Continuing early mTICI 2b recanalization may improve functional outcome but is associated with a higher risk of intracranial hemorrhage.

Background: Successful reperfusion (mTICI 2c/3) and low number of passes are key determinants for good clinical outcome in acute large vessel occlusion. While final mTICI 2c/3 reperfusion is superior to partial reperfusion (mTICI 2b) it remains unclear if this is also true for the subgroup of patients with early mTICI 2b (achieved in ≤2 retrieval attempts) reperfusion who are secondarily improved to mTICI 2c/3. This study was designed to examine if early mTICI2b should be continued or stopped during mechanical thrombectomy (MT). Methods: Nine hundred and thirteen ischemic stroke patients who received MT were retrospectively analyzed. Angiography runs following each recanalization attempt were scored for mTICI. The patients with early mTICI 2b reperfusions were dichotomized in "TICI2b-stopped" (MT withdrawal after mTICI 2b was achieved with first or second retrieval) and "TICI2b-continued" (MT was continued after mTICI 2b was achieved with first or second retrieval). Functional outcome was obtained after 90 days using the modified Rankin scale (mRS90). Results: Of 362 Patients with a M1-occlusion, 100 patients fulfilled the inclusion criteria with an early mTICI 2b. 78/100 patients were included in the "TICI2b-stopped" group and 22/100 patients were in the "TICI2b-continued" group. Of these 22 patients, none had a final mTICI score lower than 2b and 11 patients had a final mTICI score of 2c/3. Regarding good functional outcome at mRS90, "TICI2b-continued" showed by trend a slight advantage of 40.1 vs. 35.6% in "TICI2b-stopped" but in multivariate logistic regression analysis adjusted for confounders, no significant difference was found between the two groups (OR 0.75, 95% CI 0.19-2.87, p = 0.67). Symptomatic intracranial hemorrhage was significantly higher in "TICI2b-continued" compared to "TICI2b-stopped" (31.8 vs. 10.3%, p = 0.031). Conclusion: Successfully improving an early mTICI 2b to mTICI 2c/3 reperfusion is possible in a substantial number of patients and might improve functional outcome. However, an increase in symptomatic intracranial hemorrhage (SICH) due to further retrieval attempts may diminish the potential functional benefit to continue early mTICI 2b. To support this finding, further investigation with more power is needed to account for the low number of events regarding SICH.

Groin Puncture to Recanalization Time May Be a Strong Predictor of mTICI 2c/3 over mTICI 2b in Patients with Large Vessel Occlusions Successfully Recanalized with Mechanical Thrombectomy.

Mechanical thrombectomy (MT) is an important therapeutic option in the management of acute ischemic stroke (AIS) caused by large vessel occlusions (LVO). While achieving a modified thrombolysis in cerebral infarction (mTICI), grades of 2b, 2c, and 3 are all considered successful recanalization; recent literature suggests that mTICI grades of 2c/3 are associated with superior outcomes than 2b. The aim of this preliminary study is to determine whether any baseline or procedural parameters can predict whether successfully recanalized patients achieve an mTICI grade of 2c/3 over 2b. Consecutive patients from 9/2019 to 10/2021 who were successfully recanalized following MT for confirmed LVO were included in the study. Baseline and procedural data were collected through manual chart review and analyzed to ascertain whether any variables of interest could predict mTICI 2c/3. A total of 47 patients were included in the preliminary study cohort, with 35 (74.5%) achieving an mTICI score of 2c/3 and 12 (25.5%) achieving an mTICI score of 2b. We found that a lower groin puncture to recanalization time was a strong, independent predictor of TICI 2c/3 (p = 0.015). These findings emphasize the importance of minimizing procedure time in achieving superior reperfusion but must be corroborated in larger scale studies.

Convulsive-like symptoms as initial indications of basilar artery occlusion: A case series study.

