Direct endovascular treatment: an alternative for bridging therapy in anterior circulation large-vessel occlusion stroke

2017 ◽  
Vol 24 (7) ◽  
pp. 935-943 ◽  
Author(s):  
H. Wang ◽  
W. Zi ◽  
Y. Hao ◽  
D. Yang ◽  
Z. Shi ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Bridging Therapy ◽  
Anterior Circulation ◽  
Vessel Occlusion

DEVT: A randomized, controlled, multicenter trial of direct endovascular treatment versus standard bridging therapy for acute stroke patients with large vessel occlusion in the anterior circulation – Protocol

2020 ◽  
pp. 174749302092534
Author(s):  
Zhongming Qiu ◽  
Hansheng Liu ◽  
Fengli Li ◽  
Weidong Luo ◽  
Deping Wu ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Acute Stroke ◽  
Multicenter Trial ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Bridging Therapy ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Randomized Controlled

Background Eight randomized controlled trials have consistently shown that endovascular treatment plus best medical treatment improves outcome after acute anterior proximal intracranial large vessel occlusion strokes. Whether intravenous thrombolysis prior to endovascular treatment in patients with anterior circulation, large vessel occlusion is of any additional benefits remains unclear. Objective This study compares the safety and efficacy of direct endovascular treatment versus intravenous recombinant tissue-type plasminogen activator bridging with endovascular treatment (bridging therapy) in acute stroke patients with intracranial internal carotid artery or middle cerebral artery-M1 occlusion within 4.5 h of symptom onset. Methods and design The DEVT study is a randomized, controlled, multicenter trial with blinded outcome assessment. This trial uses a five-look group-sequential non-inferiority design. Up to 194 patients in each interim analysis will be consecutively randomized to direct endovascular treatment or bridging therapy group in 1:1 ratio over three years from about 30 hospitals in China. Outcomes The primary end-point is the proportion of independent neurological function defined as modified Rankin scale score of 0 to 2 at 90 days. The primary safety measure is symptomatic intracerebral hemorrhage at 48 h and mortality at 90 days. Trial registry number ChiCTR-IOR-17013568 ( www.chictr.org.cn ).

scholarly journals Workflow Intervals of Endovascular Acute Stroke Therapy During On- Versus Off-Hours

Stroke ◽  
2019 ◽  
Vol 50 (10) ◽  
pp. 2842-2850 ◽  
Author(s):  
Wouter H. Hinsenveld ◽  
Inger R. de Ridder ◽  
Robert J. van Oostenbrugge ◽  
Jan A. Vos ◽  
Adrien E. Groot ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Large Vessel ◽  
Complication Rates ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Significant Difference

Background and Purpose— Endovascular treatment (EVT) of patients with acute ischemic stroke because of large vessel occlusion involves complicated logistics, which may cause a delay in treatment initiation during off-hours. This might lead to a worse functional outcome. We compared workflow intervals between endovascular treatment–treated patients presenting during off- and on-hours. Methods— We retrospectively analyzed data from the MR CLEAN Registry, a prospective, multicenter, observational study in the Netherlands and included patients with an anterior circulation large vessel occlusion who presented between March 2014 and June 2016. Off-hours were defined as presentation on Monday to Friday between 17:00 and 08:00 hours, weekends (Friday 17:00 to Monday 8:00) and national holidays. Primary end point was first door to groin time. Secondary end points were functional outcome at 90 days (modified Rankin Scale) and workflow time intervals. We stratified for transfer status, adjusted for prognostic factors, and used linear and ordinal regression models. Results— We included 1488 patients of which 936 (62.9%) presented during off-hours. Median first door to groin time was 140 minutes (95% CI, 110–182) during off-hours and 121 minutes (95% CI, 85–157) during on-hours. Adjusted first door to groin time was 14.6 minutes (95% CI, 9.3–20.0) longer during off-hours. Door to needle times for intravenous therapy were slightly longer (3.5 minutes, 95% CI, 0.7–6.3) during off-hours. Groin puncture to reperfusion times did not differ between groups. For transferred patients, the delay within the intervention center was 5.0 minutes (95% CI, 0.5–9.6) longer. There was no significant difference in functional outcome between patients presenting during off- and on-hours (adjusted odds ratio, 0.92; 95% CI, 0.74–1.14). Reperfusion rates and complication rates were similar. Conclusions— Presentation during off-hours is associated with a slight delay in start of endovascular treatment in patients with acute ischemic stroke. This treatment delay did not translate into worse functional outcome or increased complication rates.

