Anastasios Mpotsaris

Mechanical recanalization in basilar artery occlusion: The ENDOSTROKE study

A study was undertaken to evaluate clinical and procedural factors associated with outcome and recanalization in endovascular stroke treatment (EVT) of basilar artery (BA) occlusion.

Direct aspiration first pass technique for the treatment of acute ischemic stroke: initial experience at a European stroke center

Introduction Over the past decade, endovascular techniques for the treatment of acute ischemic stroke have emerged significantly. However, revascularization rates are limited at approximately 80%, and mechanical thrombectomy procedures still last about 1 h. Therefore, we investigated the novel direct aspiration first pass technique for its efficacy and safety. Methods Our neurointerventional database was screened for patients who received mechanical thrombectomy for acute ischemic stroke using the Penumbra 5MAX ACE aspiration catheter on an intention to treat basis between November 2013 and June 2014. Procedural data, including modified Thrombolysis in Cerebral Infarction (mTICI) score, procedural timings, and complications, as well as clinical data at admission and discharge, were analyzed. Results 54 patients received mechanical thrombectomy using the 5MAX ACE. Median age was 69 (39–94) years (54% were men). Baseline National Institutes of Health Stroke Scale (NIHSS) score was 15 (2–27) and 44/54 (81%) patients received intravenous thrombolysis. Vessel occlusion sites were 91% anterior circulation and 9% posterior circulation. A successful revascularization result (mTICI ≥2b) was achieved in 93% of cases whereas direct aspiration alone was successful in 30/54 (56%) cases; among these, median time from groin puncture to revascularization was 30 min (9–113). Symptomatic intracranial hemorrhage occurred in 2/54 (4%) patients, and embolization to new territories in 3/54 (6%). Median NIHSS at discharge was 6 (0–24); 46% of patients were independent at discharge. Conclusions The direct aspiration first pass technique proofed to be fast, effective, and safe. Promising revascularization results can be achieved quickly in more than 50% of patients using this technique as the firstline option. Nevertheless, stent retrievers are still warranted in approximately 40% of cases to achieve a favorable revascularization result.

Mechanical thrombectomy in severe acute stroke: preliminary results of the Solitaire stent

Intravenous recombinant tissue plasminogen activator (rTPA) therapy has limited recanalisation-rates in large artery occlusions (nadir of 5.9% in Carotid-T-Occlusions).1 Therefore, we prospectively evaluated the Solitaire stent (versions AB and FR, ev3 Inc., Plymouth, Minnesota, USA) in mechanical thrombectomy in acute ischaemic stroke. Acute stroke patients were triaged on admission for potential mechanical thrombectomy. ### Inclusion criteria ### Exclusion criteria Eligible patients had immediate CT-angiography without delaying intravenous rTPA-thrombolysis if applicable according to the guidelines of the German Neurological Society (DGN). In case of occlusion of either the internal carotid artery (ICA), the MCA-M1-segment or the basilar artery (BA) mechanical thrombectomy was carried out. Up to four clot extraction maneuvers were performed. Any preceding stenosis was a priori stented. These patients received intravenous eptifibatide for 24 h to prevent in-stent-thrombosis; its short half-life would allow for emergency decompressive craniectomy. Combination of rTPA and eptifibatide is safe.2 NIHSS and mRS scores were assessed on admission and …

Mechanical Thrombectomy of M2-Occlusion

BACKGROUND There is growing evidence for the efficacy of mechanical thrombectomy in acute stroke patients with large-vessel occlusions in the anterior circulation. Although distal occlusions of the middle cerebral artery (MCA) can cause severe clinical symptoms, endovascular therapy is not considered here as the first choice. The aim of our study was to prove the efficacy and safety of mechanical thrombectomy for distal occlusion types in the anterior circulation (M2-segment). METHODS Stentretriever-based thrombectomy was performed in 119 patients with acute MCA occlusions between October 2011 and April 2013: 104 (87.4%) were M1- and 15 (12.6%) M2-occlusions. These groups were compared with regard to recanalization success, periprocedural complications, hemorrhage, and modified Rankin Scale (mRS) at 90 days. RESULTS Thrombolysis in cerebral infarction 2b/3 reperfusion was more frequent in M2- than in M1-occlusions (93.3% versus 76.0%; P = .186). There was no significant difference in the mean National Institutes of Health Stroke Scale between the M1- and the M2-group both at admission and at discharge (16.18 ± 7.30 versus 13.73 ± 8.30, P = .235; 9.36 ± 8.60 versus 7.43 ± 9.84, P = .446). A good clinical outcome (mRS 0-2) at 3 months was more frequent in the M2-group (60% versus 43.3%; P = .273) and mortality was higher in the M1-group (21.2% versus 6.7%; P = .297). There were 3 periprocedural complications in the M1- and none in the M2-group. CONCLUSIONS Endovascular treatment of M2-occlusions in severely affected patients is not associated with a higher procedural risk or postprocedural hemorrhage. Compared with M1-occlusions, there was a greater chance for a good angiographic and clinical result in our case series. Therefore, stentretriever-based thrombectomy should also be considered for patients with severe symptoms because of an acute M2-occlusion.

