Thrombectomy for Anterior Circulation Stroke in a Witnessed Late Time Window Versus Early Time Window.

Introduction: Thrombectomy is the standard treatment for anterior circulation stroke due to large vessel occlusions in a late time window (6 to 24 hours) for patients selected based on perfusion imaging. Most patients treated in late time window studies presented as unwitnessed or wake-up strokes. Whether patients presenting with unwitnessed stroke have an actual time window greater than 6 hours is unclear. The aim of this study was to assess the outcomes of thrombectomy in the treatment of patients presenting with anterior circulation large vessel stroke in an actual late time window of more than 6 hours. Methods: This single-center registry of thrombectomy in the treatment of stroke caused by anterior circulation large vessel occlusions (LVOs) included 430 patients treated between 2011 and 2019. Patients were divided into 2 groups: an early time window (≤ 6 hours) group and a late time window group (> 6 hours). Results: Outcomes of the early and the late time window groups, respectively, were recanalization of 86.8% vs 82.7% (P = .29), symptomatic intracranial hemorrhage of 8.2% vs 5.7% (P = .40), good clinical outcome of 45.4% vs 41.3% (P = .46), and mortality of 20.2% vs 25% (P = .30) at 3 months. Conclusions: Thrombectomy for anterior circulation large vessel occlusions after 6 hours of symptoms onset seems to be as safe and effective as the standard thrombectomy within 6 hours from symptoms onset, even without perfusion analysis. Randomized trials are needed to confirm these findings.

Mechanical Thrombectomy in Acute Ischemic Stroke: Angiographic Predictors of Outcome.

Background: In patients with acute ischemic stroke with large vessel occlusion, various angiographic features are important in patient selection and predicting outcome. Objective: We evaluated angiographic features like collaterals, clot burden score, angiographic recanalization, number of passes, and intracranial atherosclerotic disease (ICAD) with the functional outcome at 90 days. Materials and Methods: This was a retrospective analysis of prospectively collected data of 163 patients with acute ischemic stroke with large vessel occlusion who underwent mechanical thrombectomy within 24 hours of symptom onset. Angiographic data were reviewed blinded to clinical data. The outcome was defined as modified Rankin scale (mRS) at 90 days (good outcome mRS ≤2). Results: The median age of patients was 60 years and 34.4% were females. The median National Institutes of Health Stroke Scale (NIHSS) and Alberta Stroke Programme Early CT Score (ASPECTS) at admission were 17 and 6, respectively. On bivariate analysis, ASPECTS was >6, clot burden score was ≥7, recanalization of TICI was ≥2b, absence of ICAD, showed a positive correlation with the good outcome at 90 days (P-values of 0.003, 0.0001, and 0.03, respectively). Multiple attempts of device passes were associated with poor recanalization (P = 0.001) and it was seen more in ICAD patients. On multivariate analysis, independent predictors of poor outcome were clot burden score <7 (P = 0.043) and TICI score <2b (P = 0.048). Out of 41 patients (26%) with ICAD, 29 had a poor outcome at 90 days. Conclusion: Lower clot burden and less degree of recanalization were associated with poor outcome in acute ischemic stroke due to Large vessel occlusion (LVO). The presence of ICAD also predicted poor outcome.

Delayed cerebral ischemia: A look at the role of endothelial dysfunction, emerging endovascular management, and glymphatic clearance.

Delayed cerebral ischemia (DCI) contributes to extensive morbidity and mortality for patients with aneurysmal subarachnoid hemorrhage (SAH). Recent contributions to the basic and translational investigation of DCI have shed light on emerging concepts that may aid in the development of novel therapeutics. A clear association between cerebral vasospasm (CV) and DCI exists, but it is also known that DCI can affect brain parenchyma remote from sites of vasospasm. In this review, we highlight the most recent contributions to the understanding of the underlying pathophysiology of DCI including the emerging role of the glymphatic system. Furthermore, we discuss treatments for DCI, including both pharmacologic therapies and endovascular treatment of vasospasm. There continues to be a disconnect between interventions and targeted treatment against pathophysiology. This review is intended to serve as a catalyst for further research and discovery that can aid in improved treatment options for DCI.

