[Intravenous thrombolysis of ischemic stroke-Current status]. / Intravenöse Thrombolyse des ischämischen Schlaganfalls ­ aktueller Stand.

Intravenous thrombolysis (IVT) treatment with alteplase (rtPA) is an essential part of the routine treatment of patients with ischemic stroke since its introduction in the late 1990s. Rapid treatment is of essential importance. For patients with an unclear time window, various mismatch concepts have been established to identify salvageable brain tissue prior to IVT. Numerous official contraindications for rtPA are not evidence-based; for example, current data from observational studies show that systemic thrombolytic treatment is possible even in patients receiving direct oral anticoagulant (DOAC) treatment. Tenecteplase (TNK) is an alternative thrombolytic agent with some pharmacologic advantages. The most recent guidelines indicate that TNK is particularly advantageous over rtPA in patients treated in combination with endovascular stroke therapy (EST). The combination of IVT and EST should primarily be performed in the 4.5­h time window in patients without contraindications; in the later time window EST alone is conceivable if it can be performed without delay.

Mortality and functional outcomes of endovascular stroke therapy in the United States.

BACKGROUND: We sought to evaluate the nationwide trends in the characteristics and outcomes of for endovascular stroke therapy in contemporary practice. METHODS: We selected patients with acute ischemic stroke who underwent endovascular stroke therapy between 01 October 2015 and 30 September 2019 in a large academic consortium database. The end points of this study were (a) in-hospital mortality and functional outcomes and, (b) predictors of poor functional outcome, defined as death or discharge to hospice, or to a long-term nursing facility. RESULTS: Among the 22,193 included patients; 50.3% were females, and 66.5% were white. Mean age was 68±15 years. Poor functional outcomes occurred in 8,274 patients (37.4%), of whom 2,741 (12.4%) died in the hospital, 1,345 (6.1%) were discharged to hospice, and 4,188 (18.9%) were discharged to other long-term facilities. Most common in-hospital complications were mechanical ventilation (32.3%), intracranial hemorrhage (18.9%), and acute kidney injury (15.6%). Median total and intensive-care length-of-stay were 7 days (IQR = 4-9), and 2 days (IQR = 1-4), respectively. Median cost was $36,609 (IQR = $26,034-$54,313). In a multi-logistic regression analysis; age, hypertension, diabetes, anemia, heart failure, vascular disease, chronic pulmonary disease, renal insufficiency, Medicare/medicaid insurance, transfer from nonendovascular capable hospital, and low procedural volume independently predicted poor functional outcomes. Tissue plasminogen activator use was associated with better functional outcomes. CONCLUSION: There is a substantial growth in the performance of endovascular stroke interventions in the United States in recent years, and those were associated with favorable short-term outcomes.

Increased Rates of Hemorrhages after Endovascular Stroke Treatment with Emergency Carotid Artery Stenting and Dual Antiplatelet Therapy.

BACKGROUND: While endovascular stroke treatment (EST) of large vessel occlusions in acute ischemic stroke (AIS) is proven to be safe and effective, there are subgroups of patients with increased rates of hemorrhages. Our goal was to identify risk factors for intracerebral hemorrhage and to assess whether acute carotid artery stenting (CAS) was associated with increased bleeding rates. METHODS: We performed a retrospective analysis of our monocentric prospective stroke registry in the period from May 2010 to May 2018 and compared AIS patients receiving EST with (n = 73) versus without acute CAS (n = 548). Patients with intracranial stents, intra-arterial thrombolysis, or dissection of the carotid artery were excluded. RESULTS: Parenchymal hemorrhage rates (PH2 according to the ECASS classification) and symptomatic hemorrhage (sICH) rates were increased in EST patients receiving CAS with odds being 6.3 (PH2) and 6.5 (sICH) times higher (PH2 17.8 vs. 3.3%, p < 0.001 and sICH: 16.4 vs. 2.9%, p < 0.001). Additional systemic thrombolysis with rtPA (IVRTPA) was no risk factor for cerebral hemorrhage (p = 0.213). CONCLUSION: AIS patients receiving EST with acute CAS and consecutive tirofiban or dual antiplatelet therapy suffered from an increased risk of relevant secondary intracranial bleeding. After adjusting for confounders, tirofiban and dual antiplatelet therapy were associated with higher bleeding rates.