Impact of Strategy on Clinical Outcome in Large Vessel Occlusion Stroke Successfully Reperfused: ETIS Registry Results

Stroke ◽  
2021 ◽  
Author(s):  
Marian Douarinou ◽  
Benjamin Gory ◽  
Arturo Consoli ◽  
Bertrand Lapergue ◽  
Maeva Kyheng ◽  
...  
Keyword(s):  
Odds Ratio ◽  
Therapy Group ◽  
Intravenous Thrombolysis ◽  
Large Vessel ◽  
Favorable Outcome ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Bridging Therapy ◽  
Anterior Circulation ◽  
Vessel Occlusion

Background and Purpose: Approximately half of the patients with acute ischemic stroke due to anterior circulation large vessel occlusion do not achieve functional independence despite successful reperfusion. We aimed to determine influence of reperfusion strategy (bridging therapy, intravenous thrombolysis alone, or mechanical thrombectomy alone) on clinical outcomes in this population. Methods: From ongoing, prospective, multicenter, observational Endovascular Treatment in Ischemic Stroke registry in France, all patients with anterior circulation large vessel occlusion who achieved successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b-3) following reperfusion therapy were included. Primary end point was favorable outcome, defined as 90-day modified Rankin Scale score ≤2. Patient groups were compared using those treated with bridging therapy as reference. Differences in baseline characteristics were reduced after propensity score-matching, with a maximum absolute standardized difference of 14% for occlusion site. Results: Among 1872 patients included, 970 (51.8%) received bridging therapy, 128 (6.8%) received intravenous thrombolysis alone, and the remaining 774 (41.4%) received MT alone. The rate of favorable outcome was comparable between groups. Excellent outcome (90-day modified Rankin Scale score 0–1) was achieved more frequently in the bridging therapy group compared with the MT alone (odds ratio after propensity score-matching, 0.70 [95% CI, 0.50–0.96]). Regarding safety outcomes, hemorrhagic complications were similar between the groups, but 90-day mortality was significantly higher in the MT alone group compared with the bridging therapy group (odds ratio, 1.60 [95% CI, 1.09–2.37]). Conclusions: This real-world observational study of patients with anterior circulation large vessel occlusion demonstrated a similar rate of favorable outcome following successful reperfusion with different therapeutic strategies. However, our results suggest that bridging therapy compared with MT alone is significantly associated with excellent clinical outcome and lower mortality. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03776877.

scholarly journals Course of Early Neurologic Symptom Severity after Endovascular Treatment of Anterior Circulation Large Vessel Occlusion Stroke: Association with Baseline Multiparametric CT Imaging and Clinical Parameters

Diagnostics ◽  
2021 ◽  
Vol 11 (7) ◽  
pp. 1272
Author(s):  
Matthias Philipp Fabritius ◽  
Teresa A. Wölfer ◽  
Moriz Herzberg ◽  
Steffen Tiedt ◽  
Daniel Puhr-Westerheide ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Clinical Improvement ◽  
Intracranial Hemorrhage ◽  
Symptom Severity ◽  
Large Vessel ◽  
Clinical Parameters ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Neurologic Symptom