Updates in mechanical thrombectomy.

Stroke is a leading cause of morbidity and mortality. The advent of mechanical thrombectomy has largely improved patient outcomes. This article reviews the features and outcomes associated with aspiration, stent retrievers, and combination catheters used in current practice. There is also a discussion on clinical considerations based on anatomical features and clot composition. The reperfusion grading scale and outcome metrics commonly used following thrombectomy when a patient is still in the hospital are reviewed. Lastly, there are proposed discharge and outpatient follow-up goals in caring for patients hospitalized for a stroke.

Mechanical thrombectomy of large vessel occlusion using adjustable vs. self-expanding stent-retriever-Comparison of Tigertriever device with stent-like stent-retrievers: A propensity score analysis.

Background: Stent-retrievers used for mechanical thrombectomy are self-expanding tubular stent-like devices with modified mesh structures for clot removal. Tigertriever is designed to provide manual control of its diameter and curvature. Methods: A retrospective single-center study was performed to compare Tigertriever with SolitaireX and pRESET (stent-like stent-retrievers group) using propensity score analysis. Patients treated in a comprehensive stroke center due to large vessel occlusion between January 2016 and August 2021 were evaluated. Baseline characteristics and treatment results were compared between these groups before and after pair matching. Results: There were 140 patients (60 in Tigertriever and 80 in the stent-like stent-retriever group). In propensity score analysis, 52 matched pairs were selected in Tigertriever and stent-like stent-retriever groups. The Tigertriever group had a better successful first pass revascularization rate [46 vs. 23%, OR (95% CI): 1.7 (1.1-2.9), p = 0.013] and 14-min shorter groin-to-revascularization time (51 vs. 65 min. p = 0.017). There were no significant differences between Tigertriever and stent-like stent-retriever groups in the following: favorable mRS 3 months, favorable recanalization rate, and symptomatic intracerebral hemorrhages. There were no observed periprocedural adverse events related to Tigertriever, SolitaireX, or pRESET. Conclusion: Tigertriever had a significantly better successful first pass revascularization rate and shorter groin-to-revascularization time in the analysis done before and after propensity score matching with stent-like stent-retrievers. Tigertriever is comparable to stent-like stent-retrievers regarding mortality at 3 months, favorable mRS at 3 months, favorable recanalization rate, or symptomatic cerebral hemorrhagic events.

Analysis of 565 thrombectomies for anterior circulation stroke: A Brazilian registry.

INTRODUCTION: The benefits of mechanical thrombectomy in the treatment of patients with acute stroke due to large vessel occlusions (LVOs) have been extensively demonstrated by randomized trials and registries in developed countries. However, data on thrombectomy outside controlled trials are scarce in developing countries. The aim of this study was to assess the safety and efficacy, and to investigate the predictors for good and poor outcomes of thrombectomy for treatment of AIS due to anterior circulation LVOs in Brazil. MATERIALS AND METHODS: This was a single center registry of thrombectomy in the treatment of stroke caused by anterior circulation LVOs. Between 2011 and 2019, a total of 565 patients were included. RESULTS: the mean baseline NIHSS score on admission was 17.2. The average baseline ASPECTS was 8, and 91.0% of patients scored ≥6. Half of the patients received intravenous thrombolysis. The mean time from symptom onset to arterial puncture was 296.4 minutes. The mean procedure time was 61.4 minutes. The rates of the main outcomes were recanalization (TICI 2b-3) 85.6%, symptomatic intracranial hemorrhage (sICH) 8,1%, good clinical outcome (mRS=0-2) 43,5%, and mortality 22.1% at three months. CONCLUSIONS: This study demonstrates the efficacy and safety of mechanical thrombectomy for treatment of patients with AIS of the anterior circulation in real-life conditions under limited facilities and resources. The results of the present study were relatively similar to those of large trials and population registers of developed countries.

