Early Postmarket Results with EmboTrap II Stent Retriever for Mechanical Thrombectomy: A Multicenter Experience.

BACKGROUND AND PURPOSE: EmboTrap II is a novel stent retriever with a dual-layer design and distal mesh designed for acute ischemic stroke emergent large-vessel occlusions. We present the first postmarket prospective multicenter experience with the EmboTrap II stent retriever. MATERIALS AND METHODS: A prospective registry of patients treated with EmboTrap II at 7 centers following FDA approval was maintained with baseline patient characteristics, treatment details, and clinical/radiographic follow-up. RESULTS: Seventy patients were treated with EmboTrap II (mean age, 69.9 years; 48.6% women). Intravenous thrombolysis was given in 34.3%, and emergent large-vessel occlusions were located in the ICA (n = 18), M1 (n = 38), M2 or M3 (n = 13), and basilar artery (n = 1). The 5 × 33 mm device was used in 88% of cases. TICI ≥ 2b recanalization was achieved in 95.7% (82.3% in EmboTrap II-only cases), and first-pass efficacy was achieved in 35.7%. The NIHSS score improved from a preoperative average of 16.3 to 12.1 postprocedure and to 10.5 at discharge. An average of 2.5 [SD, 1.8] passes was recorded per treatment, including non-EmboTrap attempts. Definitive treatment was performed with an alternative device (aspiration or stent retriever) in 9 cases (12.9%). Some hemorrhagic conversion was noted in 22.9% of cases, of which 4.3% were symptomatic. There were no device-related complications. CONCLUSIONS: Initial postmarket results with the EmboTrap II stent retriever are favorable and comparable with those of other commercially available stent retrievers. Compared with EmboTrap II, the first-generation EmboTrap may have a higher first-pass efficacy; however, data are limited by retrospective case analysis, incomplete clinical follow-up, and small sample size, necessitating future trials.

Impact of Time on Thrombolysis in Cerebral Infarction Score Results.

PURPOSE: Extended thrombolysis in cerebral infarction (eTICI) score results of 2b or higher are known to be predictors for favorable outcome after acute stroke. Additionally, time is a major factor influencing outcome after ischemic stroke. Until today only little is known about the impact of time on angiographic results regarding the outcome after mechanical thrombectomy; however, this impact might be of interest if an initially unfavorable angiographic result has to be improved. METHODS: Retrospective study of 164 patients with large vessel occlusion of the anterior circulation treated by mechanical thrombectomy. Multiple logistic regression analysis of relevant periprocedural and procedural times in respect to the probability of achieving functional independence at 90 days in respect to different eTICI results was performed to build a time and TICI score-dependent model for outcome prediction in which the influence of time was assumed to be steady among the TICI grades. RESULTS: The probability of achieving a favorable outcome is significantly different between eTICI2b-50, 67, TICI2c and TICI3 results (p < 0.001). The odds for achieving a favorable outcome decrease over time and differ for each TICI category and time point. The individual odds for each patient, time point and TICI grade can be calculated based on this model. CONCLUSION: The impact of periprocedural and procedural times and eTICI reperfusion results adds a new dimension to the decision-making process in patients with primary unfavorable angiographic results.

One-Stop Management with Perfusion for Transfer Patients with Stroke due to a Large-Vessel Occlusion: Feasibility and Effects on In-Hospital Times.

BACKGROUND AND PURPOSE: In-hospital time delays lead to a relevant deterioration of neurologic outcomes in patients with stroke with large-vessel occlusions. At the moment, CT perfusion is relevant in the triage of late-window patients with stroke. We conducted this study to determine whether one-stop management with perfusion is feasible and leads to a reduction of in-hospital times. MATERIALS AND METHODS: In this observational study, we report the first 15 consecutive transfer patients with stroke with externally confirmed large-vessel occlusions who underwent flat panel detector CT perfusion and thrombectomy in the same room. Preinterventional imaging consisted of noncontrast flat panel detector CT and flat panel detector CT perfusion, acquired with a biplane angiography system. The flat panel detector CT perfusion was used to reconstruct a flat panel detector CT angiography to confirm the large-vessel occlusions. After confirmation of the large-vessel occlusion, the patient underwent mechanical thrombectomy. We recorded time metrics and safety parameters prospectively and compared them with those of transfer patients whom we treated before the introduction of one-stop management with perfusion. RESULTS: Fifteen transfer patients underwent flat panel detector CT perfusion and were treated with mechanical thrombectomy from June 2017 to January 2019. The median time from symptom onset to admission was 241 minutes. Median door-to-groin time was 24 minutes. Compared with 23 transfer patients imaged with multidetector CT, it was reduced significantly (24 minutes; 95% CI, 19-37 minutes, versus 53 minutes; 95% CI, 44-66 minutes; P < .001). Safety parameters were comparable between groups. CONCLUSIONS: In this small series, one-stop management with perfusion led to a significant reduction of in-hospital times compared with our previous workflow.

The problem of strict image-based inclusion criteria for mechanical thrombectomy - an analysis of stroke patients with an initial low CBV-ASPECTS score.

