Jan Vargas

Comparison of endovascular treatment approaches for acute ischemic stroke: cost effectiveness, technical success, and clinical outcomes

Introduction The use of mechanical thrombectomy for the treatment of acute ischemic stroke has significantly advanced over the last 5 years. Few data are available comparing the cost and clinical and angiographic outcomes associated with available techniques. The aim of this study is to compare the cost and efficacy of current endovascular stroke therapies. Methods A single-center retrospective review was performed of the medical record and hospital financial database of all ischemic stroke cases admitted from 2009 to 2013. Three discrete treatment methodologies used during this time were compared: traditional Penumbra System (PS), stent retriever with local aspiration (SRLA) and A Direct Aspiration first Pass Technique (ADAPT). Statistical analyses of clinical and angiographic outcomes and costs for each group were performed. Results 222 patients (45% men) underwent mechanical thrombectomy. Successful revascularization was defined as Thrombolysis In Cerebral Infarction (TICI) 2b/3 flow, which was achieved in 79% of cases with PS, 83% of cases with SRLA, and 95% of cases with ADAPT. The average total cost of hospitalization for patients was

Long term experience using the ADAPT technique for the treatment of acute ischemic stroke

51 599 with PS,

Proximal to distal approach in the treatment of tandem occlusions causing an acute stroke

54 700 with SRLA, and

The golden hour of stroke intervention: effect of thrombectomy procedural time in acute ischemic stroke on outcome

33 611 with ADAPT (p<0.0001). Average times to recanalization were 88 min with PS, 47 min with SRLA, and 37 min with ADAPT (p<0.0001). Similar rates of good functional outcomes were seen in the three groups (PS 36% vs SRLA 43% vs ADAPT 47%; p=0.4). Conclusions The ADAPT technique represents the most technically successful yet cost-effective approach to revascularization of large vessel intracranial occlusions.

An investigation of the cost and benefit of mechanical thrombectomy for endovascular treatment of acute ischemic stroke

Introduction The direct aspiration first pass technique (ADAPT) has been introduced as a simple and fast method for achieving good angiographic and clinical outcomes using large bore aspiration catheters for the treatment of acute ischemic stroke (AIS). We present a single centers long term experience with ADAPT. Methods Retrospective analysis of a database was gathered on patients undergoing stroke thrombectomy with ADAPT at a stroke center. Specific parameters captured included age, gender, National Institutes of Health Stroke Scale (NIHSS) score at presentation, time to presentation from last normal, and modified Rankin Scale (mRS) score at the 90 day follow-up. Radiological and angiographic imaging was reviewed to document the location of the vascular occlusion, Thrombolysis in Cerebral Infarction (TICI) flow postprocedure, and procedural complications. Results 191 consecutive patients who suffered an AIS treated with ADAPT were reviewed; 91 were women, and mean age was 67 years. Patients presented with a mean NIHSS score of 15.4, and 71 patients received intravenous tissue plasminogen activator. The average time from onset to puncture was 7.8 h. The average time for recanalization was 37.3 min. TICI 2B or better recanalization was achieved in 180 (94.2%) patients. 98 (54.1%) patients had an mRS of 0–2 at 90 days. Direct aspiration alone was performed in 145 cases, and 43 cases required the additional use of a stent retriever. There was no significant difference in presenting NIHSS score, average time to presentation, average mRS at 90 days, or 90 day mortality between the two groups. Time to recanalization was 29.6 min for direct aspiration compared with 61.4 min in cases that required adjunct devices (p=0.00000201). 79 (57.7%) patients who underwent direct aspiration only achieved a good outcome at 90 days (mRS 0–2) compared with 19 (43.2%) who underwent adjunct therapies (p=0.12). Conclusions ADAPT is an effective method to achieve good clinical and angiographic outcomes, and serves as a useful firstline method for revascularization.

