Thabele M Leslie-Mazwi

Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging

Background Thrombectomy is currently recommended for eligible patients with stroke who are treated within 6 hours after the onset of symptoms. Methods We conducted a multicenter, randomized, open‐label trial, with blinded outcome assessment, of thrombectomy in patients 6 to 16 hours after they were last known to be well and who had remaining ischemic brain tissue that was not yet infarcted. Patients with proximal middle‐cerebral‐artery or internal‐carotid‐artery occlusion, an initial infarct size of less than 70 ml, and a ratio of the volume of ischemic tissue on perfusion imaging to infarct volume of 1.8 or more were randomly assigned to endovascular therapy (thrombectomy) plus standard medical therapy (endovascular‐therapy group) or standard medical therapy alone (medical‐therapy group). The primary outcome was the ordinal score on the modified Rankin scale (range, 0 to 6, with higher scores indicating greater disability) at day 90. Results The trial was conducted at 38 U.S. centers and terminated early for efficacy after 182 patients had undergone randomization (92 to the endovascular‐therapy group and 90 to the medical‐therapy group). Endovascular therapy plus medical therapy, as compared with medical therapy alone, was associated with a favorable shift in the distribution of functional outcomes on the modified Rankin scale at 90 days (odds ratio, 2.77; P<0.001) and a higher percentage of patients who were functionally independent, defined as a score on the modified Rankin scale of 0 to 2 (45% vs. 17%, P<0.001). The 90‐day mortality rate was 14% in the endovascular‐therapy group and 26% in the medical‐therapy group (P=0.05), and there was no significant between‐group difference in the frequency of symptomatic intracranial hemorrhage (7% and 4%, respectively; P=0.75) or of serious adverse events (43% and 53%, respectively; P=0.18). Conclusions Endovascular thrombectomy for ischemic stroke 6 to 16 hours after a patient was last known to be well plus standard medical therapy resulted in better functional outcomes than standard medical therapy alone among patients with proximal middle‐cerebral‐artery or internal‐carotid‐artery occlusion and a region of tissue that was ischemic but not yet infarcted. (Funded by the National Institute of Neurological Disorders and Stroke; DEFUSE 3 ClinicalTrials.gov number, NCT02586415.)

Interobserver Reliability of Baseline Noncontrast CT Alberta Stroke Program Early CT Score for Intra-Arterial Stroke Treatment Selection

The ASPECTS has been shown to predict outcomes of early ischemic patients after intra-arterial therapy by providing semiquantitative data regarding infarction core. In this article the authors assessed the interobserver reliability of this scale in patients with proximal occlusions. CT studies in 155 patients were retrospectively analyzed by 2 independent observers. Among patients with anterior circulation proximal artery occlusions who were eligible for intra-arterial therapy, interrater reliability for ASPECTS grading was substantial across the entire scale. When using the dichotomized ASPECTS (≤ 7 versus >7) for treatment selection, agreement was only moderate, limiting its utility. In the patient cohort, approximately 25% of treatment decisions would have been affected by interrater reliability. BACKGROUND AND PURPOSE: Early ischemic changes on pretreatment NCCT quantified using ASPECTS have been demonstrated to predict outcomes after IAT. We sought to determine the interobserver reliability of ASPECTS for patients with AIS with PAO and to determine whether pretreatment ASPECTS dichotomized at 7 would demonstrate at least substantial κ agreement. MATERIALS AND METHODS: From our prospective IAT data base, we identified consecutive patients with anterior circulation PAO who underwent IAT over a 6-year period. Only those with an evaluable pretreatment NCCT were included. ASPECTS was graded independently by 2 experienced readers. Interrater agreement was assessed for total ASPECTS, dichotomized ASPECTS (≤7 versus >7), and each ASPECTS region. Statistical analysis included determination of Cohen κ coefficients and concordance correlation coefficients. PABAK coefficients were also calculated. RESULTS: One hundred fifty-five patients met our study criteria. Median pretreatment ASPECTS was 8 (interquartile range 7–9). Interrater agreement for total ASPECTS was substantial (concordance correlation coefficient = 0.77). The mean ASPECTS difference between readers was 0.2 (95% confidence interval, −2.8 to 2.4). For dichotomized ASPECTS, there was a 76.8% (119/155) observed rate of agreement, with a moderate κ = 0.53 (PABAK = 0.54). By region, agreement was worst in the internal capsule and the cortical areas, ranging from fair to moderate. After adjusting for prevalence and bias, agreement improved to substantial or near perfect in most regions. CONCLUSIONS: Interobserver reliability is substantial for total ASPECTS but is only moderate for ASPECTS dichotomized at 7. This may limit the utility of dichotomized ASPECTS for IAT selection.

