RESUMO
OBJECTIVES: To determine the cost-effectiveness of stent retriever thrombectomy (SRT) added to standard of care (SOC) in large vessel occlusion (LVO) strokes, adopting the French societal perspective given the lack of published studies with such perspective. METHODS: We developed an hybrid model (decision tree until one year post-stroke followed by a Markov model from one year onward). The time horizon was 20 years. We calculated transition probabilities across the modified Rankin Scale (mRS) based on a published meta-analysis. The main outcome measure was quality adjusted life-years (QALYs) gained. Resources and input costs were derived from a literature search. We calculated the incremental cost-effectiveness ratio (ICER) expressed as cost/QALY. We used 1-way deterministic and probabilistic sensitivity analysis (PSA) to evaluate the model uncertainty. RESULTS: In the base-case, adding SRT to SOC resulted in increased effectiveness of 0.73 QALY while total costs were reduced by 3,874 (ICER of -5,400/QALY). In the scenario analysis adopting the French healthcare system perspective, the ICER was 4,901/QALY. Parameters the most influential were the relative risks of SRT over SOC for 90-days mortality and for 90-days mRS 0-2, and the time horizon. PSA showed the 95% confidence interval of the ICER was -21,324 to 4,591/QALY, with SRT having 85.5% chance to be dominant and 100% to be cost-effective at a threshold of 50,000/QALY. CONCLUSION: SRT was dominant from a French societal perspective, from 9 years post-stroke onwards. Cost-effectiveness of SRT added to SOC becomes undisputable with evidences from payer and societal viewpoints.
Assuntos
Stents/economia , Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/cirurgia , Trombectomia/economia , Circulação Cerebrovascular/fisiologia , Análise Custo-Benefício , França/epidemiologia , Custos de Cuidados de Saúde , Recursos em Saúde/economia , Recursos em Saúde/estatística & dados numéricos , Humanos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Saúde Pública/economia , Padrão de Cuidado/economia , Stents/efeitos adversos , Acidente Vascular Cerebral/fisiopatologia , Trombectomia/efeitos adversos , Trombectomia/instrumentação , Trombectomia/métodos , Ativador de Plasminogênio Tecidual/economia , Ativador de Plasminogênio Tecidual/uso terapêuticoRESUMO
BACKGROUND AND PURPOSE: A direct aspiration first pass technique (ADAPT), involving the first-line use of a large-bore distal aspiration catheter, is a new strategy in the mechanical thrombectomy of acute ischemic stroke caused by large-vessel occlusion. However, its impact on reperfusion rates, clinical outcomes and complication rates has not been fully examined. METHODS: We conducted a systematic review of the literature searching multiple databases for reports on thrombectomy of acute stroke with ADAPT and performed meta-analyses of clinical and radiographic outcomes. RESULTS: We selected 16 articles that included a total of 1378 patients treated with ADAPT. The mean admission National Institutes of Health Stroke Scale score was 17 and pre-treatment intravenous thrombolysis was used in 51% of cases. The successful recanalization (thrombolysis in cerebral ischemia 2b-3) rate was 66% [95% confidence interval (CI), 59-72%] with ADAPT and a rescue stent retriever was used in 31% of cases (95% CI, 24-37%) yielding an overall thrombolysis in cerebral ischemia 2b-3 rate of 89% (95% CI, 85-92%). We found a pooled estimate of 50% (95% CI, 45-54%) for functional independence (modified Rankin Scale score 0-2) at 90 days, 15% (95% CI, 10-21%) for mortality within 90 days and 5% (95% CI, 3-7%) for symptomatic intracranial hemorrhage. CONCLUSIONS: ADAPT therapy is associated with similar reperfusion rates, clinical outcomes and complication rates compared with thrombectomy with stent retrievers. However, the major limitations of current evidence (i.e. retrospective studies and selection bias) indicate a need for adequately powered, multicenter randomized controlled trials to determine the best strategy.
