Simulation of transportation of acute stroke patients in border regions.

Determining the optimal transportation for each stroke patient is critically important to achieve the best possible outcomes. In border regions the next comprehensive stroke center may be just across an international border, but bureaucratic and financial hurdles may prevent a simple transfer to the next stroke center. We hypothesized that in regions close to international borders, patients may benefit from an "open border, closed transfer scenario", meaning that patients in whom a large vessel occlusion (LVO) is detected in the primary stroke center will benefit from a transfer to the nearest stroke center offering endovascular thrombectomy-even if this may be across a national border. We used the Swiss-German-French trinational region as an example for a region with several international borders within close proximity to one another, and compared two feasible scenarios; (a) a "closed borders, open transfer" scenario, where the patient is transported to any center in the same country, (b) an "open border, closed transfer" scenario, where patients are always transported to the nearby primary stroke center first and then to the nearest comprehensive stroke center in either the same or a neighboring country and (c) and "open borders, open transfer" scenario. The outcome of interest was the predicted probability of acute ischemic stroke patients to achieve a good outcome using a conditional probability model which predicts the likelihood of excellent outcome (modified Rankin scale score of 0-1 at 90 days post-stroke) for patients with suspected LVO. Results were modeled in a virtual map from which the ideal transport concept emerged. For an exemplary LVO stroke patient in Germany, the probability of a good outcome was higher in an open border, closed transfer scenario than with closed borders, open transfer (33.1 vs. 30.1%). Moreover, time to EVT would decrease from 232 min in the first scenario to 169 min in an open border, closed transfer scenario. The catchment area of the University Hospital Basel was almost double the size in an open border, closed transfer scenario compared to closed borders (1674 km2 vs. 2897 km2) and would receive transfers from 3 primary stroke centers in other countries (2 in Germany and 1 in France). Stroke patients showed a higher likelihood of good outcome in the "open border" scenarios without transfer restrictions to a specific healthcare system. This probably has implications for stroke treatment in all border regions where EVT eligible stroke patients may benefit from transport to the closest EVT capable center whenever possible, regardless of whether this hospital is located in the same or a neighboring country/jurisdiction.

Initial Experience with the Solitaire X 3 mm Stent Retriever for the Treatment of Distal Medium Vessel Occlusions.

Endovascular therapy (EVT) is the standard treatment for ischemic stroke caused by a large vessel occlusion (LVO). The effectiveness of EVT for distal medium vessel occlusions (MDVOs) is still uncertain, but newer, smaller devices show potential for EVT in MDVOs. The new Solitaire X 3 mm device offers a treatment option for MDVOs. Our study encompassed consecutive cases of primary and secondary MDVOs treated with the Solitaire X 3 mm stent-retriever as first-line EVT device between January and December 2022 at 12 European stroke centers. The primary endpoint was a first-pass near-complete or complete reperfusion, defined as a modified treatment in cerebral infarction (mTICI) score of 2c/3. Additionally, we examined reperfusion results, National Institutes of Health Stroke Scale (NIHSS) scores at 24 h and discharge, device malfunctions, complications and procedural technical parameters. Sixty-eight patients (38 women, mean age 72 ± 14 years) were included in our study. Median NIHSS at admission was 11 (IQR 6-16). In 53 (78%) cases, a primary combined approach was used as the frontline technique. Among all enrolled patients, first-pass mTICI 2c/3 was achieved in 22 (32%) and final mTICI 2c/3 in 46 (67.6%) patients after a median of 1.5 (IQR 1-2) passes. Final reperfusion mTICI 2b/3 was observed in 89.7% of our cases. We observed no device malfunctions. Median NIHSS at discharge was 2 (IQR 0-4), and no symptomatic intracranial hemorrhages were reported. Based on our analysis, the utilization of the Solitaire X 3 mm device appears to be both effective and safe for performing EVT in cases of MDVO stroke.

