Background A direct admission to angiosuite (DAA) strategy in transfer patients with large vessel occlusion (LVO) is considered to decrease stroke time metrics and benefit functional outcomes. However, feasibility and effectiveness of DAA have not been established in rural settings. Fast door‐to‐reperfusion times and high‐quality reperfusion are key predictors of outcome in patients with LVO. To reduce treatment times in transferred patients with suspected LVO, we initiated a DAA triage protocol in 2017. Methods We conducted a nested interventional cohort study of adult patients with anterior LVO from January 2015 to August 2019 transferred to our center from an outside hospital. Patients were divided into DAA for mechanical thrombectomy (MT) and patients directly admitted to the emergency department (DAED). DAED was subdivided into patients undergoing MT and patients who did not. Workflow times and clinical and radiographic outcomes were analyzed. Results Forty‐five DAA patients and 241 DAED patients (DAED patients undergoing MT=134 patients and DAED patients not undergoing MT=107 patients) were identified. DAA patients had significantly shorter median door‐to‐arterial‐puncture times (15 versus 71 minutes) and puncture‐to‐recanalization times (27 versus 42.5 minutes). At discharge, DAA patients had a significant decrease in median admission National Institutes of Health Stroke Scale (NIHSS) score (ΔNIHSS score 10 versus 4; P =0.02), and higher rate of dramatic clinical improvement (ΔNIHSS score >10; 48.9% versus 23.5%; P <0.001). Both groups had comparable rates of functional independence (modified Rankin Scale; mRS 0–2; 36.1% versus 29.2%; P =0.52), and mortality at 90 days ( P =0.63). When mortality was excluded, DAA patients showed a significant proportion of excellent functional outcome (mRS 0–1; 50% versus 26%) before ( P =0.04) and after ( P =0.02) adjusting for confounders. Conclusions DAA is feasible and can safely reduce reperfusion times in transferred patients with LVO to MT centers in a rural setting. Reducing workflow times may impact the functional recovery of patients undergoing MT.
Background and Purpose: Elevated blood pressure after endovascular thrombectomy (EVT) has been associated with an increased risk of hemorrhagic transformation and poor functional outcomes. However, the optimal hemodynamic management after EVT remains unknown, and the blood pressure course in the acute phase of ischemic stroke has not been well characterized. This study aimed to identify patient subgroups with distinct blood pressure trajectories after EVT and study their association with radiographic and functional outcomes. Methods: This multicenter retrospective cohort study included consecutive patients with anterior circulation large-vessel occlusion ischemic stroke who underwent EVT. Repeated time-stamped blood pressure data were recorded for the first 72 hours after thrombectomy. Latent variable mixture modeling was used to separate subjects into five groups with distinct postprocedural systolic blood pressure (SBP) trajectories. The primary outcome was functional status, measured on the modified Rankin Scale 90 days after stroke. Secondary outcomes included hemorrhagic transformation, symptomatic intracranial hemorrhage, and death. Results: Two thousand two hundred sixty-eight patients (mean age [±SD] 69±15, mean National Institutes of Health Stroke Scale 15±7) were included in the analysis. Five distinct SBP trajectories were observed: low (18%), moderate (37%), moderate-to-high (20%), high-to-moderate (18%), and high (6%). SBP trajectory group was independently associated with functional outcome at 90 days ( P <0.0001) after adjusting for potential confounders. Patients with high and high-to-moderate SBP trajectories had significantly greater odds of an unfavorable outcome (adjusted odds ratio, 3.5 [95% CI, 1.8–6.7], P =0.0003 and adjusted odds ratio, 2.2 [95% CI, 1.5–3.2], P <0.0001, respectively). Subjects in the high-to-moderate group had an increased risk of symptomatic intracranial hemorrhage (adjusted odds ratio, 1.82 [95% CI, 1–3.2]; P =0.04). No significant association was found between trajectory group and hemorrhagic transformation. Conclusions: Patients with acute ischemic stroke demonstrate distinct SBP trajectories during the first 72 hours after EVT that have differing associations with functional outcome. These findings may help identify potential candidates for future blood pressure modulation trials.
