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1. Thrombectomy Technique Predicts Outcome in Posterior Circulation Stroke—Insights from the STAR Collaboration

Author

Ilko Maier, Jonathan A Grossberg, Vasu Saini, Maya Eid, Ansaar T Rai, Stacey Q Wolfe, Travis M. Dumont, Marios-Nikos Psychogios, Nitin Goyal, Mohammad Anadani, Jan Liman, J Mocco, Mithun G. Sattur, Ali Alawieh, Robert M. Starke, Kyle M Fargen, Alejandro M Spiotta, W. Christopher Fox, Michelle Allen, Fábio A. Nascimento, Adam S Arthur, Jonathan Lena, Lucas Elijovich, Reade De Leacy, Salah G. Keyrouz, Benjamin Gory, Wuwei Feng, Johanna T Fifi, David J McCarthy, Peter Kan, James A Giles, Roberto Crosa, Medical University of South Carolina [Charleston] (MUSC), Emory University School of Medicine, Emory University [Atlanta, GA], University Medical Center Göttingen (UMG), The University of Tennessee Health Science Center [Memphis] (UTHSC), University of Miami Leonard M. Miller School of Medicine (UMMSM), West Virginia University [Morgantown], Wake Forest University, University Hospital Basel [Basel], Mount Sinai Health System, Washington University School of Medecine [Saint Louis, MO], University of Arizona, Baylor College of Medicine (BCM), Baylor University, University of Florida [Gainesville] (UF), Imagerie Adaptative Diagnostique et Interventionnelle (IADI), Université de Lorraine (UL)-Institut National de la Santé et de la Recherche Médicale (INSERM), Département de neuroradiologie diagnostique et thérapeutique [CHRU Nancy], and Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy)

Subjects
Male, medicine.medical_specialty, [SDV.IB.MN]Life Sciences [q-bio]/Bioengineering/Nuclear medicine, law.invention, 03 medical and health sciences, 0302 clinical medicine, Randomized controlled trial, law, Internal medicine, Diabetes mellitus, Occlusion, medicine, [INFO.INFO-IM]Computer Science [cs]/Medical Imaging, Humans, 030212 general & internal medicine, Stroke, Aged, Retrospective Studies, Thrombectomy, Stent retriever, business.industry, Endovascular Procedures, Retrospective cohort study, Middle Aged, medicine.disease, Combined approach, 3. Good health, Mechanical thrombectomy, Treatment Outcome, Cardiology, Female, Surgery, Neurology (clinical), business, 030217 neurology & neurosurgery, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology
Abstract

International audience; Abstract BACKGROUND Randomized controlled trials evaluating mechanical thrombectomy (MT) for acute ischemic stroke predominantly studied anterior circulation patients. Both procedural and clinical predictors of outcome in posterior circulation patients have not been evaluated in large cohort studies. OBJECTIVE To investigate technical and clinical predictors of functional independence after posterior circulation MT while comparing different frontline thrombectomy techniques. METHODS In a retrospective multicenter international study of 3045 patients undergoing MT for stroke between 06/2014 and 12/2018, 345 patients had posterior circulation strokes. MT was performed using aspiration, stent retriever, or combined approach. Functional outcomes were assessed using the 90-d modified Rankin score dichotomized into good (0-2) and poor outcomes (3-6). RESULTS We included 2700 patients with anterior circulation and 345 patients with posterior circulation strokes. Posterior patients (age: 60 ± 14, 46% females) presented with mainly basilar occlusion (80%) and were treated using contact aspiration or ADAPT (39%), stent retriever (31%) or combined approach (19%). Compared to anterior strokes, posterior strokes had delayed treatment (500 vs 340 min, P

