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Background and Purpose: Several studies have shown that thrombectomy is safe and effective in occlusions of the M2 segment of the middle cerebral artery. This retrospective study compared superior and inferior division occlusions regarding radiological and clinical outcomes., Methods: Between 2009 and 2017, patients treated with thrombectomy due to occlusion of the superior or inferior division were selected. Univariate and multivariate analyses were performed to identify predictors of outcome and compare superior and inferior division occlusions., Results: A total of 140 patients with superior (n = 87) and inferior (n = 53) division occlusion were included. Of patients with inferior division occlusion 66.0% achieved good outcome compared to 48.3% in patients with superior division occlusion (P = 0.041). Time from groin puncture to reperfusion, recanalization success, complication rate, hemorrhage rate and follow-up infarct size were similar in both groups. Independent predictors of good outcome were baseline Alberta Stroke Program Early CT Score (ASPECTS) (odds ratio, OR 1.74, 95% confidence interval, CI 1.21-2.58, P = 0.004), time from groin puncture to reperfusion (OR 0.99, 95% CI 0.98-1.0, P = 0.019) and Thrombolysis In Cerebral Infarction (TICI) score 2b-3 (OR 4.51, 95% CI 1.31-18.74, P = 0.024). Superior division occlusion was an independent predictor of poor outcome (OR 2.41, 95% CI 1.05-5.80, P = 0.042). Dominance of the occluded vessel and side of occlusion were not predictive., Conclusion: Patients with superior division occlusion appear to have a lower chance of achieving good outcome despite similar recanalization rates and complication rates compared to inferior division occlusions.

Background and Purpose: Although the treatment window for mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) has been extended in recent years, it has been proven that recanalizing treatment must be administered as soon as possible. We present a new standard operating procedure (SOP) to reduce in-house delay, standardize periinterventional management and improve patient safety during MT., Methods: KEep Evaluating Protocol Simplification In Managing Periinterventional Light Sedation for Endovascular Stroke Treatment (KEEP SIMPLEST) was a prospective, single-center observational study aimed to compare aspects of periinterventional management in AIS patients treated according to our new SOP using a combination of esketamine and propofol with patients having been randomized into conscious sedation (CS) in the Sedation versus Intubation for Endovascular Stroke TreAtment (SIESTA) trial. Primary outcome was early neurological improvement at 24h using the National Institutes of Health Stroke Scale, and secondary outcomes were door-to-recanalization, recanalization grade, conversion rate and modified Rankin Scale (mRS) at 3 months., Results: Door-to-recanalization time (128.6 ± 69.47 min vs. 156.8 ± 75.91 min; p = 0.02), mean duration of MT (92.01 ± 52 min vs. 131.9 ± 64.03 min; p < 0.001), door-to-first angiographic image (51.61 ± 31.7 min vs. 64.23 ± 21.53 min; p = 0.003) and computed tomography-to-first angiographic image time (31.61 ± 20.6 min vs. 44.61 ± 19.3 min; p < 0.001) were significantly shorter in the group treated under the new SOP. There were no differences in early neurological improvement, mRS at 3 months or other secondary outcomes between the groups. Conversion rates of CS to general anesthesia were similar in both groups., Conclusion: An SOP using a novel sedation regimen and optimization of equipment and procedures directed at a leaner, more integrative and compact periinterventional management can reduce in-house treatment delays significantly in stroke patients receiving thrombectomy in light sedation and demonstrated the safety and feasibility of our improved approach.

Purpose: Intracranial hemorrhage (ICH) is a potentially severe complication after mechanical thrombectomy (MT). Here, we investigated risk factors for the occurrence of any and symptomatic ICH after MT due to large-vessel occlusion of the anterior circulation., Methods: Consecutive patients with acute ischemic anterior circulation stroke with large-vessel occlusion undergoing MT were analyzed. ICH was categorized according to the Heidelberg Bleeding Classification. Forty-three procedural and clinical parameters were analyzed using univariate tests and multivariate logistic regressions., Results: Of 612 patients, any ICH was detected in 195 (31.9%), while 27 (4.4%) developed a symptomatic ICH. Infarct size > 1/3 of vascular territory in control imaging (OR 2.18, 95% CI 1.45-3.21), higher serum glucose levels (OR 1.23 for change of 15 units mg/dL, 95% CI 1.10-1.39), and higher thrombectomy maneuver count (OR 1.21, 95% CI 1.11-1.32) were significantly associated with a higher risk of developing any ICH compared to no ICH. Wake-up strokes (OR 3.99, 95% CI 1.38-11.60), transfer from an external clinic (OR 3.04, 95% CI 1.24-7.48), and higher serum glucose levels (OR 1.22 for change of 15 units mg/dL, 95% CI 1.05-1.42) were revealed as independent risk factors for development of symptomatic ICH compared to no symptomatic ICH. Patients with no infarct demarcation (OR 0.10, 95% CI 0.01-0.80) and complete recanalization (OR 0.57, 95% CI 0.37-0.86) showed a lower risk of developing any ICH., Conclusion: Wake-up strokes and patients who are treated within a drip-and-ship concept are especially vulnerable for symptomatic ICH, while complete recanalization, contrary to subtotal recanalization only, was revealed as a protective factor against ICH.

