BACKGROUND Among patients with acute ischemic stroke due to occlusions in the proximal anterior intracranial circulation, less than 40% regain functional independence when treated with intravenous tissue plasminogen activator (t-PA) alone. Thrombectomy with the use of a stent retriever, in addition to intravenous t-PA, increases reperfusion rates and may improve long-term functional outcome. METHODS We randomly assigned eligible patients with stroke who were receiving or had received intravenous t-PA to continue with t-PA alone (control group) or to undergo endovascular thrombectomy with the use of a stent retriever within 6 hours after symptom onset (intervention group). Patients had confirmed occlusions in the proximal anterior intracranial circulation and an absence of large ischemic-core lesions. The primary outcome was the severity of global disability at 90 days, as assessed by means of the modified Rankin scale (with scores ranging from 0 [no symptoms] to 6 [death]). RESULTS The study was stopped early because of efficacy. At 39 centers, 196 patients underwent randomization (98 patients in each group). In the intervention group, the median time from qualifying imaging to groin puncture was 57 minutes, and the rate of substantial reperfusion at the end of the procedure was 88%. Thrombectomy with the stent retriever plus intravenous t-PA reduced disability at 90 days over the entire range of scores on the modified Rankin scale (P<0.001). The rate of functional independence (modified Rankin scale score, 0 to 2) was higher in the intervention group than in the control group (60% vs. 35%, P<0.001). There were no significant between-group differences in 90-day mortality (9% vs. 12%, P = 0.50) or symptomatic intracranial hemorrhage (0% vs. 3%, P = 0.12). CONCLUSIONS In patients receiving intravenous t-PA for acute ischemic stroke due to occlusions in the proximal anterior intracranial circulation, thrombectomy with a stent retriever within 6 hours after onset improved functional outcomes at 90 days. (Funded by Covidien; SWIFT PRIME ClinicalTrials.gov number, NCT01657461.)

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Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke

Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.

BackgroundThe effect of endovascular thrombectomy that is performed more than 6 hours after the onset of ischemic stroke is uncertain. Patients with a clinical deficit that is disproportionately severe relative to the infarct volume may benefit from late thrombectomy. MethodsWe enrolled patients with occlusion of the intracranial internal carotid artery or proximal middle cerebral artery who had last been known to be well 6 to 24 hours earlier and who had a mismatch between the severity of the clinical deficit and the infarct volume, with mismatch criteria defined according to age (<80 years or ≥80 years). Patients were randomly assigned to thrombectomy plus standard care (the thrombectomy group) or to standard care alone (the control group). The coprimary end points were the mean score for disability on the utility-weighted modified Rankin scale (which ranges from 0 [death] to 10 [no symptoms or disability]) and the rate of functional independence (a score of 0, 1, or 2 on the modified Rankin scale, whic...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa1706442

Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct.

Background: The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascul...

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association.

Purpose—The aim of this guideline is to provide a focused update of the current recommendations for the endovascular treatment of acute ischemic stroke. When there is overlap, the recommendations made here supersede those of previous guidelines. Methods—This focused update analyzes results from 8 randomized, clinical trials of endovascular treatment and other relevant data published since 2013. It is not intended to be a complete literature review from the date of the previous guideline publication but rather to include pivotal new evidence that justifies changes in current recommendations. Members of the writing committee were appointed by the American Heart Association/American Stroke Association Stroke Council’s Scientific Statement Oversight Committee and the American Heart Association/American Stroke Association Manuscript Oversight Committee. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Recommendations follow the Amer...

2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.

In an iconic scene in ‘The Matrix’, Morpheus gives Neo the choice of taking either the blue pill or the red pill. The blue pill to keep him in his current blissful, fantastical world of illusion and the red pill to shatter that fantasy jolting him into the ‘real world’. The current hype about the potentially explosive growth of endovascular stroke therapy is a blue pill. Neo of course takes the red pill and wakes up to the realities of his time, but will we?

