RESUMO

BACKGROUND AND PURPOSE: Intravenous Thrombolysis (IVT) prior to Mechanical Thrombectomy (MT) for Acute Ischaemic Stroke (AIS) due to Large-Vessel Occlusion (LVO) remains controversial. Therefore, the authors performed a meta-analysis of the available real-world evidence focusing on the efficacy and safety of Bridging Therapy (BT) compared with direct MT in patients with AIS due to LVO. METHODS: Four databases were searched until 01 February 2023. Retrospective and prospective studies from nationwide or health organization registry databases that compared the clinical outcomes of BT and direct MT were included. Odds Ratios (ORs) and 95 % Confidence Intervals (CIs) for efficacy and safety outcomes were pooled using a random-effects model. RESULTS: Of the 12 studies, 86,695 patients were included. In patients with AIS due to LVO, BT group was associated with higher odds of achieving excellent functional outcome (modified Rankin Scale score 0-1) at 90 days (OR = 1.48, 95 % CI 1.25-1.75), favorable discharge disposition (to the home with or without services) (OR = 1.33, 95 % CI 1.29-1.38), and decreased mortality at 90 days (OR = 0.62, 95 % CI 0.56-0.70), as compared with the direct MT group. In addition, the risk of symptomatic intracranial hemorrhage did not increase significantly in the BT group. CONCLUSION: The present meta-analysis indicates that BT was associated with favorable outcomes in patients with AIS due to LVO. These findings support the current practice in a real-world setting and strengthen their validity. For patients eligible for both IVT and MT, BT remains the standard treatment until more data are available.

Assuntos

RESUMO

Abstract Background and purpose Intravenous Thrombolysis (IVT) prior to Mechanical Thrombectomy (MT) for Acute Ischaemic Stroke (AIS) due to Large-Vessel Occlusion (LVO) remains controversial. Therefore, the authors performed a meta-analysis of the available real-world evidence focusing on the efficacy and safety of Bridging Therapy (BT) compared with direct MT in patients with AIS due to LVO. Methods Four databases were searched until 01 February 2023. Retrospective and prospective studies from nationwide or health organization registry databases that compared the clinical outcomes of BT and direct MT were included. Odds Ratios (ORs) and 95 % Confidence Intervals (CIs) for efficacy and safety outcomes were pooled using a random-effects model. Results Of the 12 studies, 86,695 patients were included. In patients with AIS due to LVO, BT group was associated with higher odds of achieving excellent functional outcome (modified Rankin Scale score 0-1) at 90 days (OR = 1.48, 95 % CI 1.25-1.75), favorable discharge disposition (to the home with or without services) (OR = 1.33, 95 % CI 1.29-1.38), and decreased mortality at 90 days (OR = 0.62, 95 % CI 0.56-0.70), as compared with the direct MT group. In addition, the risk of symptomatic intracranial hemorrhage did not increase significantly in the BT group. Conclusion The present meta-analysis indicates that BT was associated with favorable outcomes in patients with AIS due to LVO. These findings support the current practice in a real-world setting and strengthen their validity. For patients eligible for both IVT and MT, BT remains the standard treatment until more data are available.

RESUMO

Introduction: Thrombectomy is the standard treatment for anterior circulation stroke due to large vessel occlusions in a late time window (6 to 24 hours) for patients selected based on perfusion imaging. Most patients treated in late time window studies presented as unwitnessed or wake-up strokes. Whether patients presenting with unwitnessed stroke have an actual time window greater than 6 hours is unclear. The aim of this study was to assess the outcomes of thrombectomy in the treatment of patients presenting with anterior circulation large vessel stroke in an actual late time window of more than 6 hours. Methods: This single-center registry of thrombectomy in the treatment of stroke caused by anterior circulation large vessel occlusions (LVOs) included 430 patients treated between 2011 and 2019. Patients were divided into 2 groups: an early time window (≤ 6 hours) group and a late time window group (> 6 hours). Results: Outcomes of the early and the late time window groups, respectively, were recanalization of 86.8% vs 82.7% (P = .29), symptomatic intracranial hemorrhage of 8.2% vs 5.7% (P = .40), good clinical outcome of 45.4% vs 41.3% (P = .46), and mortality of 20.2% vs 25% (P = .30) at 3 months. Conclusions: Thrombectomy for anterior circulation large vessel occlusions after 6 hours of symptoms onset seems to be as safe and effective as the standard thrombectomy within 6 hours from symptoms onset, even without perfusion analysis. Randomized trials are needed to confirm these findings.

