BACKGROUND: Acute ischemic stroke (AIS) due to anterior circulation tandem lesion (TL) remains a technical and clinical challenge for endovascular treatment (EVT). Conflicting results from observational studies and missing evidence from the randomized trials led us to report a recent real-world multicenter clinical experience and evaluate possible predictors of good outcome after EVT. METHODS: We analyzed all AIS patients with TL enrolled in the prospective national study METRICS (Mechanical Thrombectomy Quality Indicators Study in Czech Stroke Centers). A good 3-month clinical outcome was scored as 0-2 points in modified Rankin Scale (mRS), achieved recanalization using the Thrombolysis In Cerebral Infarction (TICI) scale and symptomatic intracerebral hemorrhage (sICH) according to the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) criteria. RESULTS: Of 1178 patients enrolled in METRICS, 194 (19.2%) (59.8% males, mean age 68.7±11.5 years) were treated for TL. They did not differ in mRS 0-2 (48.7% vs 46.7%; p=0.616), mortality (17.3% vs 22.7%; p=0.103) and sICH (4.7% vs 5.1%; p=0.809) from those with single occlusion (SO). More TL patients with prior intravenous thrombolysis (IVT) reached TICI 3 (70.3% vs 50.8%; p=0.012) and mRS 0-2 (55.4% vs 34.4%; p=0.007) than those without IVT. No difference was found in the rate of sICH (6.2% vs 1.6%; p=0.276). Multivariate logistic regression analysis showed prior IVT as a predictor of mRS 0-2 after adjustment for potential confounders (OR 3.818, 95% CI 1.614 to 9.030, p=0.002). CONCLUSION: Patients with TL did not differ from those with SO in outcomes after EVT. TL patients with prior IVT had more complete recanalization and mRS 0-2 and IVT was found to be a predictor of good outcome after EVT.
- MeSH
- benchmarking MeSH
- cerebrální krvácení etiologie MeSH
- cévní mozková příhoda * diagnostické zobrazování chirurgie MeSH
- endovaskulární výkony * metody MeSH
- fibrinolytika MeSH
- ischemická cévní mozková příhoda * diagnostické zobrazování chirurgie MeSH
- ischemie mozku * diagnostické zobrazování terapie etiologie MeSH
- lidé středního věku MeSH
- lidé MeSH
- prospektivní studie MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- trombektomie škodlivé účinky MeSH
- trombolytická terapie metody MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
Ischemická cévní mozková příhoda je závažný stav zatížený vysokou mortalitou a značně vysokým rizikem trvalých funkčních následků. Léčba akutní ischemické cévní mozkové příhody prodělala trombektomiepři využití mechanické k okluze velkých cév mozku v porovnání s nejlepší medikamentózní terapií zahrnující systémovou trombolýzu, a zásadně tak změnily dosud zavedené paradigma léčby. V současné době je k dispozici široký výběr nástrojů pro mechanickou a nové jsou ve vývoji. Tato práce si klade za cíl shrnout současné možnosti léčby akutní ischemické cévní mozkové příhody metodami mechanické trombektomie a nastínit i další aspekty terapie tohoto onemocnění.
Ischemic stroke is a severe condition with a high mortality and a serious risk of permanent functional dis- ability. The treatment of acute ischemic stroke has undergone a number of major changes in recent years - from systemic thrombolysis to the wide range of current mechanical thrombectomy modalities. Studies such as MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME and others have demonstrated improved outcomes in patients with large vessel occlusion when mechanical thrombectomy was used compared with best medical treatment including systemic thrombolysis. These results have completely changed the treatment paradigm. Currently, a wide variety of endovascular tools are available for mechanical thrombectomy and new ones are still under development. This paper aims to summarize the current options for the treatment of ischemic stroke by mechanical thrombectomy and to outline other therapy aspects of this disease.