Incidence and outcome of perforations during medium vessel occlusion compared with large vessel occlusion thrombectomy.

BACKGROUND: Vessel perforation during thrombectomy is a severe complication and is hypothesized to be more frequent during medium vessel occlusion (MeVO) thrombectomy. The aim of this study was to compare the incidence and outcome of patients with perforation during MeVO and large vessel occlusion (LVO) thrombectomy and to report on the procedural steps that led to perforation. METHODS: In this multicenter retrospective cohort study, data of consecutive patients with vessel perforation during thrombectomy between January 1, 2015 and September 30, 2022 were collected. The primary outcomes were independent functional outcome (ie, modified Rankin Scale 0-2) and all-cause mortality at 90 days. Binomial test, chi-squared test and t-test for unpaired samples were used for statistical analysis. RESULTS: During 25 769 thrombectomies (5124 MeVO, 20 645 LVO) in 25 stroke centers, perforation occurred in 335 patients (1.3%; mean age 72 years, 62% female). Perforation occurred more often in MeVO thrombectomy (2.4%) than in LVO thrombectomy (1.0%, p<0.001). More MeVO than LVO patients with perforation achieved functional independence at 3 months (25.7% vs 10.9%, p=0.001). All-cause mortality did not differ between groups (overall 51.6%). Navigation beyond the occlusion and retraction of stent retriever/aspiration catheter were the two most common procedural steps that led to perforation. CONCLUSIONS: In our cohort, perforation was approximately twice as frequent in MeVO than in LVO thrombectomy. Efforts to optimize the procedure may focus on navigation beyond the occlusion site and retraction of stent retriever/aspiration catheter. Further research is necessary in order to identify thrombectomy candidates at high risk of intraprocedural perforation and to provide data on the effectiveness of endovascular countermeasures.

Neqstent coil-assisted flow diverter (NQS) for the treatment of bifurcation aneurysms: the coil-assisted flow diversion safety and performance study (CAFI).

BackgroundThe Neqstent coil-assisted flow diverter (NQS) is a neck bridging device to facilitate coil occlusion of intracranial aneurysms. CAFI is a prospective, single-arm, multicenter study on the safety and performance of the NQS adjunctive therapy device together with platinum coils for treatment of unruptured intracranial aneurysms. METHODS: Thirty-eight patients were enrolled. Primary endpoints were occlusion at 6 months for efficacy, and any major stroke or non-accidental death up to 30 days or major disabling stroke within 6 months for safety. Secondary endpoints were re-treatment rate, procedure time, and procedure/device-related adverse events. Procedural and follow-up imaging was reviewed by an independent core laboratory. Adverse events were reviewed and adjudicated by a clinical events committee. RESULTS: The NQS was successfully implanted in 36/38 aneurysms, 2/38 in the intention-to-treat group did not receive a NQS and were excluded from follow-up after 30 days. In the per protocol group (PP), 33/36 patients were available for angiographic follow-up. Device related adverse events were recorded in 4/38 (10.5%) patients, one hemorrhagic and three thromboembolic. In the PP group, immediate post-treatment adequate occlusion (RR1 and RR2) was seen in 9/36 (25%) and progressed to 28/36 (77.8%) at 6 months. Complete occlusion (RR1) was achieved in 29/36 (80.6%) at the last available angiogram (3/36 were post procedure). The mean procedure time was 129 min (50-300 min, median 120 min). CONCLUSION: The NQS in conjunction with coils appears to be effective in the treatment of intracranial wide-neck bifurcation aneurysms, but its safety remains to be proved in larger series. TRIAL REGISTRATION NUMBER: NCT04187573.

Endovascular Treatment and Peri-interventional Management of Ruptured Cerebrovascular Lesions During Pregnancy : Case Series and Case-based Systematic Review.

