RESUMEN
BACKGROUND AND PURPOSE: Reocclusion after treatment is a concern in endovascular therapy (EVT) for isolated intracranial atherothrombotic stroke-related large vessel occlusion (AT-LVO). However, the optimal EVT technique for AT-LVO has not yet been investigated. This study evaluated the optimal EVT technique for AT-LVO in a real-world setting. MATERIALS AND METHODS: We conducted a historical multicenter registry study at 51 centers that enrolled patients with AT-LVO. We divided the patients into three groups based on the EVT technique: mechanical thrombectomy alone (MT-only), percutaneous transluminal angioplasty (PTA), and stent deployment (Stent). MT alone was classified into the MT-only group, PTA and MT-PTA into the PTA group, and MT-Stent, MT-PTA-Stent, PTA-Stent, and Stent-only into the Stent group. The primary outcome was the incidence of reocclusion of the treated vessels within 90 days of EVT completion. RESULTS: We enrolled 770 patients and analyzed 509 patients. The rates in the MT-only, PTA, and Stent groups were 40.7, 44.4, and 14.9%, respectively. The incidence rate of residual stenosis >70% of final angiography was significantly higher in the MT-only group than in the PTA and Stent groups (MT-only vs. PTA vs. Stent: 34.5% vs. 26.3% vs. 13.2%, p=0.002). The reocclusion rate was significantly lower in the PTA group than in the MT-only group (adjusted hazard ratio [95% confidence interval], 0.48 [0.29-0.80]). Of the patients, 83.5% experienced reocclusion within 10 days after EVT. Alarmingly, a substantial subset (approximately 62.0%) of patients underwent reocclusion within 2 days of EVT. The incidence of modified Rankin scale scores of 0-2 90 days after EVT was not significantly different among the three groups. The incidences of symptomatic intracranial hemorrhage (ICH), any other ICH, and death were not significantly different. CONCLUSIONS: The incidence rate of reocclusion was significantly lower in the PTA group than in the MT-only group. We found no significant difference in reocclusion rates between the Stent and MT-only groups. In Japan, GP IIb/IIIa inhibitors are not reimbursed. Therefore, PTA might be the preferred choice for AT-LVOs due to the higher reocclusion risk with MT-only. Reocclusion was likely to occur within 10 days, particularly within 2 days post-EVT. ABBREVIATIONS: EVT = endovascular treatment; LVO = large vessel occlusion; MT = mechanical thrombectomy; PTA = percutaneous transluminal angioplasty; ICH = intracranial hemorrhage; SD = standard deviation; IQR = interquartile range; HRs = hazard ratios; BMI = body mass index; LDL = low-density lipoprotein; HDL = high-density lipoprotein; DAPT = dual antiplatelet therapy; TAPT = triple antiplatelet therapy.
RESUMEN
BACKGROUND: The outcomes of endovascular thrombectomy (EVT) for medium vessel occlusions (MeVOs) of specific vascular territories remain unknown. We aimed to investigate EVT outcomes by MeVO locations using the data from an ongoing international multicenter registry. METHODS: Patients with isolated MeVO who underwent EVT between January 2013 and December 2022 were retrospectively analyzed. Isolated MeVO was defined as an occlusion of the A2 or A3 (A2/A3), M2 or M3, and P2 or P3 (P2/P3). Outcomes included a 90-day modified Rankin score (mRS) of 0-2, successful recanalization (modified Thrombolysis in Cerebral Infarction score ≥ 2b), early neurological deterioration (END) or improvement (ENI), and 90-day mortality. END was defined as a worsening of ≥4 points from the baseline National Institutes of Health Stroke Scale (NIHSS) score within 24 h of EVT, while ENI was defined as an improvement of ≥4 points from the baseline NIHSS score within 24 h of EVT. RESULTS: 1744 MeVOs included. Compared to M2 occlusions (n = 1542, 88.4%), A2/A3 (n = 36, 2.1%) occlusions had lower odds of 90-day mRS 0-2 (adjusted odds ratio [aOR] 0.30, 95% confidence interval [CI] 0.11-0.80), and P2/P3 occlusions (n = 49, 2.8%) had lower odds of successful recanalization (aOR 0.19, 95% CI 0.07-0.50), and higher odds of END (aOR 3.53, 95% CI 1.35-9.25). Other outcomes showed no significant differences. CONCLUSIONS: A2/A3 occlusions were more likely to have worse outcomes compared to M2 occlusions after EVT for patients with isolated MeVOs.
