Expanding indications for endovascular thrombectomy-how to leave no patient behind

Sporns, Peter; Fiehler, Jens; Ospel, Johanna M.; Safouris, Apostolos; Hanning, Uta; Fischer, Urs; Goyal, Mayank; McTaggart, Ryan; Psychogios, Marios

doi:10.1177/1756286421998905

Cited by 23 publications

(16 citation statements)

References 78 publications

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“…EVT was performed in 15 patients (5%) and i.v.-tPA was administered in 48 (16%) of the ischemic strokes. ASPECTS was very low (0–3) in 1 patient (2.1%), low ( 4 , 5 ) in 2 patients (4.2%), medium ( 6 – 8 ) in 10 patients (20.8%), and high ( 9 , 10 ) in 35 patients (72.9%) with an occlusion in the anterior circulation.…”

Section: Resultsmentioning

confidence: 96%

“…These results demonstrate that it is important to plan resources in thrombectomy-capable centers not only for patients with LVO and selection criteria in randomized trials but also for patients with low NIHSS, low-ASPECTS patients, patients with distal occlusions, and patients presenting in extended time windows. Recent guidelines of the American Heart Association/American Stroke Association (AHA/ASA) and the European Stroke Organization (ESO)/European Society of Minimally Invasive Neurological Therapy (ESMINT) ( 8 , 9 ) already partially account for these upcoming changes, and a recent review on expanding indication for EVT gives a foresight on the direction in which EVT will move with the help of advanced imaging and better endovascular devices ( 6 ). In this context, our study shows that an additional percentage of up to 20% of all patients with ischemic strokes might be candidates for EVT.…”

Section: Discussionmentioning

confidence: 99%

“…Even though the number of patients with large-vessel occlusions and occlusions of the M2 segment of the middle cerebral artery has been estimated ( 2 – 5 ), detailed information about further characteristics such as frequency of stroke mimics and intracranial hemorrhages is lacking. Moreover, the available information is mostly confined to large-vessel occlusion strokes, but in times of expanding indications for EVT ( 6 ), the frequency of more medium-vessel occlusions, the distribution of Alberta Stroke Program Early Computed Tomography Score (ASPECTS), the time window of presentation, and the National Institutes of Health Stroke Scale (NIHSS) of those patients are also of crucial importance for planning thrombectomy resources. We therefore conducted a cohort study of consecutive patients admitted with suspected stroke to a tertiary care hospital and describe all these strategically important variables.…”

Section: Introductionmentioning

confidence: 99%

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Distribution of Diagnoses and Clinical and Imaging Characteristics in 1,322 Consecutive Suspected Stroke Patients

et al. 2021

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Background: Endovascular thrombectomy (EVT) has become the standard of care for large-vessel occlusion strokes, but several barriers for implementing an optimal organization of stroke management remain. Major issues include the lack of reliable data on the percentage of stroke patients potentially eligible for EVT especially in times of expanding indications for EVT. Our aim was therefore to study the frequencies of possible EVT-eligible patients such as patients with medium-vessel occlusions, patients with low Alberta Stroke Program Early Computed Tomography Scores (ASPECTS), patients presenting in an extended time window after onset of symptoms, and patients with mild symptoms at presentation (National Institutes of Health Stroke Scale, NIHSS ≤ 5). We also give detailed imaging and clinical information about the patients presenting with intracranial hemorrhage and other ischemic stroke mimics stratified by symptoms at presentation.Methods: Cohort study of all consecutive patients with suspected acute stroke presenting to a tertiary care center in Germany between September 1, 2016, and August 31, 2017. Baseline and follow-up clinical and imaging characteristics were collected from patients' medical charts.Results: Of 1,322 patients with a suspected acute stroke, 592 (44.8%) had ischemic strokes, 221 (16.7%) had hemorrhagic strokes, 190 (10.9%) had transient ischemic attacks (TIAs), and 319 (24.1%) were classified as stroke mimics. Stroke severity was mild (NIHSS ≤ 5) in 866 (65.5%) patients; 15.7% of the patients with an occlusion of the anterior circulation had an ASPECTS ≤ 5, 17.4% of the patients with an ischemic stroke had distal vessel occlusions, and 49% of the patients presented later than 6 h after onset of symptoms.Conclusion: Our results help to plan resources in thrombectomy-capable centers in times of expanding indications for EVT where resources will have to be adjusted to patients with low-NIHSS, low-ASPECTS, and distal occlusions, and patients presenting in the extended time window, which may altogether account for an additional 20% of all ischemic stroke patients.