PURPOSE: Hemorrhagic stroke, particularly occurring from ruptured cerebrovascular malformations, is responsible for 5-12% of all maternal deaths during pregnancy and the puerperium. Whether endovascular treatment is feasible and safe for both the mother and the fetus, is still a matter of debate. The main objective of this case series and systematic review was to share our multi-institutional experience and to assess the feasibility and safety of endovascular treatment during pregnancy, as well as the corresponding maternal and fetal outcomes based on currently available evidence. METHODS: We report a case series of 12 pregnant women presenting with hemorrhagic stroke from ruptured cerebrovascular arteriovenous malformations or aneurysms who underwent endovascular treatment prior to delivery. A systematic literature review of pregnant patients with endovascular treated cerebrovascular malformations, published between 1995 and 2022, was performed. Clinical patient information, detailed treatment strategies, maternal and fetal outcomes as well as information on the delivery were collected and assessed. RESULTS: In most patients the course was uneventful and an excellent outcome without significant neurological deficits (mRS ≤ 1) was achieved. Furthermore, the maternal outcome was not worse compared to the general population who underwent endovascular treatment of ruptured vascular brain lesions. Also, in most cases a healthy fetus was born. CONCLUSION: Endovascular treatment of ruptured cerebrovascular malformations during pregnancy is safe and feasible regarding both aspects, the maternal and fetal outcomes. Still, a stronger knowledge base is needed to correctly approach future cases of intracranial hemorrhage in the pregnant population.

Direct to angiography suite approaches for the triage of suspected acute stroke patients: a systematic review and meta-analysis.

BACKGROUND: Increasing evidence suggests improved time metrics leading to better clinical outcomes when stroke patients with suspected large vessel occlusion (LVO) are transferred directly to the angiography suite (DTAS) compared with cross-sectional imaging followed by transfer to the angiography suite. We performed a systematic review and meta-analysis on the efficacy and safety of DTAS approaches. METHODS: We searched Embase, Medline, Scopus, and clinicaltrials.gov for studies comparing outcomes of DTAS and conventional triage. Eligible studies were assessed for risk of bias. We performed a random-effects meta-analysis on the differences of median door-to-groin and door-to-reperfusion times between intervention and control group. Secondary outcomes included good outcome at 90 days (modified Rankin Scale ⩽ 2) rate of symptomatic intracranial hemorrhage (sICH) and mortality within 90 days. RESULTS: Eight studies (one randomized, one cluster-randomized trial and six observational studies) with 1938 patients were included. Door-to-groin and door-to-reperfusion times in the intervention group were on median 29.0 min [95% confidence interval (CI): 14.3-43.6; p < 0.001] and 32.1 min (95% CI: 15.1-49.1; p < 0.001) shorter compared with controls. Prespecified subgroup analyses for transfer (n = 1753) and mothership patients (n = 185) showed similar reductions of the door-to-groin and door-to-reperfusion times in response to the intervention. The odds of good outcome did not differ significantly between both groups but were numerically higher in the intervention group (odds ratio: 1.38, 95% CI: 0.97-1.95; p = 0.07). There was no significant difference for mortality and sICH between the groups. CONCLUSION: DTAS approaches for the triage of suspected LVO patients led to a significant reduction in door-to-groin and door-to-reperfusion times but an effect on functional outcome was not detected. The subgroup analysis showed similar results for transfer and mothership patients.Registration: This study was registered in PROSPERO (CRD42020213621).

Distribution of Diagnoses and Clinical and Imaging Characteristics in 1,322 Consecutive Suspected Stroke Patients.

