Neurological improvement predicts clinical outcome after acute basilar artery stroke thrombectomy.

BACKGROUND AND PURPOSE: Mechanical thrombectomy (MT) is the standard of care for patients with anterior circulation large vessel occlusion. Early neurological improvement (ENI), defined as a reduction of ≥ 8 on the National Institutes of Health Stroke Scale (NIHSS) compared with baseline score, or an NIHSS score of 0 or 1 at 24 h after MT, is a strong predictor of 3-month favorable outcome in such patients. The impact of ENI after MT in stroke patients with basilar artery occlusion (BAO) on 3-month outcome is not clear. We aimed to study the effects of ENI in patients with BAO. METHODS: We performed a retrospective analysis of a multicenter prospective cohort of all consecutive stroke patients with BAO who underwent MT. We compared clinical outcomes between BAO patient groups according to ENI status. Multivariate analyses were performed to determine the impact of ENI on favorable 90-day outcome (modified Rankin scale score 0-3) and to report factors contributing to ENI. RESULTS: A total of 237 patients were included. ENI was observed in 70 patients (30%). Outcomes were significantly better in ENI-positive patients, with 84% achieving favorable outcome (mRS score 0-3) at 3 months versus 30% for ENI-negative patients (P < 0.0001). In multivariate analysis, ENI was an independent predictive factor associated with higher rates of favorable outcome {odds ratio (OR) 18.12 [95% confidence interval (CI) 3.95-83.10]; P = 0.0001}. Higher number of passes [OR 0.62 (95% CI 0.43-0.89); P = 0.010] and need for stenting [OR 0.27 (95% CI 0.07-0.95); P = 0.041] were negatively associated with ENI. CONCLUSION: Early neurological improvement on day 1 following MT for BAO is a strong independent predictor of a favorable 3-month clinical outcome.

Economic challenges of using innovative medical devices in major public health pathologies: Example of acute ischemic stroke management by mechanical thrombectomy.

BACKGROUND: Activity-based Funding can induce financial imbalances for health institutions if innovative medical devices (MD) used to perform acts are included in Diagnosis Related Groups (DRG) tariff. To be reimbursed in addition to the DRG tariff, innovative MD must have received a favorable evaluation by the French National Authority for Health (Haute Autorité de Santé) and be registered on the positive list. The aim of this study was to evaluate the expenses and incomes generated by each scenario (before and after the reimbursement of MD), and the financial reports. This study concerned the management of ischemic stroke by mechanical thrombectomy devices, in high-volume French hospital. METHODS: All patients who have had an acute ischemic stroke and admitted to the interventional neuroradiology unit between January 2016 and December 2017 were included retrospectively in this monocentric study. They were divided into four subgroups based on the severity of the DRG. The cost study was carried out using the French National Cost Study Methodology adjusted for the duration of the stays and by micro-costing on MD. RESULTS: A total of 267 patients were included. Over the study period, the average cost of the hospital stay was €10,492±6364 for a refund of €9838±6749 per patient. The acts performed became profitable once the MD were registered on the positive list (€-1017±3551 vs. €560±2671; P<0.05). Despite this reimbursement, this activity remained in deficit for DRG lowest severity (level 1) patients (€-492±1244). Specific MD used for mechanical thrombectomy represented 37% of the total cost of stay. CONCLUSION: The time required to evaluate MD reimbursement files is too long compared to their development. As a result, practitioners are in difficulty to be able to carry out acts according to the consensual practices of their learned societies, without causing any financial deficit of their institutions.

Posterior Fossa Dural Arteriovenous Fistulas with Subarachnoid Venous Drainage: Outcomes of Endovascular Treatment.

BACKGROUND AND PURPOSE: Dural AVFs located in the posterior fossa are a rare entity. The objectives of the study were to analyze the anatomy of dural AVFs, their endovascular treatment strategies, and clinical outcomes. MATERIALS AND METHODS: Two centers retrospectively selected patients treated between January 2009 and June 2018 having posterior fossa dural AVFs. We collected patient demographics, clinical presentation, arterial and venous outflow anatomy of the dural AVFs, and treatment outcomes. RESULTS: Twenty-six patients treated endovascularly for posterior fossa dural AVFs, type III, IV, or V, were included. One hundred percent of the dural AVFs were occluded. A transarterial approach was performed in 23 dural AVFs (88.5%); a combined transarterial and transvenous approach, for 2 dural AVFs (7.7%); and a transvenous approach alone, for 1 dural AVF (3.8%). The middle meningeal artery was the most common artery chosen to inject embolic liquid (46%, 12/26). Procedure-related morbidity was 15.4% at 24 hours, 7.7% at discharge, and 0% at 6 months. Procedure-related mortality was 0%. CONCLUSIONS: Endovascular treatment offers high occlusion rates for posterior fossa dural AVFs with low morbidity and mortality rates. The arterial approach is the first-line preferred approach, even if a transvenous or combined approach would be a safe and effective option for patients with favorable anatomy.

