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Objective To observe the severity of cerebral edema after mechanical thrombectomy in the patients with acute ischemic stroke caused by large vessel occlusion,and to statistically analyze the related fac-tors affecting the prognosis quality of the patients,so as to guide the patients to conduct scientific interven-tion.Methods Ninety-one patients with acute ischemic stroke due to anterior circulation large vessel occlusion treated with mechanical thrombectomy in this hospital from October 2021 to October 2022 served as the ana-lytic subjects.According to the severity of brain edema,they were divided into the group Ⅰ(mild),group Ⅱ(moderate),and group Ⅲ(severe);after 12-week treatment,the improved Rankin scale was used to evaluate the prognosis.The patients with good prognosis were included in the excellent group,and the patients with poor prognosis were included in the poor group.Single factor and multifactor logistic analysis was used to ana-lyze the influencing factors and prognostic related factors of different degrees of brain edema.Results The univariate analysis showed that the percentage of patients with NIHSS score at admission ≥15,time from on-set to thrombolysis ≥6 h,history of hypertension,successful vascular recanalization and good collateral circu-lation were significantly different among the groups Ⅰ,Ⅱ and Ⅲ(P＜0.05);the multivariate logistic regres-sion analysis results showed that the NIHSS score at admission ≥15,time from onset to thrombolysis ≥6 h,and hypertension history were the risk factors leading to severe cerebral edema,while successful recanalization of blood vessels was a protective factor for cerebral edema(P＜0.05).The univariate analysis showed that in the good prognosis group the percentage of patients had good circulation of lateral branches,successful reca-nalization of blood vessels,severe cerebral edema,hypertension,time from onset to thrombolysis ≥6 h,and NIHSS score ≥15 at admission were significantly different from those in the poor prognosis group(P＜0.05).The multivariate logistic regression analysis results showed that severe cerebral edema,time from onset to thrombolysis ≥6 h and NIHSS score ≥15 at admission were the risk factors for poor prognosis,while good collateral circulation and successful recanalization of blood vessels were the positive factors for good prognosis(P＜0.05).Conclusion Mechanical thrombectomy patients with hypertension and time from onset to throm-bolysis ≥6 h and NIHSS score at admission ≥15 have more severe brain edema after treatment;severe brain edema,time from onset to thrombolysis ≥6 h,NIHSS score at admission ≥15 were the adverse factors affect-ing the prognosis of the patients with mechanical thrombectomy.
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In recent years, endovascular therapy has become the most important progress in the field of the treatment of acute ischemic stroke caused by large vessel occlusion. However, the vascular recanalization shown by imaging after endovascular treatment cannot fully translate into effective tissue reperfusion and functional outcome, a phenomenon known as "futile recanalization". Combined neuroprotective therapy after vascular recanalization is expected to reduce the occurrence of futile recanalization and improve the outcome of patients. This article briefly summarizes the main application progress of commonly used neuroprotective therapies in clinical practice (edaravone dexborneol, glucocorticoids, hypothermia, and remote ischemic conditioning). It explores the trend and direction of combining endovascular therapy and neuroprotective therapy for patients with acute ischemic stroke caused by large vessel occlusion, and provides further reference and suggestions for intervention measures after endovascular therapy.
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Endovascular treatment has become the standard treatment method for acute ischemic stroke caused by large vessel occlusion. The application of neuroimaging techniques for appropriate patient selection and prognosis prediction is of great significance for successful endovascular treatment. This article reviews the application progress of fluid-attenuated inversion recovery sequence vascular hyperintensity in patients with acute ischemic stroke underwent endovascular treatment.
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At present,mechanical thrombectomy(MT)is the most effective means of achieving vascular recanalization in treating acute ischemic stroke(AIS)caused by large vessel occlusion.However,the monitoring and management of the patient's complications after MT has become a thorny clinical problem and it has attracted wide attention.Being of its non-invasive,flexible and quick diagnosis,and other advantages,the neurosonography has already established a perfect system in the evaluation and monitoring field of cerebral hemodynamic and structural pathology.With the innovation in technology and equipment,the guiding mode for non-invasive monitoring of intracranial pressure,autoregulation of cerebral blood flow,monitoring of intracranial hemorrhage and detection of other space-occupying lesions has been used for AIS patients,which has gradually become an important tool for the postoperative management of MT.This paper aims to make a comprehensive review about the application of neurosonography monitoring technology in AIS patients after MT,so as to provide a basis for the clinical implementation of prospective interventions,to enable AIS patients to obtain the maximum benefits from the postoperative management of MT,and to reduce the mortality of AIS patients.
