1.Updated New York City Emergency Medical Services Acute Stroke Triage Protocol Reduces Interfacility Transfers and Time to Endovascular Thrombectomy for Emergent Large Vessel Occlusion Stroke Patients
Jacob R. MOREY ; Brian D. KIM ; Michael REDLENER ; Xiangnan ZHANG ; Naoum Fares MARAYATI ; Stavros MATSOUKAS ; Emily FIANO ; Laura K. STEIN ; J MOCCO ; Johanna T. FIFI
Journal of Stroke 2022;24(3):417-420
2.Tissue Clock Beyond Time Clock: Endovascular Thrombectomy for Patients With Large Vessel Occlusion Stroke Beyond 24 Hours
Ghada A. MOHAMED ; Raul G. NOGUEIRA ; Muhammed Amir ESSIBAYI ; Hassan ABOUL-NOUR ; Mahmoud MOHAMMADEN ; Diogo C. HAUSSEN ; Aldo Mendez RUIZ ; Bradley A. GROSS ; Okkes KUYBU ; Mohamed M. SALEM ; Jan-Karl BURKHARDT ; Brian JANKOWITZ ; James E. SIEGLER ; Pratit PATEL ; Taryn HESTER ; Santiago ORTEGA-GUTIERREZ ; Mudassir FAROOQUI ; Milagros GALECIO-CASTILLO ; Thanh N. NGUYEN ; Mohamad ABDALKADER ; Piers KLEIN ; Jude H. CHARLES ; Vasu SAINI ; Dileep R. YAVAGAL ; Ammar JUMAH ; Ali ALARAJ ; Sophia PENG ; Muhammad HAFEEZ ; Omar TANWEER ; Peter KAN ; Jacopo SCAGGIANTE ; Stavros MATSOUKAS ; Johanna T. FIFI ; Stephan A. MAYER ; Alex B. CHEBL
Journal of Stroke 2023;25(2):282-290
Background:
and Purpose Randomized trials proved the benefits of mechanical thrombectomy (MT) for select patients with large vessel occlusion (LVO) within 24 hours of last-known-well (LKW). Recent data suggest that LVO patients may benefit from MT beyond 24 hours. This study reports the safety and outcomes of MT beyond 24 hours of LKW compared to standard medical therapy (SMT).
Methods:
This is a retrospective analysis of LVO patients presented to 11 comprehensive stroke centers in the United States beyond 24 hours from LKW between January 2015 and December 2021. We assessed 90-day outcomes using the modified Rankin Scale (mRS).
Results:
Of 334 patients presented with LVO beyond 24 hours, 64% received MT and 36% received SMT only. Patients who received MT were older (67±15 vs. 64±15 years, P=0.047) and had a higher baseline National Institutes of Health Stroke Scale (NIHSS; 16±7 vs.10±9, P<0.001). Successful recanalization (modified thrombolysis in cerebral infarction score 2b-3) was achieved in 83%, and 5.6% had symptomatic intracranial hemorrhage compared to 2.5% in the SMT group (P=0.19). MT was associated with mRS 0–2 at 90 days (adjusted odds ratio [aOR] 5.73, P=0.026), less mortality (34% vs. 63%, P<0.001), and better discharge NIHSS (P<0.001) compared to SMT in patients with baseline NIHSS ≥6. This treatment benefit remained after matching both groups. Age (aOR 0.94, P<0.001), baseline NIHSS (aOR 0.91, P=0.017), Alberta Stroke Program Early Computed Tomography (ASPECTS) score ≥8 (aOR 3.06, P=0.041), and collaterals scores (aOR 1.41, P=0.027) were associated with 90-day functional independence.
Conclusion
In patients with salvageable brain tissue, MT for LVO beyond 24 hours appears to improve outcomes compared to SMT, especially in patients with severe strokes. Patients’ age, ASPECTS, collaterals, and baseline NIHSS score should be considered before discounting MT merely based on LKW.