Background: Endovascular thrombectomy (EVT) has become the standard of care for large-vessel occlusion strokes, but several barriers for implementing an optimal organization of stroke management remain. Major issues include the lack of reliable data on the percentage of stroke patients potentially eligible for EVT especially in times of expanding indications for EVT. Our aim was therefore to study the frequencies of possible EVT-eligible patients such as patients with medium-vessel occlusions, patients with low Alberta Stroke Program Early Computed Tomography Scores (ASPECTS), patients presenting in an extended time window after onset of symptoms, and patients with mild symptoms at presentation (National Institutes of Health Stroke Scale, NIHSS ≤ 5). We also give detailed imaging and clinical information about the patients presenting with intracranial hemorrhage and other ischemic stroke mimics stratified by symptoms at presentation. Methods: Cohort study of all consecutive patients with suspected acute stroke presenting to a tertiary care center in Germany between September 1, 2016, and August 31, 2017. Baseline and follow-up clinical and imaging characteristics were collected from patients' medical charts. Results: Of 1,322 patients with a suspected acute stroke, 592 (44.8%) had ischemic strokes, 221 (16.7%) had hemorrhagic strokes, 190 (10.9%) had transient ischemic attacks (TIAs), and 319 (24.1%) were classified as stroke mimics. Stroke severity was mild (NIHSS ≤ 5) in 866 (65.5%) patients; 15.7% of the patients with an occlusion of the anterior circulation had an ASPECTS ≤ 5, 17.4% of the patients with an ischemic stroke had distal vessel occlusions, and 49% of the patients presented later than 6 h after onset of symptoms. Conclusion: Our results help to plan resources in thrombectomy-capable centers in times of expanding indications for EVT where resources will have to be adjusted to patients with low-NIHSS, low-ASPECTS, and distal occlusions, and patients presenting in the extended time window, which may altogether account for an additional 20% of all ischemic stroke patients.

Initial Experience With the Trevo NXT Stent Retriever.

Background: The application of a new coating to the delivery wire of the Trevo retriever has the potential to improve its handling. We therefore report our initial experience with this new stent retriever for mechanical thrombectomy of large and medium vessel occlusions. Methods: We pooled data of four high-volume European stroke centers over the time period from October 2020 to February 2021. Patients were included in our study if the Trevo NXT stent retriever was used as a first-line device. Primary endpoints were first-pass near-complete or complete reperfusion, defined as mTICI score of ≥2c. Secondary endpoints were final reperfusion, National Institutes of Health Stroke Scale (NIHSS) at 24 h and discharge, device malfunctions, complications during the procedure, and subjective ratings of the interventionalists regarding device functionality. Results: Eighty patients (39 women, mean age 74 ± 14 years) were eligible for our study. Median NIHSS at admission was 15 (IQR, 8-19), and median Alberta Stroke Program Early CT Score at baseline was 9 (IQR, 8-10). In 74 (93%) patients a primary combined approach was used as first-line technique. First-pass near-complete reperfusion was achieved in 43 (54%) and first-pass complete reperfusion in 34 (43%) patients. Final near-complete reperfusion was achieved in 66 (83%) patients after a median of 1.5 (1-3) passes, while final successful reperfusion was observed in 96% of our cases. We observed no device malfunctions. Median NIHSS at discharge was 2 (IQR, 0-5), and 3 patients (4%) suffered a symptomatic intracranial hemorrhage. Conclusions: Based on our initial data, we conclude that the Trevo NXT is an effective and safe tool for mechanical thrombectomy especially when used for combined approaches.

The impact of transcranial direct current stimulation on cerebral vasospasm in a rat model of subarachnoid hemorrhage.

Transcranial direct current stimulation (tDCS) has been shown to induce changes in cortical excitability and perfusion in a rat ischemic stroke model. Since perfusion disturbances are a common phenomenon, not only in ischemic but also in hemorrhagic stroke, tDCS might have a possible beneficial effect on cerebral perfusion in hemorrhagic stroke as well. We applied tDCS in a rat model of subarachnoid hemorrhage (SAH) and evaluated its impact on vasospasm. SAH was induced using the double-hemorrhage rat model. TDCS was applied on day 3 and 4. For vasospasm assessment magnetic resonance angiography was performed on day 1, day 2 and day 5. A total of 147 rats were operated, whereat 72 rats died before day 5 and 75 rats survived the whole experiment and could be analyzed. The cathodal group consisted of 26 rats, the anodal group included 24 rats. Thirteen rats served as controls without tDCS, and twelve rats underwent a sham operation. The cathodal group revealed the lowest incidence of new vasospasm on day 5 (p = 0.01), and the lowest mean number of vasospastic vessels per rat (p = 0.02). TDCS influences the vasospasm incidence in an SAH-model in rats, where cathodal-tDCS was associated with a lower vasospasm incidence and severity.