Don't get me wrong, I firmly believe that the recent trials will do for acute ischemic stroke what the International Subarachnoid Aneurysm Trial did for aneurysms. Over a few months we reached milestones that were thought to be many years away, if not unreachable. Suddenly, what we did as neurointerventionalists made sense and was supported by data—not data open to interpretation, but unstinted evidence that appropriately triaged patients will benefit from endovascular revascularization. These trials were the result of a focused, shared objective and collaboration between physicians, industry, and government agencies to assess the cohort of patients best suited for endovascular therapy— that is, those with large vessel strokes.

Working at a center that participated in these and previous studies, I am well aware of the resource-intensive and logistically challenging nature of interventional ischemic stroke trials. About 3 years ago, after much soul searching and review of the evidence, our institution decided to offer endovascular therapy only to patients in a clinical trial. We did this despite our personal convictions and criticisms of the negative endovascular studies because we might be wrong—and if wrong, then doing everything right to discover the truth. Thus all eligible, consecutive patients were enrolled without bias in a trial and we experienced the agony of randomizing relatively young patients with middle …

https://jnis.bmj.com/content/neurintsurg/7/9/623.full.pdf

Red pill, blue pill: reflections on the emerging large vessel stroke ‘market’

Background Pre-intervention perfusion imaging is increasingly becoming part of stroke triage. Small studies supporting imaging based patient selection have been published. The goal of this larger study was to determine if perfusion imaging could impact on functional outcomes in patients undergoing stroke interventions. Methods All patients who had undergone endovascular therapy for anterior circulation strokes over a 7 year period were retrospectively analyzed. The pre-intervention perfusion imaging was assessed for size of cerebral blood volume (CBV), cerebral blood flow and mean transit time (MTT) abnormalities. A perfusion mismatch for irreversible versus reversible ischemia was based on CBV and MTT. Clinical outcome and mortality were based on the 90 day modified Rankin Scale. An analysis of the pre-intervention perfusion parameters was then performed to determine any impact on functional outcomes. Results 110 patients underwent endovascular therapy for anterior circulation strokes. A younger age and lower National Institutes of Health Stroke Scale score were important clinical predictors of favorable outcome (modified Rankin Scale ≤2). The extent of the CBV abnormality and percentage of CBV/MTT mismatch were the strongest imaging predictors of outcome and mortality. A CBV area of 229.5 mm 2 (±290) was seen for favorable outcomes versus 968 mm 2 (±1173) for poor outcomes (p 2 (±392) in patients without mortality versus 1401.1 mm 2 (±1310) in patients with mortality (p Conclusion The extent of pre-intervention CBV abnormality is a strong predictor of functional outcomes following endovascular stroke therapy. This information can aid in patient selection and improve procedure efficacy.

https://jnis.bmj.com/content/neurintsurg/early/2012/03/19/neurintsurg-2012-010293.full.pdf

Pre-intervention cerebral blood volume predicts outcomes in patients undergoing endovascular therapy for acute ischemic stroke

Objective and importance Cerebral revascularization with extracranial-to-intracranial bypass is often required during the surgical treatment of complex intracranial aneurysms. This report is the first in which a vertebral artery (VA)-to-middle cerebral artery (MCA) bypass in conjunction with endovascular coil embolization is used in the successful treatment of a giant intracranial aneurysm. Clinical presentation A 68-year-old man previously diagnosed with a 6-cm internal carotid artery (ICA) aneurysm presented complaining of progressing left hemiparesis and mental status changes. His aneurysm had been treated previously by common carotid artery occlusion 20 years earlier. Arteriography defined the partially thrombosed, right supraclinoid ICA aneurysm arising at the junction of the posterior communicating artery and the supraclinoid ICA. Intervention Because of the patient's worsening symptomatology, endovascular coiling with placement of a superficial temporal artery-to-MCA bypass was performed. The patient tolerated this procedure well, and his symptoms resolved. However, they recurred several months later, and imaging suggested poor right hemispheric perfusion despite a patent bypass. A VA-MCA bypass using a saphenous vein graft was then performed using the distal right VA at the level of cervical vertebra 1 (C1) as the donor vessel with a distal anastomotic site on the right MCA. Coil embolization of the aneurysm was repeated, and the feeding posterior communicating artery was sacrificed. The patient is currently asymptomatic more than 1 year after the second bypass and coil embolization. Conclusion This report describes a safe and definitive treatment option for a giant intracranial ICA aneurysm using a posterior-to-anterior circulation (VA-MCA) bypass, followed by endovascular coil embolization in a patient with previous ligation of the common carotid artery. VA-MCA high-flow saphenous vein bypass followed by coil embolization is a useful technique that is especially valuable in the subset of giant aneurysm patients who have previously been treated by carotid ligation.