Emergency Stenting of the Extracranial Internal Carotid Artery in Combination with Anterior Circulation Thrombectomy in Acute Ischemic Stroke: A Retrospective Multicenter Study

BACKGROUND AND PURPOSE: Several small case series reported a favorable clinical outcome for emergency stent placement in the extracranial internal carotid artery combined with mechanical thrombectomy in acute stroke. The rate of postinterventional symptomatic intracranial hemorrhages was reported to be as high as 20%. Therefore, we investigated the safety and efficacy of this technique in a large multicentric cohort. MATERIALS AND METHODS: The data bases of 4 German stroke centers were screened for all patients who received emergency stent placement of the extracranial internal carotid artery in combination with mechanical thrombectomy of the anterior circulation between 2007 and 2014. The primary outcome measure was the rate of symptomatic intracranial hemorrhage according to the European Cooperative Acute Stroke Study III criteria; secondary outcome measures included the angiographic revascularization results and clinical outcome. RESULTS: One hundred seventy patients with a median age of 64 years (range, 25–88 years) were treated. They presented after a median of 98 minutes (range, 52–160 minutes) with a median NIHSS score of 15 (range, 12–19). Symptomatic intracranial hemorrhages occurred in 15/170 (9%) patients; there was no statistically significant difference among groups pertaining to age, sex, intravenous rtPA, procedural timings, and the rate of successful recanalization. In 130/170 (77%) patients, a TICI score of ≥2b could be achieved. The in-hospital mortality rate was 19%, and 36% of patients had a favorable outcome at follow-up. CONCLUSIONS: Emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy is effective and safe. It is not associated with a significantly higher risk of symptomatic intracranial hemorrhage compared with published series for mechanical thrombectomy alone.

First-line lesional aspiration in acute stroke thrombectomy using a novel intermediate catheter: Initial experiences with the SOFIA

Introduction Five randomized controlled trials (RCTs) on endovascular therapy (EVT) of stroke have proven a clinical benefit over conservative treatment or IV-thrombolysis alone. Lesional clot aspiration with a dedicated system can achieve revascularization without an additional retriever (a direct-aspiration first-pass technique, ADAPT), and the SOFIA has been shown to be both safe and efficacious in a multicentric retrospective study. We have evaluated a subset of these data acquired in two major stroke centers with regard to using the SOFIA for first-line lesional aspiration. Methods Thirty patients with large-vessel occlusions treated with first-line lesional aspiration were identified. Procedural data, clot length, reperfusion success (mTICI), procedural timings, complications, and clinical status at admission, discharge and at 90 days were analyzed. Results The median baseline NIHSS was 16. IV thrombolysis was administered in 15/30 patients. Ninety-three percent of occlusions were in the anterior circulation. TICI ≥ 2b was achieved in 90% of multimodality treatments; lesional aspiration was successful in 67% within a median time of 20 minutes. The highest first-attempt success rate was in MCA occlusions (median time to recanalization 10 minutes). There were no device-related events. Symptomatic intracerebral hemorrhage (sICH) occurred in 10%, but never with sole lesional aspiration. Embolization to new territories was recorded in 1/30 (3%). Median discharge NIHSS was 7; 30% were mRS ≤ 2 at discharge and 43% at 90-day follow-up. Conclusions Lesional aspiration with SOFIA is in line with published data. The SOFIA may be used as a first-line device, aiming at fast recanalization by sole aspiration with good safety and efficacy. If unsuccessful, it converts into part of a stent retriever-based multimodality treatment.

Initial experience with a new distal intermediate and aspiration catheter in the treatment of acute ischemic stroke: clinical safety and efficacy

Purpose To describe our initial experience with the novel 5 F SOFIA (Soft Torqueable catheter Optimized For Intracranial Access) intermediate and aspiration catheter for endovascular treatment of patients with acute ischemic stroke. Methods A retrospective review was performed in three centers of prospectively collected data of all stroke patients who underwent endovascular therapy using the SOFIA catheter. Patients were enrolled between November 2013 and December 2014. The primary endpoint of the study was accessibility of the thrombus with the SOFIA catheter. As a secondary endpoint, the study assessed recanalization success (Thrombolysis In Cerebral Infarction (TICI) ≥2b). Clinical presentation on admission and discharge was also documented. In addition, catheter- and procedure-related complications (particularly thromboembolic complications) were recorded. Results The SOFIA catheter was used in 115 acute stroke procedures. In 110 cases (96%) the catheter could be advanced to the occlusion site. After mechanical thrombectomy, successful recanalization (TICI ≥2b) was documented in 86.9%. There were no complications related to positioning of the catheter. Distal thrombus migration into a new vascular territory occurred in three patients following thrombectomy with a stent retriever (2.6%). The mean NIH Stroke Scale (NIHSS) score on admission was 16.8±6 and at discharge the mean NIHSS score was 8.2±7.7. Sixteen patients died. Conclusions The SOFIA catheter is a safe and efficient catheter for endovascular stroke therapy.