BACKGROUND: There is little evidence regarding relevant clinical findings for the early diagnosis of basilar artery occlusion (BAO) in the prehospital setting. We focused on "convulsive-like symptoms", including convulsive seizures and other convulsive-like movements, and examined the frequency and clinical characteristics of patients with BAO having these symptoms as an initial symptom. METHODS: In this single-center case series from 2015 to 2020, we identified patients who underwent endovascular therapy (EVT) for BAO and presented with convulsive-like symptoms between the stroke onset and initiation of emergency medical care. The clinical course and neurological findings were evaluated by reviewing the run sheets of emergency medical services and medical records. RESULTS: Among a total of 32 patients with BAO, 7 (21.9%) developed convulsive-like symptoms before EVT, of whom 6 were men and whose median age was 72 (interquartile range, 69-78) years. These 7 patients had no history of epilepsy or stroke, and the semiology of convulsive-like symptoms was generalized in 6 of them. In only 3 of the 7 cases, emergency medical services could consider the possibility of stroke on scene, and time from hospital arrival to groin puncture was longer in those who were transported without suspicion of stroke. CONCLUSIONS: 21.9% of our patients who underwent EVT for BAO experienced convulsive-like symptoms initially. We should be vigilant in the possibility of BAO when managing the first-time generalized convulsive-like symptoms occurring in older patients, which may enable to adequate triage and better management for patients with acute BAO.

Association of CHA2DS2-VASc score with successful recanalization in acute ischemic stroke patients undergoing endovascular thrombectomy.

Introduction: The CHA2DS2-VASc (congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease and sex) score is a simple risk stratification algorithm to estimate stroke/thromboembolic risk in patients with non-valvular atrial fibrillation (AF). Higher pre-stroke CHA2DS2-VASc score is known to be associated with greater stroke severity and poorer outcomes. AF patients generally have higher CHA2DS2-VASc scores than non-AF patients. The Modified Thrombolysis in Cerebral Infarction (mTICI) score is the most widely used grading system to assess the result of recanalizing therapies in acute ischemic stroke (AIS). mTICI 2c and mTICI 3 are conventionally accepted as successful recanalization. Aim: We investigated whether pre-stroke CHA2DS2-VASc score is associated with mTICI recanalization score in AIS patients with and without AF undergoing percutaneous thrombectomy. Material and methods: One hundred fifty-nine patients with the diagnosis of AIS who were admitted within 6 h from symptom onset were included in the study (mean age: 65.7 ±12.9). All subjects underwent endovascular treatment. CHA2DS2-VASc scores of the participants were calculated. Subjects were grouped according to mTICI scores achieved after endovascular treatment. mTICI 2c and mTICI 3 were accepted as successful recanalization. Results: Successful reperfusion was observed in 130 (81.8%) of all patients who underwent endovascular treatment (mTICI flow ≥ 2c) and first-pass reperfusion was observed in 107 (67.3%) patients. When the patients with successful (mTICI flow ≥ 2c) and unsuccessful (mTICI flow ≤ 2b) reperfusion were divided into groups, no significant difference was observed between the patients in terms of comorbidities such as AF, hypertension, hyperlipidemia, coronary artery disease and cerebrovascular accident history. Patients with unsuccessful reperfusion were older than patients with successful reperfusion (71.4 ±11.2 vs. 64.5 ±13.01, p = 0.006), with a higher CHA2DS2-VASc score (4.1 ±1.5 vs. 3.04 ±1.6, p = 0.002). In addition, the duration of the procedure was longer in the unsuccessful reperfusion group (92.4 ±27.2 min vs. 65.0 ±25.1 min, p < 0.001). CHA2DS2-VASc score significantly correlated with successful recanalization (correlation coefficient; 0.243, p = 0.002). Multivariate logistic regression analysis revealed that only CHA2DS2-VASc score (OR = 1.43, 95% CI: 1.09-1.87, p = 0.006) and procedure time (OR = 1.03, 95% CI: 1.01-1.05, p < 0.001) were independent predictors of successful reperfusion. The receiver-operating characteristic (ROC) curve was used to determine the cut-off value for the CHA2DS2-VASc score that best predicts successful reperfusion. The optimal threshold was 3.5, with a sensitivity of 58.6% and specificity of 59.2% (area under the curve (AUC): 0.669, p = 0.005). Conclusions: For the first time in the literature, we investigated and demonstrated that pre-stroke CHA2DS2-VASc score was associated with success of recanalization as assessed with mTICI 2c and mTICI 3 in a cohort of AIS patients regardless of AF presence who underwent endovascular treatment. Our findings deserve to be tested with large scale long term studies.

Efficacy of Mechanical Thrombectomy Using an Aspiration Catheter Compared with a Stent Retriever Alone for Middle Cerebral Artery M2 Occlusion.