Asunto(s)
Procedimientos Endovasculares , Trombectomía , Humanos , Masculino , Femenino , Trombectomía/métodos , Anciano , Procedimientos Endovasculares/métodos , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Sistema de Registros , Anciano de 80 o más AñosRESUMEN
We reported the main results of the Japanese Registry of Neuroendovascular Therapy (JR-NET) 4, a nationwide surveillance of therapy (NET) in Japan from January 2015 to December 2019. JR-NET 4 registered consecutive patients who underwent NETs by Japan Society of Neuroendovascular Therapy (JSNET) -certified specialists. The primary endpoint was functional independence (mRS score of 0-2) at 30 days post-NET, with secondary endpoints focusing on technical success and major adverse events within 30 days.A total of 63,230 patients and 60,354 NET procedures from 166 participating centers were analyzed. During the study period, NET cases have consistently increased, with an increase in the proportion of elderly patients. A significant trend shift was observed in the distribution of NET procedures, with endovascular treatment for acute ischemic stroke that showed a dramatic increase in 5 years. This trend aligns with key randomized clinical trials from 2015 that presented the efficacy of this treatment. Clinical outcomes at 30 days posttreatment revealed that endovascular treatment for acute ischemic stroke and other NETs maintained safety and effectiveness despite varying prevalence of functional independence between target diseases. The study also observed a steady increase in emergency treatment cases, reflecting the increase in acute ischemic stroke, a time-sensitive medical condition.This comprehensive surveillance highlights the trend of NET practices in Japan, driven by clinical evidence and advancements in treatment devices. Although these findings were specific to Japan, they offer valuable insights into the broader trends in NETs and acute stroke care.
Asunto(s)
Procedimientos Endovasculares , Accidente Cerebrovascular Isquémico , Sistema de Registros , Humanos , Japón , Procedimientos Endovasculares/tendencias , Anciano , Masculino , Femenino , Persona de Mediana Edad , Accidente Cerebrovascular Isquémico/terapia , Accidente Cerebrovascular Isquémico/epidemiología , Anciano de 80 o más Años , Resultado del Tratamiento , Pueblos del Este de AsiaRESUMEN
BACKGROUND AND PURPOSE: We compared the outcomes of endovascular therapy (EVT) in an extended time window in patients with large-vessel occlusion (LVO) between patients with and without pre-stroke disability. METHODS: In this prespecified analysis of the multinational CT for Late Endovascular Reperfusion study (66 participating sites, 10 countries between 2014 and 2022), we analyzed data from patients with acute ischemic stroke with a pre-stroke modified Rankin Scale (mRS) score of 0-4 and LVO who underwent EVT 6-24 hours from the time last seen well. The primary outcome was the composite of functional independence (FI; mRS score 0-2) or return to the pre-stroke mRS score (return of Rankin, RoR) at 90 days. Outcomes were compared between patients with pre-stroke disability (pre-stroke mRS score 2-4) and those without (mRS score 0-1). RESULTS: A total of 2,231 patients (median age, 72 years; median National Institutes of Health Stroke Scale score, 16) were included in the present analysis. Of these, 564 (25%) had pre-stroke disability. The primary outcome (FI or RoR) was observed in 30.7% of patients with pre-stroke disability (FI, 16.5%; RoR, 30.7%) compared to 44.1% of patients without (FI, 44.1%; RoR, 13.0%) (P<0.001). In multivariable logistic regression analysis with inverse probability of treatment weighting, pre-stroke disability was not associated with significantly lower odds of achieving FI or RoR (adjusted odds ratio 0.73, 95% confidence interval 0.43-1.25). Symptomatic intracranial hemorrhage occurred in 6.3% of both groups (P=0.995). CONCLUSION: A considerable proportion of patients with late-presenting LVO and pre-stroke disability regained pre-stroke mRS scores after EVT. EVT may be appropriate for patients with pre-stroke disability presenting in the extended time window.
RESUMEN
BACKGROUND: The effectiveness and safety of carotid artery stenting (CAS) are comparable to those of carotid endarterectomy in both symptomatic and asymptomatic patients with carotid artery stenosis, but real-world outcomes are not well-known. OBJECTIVES: The purpose of this study was to investigate the real-world clinical outcomes of CAS in symptomatic and asymptomatic patients with carotid artery stenosis. METHODS: We conducted a nationwide retrospective registry study of 156 centers between January 2015 and December 2019. We enrolled consecutive patients with CAS managed by certified specialists from the Japanese Society of Neuroendovascular Therapy. Outcomes between symptomatic and asymptomatic patients were compared. The primary outcome was a composite of ischemic stroke and all-cause death at 30 days after CAS. Secondary outcomes were ischemic stroke, all-cause death, intracranial hemorrhage (ICH), and procedural complications. RESULTS: We analyzed 9,792 patients (symptomatic, n = 5,351; asymptomatic, n = 4,441). The mean age was 73.5 years, and men were dominant (86.4%). Embolism protection devices were used in 99% of patients. The primary outcome was not significantly different between the symptomatic and asymptomatic groups (120 [2.2%] vs 65 [1.5%]; adjusted OR: 1.30; 95% CI: 0.92-1.83). The incidences of symptomatic ICH, any ICH, acute in-stent occlusion, and hyperperfusion syndrome were significantly more prevalent in the symptomatic group (47 [0.9%] vs 8 [0.2%], aOR: 4.41 [95% CI: 1.68-11.6]; 73 [1.4%] vs 12 [0.3%], aOR: 3.56 [95% CI: 1.71-7.39]; 45 [0.8%] vs 19 [0.4%], aOR: 2.18 [95% CI: 1.08-4.40]; and 102 [1.9%] vs 36 [0.8%], aOR: 1.78 [95% CI: 1.17-2.71], respectively). Other secondary outcomes were not significantly different between the 2 groups. CONCLUSIONS: The complication rate after specialist-involved CAS at 30 days was low in real-world practice.