Background: Neurologic symptom severity and deterioration at 24 hours (h) predict long-term outcomes in patients with acute large vessel occlusion (LVO) stroke of the anterior circulation. We aimed to examine the association of baseline multiparametric CT imaging and clinical factors with the course of neurologic symptom severity in the first 24 h after endovascular treatment (EVT). Methods: Patients with LVO stroke of the anterior circulation were selected from a prospectively acquired consecutive cohort of patients who underwent multiparametric CT, including non-contrast CT, CT angiography and CT perfusion before EVT. The symptom severity was assessed on admission and after 24 h using the 42-point National Institutes of Health Stroke Scale (NIHSS). Clinical and imaging data were compared between patients with and without early neurological deterioration (END). END was defined as an increase in ≥4 points, and a significant clinical improvement as a decrease in ≥4 points, compared to NIHSS on admission. Multivariate regression analyses were used to determine independent associations of imaging and clinical parameters with NIHSS score increase or decrease in the first 24 h. Results: A total of 211 patients were included, of whom 38 (18.0%) had an END. END was significantly associated with occlusion of the internal carotid artery (odds ratio (OR), 4.25; 95% CI, 1.90–9.47) and the carotid T (OR, 6.34; 95% CI, 2.56–15.71), clot burden score (OR, 0.79; 95% CI, 0.68–0.92) and total ischemic volume (OR, 1.01; 95% CI, 1.00–1.01). In a comprehensive multivariate analysis model including periprocedural parameters and complications after EVT, carotid T occlusion remained independently associated with END, next to reperfusion status and intracranial hemorrhage. Favorable reperfusion status and small ischemic core volume were associated with clinical improvement after 24 h. Conclusions: The use of imaging parameters as a surrogate for early NIHSS progression in an acute LVO stroke after EVT reached limited performance with only carotid T occlusion as an independent predictor of END. Reperfusion status and early complications in terms of intracranial hemorrhage are critical factors that influence patient outcome in the acute stroke phase after EVT.

scholarly journals Mechanical Thrombectomy of the Fetal Posterior Cerebral Artery

2021 ◽  
Author(s):  
Mohamad Abdalkader ◽  
Anurag Sahoo ◽  
Adam A. Dmytriw ◽  
Waleed Brinjikji ◽  
Guilherme Dabus ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Endovascular Treatment ◽  
Cerebral Artery ◽  
Computed Tomography Angiography ◽  
Mechanical Thrombectomy ◽  
Posterior Cerebral Artery ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion

Abstract BACKGROUND Fetal posterior cerebral artery (FPCA) occlusion is a rare but potentially disabling cause of stroke. While endovascular treatment is established for acute large vessel occlusion stroke, FPCA occlusions were excluded from acute ischemic stroke trials. We aim to report the feasibility, safety, and outcome of mechanical thrombectomy in acute FPCA occlusions. METHODS We performed a multicenter retrospective review of consecutive patients who underwent mechanical thrombectomy of acute FPCA occlusion. Primary FPCA occlusion was defined as an occlusion that was identified on the pre‐procedure computed tomography angiography or baseline angiogram whereas a secondary FPCA occlusion was defined as an occlusion that occurred secondary to embolization to a new territory after recanalization of a different large vessel occlusion. Demographics, clinical presentation, imaging findings, endovascular treatment, and outcome were reviewed. RESULTS There were 25 patients with acute FPCA occlusion who underwent mechanical thrombectomy, distributed across 14 centers. Median National Institutes of Health Stroke Scale on presentation was 16. There were 76% (19/25) of patients who presented with primary FPCA occlusion and 24% (6/25) of patients who had a secondary FPCA occlusion. The configuration of the FPCA was full in 64% patients and partial or “fetal‐type” in 36% of patients. FPCA occlusion was missed on initial computed tomography angiography in 21% of patients with primary FPCA occlusion (4/19). The site of occlusion was posterior communicating artery in 52%, P2 segment in 40% and P3 in 8% of patients. Thrombolysis in cerebral infarction 2b/3 reperfusion was achieved in 96% of FPCA patients. There were no intraprocedural complications. At 90 days, 48% (12/25) were functionally independent as defined by modified Rankin scale≤2. CONCLUSIONS Endovascular treatment of acute FPCA occlusion is safe and technically feasible. A high index of suspicion is important to detect occlusion of the FPCA in patients presenting with anterior circulation stroke syndrome and patent anterior circulation. Novelty and significance This is the first multicenter study showing that thrombectomy of FPCA occlusion is feasible and safe.