Understanding the Radial Force of Stroke Thrombectomy Devices to Minimize Vessel Wall Injury: Mechanical Bench Testing of the Radial Force Generated by a Novel Braided Thrombectomy Assist Device Compared to Laser-Cut Stent Retrievers in Simulated MCA Vessel Diameters.

BACKGROUND: Recent reports have raised various concerns about the risk of vessel wall injury while withdrawing current laser-cut stent retrievers during active strut apposition to the vessel walls. The development of braided thrombectomy assist devices in conjunction with aspiration systems may be gentler on the fragile brain vessels and more optimized with regard to the radial force (RF) for vessel diameters of proximal (M1) and distal (M2) large vessel occlusions (LVOs). METHODS: Mechanical bench testing of the RF was performed using a radial compression station mounted on a tensile testing machine. The total RF in newtons (N) generated in vessels with diameters ranging from 2.25 to 3 mm as seen in proximal LVOs (∼M1), and in vessel diameters ranging from 1.5 to 2.24 mm as seen in distal LVOs (∼M2), was measured. The outer diameter of each stent was recorded, and an RF ≤1 N was grouped as "low," while an RF >1 N was grouped as "high" for this analysis. RESULTS: The total RFs of all laser-cut stent retrievers were all higher in the simulated M2 vessels (>1 N) than in the M1 vessels (<1 N), whereas the total RFs of the braided thrombectomy assist devices were uniformly low in both the simulated M1 and the simulated M2 vessels. CONCLUSIONS: Novel braided thrombectomy assist devices in conjunction with aspiration systems have lower RFs than existing laser-cut stent retrievers in M1 and M2 vessel diameters. Further in vivo studies are needed to delineate the impact of lowering the RF on vessel wall integrity.

Thrombectomy in acute vertebrobasilar occlusion: a single-centre experience.

PURPOSE: Acute vertebrobasilar occlusion (VBO) has a grave clinical course; however, thrombectomy in VBO patients has rarely been reported. We retrospectively evaluated the clinical and radiological outcomes of thrombectomy in VBO patients. METHODS: From March 2010 to December 2017, 38 patients with 40 acute VBOs underwent thrombectomy at our hospital. Thrombectomy was performed using catheter aspiration (n = 11, 26.8%) or a stent retriever (n = 29, 70.7%). RESULTS: Good clinical outcomes (3-month modified Rankin scale (mRS) of 2 or lower) were achieved in 9 cases (22.5%), and successful recanalization (thrombolysis in cerebral infarction (TICI) grade of 2b or 3) was achieved in 35 cases (87.5%). Good clinical outcomes were significantly related to aetiologies other than atherosclerosis (p = 0.020) and lower National Institutes of Health Stroke Scale (NIHSS) scores on admission (p = 0.025). The clinical and radiological outcomes did not differ significantly between catheter aspiration and stent retriever thrombectomy (p = 1.000 and p = 0.603, respectively); however, stent retriever thrombectomy had a shorter procedure time than catheter aspiration (59.7 ± 31.2 vs. 84.5 ± 35.1 min, p = 0.037). CONCLUSION: In our series, good clinical outcomes were associated with a lower NIHSS score on admission and stroke aetiologies other than atherosclerosis. The two thrombectomy modalities showed similar clinical and radiological outcomes. However, stent retrievers seemed to allow more rapid recanalization than catheter aspiration in VBO.

Mechanical Thrombectomy of Distal Occlusions Using a Direct Aspiration First Pass Technique Compared with New Generation of Mini-0.017 Microcatheter Compatible-Stent Retrievers: A Meta-Analysis.

