Acute Endovascular Treatment
By Matthew E. Fink, MD, Editor
Feil Professor and Chairman, Department of Neurology, and Assistant Dean of Clinical Affairs, Weill Cornell Medical College; Neurologist-in-Chief, New York Presbyterian Hospital
Dr. Fink reports he is a consultant for Procter & Gamble.
These articles are based on the editor's personal interactions as a participant at the International Stroke Conference in Houston, Feb. 22-24, 2017. All interpretations and opinions are exclusively those of the editor.
General Anesthesia in Endovascular Reperfusion Stroke Trials
Bruce Campbell from the University of Calgary, representing the HERMES collaboration, presented the effect of general anesthesia on outcomes in five endovascular reperfusion stroke trials that were reported in 2015, using pooled data. A logistic regression model was developed and adjusted for variables, which included age, sex, stroke severity on the NIH stroke scale, time from symptom onset to randomization, baseline ASPECT score, baseline site of occlusion, and whether the patient received alteplase prior to undergoing endovascular treatment. About 25% of patients received general anesthesia, and there were no significant differences in the baseline characteristics between the two groups. tPA was administered in 88% of the general anesthesia group and about 80% of the group that did not receive general anesthesia. Functional outcome was shown to be significantly better (mRS 0-2) in the group that did not receive general anesthesia, with an odds ratio of 2.62 in favor of no anesthesia resulting in improved outcomes (statistically significant, P < 0.001). In patients who underwent thrombectomy, there was a 50% return to functional independence in those who were treated without general anesthesia, compared to only a 36% recovery to functional independence in those who were treated with general anesthesia. There was an improvement in terms of early recovery, return to normal function, and reduced mortality in patients who were treated with thrombectomy without general anesthesia, all statistically significant. In conclusion, neurological outcomes are better in patients who were treated without general anesthesia, and there were more complications associated with general anesthesia, particularly an increased risk of pneumonia.
CT Perfusion Imaging
In a second presentation, Bruce Campbell presented data from seven recent trials of endovascular therapy, which included pool data from 1,764 patients, using CT perfusion imaging to define the ischemic core volume and determine the relationship of ischemic core volume to functional outcome following endovascular thrombectomy. Ischemic core was calculated by a fully automated computerized system from Phillips imaging. The ischemic core was defined as a reduction of cerebral blood flow > 30% of blood flow to normal brain. The endovascular group and the control group were well matched for baseline characteristics, including median NIHSS of 17, initial median ASPECTS score of 8, percent that received alteplase, and baseline median ischemic core volume of 10 mL in the endovascular group and 9 mL in the control group. In the control group that received IV tPA, there was a rapid drop-off in functional independence (mRS 0-2) as the ischemic core volume increased, from 50% recovery when there was a core volume close to 0 down to 10% as the ischemic core approached 70 mL. With endovascular therapy, the curve shifted upward, showing 70% functional recovery with an ischemic core of 0, and as much as 30% functional recovery with an ischemic core of 70 mL, and a straight-line relationship between those two points. The differences between the two groups were highly significant after adjustment for all other variables. If full reperfusion was accomplished, the curve shifted upward again, and functional independent outcome improved a step further. In patients who had ischemic cores > 70 mL, there was no statistically significant benefit or difference between treatment with intravenous tPA compared to endovascular thrombectomy. In conclusion, ischemic core volume is correlated with worse outcome, and ischemic core volume > 70 mL does not seem to favor endovascular thrombectomy over intravenous thrombolysis.
Contact Aspiration of Intracranial Clot vs. Stent-retriever
Bertrand Lapergue, from Versailles, France, presented the results of the ASTER trial, comparing the addition of contact aspiration of intracranial clot vs. stent-retriever as the initial intervention for recanalization in patients with acute cerebral infarction. The investigators aimed to ascertain whether contact aspiration was more efficient as a front-line endovascular procedure. The ASTER trial was a prospective, randomized, multicenter, controlled, open-label trial with a blinded-outcome design. Patients with acute ischemic anterior circulation large vessel occlusion, with onset of symptoms less than six hours, were randomized to either contact aspiration or stent retriever interventions and were stratified by center and by prior IV thrombolysis. If the assigned treatment technique was unsuccessful after three attempts, the procedure was continued with another technique at the operator’s discretion. The primary outcome measure was successful recanalization as measured by the TICI score 2b-3 at the end of treatment. Secondary outcomes were successful recanalization after the assigned treatment technique, procedural times, need for rescue intervention, complications, and functional outcome as measured by the modified Rankin scale at three months. Results of success of reperfusion showed that contact aspiration resulted in successful reperfusion in 85.4% of patients, and the stent retriever resulted in successful reperfusion in 83.1% of patients, with no statistically significant difference in either the safety or efficacy of these two techniques. In summary, there was no advantage of one technique over the other in terms of successful reperfusion or complication rates.
These articles are based on the editor's personal interactions as a participant at the International Stroke Conference in Houston, Feb. 22-24, 2017. All interpretations and opinions are exclusively those of the editor.
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