Objective: Mechanical thrombectomy (MT) for middle cerebral artery M2 occlusion (M2O) is challenging because the procedure is performed in a narrow and tortuous artery. In this study, we compared MT using an aspiration catheter (AC) versus a stent retriever (SR) used alone, and retrospectively evaluated the efficacy and safety of MT using an AC for M2O. Methods: Seventy-four consecutive patients who underwent MT for M2O at our institution between April 2016 and April 2020 were evaluated. The subjects were classified into those treated by AC (AC group) or SR alone (SR group). The AC group included patients treated by both contact aspiration and a combination technique of AC and SR. Background factors and outcomes, including modified treatment in cerebral infarction (mTICI) 2c-3 recanalization, were compared between the groups. Results: AC and SR groups consisted of 47 and 27 patients respectively. Among them, the rate of mTICI 2b-3 was 93.6% vs 92.6%, and that of mTICI 2c-3 was 72.3% vs 48.2% (P = 0.004). The perioperative symptomatic subarachnoid hemorrhage (SAH) rate was 0% vs 7.4%, and modified Rankin scale scores of 0-2 were 78.6% vs 50% (P = 0.03). In the AC group, the mTICI 2c-3 rate was higher in patients in whom the AC was adequately advanced to the thrombus compared to those with inadequate AC advancement (83.3% vs 36.3%, P = 0.002). Conclusion: The rate of mTICI 2c-3 was higher in the AC than SR group, with no cases of symptomatic SAH. MT using AC for M2O might achieve safe and effective thrombectomy.

Identification of successful cerebral reperfusions (mTICI ≥2b) using an artificial intelligence strategy.

BACKGROUND: The modified thrombolysis in cerebral infarction (mTICI) scale is a widely used and validated qualitative tool to evaluate angiographic intracerebral inflow following endovascular thrombectomy (EVT). We validated a machine-learning (ML) algorithm to grade digital subtraction angiograms (DSA) using the mTICI scale. MATERIALS AND METHODS: We included angiograms of identified middle cerebral artery (MCA) occlusions who underwent EVT. The complete DSA sequences were preprocessed and normalized. We created three convolutional neural networks to classify DSA into two outcomes, low- (mTICI 0,1,2a) and high-grade (mTICI 2b,2c,3). RESULTS: We included a total of 234 angiograms in this study. The area under the receiver operating characteristic was 0.863 (95% CI 0.816-0.909), 0.914 (95% CI 0.876-0.951), and 0.890 (95% CI 0.848-0.932) for the anteroposterior (AP), lateral (L), and combined models, respectively, when dichotomizing outcomes into low and high grade. The models' area under the precision-recall curve was 0.879 (95% CI 0.829-0.930), 0.906 (95% CI 0.844-0.968), and 0.887 (95% CI 0.834-0.941) for the AP, L, and combined models. CONCLUSION: In complete cerebral DSA, our angiography-based ML strategy was able to predict mTICI scores following EVT rapidly and reliably for MCA occlusions.

The Therapeutic Effects of Endovascular Therapy with mTICI2b and 3 Recanalization for Acute Anterior Circulation Stroke Patients.

BACKGROUND AND PURPOSE: Modified Thrombolysis in Cerebral Infarction (mTICI)2b/3 has been considered the criterion for successful reperfusion in endovascular treatment. This study aimed to compare the therapeutic safety and efficacy of mTICI2b and mTICI3 recanalization, and to analyze the factors related to outcomes in everyday clinical practice. MATERIALS AND METHODS: This is a single-center retrospective analysis of 224 patients who underwent successful thrombectomy (achieving a mTICI score ≥2b). The primary outcomes included a modified Rankin score (mRS) of 0-2 at 90-day, mortality, and symptomatic intracranial hemorrhage. RESULTS: A total of 111 patients achieved mTICI2b status (49.6%), and 113 achieved mTICI3 status (50.4%). The comparison between mTICI2b and 3 reperfusions showed no differences in short-term outcomes, 90-day mRS, complications, and mortality. There was a trend toward more passes in mTICI2b patients, although the difference was not significant. The univariate analysis showed that poor outcomes after endovascular treatment were associated with older age, previous history of coronary heart disease, atrial fibrillation, diabetes, tandem occlusions, high National Institutes of Health Stroke Scale (NIHSS) score on admission, and general anesthesia. A previous history of coronary heart disease, a high NIHSS score on admission, and the use of general anesthesia were independent factors that affected the therapeutic effects. CONCLUSION: The superiority (efficacy and safety) of mTICI3 reperfusion was not significant compared with that of mTICI2b reperfusion. Prolonged efforts to achieve mTICI3 after achieving mTICI2b should be considered prudently for those with difficulty achieving 100% reperfusion.