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Mechanical thrombectomy can improve the clinical outcome of patients with acute anterior circulation larger vessel occlusive stroke.However,a remarkable proportion of patients,even they have achieved a successful recanalization,still develop adverse outcomes,such as futile recanalization(FR).According to relevant literature reports,there are many factors that can affect futile recanalization.In this paper,a series of factors such as age,recanalization time,infarct volume,baseline severity,blood pressure that may affect futile recanalization of mechanical thrombectomy in patients with inanterior circulation large vessel occlusion will be comprehensively described and analyzed.(J Intervent Radiol,2024,33:321-324)
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Objective To investigate the application of Rotarex mechanical thrombectomy system in lower extremity arterial thrombosis and to evaluate its clinical efficacy.Methods The clinical data of 61 patients(71 limbs,35 cases in acute phase,21 cases in subacute phase and 5 cases in chronic phase)with lower extremity arterial thrombosis treated with Rotarex were analyzed retro-spectively.Distal protective device was used in patients with poor distal artery outflow.High pressure saline was used during the pro-cedure and stent was used in patients with flow-limiting dissection.Catheter aspiration was performed in patients with distal artery embo-lization.Anticoagulant therapy was used in patients with thromboembolism and dual antiplatelet therapy was used in patients with in-situ thrombosis.Postoperative follow-up was performed with color Doppler ultrasound or computed tomography angiography(CTA)at 1 month,3 months and 6 months.Results Fifty-nine cases were treated with 6F Rotarex catheters and 2 cases were treated with 8F Rotarex catheters.Distal protective device was used in 10 cases,balloon dilation was performed in 49 cases and stent was used in 5 cases.Catheter aspiration was performed in 10 cases.Vessel rupture occurred in 4 cases,among whom 3 cases were successfully treated with the method of balloon compression and 1 case was treated with covered stent.Severe adverse events occurred in 4 cases and perioperative toe amputation was performed in 7 cases.Follow-up time was 3 to 6 months(mean 4.9 months).Lower extremity ischemic event occurred in 1 case at 6th month follow-up and was treated with stent.No other lower extremity ischemic events occurred in the course of follow-up.Conclusion For the treatment of lower extremity arterial thrombosis,Rotarex mechanical thrombectomy sys-tem has the advantages of minimally invasion,rapid and high efficiency.Combined with the therapy of catheter aspiration and stent place-ment,vascular patency can be further maintained and the lower extremity ischemic symptoms can be quickly relieved.
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Objective To compare the safety and efficacy of direct thrombectomy versus bridging thrombectomy in the treatment of acute anterior circulation large vessel occlusion stroke under different collateral circulation statuses.Methods Totally 93 patients with acute anterior circulation ischemic stroke admitted to the First Affiliated Hospital of Xinxiang Medical University from September 2020 to March 2023 were selected as the research subjects.Patients were divided into direct throm-bectomy group(n=47)and bridging thrombectomy group(n=46)based on the type of thrombectomy.Patients in the direct thrombectomy group received direct intravascular thrombectomy,while patients in the bridging thrombectomy group received intravenous thrombolysis with alteplase combined with mechanical thrombectomy.According computed tomography angiography,the collateral circulation Tan classification was applied to divide the patients into good collateral circulation sub-group and poor collateral circulation sub-group.The modified thrombolysis in cerebral infarction grading(mTICI)was used to evaluate vessel recanalization.Head computed tomography plain scan was performed at 24-48 hours postoperatively to assess if there was hemorrhagic transformation,and modified Rankin Scale score was performed at 90 days postoperatively.Information such as imaging examination time,femoral artery puncture time,vessel recanalization time after thrombectomy,prognosis and spontaneous non-traumatic symptomatic intracerebral hemorrhage(SICH)were collected.Results The age,gender,baseline Alberta stroke program early computed tomography score,baseline national institutes of health stroke scale score,proportions of hypertension,diabetes and atrial fibrillation,baseline systolic pressure,creatinine,baseline blood glucose,platelet count,occlusion site,stroke etiologies and collateral circulation status of patients in the two groups were not statistically significantly different(P＞0.05).There were no significant differences in the post-admission imaging examination time,femoral artery puncture time,vessel recanalization time after thrombectomy,successful vascular reperfusion rate,good prognosis rate,mortality rate,and SICH incidence between the two groups(P＞0.05).The hemorrhagic transformation rate of patients in the direct thrombectomy group was significantly lower than that in the bridging thrombectomy group(P＜0.05).There were no significant differences in the post-admission imaging examination time,femoral artery puncture time,vessel recanalization time after thrombectomy,successful vascular reperfusion rate,good prognosis rate,mortality rate,and SICH incidence between patients with good collateral circulation and patients with poor collateral circulation in the two groups(P＞0.05).The hemorrhagic transformation rate of patients with good and poor collateral circulation in the direct thrombectomy group was significantly lower than that in the bridging thrombectomy group(P＜0.05).Conclusion Under different collateral circulation conditions,the safety and efficacy of direct thrombectomy and bridging thrombectomy in the treatment of acute anterior circulation large vessel occlusion stroke are similar,but bridging thrombectomy is more likely to result in cerebral hemorrhage transformation compared with direct thrombectomy.
