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The Safety and Efficacy of Endovascular Treatment in Acute Ischemic Stroke Patients Caused by Large-Vessel Occlusion with Different Etiologies of Stroke: Data from ANGEL-ACT Registry.

ABSTRACT: This study aimed to investigate the safety and efficacy of endovascular treatment (EVT) in acute ischemic stroke (AIS) patients caused by large-vessel occlusion (LVO) with different etiologies of stroke. A total of 928 AIS patients were assigned into intracranial atherosclerotic stenosis (ICAS)-LVO, cardioembolic (CE)-LVO, and artery to artery embolism (ATA)-LVO groups. The safety and efficacy endpoints were symptomatic intracranial hemorrhage (SICH) at 24 h after EVT, 90-day favorable outcomes (modified Rankin Scale (mRS) of 0-2), successful recanalization (modified thrombolysis in cerebral infarct (mTICI) 2b/3), and complete recanalization (mTICI 3). The logistic regression analysis was used to determine the associations between the safety and efficacy endpoints. There were 305 (32.9%), 535 (57.6%), and 88 (9.5%) patients in ICAS-LVO, CE-LVO, and ATA-LVO groups, respectively. No significant difference was found in the 90-day mRS and successful recanalization among the three groups. However, compared with the ICAS-LVO group, complete recanalization rate was higher in the CE-LVO (adjusted odds ratio, 4.50; 95% confidence interval (CI), 2.37-8.56) and ATA-LVO groups (aOR, 2.43; 95% CI, 1.16-5.10). The results of subgroup analysis showed a significant association between CE-LVO stroke etiology and complete recanalization in the age population < 65 years old (aOR, 14.33; 95% CI, 4.39-46.79, P = 0.019). Functional outcomes were similar among different etiologies of stroke. CE-LVO and ATA-LVO could be related to a higher rate of complete recanalization, and there was a trend of the increased risk of parenchymal hemorrhage in the CE-LVO group.

SUBMITTER: Raynald

PROVIDER: S-EPMC9226213 | biostudies-literature | 2022 Mar

REPOSITORIES: biostudies-literature

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The Safety and Efficacy of Endovascular Treatment in Acute Ischemic Stroke Patients Caused by Large-Vessel Occlusion with Different Etiologies of Stroke: Data from ANGEL-ACT Registry.

Raynald Sun Dapeng D Huo Xiaochuan X Jia Baixue B Tong Xu X Ma Gaoting G Wang Anxin A Mo Dapeng D Ma Ning N Gao Feng F Amin Sheyar S Ren Zeguang Z Miao Zhongrong Z

Neurotherapeutics : the journal of the American Society for Experimental NeuroTherapeutics 20220303 2

This study aimed to investigate the safety and efficacy of endovascular treatment (EVT) in acute ischemic stroke (AIS) patients caused by large-vessel occlusion (LVO) with different etiologies of stroke. A total of 928 AIS patients were assigned into intracranial atherosclerotic stenosis (ICAS)-LVO, cardioembolic (CE)-LVO, and artery to artery embolism (ATA)-LVO groups. The safety and efficacy endpoints were symptomatic intracranial hemorrhage (SICH) at 24 h after EVT, 90-day favorable outcomes ...[more]

