Endovascular treatment of primary M3 occlusion stroke in clinical practice: analysis of the German Stroke Registry.

BACKGROUND: Endovascular treatment (ET) options for acute stroke due to distal middle cerebral artery occlusions are rapidly evolving, but data on outcome and safety are sparse. We therefore performed an analysis of patients undergoing ET for primary M3 occlusions in routine clinical practice in a nationwide registry. METHODS: Patients enrolled between 01/20 and 12/21 in the prospective, multicenter German Stroke Registry-Endovascular Treatment (GSR-ET) were screened for mechanical thrombectomy performed for primary M3 occlusion. We analyzed neurological deficit as measured by the National Institute of Health Stroke Scale (NIHSS), symptomatic intracranial hemorrhage (sICH), thrombectomy technique, successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score of 2b-3) and functional outcome as measured by the modified Rankin Scale (mRS) at discharge and 90 days. RESULTS: Out of 5574 patients, 11 patients (0.2%, median age 80 years, 54.5% female) underwent ET for primary M3 occlusion. All patients had pre-admission mRS ≤ 1, median NIHSS on admission was 8, and successful reperfusion was achieved in 6/11 patients (54.5%). While no vasospasm, dissection or perforation was reported, symptomatic intracranial hemorrhage occurred in 2 patients (18.2%). Favorable outcome (mRS ≤ 2) was achieved in 6/11 patients (54.5%) at 90-day follow-up. CONCLUSIONS: ET for primary M3 occlusions is rarely performed. While technically feasible, the procedure's potential benefits must be carefully weighed against its associated risks, including clinically relevant complications. Caution and further research is needed to optimize patient selection for this intervention. TRIAL REGISTRATION: GSR-ET; ClinicalTrials.gov Identifier: NCT03356392; Trial Registration Date: 11/29/2017.

How do treatment times impact on functional outcome in stroke patients undergoing thrombectomy in Germany? Results from the German Stroke Registry.

BACKGROUND: Functional outcome post-stroke depends on time to recanalization. Effect of in-hospital delay may differ in patients directly admitted to a comprehensive stroke center and patients transferred via a primary stroke center. We analyzed the current door-to-groin time in Germany and explored its effect on functional outcome in a real-world setting. METHODS: Data were collected in 25 stroke centers in the German Stroke Registry-Endovascular Treatment a prospective, multicenter, observational registry study including stroke patients with large vessel occlusion. Functional outcome was assessed at three months by modified Rankin Scale. Association of door-to-groin time with outcome was calculated using binary logistic regression models. RESULTS: Out of 4340 patients, 56% were treated primarily in a comprehensive stroke center and 44% in a primary stroke center and then transferred to a comprehensive stroke center ("drip-and-ship" concept). Median onset-to-arrival at comprehensive stroke center time and door-to-groin time were 103 and 79 min in comprehensive stroke center patients and 225 and 44 min in primary stroke center patients. The odds ratio for poor functional outcome per hour of onset-to-arrival-at comprehensive stroke center time was 1.03 (95%CI 1.01-1.05) in comprehensive stroke center patients and 1.06 (95%CI 1.03-1.09) in primary stroke center patients. The odds ratio for poor functional outcome per hour of door-to-groin time was 1.30 (95%CI 1.16-1.46) in comprehensive stroke center patients and 1.04 (95%CI 0.89-1.21) in primary stroke center patients. Longer door-to-groin time in comprehensive stroke center patients was associated with admission on weekends (odds ratio 1.61; 95%CI 1.37-1.97) and during night time (odds ratio 1.52; 95%CI 1.27-1.82) and use of intravenous thrombolysis (odds ratio 1.28; 95%CI 1.08-1.50). CONCLUSION: Door-to-groin time was especially relevant for outcome of comprehensive stroke center patients, whereas door-to-groin time was much shorter in primary stroke center patients.Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT03356392. Unique identifier NCT03356392.

Quality of Stroke Patient Information Applied in Randomized Controlled Trials-Literature Review.