BACKGROUND: There are no current evidence-based recommendations on mechanical thrombectomy (MT) in M2 or other distal occlusions. The objective of this paper was to investigate clinical and radiologic outcomes of MT in distal locations using the new generation of mini-0.017 microcatheter compatible-stent retrievers (SRs) compared with a direct aspiration first pass technique (ADAPT) MT. METHODS: A systematic search was performed for studies published from January 2016 to March 2019. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies that reported clinical and radiologic outcomes of patients undergoing MT using new generation of SRs or ADAPT in distal locations. The cumulative prevalence was estimated for each outcome. Heterogeneity of the data was assessed by the Higgins index (I2), and a random-effects model was applied. RESULTS: Fifteen studies and 494 patients were included; 7 studies reported on patients treated with a new SR and 8 studies analyzed patients treated with ADAPT. The rate of thrombolysis in cerebral infarction score 2b-3 after MT for distal occlusions was 80.6% (383 of 494; 95% confidence interval [CI], 74.8%-86.3%; I2 = 64.4%). Successful recanalization was comparable after SR use with low-profile devices and ADAPT (176 of 226; 82%; 95% CI, 72.6%-1.5%; I2 = 70.5% vs. 207 of 268; 79.4%; 95% CI, 71.8%-86.9%; I2 = 60.8%, respectively; P = 0.4). The rate of the modified Rankin scale score of 0-2 at 3 months was higher in the ADAPT group (160 of 251; 68.9%; 95% CI, 51.8%-85.9%; I2 = 92.2%) than the SR group (92 of 177; 58.7%; 95% CI, 37.3%-80%; I2 = 58.7%; P = 0.01). The mortality rate was lower among the ADAPT group (20 of 251; 5.4%; 95% CI, 1.4%-9%; I2 = 63%) than the SR group (16 of 108; 13%; 95% CI, 6%-19%; I2 = 13%; P = 0.008). CONCLUSIONS: MT in distal locations using the new generation of SR yields comparable results compared with ADAPT in terms of recanalization; however, the use of SR is associated with lower functional independence and higher mortality rate.

Endovascular Thrombectomy for Acute Ischemic Stroke.

PURPOSE OF REVIEW: To review the current evidence supporting the use of endovascular thrombectomy (EVT) for the treatment of acute ischemic stroke (AIS) due to anterior circulation large vessel occlusion (LVO). RECENT FINDINGS: Recent advances in AIS management by EVT have led to significant reduction in morbidity and mortality in selected patients with LVO within the anterior circulation. Until recently, use of EVT was strictly based on time criteria, within 4.5 to 12 h of symptom onset with many patients presenting with "wake-up" stroke who were not considered for EVT. The positive results of the DAWN and DEFUSE-3 trials have shown benefit in extending the therapeutic window for EVT to 24 and 16 h, respectively, after last known normal (LKN) time in the setting of large ischemic penumbra. These trials represent a paradigm shift in contemporary treatment of AIS, changing from a purely time-based decision to treat to an individualized decision based on clinical and radiographic findings of salvageable tissue. Overall, acute stroke management has evolved considerably over the years from intravenous thrombolysis to include EVT, with paralleled improvements in patient selection and thrombectomy devices. Since the results of the DAWN and DEFUSE-3, EVT is now considered the standard of care in select patients with anterior circulation LVO up to 24 h from LKN time. Despite these developments, post-stroke disability remains pervasive and further studies are warranted in establishing the role of EVT in posterior circulation and distal vessel occlusions, with need for development of new and effective techniques for revascularization of small vessels.

Current Endovascular Approach to the Management of Acute Ischemic Stroke.

PURPOSE OF REVIEW: The review provides an overview of current endovascular management of patients with acute ischemic stroke in the light of recent landmark trials proving unequivocal benefit of the intervention. RECENT FINDINGS: Several randomized trials looking at selective groups of patients presenting after an acute ischemic stroke due to large vessel occlusion in the anterior circulation demonstrated an overwhelming benefit of the endovascular treatment compared to intravenous thrombolysis, leading to expedited changes in the American Heart Association/American Stroke Association guidelines. Nonetheless, there are a relative large number of patients that were not included in those trials that might still benefit from endovascular treatment (acute posterior circulation-related strokes or acute embolic occlusion of middle cerebral artery beyond the main trunk for instances) and in which further studies are needed. We also briefly discuss endovascular techniques, post-procedure care, and endovascular treatment delivery models to expedite stroke patient assessment and rapid transport using updated and improved workflow protocols to provide timely recanalization. Endovascular treatment of acute occlusion of a proximal large artery in the anterior circulation is currently the standard of care. Time and quality of recanalization are the most important variables that determine the outcome. The indication for endovascular therapy in different scenarios (acute embolic occlusion in the posterior circulation or more distal branch occlusions) has to be individualized according to each patient's particular characteristics until new evidence is provided.