Distal arterial occlusions in patients with mild strokes - is endovascular therapy superior to thrombolysis alone?

BACKGROUND AND PURPOSE: Safety and efficacy of endovascular thrombectomy (EVT) in patients with mild stroke syndromes is unclear, especially in distal vessel occlusions. METHODS: We analysed in our stroke database (HeiReKa) between 2002 and April 2019 safety and efficacy of EVT compared to intravenous thrombolysis (IVT) in patients with occlusions distal to the M1 segment of the middle cerebral artery and the top of the basilar artery who presented with a National Institute of Health Stroke Scale (NIHSS) below 6. Excellent (good) outcome was defined as modified rankin scale (mRS) 0-1 (0-2) or return to baseline mRS (good) after 3 months. Safety endpoints were mortality after 3 months and intracranial hemorrhage according to the Heidelberg Bleeding Classification (HBC). RESULTS: Of 4167 patients 94 met the inclusion criteria. Sixty-four patients were allocated to the IVT group and 30 to the EVT group of which 15 also received IVT; three patients (4.6%) in the IVT group received rescue EVT. Baseline characteristics did not differ but more M2 occlusions were found in the EVT group (93.3% vs. 64.1%, p = 0.02). Intracranial bleeding occurred more often in EVT patients (HBC class 2: 13.3% vs. 1.6%, p = 0.01). Excellent and good outcome were not significantly different (75% vs. 70%, p = 0.65 and 87.5% vs. 73.3%, p = 0.14). Mortality was significantly lower in IVT patients (1.6% vs. 13.3%, p = 0.04). CONCLUSION: Rates of excellent and good outcome after IVT or EVT were almost similar, but safety parameters were increased after EVT. EVT may be considered in selected patients after careful risk/benefit analysis.

A Network-Wide Stroke Team Program Reduces Time to Treatment for Endovascular Stroke Therapy in a Regional Stroke-Network.

BACKGROUND AND PURPOSE: Driven by the positive results of randomized, controlled trials of endovascular stroke therapies (EVT) in stroke patients with large vessel occlusion, different approaches to speed up the workflow for EVT candidates are currently being implemented worldwide. We aimed to assess the effect of a simple stroke network-wide workflow improvement project, primarily focusing on i.v. thrombolysis, on process times for patients undergoing EVT. METHODS: In 2015, we conducted a network-wide, peer-to-peer acute stroke workflow improvement program for i.v. thrombolysis with the main components of implementing a binding team-based algorithm at every stroke unit of the regional network, educating all stroke teams about non-technical skills and providing a stroke-specific simulation training. Before and after the intervention we recorded periprocedural process times, including patients undergoing EVT at the 3 EVT-capable centers (January - June 2015, n = 80 vs. July 2015 - June 2016, n = 184). RESULTS: In this multi-centric evaluation of 268 patients receiving EVT, we observed a relevant shortening of the median time from symptom onset to EVT specifically in patients requiring secondary transfer by almost an hour (300 min, 25-75% interquartile range [IQR] 231-381 min to 254 min, IQR 215.25-341 min; p = 0.117), including a reduction of the median door-to-groin time at the EVT-capable center in this patient group by 15.5 min (59 min, IQR 35-102 min to 43.5 min, IQR 27.75-81.25 min; p = 0.063). In patients directly admitted to an EVT-capable center, the median door-to-groin interval was reduced by 10.5 min (125 min, IQR 83.5-170.5 min to 114.5 min, IQR 66.5-151 min; p = 0.167), but a considerable heterogeneity between the centers was observed (p < 0.001). CONCLUSIONS: We show that a simple network-wide workflow improvement program primarily directed at fast i.v. thrombolysis also accelerates process times for EVT candidates and is a promising measure to improve the performance of an entire stroke network.

Time to Reset the Definition of Successful Revascularization in Endovascular Treatment of Acute Ischemic Stroke.