Elderly Patients Are at Higher Risk for Poor Outcomes After Intra-Arterial Therapy

Background and Purpose— Conflicting data exist regarding outcomes after intra-arterial therapy (IAT) in elderly stroke patients. We compare safety and clinical outcomes of multimodal IAT in elderly versus nonelderly patients and investigate differences in baseline health and disability as possible explanatory factors. Methods— Data from a prospectively collected institutional IAT database were analyzed comparing elderly (80 years or older) versus nonelderly patients. Baseline demographics, angiographic reperfusion (Thrombolysis in Cerebral Infarction scale score 2–3), rate of parenchymal hematoma type 2, and 90-day modified Rankin Scale scores were compared in univariate and multivariate analyses. Results— There were 49 elderly and 130 nonelderly patients treated between 2005 and 2010. Between the 2 cohorts, there was no significant difference in Thrombolysis in Cerebral Infarction 2 to 3 reperfusion (71% vs 75%; P=0.57), time to reperfusion (P=0.77), or rate of parenchymal hematoma type 2 (4% vs 7%; P=0.73) after IAT. However, elderly patients had significantly lower rates of good outcome (modified Rankin Scale score 0–2: 2% vs 33%; P<0.0001) and higher mortality (59% vs 24%; P<0.0001) at 90 days. Atrial fibrillation, coronary artery disease, hypertension, hyperlipidema, and baseline disability were significantly more common in elderly patients. Adjusting for baseline disability, stroke severity, and reperfusion, elderly patients were 29-times more likely to be dependent or dead at 90 days (odds ratio, 28.7; 95% confidence interval, 3.2–255.7; P=0.003). Conclusions— Despite comparable rates of reperfusion and significant hemorrhage, elderly patients had worse clinical outcomes after IAT, which may relate, in part, to worse baseline health and disability. The use of IAT in the elderly should be performed after a careful analysis of the potential risks and benefits.

MACRA: background, opportunities and challenges for the neurointerventional specialist

The legislative branch of government took many by surprise when it announced the Medicare Access and CHIP Reauthorization Act of 2015. Once the Act was passed, President Obama quickly signed this bipartisan, bicameral effort into law. A foundational element of this legislation was the permanent repeal of the sustainable growth rate formula. Physicians and their patients were appropriately enthusiastic about this development. The Medicare Access and CHIP Reauthorization Act of 2015 included additional elements of considerable interest to neurointerventional specialists.

Does the use of IV tPA in the current era of rapid and predictable recanalization by mechanical embolectomy represent good value

As healthcare delivery in the USA transforms into a model that at its core requires value-based considerations, ischemic stroke is confronted by intersecting forces. Modern techniques allow rapid revascularization in the majority of patients with large vessel occlusions. Dramatic advances in the evidentiary basis for mechanical embolectomy are increasing the number of patients treated with this therapy. A key part of the therapeutic arsenal in many patients treated with interventional techniques has been concurrent intravenous thrombolysis. We consider whether this paradigm warrants change.

Door‐to‐Puncture: A Practical Metric for Capturing and Enhancing System Processes Associated With Endovascular Stroke Care, Preliminary Results From the Rapid Reperfusion Registry

Background In 2011, the Brain Attack Coalition proposed door‐to‐treatment times of 2 hours as a benchmark for patients undergoing intra‐arterial therapy (IAT). We designed the Rapid Reperfusion Registry to capture the percentage of stroke patients who meet the target and its impact on outcomes. Methods and Results This is a retrospective analysis of anterior circulation patients treated with IAT within 9 hours of symptom onset. Data was collected from December 31, 2011 to December 31, 2012 at 2 centers and from July 1, 2012 to December 31, 2012 at 7 centers. Short “Door‐to‐Puncture” (D2P) time was hypothesized to be associated with good patient outcomes. A total of 478 patients with a mean age of 68±14 years and median National Institutes of Health Stroke Scale (NIHSS) of 18 (IQR 14 to 21) were analyzed. The median times for IAT delivery were 234 minutes (IQR 163 to 304) for “last known normal‐to‐groin puncture” time (LKN‐to‐GP) and 112 minutes (IQR 68 to 176) for D2P time. The overall good outcome rate was 39.7% for the entire cohort. In a multivariable model adjusting for age, NIHSS, hypertension, diabetes, reperfusion status, and symptomatic hemorrhage, both short LKN‐to‐GP (OR 0.996; 95% CI [0.993 to 0.998]; P<0.001) and short D2P times (OR 0.993, 95% CI [0.990 to 0.996]; P<0.001) were associated with good outcomes. Only 52% of all patients in the registry achieved the targeted D2P time of 2 hours. Conclusions The time interval of D2P presents a clinically relevant time frame by which system processes can be targeted to streamline the delivery of IAT care nationally. At present, there is much opportunity to enhance outcomes through reducing D2P.

