Stent-Retriever Thrombectomy for Acute Anterior Ischemic Stroke with Tandem Occlusion: A Systematic Review and Meta-Analysis.

OBJECTIVES: To assess the efficacy and safety profile of stent-retriever thrombectomy (SRT) in acute anterior ischemic stroke patients with tandem occlusion. MATERIALS AND METHODS: Using the MEDLINE database, we conducted a systematic review and meta-analysis of all studies that included patients with acute ischemic stroke attributable to tandem occlusion who received treatment with SRT between November 2010 and May 2015. RESULTS: The literature search identified 11 previous studies involving a total of 237 subjects out of whom 193 (81.4 %) were treated with acute stent placement for the extracranial internal carotid artery occlusion. Mean initial NIHSS score was 17, and median time from onset to recanalization was 283.5 min. Mean intravenous thrombolysis rate was 63.8 %. In the meta-analysis, the recanalization rate reached 81 % (95 % CI, 73-89). Meta-analysis of clinical outcomes showed a pooled estimate of 44 % (95 % CI, 33-55; 10 studies) for favourable outcome, 13 % (95 % CI, 8-20; 10 studies) for mortality, and 7 % (95 % CI, 2-13; eight studies) for symptomatic intracranial haemorrhage. CONCLUSION: SRT with emergency carotid stenting is associated with acceptable safety and efficacy in acute anterior stroke patients with tandem occlusion compared to natural history. However, the best modality to treat proximal stenosis is based on an individual case basis. KEY POINTS: • Stent retriever thrombectomy of tandem occlusion is efficient and safe. • Emergent carotid stenting during thrombectomy increase symptomatic intracranial haemorrhage without impact mortality. • Thrombectomy of tandem anterior circulation occlusion may be the first therapeutic option.

Outcomes of stent retriever thrombectomy in basilar artery occlusion: an observational study and systematic review.

BACKGROUND: Basilar artery occlusion (BAO) remains one of the most devastating subtypes of stroke with high mortality and poor outcome. Early recanalisation is the most powerful predictor of favourable outcome in patients with stroke, and may be improved with mechanical thrombectomy using stent retriever devices. However, the benefit in functional outcome and safety of stent retrievers are not yet well known. The aim of this study was to assess efficacy and safety profiles of stent retriever thrombectomy in BAO patients with stroke. METHODS: We analysed data retrospectively from our consecutive clinical series and conducted a systematic review and meta-analysis of all previous studies of stent retriever thrombectomy in BAO patients with stroke between November 2010 and April 2014. RESULTS: From March 2010 to March 2013, 22 patients with acute BAO were treated with a Solitaire stent retriever in our series. Favourable outcome was significantly associated with younger age and distal BAO. The literature search identified 15 previous studies involving a total of 312 subjects. In the meta-analysis, including our series data, the recanalisation rate (Thrombolysis In Cerebral Infarction (TICI) score ≥ 2b) reached 81% (95% CI 73% to 87%). The rate of symptomatic intracranial haemorrhage was 4% (95% CI 2% to 8%), favourable outcome (modified Rankin Scale (mRS) ≤ 2 at 3 months) was found in 42% (95% CI 36% to 48%) and mortality rate was 30% (95% CI 25% to 36%). CONCLUSIONS: Stent retriever thrombectomy is a safe treatment modality for patients with stroke presenting with BAO. Although the stent retrievers showed a good recanalisation rate, there are currently no randomised clinical trials to assess its clinical efficacy in comparison with the reference treatment.

Patient Outcomes with Stent-Retriever Thrombectomy for Anterior Circulation Stroke: A Meta-Analysis and Review of the Literature.

BACKGROUND: Mechanical thrombectomy with stent retrievers is now the reference therapy for acute ischemic stroke (AIS) in the anterior circulation in association with thrombolysis. We conducted an extensive systematic review and meta-analysis to evaluate the clinical and angiographic outcomes of stent-retriever thrombectomy in patients with acute anterior circulation stroke. Available literature published to date on observational studies and three randomized trials (MR CLEAN, ESCAPE, and EXTEND-IA) involving the stent-retriever device were reviewed. Successful recanalization and favorable clinical outcome were defined by a TICI ≥ 2b and modified Rankin Scale score of ≤ 2 at 90 days following AIS, respectively. A total of 2067 patients harboring an anterior circulation stroke were treated with a stent retriever: 433 patients from 3 randomized trials involving the device and 1634 patients from observational studies. Mean NIH Stroke Scale score on admission was 16.6, and mean time from onset to recanalization was 300 minutes. Successful recanalization was achieved in 82% (95%CI 77-86, 31 studies). The 90 day favorable outcome was achieved in 47% (95%CI 42-5.2, 34 studies) with an overall mortality rate of 17% (95%CI 13-20, 31 studies). Symptomatic intracerebral hemorrhage was identified in 6% (95%CI 4-8, 32 studies). In patients with AIS caused by a proximal intracranial occlusion of the anterior circulation, stent-retriever thrombectomy is safe and restores brain reperfusion in four of five treated patients, allowing favorable clinical outcome in one of two AIS patients with large vessel occlusion.

Validation of a cloud-based tele-stroke system reliability in determining national institutes of health stroke scale scores for acute ischemic stroke screening in the emergency department.

