Comparing Bridging Thrombolysis with Direct Thrombectomy in Stroke due to Large Vessel Occlusion- Indian Experience (LVO-Direct).

Objectives: Intravenous thrombolysis alone has poor recanalization rates in large vessel occlusion strokes. Bridging thrombolysis has evolved as a standard treatment approach in emergent large vessel occlusions. Patients who undergo thrombectomy have a higher probability of favorable outcomes irrespective of the use of prior intravenous thrombolysis. Our aim was to compare bridging thrombolysis with direct thrombectomy in ischemic stroke due to large vessel occlusion. Methods: We included patients from our stroke registry, with large vessel occlusion strokes, presenting <4.5 hr from onset. Bridging thrombolysis was the standard approach. Direct thrombectomy was done in patients with contraindications to intravenous thrombolysis. The primary outcome was the modified Rankin scale at 3 months. Secondary outcomes were National Institute of Health Stroke Scale at 24 hr post-procedure, door to puncture time, puncture to recanalization time, the extent of recanalization, and the number of passes required. Safety outcomes were any occurrence of intracranial hemorrhage or other complications related to procedure or death. Logistic regression analysis was used to find the factors affecting the outcome. Results: Total 76 patients were included, 29 underwent bridging thrombolysis and 47 underwent direct thrombectomy. A favorable outcome (mRS 0-2) was achieved in 19 (65.5%) patients in the bridging group and 25 (58.1%) patients in the direct group (P = 0.4, Chi-square test). There was no significant difference in any of the secondary outcomes as well. Symptomatic intracranial hemorrhage occurred in 2 (2.6%) patients and a total of 10 (13.9%) were dead at 3-month follow-up, comparable in both groups. Conclusion: Direct thrombectomy has comparable outcomes to bridging thrombolysis in emergent large vessel occlusions.

Mechanical Thrombectomy: Review.

Large vessel occlusion stroke contributes to disability and mortality out of proportion to its incidence. Over time it was noted that intravenous thrombolysis alone was not sufficient for this stroke type. Slowly, endovascular approach and mechanical clot retrieval have come out to be the biggest advances in the field of neurology as well as modern medicine. Although the careful selection of patients is needed as standardized by landmark trials. At the same time, thrombectomy is now being studied in patients excluded by previous trials and is seemingly coming out be effective in the vast majority of patients with large vessel occlusions. Further, techniques and devices are getting refined day by day to achieve the maximum possible benefit.

Rescue Stenting for Refractory Large Vessel Occlusions in the Thrombectomy Era: Intracranial Use of Coronary Stents in Low-mid Economic Settings.

BACKGROUND:  Failed mechanical thrombectomy due to a refractory emergent large vessel occlusion (RELVO) in patients presenting with an acute stroke poses a major challenge to the outcomes. OBJECTIVE:  We demonstrate the use of coronary stents in the intracranial circulation as rescue stenting for an already expensive mechanical thrombectomy procedure in a mid-low socioeconomic setting. METHODS:  A retrospective, multicenter study was conducted between December 2015 and January 2021. The studied cohort were patients who required the use of a rescue stenting using a coronary stent for emergent large vessel occlusion to avoid failed recanalization. Failed recanalization was defined as failed vessel recanalization after at least two passes. Patient demographic data, procedure specifics, type of stent used, and procedural outcomes were collected. RESULTS:  A total of 26 patients with acute ischemic stroke were included from eight different centers across India. Out of 26 patients, 19 (73.0%) were male and seven were female (26.9%). The mean age was 53.6 years, the youngest patient was 23 years old and the eldest was 68 years old. Seven patients (26.9%) had posterior circulation stroke due to occlusion of the vertebral or basilar artery and 19 patients (73.0%) had anterior circulation stroke median NIHSS at presentation was 16 (range 10 to 28) in anterior circulation stroke and 24 (range 16 to 30) in posterior circulation stroke. Intravenous thrombolysis with tissue plasminogen activator (IV tPA) was given in three patients (11.5%). The hospital course of two patients was complicated by symptomatic intracranial hemorrhage (sICH), which was fatal. Favorable revascularization outcome and favorable functional outcome was achieved in 22 patients (84.6%), three patients passed away (11.5%), and one patient was lost to follow up. CONCLUSIONS:  Overall, our study finds that rescue stenting using coronary stents can potentially improve outcomes in refractory large vessel occlusions while minimizing costs in low-mid economic settings.

Comparing long-term outcomes of epilepsy patients from a single-visit outreach clinic with a conventional epilepsy clinic: A cross-sectional observational study from India.

PURPOSE: To compare long-term treatment outcomes in epilepsy patients from a single-visit outreach clinic on the Lifeline Express (LLE) with a conventional hospital (AIIMS) based epilepsy clinic in India. METHODS: Using a cross-sectional observational study design, consecutive epilepsy patients from fifteen LLE clinics conducted from 2009 to 2014 were compared to epilepsy patients registered in the same duration at the AIIMS epilepsy clinic. The primary outcome was to determine if patients were still taking AEDs. To determine current AED status, patients from the LLE clinic were contacted telephonically. For the AIIMS patients, hospital records were reviewed and phone calls made to those patients who had not followed-up for more than a year. RESULTS: In the 5 years under review, 1923 and 1257 patients had consulted at the LLE and AIIMS clinics respectively. Long-term outcomes were available for analysis in 688 AIIMS and 531 LLE clinic patients. Of the AIIMS patients, 581(87%) were continuing AEDs, 49(7%) had discontinued AEDs after being seizure-free for at least 5 years, 39(6%) had discontinued AEDs without medical advice and 19(2.8%) were dead. Outcomes in 531 LLE patients revealed that 351(72%) continued to be on AEDs, 34(7%) had discontinued AEDs on advice, 106 (22%) had discontinued AEDs without any medical advice and 40 (7.5%) were dead. The treatment gap in the LLE patients was reduced from 49% at first contact to 22% at follow-up 2-8 years later. CONCLUSIONS: Even single-visit epilepsy clinics may be an effective option for reducing treatment gap in limited-resource regions of the world.