Asunto(s)
Enfermedades Asintomáticas , Estenosis Carotídea , Procedimientos Endovasculares , Sistema de Registros , Stents , Humanos , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/terapia , Estenosis Carotídea/mortalidad , Estenosis Carotídea/complicaciones , Masculino , Femenino , Anciano , Estudios Retrospectivos , Resultado del Tratamiento , Factores de Tiempo , Factores de Riesgo , Japón , Anciano de 80 o más Años , Medición de Riesgo , Persona de Mediana Edad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Accidente Cerebrovascular Isquémico/mortalidad , Accidente Cerebrovascular Isquémico/etiología , Hemorragias Intracraneales/etiologíaRESUMEN
BACKGROUND: Studies comparing bridging intravenous thrombolysis (IVT) with direct endovascular therapy (EVT) in patients with acute ischemic stroke who present late are limited. We aimed to compare the clinical outcomes and safety of bridging IVT in patients with acute ischemic stroke due to anterior circulation large vessel occlusion who underwent EVT 6 to 24 hours after time last known well. METHODS: We enrolled patients with anterior circulation large vessel occlusion stroke and a National Institutes of Health Stroke Scale score of ≥6 from 20 centers across 10 countries in the multicenter retrospective CLEAR study (CT for Late Endovascular Reperfusion) between January 2014 and May 2022. We used inverse probability of treatment weighting modeling adjusted for clinical and imaging confounders to compare functional outcomes, reperfusion success, symptomatic intracranial hemorrhage, and mortality between EVT patients with and without prior IVT. RESULTS: Of 5098 patients screened for eligibility, we included 2749 patients, of whom 549 received bridging IVT before EVT. The timing of IVT was not recorded. Witnessed stroke onset and transfer rates were higher in the bridging IVT group (25% versus 12% and 77% versus 55%, respectively, P value for both <0.0001), and time intervals between stroke onset and treatment were shorter (time last known well-start of EVT median 560 minutes [interquartile range, 432-791] versus 724 minutes [interquartile range, 544-912]; P<0.0001). After adjustment for confounders, there was no difference in functional outcome at 3 months (adjusted common odds ratio for modified Rankin Scale shift, 1.03 [95% CI, 0.89-1.19]; P=0.72) or successful reperfusion (adjusted odds ratio, 1.19 [95% CI, 0.81-1.75]; P=0.39). There were no safety concerns associated with bridging IVT versus direct EVT (symptomatic intracranial hemorrhage: adjusted odds ratio, 0.75 [95% CI, 0.38-1.48]; P=0.40; mortality: adjusted odds ratio, 1.14 [95% CI, 0.89-1.46]; P=0.31). Results were unchanged when the analysis was limited to patients who received IVT >6 hours after last known well. CONCLUSIONS: In patients with an anterior circulation large vessel occlusion stroke who underwent EVT 6 to 24 hours from last known well, bridging IVT was not associated with a difference in outcomes compared with direct EVT. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04096248.
Asunto(s)
Procedimientos Endovasculares , Accidente Cerebrovascular Isquémico , Terapia Trombolítica , Humanos , Masculino , Femenino , Anciano , Accidente Cerebrovascular Isquémico/terapia , Accidente Cerebrovascular Isquémico/tratamiento farmacológico , Accidente Cerebrovascular Isquémico/cirugía , Procedimientos Endovasculares/métodos , Persona de Mediana Edad , Terapia Trombolítica/métodos , Resultado del Tratamiento , Estudios Retrospectivos , Anciano de 80 o más Años , Fibrinolíticos/uso terapéutico , Fibrinolíticos/administración & dosificación , Tiempo de Tratamiento , Isquemia Encefálica/tratamiento farmacológico , Isquemia Encefálica/terapiaRESUMEN
BACKGROUND: We aimed to examine the boundary of the ischemic core volume in patients undergoing endovascular thrombectomy (EVT) versus those receiving medical management to determine the minimum optimal size for favorable treatment outcomes. METHODS: This is a prespecified substudy of the RESCUE-Japan LIMIT (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism-Japan Large Ischemic Core Trial). Patients with large vessel occlusion were enrolled between November 2018 and September 2021 with a National Institutes of Health Stroke Scale score of at least 6 on admission and an Alberta Stroke Program Early Computed Tomography Score value of 3 to 5. We investigated the correlation between optimal quantified ischemic core volume, assessed solely using magnetic resonance diffusion-weighted imaging, and functional outcomes (modified Rankin Scale score, 0-3) at 90 days by predictive marginal plots. Final infarct volume and safety outcomes (symptomatic intracerebral hemorrhage and mortality) were also assessed. RESULTS: Of the 203 cases, 168 patients (85 in the EVT group versus 83 in the medical management group) were included. The median (interquartile range) core volume was 94 (65-160) mL in patients with EVT and 115 (71-141) mL in the medical management group (P=0.72). The predictive marginal probabilities of the 2 groups intersected at 128 mL for estimating functional outcomes. Symptomatic intracerebral hemorrhage and mortality within 90 days had overlay margins through all core volumes in both groups. The median final infarct volume (interquartile range) was smaller in the EVT group (142 [80-223] mL versus 211 [123-289] mL in the medical management group; P<0.001). CONCLUSIONS: In this prespecified analysis of a randomized clinical trial involving patients with large ischemic strokes, patients with an estimated core volume of up to 128 mL on diffusion-weighted imaging benefit from EVT. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03702413.