scholarly journals Endovascular Application of Magnetic Resonance Double Mismatch Technique for Acute Anterior Circulation Large Vessel Occlusion with Cerebral Infarction in an Unknown Time Window

2020 ◽  
Vol 4 (5) ◽  
Author(s):  
Xiangkong Song ◽  
Qing Zhang ◽  
Lilin Gao ◽  
Jie Qi ◽  
Guoqing Wang
Keyword(s):  
Magnetic Resonance ◽  
Cerebral Infarction ◽  
Endovascular Treatment ◽  
Time Window ◽  
Research Work ◽  
Large Vessel ◽  
Clinical Effects ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion

Objective: To investigate the clinical effects of applying the magnetic resonance double mismatch technique to endovascular treatment of acute anterior circulation, large vessel occlusion with cerebral infarction in an unknown time window. Methods: The research work was carried out in our hospital, the work was carried out from November 2018 to November 2019, the patients with acute anterior circulation large vessel occlusion with cerebral infarction who were treated in our hospital during this period, 100 patients, 50 patients with an unknown time window and 50 patients with definite time window were selected, and they were named as the experimental and control groups, given different examination methods, were given to investigate the clinical treatment effect. Results: Patients' data on HIHSS score before treatment, the incidence of intracranial hemorrhage and rate of Mrs?2 rating after 90 days of treatment were not significantly different(P>0.05), which was not meaningful. The differences in data between the two groups concerning HIHSS scores were relatively significant before, and after treatment(P<0.05). Conclusion: The magnetic resonance double mismatch technique will be applied in the endovascular treatment of acute anterior circulation large vessel occlusion with cerebral infarction of unknown time window.

Clinical and neuroimaging criteria to improve the workflow in transfers for endovascular treatment evaluation

2019 ◽  
Vol 15 (9) ◽  
pp. 988-994 ◽  
Author(s):  
Manuel Requena ◽  
Marta Olivé-Gadea ◽  
Sandra Boned ◽  
Anna Ramos ◽  
Pere Cardona ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Treatment Success ◽  
Population Based ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Infarct Core ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background Transfer protocols from primary to comprehensive stroke centers are crucial for endovascular treatment success. Aim To evaluate clinical and neuroimaging data of transferred patients and their likelihood of presenting a large infarct core at comprehensive stroke center arrival. Methods Retrospective analysis of population-based mandatory prospective registry of acute stroke patients evaluated for endovascular treatment. Consecutive patients evaluated at primary stroke center with suspected large vessel occlusion and PSC-ASPECTS ≥ 6 transferred to a comprehensive stroke center were included. PSC and CSC-ASPECTS, time-metrics, and clinical data were analyzed. Results During 28 months, 1185 endovascular treatment candidates were transferred from PC to comprehensive stroke center in our public stroke network, 477 had an anterior circulation syndrome and available neuroimaging information and were included. Median baseline NIHSS was 13 (8–19). On arrival to comprehensive stroke center, large vessel occlusion was confirmed in 60.2% patients, and 41.2% received endovascular treatment. Median interfacility ASPECTS decay was 1 (0–2) after a median of 150.7 (SD 101) min between both CT-acquisitions. A logistic regression analysis adjusted by age, time from symptoms to PC-CT, and time from PC-CT to CSC-CT showed that only a baseline NIHSS and PSC-ASPECTS independently predicted a CSC-ASPECTS < 6. ROC curves identified baseline NIHSS ≥ 16 and PSC-ASPECTS ≤ 7 as the best cut-off points. The rate of CSC-ASPECTS < 6 increased from 7% to 57% among patients with NIHSS ≥ 16 and PSC-ASPECS ≤ 7. Conclusion After a median transfer time >2 h, only 11.9% showed ASPECTS < 6 at the comprehensive stroke center. Activation of endovascular treatment teams should not require confirming neuroimaging on arrival and repeating neuroimaging at comprehensive stroke center should only be performed in selected cases.

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