Stent-Retriever Thrombectomy after Intravenous t-PA vs. t-PA Alone in Stroke

PurposeClinically successful endovascular therapy (EVT) in ischemic stroke requires reliable noninvasive pretherapeutic selection criteria. We investigated the association of imaging parameters including CT angiographic collaterals and degree of reperfusion with clinical outcome after EVT.MethodsIn our database, we identified 93 patients with large vessel occlusion in the anterior circulation treated with EVT. Besides clinical data, we assessed the baseline Alberta Stroke Program Early CT score (ASPECTS) on noncontrast CT (NCCT) and CT angiography (CTA) source images, collaterals (CT‐CS) and clot burden score (CBS) on CTA and the degree of reperfusion after EVT on angiography. Three readers, blinded to clinical information, evaluated the images in consensus. Data‐driven multivariable ordinal regression analysis identified predictors of good outcome after 90 days as measured with the modified Rankin Scale.ResultsSuccessful angiographic reperfusion (OR 26.50; 95%‐CI 9.33–83.61) and good collaterals (OR 9.69; 95%‐CI 2.28–59.27) were independent predictors of favorable outcome along with female sex (OR 0.35; 95%‐CI 0.14–0.85), younger age (OR 0.88; 95%‐CI 0.83–0.92) and higher NCCT ASPECTS (OR 2.54; 95%‐CI 1.01–6.63). Outcome was best in patients with good collaterals and successful reperfusion, but there was no statistical interaction between collaterals and reperfusion.Conclusions CTA‐collateral status was the strongest pretherapeutic predictor of favorable outcome in ischemic stroke patients treated with EVT. CTA‐collaterals are thus well suited for patient selection in EVT. However, the independent effect of reperfusion on outcome tended to be stronger than that of CTA‐collaterals.

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“…2015; Saver et al. 2015). This might partially explain the lower rate of good outcome (mRS 0–2 in 31%) in our patients.…”

Section: Discussionmentioning

confidence: 99%

Collateral state and the effect of endovascular reperfusion therapy on clinical outcome in ischemic stroke patients

et al. 2016

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“…Recently it was shown that intra‐arterial treatment (IAT) is highly effective in patients with acute ischemic stroke caused by a proximal intracranial arterial occlusion, and it has revolutionized stroke treatment 1, 2, 3, 4, 5, 6…”

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confidence: 99%

High‐Resolution Imaging of Interaction Between Thrombus and Stent‐Retriever in Patients With Acute Ischemic Stroke

Autar

Hund

Ramlal

et al. 2018

JAHA

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BackgroundCurrently, acute ischemic stroke is still a leading cause of mortality and morbidity. Approximately 2 years ago, mechanical thrombectomy was proven beneficial as a revolutionary new therapy for stroke in the MR‐CLEAN trial (A Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands). However, the mechanisms by which the thrombectomy device, or stent‐retriever, interacts with the thrombus are largely unknown. A better understanding could lead to improved efficacy of mechanical thrombectomy devices.Methods and ResultsSeven stent‐retrievers with thrombi still entrapped were collected directly after thrombectomy. The stent‐retrievers were studied using micro computed tomography, followed by scanning electron microscopy and light microscopy. Two independent observers rated interaction type and thrombus surface structure (porous filamentous or dense) at the interaction sites.A total of 79 interaction sites between thrombus and stent‐retriever were categorized. Thrombus‐stent‐retriever interaction was found to be adhesive (n=44; 56%) or mechanical (n=35; 44%). Adhesive interaction was most frequently observed at interaction sites with a dense surface, compared with interaction sites with a porous filamentous fibrin surface (38/58; 66% versus 6/21; 29%, P=0.011).ConclusionsThe interaction between thrombus and stent‐retriever was predominantly adhesive, not mechanical. Adhesive interaction was strongly associated with the presence of a dense thrombus surface without a porous filamentous fibrin network.

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“…Previous studies have described short‐term (measured at 3 months) clinical benefits post‐IAT (Berkhemer et al., 2015; Campbell et al., 2015; Goyal et al., 2015; Jovin et al., 2015; Saver et al., 2015), and statistically estimated the lifelong cost‐benefits of IAT (Aronsson et al., 2016). We evaluated the long‐term functional outcome and cost utility at 1‐year post‐IAT by stratifying the study sample based on the symptom onset‐to‐recanalization interval.…”

Section: Discussionmentioning

confidence: 99%

“…Intraarterial thrombectomy (IAT) clinically improves patients with acute ischemic stroke by allowing rapid recanalization of occluded intracranial vessels (Berkhemer et al., 2015; Campbell et al., 2015; Goyal et al., 2015; Jovin et al., 2015; Saver et al., 2015). Despite its clinical success, the direct cost‐effectiveness of IAT remains unexplored.…”

Section: Introductionmentioning

confidence: 99%

Cost benefits of rapid recanalization using intraarterial thrombectomy

et al. 2017

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ObjectivesThrombolytic therapy is associated with favorable clinical outcomes after successful and rapid recanalization in patients with acute ischemic stroke. This study aimed to evaluate the cost benefits and clinical outcomes at 1 year after intraarterial thrombectomy (IAT) by the rapidity of the successful recanalization.Materials & MethodsClinical outcomes of and medical costs incurred by 230 patients with acute ischemic stroke who underwent IAT were compared by the rapidity from symptom onset to successful recanalization (2b/3 thrombolysis in cerebral infarction grade): ≤6‐hr (n = 143), >6‐hr (n = 31), and no‐recanalization (n = 56). Clinical outcomes including functional independence (0–2 modified Rankin Score), mortality, and home‐discharge checked at 1 year post‐IAT were compared among the three groups. Cost utility was calculated using quality‐adjusted life years (QALY) estimated using the EuroQol‐5 dimensions‐3 levels questionnaire and the fees paid for institutional rehabilitation during the year post‐IAT, and, was compared among the groups.ResultsPatients in the ≤6‐hr group showed higher functional independence (≤6‐hr, 70%; >6‐hr, 40%; no‐recanalization, 6%, p < .001) and home‐discharge rate (73%, 52%, 21%, and respectively, p < .001), and lower mortality (10%, 16%, and 43%, respectively, p < .001) at 1 year after IAT than other two groups. The cost utility of the ≤6‐hr group was $35,557/QALY higher than that of the >6‐hr group, and $27.829/QALY higher than no‐recanalization group.ConclusionsRapid and successful recanalization of the occluded intracranial vessels within 6 hr after the onset of symptoms resulted in markedly higher cost utility and functional independence at 1 year post‐IAT.

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Stent-Retriever Thrombectomy after Intravenous t-PA vs. t-PA Alone in Stroke

Cited by 4,310 publications

References 29 publications

Collateral state and the effect of endovascular reperfusion therapy on clinical outcome in ischemic stroke patients

Collateral state and the effect of endovascular reperfusion therapy on clinical outcome in ischemic stroke patients

High‐Resolution Imaging of Interaction Between Thrombus and Stent‐Retriever in Patients With Acute Ischemic Stroke

Cost benefits of rapid recanalization using intraarterial thrombectomy

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