BACKGROUND: A 2013 consensus statement recommended the use of the modified Treatment In Cerebral Ischemia (mTICI) scale to evaluate angiographic revascularization after endovascular treatment (EVT) of acute ischemic stroke due to its higher inter-rater agreement and capacity of clinical outcome prediction. The current definition of successful revascularization includes the achievement of grades mTICI 2b or 3. However, mTICI 2b grade encompasses a large heterogeneity of revascularization states, and prior studies suggested that the magnitude of benefit derived from mTICI 2b and mTICI 3 does not seem to be equivalent. In a way to restrain the referred heterogeneity, Goyal et al. [J Neurointerv Surg 2014; 6: 83-86] proposed a revised mTICI scale that includes a 2c grade (rTICI). METHODS: Retrospective analysis of prospectively collected data from consecutive cases of EVT for anterior circulation large-vessel occlusion, performed between January 2015 and July 2017. Patients with mTICI 2b or 3 grades were reclassified according to the rTICI scale, and the outcomes between the 3 revascularization grades (rTICI 2b, 2c, 3) compared. RESULTS: Our study population of 226 patients (64 rTICI 2b, 30 rTICI 2c, 132 rTICI 3) has a mean age of 71 years, 48.2% males, median baseline NIHSS of 16 (13-19) and ASPECTS of 8 (7-9). The 3 revascularization grades are represented by homogeneous populations. Logistic regression analysis showed statistically significant higher rates of functional independence at 3 months (65.9 vs. 50.0%; adjusted OR 0.39, 95% CI 0.18-0.86), with lower rates of mortality (8.3 vs. 15.6%; adjusted OR 3.54, 95% CI 1.14-10.97) and intracranial hemorrhage (ICH) in rTICI 3 than 2b groups. When comparing rTICI 3 with 2c groups, there were only statistically significant differences in the total ICH rate (8.3 vs. 26.7%; adjusted OR 7.08, 95% CI 1.80-27.82) but not in symptomatic ICH. CONCLUSIONS: These results corroborate the scarce prior findings suggesting that patients with rTICI 2c grade should be reported separately, since they have similar outcomes to rTICI 3, and better than rTICI 2b patients. Therefore, we suggest resetting the angiographic revascularization endpoint to perfect revascularization (rTICI 2c or 3 grades), a target that neurointerventionalists should strive to achieve.

Improving Regional Stroke Systems of Care.

PURPOSE OF REVIEW: Acute ischemic stroke (AIS) care is rapidly evolving. This review discusses current diagnostic, therapeutic, and process models that can expedite stroke treatment to achieve best outcomes. RECENT FINDINGS: Use of stent retrievers after selection via advanced imaging is safe and effective, and is an important option for AIS patients with large vessel occlusion (LVO). Significant time delays occur before and during patient transfers, and upon comprehensive stroke center (CSC) arrival, and have deleterious effects on functional outcome. Removing obstacles, enhancing inter-facility communication, and creating acute stroke management processes and protocols are paramount strategies to enhance network efficiency. Inter-departmental CSC collaboration can significantly reduce door-to-treatment times. Streamlined stroke systems of care may result in higher treatment rates and better functional outcomes for AIS patients, simultaneously conserving healthcare dollars. Stroke systems of care should be structured regionally to minimize time to treatment. A proactive approach must be employed; a management plan incorporating stroke team prenotification and parallel processes between departments can save valuable time, maximize brain salvage, and reduce disability from stroke.

Prediction of infarction development after endovascular stroke therapy with dual-energy computed tomography.