Published
2020

2. Head or Neck First? Speed and Rates of Reperfusion in Thrombectomy for Tandem Large Vessel Occlusion Strokes

Author

Serge Bracard, Mikael Mazighi, René Anxionnat, Salvatore Mangiafico, Panagiotis Papanagiotou, Christian Taschner, Christophe Cognard, Alessandra Biondi, Monika Killer, Bertrand Lapergue, Benjamin Gory, Diogo C Haussen, Markus Holtmannspötter, Maria Boutchakova, Marios Psychogios, Michel Piotin, Adnan H. Siddiqui, Jonathan A. Grossberg, Marc-Antoine Labeyrie, Franziska Dorn, Francis Turjman, Raul G Nogueira, Alejandro M Spiotta, Marc Ribó, Sebastian Eiden, Henrik Steglich-Arnholm, Sébastien Richard, Julien Labreuche, Emory University [Atlanta, GA], Hospices Civils de Lyon (HCL), Hôpital de la Fondation Ophtalmologique Adolphe de Rothschild [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Evaluation des technologies de santé et des pratiques médicales - ULR 2694 (METRICS), Université de Lille-Centre Hospitalier Régional Universitaire [Lille] (CHRU Lille), Rigshospitalet [Copenhagen], Copenhagen University Hospital, Universitäts Klinikum Freiburg = University Medical Center Freiburg (Uniklinik), Klinikum Bremen-Mitte, State University of New York (SUNY), Hôpital Foch [Suresnes], University-Hospital Munich-Großhadern [München], Service Neuroradiologie Diagnostique et Thérapeutique [CHU Toulouse], Pôle imagerie médicale [CHU Toulouse], Centre Hospitalier Universitaire de Toulouse (CHU Toulouse)-Centre Hospitalier Universitaire de Toulouse (CHU Toulouse), Paracelsus Medizinische Privatuniversität = Paracelsus Medical University (PMU), Azienda Ospedaliero-Universitaria Careggi [Firenze] (AOUC), Vall d'Hebron University Hospital [Barcelona], University Medical Center Göttingen (UMG), Medical University of South Carolina [Charleston] (MUSC), Service de Neuroradiologie [CHU Lariboisière], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpital Lariboisière-Fernand-Widal [APHP], Laboratoire de Recherche Vasculaire Translationnelle (LVTS (UMR_S_1148 / U1148)), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité)-Université Sorbonne Paris Nord, Centre Hospitalier Régional Universitaire de Besançon (CHRU Besançon), Service de neurologie [CHRU Nancy], Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Défaillance Cardiovasculaire Aiguë et Chronique (DCAC), Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lorraine (UL), Imagerie Adaptative Diagnostique et Interventionnelle (IADI), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lorraine (UL), Département de neuroradiologie diagnostique et thérapeutique [CHRU Nancy], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), Freiburg University Medical Center, Neuroradiologie Diagnostique et Thérapeutique [Toulouse], Université Toulouse III - Paul Sabatier (UT3), Université Fédérale Toulouse Midi-Pyrénées-Université Fédérale Toulouse Midi-Pyrénées-CHU Toulouse [Toulouse]-Hôpital Purpan [Toulouse], CHU Toulouse [Toulouse], Azienda Ospedaliero-Universitaria Careggi (AOU Careggi), and Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP)-Université Sorbonne Paris Nord

Subjects
medicine.medical_specialty, medicine.medical_treatment, [SDV.IB.MN]Life Sciences [q-bio]/Bioengineering/Nuclear medicine, 030204 cardiovascular system & hematology, Revascularization, Lesion, 03 medical and health sciences, 0302 clinical medicine, medicine.artery, Angioplasty, medicine, [INFO.INFO-IM]Computer Science [cs]/Medical Imaging, Stroke, Original Paper, Cerebral infarction, business.industry, Stent, Thrombolysis, medicine.disease, 3. Good health, Surgery, Neurology (clinical), medicine.symptom, Internal carotid artery, Cardiology and Cardiovascular Medicine, business, 030217 neurology & neurosurgery, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology
Abstract