3.Clinical and Safety Outcomes of Endovascular Therapy 6 to 24 Hours After Large Vessel Occlusion Ischemic Stroke With Tandem Lesions
Milagros GALECIO-CASTILLO ; Mudassir FAROOQUI ; Ameer E. HASSAN ; Mouhammad A. JUMAA ; Afshin A. DIVANI ; Marc RIBO ; Michael ABRAHAM ; Nils H. PETERSEN ; Johanna T. FIFI ; Waldo R. GUERRERO ; Amer M. MALIK ; James E. SIEGLER ; Thanh N. NGUYEN ; Sunil SHETH ; Albert J. YOO ; Guillermo LINARES ; Nazli JANJUA ; Darko QUISPE-OROZCO ; Wondwossen TEKLE ; Syed F. ZAIDI ; Sara Y. SABBAGH ; Marta OLIVÉ-GADEA ; Tiffany BARKLEY ; Reade De LEACY ; Kenyon W. SPRANKLE ; Mohamad ABDALKADER ; Sergio SALAZAR-MARIONI ; Jazba SOOMRO ; Weston GORDON ; Charoskhon TURABOVA ; Juan VIVANCO-SUAREZ ; Aaron RODRIGUEZ-CALIENES ; Maxim MOKIN ; Dileep R. YAVAGAL ; Tudor JOVIN ; Santiago ORTEGA-GUTIERREZ
Journal of Stroke 2023;25(3):378-387
Background:
and Purpose Effect of endovascular therapy (EVT) in acute large vessel occlusion (LVO) patients with tandem lesions (TLs) within 6–24 hours after last known well (LKW) remains unclear. We evaluated the clinical and safety outcomes among TL-LVO patients treated within 6–24 hours.
Methods:
This multicenter cohort was divided into two groups, based on LKW to puncture time: early window (<6 hours), and late window (6–24 hours). Primary clinical and safety outcomes were 90-day functional independence measured by the modified Rankin Scale (mRS: 0–2) and symptomatic intracranial hemorrhage (sICH). Secondary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction score ≥2b), first-pass effect, early neurological improvement, ordinal mRS, and in-hospital and 90-day mortality.
Results:
Of 579 patients (median age 68, 32.1% females), 268 (46.3%) were treated in the late window and 311 (53.7%) in the early window. Late window group had lower median National Institutes of Health Stroke Scale score at admission, Alberta Stroke Program Early Computed Tomography Score, rates of intravenous thrombolysis, and higher rates for perfusion imaging. After adjusting for confounders, the odds of 90-day mRS 0–2 (47.7% vs. 45.0%, adjusted odds ratio [aOR] 0.71, 95% confidence interval [CI] 0.49–1.02), favorable shift in mRS (aOR 0.88, 95% CI 0.44–1.76), and sICH (3.7% vs. 5.2%, aOR 0.56, 95% CI 0.20–1.56) were similar in both groups. There was no difference in secondary outcomes. Increased time from LKW to puncture did not predicted the probability of 90-day mRS 0–2 (aOR 0.99, 95% CI 0.96–1.01, for each hour delay) among patients presenting <24 hours.
Conclusion
EVT for acute TL-LVO treated within 6–24 hours after LKW was associated with similar rates of clinical and safety outcomes, compared to patients treated within 6 hours.