Assessing variability in neurointerventional practice patterns for acute ischemic stroke

Background Intra-arterial therapy (IAT) is increasingly used to treat patients with acute stroke with large vessel occlusions. There are minimal data and guidelines for treatment indications and performance standards. We aimed to gain a better understanding of real-world practice patterns for IAT. Methods An internet-based survey was launched to address six specific areas of IAT: practice setting, operator background, operational protocols, quality/safety, decision-making and treatment strategies. The survey invitation was distributed to members of multiple neurointerventional societies. Results Responses from 140 neurointerventionalists worldwide were analyzed. The median annual volume of IAT cases per institution was 40, and the median neurointerventional group size was three staff members. Independent predictors of case volume were presence of comprehensive stroke services and telestroke capability. The median minimum National Institutes of Health Stroke Scale score for treatment consideration was 8, although 60% of respondents reported no minimum score cut-off. There was no strict time window from symptom onset to treatment among 41% of respondents for anterior circulation strokes and among 56% for posterior circulation strokes, instead basing treatment decisions on clinical and imaging findings. Despite the emphasis on imaging-based selection, there was pronounced variability in the criteria used. Only 27% used one imaging approach exclusively. IAT following full- or partial-dose intravenous tissue plasminogen activator was performed by 89%. Mechanical devices were the predominant first-line therapy, but specific device usage depended on practice location. Approximately half preferred conscious sedation during IAT. Conclusions This survey illustrates significant variation among neurointerventionalists in the real-world use of IAT. Our findings highlight the need for evidence-based practice guidelines.

Current procedural terminology; a primer.

In 1966, The American Medical Association (AMA) working with multiple major medical specialty societies developed an iterative coding system for describing medical procedures and services using uniform language, the Current Procedural Terminology (CPT) system. The current code set, CPT IV, forms the basis of reporting most of the services performed by healthcare providers, physicians and non-physicians as well as facilities allowing effective, reliable communication among physician and other providers, third parties and patients. This coding system and its maintenance has evolved significantly since its inception, and now goes well beyond its readily perceived role in reimbursement. Additional roles include administrative management, tracking new and investigational procedures, and evolving aspects of ‘pay for performance’. The system also allows for local, regional and national utilization comparisons for medical education and research. Neurointerventional specialists use CPT category I codes regularly—for example, 36 215 for first-order cerebrovascular angiography, 36 216 for second-order vessels, and 37 184 for acute stroke treatment by mechanical means. Additionally, physicians add relevant modifiers to the CPT codes, such as ‘−26’ to indicate ‘professional charge only,’ or ‘−59’ to indicate a distinct procedural service performed on the same day.

Endovascular Stroke Treatment Outcomes After Patient Selection Based on Magnetic Resonance Imaging and Clinical Criteria

IMPORTANCE Which imaging modality is optimal to select patients for endovascular stroke treatment remains unclear. OBJECTIVE To evaluate the effectiveness of specific magnetic resonance imaging (MRI) and clinical criteria in the selection of patients with acute ischemic stroke for thrombectomy. DESIGN, SETTING, AND PARTICIPANTS In this observational, single-center, prospective cohort study, we studied 72 patients with middle cerebral artery or terminal internal carotid artery occlusion using computed tomographic angiography, followed by core infarct volume determination by diffusion weighted MRI, who underwent thrombectomy after meeting institutional criteria from January 1, 2012, through December 31, 2014. In this period, 31 patients with similar ischemic strokes underwent endovascular treatment without MRI and are categorized as computed tomography only and considered in a secondary analysis. INTERVENTIONS Patients were prospectively classified as likely to benefit (LTB) or uncertain to benefit (UTB) using diffusion-weighted imaging lesion volume and clinical criteria (age, National Institutes of Health Stroke Scale score, time from onset, baseline modified Rankin Scale [mRS] score, life expectancy). MAIN OUTCOMES AND MEASURES The 90-day mRS score, with favorable defined as a 90-day mRS score of 2 or less. RESULTS Forty patients were prospectively classified as LTB and 32 as UTB. Reperfusion (71 of 103 patients) and prospective categorization as LTB (40 of 103 patients) were associated with favorable outcomes (P < .001 and P < .005, respectively). Successful reperfusion positively affected the distribution of mRS scores of the LTB cohort (P < .001). Reperfusion was achieved in 27 LTB patients (67.5%) and 24 UTB patients (75.0%) (P = .86). Favorable outcomes were obtained in 21 (52.5%) and 8 (25.0%) of LTB and UTB patients who were treated, respectively (P = .02). Favorable outcomes were observed in 20 of the 27 LTB patients (74.1%) who had successful reperfusion compared with 8 of the 24 UTB patients (33.3%) who had successful reperfusion (P = .004). The ratio of treated to screened patients was 1:3. CONCLUSIONS AND RELEVANCE Prospective classification as LTB by MRI and clinical criteria is associated with likelihood of favorable outcome after thrombectomy, particularly if reperfusion is successful. Selection of patients using MRI compares favorably with selection using computed tomographic techniques with the distinction that a higher proportion of screened patients were treated.

Stent Retriever Use for Retrieval of Displaced Microcoils: A Consecutive Case Series

SUMMARY: Coil displacement during endovascular coiling procedures may require coil retrieval in the context of flow limitation or thromboembolic risk. No standard recommended method of coil retrieval exists. We present a consecutive series of 14 patients with displaced coil during aneurysm coiling in whom the complication was effectively managed with the use of a stent retriever system. Two illustrative cases from the 14 are described, and technical notes are detailed regarding use of the technique. The use of stent retrievers presents a simple, safe, and effective choice for removal of prolapsed coils during aneurysm coiling.