- MeSH
- ischemická cévní mozková příhoda * dějiny terapie MeSH
- klinická studie jako téma MeSH
- lidé MeSH
- mechanická trombolýza * metody ošetřování přístrojové vybavení škodlivé účinky MeSH
- trombektomie metody ošetřování přístrojové vybavení škodlivé účinky MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- přehledy MeSH
PURPOSE: To investigate the safety and efficacy of baseline antiplatelet treatment in patients with acute ischemic stroke (AIS) undergoing mechanical thrombectomy (MT). MATERIALS AND METHODS: Baseline use of antiplatelet medication before MT for (AIS) may provide benefit on reperfusion and clinical outcome but could also carry an increased risk of intracranial hemorrhage (ICH). All consecutive patients with AIS and treated with MT with and without intravenous thrombolysis (IVT) between January 2012 and December 2019 in all centers performing MT nationwide were reviewed. Data were prospectively collected in national registries (eg, SITS-TBY and RES-Q). Primary outcome was functional independence (modified Rankin Scale 0-2) at 3 months; secondary outcome was ICH. RESULTS: Of the 4,351 patients who underwent MT, 1,750 (40%) and 666 (15%) were excluded owing to missing data from the functional independence and ICH outcome cohorts, respectively. In the functional independence cohort (n = 2,601), 771 (30%) patients received antiplatelets before MT. Favorable outcome did not differ in any antiplatelet, aspirin, and clopidogrel groups when compared with that in the no-antiplatelet group: odds ratio (OR), 1.00 (95% CI, 0.84-1.20); OR, 1.05 (95% CI, 0.86-1.27); and OR, 0.88 (95% CI, 0.55-1.41), respectively. In the ICH cohort (n = 3,685), 1095 (30%) patients received antiplatelets before MT. The rates of ICH did not increase in any treatment options (any antiplatelet, aspirin, clopidogrel, and dual antiplatelet groups) when compared with those in the no-antiplatelet group: OR, 1.03 (95% CI, 0.87-1.21); OR, 0.99 (95% CI, 0.83-1.18); OR, 1.10 (95% CI, 0.82-1.47); and OR, 1.43 (95% CI, 0.87-2.33), respectively. CONCLUSIONS: Antiplatelet monotherapy before MT did not improve functional independence or increase the risk of ICH.
- MeSH
- Aspirin škodlivé účinky MeSH
- cévní mozková příhoda * diagnostické zobrazování terapie MeSH
- intrakraniální krvácení chemicky indukované MeSH
- ischemická cévní mozková příhoda * diagnostické zobrazování terapie MeSH
- ischemie mozku * diagnostické zobrazování terapie MeSH
- klopidogrel škodlivé účinky MeSH
- lidé MeSH
- mechanická trombolýza * škodlivé účinky MeSH
- trombektomie škodlivé účinky MeSH
- trombolytická terapie škodlivé účinky MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
BACKGROUND: Despite all the gains that have been achieved with endovascular mechanical thrombectomy revascularization and intravenous thrombolysis logistics since 2015, there is still a subgroup of patients with salvageable brain tissue for whom persistent emergent large vessel occlusion portends a catastrophic outcome. OBJECTIVE: To test the safety and efficacy of emergent microsurgical intervention in patients with acute ischemic stroke and symptomatic middle cerebral artery occlusion after failure of mechanical thrombectomy. METHODS: A prospective two-center cohort study was conducted. Patients with acute ischemic stroke and middle cerebral artery occlusion for whom recanalization failed at center 1 were randomly allocated to the microsurgical intervention group (MSIG) or control group 1 (CG1). All similar patients at center 2 were included in the control group 2 (CG2) with no surgical intervention. Microsurgical embolectomy and/or extracranial-intracranial bypass was performed in all MSIG patients at center 1. RESULTS: A total of 47 patients were enrolled in the study: 22 at center 1 (12 allocated to the MSIG and 10 to the CG1) and 25 patients at center 2 (CG2). MSIG group patients showed a better clinical outcome on day 90 after the stroke, where a modified Rankin Scale score of 0-2 was reached in 7 (58.3%) of 12 patients compared with 1/10 (10.0%) patients in the CG1 and 3/12 (12.0%) in the CG2. CONCLUSIONS: This study demonstrated the potential for existing microsurgical techniques to provide good outcomes in 58% of microsurgically treated patients as a third-tier option.
