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Journal ArticleDOI: 10.3174/AJNR.A7023

Posterior Circulation Endovascular Thrombectomy for Large-Vessel Occlusion: Predictors of Favorable Clinical Outcome and Analysis of First-Pass Effect.

04 Mar 2021-American Journal of Neuroradiology (American Journal of Neuroradiology)-Vol. 42, Iss: 5, pp 896-903
Abstract: BACKGROUND AND PURPOSE: Successful vessel recanalization in posterior circulation large-vessel occlusion is considered crucial, though the evidence of clinical usefulness, compared with the anterior circulation, is not still determined. The aim of this study was to evaluate predictors of favorable clinical outcome and to analyze the effect of first-pass thrombectomy. MATERIALS AND METHODS: A retrospective, multicenter, observational study was conducted in 10 high-volume stroke centers in Europe, including the period from January 2016 to July 2019. Only patients with an acute basilar artery occlusion or a single, dominant vertebral artery occlusion (“functional” basilar artery occlusion) who had a 3-month mRS were included. Clinical, procedural, and radiologic data were evaluated, and the association between these parameters and both the functional outcome and the first-pass effect was assessed. RESULTS: A total of 191 patients were included. A lower baseline NIHSS score (adjusted OR, 0.77; 95% CI, 0.61–0.96; P = .025) and higher baseline MR imaging posterior circulation ASPECTS (adjusted OR, 3.01; 95% CI, 1.03–8.76; P = .043) were predictors of better outcomes. The use of large-bore catheters (adjusted OR, 2.25; 95% CI, 1.08–4.67; P = .030) was a positive predictor of successful reperfusion at first-pass, while the use of a combined technique was a negative predictor (adjusted OR, 0.26; 95% CI, 0.09–0.76; P = .014). CONCLUSIONS: The analysis of our retrospective series demonstrates that a lower baseline NIHSS score and a higher MR imaging posterior circulation ASPECTS were predictors of good clinical outcome. The use of large-bore catheters was a positive predictor of first-pass modified TICI 2b/3; the use of a combined technique was a negative predictor.

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Topics: Occlusion (52%)
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5 results found


Open accessJournal ArticleDOI: 10.3390/BRAINSCI11040504
16 Apr 2021-Brain Sciences
Abstract: Background: Mechanical thrombectomy is the standard therapy in patients with acute ischemic stroke (AIS). The primary aim of our study was to compare the procedural efficacy of the direct aspiration technique, using Penumbra ACETM aspiration catheter, and the stent retriever technique, with a SolitaireTM FR stent. Secondarily, we investigated treatment-dependent and treatment-independent factors that predict a good clinical outcome. Methods: We analyzed our series of mechanical thrombectomies using a SolitaireTM FR stent and a Penumbra ACETM catheter. The clinical and radiographic data of 76 patients were retrospectively reviewed. Using binary logistic regression, we looked for the predictors of a good clinical outcome. Results: In the Penumbra ACETM group we achieved significantly higher rates of complete vessel recanalization with lower device passage counts, shorter recanalization times, shorter procedure times and shorter fluoroscopy times (p < 0.001) compared to the SolitaireTM FR group. We observed no significant difference in good clinical outcomes (52.4% vs. 56.4%, p = 0.756). Predictors of a good clinical outcome were lower initial NIHSS scores, pial arterial collateralization on admission head CT angiography scan, shorter recanalization times and device passage counts. Conclusions: The aspiration technique using Penumbra ACETM catheter is comparable to the stent retriever technique with SolitaireTM FR regarding clinical outcomes.

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Topics: Penumbra (55%), Stent (54%)

1 Citations


Journal ArticleDOI: 10.1177/19714009211049088
Ludger Feyen1, Peter Schott, Hendrik Ochmann, Marcus Katoh  +2 moreInstitutions (1)
Abstract: PurposeClinical outcomes vary considerably among individuals with vessel occlusion of the posterior circulation. In the present study we evaluated machine learning algorithms in their ability to di...