BACKGROUND: Successful reperfusion is one of the strongest predictors of functional outcomes after mechanical thrombectomy (MT). Despite continuous advancements in MT technology and techniques, reperfusion failure still occurs in ≈15% to 30% of patients with large vessel occlusion strokes undergoing MT. We aim to evaluate the safety and efficacy of rescue intracranial stenting for large vessel occlusion stroke after failed MT. METHODS: The SAINT (Stenting and Angioplasty in Neurothrombectomy) Study is a retrospective analysis of prospectively collected data from 14 comprehensive stroke centers through January 2015 to December 2020. Patients were included if they had anterior circulation large vessel occlusion stroke due to intracranial internal carotid artery and middle cerebral artery-M1/M2 segments and failed MT. The cohort was divided into 2 groups: rescue intracranial stenting and failed recanalization (modified Thrombolysis in Cerebral Ischemia score 0–1). Propensity score matching was used to balance the 2 groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale at 90 days. Secondary outcomes included functional independence (90-day modified Rankin Scale score 0–2). Safety measures included symptomatic intracranial hemorrhage and 90-day mortality. RESULTS: A total of 499 patients were included in the analysis. Compared with the failed reperfusion group, rescue intracranial stenting had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 2.31 [95% CI, 1.61–3.32]; P <0.001), higher rates of functional independence (35.1% versus 7%; adjusted odds ratio [aOR], 6.33 [95% CI, 3.14–12.76]; P <0.001), and lower mortality (28% versus 46.5%; aOR, 0.55 [95% CI, 0.31–0.96]; P =0.04) at 90 days. Rates of symptomatic intracerebral hemorrhage were comparable across both groups (7.1% versus 10.2%; aOR, 0.99 [95% CI, 0.42–2.34]; P =0.98). The matched cohort analysis demonstrated similar results. Specifically, rescue intracranial stenting (n=107) had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 3.74 [95% CI, 2.16–6.57]; P <0.001), higher rates of functional independence (34.6% versus 6.5%; aOR, 10.91 [95% CI, 4.11–28.92]; P <0.001), and lower mortality (29.9% versus 43%; aOR, 0.49 [95% CI, 0.25–0.94]; P =0.03) at 90 days with similar rates of symptomatic intracerebral hemorrhage (7.5% versus 11.2%; aOR, 0.87 [95% CI, 0.31–2.42]; P =0.79) compared with patients who failed to reperfuse (n=107). There was no heterogeneity of treatment effect across the prespecified subgroups for improvement in functional outcomes. CONCLUSIONS: Acute intracranial stenting appears to be a safe and effective rescue strategy in patients with large vessel occlusion stroke who failed MT. Randomized multicenter trials are warranted.
Background The hyperdense middle cerebral artery sign on computed tomography indicates proximal middle cerebral artery occlusion. Recent reports suggest an association between the hyperdense sign and successful reperfusion. The prognostic value of the hyperdense middle cerebral artery sign in patients receiving mechanical thrombectomy has not been extensively studied. Aims Our study aims to evaluate the association between the hyperdense middle cerebral artery sign and functional outcome in patients with M1 occlusions that had undergone mechanical thrombectomy. Methods We conducted a single-center retrospective observational cohort study of 102 consecutive patients presenting with acute M1 occlusions that had undergone mechanical thrombectomy. Patients were stratified into cohorts based on the presence of hyperdense middle cerebral artery sign visually assessed on computed tomography by two readers. The outcomes of interests were functional disability measured by the ordinal Modified Rankin Scale (mRS) at 90 days, mortality, reperfusion status and hemorrhagic conversion. Results Out of the 102 patients with M1 occlusions, 71 had hyperdense middle cerebral artery sign. There was no significant difference between the cohorts in age, baseline mRS, NIHSS, ASPECTS, and time to reperfusion. The absence of hyperdense middle cerebral artery sign was associated with increased odds of being dependent or dying (higher mRS) (OR: 3.24, 95% CI: 1.30–8.06, p = 0.011) after adjusting for other significant predictors, including age, female sex, hypertension, presenting serum glucose, ASPECTS, CTA collateral score, and successful reperfusion. Conclusion The absence of hyperdense middle cerebral artery sign is associated with worse functional outcome in patients presenting with M1 occlusions undergoing thrombectomy.
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