Background: We aim to evaluate the speed and rates of reperfusion in tandem large vessel occlusion acute stroke patients undergoing upfront cervical lesion treatment (Neck-First: angioplasty and/or stent before thrombectomy) as compared to direct intracranial occlusion therapy (Head-First) in a large international multicenter cohort. Methods: The Thrombectomy In TANdem Lesions (TITAN) collaboration pooled individual data of prospectively collected thrombectomy international databases for all consecutive anterior circulation tandem patients who underwent emergent thrombectomy. The co-primary outcome measures were rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b/3) and time from groin puncture to successful reperfusion. Results: In total, 289 patients with tandem atherosclerotic etiology were included in the analysis (182 Neck-First and 107 Head-First patients). Except for differences in the Alberta Stroke Program Early CT Score (ASPECTS; median 8 [range 7–10] Neck-First vs. 7 [range 6–8] Head-First; p < 0.001) and cervical internal carotid artery (ICA) lesion severity (complete occlusion in 35% of the Neck-First vs. 57% of the Head-First patients; p < 0.001), patient characteristics were well balanced. After adjustments, there was no difference in successful reperfusion rates between the study groups (odds ratio associated with Neck-First: 1.18 [95% confidence interval, 0.60–2.17]). The time to successful reperfusion from groin puncture was significantly shorter in the Head-First group after adjustments (median 56 min [range 39–90] vs. 70 [range 50–102]; p = 0.001). No significant differences in the rates of full reperfusion, symptomatic hemorrhage, 90-day independence, or mortality were observed. Sensitivity analysis excluding patients with complete cervical ICA occlusion yielded similar results. Conclusions: The upfront approach of the intracranial lesion in patients with tandem large vessel occlusion strokes leads to similar reperfusion rates but faster reperfusion as compared to initial cervical revascularization followed by mechanical thrombectomy. Controlled studies are warranted.

Published
2020

3. Differential effect of mechanical thrombectomy and intravenous thrombolysis in atrial fibrillation associated stroke

Author

Peter Kan, Hassan Saad, Benjamin Gory, Brian M. Howard, C. Michael Cawley, Christian M. Mustroph, Jonathan A Grossberg, Roberto Crosa, Adam S Arthur, Pascal Jabbour, Ansaar T Rai, Reade De Leacy, Marios Psychogios, Gustavo Pradilla, Frank C. Tong, James A Giles, Kyle M Fargen, Travis M. Dumont, Fadi Nahab, Laurie Dimisko, Ilko Maier, Feras Akbik, Owen Samuels, Nitin Goyal, Ali Alawieh, Robert M. Starke, Alejandro M Spiotta, Emory University [Atlanta, GA], University Medical Center Göttingen (UMG), The University of Tennessee Health Science Center [Memphis] (UTHSC), University of Miami Leonard M. Miller School of Medicine (UMMSM), Wake Forest University, University Hospital Basel [Basel], Jefferson (Philadelphia University + Thomas Jefferson University), Icahn School of Medicine at Mount Sinai [New York] (MSSM), Washington University School of Medicine in St. Louis, Washington University in Saint Louis (WUSTL), University of Arizona, Baylor College of Medicine (BCM), Baylor University, Imagerie Adaptative Diagnostique et Interventionnelle (IADI), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lorraine (UL), Département de neuroradiologie diagnostique et thérapeutique [CHRU Nancy], Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Medical University of South Carolina [Charleston] (MUSC), and Emory University School of Medicine

Subjects
medicine.medical_specialty, Multivariate analysis, medicine.medical_treatment, [SDV.IB.MN]Life Sciences [q-bio]/Bioengineering/Nuclear medicine, 030204 cardiovascular system & hematology, Article, 03 medical and health sciences, 0302 clinical medicine, Aneurysm, Internal medicine, Atrial Fibrillation, medicine, [INFO.INFO-IM]Computer Science [cs]/Medical Imaging, Humans, In patient, Thrombolytic Therapy, Stroke, Retrospective Studies, Thrombectomy, business.industry, Atrial fibrillation, Retrospective cohort study, General Medicine, Thrombolysis, medicine.disease, Mechanical thrombectomy, Treatment Outcome, Cardiology, Surgery, Neurology (clinical), business, 030217 neurology & neurosurgery, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology
Abstract