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Objective:To compare the mid-term clinical effects of AngioJet rheolytic thrombectomy assisted catheter-directed thrombolysis (ART+CDT) with catheter-directed thrombolysis (CDT) in the treatment of acute deep venous thrombosis of lower extremities.Methods:Ninety-one patients admitted to the Department from Jan 2016 to Dec 2017 were placed with inferior vena cava filters and divided into ART+CDT group (30 cases)and CDT group (61 cases). Total urokinase dosge, thrombolytic time, operative cost, length of hospital stay, detumescence rate, thrombus clearance rate, cumulative patency rate of lower limb veins, Villalta score at 2 years and 5 years, thrombosis recurrence rate and chronic venous insufficiency quality of life questionnaire were compared between the two groups.Results:The success rate of surgery was 100% in both groups, there was no mortality. There were significant differences in the short-term postoperative outcomes between the two groups in terms of total dosage of urokinase, thrombolysis time, total cost of surgery, length of hospital stay, detumescence rate, venous patency scores before and after treatment, and venous patency rate (all P<0.05). For the mid- and long-term postoperative outcomes of 2 and 5 years, there were no significant differences in the incidence of PTS, recurrence rate of thrombus, chronic venous function scale, and cumulative patency rate at 2 years (all P>0.05). Conclusions:ART+CDT has a significant advantage over CDT alone in terms of early efficacy and early reopening of blood flow in patients. Both ART+CDT and CDT have a low incidence of PTS and a low recurrence rate of thrombus in the mid-term follow-up, and both have satisfactory performance in the mid- and long-term efficacy of interventional treatment of deep venous thrombosis of lower limbs.
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Objective:To investigate the predictive value of preoperative D-dimer level for futile recanalization (FR) after mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS).Methods:It was a nested case-control study. A total of 116 patients with large vessel occlusion (LVO) stroke, who underwent successful recanalization (modified Thrombolysis in Cerebral Infarction, mTICI≥2b) after MT at the Stroke Unit of Beijing Hospital from August 2018 to January 2022,were consecutively enrolled, including 72 males (62.1%) with the age of (72.8±13.1) years. According to the 3-month modified Rankin Scale (mRS) score after MT, patients were divided into the meaningful recanalization group (mRS 0-2, n=41) and the futile recanalization group (mRS 3-6, n=75). The baseline clinical data of enrolled patients was collected. Logistic regression analysis was used to identify the independent risk factors for FR after MT in patients with AIS. Receiver operating characteristic (ROC) curve was used to evaluate the predictive value of D-dimer for FR. Results:Multivariate logistic regression analysis showed that high baseline systolic blood pressure (SBP) ( OR=1.038, 95% CI: 1.012-1.065, P=0.004), baseline National Institutes of Health Stroke Scale (NIHSS) score≥12 ( OR=10.157, 95% CI: 3.624-28.470, P<0.001) and high preoperative D-dimer level ( OR=4.536, 95% CI: 1.379-14.922, P=0.013) were independent predictors of FR after MT in AIS patients with LVO. ROC curve analysis indicated a good predictive value of preoperative D-dimer for the occurrence of FR ( AUC=0.733, 95% CI: 0.638-0.829, P<0.05), the optimal cut-off value of D-dimer was 2.65 μg/L(Lg), with the Youden index, sensitivity, specificity and accuracy of 0.435, 53.3%, 90.2% and 66.4%, respectively. Conclusion:High preoperative D-dimer level is an independent predictor of futile recanalization after MT in AIS patients with LVO, which shows good predictive ability for futile recanalization.
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In patients with acute ischemic stroke, there is a wide variation in the composition of blood clots that block the blood vessels. Some imaging features are associated with the components of the clot, such as thrombus permeability, which is related to higher red blood cell density and lower fibrinogen density. The different components and mechanical properties of the clot may have an impact on treatment effectiveness and risk. Therefore, this article aims to summarize the correlation between thrombus permeability and biological, imaging characteristics, and explore the clinical significance of thrombus permeability in the treatment of patients with acute ischemic stroke, providing reference and assistance for neurologists.