OBJECTIVES: After intraarterial recanalisation (IAR), the haemorrhage and the blood-brain barrier (BBB) disruption can be distinguished using dual-energy computed tomography (DECT). The aim of the present study was to investigate whether future infarction development can be predicted from DECT. METHODS: DECT scans of 20 patients showing 45 BBB disrupted areas after IAR were assessed and compared with follow-up examinations. Receiver operator characteristic (ROC) analyses using densities from the iodine map (IM) and virtual non-contrast (VNC) were performed. RESULTS: Future infarction areas are denser than future non-infarction areas on IM series (23.44 ± 24.86 vs. 5.77 ± 2.77; p < 0.0001) and more hypodense on VNC series (29.71 ± 3.33 vs. 35.33 ± 3.50; p < 0.0001). ROC analyses for the IM series showed an area under the curve (AUC) of 0.99 (cut-off: <9.97 HU; p < 0.05; sensitivity 91.18 %; specificity 100.00 %; accuracy 0.93) for the prediction of future infarctions. The AUC for the prediction of haemorrhagic infarctions was 0.78 (cut-off >17.13 HU; p < 0.05; sensitivity 90.00 %; specificity 62.86 %; accuracy 0.69). The VNC series allowed prediction of infarction volume. CONCLUSIONS: Future infarction development after IAR can be reliably predicted with the IM series. The prediction of haemorrhages and of infarction size is less reliable. KEY POINTS: • The IM series (DECT) can predict future infarction development after IAR. • Later haemorrhages can be predicted using the IM and the BW series. • The volume of definable hypodense areas in VNC correlates with infarction volume.

Improving Transfer Times for Acute Ischemic Stroke Patients to a Comprehensive Stroke Center.

BACKGROUND AND OBJECTIVE: The transfer of acute ischemic stroke (AIS) patients to a comprehensive stroke center (CSC) must be rapid. Delays pose an obstacle to time-sensitive stroke treatments and, therefore, increase the likelihood of exclusion from endovascular stroke therapy. This study aims to evaluate the impact of the Stroke Rescue Program, with its goal of minimizing interfacility transfer delays and increasing the number of transport times completed within 60 minutes. METHODS: The Stroke Rescue Program was initiated to facilitate the rapid transfer of AIS patients from regional primary stroke centers (PSCs) to the network's CSC. The transfer process was divided into 3 time elements: transport 1 time (initial phone call from the PSC until emergency medical service [EMS] arrival at the PSC), emergency department (ED) time (EMS PSC arrival to PSC departure), and transport 2 time (PSC departure to CSC arrival). The total transport time target was set at less than 60 minutes. Protocols and procedures were implemented with a focus on decreasing the ED time. RESULTS: Comparing baseline (preimplementation) quarter (n = 21) to postproject quarter (1 year later, n = 31), the percent transported within 60 minutes increased from 62% to 81%. A statistically significant improvement was seen for both median ED time (23 minutes versus 14 minutes; U = 171, P < .01) and median total transport time (56 minutes versus 44 minutes; U = 199, P < .05). CONCLUSION: Interfacility transfer protocols minimizing the time paramedics spend in a PSC ED can significantly reduce total transfer time to a comprehensive stroke center.

Intra-arterial Stroke Treatment prior to the Stent-Retriever Era: High Mortality and Lack of Volume-Outcome Association.

BACKGROUND: Mechanical thrombectomy for acute large-vessel occlusive stroke is beneficial when performed with stent-retriever devices; however, little is known about real-world experience with intra-arterial treatment (IAT). We aimed to clarify how hospitals influence outcomes for Medicare thrombectomy patients to inform future delivery of effective mechanical thrombectomy treatment. METHODS: This is a retrospective cohort study that includes a Medicare fee-for-service patient population. Patients with a primary stroke discharge (ICD-9-CM 433.x1, 434.x1, 436) were included; billing codes were used to identify patients receiving IAT, intravenous thrombolytics (IVT), or a combination of these treatments. Characteristics of treated patients were summarized using descriptive statistics; long-term mortality was summarized via Kaplan-Meier curves; and multilevel logistic regression models with random hospital-level intercept were built to determine hospital influence on outcome and whether a volume-outcome association existed. RESULTS: A total of 4557 patients received IAT at 544 hospitals. The mean age of IAT patients was 76 years. IAT patients had longer hospital stay (9.7 versus 6.8 days), longer stay in the ICU (5.5 versus 3.3 days), and greater probability of intubation (36.7% versus 9.5%) compared with IVT patients. Ninety-day mortality was 46% IAT versus 26% IVT. Hospitals had little influence on outcomes (intraclass correlation coefficient, <.01). No association between procedural volume and outcomes was identified. CONCLUSIONS: IAT for 2007-2010 was associated with higher patient mortality than recent and prior clinical trials. Treated Medicare patients were considerably older than clinical trial populations. Hospitals had little influence on mortality, and increased hospital volume was not associated with lower mortality. Future real-world experience should monitor these parameters as use of stent retrievers disseminates.

