Mechanical Thrombectomy Workshops Improve Procedural Knowledge and Skills Among Neurointerventional Teams in Low- to Middle-Income Countries.

BACKGROUND: While mechanical thrombectomy (MT) is proven to be lifesaving and disability sparing, there remains a disparity in its access in low- to middle-income countries. We hypothesized that team-based MT workshops would improve MT knowledge and skills. METHODS: We designed a 22-hour MT workshop, conducted as 2 identical events: in English (Jamaica, January 2022) and in Spanish (Dominican Republic, May 2022). The workshops included participating neurointerventional teams (practicing neurointerventionalists, neurointerventional nurses, and technicians) focused on acute stroke due to large vessel occlusion. The course faculty led didactic and hands-on components, covering topics from case selection and postoperative management to device technology and MT surgical techniques. Attendees were evaluated on stroke knowledge and MT skills before and after the course using a multiple choice exam and simulated procedures utilizing flow models under fluoroscopy, respectively. Press conferences for public education with invited government officials were included to raise stroke awareness. RESULTS: Twenty-two physicians and their teams from 8 countries across the Caribbean completed the didactic and hands-on training. Overall test scores (n=18) improved from 67% to 85% (P<0.002). Precourse and postcourse hands-on assessments demonstrated reduced time to completion from 36.5 to 21.1 minutes (P<0.001). All teams showed an improvement in measures of good MT techniques, with 39% improvement in complete reperfusion. Eight teams achieved a Thrombolysis in Cerebral Infarction score of 3 on pre-course versus 15 of 18 teams on post-course. There was a significant reduction in total potentially dangerous maneuvers (70% pre versus 20% post; P<0.002). Universally, the workshop was rated as satisfactory and likely to change practice in 93% Dominican Republic and 75% Jamaica. CONCLUSIONS: A team-based hands-on simulation approach to MT training is novel, feasible, and effective in improving procedural skills. Participants viewed these workshops as practice-changing and instrumental in creating a pathway for increasing access to MT in low- to middle-income countries.

Endovascular treatment of acute ischemic stroke: an Indian experience from a tertiary care center.

BACKGROUND: In India, late presentation due to poor awareness about stroke precludes intravenous thrombolysis (IVT). Endovascular therapy can be used in these circumstances. We present our experience of endovascular treatment of acute ischemic stroke in a tertiary care center. AIM: Endovascular treatment of acute ischemic stroke in a tertiary care center in India. SETTINGS, DESIGN, MATERIALS, AND METHODS: The study period was from 2009 till 2013. Consecutive patients with acute ischemic stroke, who either had contraindications to IVT or had failed IVT, underwent endovascular treatment. Before the publication of interventional management of stroke 3 results, we took a few patients, with large vessel occlusions, directly for endovascular treatment. After imaging, patients were considered for endovascular treatment, using either intra-arterial thrombolysis or mechanical thrombectomy, if there was a documented large vessel occlusion. Outcome was assessed at 3 months using the modified Rankin Scale. STATISTICAL ANALYSIS: Statistical analysis was done using the Statistical Package for the Social Sciences 17.0 software. RESULTS: A total of 45 patients underwent endovascular treatment. The mean age at presentation was 49 years, median National Institutes of Health Stroke Scale (NIHSS) was 19 and the most common site was the middle cerebral artery (23 patients). Solitaire™ stentriever was used in 33 patients. The median pre-procedure Thrombolysis In Myocardial Infarction (TIMI) score was 0 and the median post-procedure TIMI score was 3. Nine patients underwent decompressive craniectomy. On follow-up at 3 months, the median Modified Rankin Scale (mRS) was 0. Eight patients died during 3 months following stroke. CONCLUSION: Endovascular treatment of acute ischemic stroke is a viable treatment option in patients who either have contraindications to IVT or who fail IVT.

"Missing clot" during mechanical thrombectomy in acute stroke using Solitaire stent retrieval system.

Stent retrieval system is an established treatment modality in acute ischemic stroke with large vessel occlusion. Here, we describe a complication which occurred during mechanical thrombectomy in three cases where the clot dislodged during retrieval. There was a possibility of the clot getting reinjected into the artery with possible dire consequences.

Mechanical Thrombectomy Using Solitaire in a 6-Year-Old Child.