BackgroundAtrial fibrillation (AF) associated ischemic stroke has worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Limited data exist about the effect of AF on procedural and clinical outcomes after mechanical thrombectomy (MT).ObjectiveTo determine whether recanalization efficacy, procedural speed, and clinical outcomes differ in AF associated stroke treated with MT.MethodsWe performed a retrospective cohort study of the Stroke Thrombectomy and Aneurysm Registry (STAR) from January 2015 to December 2018 and identified 4169 patients who underwent MT for an anterior circulation stroke, 1517 (36.4 %) of whom had comorbid AF. Prospectively defined baseline characteristics, procedural outcomes, and clinical outcomes were reported and compared.ResultsAF predicted faster procedural times, fewer passes, and higher rates of first pass success on multivariate analysis (pConclusionsIn patients treated with MT, comorbid AF is associated with faster procedural time, fewer passes, and increased rates of first pass success without increased risk of intracranial hemorrhage or worse functional outcomes. These results are in contrast to the increased hemorrhage rates and worse functional outcomes observed in AF associated stroke treated with supportive care and or IVT. These data suggest that MT negates the AF penalty in ischemic stroke.

Published
2020

4. Multicenter Experience with Stenting for Symptomatic Carotid Web

Author

Sebastian Koch, Clara M Barreira, Ameer E Hassan, Gustavo Pradilla, Jonathan A. Grossberg, Sébastien Richard, Benjamin Gory, D Yavagal, Raul G Nogueira, Diogo C Haussen, Wolfgang Leesch, Anne Laure Derelle, Amer M. Malik, Emory University School of Medicine, Emory University [Atlanta, GA], Jackson Memorial Hospital, Département de neuroradiologie diagnostique et thérapeutique [CHRU Nancy], Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Imagerie Adaptative Diagnostique et Interventionnelle (IADI), Université de Lorraine (UL)-Institut National de la Santé et de la Recherche Médicale (INSERM), and Service de neurologie [CHRU Nancy]

Subjects
Bradycardia, medicine.medical_specialty, medicine.medical_treatment, Fibromuscular dysplasia, [SDV.IB.MN]Life Sciences [q-bio]/Bioengineering/Nuclear medicine, Asymptomatic, 030218 nuclear medicine & medical imaging, 03 medical and health sciences, 0302 clinical medicine, medicine, [INFO.INFO-IM]Computer Science [cs]/Medical Imaging, cardiovascular diseases, Stroke, Original Paper, medicine.diagnostic_test, business.industry, Stent, medicine.disease, 3. Good health, Surgery, Stenosis, Angiography, Neurology (clinical), medicine.symptom, Carotid stenting, Cardiology and Cardiovascular Medicine, business, 030217 neurology & neurosurgery, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology
Abstract