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Topics: Stroke (51%)

Open accessJournal ArticleDOI: 10.3390/BRAINSCI11101321
05 Oct 2021-Brain Sciences
Abstract: A direct aspiration-first pass technique (ADAPT) has recently gained popularity for the treatment of large vessel ischemic stroke. Here, we sought to create a machine learning-based model that uses pre-treatment imaging metrics to predict successful outcomes for ADAPT in middle cerebral artery (MCA) stroke cases. In 119 MCA strokes treated by ADAPT, we calculated four imaging parameters—clot length, perviousness, distance from the internal carotid artery (ICA) and angle of interaction (AOI) between clot/catheter. We determined treatment success by first pass effect (FPE), and performed univariate analyses. We further built and validated multivariate machine learning models in a random train-test split (75%:25%) of our data. To test model stability, we repeated the machine learning procedure over 100 randomizations, and reported the average performances. Our results show that perviousness (p = 0.002) and AOI (p = 0.031) were significantly higher and clot length (p = 0.007) was significantly lower in ADAPT cases with FPE. A logistic regression model achieved the highest accuracy (74.2%) in the testing cohort, with an AUC = 0.769. The models had similar performance over the 100 train-test randomizations (average testing AUC = 0.768 ± 0.026). This study provides feasibility of multivariate imaging-based predictors for stroke treatment outcome. Such models may help operators select the most adequate thrombectomy approach.

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Open accessJournal ArticleDOI: 10.1007/S00234-021-02843-3
Birgitta Ramgren1, Petrea Frid1, Bo Norrving1, Johan Wassélius1  +1 moreInstitutions (1)
30 Oct 2021-Neuroradiology
Abstract: Purpose: We present the first nationwide study on endovascular therapy for basilar artery occlusion (BAO) from early hospital management to 3-month outcome. Methods: Data were collected on all acute ischaemic stroke patients registered 2016–2019 in the two national quality registers for stroke care and endovascular therapy (EVT), receiving EVT for BAO and subclassified into proximal, middle and distal. Results: In all, 251 patients were included: 69 proximal, 73 middle and 109 distal BAO. Patients with proximal BAO were younger (66, middle 71, distal 76, p < 0.0001), less often female (27.5%, middle 47.9%, distal 47.7%, p = 0.015), more often smokers (28.6%, middle 20.3%, distal 11.5%, p < 0.0001), and fewer had atrial fibrillation (13.2%, middle 24.7%, distal 48.6%, p < 0.0001). Level of consciousness and NIHSS score did not differ by BAO subtype and 52.2% were alert on admission. Time from groin puncture to revascularization was significantly longer in patients with proximal BAO (71, middle 46, distal 42 min, p < 0.0001), and angioplasty and/or stenting was more often performed in patients with proximal (43.4%) and middle (27.4%) than distal (6.4%) BAO (p < 0.0001). Cumulative 90-day mortality was 38.6% (proximal 50.7%, middle 32.9%, distal 34.9%, p = 0.02). Older and pre-stroke dependent patients had higher mortality, as did patients in whom angioplasty/stenting was performed. Conclusion: We confirm a serious outcome in BAO despite endovascular therapies, and demonstrate important differences relating to occlusion location in baseline characteristics, procedural time, therapeutic measures and outcome. Further in-depth analyses of factors affecting outcome in BAO are warranted.

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Topics: Angioplasty (50%)

Open accessJournal ArticleDOI: 10.1055/A-1330-5239
Abstract: Stroke is one of the most common neurological emergencies and requires rapid detection and treatment (time is brain). There is still insufficient knowledge about stroke warning signs. It is therefore of crucial importance that trained personnel in the preclinical setting recognize the relevant warning symptoms and collect the necessary information to quickly refer the patient to the appropriate additional care structure. For this purpose, training of the emergency medical services (EMS) and the correct triage are of particular importance. The on-site assessment of a patient with a suspected stroke by EMS should include airway, breathing, vital functions, a basic neurological examination, blood glucose testing and cardiac monitoring.Patients with suspected acute ischemic stroke should be brought to the nearest hospital with a stroke unit, ideally connected with a tertiary stroke centre. From there, once the primary diagnosis has been carried out and appropriate therapy initiated, the patient can be transferred to a thrombectomy center if necessary. To improve supply times, teleradiological networking plays a major role both between clinics of different levels of care and in communication between pre- and intra-hospital care providers. Also, the use of mobile stroke units can improve preclinical stroke care and reduce delays in access to intravenous thrombolytic therapy and mechanical thrombectomy. The identification of preclinical biomarkers could also save time.

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Topics: Stroke (60%), Emergency medical services (53%), Triage (50%)
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25 results found


Open accessJournal ArticleDOI: 10.1161/STR.0000000000000211
01 Dec 2019-Stroke
Abstract: 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.