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Objective:To compare the efficacy of catheter-directed thrombolysis versus catheter-directed thrombectomy for high-risk pulmonary embolism.Methods:The clinical data of 105 patients with high-risk pulmonary embolism from April 2020 to January 2023 in Hebei China Petroleum Central Hospital were retrospectively analyzed. Among them, 52 patients were treated with catheter-directed thrombolysis (thrombolysis group), and 53 patients were treated with catheter-directed thrombectomy (thrombectomy group). The efficacy, symptom relief time, oxygen saturation recovery time, mortality rate, Qanadli embolic index, pulmonary artery pressure and complications were compared between two groups.Results:There were no statistical differences in total effective rate, symptom relief time, oxygen saturation recovery time, mortality rate and total incidence of complications between two groups ( P>0.05). Compared with before treatment, the Qanadli embolic index and pulmonary artery pressure after treatment in thrombolysis group and thrombectomy group were significantly lower, thrombolysis group: 22.08 ± 8.57 vs. 45.18 ± 13.27 and (24.18 ± 5.19) mmHg (1 mmHg = 0.133 kPa) vs. (34.15 ± 6.22) mmHg, thrombectomy group: 23.11 ± 8.62 vs. 44.82 ± 13.14 and (23.66 ± 5.02) mmHg vs. (34.89 ± 6.27) mmHg, and there were statistical differences ( P<0.01); but there was no statistical difference the Qanadli embolic index and pulmonary artery pressure before and after treatment between two groups ( P>0.05). Conclusions:In patients with high-risk pulmonary embolism, both catheter-directed thrombolysis and catheter-directed thrombectomy have good efficacy and can promote the relief of clinical symptoms and the recovery of oxygen saturation, improving the prognosis.
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Objective To explore the association of the magnitude of systolic blood pressure reduction(SBPr)with post-procedure 24 h symptomatic intracranial hemorrhage(sICH)and 90-day clinical outcomes in patients with successful endovascular thrombectomy(EVT).Methods Consecutively registered patients with EVT caused by anterior circulation large vessel occlusion stroke(LVOS)in the First Affiliated Hospital of Wannan Medical College(Yijishan Hospital)between July 2015 and April 2023 and patients with successful reperfusion were analyzed.Demographic data,medical history(hypertension,diabetes),the trial of Org 10172 in acute stroke treatment(TOAST)classification,the baseline National Institutes of Health Stroke Scale(NIHSS)score and the baseline Alberta stroke early CT(ASPECT)score of patients were collected.And procedure related parameters(including time from onset to puncture,time from onset to reperfusion,occluded site[internal carotid artery,M1 segment of middle cerebral artery,M2 segment of middle cerebral artery],collateral circulation status[determined based on preoperative occluded angiography showing the range of collateral circulation in the occluded vessel area,defined as good collateral circulation with a reflux range of ≥ 50％and poor collateral circulation with a reflux range of＜50％]),immediate postoperative reperfusion status(evaluated using the modified thrombolysis for cerebral infarction[mTICI]grading,successful reperfusion defined as mTICI grading of 2b-3),24 hours sICH,and 90 days clinical outcomes(evaluated using the modified Rankin scale score at 90days after EVT,with a score ≤ 2indicating a good prognosis and a score＞2indicating a poor prognosis).SBPr was defined as(baseline SBP-mean SBP)/baseline SBP x 100％.According to the the magnitude of SBPr,SBPr is divided into 5 categories(＜-10％,-10％-10％,＞10％-20％,＞20％-30％and＞30％).Based on the clinical outcomes at 90 days and the occurrence of sICH at 24 hours after EVT,patients were divided into a good prognosis group and a poor prognosis group,as well as an sICH group and a non-sICH group.The relationship between SBPr and postoperative 90 days clinical prognosis or sICH was analyzed using a binary Logistic regression model.Subgroup analysis was conducted based on a history of hypertension(yes and no),continuous intravenous hypotensive therapy(yes and no),baseline ASPECT scores(3-5 and 6-10),and collateral circulation status(good and bad).Using a restricted cubic plot to depict the relationship between SBPr and sICH and clinical prognosis at 90days.Results(1)In total,731 patients were included.The median age was 71(62,77)years and 424(58.0％)were men.The median baseline NIHSS score was 14(12,18),the median baseline ASPECT was 9(7,10),405(55.4％)patients achieved 90-day modified Rankin scale score 0-2,and 35 patients(4.8％)developed sICH.