Mechanical thrombectomy for anterior circulation stroke: 5-year experience in a statewide service with differences in pretreatment time metrics across two hospitals sites

Kabra, Ruchi; Phillips, Timothy J; Saw, Jacqui-Lyn; Phatouros, Constantine C.; Singh, Tejinder; Hankey, Graeme J.; Blacker, David; Ghia, Darshan; Prentice, David; McAuliffe, William

doi:10.1136/neurintsurg-2016-012304

Cited by 5 publications

(5 citation statements)

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“…Of these, 52.5% showed significant early neurological improvement (52.6% for EVT plus thrombolysis vs. 52.4% for EVT alone, p = 0.987). These results are comparable to the 59% of patients showing early neurological improvement in REVASCAT and confirm our earlier findings [7] that results from the EVT trials are achievable in a service setting.…”

Section: Discussionsupporting

confidence: 91%

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Outcomes of Endovascular Thrombectomy with and without Thrombolysis for Acute Large Artery Ischaemic Stroke at a Tertiary Stroke Centre

Wee

McAuliffe

Phatouros

et al. 2017

Cerebrovasc Dis Extra

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Background and Purpose: Endovascular thrombectomy (EVT) improves the functional outcome when added to best medical therapy, including alteplase, in patients with acute ischaemic stroke secondary to large vessel occlusion (LVO) in the anterior circulation. However, the evidence for EVT in alteplase-ineligible patients is less compelling. It is also uncertain whether alteplase is necessary in patients with successful recanalization by EVT, as the treatment effect of EVT may be so powerful that bridging alteplase may not add to efficacy and may compromise safety by increasing bleeding risks. We aimed to survey the proportion of patients suitable for EVT who are alteplase-ineligible and to compare the safety and effectiveness of standard care of acute large artery ischaemic stroke by EVT plus thrombolysis with that of EVT alone in a tertiary hospital clinical stroke service. Methods: We performed a retrospective analysis of acute ischaemic stroke patients treated with EVT at our centre between October 2013 and April 2016, based on a registry with prospective and consecutive patient collection. Individual patient records were retrieved for review. Significant early neurological improvement was defined as a NIHSS score of 0–1, or a decrease from baseline of ≤8, at 24 h after stroke onset. Results: Fifty patients with acute ischaemic stroke secondary to LVO in the anterior circulation received EVT in this period, of whom 21 (42%) received concurrent alteplase and 29 (58%) EVT alone. The 2 groups had similar baseline characteristics and similar outcomes. Significant neurological improvement at 24 h occurred in 47.6% of the patients with EVT and bridging alteplase and in 51.7% of the patients with EVT alone (p = 0.774). Mortality during acute hospitalization was 20% for the bridging alteplase group versus 7.1% for EVT alone (p = 0.184). Intracranial haemorrhage rates were 14.3% for bridging alteplase versus 20.7% for EVT alone (p = 0.716). Local complications, groin haematoma (23.8 vs. 10.3%) and groin pseudoaneurysms (4.8 vs. 0%) (p = 0.170), were not significantly different. Conclusion: Our study highlights the relatively large proportion of patients suitable for EVT who have a contraindication to alteplase and raises the hypothesis that adding alteplase to successful EVT may not be necessary to optimize functional outcome. The results are consistent with observational data from other endovascular centres and support a randomised controlled trial of EVT versus EVT with bridging alteplase.

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Section: Discussionsupporting

confidence: 91%

“…We studied patients from October 2013 until April 2016. Some patients from February 2015 and prior were included in a separate state-wide audit published elsewhere [7]. Baseline information including age, sex, premorbid conditions, current medications, and initial NIHSS scores were obtained from case note review.…”

Section: Methodsmentioning

confidence: 99%

Outcomes of Endovascular Thrombectomy with and without Thrombolysis for Acute Large Artery Ischaemic Stroke at a Tertiary Stroke Centre

Wee

McAuliffe

Phatouros

et al. 2017

Cerebrovasc Dis Extra

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“…The rate of reperfusion with an mTICI grade ≥ 2a with the RECO device was 91%, whereas the rate of reperfusion with an mTICI grade ≥ 2b was 87%, rates in accordance with values in the lit-erature, which vary from 66.7% to 94.8%. [16][17][18][19][20] Functional independence at 90 days was attained in 63% of patients in the RECO group, again within the range described in the most optimistic studies (53%-71%). No significant difference was found in the rate of recanalization or functional independence between the RECO and Solitaire groups, confirming the efficacy of the device.…”

Section: Discussionsupporting

confidence: 78%

RECO Flow Restoration Device Versus Solitaire FR With the Intention for Thrombectomy Study (REDIRECT): a prospective randomized controlled trial

