Endovascular thrombectomy with and without preceding intravenous thrombolysis for treatment of large vessel anterior circulation stroke: A cross-sectional analysis of 50,000 patients

Dicpinigaitis, Alis J.; Gandhi, Chirag D.; Shah, Smit; Galea, Vincent P; Cooper, Jared; Feldstein, Eric; Shapiro, Steven D.; Kamal, Haris; Kurian, Christeena; Kaur, Gurmeen; Tyagi, Rachana; Biswas, Anup; Rosenberg, Jon; Bauerschmidt, Andrew; Bowers, Christian A.; Mayer, Stephan A.; Al‐Mufti, Fawaz

doi:10.1016/j.jns.2022.120168

Cited by 9 publications

(7 citation statements)

References 22 publications

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“…The observational study design inherent to analysis of administrative registry data, in which all diagnoses and procedures are identified by billing codes, is the primary limitation of this investigation. 35,36 These ICD codes do not carry a temporal qualifier, meaning that their occurrence with respect to vasospasm (before or after) cannot be ascertained, which limits conclusions regarding causality. 11 The inability of the NIS to accurately identify vasospasm and DCI and to differentiate these entities from ischemia and infarction due to the mass effect from hematoma expansion, increased intracranial pressure, or iatrogenic causes may have led to overreporting and a potential type I error.…”

Section: Discussionmentioning

confidence: 99%

Cerebral vasospasm following arteriovenous malformation rupture: a population-based cross-sectional study

Dicpinigaitis

Feldstein

Shapiro

et al. 2022

Neurosurgical Focus

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OBJECTIVE Studies examining the risk factors and clinical outcomes of arterial vasospasm secondary to cerebral arteriovenous malformation (cAVM) rupture are scarce in the literature. The authors used a population-based national registry to investigate this largely unexamined clinical entity. METHODS Admissions for adult patients with cAVM ruptures were identified in the National Inpatient Sample during the period from 2015 to 2019. Complex samples multivariable logistic regression and chi-square automatic interaction detection (CHAID) decision tree analyses were performed to identify significant associations between clinical covariates and the development of vasospasm, and a cAVM–vasospasm predictive model (cAVM-VPM) was generated based on the effect sizes of these parameters. RESULTS Among 7215 cAVM patients identified, 935 developed vasospasm, corresponding to an incidence rate of 13.0%; 110 of these patients (11.8%) subsequently progressed to delayed cerebral ischemia (DCI). Multivariable adjusted modeling identified the following baseline clinical covariates: decreasing age by decade (adjusted odds ratio [aOR] 0.87, 95% CI 0.83–0.92; p < 0.001), female sex (aOR 1.68, 95% CI 1.45–1.95; p < 0.001), admission Glasgow Coma Scale score < 9 (aOR 1.34, 95% CI 1.01–1.79; p = 0.045), intraventricular hemorrhage (aOR 1.87, 95% CI 1.17–2.98; p = 0.009), hypertension (aOR 1.77, 95% CI 1.50–2.08; p < 0.001), obesity (aOR 0.68, 95% CI 0.55–0.84; p < 0.001), congestive heart failure (aOR 1.34, 95% CI 1.01–1.78; p = 0.043), tobacco smoking (aOR 1.48, 95% CI 1.23–1.78; p < 0.019), and hospitalization events (leukocytosis [aOR 1.64, 95% CI 1.32–2.04; p < 0.001], hyponatremia [aOR 1.66, 95% CI 1.39–1.98; p < 0.001], and acute hypotension [aOR 1.67, 95% CI 1.31–2.11; p < 0.001]) independently associated with the development of vasospasm. Intraparenchymal and subarachnoid hemorrhage were not associated with the development of vasospasm following multivariable adjustment. Among significant associations, a CHAID decision tree algorithm identified age 50–59 years (parent node), hyponatremia, and leukocytosis as important determinants of vasospasm development. The cAVM-VPM achieved an area under the curve of 0.65 (sensitivity 0.70, specificity 0.53). Progression to DCI, but not vasospasm alone, was independently associated with in-hospital mortality (aOR 2.35, 95% CI 1.29–4.31; p = 0.016) and lower likelihood of routine discharge (aOR 0.62, 95% CI 0.41–0.96; p = 0.031). CONCLUSIONS This large-scale assessment of vasospasm in cAVM identifies common clinical risk factors and establishes progression to DCI as a predictor of poor neurological outcomes.