Recent Trends in Clot Retrieval Devices: A Review.

Stroke is the second leading cause of death worldwide and in Europe. Even with gold standard medical management of acute ischemic stroke, which is intravenous (IV) thrombolysis by administration of recombinant tissue plasminogen activator (rt-PA), the mortality rate remains the same. Intra-arterial (IA) thrombolysis therapy also did not achieve significant results and was not approved by the US Food and Drug Administration (FDA) because of limited sample size. This encouraged scientists and engineers to develop endovascular clot retrieval devices for the mechanical recanalization of the occluded arteries in stroke patients. Although the initial designs of clot retrieval devices failed, efforts to improve these devices continue. Recently clot retrieval devices were approved by the FDA as first-line treatment along with IV rt-PA. This article gives an in-depth review of different clot retrieval devices which includes MERCI (the first), the Penumbra Aspiration System, EmboTrap®II, stent retrievers, and the way forward with the new FDA clearance of the devices as first-line treatment for acute ischemic stroke along with IV rt-PA. The review also includes a comparison of clot retrieval devices to gold standard treatment.

Mechanical Thrombectomy in Wake-Up Strokes: A Case Series Using Alberta Stroke Program Early CT Score (ASPECTS) for Patient Selection.

BACKGROUND: There is lack of published studies on mechanical thrombectomy with stent retrievers for wake-up stroke (WUS). OBJECTIVE: To report the outcomes of WUS patients with large vessel occlusions, selected for intervention based on Alberta Stroke Program Early CT Score (ASPECTS) and treated with stent retrievers or primary aspiration thrombectomy. METHODS: Data were collected retrospectively for each consecutive WUS patient undergoing mechanical thrombectomy with a stent retriever or primary aspiration catheter between February 2015 and September 2016. ASPECTS ≥ 6 was used as the primary imaging criterion for offering thrombectomy in these WUS patients. Main outcomes were the in-hospital improvement in the National Institutes of Health Stroke Scale (NIHSS) and the occurrence of symptomatic hemorrhage. RESULTS: Twelve patients were included in this study; 11 were treated with stent retrievers and 1 was treated with primary aspiration thrombectomy alone. Successful recanalization was achieved in 100% of the patients (33% thrombolysis in cerebral infarction [TICI] 2B and 67% TICI 3). Every patient experienced a reduction in the NIHSS during hospitalization, with a mean NIHSS decrease of 11.1 ± 5.1 points. There was a trend for a larger reduction in the NIHSS in patients with TICI 3 compared to TICI 2B recanalization. There was no symptomatic intracranial hemorrhage in our cohort. CONCLUSIONS: For patients with WUS, careful selection of patients using ASPECTS may allow for safe interventions, with low risk of clinical deterioration, and no-periprocedural mortality. All our patients demonstrated a reduction in their NIHSS after the thrombectomy and clinical improvement.

Mechanical Thrombectomy in Acute Ischemic Stroke: Initial Single-Center Experience and Comparison with Randomized Controlled Trials.