Hounsfield unit value and clot length in the acutely occluded vessel and time required to achieve thrombectomy, complications and outcome

Introduction A tandem occlusion is a rare presentation of acute stroke that involves an occlusion of the internal carotid artery at the bifurcation with an intracranial middle cerebral artery occlusion. This study describes the experience at our institution in treating tandem occlusions with a proximal to distal approach in the acute stroke setting. Methods A retrospective review of acute strokes caused by tandem occlusions requiring thrombectomy were performed. Results 16 cases were identified with a mean National Institutes of Health Stroke Scale score at presentation of 13.1±3.9. The proximal occlusion was crossed initially with a microwire in all cases. All carotid occlusions were treated with stenting, and intracranial vessel thrombectomy was performed with a variety of devices. Procedure related complications occurred in two (12.5%) patients. Eight patients (50%) achieved a good outcome (modified Rankin Scale score of 0–2). Conclusions A tandem occlusion of the carotid artery at the bifurcation with a concomitant intracranial occlusion is a relatively rare and complex presentation of acute stroke. We have found that addressing the proximal lesion first and covering it with a stent prior to performing distal thrombectomy appears to be a safe and effective option in the treatment algorithm.

Initial multicenter technical experience with the Apollo device for minimally invasive intracerebral hematoma evacuation.

Introduction Outcome studies in acute ischemic stroke (AIS) have focused on time from symptom onset to treatment. The purpose of this study was to investigate whether time to achieve vessel recanalization from groin puncture affects outcomes. Methods We studied all AIS cases that underwent intra-arterial therapy between May 2008 and October 2012 at a high volume center for anterior circulation occlusions. Candidacy for thrombectomy is determined by CT perfusion imaging, irrespective of time of onset. Patients were then dichotomized into two groups: ‘Early recan’ assigned in which recanalization was achieved in ≤60 min from groin puncture and ‘Delayed recan’ in which procedures extended beyond 60 min. Time to recanalize was also studied as a continuous variable. Results 159 patients (53.5% women, mean age 66.4±15.2 years) were identified. The mean National Institutes of Health Stroke Scale (NIHSS) score was similar between ‘Early recan’ patients (16.8±6.1) compared with ‘Delayed recan’ patients (15.4±5.8, p=0.149). Among the ‘Early recan’ patients, recanalization was achieved in 40.7±13.6 min compared with 101.7±32.5 min in the ‘Delayed recan’ patients (p<0.0001). The likelihood of achieving a good outcome (modified Rankin Scale score 0–2) was higher in the ‘Early recan’ group (53.6%) compared with the ‘Late recan’ group (30.8%; p=0.009). On logistic regression analysis, time to recanalization from groin puncture, baseline NIHSS, revascularization, diabetes, and hemorrhages were found to significantly impact on outcome at 90 days, as measured by the modified Rankin Scale. Conclusions Our findings suggest that extending mechanical thrombectomy procedure times beyond 60 min increases complications and device cost rates while worsening outcomes. These findings can serve as a time frame of when it is prudent to abort a failed thrombectomy case.

Balloon augmented Onyx embolization utilizing a dual lumen balloon catheter: utility in the treatment of a variety of head and neck lesions

Introduction The use of mechanical thrombectomy for the treatment of acute ischemic stroke has significantly advanced over the past 5 years, with few available data. The aim of this study was to analyze the cost and benefit of mechanical thrombectomy devices utilized during endovascular therapy of ischemic stroke patients. Methods A retrospective chart review of patients that underwent intra-arterial stroke interventions was conducted. Clinical, angiographic, all devices used, procedural and postprocedural event and outcome data were collected. Thrombectomy devices were categorized as Penumbra aspiration system thrombectomy (group P) or stent retriever (group S). Statistical analysis of outcomes and costs for each group was performed. Results 171 patients underwent mechanical thrombectomy. The Penumbra aspiration system was able to primarily achieve recanalization in 41.7% and the stent retriever in 70.4% of the time (p=0.006). The average cost was

Balloon-augmented Onyx embolization of cerebral arteriovenous malformations using a dual-lumen balloon: a multicenter experience

11 159 and

Lenticulostriate aneurysms: a case series and review of the literature

16 022 (p=0.0002) in groups P and S, respectively. Average time to recanalization for group P was 85.1 min and for group S, 51.6 min (p<0.0001). Procedural complications were more frequent with the stent retriever (11.1% vs 9.0%; p=0.72) as were periprocedural significant complications (14.8 v 3%; p=0.04). Successful recanalization rates (Thrombolysis in Cerebral Infarction score 2b-3) were the same in groups P and S (78.5 vs. 77.8%). Similar rates of good neurologic outcomes were seen in group P (36.4%) and group S (50.0%) (p=0.19). Conclusions For the treatment of acute stroke patients, the use of aspiration appears to be the most cost effective method to achieve acceptable recanalization rates and low complication rates. Stent retriever with local aspiration, despite higher costs and complication rates, yielded better overall outcome.