PMID: 35243592

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Project description:Background and Purpose- Accurate prediction of acute ischemic stroke (AIS) caused by anterior large vessel occlusion (LVO) that is amendable to mechanical thrombectomy remains a challenge. We developed and validated a prediction model for anterior circulation LVO stroke using past medical history elements present on admission and neurological examination. Methods- We retrospectively reviewed AIS patients admitted between 2009 and 2017 to 3 hospitals within a large healthcare system in the United States. Patients with occlusions of the internal carotid artery or M1 or M2 segments of the middle cerebral artery were randomly split into 2/3 derivation and 1/3 validation cohorts for development of an anterior circulation LVO prediction model and score that was further curtailed for potential use in the prehospital setting. Results- A total of 1654 AIS were reviewed, including 248 (15%) with proximal anterior circulation LVO AIS. In the derivation cohort, National Institutes of Health Stroke Scale score at the time of cerebrovascular imaging, current smoking status, type 2 diabetes mellitus, extracranial carotid, and intracranial atherosclerotic stenosis was significantly associated with anterior circulation LVO stroke. The prehospital score was curtailed to National Institutes of Health Stroke Scale score, current smoking status, and type 2 diabetes mellitus. The areas under the curve for the prediction model, prehospital score, and National Institutes of Health Stroke Scale score alone were 0.796, 0.757, and 0.725 for the derivation cohort and 0.770, 0.689, and 0.665 for the validation cohort, respectively. The Youden index J was 0.46 for a score of >6 with 84.7% sensitivity and 62.0% specificity for the prediction model. Conclusions- Previously reported LVO stroke prediction scores focus solely on elements of the neurological examination. In addition to stroke severity, smoking, diabetes mellitus, extracranial carotid, and intracranial atherosclerotic stenosis were associated with anterior circulation LVO AIS. Although atherosclerotic stenosis may not be known until imaging is obtained, smoking and diabetes mellitus history can be readily obtained in the field and represent important elements of the prehospital score supplementing National Institutes of Health Stroke Scale score.

Project description:BackgroundRecent randomized trials have suggested that endovascular thrombectomy (EVT) alone may provide similar functional outcomes as the current standard of care, EVT combined with intravenous alteplase treatment, for acute ischemic stroke secondary to large vessel occlusion. We conducted an economic evaluation of these 2 therapeutic options.MethodsWe constructed a decision analytic model with a hypothetical cohort of 1000 patients to assess the cost-effectiveness of EVT with intravenous alteplase treatment versus EVT alone for acute ischemic stroke secondary to large vessel occlusion from both the societal and public health care payer perspectives. We used studies and data published in 2009-2021 for model inputs, and acquired cost data for Canada and China, representing high- and middle-income countries, respectively. We calculated incremental cost-effectiveness ratios (ICERs) using a lifetime horizon and accounted for uncertainty using 1-way and probabilistic sensitivity analyses. All costs are reported in 2021 Canadian dollars.ResultsIn Canada, the difference in quality-adjusted life-years (QALYs) gained between EVT with alteplase and EVT alone was 0.10 from both the societal and health care payer perspectives. The difference in cost was $2847 from a societal perspective and $2767 from the payer perspective. In China, the difference in QALYs gained was 0.07 from both perspectives, and the difference in cost was $1550 from the societal perspective and $1607 from the payer perspective. One-way sensitivity analyses showed that the distributions of modified Rankin Scale scores at 90 days after stroke were the most influential factor on ICERs. For Canada, compared to EVT alone, the probability that EVT with alteplase would be cost-effective at a willingness-to-pay threshold of $50 000 per QALY gained was 58.7% from a societal perspective and 58.4% from a payer perspective. The corresponding values for at a willingness-to-pay threshold of $47 185 (3 times the Chinese gross domestic product per capita in 2021) were 65.2% and 67.4%.InterpretationFor patients with acute ischemic stroke due to large vessel occlusion eligible for immediate treatment with both EVT alone and EVT with intravenous alteplase treatment, it is uncertain whether EVT with alteplase is cost-effective compared to EVT alone in Canada and China.

Project description:Introduction: Carotid artery dissection (CAD) and atherosclerotic carotid artery occlusion (ACAO) are major causes of a tandem occlusion in patients with intracranial large vessel occlusion (LVO). Presence of tandem occlusions may hamper intracranial access and potentially increases the risk of procedural complications of endovascular treatment (EVT). Our aim was to assess neurological, functional and technical outcome and complications of EVT for intracranial LVO in patients with CAD in comparison to patients with ACAO and to patients without CAD or ACAO. Methods: We analyzed data of the MR CLEAN trial intervention arm and MR CLEAN Registry, acquired in 16 Dutch EVT-centers. Primary outcome was the change in stroke severity by comparing the National Institute of Health Stroke Scale (NIHSS) score at 24-48 h after treatment vs. baseline. Secondary outcomes included reperfusion rate and symptomatic intracranial hemorrhage (sICH). We compared outcomes and complications between patients with CAD vs. patients with ACAO and patients without CAD or ACAO. Results: In total, we identified 74 (4.7%) patients with CAD, 92 (5.9%) patients with ACAO and 1398 (89.4%) patients without CAD or ACAO. Neurological improvement at short-term after EVT in patients with CAD was significantly better compared to ACAO (resp. mean -5 vs. mean -1 NIHSS point; p = 0.03) and did not differ compared to patients without CAD or ACAO (-4 NIHSS points; p = 0.62). Rates of successful reperfusion in patients with CAD (47%) was comparable to patients with ACAO (47%; p = 1.00), but was less often achieved compared to patients without CAD or ACAO (58%; p = 0.08). Occurrence of sICH did not differ significantly between CAD patients (5%) and ACAO (11%; p = 0.33) or without CAD/ACAO (6%; p = 1.00). Conclusion: EVT in patients with intracranial LVO due to CAD results in neurological improvement comparable to patients without tandem occlusions. Therefore, carotid artery dissection by itself should not be a contraindication for endovascular treatment in stroke patients with intracranial large vessel occlusion. Although more challenging endovascular procedures are to be suspected in both patients with CAD or ACAO, accurate distinction between CAD and ACAO might influence clinical decision making as better clinical outcome can be expected in patients with CAD.

