BACKGROUND: Insight in differences in patient outcomes between endovascular thrombectomy (EVT) centers can help to improve stroke care. We assessed between-center variation in functional outcome of patients with acute ischemic stroke who were treated with EVT. We analyzed to what extent this variation may be explained by modifiable center characteristics. METHODS: We used nationwide registry data of patients with stroke treated with EVT in the Netherlands and in the Czech Republic. Primary outcome was modified Rankin Scale score at 90 days as an indicator of disability. We used multilevel ordinal logistic regression to quantify the between-center variation in outcomes and the impact of patient and center characteristics. Between-center variation was expressed as the relative difference in odds of a more favorable modified Rankin Scale score between a relatively better performing center (75th percentile) and a relatively worse performing center (25th percentile). RESULTS: We included a total of 4518 patients treated in 33 centers. Adjusted for patient characteristics, the odds of a more favorable outcome in a center at the 75th percentile of the outcome distribution were 1.46 times higher (95% CI, 1.31-1.70) than the odds in a center at the 25th percentile. Adjustment for center characteristics, including the median time between stroke onset and reperfusion per center, decreased this relative difference in odds to 1.30 (95% CI, 1.18-1.50, P=0.01). This translates into an absolute difference in likelihood of good functional outcome of 8% after adjustment for patient characteristics and to 5% after further adjustment for modifiable center characteristics. CONCLUSIONS: The considerable between-center variation in patient outcomes after EVT for acute ischemic stroke could be largely explained by center-specific characteristics, such as time to reperfusion. Improvement of these parameters may likely result in a decrease in center-specific differences, and an overall improvement in outcome of patients with acute ischemic stroke.

• Keywords
• hospitals, multicenter study, quality improvement, stroke, thrombectomy,
• MeSH
• Stroke * diagnosis   etiology   therapy   MeSH
• Endovascular Procedures * adverse effects   MeSH
• Ischemic Stroke * MeSH
• Brain Ischemia * diagnosis   etiology   therapy   MeSH
• Humans MeSH
• Registries MeSH
• Treatment Outcome MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Research Support, Non-U.S. Gov't MeSH

OBJECTIVE: To undertake an effectiveness and safety analysis of EVT in patients with LVO and NIH Stroke Scale (NIHSS) score ≤6 using datasets of multicenter and multinational nature. METHODS: We pooled patients with anterior circulation occlusion from 3 prospective international cohorts. Patients were eligible if presentation occurred within 12 hours from last known well and baseline NIHSS ≤6. Primary outcome was modified Rankin Scale (mRS) score 0-1 at 90 days. Secondary outcomes included neurologic deterioration at 24 hours (change in NIHSS of ≥2 points), mRS 0-2 at 90 days, and 90-day all-cause mortality. We used propensity score matching to adjust for nonrandomized treatment allocation. RESULTS: Among 236 patients who fit inclusion criteria, 139 received EVT and 97 received medical management. Compared to medical management, the EVT group was younger (65 vs 72 years; p < 0.001), had more proximal occlusions (p < 0.001), and less frequently received concurrent IV thrombolysis (57.7% vs 71.2%; p = 0.04). After propensity score matching, clinical outcomes between the 2 groups were not significantly different. EVT patients had an 8.6% (95% confidence interval [CI] -8.8% to 26.1%) higher rate of excellent 90-day outcome, despite a 22.3% (95% CI, 3.0%-41.6%) higher risk of neurologic deterioration at 24 hours. CONCLUSIONS: EVT for LVO in patients with low NIHSS score was associated with increased risk of neurologic deterioration at 24 hours. However, both EVT and medical management resulted in similar proportions of excellent clinical outcomes at 90 days. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that for patients with acute anterior circulation ischemic strokes and LVO with NIHSS < 6, EVT and medical management result in similar outcomes at 90 days.

