Safety and Outcomes of Thrombectomy in Ischemic Stroke With vs Without IV Thrombolysis.

OBJECTIVE: To test the hypothesis that IV thrombolysis (IVT) treatment before endovascular thrombectomy (EVT) is associated with better outcomes in patients with anterior circulation large artery occlusion (LAO) stroke, we examined a large real-world database, the Safe Implementation of Treatment in Stroke-International Stroke Thrombectomy Register (SITS-ISTR). METHODS: We identified centers recording ≥10 consecutive patients in the SITS-ISTR, with at least 70% available modified Rankin Scale (mRS) scores at 3 months during 2014 to 2019. We defined LAO as intracranial internal carotid artery, first and second segment of middle cerebral artery, and first segment of anterior cerebral artery. Main outcomes were functional independence (mRS score 0-2) and death at 3 months and symptomatic intracranial hemorrhage (SICH) per modified SITS-Monitoring Study. We performed propensity score-matched (PSM) and multivariable logistic regression analyses. RESULTS: Of 6,350 patients from 42 centers, 3,944 (62.1%) received IVT. IVT + EVT-treated patients had less frequent atrial fibrillation, ongoing anticoagulation, previous stroke, heart failure, and prestroke disability. PSM analysis showed that IVT + EVT-treated patients had a higher rate of functional independence than patients treated with EVT alone (46.4% vs 40.3%, p < 0.001) and a lower rate of death at 3 months (20.3% vs 23.3%, p = 0.035). SICH rates (3.5% vs 3.0%, p = 0.42) were similar in both groups. Multivariate adjustment yielded results consistent with PSM. CONCLUSION: Pretreatment with IVT was associated with favorable outcomes in EVT-treated LAO stroke in the SITS-ISTR. These findings, while indicative of international routine clinical practice, are limited by observational design, unmeasured confounding, and possible residual confounding by indication. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that IVT before EVT increases the probability of functional independence at 3 months compared to EVT alone.

Comparison of Mechanical Thrombectomy with Contact Aspiration, Stent Retriever, and Combined Procedures in Patients with Large-Vessel Occlusion in Acute Ischemic Stroke.

BACKGROUND We investigated the properties and effects of 5 mechanical thrombectomy procedures in patients with acute ischemic stroke. The relationships between the type of procedure, the time required, the success of recanalization, and the clinical outcome were analyzed. MATERIAL AND METHODS This prospective comparative analysis included 500 patients with acute ischemic stroke and large-vessel occlusion. We compared contact aspiration thrombectomy (ADAPT, n=100), stent retriever first line (SRFL, n=196), the Solumbra technique (n=64), mechanical thrombectomy plus stent implantation (n=81), and a combined procedure (n=59). RESULTS ADAPT provided shorter procedure (P<0.001) and recanalization times (P<0.001) than the other techniques. Better clinical outcome was achieved for ischemia in the anterior circulation than ischemia in the posterior fossa (P<0.001). Compared to the other techniques, patients treated with ADAPT procedure had increased odds of achieving better mTICI scores (P=0.002) and clinical outcome (NIHSS) after 7 days (P=0.003); patients treated with SRFL had increased odds of achieving better long-term clinical status (3M-mRS=0-2; P=0.040). Patients with SRFL and intravenous thrombolysis (IVT) had increased odds of better clinical status (3M-mRS=0-2; P=0.031) and decreased odds of death (P=0.005) compared to patients with SRFL without IVT. The other treatment approaches had no additional effect of IVT. Patients with SRFL with a mothership transfer had increased odds of achieving favorable clinical outcome (3M-mRS) compared to SRFL with the drip-and-ship transfer paradigm (P=0.015). CONCLUSIONS Our results showed that ADAPT and SRFL provided significantly better outcomes compared to the other examined techniques. A mothership transfer and IVT administration contributed to the success of the SRFL approach.

Sonolysis in Prevention of Brain Infarction During Cardiac Surgery (SONORESCUE): Randomized, Controlled Trial.

Here, we examined whether intraoperative sonolysis can alter the risk of new ischemic lesions in the insonated brain artery territory during coronary artery bypass grafting (CABG) or valve surgery.Silent brain ischemic lesions could be detected in as many as two-thirds of patients after CABG or valve surgery.Patients indicated for CABG or valve surgery were allocated randomly to sonolysis (60 patients, 37 males; mean age, 65.3 years) of the right middle cerebral artery (MCA) during cardiac surgery and control group (60 patients, 37 males; mean age, 65.3 years). Neurologic examination, cognitive function tests, and brain magnetic resonance imaging (MRI) were conducted before intervention as well as 24 to 72 hours and 30 days after surgery.New ischemic lesions on control diffusion-weighted MRI in the insonated MCA territory ≥0.5 mL were significantly less frequent in the sonolysis group than in the control group (13.3% vs 26.7%, P = 0.109). The sonolysis group exhibited significantly reduced median volume of new brain ischemic lesions (P = 0.026). Stenosis of the internal carotid artery ≥50% and smoking were independent predictors of new brain ischemic lesions ≥0.5 mL (odds ratio = 5.685 [1.272-25.409], P = 0.023 and 4.698 [1.092-20.208], P = 0.038, respectively). Stroke or transient ischemic attack occurred only in 2 control patients (P = 0.496). No significant differences were found in scores for postintervention cognitive tests (P > 0.05).This study provides class-II evidence that sonolysis during CABG or valve surgery reduces the risk of larger, new ischemic lesions in the brain.www.clinicaltrials.gov (NCT01591018).

Laboratory-Based Markers as Predictors of Brain Infarction During Carotid Stenting: a Prospective Study.

AIM: New ischemic lesions in the brain can be detected in approximately 50% of patients undergoing carotid artery stenting (CAS). We wished to discover the laboratory-based predictors of new infarctions in the brain after CAS. METHODS: All consecutive patients with internal carotid artery stenosis of ≥70% with indication for CAS were enrolled in a prospective study for 16 months. All patients used dual antiplatelet therapy for ≥7 days before CAS. Neurologic examination and magnetic resonance imaging (MRI) of the brain were undertaken before and at 24 h after CAS. Samples of venous blood were collected at ＜24 h before CAS for the evaluation of hematology, reticulocytes, coagulation markers (PT, APTT, Fbg, Clauss), vWF antigen, PAI-1 activity, PAI-1 polymorphism 4G/5G, and the multiplate (aspirin and clopidogrel) resistance test. Blood samples for the assessment of anti-Xa activity were collected during CAS. Differences in the values of laboratory markers between patients with and without new ischemic lesions of the brain on control MRI were evaluated. RESULTS: The cohort comprised 81 patients (53 males; mean age, 67.3±7.2 years). New ischemic infarctions in the brain on control MRI were found in 46 (56.8%) patients. Three of seven patients with resistance to aspirin or clopidogrel had a new ischemic infarction in the brain. No significant differences for particular markers were found between patients with and without an ischemic lesion in the brain. CONCLUSION: A high risk of a new ischemic infarction in the brain was detected in patients undergoing CAS, but a laboratory-based predictor of such an infarction could not be identified.