Hemorrhagic risk of emergent endovascular treatment plus stenting in patients with acute ischemic stroke.

BACKGROUND: Several endovascular revascularization strategies have been described for the treatment of acute ischemic stroke (AIS). One of them is stenting when a very narrow stenosis with high reocclusion risk remains after recanalization. This study describes the risk of symptomatic intracerebral hemorrhage (SICH) after emergent stenting in patients with AIS treated with endovascular therapies. METHODS: Consecutive patients who underwent endovascular treatment over a 37-month period were retrospectively analyzed. Patients were classified in 2 groups: (1) patients in whom a stent was deployed; and (2) patients without stenting. Double antiplatelet treatment with aspirin and clopidogrel was administered at the time of stenting. SICH was defined as any hemorrhagic transformation with National Institutes of Health Stroke Scale (NIHSS) score worsening 4 points or more (European-Australasian Acute Stroke Study II criteria). RESULTS: A total of 143 patients were included (mean age: 66.1±11.7 years, median NIHSS score: 18). Acute phase stenting was performed in 24 subjects (16.8%): 4 intracranial (3 in basilar artery, 1 in middle cerebral artery) and 20 extracranial (internal carotid artery). SICH occurred in 11 patients, 5 of 24 (20.8%) in patients with stenting and in 3 of 119 (2.5%) without (P=.008). No differences were found with respect to baseline NIHSS score or intravenous tissue plasminogen activator administration. Acute phase stenting emerged as an independent predictor of SICH after adjustment for potential confounders and procedure duration: odds ratio 7.3 (confidence interval 1.4-36.8, P=.016). CONCLUSIONS: Our findings suggest that emergent stenting in endovascular treatment of AIS is associated with SICH.

The Bigger the Better? Center Volume Dependent Effects on Procedural and Functional Outcome in Established Endovascular Stroke Centers.

Background: Mechanical thrombectomy (MT) rates for the treatment of acute ischaemic stroke due to large vessel occlusion are steadily increasing, but are delivered in heterogenic settings. We aim to investigate effects of procedural load in centers with established MT-structures by comparing high- vs. low-volume centers with regard to procedural characteristics and functional outcomes. Methods: Data from 5,379 patients enrolled in the German Stroke Registry Endovascular Treatment (GSR-ET) between June 2015 and December 2019 were compared between three groups: high volume: ≥180 MTs/year, 2,342 patients; medium volume: 135-179 MTs/year, 2,202 patients; low volume: <135 MTs/year, 835 patients. Univariate analysis and multiple linear and logistic regression analyses were performed to identify differences between high- and low-volume centers. Results: We identified high- vs. low-volume centers to be an independent predictor of shorter intra-hospital (admission to groin puncture: 60 vs. 82 min, ß = -26.458; p < 0.001) and procedural times (groin puncture to flow restoration: 36 vs. 46.5 min; ß = -12.452; p < 0.001) after adjusting for clinically relevant factors. Moreover, high-volume centers predicted a shorter duration of hospital stay (8 vs. 9 days; ß = -2.901; p < 0.001) and favorable medical facility at discharge [transfer to neurorehabilitation facility/home vs. hospital/nursing home/in-house fatality, odds ratio (OR) 1.340, p = 0.002]. Differences for functional outcome at 90-day follow-up were observed only on univariate level in the subgroup of primarily to MT center admitted patients (mRS 0-2 38.5 vs. 32.8%, p = 0.028), but did not persist in multivariate analyses. Conclusion: Differences in efficiency measured by procedural times call for analysis and optimization of in-house procedural workflows at regularly used but comparatively low procedural volume MT centers.

Intraoperative management of thrombectomy for acute ischemic stroke: Do we need general anesthesia?