- MeSH
- arteria carotis interna chirurgie MeSH
- cévní mozková příhoda * diagnostické zobrazování chirurgie MeSH
- endovaskulární výkony * metody MeSH
- infarkt arteria cerebri media MeSH
- ischemická cévní mozková příhoda * MeSH
- ischemie mozku * diagnostické zobrazování chirurgie MeSH
- kohortové studie MeSH
- lidé MeSH
- prospektivní studie MeSH
- retrospektivní studie MeSH
- trombektomie škodlivé účinky metody MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- randomizované kontrolované studie MeSH
INTRODUCTION: There are today two models of transporting patients with acute ischaemic stroke because of large artery occlusion (AIS-LVO): mothership (MS) and drip-and-ship (DS). Our aim was to evaluate our ongoing transport strategy (OT), which is an MS/DS hybrid. In our OT, the patient is transported directly to the CT of the Primary Stroke Centre (PSC), where intravenous thrombolysis (IVT) is administered. The patient then continues without delay to a Comprehensive Stroke Centre (CSC) with the same medical rescue team (MRT). The distance between our centres is 73 km. MATERIAL AND METHODS: We retrospectively analysed data of 100 consecutive AIS-LVO patients treated with mechanical thrombectomy (MT) between January 2017 and October 2019. OT, MS and DS groups were compared. 31 patients were transported as MS, 32 as DS, and 37 as OT. RESULTS: DS had significantly longer time to groin puncture (185 min) compared to OT and MS (p < 0.0001). OT shortened time almost to MS level (OT 124 min, MS 110 min, p = 0.002. Time to IVT administration (from MRT departure) differed statistically significantly in favour of OT (OT 27 min, MS 63 min, p < 0.0001). Logistical change in PSC had a significant effect on decreasing the door-to-needle time (DNT) median from 37 min to 11 min (p < 0.0001). DNT reduction also occurred in patients with AIS and without an indication for MT. CONCLUSIONS: OT is highly effective, significantly reducing the time to IVT administration, and combining all the benefits, while eliminating all the disadvantages, of DS and MS. The OT concept gives all indicated patients a chance for MT to be performed, and does not overload the performing centre.
- MeSH
- cévní mozková příhoda * farmakoterapie etiologie MeSH
- ischemická cévní mozková příhoda * MeSH
- ischemie mozku * farmakoterapie MeSH
- lidé MeSH
- retrospektivní studie MeSH
- trombektomie škodlivé účinky MeSH
- trombolytická terapie škodlivé účinky MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
BACKGROUND: It is unclear whether more effective forms of thrombus removal than current aspiration catheters would lead to improved outcomes. We sought to evaluate the prognostic role of residual thrombus burden (rTB), after manual thrombectomy, in patients undergoing primary percutaneous coronary intervention with routine manual thrombectomy in the TOTAL trial (Thrombectomy Versus PCI Alone). METHODS: This is a single-arm analysis of patients from the TOTAL trial who underwent routine manual aspiration thrombectomy. The rTB was quantified by an angiographic core laboratory using the Thrombolysis in Myocardial Infarction criteria and validated using existing optical coherent tomography data. Large rTB was defined as grade ≥3. The primary outcome was death from cardiovascular causes, recurrent myocardial infarction, cardiogenic shock, or new or worsening heart failure within 180 days. RESULTS: Of 5033 patients randomized to routine thrombectomy, 2869 patients had quantifiable rTB (1014 [35%] had large rTB). Patients with large rTB were more likely to have hypertension, previous percutaneous coronary intervention, myocardial infarction, or Killip class III on presentation but less likely to have Killip class I. The primary outcome occurred more frequently in patients with large rTB, even after adjustment for known risk predictors (8.6% versus 4.6%; adjusted hazard ratio, 1.83 [95% CI, 1.34-2.48]). These patients also had a higher risk of cardiovascular death (adjusted hazard ratio, 1.83 [95% CI, 1.13-2.95]), cardiogenic shock (adjusted hazard ratio, 2.02 [95% CI, 1.08-3.76]), and heart failure (adjusted hazard ratio, 1.74 [95% CI, 1.02-2.96]) but not myocardial infarction or stroke. CONCLUSIONS: Large rTB is a common finding in primary percutaneous coronary intervention and is associated with increased risk of adverse cardiovascular outcomes, including cardiovascular death. Future technologies offering better thrombus removal than current devices may decrease or even eliminate the risk associated with rTB. This, potentially, can turn into a strategic option to be studied in clinical trials. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT01149044.