Treatment and Postinterventional Management of a Fusiform Intracranial Aneurysm in a Professional Soccer Player: A Case Report.

INTRODUCTION: While intracranial aneurysms are common lesions affecting between 1 and 5% of the general population, the prevalence in professional athletes remains unknown. The result is uncertainty and lack of guidelines on appropriate treatment of these patients. CASE PRESENTATION: A 29-year-old professional soccer player presented in our hospital with an incidentally found intracranial aneurysm. After detailed depiction of the aneurysm and interdisciplinary discussion, endovascular treatment using a flow diverter was chosen to be the best treatment modality. Postinterventional medication consisted of dual antiplatelet therapy with aspirin and clopidogrel. The main challenge in managing the case of our patient was the combination of the dual antiplatelet treatment regime with his professional career in a contact sport. CONCLUSION: Due to lack of literature or similar reports regarding the management of professional athletes with intracranial aneurysms, the optimal treatment strategy remains unclear. Even though decisions should be made dynamically and case-adapted to each situation, developing a registry could help provide guidance and new ideas for similar cases in the future.

Angioplasty with the scepter C dual lumen balloon catheter and postprocedural result evaluation in patients with subarachnoid hemorrhage related vasospasms.

BACKGROUND: Delayed cerebral ischemia is one of the leading causes of death and disability in patients with subarachnoid hemorrhage (SAH). Transluminal balloon angioplasty (TBA) is a therapeutic option for vasospasms affecting proximal intracranial arteries. METHODS: Aim of this study was to report our experience using the Scepter C balloon catheter in the treatment of cerebral vasospasms due to SAH and evaluate the postprocedural result with the iFlow tool. We reviewed cases of patients treated at our hospital from 2014 to 2018. Patients were screened with transcranial doppler sonography (TCD) and multimodal computed tomography. In case of significant vasospasms, patients were transferred to the angiography suite and treated. We used the iFlow tool to quantify and evaluate the angiographic results by measuring and comparing peak density values on angiograms before and after the mechanical dilation. RESULTS: The use of the Scepter C balloon catheter was feasible in all cases. Vasospasms of the anterior cerebral artery were treated in ten cases. We didn't observe complications or vasospasm recurrences of the treated arteries. The temporal difference between distal vessels and the proximal reference vessel was significantly reduced from a mean of 53%, prior to dilatation, to 26% after the treatment. The difference between pre-dilatation and post-dilatation values was statistically significant for the anterior circulation at the proximal as well as at the distal vessels. CONCLUSIONS: We successfully treated endovascularly patients suffering from cerebral vasospasms refractory to medical treatment using the Scepter C balloon catheter. We didn't observe any complications. The therapeutic effect could be easily and reliably assessed with the iFlow tool.

Correction to: SMART coils for intracranial aneurysm repair - a single center experience.

An amendment to this paper has been published and can be accessed via the original article.

Initial Experience with Transradial Access for Cerebrovascular Procedures: Is It Feasible and Safe?

BACKGROUND: Despite the proven benefit of transradial access over transfemoral access in cardiac procedures, the transition for cerebrovascular procedures has only been slowly enforced. We present our experience with transradial access in cerebral diagnostic angiographies and neurointerventional procedures. METHODS: We performed a retrospective analysis of patients who underwent transradial access for cerebrovascular procedures in 3 German centers between February 2017 and May 2019. Demographics, technical features, and complications were evaluated. RESULTS: Transradial access was successful in 40/45 endovascular procedures (89%). Selected catheterization of the intended vessels was obtained in 95% of cases (40/42). The rate of procedure-related vascular complications was 2% (1/45). CONCLUSIONS: In this small retrospective series, transradial access proved to be safe and efficient. In the future, it is planned to further promote it as a standard access alternative for more patients.