Since 2015, endovascular thrombectomy has been established as the standard of care for re-establishing cerebral blood flow in patients with acute ischemic stroke. Several retrospective observational studies and prospective clinical trials have investigated two anesthetic techniques for endovascular stroke therapy: general anesthesia (GA) and conscious sedation (CS). The recent randomized studies suggest that GA is associated with higher rates of successful recanalization and better functional independence at 3 months compared with the CS technique. However, CS techniques are highly variable, and there is currently a lack of consensus on which anesthetic approach is best in all patients. Numerous patient and procedural factors should ultimately guide the decision of whether GA or CS should be used for a particular patient.

Trends of Acute Ischemic Stroke Reperfusion Therapies from 2012 to 2016 in the United States.

BACKGROUND: American Heart Association/American Stroke Association guidelines recommend endovascular stroke therapy (EST) with recombinant tissue plasminogen activator (rt-PA) for eligible patients in acute ischemic stroke (AIS). Using the National Inpatient Sample database, we evaluated trends in treatment with rt-PA and EST for AIS and their outcomes. METHODS: This is a cross-sectional observational study of patients with AIS admitted in US hospitals from 2012 to 2016. Patients were grouped into those who received rt-PA alone, EST alone, and rtPA+EST. Survey statistical procedures were performed. Multivariable regression analysis with pairwise comparisons of each treatment group with no treatment group was performed for discharge outcomes. RESULTS: The study included 2,290,520 patients with AIS with the mean age of 70.46 years. Treatment rates increased from 2012 to 2016 for rt-PA by 7% per year (5.86%-7.67%, odds ratio [OR] = 1.07, 95% confidence interval [CI]: 1.05-1.08) and EST by 38% per year (0.55%-1.75%, OR = 1.38, 95% CI: 1.31-1.45) but not rt-PA+EST (0.54%-0.57%, OR = 1.04, 95% CI: 0.99-1.08). The mean length of stay reduced from 2012 to 2016 for rt-PA (6.07-4.91 days, P < 0.0001) and rt-PA+EST (9.19-7.10 days, P = 0.0067) but not for EST (9.61-8.51 days, P = 0.5074). The odds of patients discharged home increased by 8%, 9%, and 15% among patients who received rt-PA alone, EST alone, and rt-PA+EST, respectively, compared with no treatment group. CONCLUSION: The utilization of rt-PA alone and EST alone increased but that of rt-PA+EST remained unchanged from 2012 to 2016 in the National Inpatient Sample.

Selective intra-carotid blood cooling in acute ischemic stroke: A safety and feasibility study in an ovine stroke model.

Selective therapeutic hypothermia (TH) showed promising preclinical results as a neuroprotective strategy in acute ischemic stroke. We aimed to assess safety and feasibility of an intracarotid cooling catheter conceived for fast and selective brain cooling during endovascular thrombectomy in an ovine stroke model.Transient middle cerebral artery occlusion (MCAO, 3 h) was performed in 20 sheep. In the hypothermia group (n = 10), selective TH was initiated 20 minutes before recanalization, and was maintained for another 3 h. In the normothermia control group (n = 10), a standard 8 French catheter was used instead. Primary endpoints were intranasal cooling performance (feasibility) plus vessel patency assessed by digital subtraction angiography and carotid artery wall integrity (histopathology, both safety). Secondary endpoints were neurological outcome and infarct volumes.Computed tomography perfusion demonstrated MCA territory hypoperfusion during MCAO in both groups. Intranasal temperature decreased by 1.1 °C/3.1 °C after 10/60 minutes in the TH group and 0.3 °C/0.4 °C in the normothermia group (p < 0.001). Carotid artery and branching vessel patency as well as carotid wall integrity was indifferent between groups. Infarct volumes (p = 0.74) and neurological outcome (p = 0.82) were similar in both groups.Selective TH was feasible and safe. However, a larger number of subjects might be required to demonstrate efficacy.

Sedation Mode During Endovascular Stroke Treatment in the Posterior Circulation-Is Conscious Sedation for Eligible Patients Feasible?

