Delayed functional independence after thrombectomy: temporal characteristics and predictors.

BACKGROUND: Variability in early neurological improvement after endovascular thrombectomy (EVT) for large vessel occlusion (LVO) stroke is well documented. Understanding the temporal progression of functional independence after EVT, especially delayed functional independence in patients who do not experience early improvement, is essential for prognostication and rehabilitation. OBJECTIVE: To determine the incidence of early and delayed functional independence and identify associated predictors after EVT. METHODS: A retrospective analysis of prospectively collected data on patients undergoing EVT in the setting of anterior circulation LVO was performed. Demographic, clinical, radiological, treatment, and procedural information were analyzed. Incidence and predictors of early functional independence (EFI, modified Rankin Scale (mRS) score 0-2 at discharge) and delayed functional independence (DFI, mRS score 0-2 at 90 days in non-EFI patients) were analyzed. RESULTS: Three hundred and fifty-five patients met the study criteria. 55% were women and mean age was 71±15. Mean National Institutes of Health Stroke Scale (NIHSS) score was 17±6 and median Alberta Stroke Program Early CT Score was 9 (8-10). EFI was observed in 21% (73) of patients. Among non-EFI patients (282), DFI was observed in 30% (85) of patients. Shorter time to treatment (p=0.03), lower 24 hours NIHSS score (p<0.001), and smaller follow-up infarct volume (p=0.003) were independent predictors of EFI. Younger age (p=0.011), lower 24 hours NIHSS score (p=0.001), and absence of parenchymal hemorrhage (PH2; p=0.039) were independent predictors of DFI. CONCLUSION: Approximately one-fifth of patients experience EFI and one-third of non-early improvers experience DFI. Younger age, lower 24 hours NIHSS score, and absence of parenchymal hemorrhage were independent predictors of DFI among non-early improvers. Further studies are required to improve our understanding of DFI.

Relationship between reperfusion and intracranial hemorrhage after thrombectomy.

INTRODUCTION: Symptomatic intracerebral hemorrhage (sICH) is a devastating complication after endovascular thrombectomy. Prior reports have demonstrated that thrombolysis in cerebral infarction (TICI) ≥2 b reperfusion is protective against sICH. We aimed to further examine the relationship between reperfusion grade and sICH, to elucidate whether a difference between TICI 2b and 3 exists, and to determine whether this relationship holds true for patients undergoing delayed thrombectomy (6-24 hours). METHODS: We performed a single-center retrospective review of prospectively-recorded data for patients undergoing endovascular thrombectomy for large vessel occlusion between January 2015 and February 2018. Multivariable logistic regression analyses were performed to identify predictors of parenchymal hematoma (PH) and sICH (NINDS-National Institute of Neurological Disorders and Stroke, SITS-MOST-Safe Implementation of Thrombolysis in Stroke Monitoring Study, ECASS III-European-Australian Cooperative Acute Stroke Study III criteria) and to identify the role of reperfusion grade. This analysis was repeated for delayed thrombectomy patients. RESULTS: 528 patients were included; mean age was 71.5% and 43% were male. Median NIHSS (National Institutes of Health Stroke Scale) and time last seen well (TLSW) to treatment were 17 and 4.8 hours, respectively. Successful recanalization was achieved in 94%. On multivariable analyses, ASPECTS (Alberta Stroke Programme Early CT Score) was a predictor of PH (OR 0.7, 95% CI 0.57 to 0.87; p=0.002) for patients achieving any reperfusion grade. For patients achieving successful reperfusion, lower ASPECTS was a predictor of PH (OR 0.73, 95% CI 0.58 to 0.91; p=0.005) and of sICH (ECASS III) (OR 0.67, 95% CI 0.45 to 0.98; p=0.04); in addition, TICI 2b as compared with TICI 3 was a predictor of PH (OR 2.1, 95% CI 1 to 4.4; p=0.04) and of sICH (NINDS) (OR 7.5, 95% CI 1 to 57; p=0.045). TLSW to treatment was not an independent predictor of PH or sICH. CONCLUSION: Higher baseline ASPECTS and higher degree of reperfusion following endovascular thrombectomy is associated with reduced likelihood of PH and sICH.

Endovascular Thrombectomy, Platelet Count, and Intracranial Hemorrhage.

BACKGROUND: Intracranial hemorrhage can be a devastating complication of endovascular thrombectomy (ET) after acute ischemic stroke increasing disability and mortality. Patients with low platelet count were excluded from major ET trials. This study explores the association between platelet count and intracranial hemorrhage after ET. METHODS: A retrospective review of patients undergoing ET for anterior circulation large vessel occlusions at a single comprehensive stroke center between January 2015 and February 2018 was performed. Demographic and clinical information including National Institutes of Health Stroke Scale score, intravenous tissue plasminogen activator administration, ASPECTS, platelet count, international normalized ratio, time from symptom onset to recanalization, and modified thrombolysis in cerebral infarction score were analyzed. Radiological imaging and clinical course in the hospital was evaluated to identify parenchymal hemorrhage and symptomatic intracranial hemorrhage (sICH). Univariable and multivariable analyses were conducted. RESULTS: A total of 555 patients underwent ET and 43% were male. The mean age and National Institutes of Health Stroke Scale score were 71 ± 14 years and 17 ± 6, respectively. Parenchymal hemorrhage-2 and sICH (European-Australian Cooperative Acute Stroke Study-III criteria) were noted in 9.7% and 5.8% patients, respectively. Rates of sICH in patients with platelet count <100,000 (n = 15), 100,000 to <150,000 (n = 59), and ≥150,000 (n = 481) were 6.7% (n = 1), 10.1% (n = 6), and 5.2% (n = 25), respectively (P = 0.25), and rates of modified Rankin Scale 0-2 at 90 days were 26.7%, 23.7%, and 36.4%, respectively (P = 0.12). Low ASPECTS was a significant predictor of sICH per European-Australian Cooperative Acute Stroke Study-III definition (P value = 0.046). Platelet count was not a predictor (P = 0.386) of sICH. CONCLUSIONS: Risk of sICH after ET is low and comparable in patients with low and normal platelet counts. Low platelets should not exclude patients from undergoing intra-arterial therapy.