A six-year-old boy was diagnosed as recurrent posterior circulation stroke secondary to basilar artery occlusion with rapid progression of symptoms. Etiology of stroke was a dissection of V3 segment of left vertebral artery, which was treated using endovascular technique 26 hours after worsening of symptoms. Since the guidelines for acute revascularization in pediatric stroke are not well established, there is limited experience in the use of mechanical devices for acute ischemic stroke revascularization in children. To our knowledge, this is one of the youngest reported cases of acute ischemic stroke from Asia managed with newer mechanical clot removal devices.

Crossover balloon technique for vertebral artery thrombus: a novel method.

A 54-year-old man presented with recurrent episodes of transient ischemic attacks and acute stroke secondary to a floating thrombus in the right vertebral artery (VA) with narrowing of the right VA. He was initially treated medically with anticoagulation, antiplatelets and statins but developed multiple fresh infarcts. He was then referred for endovascular treatment, which was performed in a novel way.

Thrombolysis in acute ischemic stroke: Experience from a tertiary care centre in India.

UNLABELLED: The management of acute ischemic stroke has undergone a sea of change with the introduction of intravenous thrombolysis (IVT). Current guidelines state that the window period for IVT using rTPA is 4.5 hours. The MERCI, Multi Merci, and Penumbra trials in which patients with acute ischemic stroke were treated using endovascular treatment demonstrated better recanalisation in patients having a large vessel occlusion. However, recently published data from the three large trials IMS 3, Synthesis Expansion, and MR rescue, which compared endovascular treatment with intravenous therapy, failed to demonstrate superiority of endovascular treatment over IVT. In these trials, stent retrievers were used in very few patients. We present our results from a tertiary care center in India where patients are treated using intravenous as well as endovascular modalities. Among the 53 patients with acute ischemic stroke treated between 2010 and 2012, 23 were treated with IVT and 30 with endovascular methods. Stent retriever was used in majority of the endovascular cases. AIMS: To compare the outcomes of acute ischemic stroke patients treated with IVT versus those who were managed using endovascular therapy. To evaluate outcomes of patients with acute ischemic stroke with a large vessel occlusion in whom endovascular modalities were used and to compare them with those of patients who were treated with IVT in presence of a large vessel occlusion. SETTINGS AND DESIGN: Data of patients who underwent thrombolysis at our centre was collected over a 3-year period, that is, from 2010 to 2012. Endovascular treatment was done by an interventional neurologist. MATERIALS AND METHODS: Data of patients with acute ischemic stroke who underwent IVT or endovascular treatment at our centre between 2010 and 2012 was analyzed. Parameters included age, National Institutes of Health Stroke Scale (NIHSS) on admission, door to needle time, stroke subtype, modality of treatment, outcome based on modified Rankin Scale (mRS) Score at 90 days follow up and mortality rates at 90 days. STATISTICAL ANALYSIS: Tabulated results were analysed using INSTAT Graphpad analyser. Data were analysed using paired and unpaired t-test, Chi-square test, and Fishers test as applicable. P value was considered significant when it was <0.05. RESULTS: Upon comparison of the outcomes of patients with acute ischemic stroke and large vessel disease treated with endovascular therapy with those treated with IVT, it was found that the former group had better outcomes. We also found that in spite of there being a significant difference in the NIHSS on admission and a significant difference in the door to needle time, the outcomes of patients treated using intravenous or endovascular therapy were similar. There was no statistically significant difference in mortality rates between intravenous and endovascular groups. CONCLUSIONS: IVT is currently the standard of care in the management of acute ischemic stroke. Endovascular treatment during the window period is reserved for those patients with contraindication to IVT. In this study, we found that patients with documented large vessel disease with no evidence of cross flow through Willisian collaterals benefit from endovascular treatment. We recommend that all patients of acute ischemic stroke, be subjected to a baseline angiogram either computed tomography (CT) or magnetic resonance imaging (MRI) to document vessel status. This will help in identifying patients who may benefit from early endovascular treatment, if they fail to improve with IVT. Further, large trials using stent retrievers are needed, to prove that endovascular treatment is superior to IVT, in presence of documented large vessel disease.

Crossover balloon technique for vertebral artery thrombus: a novel method.

A 54-year-old man presented with recurrent episodes of transient ischemic attacks and acute stroke secondary to a floating thrombus in the right vertebral artery (VA) with narrowing of the right VA. He was initially treated medically with anticoagulation, antiplatelets and statins but developed multiple fresh infarcts. He was then referred for endovascular treatment, which was performed in a novel way.