(2)Multivariate analysis showed that the older age(OR,1.036,95％CI 1.017-1.056),the higher baseline NIHSS score(OR,1.095,95％CI1.049-1.144),the lower baseline ASPECT score(OR,0.704,95％CI 0.636-0.780),diabetes(OR,1.729,95％CI 1.084-2.758),bad collateral circulation(good collateral circulation vs.bad collateral circulation,OR,0.481,95％CI 0.332-0.696)and SBPr＞30％(SBPr-10％-10％as a reference,OR,2.238,95％CI 1.230-4.071),the higher the risk of poor clinical outcomes at 90 days(all P＜0.05).Continuous intravenous hypotensive therapy is a risk factor for postoperative 24 h sICH(OR,2.278,95％CI 1.047-4.953;P=0.038),while SBPr 20％-30％is associated with a lower risk of postoperative 24 h sICH(SBPr-10％-10％as a reference,OR,0.362,95％CI0.131-0.998;P=0.049).(3)The restrictive cube plot shows that there is a U-shaped relationship between SBPr after EVT and poor clinical outcomes at 90 days,while there is a nearly linear relationship with the occurrence of sICH.The more SBP reduction,the lower the incidence of sICH.(4)In the subgroup analyses,in the non-hypertension history and the good collateral circulation group,SBPr＞30％has a higher risk of poor clinical outcomes compared to SBPr-10％-10％(OR and 95％CI were 2.921[1.000-8.528]and 2.363[1.078-5.183],respectively,with P=0.05 or P＜0.05);After EVT,the group receiving continuous intravenous hypotensive therapy and the baseline ASPECT score 6-10 groups showed a significant correlation between SBPr＞30％and poor clinical outcomes at 90 days(SBPr-10％-10％as a reference,OR and 95％CI were 2.646[1.168-5.993]and 2.481[1.360-4.527],respectively,with P＜0.05).The correlation between SBPr and lower incidence of sICH was only found in the subgroup of poor collateral circulation(SBPr-10％-10％as a reference,SBPr＞20％-30％:OR,0.133,95％CI 0.027-0.652;SBPr＞30％:OR,0.104,95％CI 0.013-0.864;all P＜0.05).Conclusions Among patients who achieved successful reperfusion with EVT,SBPr might be related to a worse functional outcome at 90 days and sICH 24 h after operation.However,the relationship may exhibit significant heterogeneity across different subgroups.Baseline ASPECT score,history of hypertension,collateral circulation,and the use of continuous venous hypertension after EVT have been highlighted in individualized blood pressure management after EVT.
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It remains unclear whether heart transplantation is still feasible on patients who develop neurological complications before surgery and underwent successful neurological treatment.This article reported the diagnosis and treatment process of a heart failure patient complicating with acute ischemic stroke,who underwent successful heart transplantation after thrombectomy for acute ischemic stroke,aiming to provide clinical evidence and decision-making plan on diagnosis and treatment options for this group of patients with severe neurological complications.
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Objective:To explore the association of cerebral venous outflow assessed by CT angiography (CTA) with first pass effect (FPE) in patients with acute anterior circulation large vessel occlusion accepted mechanical thrombectomy (MT).Methods:A retrospective analysis was performed; patients with acute anterior circulation large vessel occlusion accepted MT and CTA in Department of Neurology, Affiliated Hospital of Xuzhou Medical University from July 2018 to June 2021 were consecutively enrolled. Cerebral venous outflow in baseline CTA was evaluated using Cortical Vein Opacification Score (COVES). Patients were categorized into either FPE or non-FPE groups based on recanalization of occluded vessels after initial MT. General information, clinical features, radiological data, and surgery-related data between the 2 groups of patients were collected and compared. Significant variables ( P<0.1) from univariate analysis were included into a multivariable Logistic regression model to explore the relation between COVES and FPE. Predictive value of COVES in FPE was assessed using receiver operating characteristic (ROC) curve. Results:Out of the 143 patients enrolled in this study, 52 were into the FPE group and 91 were into the non-FPE group. Compared with the non-FPE group, the FPE group had higher COVES scores, higher proportion of patients with good cerebral venous drainage (COVES≥3), smaller core infarct volume, and shorter time from femoral artery puncture to vessel recanalization, with significant differences ( P<0.05). Multivariable Logistic regression analysis revealed that COVES was still corelated with FPE after adjusting covariates such as baseline NIHSS scores, core infarct volume, and time from femoral artery puncture to vessel recanalization ( OR=0.730, 95% CI: 0.567-0.940, P=0.015). ROC curve demonstrated that the combined model of COVES with aforementioned factors (COVES scores+baseline NIHSS scores+core infarct volume+time from femoral artery puncture to vessel recanalization) had an area under the curve of 0.757 (95% CI: 0.672-0.841, P<0.001), with sensitivity of 61.5% and specificity of 78.0%. Conclusion:Favorable cerebral venous drainage is an independent predictor for successful FPE in patients with acute anterior circulation large vessel occlusion accepted MT.