Mechanical thrombectomy in pediatric stroke: systematic review, individual patient data meta-analysis, and case series.

OBJECTIVE: The role of mechanical thrombectomy in pediatric acute ischemic stroke is uncertain, despite extensive evidence of benefit in adults. The existing literature consists of several recent small single-arm cohort studies, as well as multiple prior small case series and case reports. Published reports of pediatric cases have increased markedly since 2015, after the publication of the positive trials in adults. The recent AHA/ASA Scientific Statement on this issue was informed predominantly by pre-2015 case reports and identified several knowledge gaps, including how young a child may undergo thrombectomy. A repeat systematic review and meta-analysis is warranted to help guide therapeutic decisions and address gaps in knowledge. METHODS: Using PRISMA-IPD guidelines, the authors performed a systematic review of the literature from 1999 to April 2019 and individual patient data meta-analysis, with 2 independent reviewers. An additional series of 3 cases in adolescent males from one of the authors' centers was also included. The primary outcomes were the rate of good long-term (mRS score 0-2 at final follow-up) and short-term (reduction in NIHSS score by ≥ 8 points or NIHSS score 0-1 at up to 24 hours post-thrombectomy) neurological outcomes following mechanical thrombectomy for acute ischemic stroke in patients < 18 years of age. The secondary outcome was the rate of successful angiographic recanalization (mTICI score 2b/3). RESULTS: The authors' review yielded 113 cases of mechanical thrombectomy in 110 pediatric patients. Although complete follow-up data are not available for all patients, 87 of 96 (90.6%) had good long-term neurological outcomes (mRS score 0-2), 55 of 79 (69.6%) had good short-term neurological outcomes, and 86 of 98 (87.8%) had successful angiographic recanalization (mTICI score 2b/3). Death occurred in 2 patients and symptomatic intracranial hemorrhage in 1 patient. Sixteen published thrombectomy cases were identified in children < 5 years of age. CONCLUSIONS: Mechanical thrombectomy may be considered for acute ischemic stroke due to large vessel occlusion (ICA terminus, M1, basilar artery) in patients aged 1-18 years (Level C evidence; Class IIb recommendation). The existing evidence base is likely affected by selection and publication bias. A prospective multinational registry is recommended as the next investigative step.

Mechanical thrombectomy using a Solitaire stent retriever in the treatment of pediatric acute ischemic stroke.

OBJECTIVE Mechanical thrombectomy using a Solitaire stent retriever has been widely applied as a safe and effective method in adult acute ischemic stroke (AIS). However, due to the lack of data, the safety and effectiveness of mechanical thrombectomy using a Solitaire stent in pediatric AIS has not yet been verified. The purpose of this study was to explore the safety and effectiveness of mechanical thrombectomy using a Solitaire stent retriever for pediatric AIS. METHODS Between January 2012 and December 2017, 7 cases of pediatric AIS were treated via mechanical thrombectomy using a Solitaire stent retriever. The clinical practice, imaging, and follow-up results were reviewed, and the data were summarized and analyzed. RESULTS The ages of the 7 patients ranged from 7 to 14 years with an average age of 11.1 years. The preoperative National Institutes of Health Stroke Scale (NIHSS) scores ranged from 9 to 22 with an average of 15.4 points. A Solitaire stent retriever was used in all patients, averaging 1.7 applications of thrombectomy and combined balloon dilation in 2 cases. Grade 3 on the modified Thrombolysis In Cerebral Infarction scale of recanalization was achieved in 5 cases and grade 2b in 2 cases. Six patients improved and 1 patient died after thrombectomy. The average NIHSS score of the 6 cases was 3.67 at discharge. The average modified Rankin Scale score was 1 at the 3-month follow-up. Subarachnoid hemorrhage after thrombectomy occurred in 1 case and that patient died 3 days postoperatively. CONCLUSIONS This study shows that mechanical thrombectomy using a Solitaire stent retriever has a high recanalization rate and excellent clinical prognosis in pediatric AIS. The safety of mechanical thrombectomy in pediatric AIS requires more clinical trials for confirmation. ABBREVIATIONS ACA = anterior cerebral artery; AIS = acute ischemic stroke; CTA = CT angiography; ICA = internal carotid artery; MCA = middle cerebral artery; mRS = modified Rankin Scale; mTICI = modified Thrombolysis In Cerebral Infarction; NIHSS = National Institutes of Health Stroke Scale; rt-PA = recombinant tissue plasminogen activator.