Background: Strokes have a huge impact on patients' quality of life. Although there are potentially effective secondary preventions and treatment options for stroke patients, adherence is mostly low. Low disease and treatment-related knowledge and, consequently, a lack of informed decision-making in stroke patients may contribute to this problem. However, stroke patient information did not seem to have relevant effects on patients' knowledge in randomized controlled trials. One contributing factor may be the lack of thoroughly developed patient information materials. Methods: We aimed to evaluate the quality of patient information materials for stroke patients by using randomized controlled trials, applying quality criteria for evidence-based patient information (EBPI). We conducted a literature search (MEDLINE, Embase, CINAHL, PsycINFO, and CENTRAL). To be included in the review, research had to be randomized controlled trials that provided stroke patient information, were published in English, and had knowledge assessed as the primary endpoint. Authors of primary studies were contacted and asked for information materials applied. Results: We screened 15,507 hits and identified 30 eligible studies. Information materials were available for only eight studies. Analyses revealed that all available materials had important shortcomings concerning EBPI quality criteria [concerning, for example, structural information (e.g., reporting conflicts of interest), content information (e.g., reporting sources of information), or comprehensive descriptions of treatment effects and side effects]. Frequently, treatment effects were reported only narratively without providing absolute numbers, values, or frequencies. Conclusion: Quality of materials differed, but none sufficiently fulfilled EBPI quality criteria. Unsatisfactory trial results concerning patient knowledge and patient involvement in decision-making may at least partially be explained by limitations of the provided materials. Future patient information should consider EBPI quality criteria.

Systematic evaluation of stroke thrombectomy in clinical practice: The German Stroke Registry Endovascular Treatment.

BACKGROUND: Endovascular treatment has become standard of care for the treatment of acute ischemic stroke with large vessel occlusion. However, patients treated in clinical practice differ from the selected populations randomized in clinical trials. AIMS: The German Stroke Registry Endovascular Treatment (GSR-ET) aims at a systematic evaluation of outcome, safety, and process parameters of endovascular stroke treatment in standard of care in Germany. METHODS: The GSR-ET is an academic, independent, prospective, multicenter, observational registry study. Participating stroke centers from all over of Germany consecutively enroll patients transferred to the angiography suite with an intention to be treated with endovascular stroke treatment. Patients receive regular care. Data are collected as part of clinical routine. Baseline clinical and procedural information and clinical follow-up information after 90 days are recorded. Here, we present an analysis of baseline data of the first 1662 patients included in the GSR-ET. RESULTS: The registry was established in June 2015. By 31 December 2017, 1662 patients were enrolled in 23 active sites. Mean age was 72 ± 13 years, 50% were female, and median National Institutes of Health Stroke Scale on admission was 15 (IQR 10-19), 88% had anterior circulation occlusion. Median ASPECT score was 8 (IQR 7-10) prior to intervention. Fifty-nine percent of patients received intravenous thrombolysis prior to thrombectomy. Mean "onset-to-groin" time was 224 ± 176 min. CONCLUSIONS: Baseline characteristics of stroke patients undergoing thrombectomy in clinical practice differ from those in the randomized trials. The GSR-ET will provide valuable insights into practices of endovascular treatment in routine care of acute ischemic stroke. (GSR-ET ClinicalTrials.gov Identifier: NCT03356392.).

Real-world experience of treatment decision-making in carotid stenosis in a neurovascular board.

OBJECTIVE: To describe our experience with consensus-based decision-making for treatment of internal carotid artery (ICA) stenosis by neurologists, interventional neuroradiologists, vascular surgeons, and neurosurgeons in a multidisciplinary neurovascular board and to study adherence to treatment recommendations in the context of uncertainty with respect to the best treatment option. METHODS: We established a multidisciplinary neurovascular board meeting twice a week with structured documentation of consensus decisions. Over a time period of 53 months, 614 cases with ICA stenosis were discussed, with 285 (46%) symptomatic and 279 (45%) asymptomatic cases. RESULTS: Recommendation for symptomatic ICA stenosis was revascularization in 76%, medical management alone in 8%, and further diagnostics in 16%. For asymptomatic ICA stenosis, recommendation was randomization in a clinical trial in 29%, revascularization in 27%, medical management alone in 23%, and further diagnostics in 22%. Treatment recommendations were followed in 94% of symptomatic ICA stenosis and 69% of asymptomatic ICA stenosis. Patients in whom carotid artery stenting was recommended for revascularization were younger and showed a higher rate of severe (≥70%) ICA stenosis. CONCLUSIONS: Interdisciplinary board decisions are a helpful and transparent tool to assure adherence to guideline recommendations, and to provide consensus-based individualized treatment strategies in clinical practice in the absence of unequivocal evidence.