Assuntos
Trombólise Mecânica/métodos , Avaliação de Processos e Resultados em Cuidados de Saúde/estatística & dados numéricos , Acidente Vascular Cerebral/terapia , Humanos , Trombólise Mecânica/efeitos adversos , Trombólise Mecânica/instrumentaçãoRESUMO
BACKGROUND AND PURPOSE: Tandem anterior circulation lesions in the setting of acute ischemic stroke (AIS) are a complex endovascular situation that has not been specifically addressed in trials. We determined the predictors of successful reperfusion and good clinical outcome at 90 days after mechanical thrombectomy (MT) in patients with AIS with tandem lesions in a pooled collaborative study. METHODS: This was a retrospective analysis of consecutive patients presenting to 18 comprehensive stroke centers with AIS due to tandem lesion of the anterior circulation who underwent MT. RESULTS: A total of 395 patients were included. Successful reperfusion (modified thrombolysis in cerebral infarction score 2b-3) was achieved in 76.7%. At 90 days, 52.2% achieved a good outcome (modified Rankin Scale score 0-2), 13.8% suffered a parenchymal hematoma and 13.2% were dead. Lower National Institutes of Health Stroke Scale score [odds ratio (OR), 1.26; 95% confidence intervals (CI), 1.07-1.48, P = 0.004], Alberta Stroke Program Early CT Score ≥7 (OR, 2.00; 95% CI, 1.07-3.43, P = 0.011), intravenous thrombolysis (OR, 1.47; 95% CI, 1.01-2.12, P = 0.042) and stenting of the extracranial carotid lesion (OR, 1.63; 95% CI, 1.04-2;53, P = 0.030) were independently associated with successful reperfusion. Lower age (OR, 1.58; 95% CI, 1.26-1.97, P < 0.001), absence of hypercholesterolemia (OR, 1.77; 95% CI, 1.10-2.84, P = 0.018), lower National Institutes of Health Stroke Scale scores (OR, 2.04; 95% CI, 1.53-2.72, P < 0.001), Alberta Stroke Program Early CT Score ≥7 (OR, 2.75; 95% CI, 1.24-6.10, P = 0.013) and proximal middle cerebral artery occlusion (OR, 1.59; 95% CI, 1.03-2.44, P = 0.035) independently predicted a good 90-day outcome. CONCLUSIONS: Intravenous thrombolysis and emergent stenting of the extracranial carotid lesion were predictors of a successful reperfusion after MT of patients with AIS with tandem lesion of the anterior circulation.
Assuntos
Artérias Carótidas , Traumatismo por Reperfusão/prevenção & controle , Stents , Acidente Vascular Cerebral/terapia , Trombectomia/métodos , Terapia Trombolítica/métodos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Circulação Cerebrovascular , Terapia Combinada , Feminino , Humanos , Infarto da Artéria Cerebral Média/complicações , Masculino , Pessoa de Meia-Idade , Prognóstico , Reperfusão , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: Endovascular thrombectomy has become the reference therapy for patients with large vessel occlusion (LVO). However, no meta-analysis including the THRACE Trial has yet been reported. Thus, the present review assessed the outcomes of stent retriever thrombectomy added to medical care compared with medical care alone in LVO patients. MATERIALS AND METHODS: A systematic review was conducted of all randomized controlled trials (RCTs) examining stent retrievers added to medical care vs medical care alone in the MEDLINE, Embase and Web of Science databases. Meta-analyses of 90-day functional outcomes and mortality, and the occurrence of symptomatic intracranial hemorrhage (sICH), with thrombectomy plus medical care vs medical care alone were performed. RESULTS: Six multicenter RCTs involving 1673 patients were included. Successful recanalization (modified thrombolysis in cerebral ischemia grades 2b-3) was seen in 71% of patients (95% CI: 62-79%) after thrombectomy. These patients also had significantly higher rates of 90-day functional independence (mRS scores 0-2) compared with those receiving medical care only (OR: 2.14, 95% CI: 1.72-2.67; P<0.00001), as well as excellent outcomes (mRS scores 0-1, OR: 2.05, 95% CI: 1.58-2.67; P<0.00001). Also, the rate of functional independence was higher (OR: 2.39, 95% CI: 1.88-3.04; P<0.00001) in the subgroup analysis without the THRACE Trial. The effect of endovascular therapy on 90-day mortality was inconclusive (OR: 0.82, 95% CI: 0.62-1.07; P=0.15), and there was no increased occurrence of sICH (OR: 1.11, 95% CI: 0.66-1.88; P=0.70). CONCLUSION: Stent retriever thrombectomy added to medical care improved 90-day functional outcomes compared with medical care alone with no impact on mortality and risk of sICH in LVO patients.