Defining cutoff values for early prediction of delayed cerebral ischemia after subarachnoid hemorrhage by CT perfusion.

Early prediction of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) is essential to prevent infarction. CT perfusion (CTP) is used to identify perfusion deficits and to guide treatment decisions. In this study, we aimed to evaluate CTP parameters and to establish cutoff values for DCI prediction in the early phase after aSAH. Whole-brain CTP was performed on day 3 after aSAH. These CTP parameters were analyzed: cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), time to peak (TTP), time to start (TTS), and time to drain (TTD). ROC analysis was performed to establish cutoff values. The outcome (modified Rankin scale (mRS)) at 3 months follow-up and the DCI incidence were evaluated. A total of 64 patients were included. A good WFNS grade (I-III) was documented in 44% of the patients. A mild modified Fisher grade (1-2) was seen in 3% of the patients. Early perfusion deficits were found in 18 of 64 patients and 10 of them developed DCI. For DCI prediction, the following cutoff values were identified: TTD > 4.93 s, CBF < 53.93 ml/100 ml/min, MTT <> 4.25 s, TTS > 0.94 s, TTP > 9.28 s, and CBV < 3.14 ml/100 ml. The positive predictive value (PPV)/negative PV (NPV) was as follows: TTD 77%/93%; CBF 94%/70%; MTT 72%/96%; TTS 71%/86%; TTP 55%/78%; CBV 75%/61%. Early perfusion deficits correlated with DCI (logistic regression p < 0.0001) but not with outcome. CTP on day 3 after aSAH allows reliable DCI prediction. TTD had high NPV/PPV for DCI prediction and should be an integral part of quantitative CTP analysis in the early phase after aSAH.

One-Stop Management of 230 Consecutive Acute Stroke Patients: Report of Procedural Times and Clinical Outcome.

BACKGROUND AND PURPOSE: Rapid thrombectomy for acute ischemic stroke caused by large vessel occlusion leads to improved outcome. Optimizing intrahospital management might diminish treatment delays. To examine if one-stop management reduces intrahospital treatment delays and improves functional outcome of acute stroke patients with large vessel occlusion. METHODS: We performed a single center, observational study from June 2016 to November 2018. Imaging was acquired with the latest generation angiography suite at a comprehensive stroke center. Two-hundred-thirty consecutive adults with suspected acute stroke presenting within 6 h after symptom onset with a moderate to severe National Institutes of Health Stroke Scale (≥10 in 2016; ≥7 since January 2017) were directly transported to the angiography suite by bypassing multidetector CT. Noncontrast flat-detector CT and biphasic flat-detector CT angiography were acquired with an angiography system. In case of a large vessel occlusion patients remained in the angiography suite, received intravenous rtPA therapy and underwent thrombectomy. As primary endpoints, door-to-reperfusion times and functional outcome at 90 days were recorded and compared in a case-control analysis with matched prior patients receiving standard management. RESULTS: A total of 230 patients (123 women, median age of 78 years (Interquartile Range (IQR) 69-84)) were included. Median symptom-to-door time was 130 min (IQR 70-195). Large vessel occlusion was diagnosed in 166/230 (72%) patients; 64/230 (28%) had conditions not suitable for thrombectomy. Median door-to-reperfusion time for M1 occlusions was 64 min (IQR 56-87). Compared to 43 case-matched patients triaged with multidetector CT, median door-to-reperfusion time was reduced from 102 (IQR 85-117) to 68 min (IQR 53-89; p < 0.001). Rate of good functional outcome was significantly better in the one-stop management group (p = 0.029). Safety parameters (mortality, sICH, any hemorrhage) did not differ significantly between groups. CONCLUSIONS: One-stop management for stroke triage reduces intrahospital time delays in our specific hospital setting.