Project description:Background The long-term outcomes of acute large vessel occlusion (LVO) in anterior circulation treated by endovascular treatment (EVT) remains to be determined. The aim of this study was to assess the 5-year outcomes of patients with LVO who underwent EVT. Methods This study was an observational, nationwide registry of consecutive patients with acute LVO who received EVT in 28 comprehensive stroke centers in China. The primary outcome was the proportion of favorable outcome [modified Rankin Scale score (mRS) 0–2] at 5 years. Secondary outcomes included proportions of patients with excellent outcome (mRS 0–1), all-cause mortality and risk of stroke recurrence at 5 years. Results A total of 807 patients were included into the study and had 90-day follow-up data, 657 patients had 5-year follow-up data. At 90 days, 218 patients (27.0%) had an excellent outcome, 349 patients (43.2%) had a favorable functional outcome. 199 patients (24.7%) died. At 5 years, 190 patients (28.9%) had an excellent outcome, 261 patients (39.7%) had a favorable functional outcome, 317 patients (48.2%) died and 129 (28.2%) had stroke recurrence. Because of missing 5-year follow-up data, among available 269 patients who achieved functional independence at 90 days, 208 (77.3%) maintained favorable outcome, 19 (7.1%) had disability (mRS 3–5) and 42 (15.6%) died at 5 years. Furthermore, among available 189 patients with mRS 3–5 at 90 days, 53 (28.0%) patients achieved favorable functional outcome, 60 (31.7%) patients maintained unfavorable functional outcome and 76 (40.2%) patients died within 5 years. Multivariate analyses identified that younger age [odds ratio (OR): 0.96; 95% CI, 0.93–0.99; P = 0.009], lower mRS at 90 days (OR: 0.15; 95% CI, 0.10–0.23; P < 0.001) and absence of stroke recurrence (OR: 0.001; 95% CI, 0.000–0.006; P < 0.001) were significantly associated with favorable outcome at 5 years. Advanced age (OR: 1.06, 95% CI, 1.04–1.08; P < 0.001), higher mRS at 90 days (OR: 0.84; 95% CI, 0.73–0.98; P = 0.021) and atrial fibrillation (OR: 1.63; 95% CI, 1.02–2.60; P = 0.04) were independent factors for stroke recurrence. Conclusion Our results indicated that the beneficial effect of EVT in patients with acute LVO can be sustained during the course of at least 5 years. Reducing the risk of stroke recurrence by anticoagulation for atrial fibrillation may be a crucial strategy to improve long-term outcome.