Background and Purpose: To compare safety and efficacy of conscious sedation (CS) vs. general anesthesia (GA) in endovascular stroke treatment (EST) of the posterior circulation (PC). Methods: Retrospective single-center analysis of patients receiving EST for large-vessel occlusion (LVO) in PC between January 2015 and November 2020. Exclusion criteria were severe stroke syndromes (NIHSS > 20), decreased level of consciousness, intubation for transport, and second stroke within 3 months of follow-up. The primary endpoint was a favorable clinical outcome 90 days after stroke onset (mRS 0-2 or 3 if pre-stroke mRS 3). Secondary endpoints were the rate of EST failure and procedural complications. Results: Of 111 included patients, 45/111 patients (40.5%) were treated under CS and 60/111 (54.0%) under GA. In 6/111 cases (5.4%), sedation mode was changed from CS to GA during EST. Patients treated under CS showed a lower mRS 90 days after stroke onset [mRS, median (IQR): 2.5 (1-4) CS vs. 3 (2-6) GA, p = 0.036] and a comparable rate of good outcome [good outcome, n (%): 19 (42.2) CS vs. 15 (32.6) GA, p = 0.311]. There was no difference in complication rates during EST (6.7% CS vs. 8.3% GA) or intracranial bleeding in follow-up imaging [n (%): 4 (8.9) CS vs. 7 (11.7) GA), p = 0.705]. The rate of successful target vessel recanalization did not differ (84.4% CS vs. 85.0 % GA). Conclusions: In this retrospective study, EST of the posterior circulation under conscious sedation was for eligible patients comparably safe and effective to patients treated under general anesthesia.

Complications of mechanical thrombectomy for acute ischemic stroke: Incidence, risk factors, and clinical relevance in the Italian Registry of Endovascular Treatment in acute stroke.

BACKGROUND: There are limited data concerning procedure-related complications of endovascular thrombectomy for large vessel occlusion strokes. AIMS: We evaluated the cumulative incidence, the clinical relevance in terms of increased disability and mortality, and risk factors for complications. METHODS: From January 2011 to December 2017, 4799 patients were enrolled by 36 centers in the Italian Registry of Endovascular Stroke Treatment. Data on demographic and procedural characteristics, complications, and clinical outcome at three months were prospectively collected. RESULTS: The complications cumulative incidence was 201 per 1000 patients undergoing endovascular thrombectomy. Ongoing antiplatelet therapy (p < 0.01; OR 1.82, 95% CI: 1.21-2.73) and large vessel occlusion site (carotid-T, p < 0.03; OR 3.05, 95% CI: 1.13-8.19; M2-segment-MCA, p < 0.01; OR 4.54, 95% CI: 1.66-12.44) were associated with a higher risk of subarachnoid hemorrhage/arterial perforation. Thrombectomy alone (p < 0.01; OR 0.50, 95% CI: 0.31-0.83) and younger age (p < 0.04; OR 0.98, 95% CI: 0.97-0.99) revealed a lower risk of developing dissection. M2-segment-MCA occlusion (p < 0.01; OR 0.35, 95% CI: 0.19-0.64) and hypertension (p < 0.04; OR 0.77, 95% CI: 0.6-0.98) were less related to clot embolization. Higher NIHSS at onset (p < 0.01; OR 1.04, 95% CI: 1.02-1.06), longer groin-to-reperfusion time (p < 0.01; OR 1.05, 95% CI: 1.02-1.07), diabetes (p < 0.01; OR 1.67, 95% CI: 1.25-2.23), and LVO site (carotid-T, p < 0.01; OR 1.96, 95% CI: 1.26-3.05; M2-segment-MCA, p < 0.02; OR 1.62, 95% CI: 1.08-2.42) were associated with a higher risk of developing symptomatic intracerebral hemorrhage compared to no/asymptomatic intracerebral hemorrhage. The subgroup of patients treated with thrombectomy alone presented a lower risk of symptomatic intracerebral hemorrhage (p < 0.01; OR 0.70; 95% CI: 0.55-0.90). Subarachnoid hemorrhage/arterial perforation and symptomatic intracerebral hemorrhage after endovascular thrombectomy worsen both functional independence and mortality at three-month follow-up (p < 0.01). Distal embolization is associated with neurological deterioration (p < 0.01), while arterial dissection did not affect clinical outcome at follow-up. CONCLUSIONS: Complications globally considered are not uncommon and may result in poor clinical outcome. Early recognition of risk factors might help to prevent complications and manage them appropriately in order to maximize endovascular thrombectomy benefits.