Assessment of tissue permeability by early CT perfusion as a surrogate parameter for early brain injury after subarachnoid hemorrhage.

OBJECTIVE: The severity of early brain injury (EBI) after aneurysmal subarachnoid hemorrhage (aSAH) correlates with delayed cerebral ischemia (DCI) and outcome. A disruption of the blood-brain barrier is part of EBI pathophysiology. The aim of this study was to assess tissue permeability (PMB) by CT perfusion (CTP) in the acute phase after aSAH and its impact on DCI and outcome. METHODS: CTP was performed on day 3 after aSAH. Qualitative and quantitative analyses of all CTP parameters, including PMB, were performed. The areas with increased PMB were documented. The value of an early PMB increase as a predictor of DCI and outcome according to the modified Rankin Scale (mRS) grade 3 to 24 months after aSAH was assessed. Possible associations of increased PMB with the Subarachnoid Hemorrhage Early Brain Edema Score (SEBES) and with early perfusion deficits, as radiographic EBI markers, were evaluated. RESULTS: A total of 69 patients were enrolled in the study. An increased PMB on early CTP was detected in 10.1% (7/69) of all patients. A favorable outcome (mRS grade ≤ 2) occurred in 40.6% (28/69) of all patients. DCI was detected in 25% (17/69) of all patients. An increased PMB was a predictor of DCI (logistic regression, p = 0.03) but not of outcome (logistic regression, p = 0.40). The detection of increased PMB predicted DCI with a sensitivity of 25%, a specificity of 94%, a positive predictive value of 57%, and a negative predictive value of 79% (chi-square test p = 0.03). Early perfusion deficits were seen in 68.1% (47/69) of the patients, a finding that correlated with DCI (p = 0.005) but not with the outcome. No correlation was found between the SEBES and increased PMB. CONCLUSIONS: Changes in PMB can be detected by early CTP after aSAH, which correlates with DCI. Future studies are needed to evaluate the time course of PMB changes and their interaction with therapeutic measures.

Intracranial mechanical thrombectomy of large vessel occlusions in the posterior circulation using SAVE.

BACKGROUND: Mechanical thrombectomy (MT) using stent retriever assisted vacuum-locked extraction (SAVE) is a promising method for anterior circulation strokes. We present our experience with SAVE for large vessel occlusions (LVO) of the posterior circulation. METHODS: We retrospectively analyzed 66 consecutive MT patients suffering from LVO of the posterior circulation. Primary endpoints were first-pass and overall complete/near complete reperfusion, defined as a modified thrombolysis in cerebral infarction (mTICI) score of 2c and 3. Secondary endpoints contained number of passes, time interval from groin puncture to reperfusion and rate of postinterventional symptomatic intracranial hemorrhage (sICH). RESULTS: Median age was 75 years (interquartile range (IQR) 54-81 years). Baseline median National Institutes of Health stroke scale (NIHSS) was 13 (IQR 8-21). Fifty-five (83%) patients had LVO of the basilar artery and 11 (17%) of the posterior cerebral artery. Eighteen (27%) patients were treated with SAVE and 21 (32%) with aspiration only. First pass mTICI2c or 3 and overall mTICI2c or 3 were documented in 11/18 (61%) and 14/18 (78%) with SAVE and in 4/21 (19%) and 13/21 (33%) with aspiration only. Median attempt was 1 (IQR 1-2) with SAVE and 2 (IQR 1-4) with aspiration (p = 0.0249). Median groin to reperfusion time did not differ significantly between groups. The rate of sICH was 5% without any complications in the SAVE cohort. CONCLUSION: Mechanical thrombectomy of posterior large vessel occlusions with SAVE is feasible, safe, and effective with high rates of near-complete and complete reperfusion.

