Outcomes of endovascular thrombectomy with and without bridging thrombolysis for acute large vessel occlusion ischaemic stroke.

BACKGROUND: Endovascular thrombectomy (EVT) for management of large vessel occlusion (LVO) acute ischaemic stroke is now current best practice. AIM: To determine if bridging intravenous (i.v.) alteplase therapy confers any clinical benefit. METHODS: A retrospective study of patients treated with EVT for LVO was performed. Outcomes were compared between patients receiving thrombolysis and EVT with EVT alone. Primary end-points were reperfusion rate, 90-day functional outcome and mortality using the modified Rankin Scale (mRS) and symptomatic intracranial haemorrhage (sICH). RESULTS: A total of 355 patients who underwent EVT was included: 210 with thrombolysis (59%) and 145 without (41%). The reperfusion rate was higher in the group receiving i.v. tissue plasminogen activator (tPA) (unadjusted odds ratio (OR) 2.2, 95% confidence interval (CI): 1.29-3.73, P = 0.004), although this effect was attenuated when all variables were considered (adjusted OR (AOR) 1.22, 95% CI: 0.60-2.5, P = 0.580). The percentage achieving functional independence (mRS 0-2) at 90 days was higher in patients who received bridging i.v. tPA (AOR 2.17, 95% CI: 1.06-4.44, P = 0.033). There was no significant difference in major complications, including sICH (AOR 1.4, 95% CI: 0.51-3.83, P = 0.512). There was lower 90-day mortality in the bridging i.v. tPA group (AOR 0.79, 95% CI: 0.36-1.74, P = 0.551). Fewer thrombectomy passes (2 versus 3, P = 0.012) were required to achieve successful reperfusion in the i.v. tPA group. Successful reperfusion (modified thrombolysis in cerebral infarction ≥2b) was the strongest predictor for 90-day functional independence (AOR 10.4, 95% CI:3.6-29.7, P < 0.001). CONCLUSION: Our study supports the current practice of administering i.v. alteplase before endovascular therapy.

Early percutaneous antegrade-retrograde rendezvous repair of a transected ureter-a real therapeutic option.

A 46-year-old female underwent elective laparoscopic hysterectomy. Seven days post-operatively, she presented with urinary leak from the vagina. Computed tomography urogram demonstrated a right complete ureteric transection with leakage of urine into the pelvis and fistulation into the vagina. A rendezvous procedure was performed via a retrograde cystoscopic approach during which a guidewire was used to cannulate the right ureteric orifice and coiled in the retroperitoneal cavity. Subsequently, via a right percutaneous nephrostomy, a guidewire was advanced through the site of ureteric transection, which was followed by a snare catheter to bring the retrograde wire externally. A nephroureteric stent was then inserted. Twelve weeks later, the nephroureteric stent was exchanged for a ureteric stent for 6 months. A subsequent retrograde ureterogram showed complete healing of the ureter. The ureteric stent was removed and follow-up ultrasounds revealed no hydronephrosis. Percutaneous rendezvous procedures represent an effective option to treat this challenging condition.

Expanding the role of stent-retriever endovascular thrombectomy: a case series of free-floating thrombus.

Carotid artery free-floating thrombus (FFT) is a rare but clinically significant cause of embolic stroke. Treatment has historically been confined to carotid surgery or best medical therapy, with neither option proved to be superior. However, recent advancements in endovascular interventions have heralded a new age of innovative management strategies for vascular disease. We present three distinct cases of stroke secondary to carotid artery FFT, successfully treated with stent retriever endovascular thrombectomy.

Endovascular thrombectomy beyond 12 hours of stroke onset: a stroke network's experience of late intervention.

BACKGROUND: Selected patients with proximal anterior circulation ischemic stroke who demonstrate limited infarct and sufficient penumbra may benefit from endovascular thrombectomy (EVT) beyond conventional time limits. OBJECTIVE: To perform a retrospective review of all cases of EVT performed at our institution for proximal anterior circulation acute ischemic stroke with onset >12 hours. MATERIALS AND METHODS: Patients were assessed with non-contrast CT brain and multiphase CT angiography, with Alberta Stroke Program Early CT Score (ASPECTS) and collateral grade informing patient selection. Data, including patient demographics, workflow, neuroimaging findings, procedural details, recanalization rates, and 90-day functional outcomes, were collected. RESULTS: Of the 542 consecutive endovascular thrombectomy cases performed during the study period, 25 (4.6%) were >12 hours from stroke onset. Median age was 69 years (IQR 55-80), median National Institute of Health Stroke Scale score on presentation was 14 (IQR 11-18.5), median ASPECTS was 8 (IQR 8-9), and rate of moderate-good collateral status was 96% (n=24). Median time to groin puncture was 14 hours 40 min (IQR 12 hours 36 min - 16 hours 18 min). Rate of successful recanalization (modified Thrombolysis in Cerebral infarction 2b-3) was 88% (n=22). Rate of functional independence (90-day modified Rankin Scale score 0-2) was 52% (n=13). There were no cases of symptomatic intracranial haemorrhage and 90-day mortality rate was 12% (n=3). CONCLUSION: With the use of ASPECTS and collateral grade to guide patient selection, good functional outcome with acceptable safety parameters may be achieved in patients undergoing EVT beyond 12 hours from stroke onset.

Borderline Alberta Stroke Programme Early CT Score Patients with Acute Ischemic Stroke Due to Large Vessel Occlusion May Find Benefit with Endovascular Thrombectomy.

OBJECTIVE: Selection of patients with acute ischemic stroke for endovascular thrombectomy (EVT) is complex and time-critical. Benefits of EVT are well established for patients with small core infarcts. The aim of this study was to compare clinical outcomes of EVT in patients with larger established infarcts (Alberta Stroke Programme Early CT Score [ASPECTS] ≤6) with patients with smaller infarcts (ASPECTS 7-10). METHODS: The study included 355 patients with acute ischemic stroke due to large vessel occlusion who underwent EVT. ASPECTS was assigned to baseline noncontrast computed tomography, and collateral perfusion scores were assigned to multiphase computed tomography angiography. Baseline stroke severity, collateral grading, and clinical outcome data (complication rate, symptomatic intracranial hemorrhage and 90-day modified Rankin Scale score) were compared between patients with borderline (≤6) and high (7-10) ASPECTS. RESULTS: There were 34 (10%) patients with borderline ASPECTS. There was no difference in rate of good clinical outcome (37% vs. 46%, P = 0.852), symptomatic intracerebral hemorrhage (9% vs. 9%, P = 0.984), or mortality (20% vs. 22%, P = 0.818) between patients with borderline ASPECTS and high ASPECTS at 90 days. Moreover, there was no significant difference in collateral perfusion grade. CONCLUSIONS: This study identifies similar clinical benefit of EVT in patients with acute large vessel occlusion stroke with borderline ASPECTS and high ASPECTS.