Feasibility and safety of direct catheter-based thrombectomy in the treatment of acute ischaemic stroke. Cooperation among cardiologists, neurologists and radiologists. Prospective registry PRAGUE-16
Abstract:Direct catheter-based thrombectomy may be considered in patients with contraindications for thrombolysis or in patients with very short CT-groin puncture times. A randomised trial is needed to evaluate better the role of direct catheter-based thrombectomy. Acute stroke interventions performed in close cooperation among cardiologists, neurologists and radiologists are feasible and safe.
“…1). [2,3,[9][10][11][12][13]. All studies were observational in nature, 5 of them with retrospective [9-13] and 2 with multicenter prospective design [2,3].…”
Section: Resultsmentioning
confidence: 99%
“…Bias assessment with NOS highlighted good quality for only 2 studies [ 2 , 3 ], the remaining having low to fair quality (Supplemental material – Table II ). Three studies reported on IVT only [ 2 , 11 , 13 ], while 4 studies reported on multiple reperfusion strategies [ 3 , 9 , 10 , 12 ]. Fig.…”
Section: Resultsmentioning
confidence: 99%
“…Three studies provided data for EVT in acute ischemic stroke due to isolated cervical ICA occlusion ( n = 150) [ 3 , 9 , 12 ]. EVT highly varied, including IA rtPA, thrombectomy, aspiration, stenting, and angioplasty.…”
Introduction
Despite intravenous thrombolysis (IVT) and endovascular treatment (EVT) have been demonstrated effective in acute ischemic stroke (AIS) due to large vessel occlusions, there are still no conclusive data to guide treatment in stroke due to cervical internal carotid artery (ICA) occlusion. We systematically reviewed available literature to compare IVT, EVT, and bridging (IVT + EVT) and define optimal treatment.
Methods
Systematic review followed predefined protocol (Open-Science-Framework osf.io/bfykj). MEDLINE, EMBASE, and Cochrane CENTRAL were searched. Results were restricted to studies in English, with sample size ≥ 10 and follow-up ≥30 days. Primary outcomes were favorable outcome (mRS ≤ 2), mortality, and symptomatic intracerebral hemorrhage(sICH), defined according to study original report. Newcastle-Ottawa scale was used for bias assessment.
Results
Seven records of 930 screened were included in meta-analysis. Quality of studies was low-to-fair in 5, good in 2. IVT (n = 450) did not differ for favorable outcome and mortality compared to EVT (n = 150), though having lower rate of sICH (OR = 0.4, 95% CI 0.2–0.8). Compared to IVT, bridging (IVT + EVT) was associated with higher rate of favorable outcome (OR = 2.2, 95% CI 1.3–3.7). Compared to EVT, bridging (IVT + EVT) provided higher rate of favorable outcome (OR = 1.9, 95% CI 1.1–3.4), with a marginally increased risk of sICH (OR = 2.1, 95% CI 1–4.4) but similar mortality rates.
Conclusions
Our systematic review highlights that, in acute ischemic stroke associated with isolated cervical ICA occlusion, bridging (IVT + EVT) might lead to higher rate of functional independence at follow-up, without increasing mortality. The low quality of available studies prevents from drawing firm conclusions, and randomized-controlled clinical trials are critically needed to define optimal treatment in this AIS subgroup.
“…1). [2,3,[9][10][11][12][13]. All studies were observational in nature, 5 of them with retrospective [9-13] and 2 with multicenter prospective design [2,3].…”
Section: Resultsmentioning
confidence: 99%
“…Bias assessment with NOS highlighted good quality for only 2 studies [ 2 , 3 ], the remaining having low to fair quality (Supplemental material – Table II ). Three studies reported on IVT only [ 2 , 11 , 13 ], while 4 studies reported on multiple reperfusion strategies [ 3 , 9 , 10 , 12 ]. Fig.…”
Section: Resultsmentioning
confidence: 99%
“…Three studies provided data for EVT in acute ischemic stroke due to isolated cervical ICA occlusion ( n = 150) [ 3 , 9 , 12 ]. EVT highly varied, including IA rtPA, thrombectomy, aspiration, stenting, and angioplasty.…”
Introduction
Despite intravenous thrombolysis (IVT) and endovascular treatment (EVT) have been demonstrated effective in acute ischemic stroke (AIS) due to large vessel occlusions, there are still no conclusive data to guide treatment in stroke due to cervical internal carotid artery (ICA) occlusion. We systematically reviewed available literature to compare IVT, EVT, and bridging (IVT + EVT) and define optimal treatment.
Methods
Systematic review followed predefined protocol (Open-Science-Framework osf.io/bfykj). MEDLINE, EMBASE, and Cochrane CENTRAL were searched. Results were restricted to studies in English, with sample size ≥ 10 and follow-up ≥30 days. Primary outcomes were favorable outcome (mRS ≤ 2), mortality, and symptomatic intracerebral hemorrhage(sICH), defined according to study original report. Newcastle-Ottawa scale was used for bias assessment.
