Search

Background: There is conflicting evidence on the utility of intravenous (IV) alteplase in patients with emergent large vessel occlusion (ELVO) treated with mechanical thrombectomy (MT)., Methods: This was a post hoc analysis of the COMPASS: a trial of aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion. We compared clinical, procedural and angiographic outcomes of patients with and without prior IV alteplase administration., Results: In the COMPASS trial, 235 patients had presented to the hospital within the first 4 hours of stroke symptom onset and were eligible for analysis. On univariate analysis, administration of IV alteplase prior to MT was found to be significantly associated with favorable outcomes (modified Rankin scale (mRS) 0-2 at 3 months; 55.6% vs 40.0% in the MT-only group, P=0.037). However, on multivariate analysis, only baseline (pre-stroke) mRS, admission National Institutes of Health Stroke Scale (NIHSS) score and age were identified as independent predictors of favorable outcomes at 3 months. We found higher final thrombolysis in cerebral infarction (TICI) 2b/3 rates in patients without the use of alteplase prior to the aspiration first approach (100.0% vs 87.9% in IV altepase +aspiration first MT, P=0.03). In the stent retriever first group, final TICI 2b/3 rates were identical in patients with and without IV alteplase administration (87.5% and 87.5%, P=1.0)., Conclusions: Prior administration of IV alteplase may adversely affect the efficacy of aspiration, but does not seem to influence the stent retriever first approach to MT in patients with anterior circulation ELVO., Competing Interests: Competing interests: MM: Grant NIH R21NS109575. Consultant: Medtronic, Cerenovus. Stock options: Brain Q, Endostream Serenity Medical, Synchron. Assistant Editor for JNIS. MW: None. JTF: Consultant: Stryker, Penumbra, Microvention. Stocks: Cerebrotech, The Stroke Project. RDL: Consultant: Cerenovus, Stryker, Penumbra, Imperative Care, Siemens. Stock options: Synchron, Endostream, Q’Apel. Social Media Editor for JNIS. DF: Consultant: Balt USA, Penumbra, Cerenovus, Stryker, Genentech, Shape Memory Medical, Marbelhead, Medtronic, MENTICE, Neuorogami, RAPID AI, Rapid Medical, Phenox. Associate Editor for JNIS. EIL: Consultant: Penumbra, NextGen Biologics, Rapid Medical, Cognition Medical, Three Rivers Medical, Stryker, MedX, Endostream Medical. KS: Consultant: Penumbra, Canon Medical Systems, Medtronic, Jacobs Institute, Neurovascular Diagnostics. RAH: Consultant: Penumbra, Endostream, Cerebrotech, Synchron, InNeuroCo, Medtronic, Microvention, Stryker, Cerenovus; Elum, Three Rivers. KW: Consultant: Penumbra. IC: Consultant: Medtronic, Microvention, Penumbra. Stocks: Cerenovus, Serenity Medical, Cerebrotech, Three Rivers Medical, Q’apel. ATR: Consultant: Penumbra, Microvention, Stryker. DF: Consultant: Penumbra, Cerenovus, Stryker, Genentech, Shape Memory Medical, Siemens. JEDA: Consultant: Penumbra, Medtronic. MK: Consultant: Penumbra, Medtronic, Endostream. ASA: Consultant: Cerenovus, Medtronic, Microvention, Penumbra, Scientia, Siemens, Stryker. Stocks: Bendit, Cerebrotech, Endostream, Magneto, Marblehead, Neurogami, Serenity, Synchron, Triad, Vascular Simulations. BWB: Consultant: Penumbra, Medtronic, Stryker, Cerenovus, Viz.ai, 880 Medical, Route 92, Artio Medical. JE: Consultant: Penumbra, Medtronic, Stryker, Route 92 Medical. IL: Consultant: Penumbra, Medtronic, Stryker, Microvention, InNeuroCo, Three Rivers. KMF: Associate Editor for JNIS. AT: Consultant: Cardinal Consulting, Cerenovus, Corindus, Medtronic, Siemens, 880 Medical. Stock: Cerebrotech, Endostream. Imperative Care, Three Rivers Medical, Vastrax, Shape Memory, Synchron, Serenity Medical, Blink TBI, Echovate, RIST, Apama, Q’Apel, VizAi, Early Bird Medical, Rapid Medical, Spinnaker Medical. AHS: Stocks: Adona Medical, Inc., Amnis Therapeutics, Bend IT Technologies, Ltd, BlinkTBI, Inc., Buffalo Technology Partners, Inc., Cardinal Consultants, LLC, Cerebrotech Medical Systems, Inc., Cerevatech Medical, Inc., Cognition Medical, CVAID Ltd, Endostream Medical, Ltd, Imperative Care, Inc., Instylla, Inc., International Medical Distribution Partners, Launch NY, Inc., NeuroRadial Technologies, Inc., Neurotechnology Investors, Neurovascular Diagnostics, Inc., PerFlow Medical, Ltd, Q’Apel Medical, Inc., QAS.ai, Inc., Radical Catheter Technologies, Inc., Rebound Therapeutics Corp. (purchased 2019 by Integra Lifesciences, Corp.), Rist Neurovascular, Inc. (purchased 2020 by Medtronic), Sense Diagnostics, Inc., Serenity Medical, Inc., Silk Road Medical, SongBird Therapy, Spinnaker Medical, Inc., StimMed, LLC, Synchron, Inc., Three Rivers Medical, Inc., Truvic Medical, Inc., Tulavi Therapeutics, Inc., Vastrax, LLC, VICIS, Inc., Viseon, Inc. Consultant/Advisory