Assuntos
Isquemia Encefálica/cirurgia , Stents , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Terapia TrombolíticaAssuntos
Imagem de Difusão por Ressonância Magnética/métodos , Processamento de Imagem Assistida por Computador/métodos , Traumatismo por Reperfusão/diagnóstico por imagem , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Trombectomia/efeitos adversos , Isquemia Encefálica/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoAssuntos
Infarto da Artéria Cerebral Média/tratamento farmacológico , Infarto da Artéria Cerebral Média/cirurgia , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/cirurgia , Trombectomia , Terapia Trombolítica , Terapia Combinada , Humanos , Infarto da Artéria Cerebral Média/complicações , Ensaios Clínicos Controlados Aleatórios como Assunto , Acidente Vascular Cerebral/complicações , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: The modified TICI Infarction grading system is a metric currently used to evaluate angiographic results of thrombectomy for large-vessel occlusion in ischemic stroke. Originally designed for evaluating MCA territories, it is currently used for other vessel occlusions, including the posterior circulation. We postulate that the modified TICI use for the posterior circulation is not accurate due to the different vascular territories supplied by vertebrobasilar vasculature, making grading more complex. MATERIALS AND METHODS: We collected angiographic results from 30 patients who presented with acute posterior circulation occlusions between 2015 and 2018 and underwent thrombectomy in our institution. Eight observers were asked to evaluate the TICI scores before and after thrombectomy. The multirater statistics were computed using Fleiss κ analysis. Further data were collected regarding the potential brain territories at risk and the existence of atherosclerotic disease in the basilar artery. RESULTS: The overall agreement κ reached 0.277 (SD, 0.013), which suggests a "fair" agreement among the raters. On average, 45% of observers achieved a high accuracy in predicting brain areas at risk of ischemia. As for the existence of basilar atherosclerotic disease, a high agreement (defined as at least 5 of 6 observers) was seen in 20 of the 30 patients. CONCLUSIONS: Despite TICI being ubiquitous in stroke diagnostics, the high variability of posterior circulation TICI scores calls into question its use in these strokes. Other methods should be developed to assess recanalization in the posterior circulation.
Assuntos
Procedimentos Endovasculares , Acidente Vascular Cerebral , Artéria Basilar/diagnóstico por imagem , Humanos , Variações Dependentes do Observador , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/terapia , Trombectomia , Resultado do TratamentoAssuntos
Infarto da Artéria Cerebral Média/cirurgia , Trombectomia/métodos , Doença Aguda , Idoso , Angioplastia , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/terapia , Terapia Combinada , Contraindicações , Endarterectomia , Humanos , Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/tratamento farmacológico , Masculino , Paresia/etiologia , Recidiva , Reoperação , Terapia Trombolítica , Tomografia Computadorizada por Raios XRESUMO
Cerebral venous and sinus thrombosis (CVT) is a rare but potentially alarming condition, which remains a diagnostic and therapeutic challenge. Endovascular procedure may be a therapeutic option when evolution is unfavourable despite medical treatment, but the use of stenting is rarely reported in CVT treatment. We report the case of a man who presented a jugular vein thrombosis responsible for severe intracranial hypertension. Because of clinical worsening despite intravenous heparin and symptomatic treatment, endovascular procedure including the placement of five venous stents, thrombolysis and balloon angioplasty, was performed and led to venous recanalization with successful clinical outcome. The patient is still asymptomatic 3 years later. Our report shows that venous stenting could represent an efficient alternative in the management of decoagulation refractory CVT.