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Distal medium arterial occlusive cerebral infarction has high incidence and high disability and mortality rates. At present, 1/2-2/3 patients cannot benefit from intravenous thrombolysis alone; no high-level recommendations for arterial thrombolysis or mechanical thrombectomy are noted either. However, with the development of interventional materials and technologies, mechanical thrombectomy may be an effective treatment for selected distal medium arterial occlusive cerebral infarction patients. This article reviews the recent research progress of mechanical thrombectomy in distal medium occlusive cerebral infarction in order to guide its treatment.
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@#Objective To detect the changes of serum microRNA-126(miR-126)before interventional thrombectomy for acute cerebral infarction,and to explore its correlation with the prognosis of patients.Methods A retrospective analysis was performed on 101 patients with cerebral infarction who underwent interventional thrombectomy in he First People's Hospital of Huzhou from January 2019 to December 2021.The patients were followed up for 2 month.According to modified Rankin scale(mRS),they were divided into good prognosis group(mRS≤2 points,56 cases)and poor prognosis group(mRS>2 points,45 cases).The clinical data of two groups and the difference of miR-126 before thrombectomy were compared,and the effect of serum miR-126 change on the prognosis of patients with cerebral infarction was analyzed.Results The serum miR-126 level before thromrectomy in good prognosis group was significantly higher than that in poor prognosis group[(9.31±2.14)vs.(1.36±0.28),P<0.01].There was a negative correlation between miR-126 and National Institute of Health stroke scale(NIHSS)score(r=-0.737,P<0.01),and a positive correlation between miR-126 and good collateral circulation(r=0.645,P<0.01).The area under the receiver operating characteristic curve for establishing miR-126 to predict prognosis after thrombolectomy for cerebral infarction was 0.818.The sensitivity and specificity were 78.9%and 86.0%at the optimal cut-off value.Conclusion The change of serum miR-126 level before thrombectomy may be related to the prognosis of patients with cerebral infarction,which can be used as a marker to predict the prognosis of cerebral infarction after interventional therapy.
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Abstract Background The relationship between collateral circulation and prognosis after endovascular treatment in anterior circulation strokes has been reported in many studies. Objective In this study, we aimed to compare the predictive power of clinical outcome by comparing five different collateral scores that are frequently used. Methods Among the patients who underwent endovascular treatment in our clinic between November 2019 and December 2021, patients with premorbid mRS < 3, intracranial ICA and/or MCA M1 occlusion, and a pre-procedural multiphase CTA examination were included in the study. Demographic, technical, and duration information about the procedure, major events after the procedure, and clinical outcomes at 3 months were recorded. The mCTA, Tan, Maas, Miteff, and rLMC collateral scores of the patients were evaluated. Results Clinical outcome at 3 months were good in 37 of the 68 patients included in the study (mRS ≤ 2). Only the mCTA and rLMC collateral scores were statistically significantly higher in those with a good clinical outcome. Significant correlation with 3-month mRS was detected only in mCTA and rLMC scores. Although rLMC and mCTA collateral scores showed a statistically significant association with prognosis, they were not sufficient to be an independent predictor of prognosis. Conclusion mCTA and rLMC were found to have the highest predictive power of clinical outcome and the highest correlation with the 3-month clinical outcome. Our study suggests that it would be beneficial to develop a new scoring system over multiphase CTA, which combines regional and temporal evaluation, which are the strengths of both collateral scoring.
Resumo Antecedentes A relação entre circulação colateral e prognóstico após tratamento endovascular em acidentes vasculares cerebrais de circulação anterior tem sido relatada em muitos estudos. Objetivo Neste estudo, nosso objetivo foi comparar o poder preditivo do desfecho clínico comparando cinco escores colaterais diferentes que são frequentemente utilizados. Métodos Entre os pacientes submetidos a tratamento endovascular em nossa clínica entre novembro de 2019 e dezembro de 2021, foram incluídos no estudo pacientes com mRS pré-mórbido < 3, oclusão intracraniana de ICA e/ou MCA M1 e exame de CTA multifásico pré-procedimento. Foram registradas informações demográficas, técnicas e de duração sobre o procedimento, eventos importantes após o procedimento e resultados clínicos em três meses. Foram avaliados os escores colaterais mCTA, Tan, Maas, Miteff e rLMC dos pacientes. Resultados Os resultados clínicos aos três meses foram bons em 37 dos 68 pacientes incluídos no estudo (mRS ≤ 2). Apenas os escores colaterais mCTA e rLMC foram estatisticamente significativamente maiores naqueles com boa evolução clínica. Correlação significativa com mRS de três meses foi detectada apenas nos escores mCTA e rLMC. Embora os escores colaterais de rLMC e mCTA tenham mostrado uma associação estatisticamente significativa com o prognóstico, eles não foram suficientes para serem um preditor independente de prognóstico. Conclusão Verificou-se que mCTA e rLMC têm o maior poder preditivo do resultado clínico e a maior correlação com o resultado clínico de três meses. Nosso estudo sugere que seria benéfico desenvolver um novo sistema de pontuação em vez de CTA multifásico, que combinasse avaliação regional e temporal, que são os pontos fortes de ambas as pontuações colaterais.
