Endovascular thrombectomy for acute ischaemic stroke with established large infarct: multicentre, open-label, randomised trial.

BACKGROUND: Recent evidence suggests a beneficial effect of endovascular thrombectomy in acute ischaemic stroke with large infarct; however, previous trials have relied on multimodal brain imaging, whereas non-contrast CT is mostly used in clinical practice. METHODS: In a prospective multicentre, open-label, randomised trial, patients with acute ischaemic stroke due to large vessel occlusion in the anterior circulation and a large established infarct indicated by an Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) of 3-5 were randomly assigned using a central, web-based system (using a 1:1 ratio) to receive either endovascular thrombectomy with medical treatment or medical treatment (ie, standard of care) alone up to 12 h from stroke onset. The study was conducted in 40 hospitals in Europe and one site in Canada. The primary outcome was functional outcome across the entire range of the modified Rankin Scale at 90 days, assessed by investigators masked to treatment assignment. The primary analysis was done in the intention-to-treat population. Safety endpoints included mortality and rates of symptomatic intracranial haemorrhage and were analysed in the safety population, which included all patients based on the treatment they received. This trial is registered with ClinicalTrials.gov, NCT03094715. FINDINGS: From July 17, 2018, to Feb 21, 2023, 253 patients were randomly assigned, with 125 patients assigned to endovascular thrombectomy and 128 to medical treatment alone. The trial was stopped early for efficacy after the first pre-planned interim analysis. At 90 days, endovascular thrombectomy was associated with a shift in the distribution of scores on the modified Rankin Scale towards better outcome (adjusted common OR 2·58 [95% CI 1·60-4·15]; p=0·0001) and with lower mortality (hazard ratio 0·67 [95% CI 0·46-0·98]; p=0·038). Symptomatic intracranial haemorrhage occurred in seven (6%) patients with thrombectomy and in six (5%) with medical treatment alone. INTERPRETATION: Endovascular thrombectomy was associated with improved functional outcome and lower mortality in patients with acute ischaemic stroke from large vessel occlusion with established large infarct in a setting using non-contrast CT as the predominant imaging modality for patient selection. FUNDING: EU Horizon 2020.

Aspiration Thrombectomy in Patients with Large Vessel Occlusion and Mild Stroke: A Single-Center Experience.

BACKGROUND The purpose of this study was to evaluate outcomes of patients with mild stroke, defined by National Institutes of Health Stroke Scale (NIHSS) score <6, caused by large vessel occlusion treated with aspiration thrombectomy. MATERIAL AND METHODS Data from the endovascular stroke registry of our center were retrospectively analyzed. Anterior or posterior circulation strokes with NIHSS score <6 upon admission were analyzed. The assessment of a good clinical outcome (modified Rankin scale score 0-2) at day 90 was the primary endpoint. Symptomatic intracranial hemorrhage, defined in European Cooperative Acute Stroke Study grade III, and mortality at day 90 were the safety measures. A successful endovascular procedure was defined as a Thrombolysis in Cerebral Infarction (TICI) score of 2b or 3. RESULTS We included 27 patients treated with immediate mechanical thrombectomy, 19 (70.4%) in the anterior circulation and 8 (29.6%) in the posterior circulation. The mean age was 69.8±12.3 years and 40.7% were male. Thirteen patients (48.1%) received bridging intravenous thrombolysis before endovascular thrombectomy. Twenty-five patients (92.6%) underwent the direct aspiration first-pass technique "ADAPT" as the first choice of endovascular procedure. Successful recanalization was achieved in 25 patients (92.6%). Twenty-one patients (77.8%) had a good functional outcome at the 3-month follow-up, 1 (3.7%) symptomatic intracranial hemorrhage was observed, and 2 patients (7.4%) died. CONCLUSIONS Immediate aspiration thrombectomy may be a safe and feasible first-line treatment option in patients suffering from mild stroke due to large vessel occlusion in the anterior and posterior circulation.

Predictors of Outcome after Direct Aspiration of Basilar Artery Occlusion.