Asunto(s)
Procedimientos Endovasculares , Accidente Cerebrovascular Isquémico , Trombectomía , Humanos , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Accidente Cerebrovascular Isquémico/cirugía , Accidente Cerebrovascular Isquémico/terapia , Masculino , Femenino , Anciano , Trombectomía/métodos , Procedimientos Endovasculares/métodos , Persona de Mediana Edad , Anciano de 80 o más Años , Imagen de Difusión por Resonancia Magnética , Resultado del Tratamiento , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/terapia , Isquemia Encefálica/cirugíaRESUMEN
OBJECTIVE: Existing evidence is inconclusive on whether women after carotid artery stenting (CAS) experience worse outcomes than men. METHODS: The outcomes of women and men were compared using the data from nationwide retrospective registry between 2015 and 2019. The primary outcome was the incidence of ischemic stroke and all-cause death. Secondary outcomes included the incidence of ischemic stroke, all-cause death, acute occlusion, and acute myocardial infarction. Functional outcomes were the achieving an mRS score of 0-1 and 0-2. Outcomes were assessed at 30 days after CAS. RESULTS: In total, 9792 patients (1330 women, 8862 men; mean age, 73.8 vs 73.5 years, p = 0.17) were analyzed. Symptomatic stenosis was common in men (52.0% vs. 55.1%; p = 0.03), while ≥50% stenosis after CAS was common in women (3.2% vs. 2.0%; p = 0.005). The primary outcome was no significantly difference in women and men (2.0% vs. 1.9%; adjusted odds ratio [aOR], 1.19; 95% confidence interval [95%CI], 0.75-1.88).The incidence of all-cause death was higher in women (0.9% vs. 0.5%; aOR, 2.45; 95%CI, 1.11-5.39). Functional outcomes were significantly less common in women than in men (mRS0-1, 72.6% vs. 74.8%; aOR, 0.77; 95%CI, 0.63-0.95; mRS0-2, 82.1% vs. 85.6%; aOR, 0.76; 95%CI, 0.60-0.95). CONCLUSIONS: This study suggests that there was no significant sex differences in the incidence of ischemic stroke and all-cause death at 30 days. However, women have higher rate of all-cause death and poorer functional outcomes at 30 days than men.
Asunto(s)
Estenosis Carotídea , Caracteres Sexuales , Stents , Humanos , Masculino , Femenino , Anciano , Estenosis Carotídea/cirugía , Estudios Retrospectivos , Resultado del Tratamiento , Sistema de Registros , Anciano de 80 o más Años , Factores Sexuales , Persona de Mediana Edad , Accidente Cerebrovascular Isquémico/epidemiología , IncidenciaRESUMEN
BACKGROUND AND OBJECTIVES: This study aimed to compare outcomes of low Alberta Stroke Program Early Computed Tomography Score (ASPECTS) patients with stroke who underwent mechanical thrombectomy (MT) within 6 hours or 6 to 24 hours after stroke onset. METHODS: A retrospective cohort study was conducted using data from a large multicenter international registry from 2013 to 2023. Patients with low ASPECTS (2-5) who underwent MT for anterior circulation intracranial large vessel occlusion were included. A propensity matching analysis was conducted for patients presented in the early (<6 hours) vs late (6-24 hours) time window after symptom onset or last known normal. RESULTS: Among the 10 229 patients who underwent MT, 274 met the inclusion criteria. 122 (44.5%) patients were treated in the late window. Early window patients were older (median age, 74 years [IQR, 63-80] vs 66.5 years [IQR, 54-77]; P < .001), had lower proportion of female patients (40.1% vs 54.1%; P = .029), higher median admission National Institutes of Health Stroke Scale score (20 [IQR, 16-24] vs 19 [IQR, 14-22]; P = .004), and a higher prevalence of atrial fibrillation (46.1% vs 27.3; P = .002). Propensity matching yielded a well-matched cohort of 84 patients in each group. Comparing the matched cohorts showed there was no significant difference in acceptable outcomes at 90 days between the 2 groups (odds ratio = 0.90 [95% CI = 0.47-1.71]; P = .70). However, the rate of symptomatic ICH was significantly higher in the early window group compared with the late window group (odds ratio = 2.44 [95% CI = 1.06-6.02]; P = .04). CONCLUSION: Among patients with anterior circulation large vessel occlusion and low ASPECTS, MT seems to provide a similar benefit to functional outcome for patients presenting <6 hours or 6 to 24 hours after onset.