Clot reduction prior to embolectomy: mSAVE as a first-line technique for large clots.

INTRODUCTION: The "Stent retriever Assisted Vacuum-locked Extraction" (SAVE) technique is a promising embolectomy method for intracranial large vessel occlusion (LVO). We report our experience using a modified SAVE (mSAVE) approach for clot reduction prior to embolectomy in acute ischemic stroke patients with large clots. MATERIALS AND METHODS: We retrospectively analyzed 20 consecutive patients undergoing mSAVE in our center due to intracranial LVO. Angiographic data (including first-pass and overall complete reperfusion, defined as an expanded Thrombolysis in Cerebral Infarction (eTICI) score of 3, rate of successful reperfusion (eTICI ≥2c), number of passes, time from groin puncture to reperfusion) and clinical data (favorable outcome at 90 days, defined as modified Rankin Scale (mRS) ≤2) were assessed. RESULTS: First-pass and overall eTICI 3 reperfusion was reached in 13/20 (65%) and 14/20 (70%), respectively. The rate of successful reperfusion (eTICI ≥2c) after one pass was 85% and on final angiogram 90% with an average number of 1.1 ± 0.3 attempts. Eight out of 11 (73%) ICA occlusions were reperfused successfully and 5 (46%) completely after a single pass. Median groin to reperfusion time was 33 minutes (IQR 25-46). A favorable clinical outcome was achieved in 9/20 (45%) patients at discharge and after 90 days, respectively. CONCLUSION: Clot reduction followed by embolectomy (mSAVE) is feasible and may be an important tool in the treatment of large clots.

Stent-retriever assisted vacuum-locked extraction (SAVE) versus a direct aspiration first pass technique (ADAPT) for acute stroke: data from the real-world.

BACKGROUND: Embolectomy is the standard of care in acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). Aim of this study was to compare two techniques: A Direct Aspiration First Pass Technique (ADAPT) and Stent-retriever Assisted Vacuum-locked Extraction (SAVE) stratified by the occluded vessel. METHODS: One hundred seventy-one patients (71 male) treated between January 2014 and September 2017 with AIS due to LVO of the anterior circulation (55 carotid T, 94 M1, 22 M2) were included. Treatment techniques were divided into two categories: ADAPT and SAVE. Primary endpoints were successful reperfusion (mTICI ≥2b), near-perfect reperfusion (mTICI ≥2c) and groin puncture to reperfusion time. Secondary endpoints were the number of device-passes, first-pass reperfusion, the frequency of emboli to new territory (ENT), clinical outcome at 90 days, and the frequency of symptomatic intracranial hemorrhage (sICH). Analysis was performed on an intention to treat basis. RESULTS: Overall, SAVE resulted in significant higher rates of successful reperfusion (mTICI≥2b) compared to ADAPT (93.5% vs 75.0%; p = 0.006). After stratification for the occluded vessel only the carotid T remained significant with higher rates of near-perfect reperfusion (mTICI≥2c) (55.2% vs 15.4%; p = 0.025), while for successful reperfusion a trend remained (93.1% vs 65.4%; p = 0.10). Groin to reperfusion times were not significantly different. Secondary analysis revealed higher rates of first-pass successful reperfusion (59.6% vs 33.3%; p = 0.019), higher rates of first-pass near-perfect reperfusion in the carotid T (35.4% vs 16.7%; p = 0.038) and a lower number of device-passes overall (median 1 IQR 1-2 vs 2 IQR 2-3; p <  0.001) and in the carotid T (median 2 IQR 1.3 vs 3 IQR 2-5; p <  0.001) for SAVE. Clinical outcome and safety parameters were comparable between groups. CONCLUSIONS: Embolectomy using SAVE appears superior to ADAPT, especially for carotid T occlusions with regard to reperfusion success.