First-Line Sofia Aspiration Thrombectomy Approach within the Endovascular Treatment of Ischemic Stroke Multicentric Registry: Efficacy, Safety, and Predictive Factors of Success.

BACKGROUND AND PURPOSE: After publications on the effectiveness of mechanical thrombectomy by stent retrievers in acute ischemic stroke with large-vessel occlusion, alternative endovascular approaches have been proposed using first-line aspiration catheters. Several devices are currently available to perform A Direct Aspiration First Pass Technique. The Sofia catheter aspiration has been widely used by interventionalists, but data are scarce about its efficacy and safety. Our aim was to report our multicenter thrombectomy experience with first-line Sofia catheter aspiration and to identify independent prognostic factors of clinical and procedural outcomes. MATERIALS AND METHODS: We performed a retrospective analysis of the prospectively maintained Endovascular Treatment of Ischemic Stroke multicentric registry. Data from consecutive patients who benefited from thrombectomy with a first-line Sofia approach between January 2013 and April 2018 were studied. We excluded other first-line approaches (stent retriever or combined aspiration and stent retriever) and extracranial occlusions. Baseline characteristics, procedural data, and angiographic and clinical outcomes were analyzed. RESULTS: During the study period, 296 patients were treated. Mean age and initial NIHSS score were, respectively, 69.5 years and 16. Successful reperfusion, defined by the modified TICI 2b/3, was obtained in 86.1% (n = 255; 95% CI, 81.7%-89.9%). Complete reperfusion (modified TICI 3) was obtained in 41.2% (n = 122; 95% CI, 35.5%-47.1%). A first-pass effect was achieved in 24.2% (n = 71; 95% CI, 19.4%-29.6%). A rescue stent retriever approach was required in 29.7% (n = 88; 95% CI, 24.6%-35.3%). The complication rate was 9.5% (n = 28; 95% CI, 6.4%-13.5%). Forty-three percent (n = 122; 95% CI, 37.1%-48.9%) of patients presented with a favorable 3-month outcome (mRS ≤ 2). Older age, M1-occlusion topography, and intravenous thrombolysis use prior to thrombectomy were independent predictors of the first-pass effect. CONCLUSIONS: The first-line contact aspiration approach appeared safe and efficient with Sofia catheters. These devices achieved very high reperfusion rates with a low requirement for stent retriever rescue therapy, especially for M1 occlusions.

MRI Quantitative T2* Mapping to Predict Dominant Composition of In Vitro Thrombus.

BACKGROUND AND PURPOSE: MR imaging quantitative T2* mapping, which provides information about thrombus composition and specifically the red blood cell content, may be obtained in the setting of acute ischemic stroke before treatment. This could be useful to adapt the endovascular strategy. We aimed to analyze the red blood cell content of in vitro thrombi in relation to the thrombus-T2* relaxation time. MATERIALS AND METHODS: Thirty-five thrombus analogs of different compositions were scanned with an MR imaging quantitative T2* mapping sequence. Two radiologists, blinded to thrombus composition, measured the thrombus-T2* relaxation time twice at an interval of 2 weeks. Quantitative histologic evaluations of red blood cell content were performed. Inter- and intraobserver reproducibility of the thrombus-T2* relaxation time was assessed by calculating intraclass correlation coefficients. Finally, a Spearman product moment correlation between the thrombus-T2* relaxation time and red blood cell content was performed. RESULTS: The median thrombus-T2* relaxation time was 78.5 ms (range, 16-268 ms; interquartile range, 60.5 ms). The median red blood cell content was 55% (range, 0%-100%; interquartile range, 75%). Inter- and intraobserver reproducibility of the thrombus-T2* relaxation time was excellent (>0.9). The Spearman rank correlation test found a significant inverse correlation between thrombus-T2* relaxation time and red blood cell content (ρ = -0.834, P < .001). CONCLUSIONS: MR imaging quantitative T2* mapping can reliably identify the thrombus red blood cell content in vitro. This fast, easy-to-use sequence could be implemented in routine practice to predict stroke etiology and adapt devices or techniques for endovascular treatment of acute ischemic stroke.