Project description:BackgroundThe effects of angioplasty on intracranial atherosclerotic disease (ICAD)-related acute large-vessel occlusion stroke (LVOS) are unknown. We analyzed the efficacy and safety of angioplasty or stenting for ICAD-related LVOS and the optimal treatment duration.MethodsPatients with ICAD-related LVOS from a prospective cohort of the Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemia Stroke registry were classified as follows: the early intraprocedural angioplasty and/or stenting (EAS) group was defined as the strategy using angioplasty or stenting without mechanical thrombectomy (MT) or one attempt of MT; the non-angioplasty and/or stenting (NAS) group, MT procedure without any angioplasty; and the late intraprocedural angioplasty and/or stenting (LAS) group, using same angioplasty techniques following two or more passes of MT. The primary endpoint was the modified Rankin Scale (mRS) score at 90 days. Other efficacy outcomes included mRS scores 0-1, mRS 0-2, and successful recanalization. Death within 90 days, and symptomatic ICH were safety endpoints. We use propensity score method to diminish the effect of treatment-selection bias. The odds ratio of recanalization rate and mRS score among EAS, NAS, and LAS groups were examined by unadjusted and adjusted logistic regression analysis among unweighted samples and inverse probability of treatment weighting (IPTW) samples.ResultsWe divided 475 cases into three groups. Functional outcomes at 90 days were better in the EAS group than in the NAS and LAS groups. The proportion of mRS 0-1, mRS 0-2, and successful recanalization cases were the highest in the EAS group. However, after IPTW, mortality rate among the three groups were similar (EAS vs. NAS vs. LAS: 19.0 vs. 18.1 vs. 18.7%, p = 0.98) as well as symptomatic intracranial hemorrhage within 24 h however, mortality rate and symptomatic intracranial hemorrhage among the three groups were similar. Logistic regression analysis in unweighted samples and IPTW samples both showed that EAS group had better outcomes. IPTW-adjusted logistic regression analysis demonstrated that the EAS group had better outcomes (mRS 0-1) than the NAS group (adjusted odds ratio [aOR], 0.55; 95% confidence interval [CI]: 0.34-0.88, p = 0.01) and LAS (aOR, 0.39; 95% CI: 0.22-0.68, p = 0.001).ConclusionsAngioplasty and/or stenting should be performed at an early stage for ICAD-related acute LVOS.RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT03370939.

Project description:BackgroundEndovascular treatment (EVT) for acute ischemic stroke (AIS) patients presenting with Alberta Stroke Program Early CT Score (ASPECTS) 0-5 has not yet proven safe and effective by clinical trials.ObjectivesThe aim of the study was to assess whether EVT in AIS patients presenting with low ASPECTS is beneficial.DesignSystematic review and meta-analysis of available studies in accordance with the PRISMA statement.Data sources and methodsWe have searched MEDLINE, the Cochrane Central Register of Controlled Trials, and reference lists of articles published until 28 May 2022 with the aim to calculate (1) modified Rankin scale (mRS) score 0-3 at 3 months, (2) mRS score 0-2 at 3 months, (3) symptomatic intracranial hemorrhage (sICH), and (3) mortality at 3 months.ResultsOverall, 24 eligible studies were included in the meta-analysis, comprising a total of 2539 AIS patients with ASPECTS 0-5 treated with EVT. The pooled proportion of EVT-treated patients achieving mRS 0-3 at 3 months was calculated at 38.4%. The pooled proportion of EVT-treated patients achieving mRS 0-2 at 3 months was 25.7%. Regarding safety outcomes, sICH occurred in 12.8% of patients. The 3-month pooled mortality was 30%. In pairwise meta-analysis, patients treated with EVT had a higher likelihood of achieving mRS 0-3 at 3 months compared with patients treated with best medical therapy (BMT, OR: 2.41). sICH occurred more frequently in EVT-treated patients compared with the BMT-treated patients (OR: 2.30). Mortality at 3 months was not different between the two treatment groups (OR: 0.71).ConclusionEVT may be beneficial for AIS patients with low baseline ASPECTS despite an increased risk for sICH. Further data from randomized-controlled clinical trials are needed to elucidate the role of EVT in this subgroup of AIS patients.RegistrationThe protocol has been registered in the International Prospective Register of Ongoing Systematic Reviews PROSPERO; Registration Number: CRD42022334417.

Dataset Information

The Safety and Efficacy of Endovascular Treatment in Acute Ischemic Stroke Patients Caused by Large-Vessel Occlusion with Different Etiologies of Stroke: Data from ANGEL-ACT Registry.

Publications

The Safety and Efficacy of Endovascular Treatment in Acute Ischemic Stroke Patients Caused by Large-Vessel Occlusion with Different Etiologies of Stroke: Data from ANGEL-ACT Registry.

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