Background: A carotid web (CaW) is a shelf-like lesion in the posterior aspect of the internal carotid bulb and represents an intimal variant of fibromuscular dysplasia. CaW has been associated with recurrent strokes and conventionally treated with surgical excision. We report a multicenter experience of stenting in patients with symptomatic CaWs. Methods: Retrospective review of consecutive patients admitted to 5 comprehensive stroke centers who were identified to have a symptomatic CaW and treated with carotid stenting. A symptomatic CaW was defined by the presence of a shelf-like/linear, smooth filling defect in the posterior aspect of the carotid bulb diagnosed by neck CT angiography (CTA) and confirmed with conventional angiography in patients with negative stroke workup. Results: Twenty-four patients with stented symptomatic CaW were identified (stroke in 83% and transient ischemic attack in 17%). Their median age was 47 years (IQR 41–61), 14 (58%) were female, and were 17 (71%) black. The degree of stenosis by NASCET was 0% (range 0–11). All patients were placed on dual antiplatelets and stented at a median of 9 days (IQR 4–35) after the last event. Closed-cell stents were used in 18 (75%) of the cases. No periprocedural events occurred with the exception of 2 cases of asymptomatic hypotension/bradycardia. Clinical follow-up after stent placement occurred for a median of 12 months (IQR 3–19) with no new cerebrovascular events noted. Functional independence at 90 days was achieved in 22 (91%) patients. Follow-up vascular imaging (ultrasound n = 18/CTA n = 5) was performed at a median of 10 months (IQR 3–18) and revealed no stenosis. Conclusions: Stenting for symptomatic CaW appears to be a safe and effective alternative to surgical resection. Further studies are warranted.

Published
2018

5. Carotid Stenting With Antithrombotic Agents and Intracranial Thrombectomy Leads to the Highest Recanalization Rate in Patients With Acute Stroke With Tandem Lesions

Author

Panagiotis Papanagiotou, Diogo C. Haussen, Francis Turjman, Julien Labreuche, Michel Piotin, Andreas Kastrup, Henrik Steglich-Arnholm, Markus Holtmannspötter, Christian Taschner, Sebastian Eiden, Raul G. Nogueira, Maria Boutchakova, Adnan Siddiqui, Bertrand Lapergue, Franziska Dorn, Christophe Cognard, Monika Killer, Salvatore Mangiafico, Marc Ribo, Marios N. Psychogios, Alejandro Spiotta, Marc Antoine Labeyrie, Alessandra Biondi, Mikaël Mazighi, Sébastien Richard, René Anxionnat, Serge Bracard, Benjamin Gory, Jonathan Andrew Grossberg, Adrien Guenego, Julien Darcourt, Isabelle Vukasinovic, Elisa Pomero, Jason Davies, Leonardo Renieri, Corentin Hecker, Maria Muchada Muchada, Arturo Consoli, Georges Rodesch, Emmanuel Houdart, Raymond Turner, Aquilla Turk, Imran Chaudry, Paul-Emile Labeyrie, Roberto Riva, Johanna Lockau, Raphaël Blanc, Hocine Redjem, Daniel Behme, Hussain Shallwani, Maurer Christopher, Anne-Laure Derelle, Romain Tonnelet, Liang Liao, Camille Amaz, Klinikum Bremen-Mitte, Emory University School of Medicine, Emory University [Atlanta, GA], Service de neuroradiologie [Lyon], Hôpital neurologique et neurochirurgical Pierre Wertheimer [CHU - HCL], Hospices Civils de Lyon (HCL)-Hospices Civils de Lyon (HCL), Evaluation des technologies de santé et des pratiques médicales - ULR 2694 (METRICS), Université de Lille-Centre Hospitalier Régional Universitaire [Lille] (CHRU Lille), Hôpital de la Fondation Ophtalmologique Adolphe de Rothschild [AP-HP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU), Rigshospitalet [Copenhagen], Copenhagen University Hospital, Freiburg University Medical Center, State University of New York (SUNY), Hôpital Foch [Suresnes], University-Hospital Munich-Großhadern [München], Neuroradiologie Diagnostique et Thérapeutique [Toulouse], Université Toulouse III - Paul Sabatier (UT3), Université Fédérale Toulouse Midi-Pyrénées-Université Fédérale Toulouse Midi-Pyrénées-CHU Toulouse [Toulouse]-Hôpital Purpan [Toulouse], CHU Toulouse [Toulouse], Paracelsus Medizinische Privatuniversität = Paracelsus Medical University (PMU), Azienda Ospedaliero-Universitaria Careggi (AOU Careggi), Vall d'Hebron University Hospital [Barcelona], University Medical Center Göttingen (UMG), Medical University of South Carolina [Charleston] (MUSC), Service de Neuroradiologie [CHU Lariboisière], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpital Lariboisière-Fernand-Widal [APHP], Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP), Centre Hospitalier Régional Universitaire de Besançon (CHRU Besançon), Service de neurologie [CHRU Nancy], Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy), Département de neuroradiologie diagnostique et thérapeutique [CHRU Nancy], Imagerie Adaptative Diagnostique et Interventionnelle (IADI), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Lorraine (UL), Service Neuroradiologie diagnostique et interventionnelle [Hôpital Foch], Universitäts Klinikum Freiburg = University Medical Center Freiburg (Uniklinik), Service Neuroradiologie Diagnostique et Thérapeutique [CHU Toulouse], Pôle imagerie médicale [CHU Toulouse], Centre Hospitalier Universitaire de Toulouse (CHU Toulouse)-Centre Hospitalier Universitaire de Toulouse (CHU Toulouse), and Azienda Ospedaliero-Universitaria Careggi [Firenze] (AOUC)