Background and Purpose: The e-ASPECTS software is a tool for the automated use of ASPECTS. Our aim was to analyze whether baseline e-ASPECT scores correlate with outcome after mechanical thrombectomy., Materials and Methods: Patients with ischemic strokes in the anterior circulation who were admitted between 2010 and 2015, diagnosed by CT, and received mechanical thrombectomy were included. The ASPECTS on baseline CT was scored by e-ASPECTS and 3 expert raters, and interclass correlation coefficients were calculated. The e-ASPECTS was correlated with functional outcome (modified Rankin Scale) at 3 months by using the Spearman rank correlation coefficient. Unfavorable outcome was defined as mRS 4-6 at 3 months, and a poor scan was defined as e-ASPECTS 0-5., Results: Two hundred twenty patients were included, and 147 (67%) were treated with bridging protocols. The median e-ASPECTS was 9 (interquartile range, 8-10). Intraclass correlation coefficients between e-ASPECTS and raters were 0.72, 0.74, and 0.76 (all, P < .001). e-ASPECTS (Spearman rank correlation coefficient = -0.15, P = .027) correlated with mRS at 3 months. Patients with unfavorable outcome had lower e-ASPECTS (median, 8; interquartile range, 7-10 versus median, 9; interquartile range, 8-10; P = .014). Sixteen patients (7.4%) had a poor scan, which was associated with unfavorable outcome (OR, 13.6; 95% CI, 1.8-104). Independent predictors of unfavorable outcome were e-ASPECTS (OR, 0.79; 95% CI, 0.63-0.99), blood sugar (OR, 1.01; 95% CI, 1.004-1.02), atrial fibrillation (OR, 2.64; 95% CI, 1.22-5.69), premorbid mRS (OR, 1.77; 95% CI, 1.21-2.58), NIHSS (OR, 1.11; 95% CI, 1.04-1.19), general anesthesia (OR, 0.24; 95% CI, 0.07-0.84), failed recanalization (OR, 8.47; 95% CI, 3.5-20.2), and symptomatic intracerebral hemorrhage (OR, 25.8; 95% CI, 2.5-268)., Conclusions: The e-ASPECTS correlated with mRS at 3 months and was predictive of unfavorable outcome after mechanical thrombectomy, but further studies in patients with poor scan are needed., (© 2017 by American Journal of Neuroradiology.)

Background and Purpose: Embolization of thrombus fragments in a new vascular territory is a potential adverse event in neurothrombectomy. This study was performed to evaluate the safety and feasibility of a novel approach combining proximal balloon occlusion and distal aspiration to prevent distal thrombembolic complications., Methods: Patients with ischemic stroke meeting the following inclusion criteria were eligible: occlusion in the anterior circulation, neurothrombectomy using a balloon catheter for proximal flow arrest, and an intermediate catheter for distal aspiration. Pre- and post-interventional Thrombolysis In Cerebral Infarction (TICI) scores were assessed. Clinical presentation at admission and discharge and after 3 months was also evaluated and complications (particularly new thrombembolic events) were recorded., Results: We retrospectively identified 31 patients from our prospectively collected stroke database who met the inclusion criteria. In all patients the initial TICI was 0. A TICI score of ≥2b was achieved in 96.8%. No new thrombembolic complications occurred. The median NIH Stroke Scale score was 19 at admission and 4.5 at discharge. After 3 months, 51.6% of the patients had a favorable clinical outcome (modified Rankin Scale score 0-2) and 19.3% had died., Conclusions: A combination of proximal internal carotid artery occlusion using a balloon catheter and distal aspiration through an intermediate catheter represents a safe and efficient adjunct to mechanical thrombectomy with stent retrievers. In our patient cohort, no new thrombembolic complications were detected., (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/.)