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Section: Resultsmentioning

confidence: 96%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Distribution of Diagnoses and Clinical and Imaging Characteristics in 1,322 Consecutive Suspected Stroke Patients

et al. 2021

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“…Beyond LVOs, treatment of distal clots as a primary or adjunctive procedure are become more common ( 88 ). However, current in-vitro models don't include distal vessels and exclusively represent the main cerebral artery lumen and major branching vessels, mainly to the M1 or M2 level.…”

Section: Discussion and Recommendations For Future Advancementsmentioning

confidence: 99%

A Review of the Advancements in the in-vitro Modelling of Acute Ischemic Stroke and Its Treatment

Johnson

Dwivedi

Mirza

et al. 2022

Front. Med. Technol.

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In-vitro neurovascular models of large vessel occlusions (LVOs) causing acute ischemic stroke (AIS) are used extensively for pre-clinical testing of new treatment devices. They enable physicians and engineers to examine device performance and the response of the occlusion to further advance design solutions for current unmet clinical needs. These models also enable physicians to train on basic skills, to try out new devices and new procedural approaches, and for the stroke team to practice workflows together in the comfort of a controlled environment in a non-clinical setting. Removal of the occlusive clot in its entirety is the primary goal of the endovascular treatment of LVOs via mechanical thrombectomy (MT) and the medical treatment via thrombolysis. In MT, recanalization after just one pass is associated with better clinical outcomes than procedures that take multiple passes to achieve the same level of recanalization, commonly known as first pass effect (FPE). To achieve this, physicians and engineers are continually investigating new devices and treatment approaches. To distinguish between treatment devices in the pre-clinical setting, test models must also be optimized and expanded become more nuanced and to represent challenging patient cohorts that could be improved through new technology or better techniques. The aim of this paper is to provide a perspective review of the recent advancements in the in-vitro modeling of stroke and to outline how these models need to advance further in future. This review provides an overview of the various in-vitro models used for the modeling of AIS and compares the advantages and limitations of each. In-vitro models remain an extremely useful tool in the evaluation and design of treatment devices, and great strides have been made to improve replication of physiological conditions. However, further advancement is still required to represent the expanding indications for thrombectomy and thrombolysis, and the generation of new thrombectomy devices, to ensure that smaller treatment effects are captured.

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“…The already initiated Save ChildS Pro registry will help to answer these questions and generate more high-level evidence for the use of MT in children. Nonetheless, we think it is reasonable to recommend MT for pediatric patients in whom no obvious arteriopathic changes are present, even in a time window of up to 24 hours from last known well if a mismatch between clinical deficit and infarct is present 12 13SP110.1136/neurintsurg-2021-018075.supp1 …”

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confidence: 99%

Correspondence on 'Thrombectomy in special populations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee' by Al-Muftiet al

Sporns

Psychogios

Fiehler

et al. 2021

J NeuroIntervent Surg

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Expanding indications for endovascular thrombectomy-how to leave no patient behind

Cited by 23 publications

References 78 publications

Distribution of Diagnoses and Clinical and Imaging Characteristics in 1,322 Consecutive Suspected Stroke Patients

Distribution of Diagnoses and Clinical and Imaging Characteristics in 1,322 Consecutive Suspected Stroke Patients

A Review of the Advancements in the in-vitro Modelling of Acute Ischemic Stroke and Its Treatment

Correspondence on 'Thrombectomy in special populations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee' by Al-Muftiet al

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