- MeSH
- infarkt myokardu * komplikace diagnostické zobrazování terapie MeSH
- kardiogenní šok etiologie terapie MeSH
- koronární angioplastika * MeSH
- koronární trombóza * diagnostické zobrazování terapie MeSH
- lidé MeSH
- prognóza MeSH
- srdeční selhání * diagnostické zobrazování terapie MeSH
- trombektomie škodlivé účinky metody MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
- randomizované kontrolované studie MeSH
BACKGROUND: To investigate perioperative complication rates at radical nephrectomy (RN) according to inferior vena cava thrombectomy (IVC-T) status and stage (metastatic vs non-metastatic) within kidney cancer patients. MATERIALS AND METHODS: We ascertained perioperative complication rates within the National Inpatient Sample database (2016-2019). First, log-link linear Generalized Estimating Equation function (GEE) regression models (adjusted for hospital clustering and weighted for discharge disposition) tested complication rates in IVC-T patients, according to metastatic stage. Subsequently, a subgroup analysis relied on RN patients with or without IVC-T. Here, multivariable logistic regression models tested complication rates in RN patients according to IVC-T status, after propensity score matching including metastatic stage. RESULTS: Of 26,299 RN patients, 461 (2%) patients underwent IVC-T. Of those, 252 (55%) were non-metastatic vs 209 (45%) were metastatic. Rates of acute kidney injury (AKI), transfusion, cardiac, thromboembolic and other medical complications in non-metastatic vs metastatic patients were 40 vs 40%, 25 vs 22%, 21 vs 23%, 19 vs 14% and 38 vs 40%, respectively (all p ≥ 0.2). Metastatic stage in IVC-T patients did not predict differences in complications in log-link linear GEE regression models (all p > 0.1). However, in logistic regression models with propensity score matching, relying on the overall cohort of RN patients, IVC-T status was associated with higher complication rates (all p < 0.001): AKI (Odds ratio [OR]:2.60; 95%-CI [95%-Confidence interval: 1.97-3.44), transfusions (OR:2.40; 95%-CI: 1.72-3.36), cardiac (OR:2.27; 95%-CI: 1.49-3.47), thromboembolic (OR:9.07; 95%-CI: 5.21-16.58) and other medical complications (OR:2.01; 95%-CI: 1.52-2.66). CONCLUSIONS: The current analyses indicate that presence of concomitant IVC-T is associated with higher complication rate at RN. Conversely, metastatic stage has no effect on recorded complication rates.
- MeSH
- akutní poškození ledvin * etiologie patologie chirurgie MeSH
- karcinom z renálních buněk * patologie chirurgie MeSH
- lidé MeSH
- nádory ledvin * patologie chirurgie MeSH
- nefrektomie škodlivé účinky MeSH
- retrospektivní studie MeSH
- trombektomie škodlivé účinky MeSH
- vena cava inferior patologie chirurgie MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
BACKGROUND AND PURPOSE: Rigorous and regular evaluation of defined quality indicators is crucial for further improvement of both technical and clinical results after mechanical thrombectomy (MT) for acute ischemic stroke (AIS). Following the recent international multi-society consensus quality indicators, we aimed to assess trend in these indicators on national level. MATERIAL AND METHODS: The prospective multicenter study (METRICS) was conducted in Czech Republic (CR) in year 2019. All participating centers collected technical and clinical data including defined quality indicators and results were subsequently compared with those from year 2016. RESULTS: In the 2019, 1375 MT were performed in the CR and 1178 (86%) patients (50.3% males, mean age 70.5 ± 13.0 years) were analyzed. Recanalization (TICI 2b-3) was achieved in 83.7% of patients and 46.2% of patients had good 3-month clinical outcome. Following time intervals were shortened in comparison to 2016: "hospital arrival - GP" (77 vs. 53 min; p<0.0001), "hospital arrival - maximal achieved recanalization" (122 vs. 93 min; p<0.0001), and "stroke onset - maximal achieved recanalization" (240 vs. 229 min; p p<0.0001). More patients with tandem occlusion were treated in 2019 (7.8 vs. 16.5%; p<0.0001) and more secondary transports were in 2019 (31.3 vs. 37.8%; p=0.002). No difference was found in 3-month clinical outcome and in the rate of periprocedural complications. Results of the METRICS study met all criteria of multi-society consensus quality indicators. CONCLUSION: Nationwide comparison between 2016 and 2019 showed improvement in the key time intervals, but without better overall clinical outcomes after MT.