Subjects
Carotid Artery Diseases, Male, medicine.medical_specialty, Time Factors, medicine.medical_treatment, [SDV.IB.MN]Life Sciences [q-bio]/Bioengineering/Nuclear medicine, 030204 cardiovascular system & hematology, Brain Ischemia, 03 medical and health sciences, 0302 clinical medicine, Fibrinolytic Agents, Risk Factors, Internal medicine, Angioplasty, medicine.artery, Antithrombotic, medicine, [INFO.INFO-IM]Computer Science [cs]/Medical Imaging, Humans, cardiovascular diseases, Registries, ComputingMilieux_MISCELLANEOUS, Aged, Retrospective Studies, Thrombectomy, Intracerebral hemorrhage, Univariate analysis, Cerebral infarction, business.industry, Endovascular Procedures, Thrombolysis, Middle Aged, medicine.disease, United States, 3. Good health, Europe, Stroke, Treatment Outcome, Cardiology, Female, Stents, Internal carotid artery, Carotid stenting, Cardiology and Cardiovascular Medicine, business, 030217 neurology & neurosurgery, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology
Abstract

Objectives The aim of this study was to identify the optimal endovascular approach in patients with acute stroke with tandem lesions. Background At present, there is no consensus about the ideal technical strategy for the endovascular treatment of patients with acute ischemic stroke with tandem lesions of the extracranial internal carotid artery (ICA) and intracranial cerebral arteries. Methods This was an international, multicenter registry with a total of 482 patients with acute ischemic stroke and tandem lesions. Patients were treated by intracranial thrombectomy as well as 1 of the following 4 strategies: 1) acute carotid artery stenting of the extracranial ICA with antithrombotic agents; 2) acute carotid artery stenting of the extracranial ICA without antithrombotic agents; 3) balloon angioplasty of the extracranial ICA; and 4) intracranial thrombectomy alone. The main outcome endpoints of the study were the degree of recanalization and the 90-day clinical outcome. The safety endpoints were symptomatic intracerebral hemorrhage and all causes of mortality at 90 days. Results Using univariate analysis, the rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction grades 2B and 3) and favorable clinical outcome after 90 days were significantly higher after acute carotid stenting with antithrombotic therapy and thrombectomy compared with the group with thrombectomy alone. After adjusting for confounding variables, acute stenting with antithrombotic therapy was independently associated with successful recanalization (odds ratio: 2.4; 95% confidence interval: 1.25 to 4.59; p = 0.008). The rates of symptomatic intracerebral hemorrhage and 90-day mortality were comparable among all 4 treatment groups. Conclusions Acute stenting of the extracranial ICA with antithrombotic therapy in combination with intracranial thrombectomy is associated with higher recanalization rates in treatment of patients with acute stroke with tandem lesions.

Published
2018

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