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Topics: Guideline (52%), Evidence-based medicine (52%), Stroke (51%)

1,777 Citations


Open accessJournal ArticleDOI: 10.1161/STROKEAHA.113.001972
Osama O. Zaidat1, Albert J Yoo2, Pooja Khatri3, Thomas A. Tomsick3  +31 moreInstitutions (23)
01 Sep 2013-Stroke
Abstract: See related article, p 2509 Intra-arterial therapy (IAT) for acute ischemic stroke (AIS) has dramatically evolved during the past decade to include aspiration and stent-retriever devices. Recent randomized controlled trials have demonstrated the superior revascularization efficacy of stent-retrievers compared with the first-generation Merci device.1,2 Additionally, the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution (DEFUSE) 2, the Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE), and the Interventional Management of Stroke (IMS) III trials have confirmed the importance of early revascularization for achieving better clinical outcome.3–5 Despite these data, the current heterogeneity in cerebral angiographic revascularization grading (CARG) poses a major obstacle to further advances in stroke therapy. To date, several CARG scales have been used to measure the success of IAT.6–14 Even when the same scale is used in different studies, it is applied using varying operational criteria, which further confounds the interpretation of this key metric.10 The lack of a uniform grading approach limits comparison of revascularization rates across clinical trials and hinders the translation of promising, early phase angiographic results into proven, clinically effective treatments.6–14 For these reasons, it is critical that CARG scales be standardized and end points for successful revascularization be refined.6 This will lead to a greater understanding of the aspects of revascularization that are strongly predictive of clinical response. The optimal grading scale must demonstrate (1) a strong correlation with clinical outcome, (2) simplicity and feasibility of scale interpretation while ensuring characterization of relevant angiographic findings, and (3) high inter-rater reproducibility. To address these issues, a multidisciplinary panel of neurointerventionalists, neuroradiologists, and stroke neurologists with extensive experience in neuroimaging and IAT, convened at the “Consensus Meeting on Revascularization Grading Following Endovascular Therapy” with the goal …

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Topics: Revascularization (57%), Cerebral Revascularization (57%), Stroke (52%)

856 Citations


Journal ArticleDOI: 10.7326/0003-4819-135-2-200107170-00012
Abstract: Increasingly, investigators rely on multicenter or multigroup studies to demonstrate effectiveness and generalizability. Authors too often overlook the analytic challenges in these study designs: the correlation of outcomes and exposures among patients within centers, confounding of associations by center, and effect modification of treatment or exposure across center. Correlation or clustering, resulting from the similarity of outcomes among patients within a center, requires an adjustment to confidence intervals and P values, especially in observational studies and in randomized multicenter studies in which treatment is allocated by center rather than by individual patient. Multicenter designs also warrant testing and adjustment for the potential bias of confounding by center, and for the presence of effect modification or interaction by center. This paper uses examples from the recent biomedical literature to highlight the issues and analytic options.

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Topics: Observational study (51%)

406 Citations


Journal ArticleDOI: 10.1016/S1474-4422(11)70229-0
01 Nov 2011-Lancet Neurology
Abstract: The clinical presentation of basilar artery occlusion (BAO) ranges from mild transient symptoms to devastating strokes with high fatality and morbidity. Often, non-specific prodromal symptoms such as vertigo or headaches are indicative of BAO, and are followed by the hallmarks of BAO, including decreased consciousness, quadriparesis, pupillary and oculomotor abnormalities, dysarthria, and dysphagia. When clinical findings suggest an acute brainstem disorder, BAO has to be confirmed or ruled out as a matter of urgency. If BAO is recognised early and confirmed with multimodal CT or MRI, intravenous thrombolysis or endovascular treatment can be undertaken. The goal of thrombolysis is to restore blood flow in the occluded artery and salvage brain tissue; however, the best treatment approach to improve clinical outcome still needs to be ascertained.

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321 Citations


Open accessJournal ArticleDOI: 10.1161/STROKEAHA.117.020315
Osama O. Zaidat1, Alicia C. Castonguay1, Italo Linfante1, Rishi Gupta1  +27 moreInstitutions (1)
01 Mar 2018-Stroke
Abstract: Background and Purpose—In acute ischemic stroke, fast and complete recanalization of the occluded vessel is associated with improved outcomes. We describe a novel measure for newer generation devic...

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Topics: Stroke (57%)

248 Citations