Effect of balloon guide catheter utilization on contact aspiration thrombectomy.

OBJECTIVEThe role of the balloon guide catheter (BGC) has not been evaluated in contact aspiration thrombectomy (CAT) for acute stroke. Here, the authors aimed to test whether the BGC was associated with recanalization success and good functional outcome in CAT.METHODSAll patients who had undergone CAT as the first-line treatment for anterior circulation intracranial large vessel occlusion were retrospectively identified from prospectively maintained registries for six stroke centers. The patients were dichotomized into BGC utilization and nonutilization groups. Clinical findings, procedural details, and recanalization success rates were compared between the two groups. Whether the BGC was associated with recanalization success and functional outcome was assessed.RESULTSA total of 429 patients (mean age 68.4 ± 11.4 years; M/F ratio 215:214) fulfilled the inclusion criteria. A BGC was used in 45.2% of patients. The overall recanalization and good outcome rates were 80.2% and 52.0%, respectively. Compared to the non-BGC group, the BGC group had a significantly reduced number of CAT passes (2.6 ± 1.6 vs 3.4 ± 1.5), shorter puncture-to-recanalization time (56 ± 27 vs 64 ± 35 minutes), lower need for the additional use of thrombolytics (1.0% vs 8.1%), and less embolization to a distal or different site (0.5% vs 3.4%). The BGC group showed significantly higher final (89.2% vs 72.8%) and first-pass (24.2% vs 8.1%) recanalization success rates. After adjustment for potentially associated factors, BGC utilization remained independently associated with recanalization (OR 4.171, 95% CI 1.523-11.420) and good functional outcome (OR 2.103, 95% CI 1.225-3.612).CONCLUSIONSBGC utilization significantly increased the final and first-pass recanalization rates and remained independently associated with recanalization success and good functional outcome.

Endovascular treatment for emergent large vessel occlusion due to severe intracranial atherosclerotic stenosis.

OBJECTIVEThe optimal treatment strategy for patients with emergent large vessel occlusion (ELVO) due to underlying severe intracranial atherosclerotic stenosis (ICAS) is unclear. The purpose of this study was to compare treatment outcomes from intracranial angioplasty with or without stenting and intraarterial infusion of a glycoprotein IIb/IIIa inhibitor in patients with ELVO due to severe ICAS, and to investigate predictors of outcome after endovascular therapy in such patients.METHODSA total of 140 consecutive patients with ELVO attributable to severe ICAS underwent endovascular therapy at two stroke centers (A and B). Intracranial angioplasty/stenting was primarily performed at center A and intraarterial infusion of glycoprotein IIb/IIIa inhibitor (tirofiban) at center B. Data from both centers were prospectively collected into a database and retrospectively analyzed.RESULTSOverall, successful reperfusion was achieved in 95% (133/140) of patients and a good outcome in 60% (84/140). The mortality rate was 7.9%. Symptomatic hemorrhage occurred in 1 patient. There were no significant differences in the rates of successful reperfusion, symptomatic hemorrhage, 3-month modified Rankin scale score 0-2, and mortality between the two centers. Multivariate logistic regression analysis revealed the only independent predictor of good outcome was a history of previous stroke or transient ischemic attack (TIA) (odds ratio 0.254, 95% confidence interval 0.094-0.689, p = 0.007).CONCLUSIONSBoth intracranial angioplasty/stenting and intraarterial infusion of a glycoprotein IIb/IIIa inhibitor are effective and safe in the treatment of underlying severe ICAS in acute stroke patients with ELVO. In addition, a lack of a history of stroke/TIA was the only independent predictor of good outcome after endovascular therapy in such patients.

Different learning curves between stent retrieval and a direct aspiration first-pass technique for acute ischemic stroke.

