours was 107±68.3mL, A total of 42% (19/45) had tPA. A 3-month favorable clinical outcome (mRS 0-2) was present in 31% (14/45) of patients. Rate of intracranial hemorrhage (ph1 or ph2) was 11% (5/45). A total of 92% (13/14) of all patients older than 75 years had a poor clinical outcome (mRS score 〉 2). Among patients with good collaterals 46% (7/15) had good clinical outcomes whereas 23% (7/30) of patients with poor collaterals score had good clinical outcomes at 3 months. The rate of good outcome at three months for patients with ASPECTS 〉 6 was 31% (11/35), while 41% of patients with both favorable ASPECTS and Collaterals had a good clinical outcome. Hemicraniectomy was performed in 4% (2/45) of all patients. Conclusions: Acute stroke thrombectomy may be beneficial in some patients with large core based on CTP with good collaterals and it should not be withhold solely based on the core infarct volume on CTP in patients presenting within 6 hours.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.50.suppl_1.WP6
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
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  • 8
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    Assessment of Discrepancies Between Follow-up Infarct Volume and 90-Day Outcomes Among Patients With Ischemic Stroke Who Received Endovascular Therapy
    American Medical Association (AMA) ; 2021
    In:  JAMA Network Open Vol. 4, No. 11 ( 2021-11-05), p. e2132376-
    Details
    In: JAMA Network Open, American Medical Association (AMA), Vol. 4, No. 11 ( 2021-11-05), p. e2132376-
    Type of Medium: Online Resource
    ISSN: 2574-3805
    URL: Article
    DOI: 10.1001/jamanetworkopen.2021.32376
    Language: English
    Publisher: American Medical Association (AMA)
    Publication Date: 2021
    detail.hit.zdb_id: 2931249-8
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  • 9
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    General anesthesia vs procedural sedation for failed NeuroThrombectomy undergoing rescue stenting: intention to treat analysis
    BMJ ; 2022
    In:  Journal of NeuroInterventional Surgery
    Details
    In: Journal of NeuroInterventional Surgery, BMJ
    Abstract: There is little data available to guide optimal anesthesia management during rescue intracranial angioplasty and stenting (ICAS) for failed mechanical thrombectomy (MT). We sought to compare the procedural safety and functional outcomes of patients undergoing rescue ICAS for failed MT under general anesthesia (GA) vs non-general anesthesia (non-GA). Methods We searched the data from the Stenting and Angioplasty In Neuro Thrombectomy (SAINT) study. In our review we included patients if they had anterior circulation large vessel occlusion strokes due to intracranial internal carotid artery (ICA) or middle cerebral artery (MCA-M1/M2) segments, failed MT, and underwent rescue ICAS. The cohort was divided into two groups: GA and non-GA. We used propensity score matching to balance the two groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included functional independence (90-day mRS0-2) and successful reperfusion defined as mTICI2B-3. Safety measures included symptomatic intracranial hemorrhage (sICH) and 90-day mortality. Results Among 253 patients who underwent rescue ICAS, 156 qualified for the matching analysis at a 1:1 ratio. Baseline demographic and clinical characteristics were balanced between both groups. Non-GA patients had comparable outcomes to GA patients both in terms of the overall degree of disability (mRS ordinal shift; adjusted common odds ratio 1.29, 95% CI [0.69 to 2.43], P=0.43) and rates of functional independence (33.3% vs 28.6%, adjusted odds ratio 1.32, 95% CI [0.51 to 3.41] , P=0.56) at 90 days. Likewise, there were no significant differences in rates of successful reperfusion, sICH, procedural complications or 90-day mortality among both groups. Conclusions Non-GA seems to be a safe and effective anesthesia strategy for patients undergoing rescue ICAS after failed MT. Larger prospective studies are warranted for more concrete evidence.
    Type of Medium: Online Resource
    ISSN: 1759-8478 , 1759-8486
    URL: Article
    DOI: 10.1136/jnis-2022-019376
    Language: English
    Publisher: BMJ
    Publication Date: 2022
    detail.hit.zdb_id: 2506028-4
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  • 10
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    Tenzing 7 delivery catheter with or without a leading microwire for single pass aspiration thrombectomy: A multicenter experience
    SAGE Publications ; 2023
    In:  Interventional Neuroradiology
    Details
    In: Interventional Neuroradiology, SAGE Publications
    Abstract: Aspiration mechanical thrombectomy traditionally includes use of an inner microcatheter and leading microwire to navigate an aspiration catheter (AC) to the site of occlusion. Early clinical experience suggests that a leading microwire is often not needed with the Tenzing 7 (T7, Route 92 Medical, San Mateo, CA), a soft tapered tip ledge-reducing delivery catheter. This multicenter experience aims to describe AC delivery success in single-pass thrombectomy using T7 with and without a leading microwire. Methods A retrospective review was conducted of consecutive patients who underwent single-pass thrombectomy with T7 at six institutions between 2020 and 2022. We examined the percentage of successful AC delivery, puncture-to-revascularization time, and procedural complication rate. Results A leading microwire with T7 was used in 19/89 (21%) of patients, and it was not used with T7 in 70/89 (79%) of patients. Successful AC delivery was similar with and without microwires (97% vs. 90%, p = 0.15). Median puncture-to-revascularization times were similar (17 min microwire vs. 16 min no-microwire, p = 0.12). No complications were associated with microwire use; one (1.4%) patient had a T7-related vasospasm resolved with verapamil during thrombectomy without a leading microwire. Differences in complication rates were not statistically significant (p = 0.46). Conclusion In our real-world clinical experience, leading microwire use was infrequently necessary with the T7 delivery catheter. Successful AC delivery and complication rates were similar with and without microwire use in single-pass T7 thrombectomies. Initial pass with T7 may be performed without use of leading microwire, reserving microwire use for refractory cases or known difficult-to-navigate vasculature.
    Type of Medium: Online Resource
    ISSN: 1591-0199 , 2385-2011
    URL: Article
    DOI: 10.1177/15910199231216765
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2023
    detail.hit.zdb_id: 2571161-1
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