4.Endovascular Thrombectomy Versus Intravenous Thrombolysis of Posterior Cerebral Artery Occlusion Stroke
Silja RÄTY ; Thanh N. NGUYEN ; Simon NAGEL ; Davide STRAMBO ; Patrik MICHEL ; Christian HERWEH ; Muhammad M. QURESHI ; Mohamad ABDALKADER ; Pekka VIRTANEN ; Marta OLIVE-GADEA ; Marc RIBO ; Marios PSYCHOGIOS ; Anh NGUYEN ; Joji B. KURAMATSU ; David HAUPENTHAL ; Martin KÖHRMANN ; Cornelius DEUSCHL ; Jordi Kühne ESCOLÀ ; Jelle DEMEESTERE ; Robin LEMMENS ; Lieselotte VANDEWALLE ; Shadi YAGHI ; Liqi SHU ; Volker PUETZ ; Daniel P.O. KAISER ; Johannes KAESMACHER ; Adnan MUJANOVIC ; Dominique Cornelius MARTERSTOC ; Tobias ENGELHORN ; Anne BERBERICH ; Piers KLEIN ; Diogo C. HAUSSEN ; Mahmoud H. MOHAMMADEN ; Hend ABDELHAMID ; Isabel FRAGATA ; Bruno CUNHA ; Michele ROMOLI ; Wei HU ; Jianlon SONG ; Johanna T. FIFI ; Stavros MATSOUKAS ; Sunil A. SHETH ; Sergio A. SALAZAR-MARIONI ; João Pedro MARTO ; João Nuno RAMOS ; Milena MISZCZUK ; Christoph RIEGLER ; Sven POLI ; Khouloud POLI ; Ashutosh P. JADHAV ; Shashvat DESAI ; Volker MAUS ; Maximilian KAEDER ; Adnan H. SIDDIQUI ; Andre MONTEIRO ; Tatu KOKKONEN ; Francesco DIANA ; Hesham E. MASOUD ; Neil SURYADAREVA ; Maxim MOKIN ; Shail THANKI ; Pauli YLIKOTILA ; Kemal ALPAY ; James E. SIEGLER ; Italo LINFANTE ; Guilherme DABUS ; Dileep YAVAGHAL ; Vasu SAINI ; Christian H. NOLTE ; Eberhart SIEBERT ; Markus A. MÖHLENBRUCH ; Peter A. RINGLEB ; Raul G. NOGUEIRA ; Uta HANNING ; Lukas MEYER ; Urs FISCHER ; Daniel STRBIAN
Journal of Stroke 2024;26(2):290-299
Background:
and Purpose Posterior cerebral artery occlusion (PCAo) can cause long-term disability, yet randomized controlled trials to guide optimal reperfusion strategy are lacking. We compared the outcomes of PCAo patients treated with endovascular thrombectomy (EVT) with or without intravenous thrombolysis (IVT) to patients treated with IVT alone.
Methods:
From the multicenter retrospective Posterior cerebraL ArTery Occlusion (PLATO) registry, we included patients with isolated PCAo treated with reperfusion therapy within 24 hours of onset between January 2015 and August 2022. The primary outcome was the distribution of the modified Rankin Scale (mRS) at 3 months. Other outcomes comprised 3-month excellent (mRS 0–1) and independent outcome (mRS 0–2), early neurological improvement (ENI), mortality, and symptomatic intracranial hemorrhage (sICH). The treatments were compared using inverse probability weighted regression adjustment.
Results:
Among 724 patients, 400 received EVT+/-IVT and 324 IVT alone (median age 74 years, 57.7% men). The median National Institutes of Health Stroke Scale score on admission was 7, and the occluded segment was P1 (43.9%), P2 (48.3%), P3–P4 (6.1%), bilateral (1.0%), or fetal posterior cerebral artery (0.7%). Compared to IVT alone, EVT+/-IVT was not associated with improved functional outcome (adjusted common odds ratio [OR] 1.07, 95% confidence interval [CI] 0.79–1.43). EVT increased the odds for ENI (adjusted OR [aOR] 1.49, 95% CI 1.05–2.12), sICH (aOR 2.87, 95% CI 1.23–6.72), and mortality (aOR 1.77, 95% CI 1.07–2.95).
Conclusion
Despite higher odds for early improvement, EVT+/-IVT did not affect functional outcome compared to IVT alone after PCAo. This may be driven by the increased risk of sICH and mortality after EVT.