- MeSH
- benchmarking MeSH
- cévní mozková příhoda * diagnostické zobrazování terapie MeSH
- ischemická cévní mozková příhoda * MeSH
- ischemie mozku * diagnostické zobrazování terapie MeSH
- lidé středního věku MeSH
- lidé MeSH
- prospektivní studie MeSH
- retrospektivní studie MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- trombektomie škodlivé účinky metody MeSH
- ukazatele kvality zdravotní péče MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
- Geografické názvy
- Česká republika MeSH
BACKGROUND AND PURPOSE: Thrombus embolization during mechanical thrombectomy occurs in up to 9% of cases, making secondary medium vessel occlusions of particular interest to neurointerventionalists. We sought to gain insight into the current endovascular treatment approaches for secondary medium vessel occlusion stroke in an international case-based survey because there are currently no clear recommendations for endovascular treatment in these patients. MATERIALS AND METHODS: Survey participants were presented with 3 cases involving secondary medium vessel occlusions, each consisting of 3 case vignettes with changes in the patient's neurologic status (improvement, no change, unable to assess). Multivariable logistic regression analyses clustered by the respondent's identity were used to assess factors influencing the decision to treat. RESULTS: In total, 366 physicians (56 women, 308 men, 2 undisclosed) from 44 countries provided 3294 responses to 9 scenarios. Most (54.1%, 1782/3294) were in favor of endovascular treatment. Participants were more likely to treat occlusions in the anterior M2/3 (74.3%; risk ratio = 2.62; 95% CI, 2.27-3.03) or A3 (59.7%; risk ratio = 2.11; 95% CI, 1.83-2.42) segment compared with the M3/4 segment (28.3%; reference). Physicians were less likely to pursue endovascular treatment in patients who showed neurologic improvement than in patients with an unchanged neurologic deficit (49.9% versus 57.0% responses in favor of endovascular treatment, respectively; risk ratio = 0.88, 95% CI, 0.83-0.92). Interventionalists and more experienced physicians were more likely to treat secondary medium vessel occlusions. CONCLUSIONS: Physicians' willingness to treat secondary medium vessel occlusions endovascularly is limited and varies per occlusion location and change in neurologic status. More evidence on the safety and efficacy of endovascular treatment for secondary medium vessel occlusion stroke is needed.
- MeSH
- arteriální okluzní nemoci * komplikace MeSH
- cévní mozková příhoda * diagnostické zobrazování etiologie chirurgie MeSH
- endovaskulární výkony * škodlivé účinky MeSH
- ischemická cévní mozková příhoda * MeSH
- lidé MeSH
- trombektomie škodlivé účinky MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
OBJECTIVES: This study analyzed the learning curve effect when a new stroke thrombectomy program was initiated in a cardiac cath lab in close cooperation with neurologists and radiologists. BACKGROUND: Mechanical thrombectomy has proven to be the best treatment option for ischemic stroke patients, but this method is not widely available. METHODS: An endovascular treatment program for acute ischemic strokes was established in the cardiac cath lab of a tertiary university hospital in 2012. The decision to perform catheter-based thrombectomy was made by a neurologist and was based on acute stroke clinical symptoms and computed tomography angiographic findings. Patients with a large vessel occlusion of either anterior or posterior circulation were enrolled. The primary endpoint was the functional neurological outcome (Modified Rankin Scale [mRS] score) of the patient at 3 months. A total of 333 patients were enrolled between October 2012 and December 2019. RESULTS: The clinical (mRS) outcomes did not vary significantly across years 2012 to 2019 (mRS 0 to 2 was achieved in 47.9% of patients). Symptomatic intracerebral hemorrhage occurred in 19 patients (5.7%). Embolization in a new vascular territory occurred in 6 patients (1.8%). CONCLUSIONS: When a catheter-based thrombectomy program was initiated in an experienced cardiac cath lab in close cooperation between cardiologists, neurologists, and radiologists, outcomes were comparable to those of neuroradiology centers. The desired clinical results were achieved from the onset of the program, without any signs of a learning curve effect. These findings support the potential role of interventional cardiac cath labs in the treatment of acute stroke in regions where this therapy is not readily available due to the lack of neurointerventionalists.