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Abstract Background After recently published randomized clinical trials, the choice of the best anesthetic procedure for mechanical thrombectomy (MT) in acute ischemic stroke (AIS) due to large vessel occlusion (LVO) is not definite. Objective To compare the efficacy and safety of general anesthesia (GA) versus conscious sedation (CS) in patients with AIS who underwent MT, explicitly focusing on procedural and clinical outcomes and the incidence of adverse events. Methods PubMed, Embase, and Cochrane were systematically searched for randomized controlled trials (RCTs) comparing GA versus CS in patients who underwent MT due to LVO-AIS. Odds ratios (ORs) were calculated for binary outcomes, with 95% confidence intervals (CIs). Random effects models were used for all outcomes. Heterogeneity was assessed with I2 statistics. Results Eight RCTs (1,300 patients) were included, of whom 650 (50%) underwent GA. Recanalization success was significantly higher in the GA group (OR 1.68; 95% CI 1.26-2.24; p < 0.04) than in CS. No significant difference between groups were found for good functional recovery (OR 1.13; IC 95% 0.76-1.67; p = 0.56), incidence of pneumonia (OR 1.23; IC 95% 0.56- 2,69; p = 0.61), three-month mortality (OR 0.99; IC 95% 0.73-1.34; p = 0.95), or cerebral hemorrhage (OR 0.97; IC 95% 0.68-1.38; p = 0.88). Conclusion Despite the increase in recanalization success rates in the GA group, GA and CS show similar rates of good functional recovery, three-month mortality, incidence of pneumonia, and cerebral hemorrhage in patients undergoing MT.
Resumo Antecedentes A trombectomia mecânica (TM) é o padrão de tratamento para pacientes com acidente vascular cerebral isquêmico agudo (AVCI) devido à oclusão de grandes vasos (OGV). No entanto, ainda não está claro qual é o procedimento anestésico mais benéfico para a TM. Objetivo Nosso objetivo foi comparar a eficácia e a segurança da anestesia geral (AG) versus sedação consciente (SC) em pacientes com AVCI submetidos à TM, focando especificamente nos resultados procedimentais e clínicos, bem como na incidência de eventos adversos. Métodos Foram realizadas buscas sistemáticas nas bases PubMed, Embase e Cochrane por ensaios clínicos randomizados (ECRs) comparando AG versus SC em pacientes submetidos à TM devido a AVCI por OGV. Razões de chances (ORs) foram calculadas para desfechos binários, com intervalos de confiança de 95% (ICs). Modelos de efeitos aleatórios foram usados para todos os resultados. A heterogeneidade foi avaliada com estatísticas I2. Resultados Oito ensaios clínicos randomizados (1.300 pacientes) foram incluídos, dos quais 650 (50%) foram submetidos à AG. O sucesso da recanalização foi significativamente maior no grupo AG (OR 1,68; IC 95% 1,26-2,24; p < 0,04) em comparação com SC. No entanto, não houve diferença significativa entre os grupos para recuperação funcional adequada (OR 1,13; IC 95% 0,76-1,67; p = 0,56), incidência de pneumonia (OR 1,23; IC 95% 0,56- 2,69; p = 0,61), mortalidade em três meses (OR 0,99; IC 95% 0,73- 1,34; p = 0,95) ou hemorragia cerebral (OR 0,97; IC 95% 0,68- 1,38; p = 0,88). Conclusão Apesar do aumento significativo nas taxas de sucesso de recanalização no grupo AG, AG e SC mostram taxas semelhantes de recuperação funcional, mortalidade, pneumonia e hemorragia em pacientes com AVCI submetidos à TM.