OBJECTIVEThe clinical outcomes of a direct aspiration first-pass technique (ADAPT) and stent retriever (SR) have been reported to be similar in several observational studies. In this study, procedural and clinical outcomes with ADAPT and SR for the treatment of acute ischemic stroke with large artery occlusion were compared in different time periods.METHODSIn each specific time period, SR and ADAPT were used as the first-line treatment approach for acute ischemic stroke patients with large artery occlusion at the authors' institution. Baseline characteristics, procedural variables, and functional outcome at 90 days were compared between patients treated with SR and those treated with ADAPT. These 2 groups were divided into 3 sequential subgroups to assess the learning curve effects of the endovascular team and individual operators on the procedural variables of each treatment strategy.RESULTSOverall, 89 patients were treated. In the SR group, the recanalization rate was higher (84% vs 65%; p = 0.01) and the procedure time was shorter than in the ADAPT group (median 42 minutes vs 76 minutes, p = 0.04). On the subgroup analysis of the learning curve, the SR group showed more rapid improvement in procedure time than the ADAPT group (p = 0.01 for the team; p < 0.01 for individual operators).CONCLUSIONSIn this initial experience, a higher recanalization rate and shorter procedure time were achieved with SR than with ADAPT. A high recanalization rate with SR was possible with relatively less clinical experience, whereas procedure time dramatically decreased with experience. These observed effects on the learning curve might be useful when choosing the method for initial endovascular treatment of acute ischemic stroke at relatively small stroke centers.

Mechanical thrombectomy in basilar artery occlusion: influence of reperfusion on clinical outcome and impact of the first-line strategy (ADAPT vs stent retriever).

OBJECTIVESeveral randomized trials have been focused on patients with anterior circulation stroke, whereas few data on posterior circulation stroke are available. Thus, new mechanical thrombectomy (MT) strategies, including a direct-aspiration first-pass technique (ADAPT), remain to be evaluated in basilar artery occlusion (BAO) patients. The authors here assessed the influence of reperfusion on outcome in BAO patients and examined whether ADAPT improves the reperfusion rate compared with stent retriever devices.METHODSThree comprehensive stroke centers prospectively collected individual data from BAO patients treated with MT. Baseline characteristics as well as radiographic and clinical outcomes were compared between the 2 MT strategies. The primary outcome measure was the rate of successful reperfusion, defined as a modified Thrombolysis in Cerebral Infarction (mTICI) grade of 2b-3. Favorable outcome was defined as a 90-day modified Rankin Scale score of 0-2.RESULTSAmong the 100 adult patients included in the study, 46 were treated with first-line ADAPT (median age 61 years, IQR 53-71 years; stent-retriever rescue therapy was secondarily used in 12 [26.1%]) and 54 were treated with a primary stent retriever (median age 67 years, IQR 53-78 years). There was no difference in baseline characteristics between the 2 treatment groups, except for the rate of diabetes (19.6% vs 5.7%, respectively, p = 0.035). Successful reperfusion was achieved in 79% of the overall study sample. Overall, the rate of favorable outcome was 36.8% and 90-day all-cause mortality was 44.2%. Successful reperfusion positively impacted favorable outcome (OR 4.57, 95% CI 1.24-16.87, p = 0.023). A nonsignificant trend toward a higher successful reperfusion rate (unadjusted OR 2.56, 95% CI 0.90-7.29, p = 0.071) and a significantly higher rate of complete reperfusion (mTICI grade 3; unadjusted OR 2.59, 95% CI 1.14-5.86, p = 0.021) was found in the ADAPT group. The procedure duration was also significantly lower in the ADAPT group (median 45 minutes, IQR 34 to 62 minutes vs 56 minutes, IQR 40 to 90 minutes; p = 0.05), as was the rate of periprocedural complications (4.3% vs 25.9%, p = 0.003). Symptomatic intracranial hemorrhage (0.0% vs 4.0%, p = 0.51) and 90-day all-cause mortality (46.7% vs 42.0%, p = 0.65) were similar in the 2 groups.CONCLUSIONSAmong BAO patients, successful reperfusion is a strong predictor of a 90-day favorable outcome, and the choice of ADAPT as the first-line strategy achieves a significantly higher rate of complete reperfusion with a shorter procedure duration.

Severe carotid stenosis and delay of reperfusion in endovascular stroke treatment: an Interventional Management of Stroke-III study.