RESUMEN
BACKGROUND: The safety and efficacy of endovascular coiling of ruptured tiny saccular intracranial aneurysms (IAs) (≤3 mm) remain unknown. METHODS: A comprehensive search of PubMed, Embase, Web of Science, and Scorpus databases up to November 15, 2023 was performed. Pooled prevalence was calculated for occlusion rates, recanalization, retreatment, long-term favorable outcome, and procedure-related complications and mortality. Pooled odds ratios were calculated to compare these outcomes between coiling and stent-assisted coiling (SAC). RESULTS: Forty-two studies with 2166 ruptured tiny saccular IAs treated with coiling were included. The follow-up complete aneurysm occlusion rate was 83.9% (95% CI: 77.2-88.9%). The rates of recanalization and retreatment were 7.7% (95% CI: 5.7-10.2%) and 5.8% (95% CI: 4.5-7.5%). The range of median Hunt and Hess grades was 1.4-2.9 and the favorable outcome rate was 85.6% (95% CI: 81.1-89.2%). The rates of thromboembolism, intraprocedural rupture, and mortality were 4.6% (95% CI: 3.6-5.8%), 5.4% (95% CI: 4.1-7.0%), and 5.6% (95% CI: 4.4-7.2%), respectively. Comparison of coiling and SAC revealed no significant difference, except for a higher likelihood of follow-up complete aneurysm occlusion in SAC (odds ratio [OR] 0.37, 95% CI: 0.17-0.80) and recanalization in the coiling (OR, 3.21 [95% CI, 1.37-7.51]). CONCLUSIONS: Our meta-analysis demonstrates that coiling for ruptured tiny saccular IA is a feasible, effective, and safe approach that is associated with favorable clinical outcomes in both the short and long term for patients with mild to moderate Hunt and Hess grades.
Asunto(s)
Aneurisma Roto , Procedimientos Endovasculares , Aneurisma Intracraneal , Humanos , Aneurisma Intracraneal/terapia , Aneurisma Intracraneal/cirugía , Aneurisma Intracraneal/diagnóstico por imagen , Procedimientos Endovasculares/métodos , Procedimientos Endovasculares/instrumentación , Aneurisma Roto/cirugía , Aneurisma Roto/terapia , Aneurisma Roto/diagnóstico por imagen , Embolización Terapéutica/métodos , Embolización Terapéutica/instrumentación , Resultado del Tratamiento , StentsRESUMEN
BACKGROUND AND OBJECTIVES: The impact of race on outcomes in the treatment of intracranial aneurysm (IA) remains unclear. We aimed to investigate the relationship between race classified into White, Black, Hispanic, and other and treatment outcomes in patients with ruptured and unruptured IAs. METHODS: The study population consisted of 2836 patients with IA with endovascular treatment or microsurgical treatment (MST) from 16 centers in the United States and Asia, all participating in the observational "STAR" registry. The primary outcome was a 90-day modified Rankin Scale of 0 to 2. Secondary outcomes included periprocedural cerebral infarction and intracranial hemorrhage, perioperative symptomatic cerebral vasospasm in ruptured IA and mortality, and all causes of mortality within 90 days. RESULTS: One thousand fifty-three patients were White (37.1%), 350 were Black (12.3%), 264 were Hispanic (9.3%), and 1169 were other (41.2%). Compared with White patients, Hispanic patients had a significantly lower proportion of primary outcome (adjusted odds ratio [aOR] 0.36, 95% CI, 0.23-0.56) and higher proportion of the periprocedural cerebral infarction, perioperative mortality, and all causes of mortality (aOR 2.53, 95% CI, 1.40-4.58, aOR 1.84, 95% CI, 1.00-3.38, aOR 1.83, 95% CI, 1.06-3.17, respectively). Outcomes were not significantly different in Black and other patients. The subgroup analysis showed that Hispanic patients with age ≥65 years (aOR 0.19, 95% CI, 0.10-0.38, interaction P = .048), Hunt-Hess grades 0 to 3 (aOR 0.29, 95% CI, 0.19-0.46, interaction P = .03), and MST (aOR 0.24, 95% CI, 0.13-0.44, interaction P = .04) had a significantly low proportion of primary outcome. CONCLUSION: This study demonstrates that Hispanic patients with IA are more likely to have a poor outcome at 90 days after endovascular treatment or MST than White patients. Physicians have to pay attention to the selection of treatment modalities, especially for Hispanic patients with specific factors to reduce racial discrepancies.