INTRODUCTION: Endovascular treatment for acute ischaemic stroke with large artery occlusion has become the standard of care. However, the question if a subgroup of patients, with a low cerebral blood volume Alberta Stroke Program Early CT score (CBV-ASPECTS) ≤ 7 should be excluded from endovascular treatment remains open. Therefore; we investigated the difference of outcome between patients who were treated by endovascular treatment vs patients who did not receive endovascular treatment. METHODS: We retrospectively analysed our stroke database for all patients who presented within six hours of onset with unfavourable imaging findings and who received endovascular treatment or best medical treatment alone. Unfavourable imaging was defined as a CBV-ASPECTS ≤ 7, which was an exclusion criterion for endovascular treatment at our institution before 2015. RESULTS: From 60 patients with an initial CBV-ASPECTS ≤ 7, 40 received best medical treatment and 20 were treated with endovascular treatment. Arterial hypertension and atrial fibrillation was more present in patients without endovascular treatment, the other baseline characteristics and percentage of patients treated with intravenous recombinant tissue plasminogen activator were not significantly different in both groups. At discharge, 40% of the interventional treated patients had a favourable outcome (eight of 20 (40%) vs six of 40 (15%; p = 0.031). The median values of the National Institute of Health Stroke Score and modified Rankin Scale at discharge were significantly lower in the treated cohort (6.5 (2.5-10.5) vs 16 (9.5-22.5); p = 0.006; 3 (0-5.5) vs 5 (4.5-5.5); p = 0.003). CONCLUSION: Patients with a CBV-ASPECTS ≤ 7 are likely to benefit from therapy and therefore may not be excluded from endovascular treatment. Further randomised trials are warranted to validate the data.

Diagnosing Early Ischemic Changes with the Latest-Generation Flat Detector CT: A Comparative Study with Multidetector CT.

BACKGROUND AND PURPOSE: One-stop management of mechanical thrombectomy-eligible patients with large-vessel occlusion represents an innovative approach in acute stroke treatment. This approach reduces door-to-reperfusion times by omitting multidetector CT, using flat detector CT as pre-mechanical thrombectomy imaging. The purpose of this study was to compare the diagnostic performance of the latest-generation flat detector CT with multidetector CT. MATERIALS AND METHODS: Prospectively derived data from patients with ischemic stroke with large-vessel occlusion and mechanical thrombectomy were analyzed in this monocentric study. All included patients underwent multidetector CT before referral to our comprehensive stroke center and flat detector CT in the angiography suite before mechanical thrombectomy. Diagnosis of early ischemic signs, quantified by the ASPECTS, was compared between modalities using cross tables, the Pearson correlation, and Bland-Altman plots. The predictive value of multidetector CT- and flat detector CT-derived ASPECTS for functional outcome was investigated using area under the receiver operating characteristic curve analysis. RESULTS: Of 25 patients, 24 (96%) had flat detector CT with sufficient diagnostic quality. Median multidetector CT and flat detector CT ASPECTSs were 7 (interquartile range, 5.5-9 and 4.25-8, respectively) with a mean period of 143.6 ± 49.5 minutes between both modalities. The overall sensitivity was 85.1% and specificity was 83.1% for flat detector CT ASPECTS compared with multidetector CT ASPECTS as the reference technique. Multidetector CT and flat detector CT ASPECTS were strongly correlated (r = 0.849, P < .001) and moderately predicted functional outcome (area under the receiver operating characteristic curve, 0.738; P = .007 and .715; P = .069, respectively). CONCLUSIONS: Determination of ASPECTS on flat detector CT is feasible, showing no significant difference compared with multidetector CT ASPECTS and a similar predictive value for functional outcome. Our findings support the use of flat detector CT for emergency stroke imaging before mechanical thrombectomy to reduce door-to-groin time.

Risk prediction of very early recurrence, death and progression after acute ischaemic stroke.

BACKGROUND AND PURPOSE: Early recurrent strokes lead to extended hospitalization and high number of complications. We investigated three stroke scores, the Essen Stroke Risk Score (ESRS), the ABCD(2) and the Recurrence Risk Estimator at 90 days (RRE-90) for their prognostic value to predict early recurrent stroke, death and progressive stroke. METHODS: Clinical and radiological data from 1727 consecutive patients with ischaemic stroke, being admitted to the stroke unit, were evaluated retrospectively. Predictive value of stroke scores was tested for early recurrence within 7 days, death and progressive stroke expressed as observational risk and area under the receiver operator curve (AUROC). RESULTS: Early recurrent stroke occurred in 56 patients (3.2%), 40 patients (2.3%) died within the first 7 days and 125 patients (7.2%) had a progressive stroke. ESRS was not predictive for early recurrence, death or progressive stroke. ABCD(2) score was predictive for death (P<0.01; χ(2); AUROC, 0.65; 0.58-0.72), and progressive stroke (P<0.001; χ(2); AUROC, 0.70; 0.66-0.74). RRE-90 predicted early recurrent stroke (P<0.001; χ(2); AUROC, 0.65; 0.58-0.73), early death (P<0.001; χ(2); AUROC, 0.72; 0.66-0.78) and progressive stroke (P<0.001; χ(2); AUROC, 0.66; 0.61-0.71). CONCLUSIONS: RRE-90 bears high potential to not only predict early recurrence but also death and progression after ischaemic stroke. ABCD(2) appears to be useful to predict risk of death and progression. These findings have relevant clinical implications for early triage of patients being admitted to stroke units.