Clinical Outcomes of On-Site Versus Off-Site Endovascular Stroke Interventions.

OBJECTIVES: The aim of this study was to assess whether offering local endovascular stroke therapy (EST) rather than transferring patients off-site to receive EST would improve outcomes. BACKGROUND: There are limited data to determine whether offering EST on-site rather than transferring patients to receive EST off-site improves clinical outcomes. METHODS: A large academic consortium database was queried to identify patients with acute ischemic stroke who received EST between October 2015 and September 2019. Primary endpoints were in-hospital mortality and poor functional outcomes. Secondary endpoints were major complications, length of stay, and cost. Baseline characteristics were adjusted for using propensity score matching and multivariate risk adjustment. RESULTS: A total of 22,193 patients with acute ischemic stroke who underwent EST (50.8% on-site, 49.2% off-site) were included. Mean ages were 67.9 ± 15.5 years and 68.4 ± 15.5 years, respectively (p = 0.03). In the propensity score matching analysis, mortality and poor functional outcomes were higher in the off-site EST group (14.7% vs. 11.2% and 40.7% vs. 35.9%, respectively; p < 0.001). In the risk-adjusted analyses with different models, in-hospital mortality and poor functional outcomes remained significantly higher in the off-site EST group. In the most comprehensive model (adjusting for age, sex, demographics, risk factors, tissue plasminogen activator use, and institutional EST volume), in-hospital mortality and poor functional outcomes were significantly higher in the off-site EST group, with odds ratios of 1.38 (95% confidence interval: 1.26 to 1.51) and 1.26 (95% confidence interval: 1.18 to 1.34), respectively (p < 0.001). The incidence of intracranial hemorrhage and mechanical ventilation was higher in the off-site group, but cost was higher in the on-site group in both the propensity score matching and risk-adjusted analyses. CONCLUSIONS: In contemporary U.S. practice, patients with acute ischemic stroke treated with EST on-site had lower in-hospital mortality and better functional outcomes compared with those transferred off-site for EST.

Local endovascular infusion and hypothermia in stroke therapy: A systematic review.

Ischemic stroke is a leading cause of death and disability worldwide, but there are no effective, widely applicable stroke therapies. Systemic hypothermia is an international mainstay of postcardiac arrest care, and the neuroprotective benefits of systemic hypothermia following cerebral ischemia have been proven in clinical trials, but logistical issues hinder clinical acceptance. As a novel solution to these logistical issues, the application of local endovascular infusion of cold saline directly to the infarct site using a microcatheter has been put forth. In small animal models, the procedure has shown incredible neuroprotective promise on the biochemical, structural, and functional levels, and preliminary trials in large animals and humans have been similarly encouraging. In addition, the procedure would be relatively cost-effective and widely applicable. The administration of local endovascular hypothermia in humans is relatively simple, as this is a normal part of endovascular intervention for neuroendovascular surgeons. Therefore, it is expected that this new therapy could easily be added to an angiography suite. However, the neuroprotective efficacy in humans has yet to be determined, which is an end goal of researchers in the field. Given the potentially massive benefits, ease of induction, and cost-effective nature, it is likely that local endovascular hypothermia will become an integral part of endovascular treatment following ischemic stroke. This review outlines relevant research, discusses neuroprotective mechanisms, and discusses possibilities for future directions.

Evidence and opportunities of hypothermia in acute ischemic stroke: Clinical trials of systemic versus selective hypothermia.

Stroke is the second leading cause of death globally and the third leading cause disability. Acute ischemic stroke (AIS), resulting from occlusion of major vessels in the brain, accounts for approximately 87% of strokes. Despite this large majority, current treatment options for AIS are severely limited and available to only a small percentage of patients. Therapeutic hypothermia (TH) has been widely used for neuroprotection in the setting of global ischemia postcardiac arrest, and recent evidence suggests that hypothermia may be the neuroprotective agent that stroke patients desperately need. Several clinical trials using systemic or selective cooling for TH have been published, reporting the safety and feasibility of these methods. Here, we summarize the major clinical trials of TH for AIS and provide recommendations for future studies.