Importance: Optimal management of sedation and airway during thrombectomy for acute ischemic stroke is controversial due to lack of evidence from randomized trials., Objective: To assess whether conscious sedation is superior to general anesthesia for early neurological improvement among patients receiving stroke thrombectomy., Design, Setting, and Participants: SIESTA (Sedation vs Intubation for Endovascular Stroke Treatment), a single-center, randomized, parallel-group, open-label treatment trial with blinded outcome evaluation conducted at Heidelberg University Hospital in Germany (April 2014-February 2016) included 150 patients with acute ischemic stroke in the anterior circulation, higher National Institutes of Health Stroke Scale (NIHSS) score (>10), and isolated/combined occlusion at any level of the internal carotid or middle cerebral artery., Intervention: Patients were randomly assigned to an intubated general anesthesia group (n = 73) or a nonintubated conscious sedation group (n = 77) during stroke thrombectomy., Main Outcomes and Measures: Primary outcome was early neurological improvement on the NIHSS after 24 hours (0-42 [none to most severe neurological deficits; a 4-point difference considered clinically relevant]). Secondary outcomes were functional outcome by modified Rankin Scale (mRS) after 3 months (0-6 [symptom free to dead]), mortality, and peri-interventional parameters of feasibility and safety., Results: Among 150 patients (60 women [40%]; mean age, 71.5 years; median NIHSS score, 17), primary outcome was not significantly different between the general anesthesia group (mean NIHSS score, 16.8 at admission vs 13.6 after 24 hours; difference, -3.2 points [95% CI, -5.6 to -0.8]) vs the conscious sedation group (mean NIHSS score, 17.2 at admission vs 13.6 after 24 hour; difference, -3.6 points [95% CI, -5.5 to -1.7]); mean difference between groups, -0.4 (95% CI, -3.4 to 2.7; P = .82). Of 47 prespecified secondary outcomes analyzed, 41 showed no significant differences. In the general anesthesia vs the conscious sedation group, substantial patient movement was less frequent (0% vs 9.1%; difference, 9.1%; P = .008), but postinterventional complications were more frequent for hypothermia (32.9% vs 9.1%; P < .001), delayed extubation (49.3% vs 6.5%; P < .001), and pneumonia (13.7% vs 3.9%; P = .03). More patients were functionally independent (unadjusted mRS score, 0 to 2 after 3 months [37.0% in the general anesthesia group vs 18.2% in the conscious sedation group P = .01]). There were no differences in mortality at 3 months (24.7% in both groups)., Conclusions and Relevance: Among patients with acute ischemic stroke in the anterior circulation undergoing thrombectomy, conscious sedation vs general anesthesia did not result in greater improvement in neurological status at 24 hours. The study findings do not support an advantage for the use of conscious sedation., Trial Registration: clinicaltrials.gov Identifier: NCT02126085.

Background and Purpose: Patients with acute ischemic stroke in the anterior circulation are at risk for either primary or, following mechanical thrombectomy, secondary occlusion of the anterior cerebral artery. Because previous studies had only a limited informative value, we report our data concerning the frequency and location of distal anterior cerebral artery occlusions, recanalization rates, periprocedural complications, and clinical outcome., Materials and Methods: We performed a retrospective analysis of prospectively collected data of patients with acute ischemic stroke undergoing mechanical thrombectomy in the anterior circulation between June 2010 and April 2015., Results: Of 368 patients included in this analysis, we identified 30 (8.1%) with either primary (n = 17, 4.6%) or secondary (n = 13, 3.5%) embolic occlusion of the distal anterior cerebral artery. The recanalization rate after placement of a stent retriever was 88%. Periprocedural complications were rare and included vasospasms (n = 3, 10%) and dissection (n = 1, 3.3%). However, 16 (53.5%) patients sustained an (at least partial) infarction of the anterior cerebral artery territory. Ninety days after the ictus, clinical outcome according to the modified Rankin Scale score was the following: 0-2, n = 11 (36.6%); 3-4, n = 9 (30%); 5-6, n = 10 (33.3%)., Conclusions: Occlusions of the distal anterior cerebral artery affect approximately 8% of patients with acute ischemic stroke in the anterior circulation receiving mechanical thrombectomy. Despite a high recanalization rate and a low complication rate, subsequent (partial) infarction in the anterior cerebral artery territory occurs in approximately half of patients. Fortunately, clinical outcome appears not to be predominately unfavorable., (© 2016 by American Journal of Neuroradiology.)