Vertebral artery-to-middle cerebral artery bypass with coil embolization of giant internal carotid artery aneurysm: technical case report.

Background An increasing number of acute ischaemic stroke patients are being treated with embolectomy devices. A pathological analysis of these extracted “clots” may be important in understanding device behaviour and procedure success. Methodology Extracted clots from AIS patients undergoing endovascular procedures were prospectively analysed. The pathological assessment included an analysis of the fibrin content and the RBC and WBC ratios. A higher fibrin content indicating a relatively organised thrombus and a higher RBC content suggesting more acute thrombus. A correlative imaging analysis was performed by measurement of the hounsefield units (HU) of the clot on the pre-intervention NCCT as well as the HU of an uninvolved vessel in the contralateral hemisphere. The demographic data and co-morbidities were recorded for each extracted thrombus. Results A total of 16 clots were analysed. The clot location, the fibrin, RBC and WBC content as well as the HU for the clot and the normal blood vessel are listed in table 1. The mean HU for the clots was 56 ± 9.7 while the HU over the normal blood vessel was 33 ± 8. A higher HU had was associated with a lower fibrin content, higher RBC content and lower WBC content. There was no significant association with age or any of the co-morbidities. However there was a trend for higher fibrin content (older clot) and lower RBC% in patients with diabetes, hypertension and hyperlipidaemia. A multi-layered clot indicated a more organised and hence older thrombus, this was also seen in a higher percentage of diabetic patients, however this was not significant. Patients with atrial fibrillation had lower mean HU corresponding to a higher fibrin content (older clot). Conclusions A preliminary analysis of prospectively collected embolectomy specimens indicated a variation in the content of fibrin and RBC composition. The sample size was not large enough to determine statistical associations however there were trends indicating older clots in patients with diabetes, hyperlipidaemia and atrial fibrillation. These preliminary trends may be significant in a larger sample and we continue to collect this data. Disclosures B. Cline: None. J. Vos: None. J. Carpenter: None. A. Rai: 2; C; Stryker Neurovascular, Codman Neurovascular.

https://jnis.bmj.com/content/neurintsurg/5/Suppl_2/A15.2.full.pdf

O-027 Pathological Analysis Of Extracted Clots In Embolectomy Patients With Acute Ischaemic Stroke

Background Economic viability is important to any hospital striving to be a comprehensive stroke center. An inability to recover cost can strain sustained delivery of advanced stroke care. Objective To carry out a comparative financial analysis of intravenous (IV) recombinant tissue plasminogen activator and endovascular (EV) therapy in treating large vessel strokes from a hospital9s perspective. Methodology Actual hospital9s charges, costs, and payments were analyzed for 265 patients who received treatment for large vessel strokes. The patients were divided into an EV (n=141) and an IV group (n=124). The net gain/loss was calculated as the difference between payments received and the total cost. Results The charges, costs, and payments were significantly higher for the EV than the IV group (p Conclusions Endovascular therapy was associated with better outcomes and higher cost–recovery than IV thrombolysis in patients with large vessel strokes.

https://jnis.bmj.com/content/neurintsurg/7/2/150.full.pdf

Ansaar T Rai

Papers

Red pill, blue pill: reflections on the emerging large vessel stroke ‘market’

Pre-intervention cerebral blood volume predicts outcomes in patients undergoing endovascular therapy for acute ischemic stroke

Vertebral artery-to-middle cerebral artery bypass with coil embolization of giant internal carotid artery aneurysm: technical case report.

O-027 Pathological Analysis Of Extracted Clots In Embolectomy Patients With Acute Ischaemic Stroke

Hospital-based financial analysis of endovascular therapy and intravenous thrombolysis for large vessel acute ischemic strokes: the ‘bottom line’