RESUMEN
BACKGROUND: Endovascular therapy (EVT) reduces functional disability in patients with acute large vessel occlusion (LVO). However, the early neurological change after EVT may be limited in patients with intracranial atherosclerotic disease (ICAD). METHODS: We analyzed the Japanese Registry of NeuroEndovascular Therapy (JR-NET) 4 which was a retrospective, nationwide, multicenter registry of patients with LVO between 2015 and 2019. We compared the early neurological change, efficacy and safety of EVT for acute LVO in ICAD and other etiologies. The primary outcome was NIHSS improvement ≥10 points, and secondary outcome were NIHSS worsening ≥4 points 7 days after EVT, effective reperfusion rate, 30-day functional outcomes, and safety outcomes. RESULTS: Among the 6710 enrolled patients, 610 (9.1%) had ICAD. The ICAD group was younger (mean 72.0 vs. 75.8 years) and predominantly male (63.4% vs. 56.0%), had lower NIHSS scores before EVT (median 16 vs. 18), and underwent percutaneous transluminal angioplasty and stenting more frequently (43.0% vs. 4.4%, 12.3% vs. 4.4%). In the ICAD group, NIHSS improvement was significantly lower (adjusted odds ratio (aOR) [95% confidence interval (95%CI)] 0.52 [0.41-0.65]), NIHSS worsening was significantly higher (aOR [95%CI] 1.76 [1.31-2.34]), and effective reperfusion was significantly lower (aOR [95%CI] 0.47 [0.36-0.60]). Fewer patients with ICAD had modified Rankin scale 0-2 at 30 days (aOR [95%CI] 0.60 [0.47-0.77]). The risk of acute reocclusion was more prominent in the ICAD group (aOR [95%CI] 4.03 [1.98-8.21]). CONCLUSIONS: Improvement in neurological severity after EVT was lower in patients with LVO and ICAD.
Asunto(s)
Procedimientos Endovasculares , Arteriosclerosis Intracraneal , Sistema de Registros , Humanos , Masculino , Femenino , Arteriosclerosis Intracraneal/cirugía , Arteriosclerosis Intracraneal/terapia , Arteriosclerosis Intracraneal/complicaciones , Arteriosclerosis Intracraneal/diagnóstico por imagen , Procedimientos Endovasculares/métodos , Anciano , Estudios Retrospectivos , Persona de Mediana Edad , Anciano de 80 o más Años , Resultado del Tratamiento , Accidente Cerebrovascular/terapia , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/cirugía , Japón/epidemiología , Accidente Cerebrovascular Isquémico/terapia , Accidente Cerebrovascular Isquémico/cirugía , Accidente Cerebrovascular Isquémico/complicacionesRESUMEN
BACKGROUND: Endovascular treatment (EVT) has become standard of care for patients with anterior circulation large vessel occlusion (LVO) stroke, with indications having recently expanded to late time-window and large ischemic core patients. There is conflicting evidence on whether EVT reduces mortality or only disability. We performed a meta-analysis of randomized controlled trials (RCTs) to assess the effect of EVT on mortality and severe disability. METHODS: We systematically searched PubMed, Web of Science, Scopus, and Embase on November 15, 2023, to identify phase 3 RCTs comparing EVT to best medical treatment (BMT) in patients with anterior circulation LVO stroke in a common effects meta-analysis. The primary outcome was mortality at 3 months. Secondary outcomes were moderately severe or severe disability (modified Rankin Scale (mRS) score 4-5) at 3 months. RESULTS: 18 studies comparing EVT to BMT were included, with a total of 4309 patients; 2159 that were treated with EVT, and 2150 treated with BMT. Mortality was significantly lower in the EVT group than in the BMT group (odds ratio (OR): 0.81, 95% CI: 0.70-0.94). Proportions of moderately severe or severe disability (OR: 0.55, 95% CI: 0.48-0.62) were also significantly lower in patients treated with EVT. CONCLUSIONS: This meta-analysis suggests that EVT reduces both mortality and moderately severe or severe disability in patients with anterior circulation LVO stroke.
Asunto(s)
Procedimientos Endovasculares , Ensayos Clínicos Controlados Aleatorios como Asunto , Humanos , Procedimientos Endovasculares/métodos , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/terapia , Personas con Discapacidad , Evaluación de la DiscapacidadRESUMEN
BACKGROUND: Little is known about endovascular therapy (EVT) for patients with medium vessel occlusion (MeVO) and more work is needed to establish its efficacy and to understand hemorrhagic complications. METHODS: We analyzed the Japan Trevo Registry, which enrolled patients with acute stroke who underwent EVT using Trevo Retriever alone or in combination with an aspiration catheter. The primary outcome was effective reperfusion, and the secondary outcome was modified Rankin scale 0-2 at 90 days. Safety outcomes, including intracranial hemorrhage (ICH), were evaluated using a subgroup analyses focused on any ICH. RESULTS: Among 1041 registered patients, 1025 patients were analyzed. 253 patients had MeVOs, and the majority (89.3%) had middle cerebral artery segment 2 (M2). The median National Institutes of Health Stroke Scale scores at admission were 15 and 19 for the MeVO and LVO groups (p < 0.0001). The primary outcome was 88.9% in MeVO vs. 91.8% in LVO group: adjusted odds ratio (aOR) [95% confidence interval (CI)] 0.60 [0.35-1.03], p = 0.07, and the secondary outcome was 43.2% vs. 42.2%, and the aOR [95%CI] was 0.70 [0.48-1.002], p = 0.051. However, the incidence of any ICH was more prominent in MeVO than in LVO group (35.7% vs. 28.8%, aOR [95%CI] 1.54 [1.10-2.15], p = 0.01). In subgroup analyses, the incidences of any ICH in MeVO group were generally higher than those in LVO group. CONCLUSIONS: The effective reperfusion rate did not differ significantly between MeVO and LVO groups. Future development of devices and treatments for MeVO with fewer hemorrhagic complications is desirable.