Board: Amnis Therapeutics, Apellis Pharmaceuticals, Inc., Boston Scientific, Canon Medical Systems USA, Inc., Cardinal Health 200, LLC, Cerebrotech Medical Systems, Inc., Cerenovus, Cerevatech Medical, Inc., Cordis, Corindus, Inc., Endostream Medical, Ltd, Imperative Care, Integra, IRRAS AB, Medtronic, MicroVention, Minnetronix Neuro, Inc., Penumbra, Q’Apel Medical, Inc., Rapid Medical, Rebound Therapeutics Corp., Serenity Medical, Inc., Silk Road Medical, StimMed, LLC, Stryker Neurovascular, Three Rivers Medical, Inc., VasSol, Viz.ai, Inc., W.L. Gore & Associates. JM: Stock options: Cerebrotech, Imperative Care, Endostream, Viseon, BlinkTBI, Serenity, Cardinal Consulting, NTI, RIST, Viz.ai, Synchron. Consultant: Imperative Care, Cerebrotech, VIseon, Endostream, Vastrax, RIST, Synchron, Viz.ai, Perflow, CVAid. Associate Editor for JNIS., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Thrombectomy is an efficacious treatment for acute ischemic stroke (AIS). However, relatively few studies to date have specifically examined the impact and clinical implications of age on outcomes for thrombectomy in anterior AIS., Objective: To provide a snapshot of patient metrics and outcomes with respect to age following thrombectomy for anterior AIS to supplement the current body of data for predictors of clinical outcomes in a real-world setting., Methods: Data were collected for 20 consecutive patients with AIS treated with thrombectomy at 15 high-volume stroke centers across North America between 2015 and 2016. Patients with anterior occlusions were dichotomized based on whether they were older or younger than 80 years. Ordinal logistic regression analyzed how clinical variables impacted disability using 90-day modified Rankin Scale (mRS) scores., Results: Adequate revascularization (TICI ≥2B) was achieved in 92.3% of patients aged <80 years with an average 1.7±0.1 passes taken with the primary technique and in 88.0% of patients aged ≥80 years with an average 1.7±0.2 passes. Despite similar baseline characteristics, mRS scores were significantly higher in older patients postoperatively and at 90 days after intervention. Age was a significant predictor of 90-day mRS across the study population., Conclusion: This analysis affirms age is a significant determinant of 90-day mRS scores following thrombectomy for large vessel anterior AIS. Further investigation into risks faced by elderly patients during thrombectomy may provide actionable information to help refine patient selection and improve outcomes., Competing Interests: Competing interests: AHS: Financial Interest/Investor/Stock Options/Ownership: Imperative Care, Q’Apel Medical; Consultant/Advisory Board: Cerenovus, Imperative Care, Medtronic, MicroVention, Penumbra, Q’Apel Medical, Stryker. JE: Consultant: Stryker Neurovascular, Medtronic. AT: Consultant: BALT/Blockade, Cerenovus, Medtronic, Microvention-Terumo, Penumbra, Imperative Care, Stryker. KW: Consultant: Cerenovus, Medtronic, Microvention, Penumbra, Stryker. AR: Consultant: Stryker, Cerenovus, Microvention. BB: Consultant: Penumbra, Medtronic, Stryker; Shareholder: Penumbra. RH: Grant/Research Support: Medtronic, Stryker, Microvention; Consultant: Medtronic, Stryker, Cerenovus, Microvention, Balt. JEDA: Consultant: Penumbra, Medtronic, Microvention. ASA: Consultant: Cerenovus, Medtronic, Microvention, Penumbra, Stryker; Research Support: Microvention, Cerenovus, Penumbra. DFi: Consultant: Medtronic, Microvention, Penumbra, Balt, Cerenovus, Stryker; Research Support: Siemens, Microvention, Penumbra, Cerenovus. MK: Consultant: Penumbra, Medtronic. LP: Consultant: Medtronic. DFr: Consultant/Speakers Bureau: Penumbra, Stryker, Research support: Cerenovus, Medtronic, Microvention, Penumbra, Stryker; Stock ownership: Penumbra. IL: Consultant: Medtronic, Stryker, Cerenovus. RDL: Consultant: Cerenovus, Penumbra, Q’Apel Medical, Imperative Care, Mivi Neuroscience; Research support: Medtronic, Asahi Intec. JM: Consultant: Cerebrotech, Rebound Therapeutics, TSP, Lazarus Effect, Medina, Pulsar Vascular; Investor: Blockade, Medina, Lazarus Effect, TSP; Research support: Penumbra., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Thrombectomy for anterior large vessel occlusion less than 24 hours since last known well is now standard of care. Certain aspects of clinical trials may limit generalizability to 'real-world' practice., Objective: To compare revascularization rates and outcomes for direct aspiration (ADAPT) and stent retriever thrombectomy following anterior acute ischemic stroke (AIS) in a real-life setting., Methods: Data from the most recent 20 consecutive patients with AIS treated with mechanical thrombectomy between 2015 and 2016 were collected from 15 high-volume stroke centers across North America for a