BACKGROUND: Until recently, intravenous thrombolysis was the only reperfusion therapy with proven efficacy in patients with acute ischemic stroke. However, this treatment option has low recanalization rates in large-vessel occlusions. The search for additional treatments continued until 5 randomized trials (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, and REVASCAT) revealed the superiority of mechanical thrombectomy for anterior circulation large-vessel occlusion. After 1 year of performing thrombectomy with stent retrievers in our tertiary hospital, we intended to answer the question: is it possible to achieve similar results in a "real-world" setting? METHODS: We analyzed data from our prospective observational registry, compared it with the trials aforementioned, and concluded that the answer is affirmative. RESULTS: Our study population of 77 patients, with a mean age of 68,2 years and 48,1% men, is comparable with these trials in much of selection criteria, baseline characteristics, and rate of previous intravenous thrombolysis (72,7%). Recovery of functional independence at 90 days was achieved in almost two thirds of patients, similarly to the referred trials. We devoted special emphasis on fast recanalization, keeping a simple image selection protocol (based on non-enhanced and computed tomography angiography) and not waiting for clinical response to thrombolysis in patients eligible for mechanical thrombectomy. We emphasize a successful recanalization rate of 87% and only 2,6% symptomatic intracranial hemorrhage. CONCLUSION: In summary, mechanical thrombectomy seems to be a safe and effective treatment option in a "real-world" scenario, with results similar to those of the recent randomized controlled trials.

Endovascular Treatment of Thrombosis and Embolism.

Deep venous thrombosis (DVT) is a common disorder with a significant mortality rate. Successful endovascular treatment of acute DVT is most likely to be achieved in patients with recently formed thrombus, (<10-14 days) with acute iliofemoral DVT. Endovascular treatment options include: Catheter-directed thrombolysis (CDT), pharmacomechanical catheter-directed thrombolysis (PCDT), percutaneous aspiration thrombectomy (PAT), vena cava filter protection, venous balloon dilatation and venous stent implantation. Current practice shows strong clinical tendency for the use of PCDT with or without other endovascular methods and an individualized approach for each DVT patient. PMT has not received general acceptance because of the associated risk of PE and damage to venous valves caused by thrombectomy devices. PAT is most commonly used as an adjunctive endovascular technique like balloon maceration to fragment thrombus, balloon angioplasty, stent implantation and vena cava filter placement. Interventional endovascular therapies for DVT have the potential to provide PE protection and prevention of PTS. Patient centered individualized approach for endovascular DVT treatment is recommended to optimize the ideal clinical result.Acute stroke is the leading cause of death for people above the age of 60 and the fifth leading cause in people aged 15-59. Mortality during the first 30 days of ischemic stroke is 20 % and 30 % of survivors will remain permanently disabled. Acute stroke patients within the therapeutic window must receive IVrtPA unless there is a contraindication. In case of contraindication to IVrtPA or for patients out of the therapeutic window for thrombolytics, standart of care is the intraarterial treatment. Patients have to be transferred to a comprehensive stroke center with capacity of dedicated neurovascular imaging and interventional neuroradiology. Noncontrast head CT that is used to rule out hemorrhage is followed by imaging studies dedicated to show if there is reasonable penumbra to save. Intraarterial thrombolysis has the main advantage of extended therapy window, earlier and more efficient recanalization and less risk of hemorrhage due to lower doses of thrombolytics. Mechanical thrombectomy has several advantages over IV/IA fibrinolysis including faster recanalization and less risk of hemorrhage especially in large artery occlusions. ASA guidelines recommend choosing stent retrievers over other devices for mechanical thrombectomy. Better recanalization rates and less infarct volume after mechanical thrombectomy result in higher numbers of functionally independent patients compared with other treatments. Two landmark studies that were published recently, SWIFT PRIME and MR CLEAN, showed that IA treatment especially with the new stent retrievers lead to a significant increase in functional recovery and independence in daily life after an acute stroke.Cerebral venous and sinus thrombosis (CVST) comprises nearly 0.5-1 % of all stroke cases. CVST causes different neurological deficits depending on the sinus/cortical vein involved. CVST may cause death and dependency in 13.4 % of patients. CT/CT venography and MR/MR venography can be effectively used to diagnose and to follow up CVT cases. Anticoagulation with heparin is the most widely accepted therapy to prevent the expansion of the thrombus. Patients deteriorating despite heparinization and patients presenting with very severe neurological deficits must receive endovascular treatment. Endovascular methods include intrasinus infusion of thrombolytics or heparin, balloon angioplasty, mechanical thrombectomy or a combination of different techniques. There is a higher rate or recanalization with endovascular methods compared to other medical therapies.