Asunto(s)
Isquemia Encefálica , Procedimientos Endovasculares , Accidente Cerebrovascular , Humanos , Isquemia Encefálica/cirugía , Isquemia Encefálica/etiología , Japón/epidemiología , Resultado del Tratamiento , Procedimientos Endovasculares/efectos adversos , Accidente Cerebrovascular/cirugía , Accidente Cerebrovascular/etiología , Trombectomía/efectos adversos , Hemorragias Intracraneales/epidemiología , Hemorragias Intracraneales/etiología , Hemorragias Intracraneales/cirugía , Sistema de RegistrosRESUMEN
Although low-dose direct oral anticoagulants (DOACs) are recommended for patients at high risk of bleeding complications, it remains unclear whether the dose reduction in real-world setting is also appropriate in patients after large-vessel occlusion (LVO) stroke. This study hypothesized that patients with atrial fibrillation (AF) and LVO receiving low-dose DOACs have an increased risk of ischemic and hemorrhagic events. The study aimed to assess 1 year morbidity and mortality in patients treated with standard-dose and low-dose apixaban after LVO stroke. A post hoc analysis was performed using the acute LVO registry data, which enrolled patients with AF and LVO who received apixaban within 14 days of stroke onset. The incidences of ischemic events (ischemic stroke, acute coronary syndrome, acute myocardial infarction, and systemic embolism), major bleeding events, and death from any cause were compared between patients receiving standard- and low-dose apixaban. Of 643 patients diagnosed with LVO, 307 (47.7%) received low-dose apixaban. After adjustment for clinically relevant variables, no significant differences were observed in the incidence of ischemic events (adjusted hazard ratio [aHR]: 2.12, 95% confidence interval [CI] 0.75-6.02), major bleeding events (aHR: 1.17, 95% CI 0.50-2.73), and death from any cause (aHR: 1.95, 95% CI 0.78-4.89) between patients receiving standard- and low-dose apixaban. No significant differences were observed in the incidence of ischemic events, major bleeding events, or death from any cause between patients with AF and LVO receiving standard- and low-dose apixaban.
Asunto(s)
Fibrilación Atrial , Accidente Cerebrovascular Isquémico , Pirazoles , Accidente Cerebrovascular , Humanos , Anticoagulantes/uso terapéutico , Accidente Cerebrovascular/etiología , Hemorragia/inducido químicamente , Piridonas/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Accidente Cerebrovascular Isquémico/complicaciones , MorbilidadRESUMEN
BACKGROUND AND PURPOSE: Outcomes following mechanical thrombectomy (MT) are strongly correlated with successful recanalization, traditionally defined as modified Thrombolysis in Cerebral Infarction (mTICI) ≥2b. This retrospective cohort study aimed to compare the outcomes of patients with low Alberta Stroke Program Early Computed Tomography Score (ASPECTS; 2-5) who achieved mTICI 2b versus those who achieved mTICI 2c/3 after MT. METHODS: This study utilized data from the Stroke Thrombectomy and Aneurysm Registry (STAR), which combined databases from 32 thrombectomy-capable stroke centers between 2013 and 2023. The study included only patients with low ASPECTS who achieved mTICI 2b, 2c, or 3 after MT for internal carotid artery or middle cerebral artery (M1) stroke. RESULTS: Of the 10,229 patients who underwent MT, 234 met the inclusion criteria. Of those, 98 (41.9%) achieved mTICI 2b, and 136 (58.1%) achieved mTICI 2c/3. There were no significant differences in baseline characteristics between the two groups. The 90-day favorable outcome (modified Rankin Scale score: 0-3) was significantly better in the mTICI 2c/3 group than in the mTICI 2b group (adjusted odds ratio 2.35; 95% confidence interval [CI] 1.18-4.81; P=0.02). Binomial logistic regression revealed that achieving mTICI 2c/3 was significantly associated with higher odds of a favorable 90-day outcome (odds ratio 2.14; 95% CI 1.07-4.41; P=0.04). CONCLUSION: In patients with low ASPECTS, achieving an mTICI 2c/3 score after MT is associated with a more favorable 90-day outcome. These findings suggest that mTICI 2c/3 is a better target for MT than mTICI 2b in patients with low ASPECTS.