Assuntos
Angiografia Digital , Angioplastia com Balão , Angiografia Cerebral , Transtornos Cerebrovasculares/diagnóstico , Transtornos Cerebrovasculares/terapia , Trombose Intracraniana/diagnóstico , Trombose Intracraniana/terapia , Veias Jugulares , Trombose do Seio Lateral/diagnóstico , Trombose do Seio Lateral/terapia , Angiografia por Ressonância Magnética , Imageamento por Ressonância Magnética , Stents , Adulto , Terapia Combinada , Seguimentos , Heparina/administração & dosagem , Humanos , Hipertensão Intracraniana/diagnóstico , Hipertensão Intracraniana/terapia , Masculino , Terapia TrombolíticaAssuntos
Dissecção Aórtica/complicações , Infarto Encefálico/complicações , Aneurisma Intracraniano/complicações , Hemorragia Subaracnóidea/etiologia , Dissecção Aórtica/cirurgia , Infarto Encefálico/cirurgia , Feminino , Humanos , Aneurisma Intracraniano/cirurgia , Pessoa de Meia-Idade , Hemorragia Subaracnóidea/cirurgiaAssuntos
Prótese Vascular/estatística & dados numéricos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/estatística & dados numéricos , Aneurisma Intracraniano/mortalidade , Aneurisma Intracraniano/terapia , Complicações Pós-Operatórias/mortalidade , Stents/estatística & dados numéricos , Causalidade , França/epidemiologia , Humanos , Prevalência , Estudos Prospectivos , Fatores de Risco , Taxa de Sobrevida , Resultado do TratamentoAssuntos
Isquemia Encefálica/terapia , Revascularização Cerebral/métodos , Avaliação de Resultados em Cuidados de Saúde/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Acidente Vascular Cerebral/terapia , Ativador de Plasminogênio Tecidual/uso terapêutico , Isquemia Encefálica/diagnóstico , Terapia Combinada , Europa (Continente) , Fibrinolíticos/uso terapêutico , Humanos , Proteínas Recombinantes/uso terapêutico , Acidente Vascular Cerebral/diagnóstico , Resultado do TratamentoRESUMO
INTRODUCTION: The optimal diagnosis and therapeutic managements of spinal dural arteriovenous fistulae, a rare disease, is discussed. MATERIAL AND METHODS: We report a series of 10 patients seen in a 7-year period, treated by embolization. RESULTS: There were 6 males and 4 females, with an average age of 58.4 years (range: 31 to 74 years). Diagnosis was made 2 days to 5 years (mean 15.3 months) after symptom onset with a high rate of incomplete or atypical clinical patterns (prolonged isolated sensory disorder, lumbo-sciatalgia, claudication, monoplegia), or sudden-onset deficit. In all cases, spinal MRI showed an intramedullary high-intensity signal on T2-weighted images but enlarged intradural vessels in only 70p.cent of cases. Angiography showed in all cases an arteriovenous fistula at the upper dorsal level (T1 to T7, 5 cases), lower dorsal (T8-T12, in 3 cases) and lumbar levels (2 cases). The fistula was successfully obliterated after initial embolization in 3 cases, but two (2 cases) or 3 procedures (2 cases) were sometimes required. The endovascular therapy failed in 3 cases. CONCLUSION: In this series, the fistula was successfully obliterated in 70p.cent of patients. In the literature, fistula of 96.8p.cent to 97.9p.cent of patients were obliterated by surgery, which is a more invasive treatment. Embolization could be used as the first-line therapy, but incomplete obliteration requires rapid surgery. While the success of embolization is demonstrated, MRI and angiography must still be performed 6 months later.
Assuntos
Fístula Arteriovenosa/patologia , Dura-Máter/patologia , Bulbo/patologia , Doenças da Coluna Vertebral/patologia , Adulto , Idoso , Fístula Arteriovenosa/diagnóstico , Angiografia Cerebral , Eletroencefalografia , Feminino , Humanos , Angiografia por Ressonância Magnética , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Prognóstico , Doenças da Coluna Vertebral/diagnósticoRESUMO
The functional benefit of stent retriever thrombectomy in acute ischemic stroke has been clearly demonstrated in recent positive MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT and THRACE trials. Thrombectomy, in association with intravenous thrombolysis, should now be offered to patients with documented occlusion of the distal internal carotid or proximal middle cerebral arteries, with a relatively normal unenhanced computed tomography (CT), and within 6hours after the onset of symptoms. Thrombectomy results in a mean absolute decrease in handicap of 22% (14 to 31%). Of the 3 up to 8 patients treated, 1 is independent at 3 months according to the initial selection. In case of a contraindication to thrombolysis, early primary thrombectomy should be considered. In acute basilar artery occlusion, thrombectomy should be performed alone or combined with thrombolysis. In an effort to increase the number of patients treated, a very rapid transfer to interventional neuroradiology centers is mandatory. In the future, thrombectomy should be evaluated in patients with distal arterial occlusion, or beyond 6hours after the onset of symptoms, or when the time of symptoms onset is unknown.