Childhood acute basilar artery thrombosis successfully treated with mechanical thrombectomy using stent retrievers: case report and review of the literature.

INTRODUCTION: Acute basilar artery occlusion (ABAO) is an infrequent but potentially fatal cause of strokes in both adults and children, and it is usually due to vertebral artery dissection (VAD). VAD has been found to be usually a consequence of traumatic vertebral artery injury. ABAO usually presents with symptoms of acute ischemic stroke (AIS) of the posterior circulation or transient ischemic attack (TIA). It may lead to death or long-term disability if not promptly recanalized. Basilar artery recanalization in children can be achieved safely and with excellent clinical outcome using endovascular thrombectomy with the new generation self-expanding and retrievable stents. CLINICAL PRESENTATION: We report the case of a 23-month old baby that came to the emergency room of our hospital for progressive impairment of consciousness associated with widespread stiffness and plaintive cry, appeared after accidental fall from stroller. An emergency brain CT scan was obtained showing multiple infarction lesions in the brainstem and left cerebellum suggestive of acute stroke in posterior circulation territories. An MR scan with angiography and diffusion-weighted sequences confirmed the multiple infarction lesions and demonstrated poor representation of the flow signal at the V3 segment of the left vertebral artery and absent representation of the flow signal at the distal segment of the basilar artery suggestive of acute thrombotic occlusion. The patient was immediately referred to interventional neuroradiology unit, and digital subtraction angiography showed complete basilar artery occlusion and left vertebral artery dissection at extracranial V2-V3 segment. The patient underwent intra-arterial thrombectomy using stent retrievers and occlusion of the V2-V3 segment of the left vertebral artery. The patient survived and long-term outcome was excellent. CONCLUSIONS: To our knowledge, only nine cases of ABAO in children treated with intra-arterial thrombectomy have been previously reported in the literature. In only three cases, the Solitaire stent was applied. Our case is the first case of basilar artery occlusion treated with Solitaire stent, in a child under 24 months. The reports that are available so far indicate that basilar artery recanalization in children can be achieved safely and with excellent clinical outcome using endovascular thrombectomy with the new generation self-expanding and retrievable stents.

Intra-arterial Stroke Treatment prior to the Stent-Retriever Era: High Mortality and Lack of Volume-Outcome Association.

BACKGROUND: Mechanical thrombectomy for acute large-vessel occlusive stroke is beneficial when performed with stent-retriever devices; however, little is known about real-world experience with intra-arterial treatment (IAT). We aimed to clarify how hospitals influence outcomes for Medicare thrombectomy patients to inform future delivery of effective mechanical thrombectomy treatment. METHODS: This is a retrospective cohort study that includes a Medicare fee-for-service patient population. Patients with a primary stroke discharge (ICD-9-CM 433.x1, 434.x1, 436) were included; billing codes were used to identify patients receiving IAT, intravenous thrombolytics (IVT), or a combination of these treatments. Characteristics of treated patients were summarized using descriptive statistics; long-term mortality was summarized via Kaplan-Meier curves; and multilevel logistic regression models with random hospital-level intercept were built to determine hospital influence on outcome and whether a volume-outcome association existed. RESULTS: A total of 4557 patients received IAT at 544 hospitals. The mean age of IAT patients was 76 years. IAT patients had longer hospital stay (9.7 versus 6.8 days), longer stay in the ICU (5.5 versus 3.3 days), and greater probability of intubation (36.7% versus 9.5%) compared with IVT patients. Ninety-day mortality was 46% IAT versus 26% IVT. Hospitals had little influence on outcomes (intraclass correlation coefficient, <.01). No association between procedural volume and outcomes was identified. CONCLUSIONS: IAT for 2007-2010 was associated with higher patient mortality than recent and prior clinical trials. Treated Medicare patients were considerably older than clinical trial populations. Hospitals had little influence on mortality, and increased hospital volume was not associated with lower mortality. Future real-world experience should monitor these parameters as use of stent retrievers disseminates.