Cao

Lin

et al. 2021

Journal of Neurosurgery

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OBJECTIVEThe RECO flow restoration (FR) device is a new stent retriever designed for rapid flow restoration in acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). Here, the authors compared the efficacy and safety of the RECO device with the predicate Solitaire FR stent retriever.METHODSThe RECO Flow Restoration Device Versus Solitaire FR With the Intention for Thrombectomy Study (REDIRECT) was a multicenter, prospective, open randomized controlled trial. Patients with acute LVO at 7 Chinese stroke centers participated in the study. The primary efficacy endpoint was defined as a modified thrombolysis in cerebral infarction (mTICI) reperfusion grade ≥ 2 within three passes. The primary safety endpoint comprised any serious adverse device effect, symptomatic intracerebral hemorrhage (sICH), and any serious adverse event (SAE; defined as cerebral palsy or death) within 24 hours after the procedure. The secondary efficacy endpoints consisted of functional independence (modified Rankin Scale score 0–2), procedure duration, and 90-day all-cause mortality.RESULTSBetween January 2014 and August 2016, 67 patients were randomly allocated to the RECO group and 69 patients to the Solitaire FR group. The primary efficacy endpoint (mTICI grade ≥ 2 within three passes) was similar in the two treatment groups (91% vs 87%, respectively, p = 0.5861), and the rate of reperfusion with an mTICI grade 2b/3 was 87% versus 75% (p = 0.1272). There were no serious adverse device effects in any patient. The rates of sICH (1.5% vs 7.2%, p = 0.1027) and SAEs (6.0% vs 1.4%, p = 0.2050) within 24 hours after the procedure were similar in the two treatment groups. There was no significant difference in the rate of functional independence (63% vs 46%, p = 0.0609) or 90-day all-cause mortality (13% vs 23%, p = 0.1848) or in procedure duration (85.39 ± 47.01 vs 89.94 ± 53.34 minutes, p = 0.5986) between the two groups.CONCLUSIONSThe RECO stent retriever is effective and safe as a mechanical thrombectomy device for AIS due to LVO.Clinical trial registration no.: NCT01983644 (clinicaltrials.gov)

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“…9 Our EVT cohort comprised 69% total anterior cerebral circulation strokes (OCSP TACS) and 24% partial anterior circulation strokes (OCSP PACS), which have median (interquartile range [IQR]) National Institutes of Health Stroke Severity Scores (NIHSS) of 18 (12-21) and 10 (7-15), respectively. 10 In the ESCAPE trial, the median (IQR) NIHSS for EVT-treated patients was 16 (13)(14)(15)(16)(17)(18)(19)(20). Compared with the ESCAPE trial cohort, more of our patients (86% vs 68% in ESCAPE, P ¼ .002) had occlusion of the first segment of the middle cerebral artery (M1) and fewer had occlusion of the distal internal carotid artery; otherwise, the cohorts were similar.…”

Section: Methodsmentioning

confidence: 85%

“…Multiple effectiveness studies of EVT had showed case fatality rates in the range of 20% to 27.9%. [17][18][19][20][21][22] The higher mortality rates in these studies may reflect the practice of providing comfort measures only for patients with severe deficits who do not respond to recanalization therapy. Early mortality after stroke, as seen in real-world studies, is most often attributed to the withdrawal or withholding of life-sustaining measures in light of poor prognosis and severe disabilities.…”

Section: Discussionmentioning

confidence: 99%

Endovascular Thrombectomy for Stroke Effectiveness Study—An Audit From a Small Tertiary Care Center

Virani

Christian

et al. 2020

Can Assoc Radiol J

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Purpose: Endovascular thrombectomy (EVT) treatment for acute ischemic stroke is now recommended as a standard of care. However, implementing EVT in routine clinical practice poses many challenges, even in countries with advanced health-care systems. The aim of the current study is to delineate if EVT at our institution is an effective treatment for acute ischemic stroke. Methods: All patients who underwent EVT at our institution between December 2011 and July 2017 were retrospectively assessed from our prospective registry. Clinical and imaging (including the Alberta Stroke Program Early CT [ASPECT] score, single-phase computed tomography angiography, and computed tomography perfusion) criteria were utilized to determine EVT suitability. Primary outcomes included modified Rankin score (mRS) at 90 days and recanalization determined by the modified Treatment in Cerebral Infarction score. Effectiveness was assessed by comparing our cohort with patients receiving EVT in the ESCAPE (Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke) trial. Results: Eighty-eight patients presented to our hospital after a median of 87 minutes last seen normal. Of these, median ASPECT score was 9. A majority (72%) also received intravenous alteplase. Successful recanalization (≥TICI 2b) was achieved in 79%. At 90 days, 48% (36/75) were functionally independent (mRS score of 0-2) and 28% (21/75) were disabled (mRS score of 3-5); 24% (18/75) died (mRS of 6) within 90 days. Conclusions: An audit of our initial experience with EVT for the treatment of acute ischemic stroke in a small tertiary care center yielded similar results compared to the ESCAPE trial, which is encouraging for implementing this treatment in routine clinical practice.

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Mechanical thrombectomy for anterior circulation stroke: 5-year experience in a statewide service with differences in pretreatment time metrics across two hospitals sites

Abstract: Outcomes similar to randomized controlled trials are attainable in 'real-world' settings. Workflow time metrics were independent predictors of clinical outcome, and differed between the two hospitals owing to site-specific organizational differences.

Cited by 5 publications

References 20 publications

Outcomes of Endovascular Thrombectomy with and without Thrombolysis for Acute Large Artery Ischaemic Stroke at a Tertiary Stroke Centre

Outcomes of Endovascular Thrombectomy with and without Thrombolysis for Acute Large Artery Ischaemic Stroke at a Tertiary Stroke Centre

RECO Flow Restoration Device Versus Solitaire FR With the Intention for Thrombectomy Study (REDIRECT): a prospective randomized controlled trial

Endovascular Thrombectomy for Stroke Effectiveness Study—An Audit From a Small Tertiary Care Center

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