Endovascular Treatment Options For Acute Anterior Circulation Large Vessel Occlusion Stroke

Recent randomized clinical trials have demonstrated that endovascular treatment with a stent retriever was a safe and effective way to achieve reperfusion in patients with acute ischemic stroke caused by large arterial occlusion.However,current evidences justifying the validity of endovascular therapy were obtained from populations of Caucasian dominance,this may not be the case in Asian patients,especially in Chinese population.Large–artery occlusion was generally due to embolism from proximal sources in Caucasians,whereas intracranial atherosclerotic lesions with in situ thrombus occlusion were much more common in Asian patients.Therefore,treatment strategy for acute large vessel occlusion in Chinese population may be different from that in western population because of different epidemiological characteristics.In addition,unlike randomized controlled trials,treatment for acute stroke in clinical practice has been complicated and personalized.It is necessary to explore the treatment options for patients undergone endovascular therapy.In China,due to lack of study with large sample,clinical and safety outcomes of intra–arterial treatment in anterior circulation stroke patients have not been reported yet.Therefore,the endov As Cular Treatment for ac Ute Anterior circu Lation ischemic stroke registry(ACTUAL)aims to investigate,in the real world practice,the safety,clinical outcomes and treatment option for patients with acute anterior circulation stroke undergone endovascular treatment in China.Part I: Endovascular Treatment for Acute Anterior Large Artery OcclusionStroke Beyond 6 Hours Time WindowPurpose:To explore the safety and efficacy of endovascular treatment in patients of acute anterior large vessel occlusion with small infarct core beyond 6 hours time window.Methods:Patients of acute anterior circulation occlusion with Alberta Stroke Program Early CT Score(ASPECTS)8–10 while beyond 6h time window were retrospectively reviewed.We evaluated modified Rankin Scale(m RS)score at 90 days,modified treatment in cerebral infarction(m TICI)score immediate post procedure,symptomatic and asymptomatic intracerebral hemorrhage within 72 hours,and mortality in hospital and at 90 days.Results: 101 patients of acute anterior circulation occlusion were enrolled.Time from onset to groin puncture was 415 minutes(interquartile range [IQR]: 387–497 minutes).Favorable collateral flow(ASITN/SIR 2–3)was existed in 62.4%(63/101)patients,and recanalization(m TICI 2b–3)was achieved in 78.2%(79/101)patients.49.5%(50/101)of patients achieved good independent outcome(m RS 0–2).Mortality was 11.9%(12/101)in hospital or at discharge,and 12.9%(13/101)at 90 days.The s ICH rate within 72 hours after treatment was 12.9%(13/101).Robust collateral flow(ASITN/SIR 3)(odds ratio [OR]: 17.55;95% confidence interval [CI]: 1.75–175.66;P=0.02)and recanalization(m TICI 2b–3)(OR: 5.27;CI: 1.25–22.21;P=0.02)were associated with good prognosis.Conclusion: Selected patients based on imaging with acute anterior circulation large vessel occlusion beyond time windows may still benefit from endovascular therapy.Randomized controlled trials are warranted.Part II: Primary Angioplasty and Stenting May Be Superior to Thrombectomyon Acute Atherosclerotic Large Artery OcclusionPurpose:To compare the effectiveness of primary angioplasty and/or stenting with stent retriever thrombectomy in acute anterior large vessel occlusion due to atherosclerotic disease.Methods:We selected patients of acute anterior circulation occlusion due to atherosclerotic disease.We evaluated modified Rankin Scale(m RS)score at 90 days,modified treatment in cerebral infarction(m TICI)score immediate post procedure,symptomatic and asymptomatic intracerebral hemorrhage within 72 hours.Results:Of 302 patients of acute anterior circulation occlusion due to atherosclerotic disease,269 were treated with stent retriever thrombectomy as first–line therapy and 33 with angioplasty and/or stenting.Patients received primary angioplasty treatment showed favorable independent outcome at 90 days(69.7% [23/33] vs 47.6% [128/269],P=0.02)and lower rate of asymptomatic intracerebral hemorrhage(9.1% [3/23] vs 30.5% [82/269],P=0.01).Recanalization immediate post procedure did not differ(78.8%% [26/33] vs 86.2% [232/269],P=0.29).Primary angioplasty therapy(OR,0.27;95% confidence interval [CI]: 0.08–0.90;P=0.03)and small baseline infarct(OR,0.36: 0.16–0.82;P=0.02)were protective factors against poor functional outcome,while old age(OR,1.04:1.01–1.07;P=0.006),severe neurological deficits(OR,3.76: 2.00–7.07;P<0.001),and high glucose(OR,1.11: 1.01–1.23;P=0.03)were associated with poor prognosis.Conclusion: Patients with acute anterior circulation large vessel occlusion due to atherosclerosis may benefit from urgent angioplasty and/or stenting as first–line therapy.Randomized controlled trials are warranted.Part III: Effect of Retrievable Stent Size on Endovascular Rreatment ofAcute Ischemic StrokePurpose: The properties of stents are influenced by the stent diameter and play an important role in endovascular treatment.In clinical practice,a guideline for stent selection has yet to be established.The aim is to investigate the difference in effect of Solitaire retrievers with regard to diameter size.Methods: Of 628 patients of acute anterior circulation ischemic stroke treated with the Solitaire retrievable stent,256 were treated with the Solitaire 4–mm device and 372 with the 6–mm device.We matched patients treated with the two sizes of stent using propensity score analysis.The successful outcome was reperfusion as measured by the modified treatment in cerebral infarction(m TICI)score immediately post procedure and the dichotomized modified Rankin Scale(m RS)score at 90 days.Symptomatic intracerebral hemorrhage and in-hospital mortality were also recorded.Results: After propensity score analysis,outcomes of the groups did not differ.In addition,in patients with intracranial atherosclerosis-related occlusion,a higher reperfusion rate(P=0.021)was observed in the Solitaire 4 group,as well as a shorter time interval(P=0.002)and fewer passes(P=0.025).Independent predictors of successful reperfusion in patients with atherosclerotic disease on logistic analysis were small stent(OR,3.217;95% CI,1.129–9.162;P=0.029)and propensity score acting as covariate(OR,52.84;95% CI,3.468–805.018;P=0.004).Conclusion: We found no evidence for a differential effect of intra-arterial therapy with regard to the size of Solitaire retrievers.In patients with intracranial atherosclerotic disease,favorable reperfusion was associated with deployment of a small stent.