Background: Basilar artery occlusion (BAO) is a serious disease with a poor prognosis if left untreated. Endovascular therapy (EVT) is the most effective treatment that is able to reduce mortality and disability. Treatment results are influenced by a wide range of factors that have not been clearly identified. In the present study, direct aspiration was chosen as a first-line treatment. The safety and effectiveness of direct aspiration in BAO were determined, and factors affecting patient outcomes were identified. Methodology: Data for patients with BAO treated between November 2013 and December 2021 were evaluated using a database. The association between clinical and procedural parameters and functional outcome was assessed. Results: A total of 89 patients with BAO were identified. Full recanalization was achieved in 69.7% of cases and partial recanalization in 19.1%. Intracranial hemorrhage was detected in 11 (12.4%) patients, of which, eight (9.0%) patients experienced symptomatic intracranial hemorrhage. Patients with good outcomes presented with milder strokes (mean NIHSS score of 12.58 vs. 24.00, p < 0.001), had higher collateral scores (6.79 vs. 5.88, p = 0.016), more often achieved complete recanalization (87.9% vs. 58.9%, p = 0.009), and more often experienced early neurological improvement (66.7% vs. 26.8%, p < 0.001). On the contrary, patients with worse outcomes had higher serum glucose levels (p = 0.05), occlusion of the middle portion of the basilar artery (MAB) (30.3% vs. 53.6%, p = 0.033), longer thrombus lengths (10.51 vs. 16.48 mm, p = 0.046), and intracranial hemorrhage (p = 0.035). Conclusions: The present study results suggest that direct aspiration is a safe and effective treatment for patients with BAO. We identified several factors affecting the patients' outcome.

Low Lymphocyte-to-Monocyte Ratio as a Possible Predictor of an Unfavourable Clinical Outcome in Patients with Acute Ischemic Stroke after Mechanical Thrombectomy.

Background: Although considerable progress has been made in the treatment of acute ischemic stroke (AIS), the clinical outcome of patients is still significantly influenced by the inflammatory response that follows stroke-induced brain injury. The aim of this study was to evaluate the potential use of complete blood count parameters, including indices and ratios, for predicting the clinical outcome in AIS patients undergoing mechanical thrombectomy (MT). Methods: This single-centre retrospective study is consisted of 179 patients. Patient data including demographic characteristics, risk factors, clinical data, laboratory parameters on admission, and clinical outcome were collected. Based on the clinical outcome assessed at 3 months after MT by the modified Rankin Scale (mRS), patients were divided into two groups: the favourable group (mRS 0-2) and unfavourable group (mRS 3-6). Stepwise multivariate logistic regression analysis was used to detect an independent predictor of the unfavourable clinical outcome. Results: An unfavourable clinical outcome was detected after 3 months in 101 patients (54.4%). Multivariate logistic regression analysis confirmed that the lymphocyte-to-monocyte ratio (LMR) was an independent predictor of unfavourable clinical outcome at 3 months (odds ratio = 0.761, 95% confidence interval 0.625-0.928, and P = 0.007). The value of 3.27 was chosen to be the optimal cut-off value of LMR. This value could predict the unfavourable clinical outcome with a 74.0% sensitivity and a 54.4% specificity. Conclusion: The LMR at the time of hospital admission is a predictor of an unfavourable clinical outcome at 3 months in AIS patients after MT.

Aspiration thrombectomy as the first-line treatment of M2 occlusions.

