Rescue Therapy for Failed Mechanical Thrombectomy in Acute Ischemic Stroke: A Pooled Analysis of the Society of Vascular and Interventional Neurology Registry.

OBJECTIVE: We aimed to evaluate the association between rescue therapy (RT) and functional outcomes compared to medical management (MM) in patients presenting after failed mechanical thrombectomy (MT). METHODS: This cross-sectional study utilized prospectively collected and maintained data from the Society of Vascular and Interventional Neurology Registry, spanning from 2011 to 2021. The cohort comprised patients with large vessel occlusions (LVOs) with failed MT. The primary outcome was the shift in the degree of disability, as gauged by the modified Rankin Scale (mRS) at 90 days. Additional outcomes included functional independence (90-day mRS score of 0-2), symptomatic intracranial hemorrhage (sICH), and 90-day mortality. RESULTS: Of a total of 7,018 patients, 958 presented failed MT and were included in the analysis. The RT group comprised 407 (42.4%) patients, and the MM group consisted of 551 (57.5%) patients. After adjusting for confounders, the RT group showed a favorable shift in the overall 90-day mRS distribution (adjusted common odds ratio = 1.79, 95% confidence interval [CI] = 1.32-2.45, p < 0.001) and higher rates of functional independence (RT: 28.8% vs MM: 15.7%, adjusted odds ratio [aOR] = 1.93, 95% CI = 1.21-3.07, p = 0.005) compared to the MM group. RT also showed lower rates of sICH (RT: 3.8% vs MM: 9.1%, aOR = 0.52, 95% CI = 0.28-0.97, p = 0.039) and 90-day mortality (RT: 33.4% vs MM: 45.5%, aOR = 0.61, 95% CI = 0.42-0.89, p = 0.009). INTERPRETATION: Our findings advocate for the utilization of RT as a potential treatment strategy for cases of LVO resistant to first-line MT techniques. Prospective studies are warranted to validate these observations and optimize the endovascular approach for failed MT patients. ANN NEUROL 2024;96:343-355.

Optimizing catheter centering enhances mechanical thrombectomy success: Performance difference in cases using novel macrowires versus traditional microwires.

BACKGROUND: The aim of this study is to determine how guidewire selection impacts procedure time and success and analyze if the trend toward the adoption of larger diameter guidewires provides a quantifiable advantage over traditional 0.014″ guidewires. METHODS: A review of 494 consecutively performed acute ischemic stroke cases performed between 2018 and 2022 were reviewed and grouped into cases using a single 0.014″ outer diameter (OD) guidewire (195 cases) and cases using a single 0.018″ or 0.024″ OD guidewire (128 cases). These groups were compared for differences in average time to recanalization, average number of passes to achieve recanalization, and first pass success. Cases were compared overall, and further analyzed by region of occlusion to look at specific guidewire related differences for cases with M1, M2, and ICA occlusions. RESULTS: Procedures using a larger OD guidewire have an average 5 min and 30 s reduction in time from puncture to recanalization (p = 0.0201). ICA occlusion cases using a larger macrowire show a 20 min reduction in recanalization time (p = 0.0005), a reduction in average number of passes from 2.6 to 1.7 (p = 0.0058), and an increase in first pass success from 18.8% to 58.3% when compared to traditional guidewires. CONCLUSION: Large 0.018″ or 0.024″ OD guidewires better fill the lumen of the catheter and help to center the thrombectomy system in the vessel and navigate to the clot face. This leads to a reduction in procedure time and number of passes, and an increase in first pass success, especially when treating occlusions in the ICA.

Fubuki XF Long Sheath guide catheter use in neuroendovascular procedures: Institutional experience in 60 cases.

BACKGROUND: Endovascular treatment devices require compatible guide catheters to navigate complex vessels and anatomy. The Fubuki XF Long Sheath guide catheter (Fubuki XF) was developed with a 0.090-inch internal diameter with hydrophilic coating, an atraumatic rounded tip, and enhanced trackability and support with gradual shaft transition zones. METHODS: We retrospectively analyzed a prospectively maintained database of neuroendovascular patients treated using Fubuki XF at our center (July 2022─May 2023). Baseline/procedural characteristics were collected. Outcomes of interest included technical success (procedure completion with Fubuki XF without alternative guide catheter use) and peri-procedural complications. RESULTS: This study included 60 patients (43.3% [26/60] female; mean age: 69.6 ± 9.7) presenting with stenosis (45.0% [27/60]), unruptured aneurysms (31.7% [19/60]), ruptured aneurysm (1.7% [1/60]), arteriovenous fistula (5.0% [3/60]), arteriovenous malformation (3.3% [2/60]), chronic subdural hematoma (3.3% [2/60]), stroke/emboli (6.7% [4/60]), vasospasm (1.7% [1/60]), or carotid web (5.0% [1/60]). Fubuki XF was used to deliver endovascular treatment devices for stenting (43.3% [26/60]), flow diversion (23.3% [14/60]), embolization (11.7% [7/60]), coiling (10.0% [6/60]), balloon angioplasty (10.0% [6/60]), and mechanical thrombectomy (1.7% [1/60]). The Fubuki XF tip was placed in the internal carotid artery in 38.3% (23/60) of cases. Technical success was achieved in all cases. One V1 non-flow-limiting dissection (not related to Fubuki XF) and one failed closure occurred (1.7% [1/60] each). No iatrogenic strokes or intraprocedural ruptures occurred. CONCLUSION: We used Fubuki XF to safely and effectively deliver a variety of compatible neuroendovascular devices. Fubuki XF was stable in all cases and locations, and there were no device-related complications or dissections.

The resolute Onyx in TIA management (ROTIA).