RESUMO

The effectiveness of endovascular thrombectomy in patients presenting low National Institutes of Health Stroke Scale (NIHSS) scores remains controversial, and the acquisition of additional evidence is required to refine the selection of candidates who may benefit the most from this therapeutic modality. In this study, we present the case of a 62-year-old individual, with left internal carotid occlusion stroke and low NIHSS, who had compensatory collateral flow from Willis polygon via the anterior communicating artery. The patient subsequently exhibited neurological deterioration and collateral flow failure from Willis polygon, indicating the need for urgent intervention. The study of collaterals in patients with large vessel occlusion stroke has garnered considerable attention, with research suggesting that individuals with low NIHSS scores and poor collateral profiles may be at a heightened risk of early neurological deterioration. We postulate that such patients may derive significant benefits from endovascular thrombectomy, and may posit that an intensive transcranial Doppler monitoring protocol could facilitate the identification of suitable candidates for such intervention.

RESUMO

OBJECTIVES: Our goal was to describe outcomes in a single-center, real-world series of patients with acute basilar artery occlusion in a middle-income country. In addition, we assessed potential outcome predictors. MATERIAL AND METHODS: Data from 28 patients were retrospectively reviewed. The primary outcome was death until last follow-up. Other outcomes were rates of favorable outcome until last follow-up and rates of intracranial hemorrhage. Outcomes were compared in subgroups according to several variables, including reperfusion (REP group) or no reperfusion (NOREP group) interventions, with chi-squared, Fisher's exact test, or Mann-Whitney tests. RESULTS: The rate of overall intrahospital death was 46%. Death until last follow-up occurred in 8/17 (47%) in the REP and in 7/11 (63%) of the NOREP group. Favorable outcomes were observed in 35.7% of the patients: 8/17 (47%) in REP and in 2/11 (18.1%) in NOREP. NIH stroke scale scores were significantly lower in patients with favorable outcomes. Intracranial hemorrhage was observed in 6/28 (21.4%) of the patients (all in REP group). Twenty patients were treated with anticoagulants within the first 24 h. No hemorrhage was observed in those treated with enoxaparin, while three occurred in subjects treated with unfractionated heparin. CONCLUSION: Together with other series, our results underscore the relevance of NIH stroke scale at admission as a prognostic marker, the importance of reperfusion to improve outcomes, and the need of clinical trials to compare the impact of treatment with anticoagulants within first 24 h in basilar artery occlusion.

Assuntos

RESUMO

INTRODUCTION: The benefits of mechanical thrombectomy in the treatment of patients with acute stroke due to large vessel occlusions (LVOs) have been extensively demonstrated by randomized trials and registries in developed countries. However, data on thrombectomy outside controlled trials are scarce in developing countries. The aim of this study was to assess the safety and efficacy, and to investigate the predictors for good and poor outcomes of thrombectomy for treatment of AIS due to anterior circulation LVOs in Brazil. MATERIALS AND METHODS: This was a single center registry of thrombectomy in the treatment of stroke caused by anterior circulation LVOs. Between 2011 and 2019, a total of 565 patients were included. RESULTS: the mean baseline NIHSS score on admission was 17.2. The average baseline ASPECTS was 8, and 91.0% of patients scored ≥6. Half of the patients received intravenous thrombolysis. The mean time from symptom onset to arterial puncture was 296.4 minutes. The mean procedure time was 61.4 minutes. The rates of the main outcomes were recanalization (TICI 2b-3) 85.6%, symptomatic intracranial hemorrhage (sICH) 8,1%, good clinical outcome (mRS=0-2) 43,5%, and mortality 22.1% at three months. CONCLUSIONS: This study demonstrates the efficacy and safety of mechanical thrombectomy for treatment of patients with AIS of the anterior circulation in real-life conditions under limited facilities and resources. The results of the present study were relatively similar to those of large trials and population registers of developed countries.