Acute Ischemic Stroke Intervention.

Acute ischemic stroke (AIS) is the leading cause of disability worldwide and among the leading causes of mortality. Although intravenous tissue plasminogen activator (IV-rtPA) was approved nearly 2 decades ago for treatment of AIS, only a minority of patients receive it due to a narrow time window for administration and several contraindications to its use. Endovascular approaches to recanalization in AIS developed in the 1980s, and recently, 5 major randomized trials showed an overwhelming superior benefit of combining endovascular mechanical thrombectomy with IV-rtPA over IV-rtPA alone. In this paper, we discuss the evolution of catheter-based treatment from first-generation thrombectomy devices to the game-changing stent retrievers, results from recent trials, and the evolving stroke systems of care to provide timely access to acute stroke intervention to patients in the United States.

The use of stent retrievers in acute ischemic stroke.

INTRODUCTION: Acute ischemic stroke (AIS) is one of the leading causes of mortality and adult disability worldwide. For two decades, the preferred approach for AIS was intravenous recombinant tissue plasminogen activator (IV tPA). However, IV tPA cannot be given to many AIS patients who do not meet strict criteria for its use. IV tPA has also had lesser benefit in patients with large clot burden in the context of large vessel occlusion (LVO). AREAS COVERED: Endovascular stroke therapy had been an 'unproven' therapy despite numerous trials of intra-arterial pharmacologic thrombolysis and mechanical thrombectomy. With the advent of stent-retriever devices, there has been a paradigm shift in the utilization of endovascular therapies for AIS. Our review discusses cerebrovascular hemodynamics, the basis of the recanalization models in AIS, aspects of intravenous thrombolysis, prior generations of endovascular therapy, and the recent successful AIS stent retriever trials. Expert commentary: Recently 'stent-retrievers', a new generation of mechanical thrombectomy devices, were shown to be associated with improved functional outcomes in AIS secondary to proximal intracranial anterior circulation LVO. Stent retrievers are a major advance in AIS care and will have significant impact on the evolution of stroke systems of care.

Intermediate Catheters Reduce the Length of Mechanical Thrombectomy Procedures in Acute Basilar Artery Occlusions.

BACKGROUND AND PURPOSE: In the past years, technical developments have raised recanalization rates of endovascular treatments of intracerebral artery occlusions in acute ischemic stroke. By using stent retrievers, several prospective trials have reported recanalization rates up to 79 % as well as good neurological outcome in up to 58 % of the cases. The degree of the recanalization and the length of the procedure are factors known to influence the clinical outcome of patients treated endovascularly. Yet, still little is known about factors influencing the angiographic results of thrombectomy procedures. The purpose of this study was to investigate whether the use of intermediate catheters affects the angiographic results of thrombectomy procedures in basilar artery occlusions. MATERIALS AND METHODS: A total of 47 consecutive patients with acute basilar artery occlusions who underwent endovascular treatment with stent retrievers in our department were retrospectively identified. We analyzed the angiographic data regarding the use of intermediate catheters, the lengths of the procedures, the number of passes of the stent retrievers, the angiographic results, and the site of access to the basilar artery. RESULTS: Recanalization with modified thrombolysis in cerebral infarction (mTICI) ≥ 2b was achieved in 74.5 %. Intermediate catheters were used in 13 cases. The mean length of the procedures was significantly shorter when intermediate catheters were used (44.8 ± 27.6 vs. 70.7 ± 41.4 min, P = .043). There were no significant differences in the number of passes or in the final mTICI scores. CONCLUSIONS: The use of intermediate catheters significantly reduces the length of mechanical thrombectomy procedures in acute basilar artery occlusions.