BACKGROUND: First-line treatment for symptomatic intracranial atherosclerotic disease (ICAD) is medical management; however, interventional approaches are increasingly considered for refractory disease. The Resolute Onyx in TIA management (ROTIA) study is a post-market evaluation of the Resolute Onyx (R-Onyx) drug-eluting stent in the treatment of recurrent transient ischemic attacks (TIAs) due to refractory ICAD (off-label use). METHODS: This is a single-center, retrospective case series of consecutive patients who underwent angioplasty and stenting with R-Onyx for treatment of recurrent TIAs due to refractory ICAD from October 2019 to November 2022. Included patients were ages 22-80, had a baseline modified Rankin Scale of ≤2, and had recurrent TIAs attributed to intracranial artery stenosis >70% despite maximal medical therapy. Primary outcomes of interest were peri-procedural complications (TIA, stroke, intracranial hemorrhage, mortality) up to 72 h post-stenting and ischemic stroke up to 18 months post-stenting. RESULTS: Twenty patients (mean age 66.84 ± 14; 25% female; 80% Hispanic) were included. A total of 21 stents were successfully deployed with no peri-procedural complications. There were no recurrent ischemic events at 30 days post-stenting. At 18 months post-stenting, there were no ischemic events and no patient exhibited in-stent restenosis. CONCLUSION: ROTIA demonstrates the feasibility of using the Resolute Onyx drug-eluting stent for the management of TIAs due to refractory ICAD, with high technical success and low peri-procedural complications. Limitations include the retrospective and single-center nature of this study. Future prospective, multi-center, randomized trials with extended observation periods are needed.

A Comparative Study of Hemorrhagic Conversion Patterns After Stroke Thrombolysis With Alteplase Versus Tenecteplase.

BACKGROUND AND PURPOSE: Tenecteplase is the thrombolytic drug of choice for acute ischemic stroke (AIS) as it has unique pharmacologic properties, along with results demonstrating its non-inferiority compared to alteplase. However, there are contradictory data concerning the risk of intracranial hemorrhage. The purpose of the study was to report the rate and patterns of symptomatic intracranial hemorrhage (sICH) in AIS patients after thrombolysis with tenecteplase compared to alteplase. METHODS: This is a retrospective cohort study with data collected 90 days before and after the change from alteplase to tenecteplase from 15 Texas stroke centers. The primary endpoint is the incidence of sICH according to the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) and European Cooperative Acute Stroke Study III (ECASS-3) criteria. The secondary endpoints are the radiographic pattern of hemorrhagic conversion according to the Heidelberg bleeding classification (HBC). RESULTS: A total of 431 patients were eligible for thrombolytic therapy. Half of the cohort received alteplase (n=216), and the other half received tenecteplase (n=215). The average age of the alteplase group was 62.94 years old (SD=15.12) and 64.45 years old (SD=14.51) for the tenecteplase group. Seven patients in the alteplase group (3.2%) and 14 (6.5%) in the tenecteplase group had sICH, with an odds ratio of 1.44 (95% CI 0.60-3.43; P=0.41). An increased National Institutes of Health Stroke Scale (NIHSS) score on arrival (1.06; 95% CI 1.0004-1.131; P=0.04) was a statistically significant predictor of sICH. Tenecteplase was associated with a statistically significant increase in HBC-3 (P=0.040) over alteplase. CONCLUSIONS: Compared with alteplase, our study revealed a higher rate of sICH with tenecteplase that was not statistically significant and a higher rate of HBC-3 hemorrhages that was statistically significant. The proposed mechanism of bleeding is hemorrhagic conversion in clinically silent infarcts and contusions underlying the lesions. Further studies are needed to confirm our findings and determine predictive risk factors.

An artificial intelligence (AI)-based approach to clinical trial recruitment: The impact of Viz RECRUIT on enrollment in the EMBOLISE trial.

BACKGROUND: EMBOLISE (NCT04402632) is an ongoing randomized controlled trial investigating the safety and efficacy of middle meningeal artery embolization for the treatment of subacute or chronic subdural hematoma (SDH). Viz RECRUIT SDH is an artificial intelligence (AI)-based software platform that can automatically detect SDH in noncontrast computed tomography (NCHCT) images and report the volume, maximum thickness, and midline shift. We hypothesized that the mobile recruitment platform would aid enrollment and coordinate communication and image sharing among the entire research team. MATERIALS AND METHODS: Patient enrollment in EMBOLISE prior to and after implementation of Viz RECRUIT SDH at a large comprehensive stroke center was compared along with the performance of the software platform. The EMBOLISE trial was activated on May 5, 2021, and Viz RECRUIT SDH was activated on October 6, 2021. The pre-AI cohort consisted of all patients from EMBOLISE to AI activation (153 days), and the post-AI cohort consisted of all patients from AI activation until August 18, 2022 (316 days). All alerts for suspected SDH candidates were manually reviewed to determine the positive predictive value (PPV) of the algorithm. RESULTS: Prior to AI-software implementation, there were 5 patients enrolled (0.99 patients/month) and one screen failure. After the implementation of the software, enrollment increased by 36% to 1.35 patients/month (14 total enrolled), and there were no screen failures. Over the entire post-AI period, a total of 6244 NCHCTs were processed by the system with 207 total SDH detections (3% prevalence). 35% of all alerts for suspected SDH were viewed within 10 min, and 50% were viewed within an hour. The PPV of the algorithm was 81.4 (CI [75.3, 86.7]). CONCLUSION: The implementation of an AI-based software for the automatic screening of SDH patients increased the enrollment rate in the EMBOLISE trial, and the software performed well in a real-world, clinical trial setting.