Background and purpose: The National Institutes of Health Stroke Scale (NIHSS) is the most recommended tool for objectively quantifying the impairment caused by a suspected stroke. Nevertheless, it is mainly used by trained neurologists in the emergency department (ED). To bring forward the NIHSS to the pre-hospital setting, a smartphone-based Telestroke system was developed. It captures the full NIHSS by video, transmits it off-line, and enables assessment by a distant stroke physician. We aimed to compare the reliability of an NIHSS score determined by a neurologist from afar, using the platform with a standard NIHSS assessment performed in the emergency departments. Methods: A multi-center prospective study was conducted in two centers (Vall d'Hebron, Barcelona, and Rambam, Israel). Patients admitted to the ED with suspected stroke had a neurological exam based on the NIHSS, while being recorded by the system. A skilled neurologist rated the NIHSS according to the videos offline. The results were compared with the NIHSS score given by a neurologist at the bedside. Results: A total of 95 patients with suspected stroke were included. The overall intraclass correlation coefficient was 0.936 (0.99 in VdH and 0.84 in Rambam), indicating excellent and good reliability, respectively. Conclusion: Remote stroke assessment based on the NIHSS, using videos segments collected by a dedicated platform, installed on a standard smartphone, is a reliable measurement as compared with the bedside evaluation.

The effect of the COVID-19 pandemic on ED referrals and care for stroke patients: A four-year comparative study.

PURPOSE: To examine the impact of the COVID-19 pandemic on the presentation and care provided to patients with acute ischemic stroke (AIS) at the emergency department (ED). METHOD: A retrospective-archive study was conducted between January-April 2020, compared with the parallel months in 2017-2019, in a comprehensive stroke center. We compared the time from symptoms onset to ED arrival, the number of neurologic consultations completed in the ED, patients diagnosed with AIS, patients receiving acute treatment and hospital mortality. RESULTS: During January-April 2020, we found an increase in the proportion of stroke patients arriving at the ED within 6 h of symptom onset: 68-100% per month during the study period, compared with 28-42% per month in the previous years. The number of patients admitted to the ED with suspected AIS declined by 41%, compared to the parallel period in 2019. An increase was noted in the number of patients diagnosed with AIS who underwent treatment, with the number of s endovascular thrombectomy increasing throughout the examined year. CONCLUSION: During the COVID-19 pandemic, we observed a significant decline in the number of AIS patients admitted to the ED. Paradoxically, we have seen an increase in the proportion of patients who arrived shortly after the onset of symptoms and received timely treatment. Future studies might investigate the medical mechanism and ramifications of this phenomenon.

Early angiographic changes of intra-aneurysmal flow after flow-diverter stent treatment are not predictive of therapeutic success.

BACKGROUND AND PURPOSE: Flow-diverter stents (FDS) are new devices for the endovascular treatment of intracranial aneurysms (IAs) promoting progressive aneurysmal thrombosis. To date, the delay of aneurysmal exclusion remains unclear. We evaluated the correlation between angiographic changes in the first 24 hours and 12-month occlusion in aneurysms treated with FDS. METHODS: We retrospectively analyzed the intra-aneurysmal flow by evaluating the in-flow and out-flow delays on preoperative, immediate postoperative, 24-hour and 12-month follow-up angiography. Dichotomy of in-flow and out-flow within the aneurysm was considered as the time of contrast filling and time of contrast washing relatively to the parent artery. The delay times were compared and correlated with the therapeutic success of FDS at 12 months of follow-up. RESULTS: Out of 14 treated IAs, in 13 consecutive patients, n = 10 (71%) aneurysms showed complete occlusion at 12 months. Between immediate postoperative and 24-hour control, 10 aneurysms (71%) demonstrated in-flow modification, with eight increasing, two decreasing and four having no change. There were no statistical differences in therapeutic success in relation to the different flow-related profiles of intra-aneurysmal flux.Out-flow modifications were found in 11 aneurysms (79%) between immediate postoperative and 24-hour control, with five increasing, six decreasing and three having no change. Similar to the in-flow changes, there were no statistical differences in therapeutic success relative to the flow-related profiles. CONCLUSIONS: Early angiographic changes after FDS placement are very frequent, but are not correlated with the 12-month technical success of flow-diversion techniques.

Endovascular treatment of bifurcation intracranial aneurysms with the WEB SL/SLS: 6-month clinical and angiographic results.

BACKGROUND: The WEB device is a recent intrasaccular flow disruption technique developed for the treatment of wide-necked intracranial aneurysms. To date, a single report on the WEB Single-Layer (SL) treatment of intracranial aneurysms has been published with 1-months' safety results. The aim of this study is to report our experience and 6-month clinical and angiographic follow-up of endovascular treatment of wide-neck aneurysm with the WEB SL. METHODS: Ten patients with 10 unruptured wide-necked aneurysms were prospectively enrolled in this study. Feasibility, intraoperative and postoperative complications, and outcomes were recorded. Immediate and 6-month clinical and angiographic results were evaluated. RESULTS: Failure of WEB SL placement occurred in two cases. Eight aneurysms were successfully treated using one WEB SL without additional treatment. Three middle cerebral artery, four anterior communicating artery, and one basilar artery aneurysms were treated. Average dome width was 7.5 mm (range 5.4-10.7 mm), and average neck size was 4.9 mm (range 2.6-6.5 mm). No periprocedural complication was observed, and morbi-mortality at discharge and 6 months was 0.0%. Angiographic follow-up at 6 months demonstrated complete aneurysm occlusion in 2/8 aneurysms, neck remnant in 5/8 aneurysms, and aneurysm remnant in 1/8 aneurysm. CONCLUSIONS: From this preliminary study, treatment of bifurcation intracranial aneurysms using WEB SL is feasible. WEB SL treatment seems safe at 6 months; however, the rate of neck remnants is not negligible due to compression of the WEB SL. Further technical improvements may be needed in order to ameliorate the occlusion in the WEB SL treatment.