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Resumo A embolia pulmonar (EP) é a terceira maior causa de morte cardiovascular e a principal de morte evitável intra-hospitalar no mundo. O conceito PERT® (do inglês, pulmonary embolism response team) envolve seu diagnóstico e tratamento precoce e multidisciplinar. A trombose venosa profunda (TVP) é a sua causa inicial na maioria dos casos e é responsável por complicações como a recidiva tromboembólica, a síndrome pós-trombótica e a hipertensão pulmonar tromboembólica crônica. Uma abordagem inicial semelhante ao PERT nos casos de TVP ilíaco-femoral grave pode reduzir não apenas o risco imediato de EP e morte, mas também suas sequelas tardias. Novas técnicas percutâneas e aparatos de trombectomia mecânica para o tromboembolismo venoso (TEV) vêm demonstrando resultados clínicos encorajadores. Propomos o desenvolvimento de um conceito ampliado de resposta rápida ao TEV, que envolve não apenas a EP (PERT®) mas também os casos graves de TVP: o time de resposta rápida para o TEV (TRETEV®), ou do inglês Venous Thromboembolism Response Team (VTERT®).
Abstract Pulmonary embolism (PE) is the third leading cause of cardiovascular death and the main cause of preventable in-hospital death in the world. The PERT® (Pulmonary Embolism Response Team) concept involves multidisciplinary diagnosis and immediate treatment. Deep venous thrombosis (DVT) is the initial cause of most cases of PE and is responsible for complications such as chronic thromboembolic recurrence, postthrombotic syndrome, and chronic thromboembolic pulmonary hypertension. An aggressive approach to severe cases of iliofemoral DVT similar to the PERT® system can not only reduce the immediate risk of PE and death but can also reduce later sequelae. New percutaneous techniques and mechanical thrombectomy devices for venous thromboembolism (VTE) have shown encouraging clinical results. We propose the development of an expanded concept of rapid response to VTE, which involves not only PE (PERT®) but also severe cases of DVT: the Venous Thromboembolism Response Team (VTERT®).
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Resumen Introducción : El inicio de la pandemia COVID-19, obligó a implementar cambios en el sistema de aten ción de los servicios de emergencia. Coincidentemente, en nuestra institución, implementamos el software de inteligencia artificial (IA), RAPID.AI, para el análisis de imágenes en el ataque cerebrovascular isquémico (ACVi). Nuestro objetivo fue evaluar el impacto del uso de la IA junto a los cambios en el triage durante la pandemia por COVID-19 en pacientes con ACVi por oclusión de gran vaso cerebral (OGVC). Métodos : Se crearon 2 grupos de pacientes con ACVi por OGVC tratados con terapia de reperfusión endovenosa más endovascular o terapia endovascu lar directa. Grupo 1: pacientes de enero 2019 a junio 2020; Grupo 2: pacientes de julio 2020 a diciembre de 2021, estudiados con RAPID.AI. Se analizaron datos clínicos, y métricas temporales. Se compararon según hora de arribo de 08:00 a 20:00 h (diurno) vs. 20:01 a 7:59 h (nocturno). Resultados : El grupo 1 comprendió 153 pacientes y el grupo 2 133. En el grupo 2 la métrica puerta-imagen y adquisición de la imagen fueron menores, con menor tiempo puerta-inicio de imagen y puerta-recanalización; los pacientes en horario nocturno presentaron mayor NIHSS y tiempos inicio-ingreso con menor proporción de independencia funcional a 90 días. Conclusiones : El uso de la IA para el análisis de imá genes junto a un menor tiempo puerta-fin de imagen, permitió acortar el intervalo hasta la punción inguinal. En el análisis por horarios durante la pandemia, los pacientes ingresados en horario diurno presentaron métricas puerta-imagen, tiempo de imagen y puerta-recanalización significativamente menores.
Abstract Introduction : The start of the COVID-19 pandemic forced the implementation of changes in the emergency services care system. Concomitantly, at our institution, we implemented the artificial intelligence (AI) software, RAPID.AI, for image analysis in ischemic stroke (IS). Our objective was to evaluate the impact of the use of AI together with the changes in the triage during the COVID-19 pandemic in patients with stroke due to large vessel occlusion (LVO). Methods : We included patients with IS due to LVO treated with intravenous reperfusion therapy plus en dovascular or direct endovascular therapy. Results : Two groups were created. Group 1: patients from January 2019 to June 2020; Group 2: patients from July 2020 to December 2021, studied with RAPID.AI. Clini cal data and temporal metrics were analyzed. They were compared according to arrival time from 08:00 to 20:00 (daytime) vs 20:01 to 7:59 (night). Results: We included 286 patients, 153 in group 1 and 133 in group 2. In group 2, door-image metric and image duration were lower, with shorter door-image onset and door-recanalization times; patients who arrived at night had higher NIHSS and longer time from onset-to-door with lower propor tion of functional independence at 90 days (mRS ≤ 2). Conclusions : The use of AI for image analysis along with a shorter door to end of image time allowed to reduce the interval to groin puncture. In the analysis by hours during the pandemic, patients admitted in daytime hours had significantly lower door to image, image time acquisition, and door to recanalization metrics.