total of 300 cases. Patients with proximal anterior large vessel occlusions were dichotomized by primary treatment technique. Ordinal logistic regression assessed the effects of clinical variables on patient disability using 90-day modified Rankin Scale (mRS) scores., Results: Adequate revascularization (Thrombolysis in Cerebral Infarction ≥2b) was ultimately achieved in 91.2% of first-line direct aspiration (ADAPT) cases with an average of 1.9±1.9 passes and in 87.5% of stent retriever cases with an average of 1.7±1.0 passes. Time from groin puncture to revascularization was shorter for ADAPT cases. The mean 90-day mRS score for both groups was 3.0±2.4. Number of passes using primary technique, and postintervention intracranial hemorrhage, were significant predictors of 90-day mRS scores after ADAPT, while age and preprocedure mRS score were predictive of outcomes following first-line stent retriever., Conclusions: Our data show similar adequate revascularization rates and 90-day functional outcomes for first-line direct aspiration and stent retrievers for anterior large vessel occlusion in a real-world setting. These results support the findings of other prospective trials evaluating the two techniques., Competing Interests: Competing interests: AHS: financial interest/investor/stock options/ownership: Imperative Care, Q’Apel Medical, Inc; consultant/advisory board: Cerenovus, Imperative Care, Medtronic, MicroVention, Penumbra, Q’Apel Medical, Inc, Stryker. JE: consultant: Stryker Neurovascular, Medtronic. AT: consultant: BALT/Blockade, Cerenovus, Medtronic, Microvention-Terumo, Penumbra, Imperative Care, Stryker. KW0: consultant: Cerenovus, Medtronic, Microvention, Penumbra, Stryker. AR: consultant: Stryker, Cerenovus, Microvention. BB: consultant: Penumbra, Medtronic, Stryker; shareholder: Penumbra. RH: grant/research support: Medtronic, Stryker, Microvention; consultant: Medtronic, Stryker, Cerenovous, Microvention, Balt. JEDA: consultant: Penumbra, Medtronic, Microvention. ASA: consultant: Cerenovus, Medtronic, Microvention, Penumbra, Stryker; research support: Microvention, Cerenovus, Penumbra. AA: consultant: Cerenovus, Medtronic, Microvention, Penumbra, Stryker; research support: Microvention, Cerenovus, Penumbra. MK: consultant: Penumbra, Medtronic. LP: consultant: Medtronic. DF: consultant/speakers bureau: Penumbra; Stryker; research support: Cerenovus, Medtronic, Microvention, Penumbra, Stryker; stock ownership: Penumbra. IL: consultant: Medtronic, Stryker, Cerenovus. RDL: consultant: Cerenovus, Penumbra, Q’Apel Medical Inc, Imperative Care, Mivi Neuroscience; research support: Medtronic, Asahi Intec. JM: consultant: Cerebrotech, Rebound Therapeutics, TSP Inc, Lazarus Effect, Medina, Pulsar Vascular; investor: Blockade, Medina, Lazarus Effect, TSP Inc; research support: Penumbra, (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Tandem occlusive disease in the setting of acute ischemic stroke involving cervical and cerebral arteries has been associated with poor neurological outcome and poses significant challenges to neurointerventionists. Previously described endovascular methods typically involve carotid revascularization with stent placement prior to or following intracranial thrombectomy. Stent-based approaches, however, require the use of antiplatelet therapy which may increase the risk of hemorrhagic transformation. We describe a novel modified Dotter technique which may be used for carotid revascularization in lieu of stenting. This technique can eliminate the need for antiplatelet therapy, reduce procedure times, and possibly reduce hemorrhagic conversion rates., Methods: Seven patients presenting between April 2013 and January 2014 were treated with this technique. All patients had carotid stenosis of 65-100% and tandem middle cerebral artery occlusions. National Institutes of Health (NIH) Stroke Scale scores as well as clinical and procedural times were recorded. Pre- and post-Dotter stenosis was measured using the NASCET criteria. Follow-up imaging and clinical data were reviewed., Results: The mean age was 64 years and mean initial NIH Stroke Scale score was 11.7. Mean groin to recanalization time was 26 min. Thrombolysis In Cerebral Infarction grade 2b-3 was achieved in all patients. The mean stenosis was 88% preoperatively and 61% postoperatively. There were no intracranial hemorrhages. The modified Rankin Scale score was 0 in six patients (86%) and 6 in one patient (14%)., Conclusions: The Dotter stroke technique is a feasible and safe alternative to carotid stenting in the setting of acute ischemic stroke and may reduce the risk of hemorrhagic conversion. No re-occlusion occurred during follow-up in patients with post-Dotter stenosis ≤65%., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)