RESUMEN
BACKGROUND: The safety and effectiveness of stent retriever use for patients with acute large vessel occlusion (LVO) due to intracranial atherosclerotic disease (ICAD) is not well established. We investigated the differences in clinical outcomes in patients with and without ICAD. METHODS: We analyzed the Japan Trevo Registry, a nationwide registry which enrolled patients with acute LVO who underwent endovascular therapy (EVT) using the Trevo retriever alone or in combination with an aspiration catheter. We compared the technical and clinical outcomes of EVT between the ICAD and No-ICAD groups. The primary outcome was effective reperfusion and the secondary outcome was modified Rankin scale (mRS) score 0-2 at 90 days. Safety outcomes were worsening of neurologic symptoms within 24 hours, any intracranial hemorrhage within 24 hours, vessel dissection/vessel perforation related to using the Trevo retriever and mortality at 90 days. RESULTS: A total of 835 patients (45 in the ICAD group and 790 in the No-ICAD group) were analyzed. In the ICAD group, more men (68.9% vs 50.8%, P=0.02) and a lower median National Institutes of Health Stroke Scale score at admission (11 vs 18, P<0.0001) were observed. The primary outcome was significantly more common in the No-ICAD group (92.5%) than in the ICAD group (80.0%) (adjusted odds ratio (aOR) 0.21, 95% CI 0.09 to 0.50). The proportion of patients with mRS score 0-2 at 90 days was significantly lower in the ICAD group (44.4% vs 42.4%, aOR 0.49, 95% CI 0.23 to 1.00, P=0.0496). Other secondary and safety outcomes were not significantly different between the two groups. CONCLUSIONS: Patients with LVO with ICAD had a lower rate of effective reperfusion than those with No-ICAD.
RESUMEN
BACKGROUND: The association between sex and outcome after endovascular thrombectomy of acute ischemic stroke is unclear. The aim of this study was to compare the clinical and safety outcomes between men and women treated with endovascular thrombectomy in the late 6-to-24-hour window period. METHODS: This multicenter, retrospective observational cohort study included consecutive patients who underwent endovascular thrombectomy of anterior circulation stroke in the late window from 66 clinical sites in 10 countries from January 2014 to May 2022. The primary outcome was the 90-day ordinal modified Rankin Scale score. Secondary outcomes included 90-day functional independence (FI), return of Rankin (RoR) to prestroke baseline, FI or RoR, symptomatic intracranial hemorrhage, and mortality. Multivariable and inverse probability of treatment weighting methods were used. We explored the interaction of sex with baseline characteristics on the outcomes ordinal modified Rankin Scale and FI or RoR. RESULTS: Of 1932 patients, 1055 were women and 877 were men. Women were older (77 versus 69 years), had higher rates of atrial fibrillation, hypertension, and greater prestroke disability, but there was no difference in baseline National Institutes of Health Stroke Scale score. Inverse probability of treatment weighting analysis showed no difference between women and men in ordinal modified Rankin Scale (odds ratio, 0.98 [95% CI, 0.79-1.21]), FI or RoR (odds ratio, 0.98 [95% CI, 0.78-1.22]), severe disability or mortality (odds ratio, 0.99 [95% CI, 0.80-1.23]). The multivariable analysis of the above end points was concordant. There were no interactions between baseline characteristics and sex on the outcomes of ordinal modified Rankin Scale and FI or RoR. CONCLUSIONS: In late presenting patients with anterior circulation stroke treated with endovascular thrombectomy in the 6 to 24-hour window, there was no difference in clinical or safety outcomes between men and women.
Asunto(s)
Fibrilación Atrial , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Estados Unidos , Humanos , Femenino , Masculino , Caracteres Sexuales , Estudios Retrospectivos , Accidente Cerebrovascular/cirugíaRESUMEN
BACKGROUND AND OBJECTIVES: Some studies have shown that female patients had a poorer prognosis after endovascular treatment for ruptured intracranial aneurysm than male patients. However, data have been sparse regarding differences in the periprocedural and perioperative complication rate with ruptured and unruptured intracranial aneurysms. METHODS: This retrospective cohort study used data from the Stroke Thrombectomy and Aneurysm Registry, a database of 9 institutions in the United States, Europe, and Asia. The study presented intracranial aneurysms after microsurgical and/or endovascular treatment from January 1, 2013, to December 31, 2022. The primary outcome was incidence of periprocedural cerebral infarction. Secondary outcomes were periprocedural intracranial hemorrhage, periprocedural mortality, perioperative vasospasm, and functional outcome at 90 days after procedure. RESULTS: Among 3342 patients with aneurysm, 2447 were female and 857 were male, and the mean age of female and male patients was 59.6 and 57.1 years, respectively. Current smoker, family history of aneurysm, and ruptured aneurysm were observed in 23.5% vs 35.7 %, 10.8 % vs 5.7%, and 28.2% vs 40.5% of female and male patients, respectively. In female patients, internal carotid artery aneurysms were more commonly observed (31.1% vs 17.3%); however, anterior cerebral artery aneurysms were less commonly observed (18.5% vs 33.8%) compared with male patients. Periprocedural cerebral infarction rate was lower in female than male patients (2.4% vs 4.4%; P = .002). The adjusted odds ratio of primary outcome of female to male patients was 0.72 (95% CI, 0.46-1.12). Incidence of periprocedural intracranial hemorrhage and periprocedural mortality and perioperative symptomatic vasospasm and functional outcome was similar in both groups. In subgroup analysis, periprocedural cerebral infarction due to microsurgical treatment occurred frequently in male patients while incidence in endovascular treatment was similar in both groups (interaction P = .005). CONCLUSION: This large multicenter registry of patients undergoing intracranial aneurysm treatment found that female patients were not at increased risk of perioperative complications.