PURPOSE: The aim of the present study was (i) to evaluate the safety and efficacy of aspiration thrombectomy in patients with M2 occlusions and (ii) to compare outcome of treatment of occlusion of different M2 segments. MATERIALS AND METHODS: Between March 2016 and June 2019, 82 patients with acute ischemic stroke and isolated M2 occlusions were treated in cerebrovascular stroke center with aspiration thrombectomy as the first-line treatment. Functional outcomes of patients with different types of M2 occlusions were statistically compared. Multivariable logistic regression analysis was performed to determine the factors associated with good clinical outcome. RESULTS: The mean age was 71.9 ± 13.4 years, 47.6% were men. Aspiration thrombectomy alone was utilized in 72.5% of patients, with 27.5% of patients being treated with a combination of aspiration thrombectomy and stent retriever. At the three-month follow-up, there was no statistically significant difference in functional outcome between different types of M2 occlusions (p = 0.662), however in the underpowered analysis because of the small sample size of patients, with good clinical outcome mRS 0-2 in 50% of all treated patients. Symptomatic intracranial hemorrhage was found in 6.1% of patients. Lower age (OR 0.932, 95% CI 0.878-0.988) and lower NIHSS score upon admission (OR 0.893, 95% CI 0.805-0.991) were independent predictors of good clinical outcome. CONCLUSION: Aspiration thrombectomy appeared to be a safe and effective first-line treatment option for patients with M2 occlusion, being the first-line option for almost three-quarters of patients.

Endovascular treatment of acute ischemic stroke in patients with recurrent intracranial large vessel occlusion.

BACKGROUND: Data on the treatment with recurrent mechanical thrombectomy of patients with acute ischemic stroke with recurrent large vessel occlusion are limited. We report our experience with recurrent mechanical thrombectomy for recurrent large vessel occlusion. METHODS: During the period between May 2013 and August 2018, data on patients with recurrent large vessel occlusion were collected. Baseline clinical characteristics, recanalization technique, recanalization rates and clinical outcomes of patients with recurrent large vessel occlusion treated with mechanical thrombectomy were analyzed. Patients with recurrent large vessel occlusion treated with mechanical thrombectomy were compared with patients who underwent single mechanical thrombectomy. RESULTS: During the study period, 7 of 474 patients (1.5%) were treated with mechanical thrombectomy for recurrent large vessel occlusion. The mean age of these patients was 64.4 (±7.9) years, and the mean time interval between thrombectomies was 47 (±48) h. The median baseline National Institutes of Health Stroke Scale (NIHSS) was 12 (range 5-24) before the first and 20 (range 3-34) before the second procedure; the mean NIHSS at discharge was 5 (range 2-25). Good clinical outcome after repeated mechanical thrombectomy defined as modified Rankin scale of 0-2 was achieved in 29% of patients at three months of follow-up. CONCLUSIONS: Repeat mechanical thrombectomy is a rare procedure, but appears to be a feasible, safe and effective treatment option in patients with acute ischemic stroke and early recurrent large vessel occlusion.

Neurointerventionalist and Patient Radiation Doses in Endovascular Treatment of Acute Ischemic Stroke.

PURPOSE: To evaluate the patient and the neurointerventionalist radiation dose levels during endovascular treatment of acute ischemic stroke, and to analyze factors affecting doses. MATERIALS AND METHODS: From October 2017 to January 2019, we prospectively collected patient radiation data and neurointerventionalist data from real-time dosimetry from all consecutive thrombectomies. Multivariate analysis was performed to analyze patient total dose area product (DAP) and neurointerventionalist dose variability in terms of clinical characteristics and the technical parameters of thrombectomies. Local dose reference levels (RL) were derived as the 75th percentile of the patient dose distributions. RESULTS: A total of 179 patients were treated during the study period and included in this study. Local dose RL for thrombectomy was derived for total DAP to 34 Gy cm2, cumulative air kerma of 242 mGy and fluoroscopy time of 12 min. The mean neurointerventionalist dose for thrombectomy was 7.7 ± 7.4 µSv. Height (P = 0.018), weight (P = 0.004), body mass index (P = 0.015), puncture to recanalisation (P < 0.001), fluoro time (P < 0.001), number of passes (P < 0.001), thrombolysis in cerebral infarction 2b/3 recanalisation (P = 0.034) and aspiration thrombectomy (P < 0.001) were independent factors affecting patient total DAP, whereas baseline National Institutes of Health Stroke Scale (P = 0.043), puncture to recanalisation (P = 0.003), fluoroscopy time (P = 0.009) and number of passes (P = 0.009) were factors affecting the neurointerventionalist dose. CONCLUSION: New reference patient doses lower than those in previously published studies were defined. However, the operator's doses were higher than those in the only available study reporting on operator's dose during cerebral interventions.