• MeSH
• Arterial Occlusive Diseases therapy   MeSH
• Endovascular Procedures * statistics & numerical data   MeSH
• Fibrinolytic Agents administration & dosage   MeSH
• Outcome Assessment, Health Care * statistics & numerical data   MeSH
• Ischemic Stroke drug therapy   therapy   MeSH
• Middle Aged MeSH
• Humans MeSH
• Follow-Up Studies MeSH
• Cerebral Arterial Diseases therapy   MeSH
• Disease Progression * MeSH
• Registries * MeSH
• Aged, 80 and over MeSH
• Aged MeSH
• Severity of Illness Index * MeSH
• Thrombectomy * statistics & numerical data   MeSH
• Check Tag
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Aged, 80 and over MeSH
• Aged MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Multicenter Study MeSH
• Observational Study MeSH
• Comparative Study MeSH
• Names of Substances
• Fibrinolytic Agents MeSH

This video shows an urgent microsurgical embolectomy of the inferior division of the left middle cerebral artery in a patient treated by intravenous thrombolysis (IVT). Patient was eligible for endovascular mechanical thrombectomy1; however, the interventional radiologist was not comfortable performing the procedure given prior unsuccessful attempts to remove a calcified cerebral embolus.2 A 75-yr-old female presented with an acute ischemic stroke with isolated aphasia (NIHSS 9). Using the drip-and-ship concept, IVT (0.9 mg/kg rt-PA) was administered in a regional hospital. Fifty-five minutes after a complete recovery following IVT, multiple transient ischemic attacks of aphasia were observed. While the patient was a candidate for mechanical thrombectomy based on CT perfusion imaging, given the unsuccessful reports in the literature and the interventional radiologist's experience, the decision was made to offer microsurgical embolectomy of the calcified cerebral embolus.3 Informed consent for the procedure was obtained directly from the patient. Calcified, crumbly embolus was removed from a 5 mm longitudinal arteriotomy. The arteriotomy was sutured with interrupted 10-0 suture. Initial flow after the embolectomy was 6.5 mL/min. Upon inspection, a distal kink was found in the M2 and after repositioning, flow improved to 35 mL/min. Postoperative CT angiography documented complete recanalization. The clinical findings completely resolved (NIHSS 0) within 12 hr and remained unchanged at 3 mo and 1 yr. Informed consent was obtained from the patient for use of media for educational and publication purposes.

• Keywords
• Brain ischemia, Embolectomy, Microsurgery, Middle cerebral artery, Perfusion imaging, Stroke, Thrombectomy, Tissue plasminogen activator,
• Publication type
• Journal Article MeSH

BACKGROUND We investigated the properties and effects of 5 mechanical thrombectomy procedures in patients with acute ischemic stroke. The relationships between the type of procedure, the time required, the success of recanalization, and the clinical outcome were analyzed. MATERIAL AND METHODS This prospective comparative analysis included 500 patients with acute ischemic stroke and large-vessel occlusion. We compared contact aspiration thrombectomy (ADAPT, n=100), stent retriever first line (SRFL, n=196), the Solumbra technique (n=64), mechanical thrombectomy plus stent implantation (n=81), and a combined procedure (n=59). RESULTS ADAPT provided shorter procedure (P<0.001) and recanalization times (P<0.001) than the other techniques. Better clinical outcome was achieved for ischemia in the anterior circulation than ischemia in the posterior fossa (P<0.001). Compared to the other techniques, patients treated with ADAPT procedure had increased odds of achieving better mTICI scores (P=0.002) and clinical outcome (NIHSS) after 7 days (P=0.003); patients treated with SRFL had increased odds of achieving better long-term clinical status (3M-mRS=0-2; P=0.040). Patients with SRFL and intravenous thrombolysis (IVT) had increased odds of better clinical status (3M-mRS=0-2; P=0.031) and decreased odds of death (P=0.005) compared to patients with SRFL without IVT. The other treatment approaches had no additional effect of IVT. Patients with SRFL with a mothership transfer had increased odds of achieving favorable clinical outcome (3M-mRS) compared to SRFL with the drip-and-ship transfer paradigm (P=0.015). CONCLUSIONS Our results showed that ADAPT and SRFL provided significantly better outcomes compared to the other examined techniques. A mothership transfer and IVT administration contributed to the success of the SRFL approach.

• MeSH
• Stroke surgery   therapy   MeSH
• Brain Ischemia therapy   MeSH
• Ischemia therapy   MeSH
• Middle Aged MeSH
• Humans MeSH
• Mechanical Thrombolysis methods   MeSH
• Prospective Studies MeSH
• Aged MeSH
• Stents MeSH
• Thrombectomy methods   MeSH
• Thrombolytic Therapy methods   MeSH
• Treatment Outcome MeSH
• Check Tag
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Aged MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Comparative Study MeSH