Multicenter clinical experience in over 125 patients with the Penumbra Separator 3D for mechanical thrombectomy in acute ischemic stroke

Background The aim of this study was to assess reperfusion and clinical outcome of treatment with the self-expanding retrievable Separator 3D in revascularization of acute ischemic stroke. The three-dimensional (3D) device secures thrombus with direct aspiration and supports debulking of the clot. Methods At two centers, 129 consecutive stroke patients with National Institutes of Health Stroke Scale (NIHSS) scores ≥5 were treated with mechanical thrombectomy using the Separator 3D as a component of the Penumbra System within 8 h of symptom onset; modified Treatment in Cerebral Infarction (mTICI) revascularization scores, NIHSS score on admission and discharge, mortality rates, and modified Rankin Scale (mRS) outcomes at 90 days were evaluated. Results A total of 129 vessels in 129 patients were treated. Occlusions were located in the middle cerebral artery (MCA, 48%), internal carotid artery (ICA, 33%), cervical ICA–MCA (3%), and vertebrobasilar arteries (16%). Intravenous thrombolytic therapy with recombinant tissue plasminogen activator was given to 78% of patients. Median NIHSS was 15 prior to treatment. Reperfusion to mTICI 2b or 3 was successful in 96/129 (74%) target arterial lesions, with more than half of cases (51%) achieving mTICI 3. The mean time from arterial puncture to revascularization was 65 min. At 90 days, the symptomatic intracranial hemorrhage rate was 4%, all cause mortality was 32%, and 43/99 patients (43%) achieved functional independence with an mRS score of ≤2. Conclusions The results suggest that the Separator 3D enables safe and effective revascularization of occluded large arteries in acute stroke intervention, leading to a high rate of functional independence at 90 days.

Intravenous Thrombolysis Facilitates Successful Recanalization with Stent-Retriever Mechanical Thrombectomy in Middle Cerebral Artery Occlusions

AIM Several factors influence the outcome after acute ischemic stroke secondary to proximal occlusions of cerebral vessels. Among others, noneligibility for intravenous thrombolysis (IVT) and incomplete revascularization have been identified as predictors of unfavorable outcome. The aim of this study was to investigate whether concomitant IVT influences the revascularization efficacy in mechanical thrombectomy (MT). METHODS This study conducted a retrospective analysis of all consecutive patients presenting with an anterior circulation stroke due to large-artery occlusion with imaging evidence who were treated with MT between July 2012 and December 2013 at 2 high-volume stroke centers. Imaging data were regraded and re-evaluated according to the modified Treatment in Cerebral Ischemia scale and its respective vessel occlusion site definitions. Clinical end points included National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale; imaging and procedural measures were technical end points. RESULTS We identified 93 patients who presented with an occlusion of the middle cerebral artery (MCA): of these patients, 66 (71%) received IVT. We did not find statistically significant differences in the baseline NIHSS score, time from symptom onset to groin puncture, and age when comparing the IVT group with the non-IVT group. The rate of successful recanalizations (modified Treatment in Cerebral Ischemia score ≥ 2b) was significantly higher in patients with MCA occlusion and concomitant IVT (P = .01). Stepwise logistic regression identified IVT and thrombus length as predictive factors for successful mechanical recanalization (P = .004, P = .002). CONCLUSION IVT and thrombus length are predictive factors for a successful recanalization in MT for acute ischemic stroke with underlying MCA occlusion.

M1 is not M1 in ischemic stroke: the disability-free survival after mechanical thrombectomy differs significantly between proximal and distal occlusions of the middle cerebral artery M1 segment

Aims Recent recommendations on the designation of target artery lesions in acute ischemic stroke include the anatomical differentiation between a proximal and a distal occlusion site of the M1 segment of the middle cerebral artery (MCA). The aim of this study was to evaluate whether these occlusion types differ in terms of a disability-free (modified Rankin Scale (mRS) 0 or 1) clinical outcome at 90 days. Methods A retrospective analysis was performed of all patients with MCA M1 occlusions who had a successful revascularization result after mechanical thrombectomy between October 2009 and September 2013 and for whom follow-up at 90 days was available. Imaging data were regraded and re-evaluated according to the modified Thrombolysis In Cerebral Infarction (mTICI) scale and the respective vessel occlusion site definitions. Outcome measures included National Institutes of Health Stroke Scale (NIHSS), mRS, Alberta Stroke Program Early CT Score (ASPECTS) scoring and procedural timings. Results 62 patients were successfully recanalized; follow-up at 90 days was available for 42/62 patients (68%). There were proximal MCA occlusions in 24/42 patients (57%) and distal occlusions in 18/42 (43%). Baseline NIHSS, ASPECTS, procedural timings and final mTICI scores did not differ significantly between proximal and distal M1 occlusions. There was a statistically significant difference between proximal and distal M1 occlusions regarding a disability-free early outcome (mRS 0 or 1) at discharge (p=0.03) and at 90 days (p=0.04). Conclusions Proximal occlusions of the M1 segment of the MCA incorporating the lenticulostriate perforators are associated with a poorer clinical outcome than distal M1 occlusions that spare these perforators. Involvement of these perforators might become an additional predictor of clinical outcome after mechanical thrombectomy in ischemic stroke.