Assuntos
Isquemia Encefálica/cirurgia , Stents , Acidente Vascular Cerebral/cirurgia , Trombectomia/instrumentação , Trombectomia/métodos , Isquemia Encefálica/complicações , Humanos , Acidente Vascular Cerebral/etiologia , Resultado do TratamentoRESUMO
The PulseRider is a novel endovascular device specifically designed to treat bifurcation intracranial aneurysms with wide necks. In an international series, we report the results of PulseRider stent-assisted coiling of 15 patients (9 women and 6 men; mean age, 62.6 years) with 15 unruptured wide-neck (median dome size, 8 mm; median neck size, 5 mm) bifurcation aneurysms. Failure of PulseRider treatment occurred in 1 case, and 1 intraprocedural thromboembolic complication was observed. There was no mortality or neurologic permanent morbidity at discharge and at 1 month. Immediate angiographic outcome showed 12 complete occlusions and 2 neck remnants. Follow-up at 6 months was available for 3 aneurysms and demonstrated 2 complete aneurysm occlusions and 1 growing neck remnant. In this small series of selected patients, PulseRider stent-assisted coiling of wide-neck bifurcation aneurysms was feasible with low procedural complication rates. Angiographic follow-up will be required to evaluate the efficacy of the PulseRider device.
Assuntos
Ligas , Embolização Terapêutica/instrumentação , Aneurisma Intracraniano/terapia , Stents , Adulto , Idoso , Angiografia Cerebral/instrumentação , Desenho de Equipamento , Feminino , Seguimentos , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Falha de Tratamento , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: Despite the improvement in technology, endovascular treatment of bifurcation intracranial wide-neck aneurysms remains challenging, mainly due to the difficulty of maintaining coils within the aneurysm sac without compromising the patency of bifurcation arteries. The Woven EndoBridge (WEB) device is a recent intrasaccular braided device specifically dedicated to treating such aneurysms with a wide neck by disrupting the flow in the aneurysmal neck and promoting progressive aneurysmal thrombosis. MATERIALS AND METHODS: Using several health data bases, we conducted a systematic review of all published studies of WEB endovascular treatment in intracranial aneurysms from 2010 onward to evaluate its efficacy and safety profile. RESULTS: The literature search identified 6 relevant studies (7 articles) including wide-neck bifurcation aneurysms in ≥80% of cases. Clinical data supporting the efficacy and safety of the WEB are limited to noncomparative cohort studies with large heterogeneity from a methodologic standpoint. The WEB deployment was feasible with a success rate of 93%-100%. Permanent morbidity (mRS of >1 at last follow-up) and mortality were measured at 2.2%-6.7% and 0%-17%, respectively. The adequate occlusion rate (total occlusion or neck remnant) varied between 65% and 85.4% at midterm follow-up (range, 3.3-27.4 months). CONCLUSIONS: Endovascular treatment of bifurcation wide-neck aneurysms with the WEB device is feasible and allows an acceptably adequate aneurysm occlusion rate; however, the rate of neck remnants is not negligible. The WEB device needs further clinical and anatomic evaluation with long-term prospective studies, especially of the risk of WEB compression. Prospective controlled studies should be encouraged.
Assuntos
Embolização Terapêutica/instrumentação , Procedimentos Endovasculares/instrumentação , Aneurisma Intracraniano/terapia , Prótese Vascular/efeitos adversos , Embolização Terapêutica/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Humanos , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: Flow disruption with the WEB device is a new technique for the endovascular treatment of wide-neck bifurcation aneurysms. To obtain precise data regarding the safety and efficacy of this treatment with high-quality methodology, the prospective French Observatory study was conducted. Analysis of these data is presented, including 1-year follow-up. MATERIALS AND METHODS: Patients with bifurcation aneurysms for which WEB treatment was indicated were included in this prospective, multicenter Good Clinical Practice study. Clinical data, including adverse events and clinical status at 1 month and 1 year, were collected and independently analyzed by a medical monitor. An independent core laboratory evaluated the anatomic results at 1 year following the procedure. RESULTS: Ten French neurointerventional centers included 62 patients (39 women), 33-74 years of age (mean, 56.6 ± 9.80 years) with 63 aneurysms. Aneurysm locations were the middle cerebral artery in 32 aneurysms (50.8%), anterior communicating artery in 16 (25.4%), basilar artery in 9 (14.3%), and internal carotid artery terminus in 6 (9.5%). Morbidity and mortality at 1 month were, respectively, 3.2% (2/62 patients) and 0.0% (0/62). Morbidity and mortality (unrelated to the treatment) at 1 year were, respectively, 0.0% (0/59) and 3.4% (2/59 patients). At 1 year, complete occlusion was observed in 30/58 aneurysms (51.7%); neck remnant, in 16/58 aneurysms (27.6%); and aneurysm remnant, in 12/58 aneurysms (20.7%). CONCLUSIONS: This prospective French Observatory study showed very good safety of aneurysm treatment with the WEB, with a high rate of adequate aneurysm occlusion at 1 year (79.3%).