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Section: Discussionmentioning

confidence: 99%

Cerebral vasospasm following arteriovenous malformation rupture: a population-based cross-sectional study

Dicpinigaitis

Feldstein

Shapiro

et al. 2022

Neurosurgical Focus

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“…Most recently, a cross-sectional population-based assessment of nearly 50 000 patients with AIS treated with MT showed that although preceding IVT was associated with higher rates of intracerebral hemorrhage, it may confer a clinical benefit with respect to clinical outcome at discharge and shorter hospital lengths of stay. 57 A pooled analysis of the TITAN (Thrombectomy In Tandem lesions) and ETIS (Endovascular Treatment in Ischemic Stroke) Registries suggested also that bridging therapy with IVT in patients with AIS because of anterior tandem occlusion may improve functional outcome, even in the setting of acute cervical carotid artery stenting during MT, without increasing the risk of hemorrhagic complications. 58 Moreover, in tandem occlusion related to cervical internal carotid artery dissection, prior IVT before MT was also associated with a higher rate of intracranial successful reperfusion (83% versus 64%) and a lower rate of sICH (4.3% versus 14.8%).…”

Section: Thrombolysis Bridge Is Down?mentioning

confidence: 99%

The End of Tissue-Type Plasminogen Activator’s Reign?

Derraz

2022

Stroke

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Mechanical thrombectomy is a highly effective treatment for acute ischemic stroke caused by large-vessel occlusion in the anterior cerebral circulation, significantly increasing the likelihood of recovery to functional independence. Until recently, whether intravenous thrombolysis before mechanical thrombectomy provided additional benefits to patients with acute ischemic stroke-large-vessel occlusion remained unclear. Given that reperfusion is a key factor for clinical outcome in patients with acute ischemic stroke-large-vessel occlusion and the efficacy of both intravenous thrombolysis and mechanical thrombectomy is time-dependent, achieving complete reperfusion with a single pass should be the primary angiographic goal. However, it remains undetermined whether extending the procedure with additional endovascular attempts or local lytics administration safely leads to higher reperfusion grades and whether there are significant public health and cost implications. Here, we outline the current state of knowledge and research avenues that remain to be explored regarding the consistent therapeutic benefit of intravenous thrombolysis in anterior circulation strokes and the potential place of adjunctive intra-arterial lytics administration, including alternative thrombolytic agent place.

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“…History of varicella was found in 12.5% (6 of 48 patients with available data) and potentially embolic heart condition in 16.2% (11). Median pedNIHSS at admission was 13 (IQR, 7-19) and was higher in patients treated with EVT (16 [IQR,(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20) vs 9 [IQR, [6][7][8][9][10][11][12][13][14][15][16][17]; P = .004). Median time from stroke onset to imaging was 2 hours and 54 minutes (IQR, 2 hours to 4 hours and 49 minutes) and was longer in patients treated with EVT (3 hours and 7 minutes; IQR, 2 hours and 3 minutes to 6 hours and 24 minutes vs 2 hours and 39 minutes; IQR, 1 hour and 51 minutes to 4 hours and 13 minutes; P = .04).…”

Section: Characteristics At the Acute Phasementioning

confidence: 99%

“…However, the generalizability of these results remains questionable because of the overrepresentation of cardioembolic events in this study and the risk of selection bias over a 220-month inclusion period in 27 centers. Recently, Dicpinigaitis et al 10 extracted data on a cohort of 190 children treated with EVT from the US National Inpatient Sample and supported the safety profile of EVT in a large pediatric sample. However, the generalizability of results remains limited by many approximations regarding the population characteristics and outcomes owing to the lack of key variables, such as the National Institutes of Health Stroke Scale (NIHSS) score or modified Rankin Scale score.…”

Section: Introductionmentioning

confidence: 99%

Recanalization Treatments for Pediatric Acute Ischemic Stroke in France

et al. 2022

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IMPORTANCEThere is to date limited evidence that revascularization strategies are associated with improved functional outcome in children with acute ischemic stroke (AIS). OBJECTIVES To report clinical outcomes and provide estimates of revascularization strategy safety and efficacy profiles of intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) in children with AIS. DESIGN, SETTING, AND PARTICIPANTS The KidClot multicenter nationwide cohort study retrospectively collected data of children (neonates excluded) with AIS and recanalization treatment

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Endovascular thrombectomy with and without preceding intravenous thrombolysis for treatment of large vessel anterior circulation stroke: A cross-sectional analysis of 50,000 patients

Cited by 9 publications

References 22 publications

Cerebral vasospasm following arteriovenous malformation rupture: a population-based cross-sectional study

Cerebral vasospasm following arteriovenous malformation rupture: a population-based cross-sectional study

The End of Tissue-Type Plasminogen Activator’s Reign?

Recanalization Treatments for Pediatric Acute Ischemic Stroke in France

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