Results
Seven records of 930 screened were included in meta-analysis. Quality of studies was low-to-fair in 5, good in 2. IVT (n = 450) did not differ for favorable outcome and mortality compared to EVT (n = 150), though having lower rate of sICH (OR = 0.4, 95% CI 0.2–0.8). Compared to IVT, bridging (IVT + EVT) was associated with higher rate of favorable outcome (OR = 2.2, 95% CI 1.3–3.7). Compared to EVT, bridging (IVT + EVT) provided higher rate of favorable outcome (OR = 1.9, 95% CI 1.1–3.4), with a marginally increased risk of sICH (OR = 2.1, 95% CI 1–4.4) but similar mortality rates.
Conclusions
Our systematic review highlights that, in acute ischemic stroke associated with isolated cervical ICA occlusion, bridging (IVT + EVT) might lead to higher rate of functional independence at follow-up, without increasing mortality. The low quality of available studies prevents from drawing firm conclusions, and randomized-controlled clinical trials are critically needed to define optimal treatment in this AIS subgroup.
“…The recently published PRAGUE-16 Registry evaluated the feasibility and safety of direct endovascular thrombectomy, not preceded by tPA, performed by cardiologists in Interventional Cardiology department, in cooperation with neurologists and radiologists. 13 It was a prospective, observational pilot registry, including 103 patients with less than 6 h onset of AS and CT scan evidence of major artery occlusion without large cerebral ischemia; patients were treated by direct catheter-based thrombectomy (73 patients) vs. double treatment with tPA plus endovascular intervention (30 patients), based on clinical picture and CT scan. Similar results have been achieved in both groups, with good functional recovery (mRS score of 0–2 at 90 days) in about 40% of patients, interesting if compared with only 30% recovery in patients who received medical treatment alone (tPA) in previous trials.…”
Section: Discussion and Review Of The Literaturementioning
Neurological and cardiovascular ischemic diseases represent the main causes of
morbidity and mortality in the world. Physiopathological mechanisms present
several similarities, based on “thromboembolic” events, as well as the
pharmacological and percutaneous treatment options. We report a case of
contemporary presentation of acute coronary and cerebral syndromes, successfully
managed with a combined percutaneous intervention driven by the emergency
setting. Whereas invasive revascularization represents nowadays the “gold
standard” therapy for acute coronary syndromes, catheter-based treatment of
acute stroke is not yet widespread and still under debate.
“…Небольшие проспективные регистровые исследования показали, что клинические исходы у пациентов после тромбоэкстракции, выполненной в отделениях кардиологического профиля, могут быть не хуже, чем в специализированных нейроинтервенционных центрах [23,24]. Недостаток фундаментальных неврологических знаний у интервенционных кардиологов решался привлечением мультидисциплинарной команды, которая включала невролога и врача лучевой диагностики.…”
Objective: to assess results from the Stroke Network created on the basis of the Infarction Network in the metropolis Moscow for endovascular treatment in patients with occlusion of the large cerebral artery (the internal carotid artery, the M1 and M2 segments of the middle cerebral artery, and the main artery).Patients and methods. A total of 742 thromboextractions were performed in patients with ischemic stroke in Moscow Stroke Network hospitals in 2019. The final analysis included 729 patients aged 25 to 97 years (mean age, 71 years); of them there were 370 (50.8%) men and 359 (49.2%) women. The selection criteria for endovascular treatment for ischemic stroke were consistent with those set out in the 2015 American Heart Association/American Stroke Association (AHA/ASA) guidelines, which included a pre-stroke modified Rankin Scale (MRS) score of 0–1; ≥18 years of age; a National Institutes of Health Stroke Scale (NIHSS) score of ≥6; and an Alberta Stroke Programme Early CT score (ASPECTS) ≥6. The angiographic results were assessed using the Thrombolysis in Cerebral Infarction (TICI) scale. The clinical outcomes were measured with the NIHSS and the MRS.Results and discussion. Successful recanalization (TICI 2b/3) was achieved in 547 (75%) patients. The predominant technique for thromboextraction was thromboaspiration that was used in 376 (51.6%) patients. Combined procedures (the co-use of an aspiration catheter and a stent retriever) were the second most commonly used – in 231 (31.7%) patients. By the end of the 20th day, good functional recovery (MSR 0–2 scores) was observed in 213 (29.2%) patients. The 20-day mortality rate was 31.8%.Conclusion. The successfully functioning Infarction Network in Moscow was used to create the Stroke Network for treatment in patients with ischemic stroke and large cerebral artery occlusion, the clinical results of which are comparable to large European registry studies.
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