Assuntos

RESUMO

BACKGROUND: Assessment of the impact of the thrombectomy learning curve on clinical outcomes is essential for developing healthcare system protocols. AIMS: The aim of this study was to assess the effect of thrombectomy case volume on procedural and clinical outcomes in a Brazilian registry. METHODS: A total of 645 patients with acute ischemic stroke treated by thrombectomy were included in the analysis. Patients were divided into two groups regarding the period of treatment: the early period group and the late period group. RESULTS: In the adjusted analysis, treatment in the late period was an independent predictor of recanalization (odds ratio 1.91, 95% CI 1.28-2.86) and excellent neurologic outcomes at three months (odds ratio 1.77, 95% CI 1.04-3.01). Treatment in the late period had no significant association with mortality (odds ratio 0.88, 95% CI 0.55-1.41). CONCLUSIONS: An increase in thrombectomy case volume for the treatment of AIS over time was an independent predictor of recanalization and excellent neurologic outcome.

Assuntos

RESUMO

The social and financial burden of stroke is remarkable. Stroke is a leading cause of death and long-term disability worldwide. For several years, intravenous recombinant tissue plasminogen activator (IV rt-PA) remained as the only proven therapy for acute ischemic stroke. However, its benefit is hampered by a narrow therapeutic window and limited efficacy for large vessel occlusion (LVO) strokes. Recent trials of endovascular therapy (EVT) for LVO strokes have demonstrated improved patient outcomes when compared to treatment with medical treatment alone (with or without IV rt-PA). Thus, EVT has become a critical component of stroke care. As in IV rt-PA, time to treatment is a crucial factor with high impact on outcomes. Unlike IV rt-PA, EVT is only available at a limited number of centers. Considering the time sensitive benefit of reperfusion therapies of acute ischemic stroke, costs and logistics associated, it is recommended that regional systems of acute stroke care should be developed. These should include rapid identification of suspected stroke, centers that provide initial emergency care, including administration of IV rt-PA, and centers capable of performing endovascular stroke treatment with comprehensive periprocedural care to which rapid transport can be arranged when appropriate. In the pre-hospital setting, the development of scales easier and quicker to perform than the NIHSS yet with a maintained accuracy for detecting LVO strokes is of paramount importance. Several scales have been developed. On the other hand, the decision whether to transport to a primary stroke center (PSC) or to a comprehensive stroke center (CSC) is complex and far beyond the simple diagnosis of a LVO. Ongoing studies will provide important answers to the best transfer strategy for acute stroke patients. At the same time, the development of new technologies to aid in real time the decision-making process will simplify the logistics of regional systems for acute stroke care and, likely improve patients' outcomes through tailored selection of the most appropriate recanalization strategy and destination center.

RESUMO

BACKGROUND AND PURPOSE: Automated computed tomography perfusion (CTP) is recommended to inform selection of stroke patients for thrombectomy >6 hours from last known normal (LKN). However, artifacts on automated perfusion output may overestimate the tissue at risk leading to misclassification of thrombectomy eligibility in some patients. METHODS: We conducted a retrospective multisite study of consecutive patients with anterior large vessel occlusion (LVO) undergoing CTP (6/2017-12/2017). The primary outcome was the RAPID automated Tmax  > 6 seconds volume that was discordant with clinical symptoms and vessel imaging, manually assessed by two independent readers. The discordant penumbral volume was compared to the automated output and corrected mismatch ratios were generated. RESULTS: Of 410 consecutive patients who underwent CTP for suspected stroke, 60 (15%) had acute anterior circulation LVO. Of these, 26 (43%) had Tmax > 6 seconds abnormalities discordant with clinical symptoms and vessel imaging. There was strong interrater agreement on artifact volume (r2 = 0.927). Among patients with discordant Tmax imaging, the median artifactual volume was 12cc (IQR 3-21cc), accounting for a median of 8% of the automated Tmax > 6 seconds volume (IQR 3-16%, range 1-64%). Recalculation of the Tmax > 6 seconds volume resulted in 1 patient being reclassified as having an "unfavorable" mismatch ratio (2.04-1.40). CONCLUSION: Nearly half of patients had evidence of artifactual penumbral imaging on automated CTP, which rarely lead to misclassification of thrombectomy eligibility. Although artifactual findings are reliably identified by trained raters, our results emphasize the need to evaluate CTP results with knowledge of the patient's clinical symptoms and vascular imaging.

Assuntos