OBJECTIVE The impact of extracranial carotid stenosis on interventional revascularization of acute anterior circulation stroke is unknown. The authors examined the effects of high-grade carotid stenosis on the results of endovascular treatment of patients in the Interventional Management of Stroke (IMS)-III trial. METHODS The 278 patients in the endovascular arm of the IMS-III trial were categorized according to the degree of carotid stenosis as determined by angiography. In comparing patients with severe stenosis or occlusion (≥ 70%) to those without severe stenosis (< 70%), the authors evaluated the time to endovascular reperfusion, modified Thrombolysis in Cerebrovascular Infarction (mTICI) scores, 24-hour mean infarct volumes, symptomatic intracerebral hemorrhage rates, and modified Rankin Scale (mRS) scores at 90 days. RESULTS Compared with the 249 patients with less than 70% stenosis, patients with severe stenosis (n = 29) were found to have a significantly longer mean time to reperfusion (105.7 vs 77.7 minutes, p = 0.004); differences in mTICI scores, infarct volumes, hemorrhage rates, and mRS scores at 90 days did not reach statistical significance. Multiple regression analysis revealed that severe carotid stenosis (p < 0.0001) and higher baseline National Institutes of Health Stroke Scale (NIHSS) scores (p = 0.004) were associated with an increase in time to reperfusion. Older age (p < 0.0001), higher NIHSS score (p < 0.0001), and the absence of reperfusion (p = 0.001) were associated with worse clinical outcomes. CONCLUSIONS Severe ipsilateral ICA stenosis was associated with a significantly longer time to reperfusion in the IMS-III trial. Although these findings may not translate directly to modern devices, this 28-minute delay in reperfusion has significant implications, raising concern over the treatment of tandem ICA stenosis and downstream large-vessel occlusion.

Improving mTICI2b reperfusion to mTICI2c/3 reperfusions: A retrospective observational study assessing technical feasibility, safety and clinical efficacy.

BACKGROUND: Recent studies suggested that modified Thrombolysis in Cerebral Infarction grade (mTICI) 3 reperfusions are associated with superior outcome to mTICI2b reperfusions, questioning if neurointerventionalists should generally strive to achieve mTICI3. METHODS: Retrospective analysis of successfully reperfused MCA occlusions (n=246) with available angiography runs between every manoeuvre was performed. Final reperfusion success and those between all single manoeuvres were evaluated applying the modified version of the TICI score (including TICI2c). Final TICI2c/3 reperfusions were dichotomized as 'direct' (reperfusion before final manoeuvre ≤mTICI2a) or 'secondary improved' (mTICI2b was achieved). RESULTS: Patients with mTICI2c reperfusion had similar outcome to patients with mTICI3 rather than mTICI2b reperfusions. Compared with mTICI2c/3-patients, mTICI2b-patients had lower rates of neurological improvement (33.3% vs. 61.2%, p<0.001) and good functional outcome (28.7% vs. 46.5%, p=0.008). In 28 patients, mTICI2b reperfusion was improved to mTICI2c/3 without complications. Outcome of patients with 'direct' or 'secondary improved' mTICI2c/3 did not differ (p>0.5). CONCLUSION: Improving mTICI2b reperfusions to mTICI2c/3 reperfusions is sometimes technically feasible and safe, and associated with clinical benefit comparable to 'direct' mTICI2c/3 reperfusions. If confirmed, a more aggressive treatment approach in cases of already achieved mTICI2b may be justified, although proper patient selection is needed. KEY POINTS: • Patients with mTICI2c or 3 reperfusions have a comparable clinical course. • mTICI2c/3 are associated with a larger therapeutic benefit than are mTICI2b reperfusions. • Improving reperfusion from mTICI2b to mTICI2c/3 is sometimes feasible and reasonably safe. • Outcome of patients with 'secondary improved' and 'direct' mTICI2c/3 is not different.

Transradial approach for mechanical thrombectomy in anterior circulation large-vessel occlusion.

OBJECTIVE The goals of this study were to describe the authors' recent institutional experience with the transradial approach to anterior circulation large-vessel occlusions (LVOs) in acute ischemic stroke patients and to report its technical feasibility. METHODS The authors reviewed their institutional database to identify patients who underwent mechanical thrombectomy via a transradial approach over the 2 previous years, encompassing their experience using modern techniques including stent retrievers. RESULTS Eleven patients were identified. In 8 (72%) of these patients the right radial artery was chosen as the primary access site. In the remaining patients, transfemoral access was initially attempted. Revascularization (modified Treatment in Cerebral Ischemia [mTICI] score ≥ 2b) was achieved in 10 (91%) of 11 cases. The average time to first pass with the stent retriever was 64 minutes. No access-related complications occurred. CONCLUSIONS Transradial access for mechanical thrombectomy in anterior circulation LVOs is safe and feasible. Further comparative studies are needed to determine criteria for selecting the transradial approach in this setting.