Background No randomized trial has investigated the effect of mechanical thrombectomy (MT) alone in patients with acute stroke. There are conflicting results as to whether prior intravenous thrombolysis (IVT) facilitates subsequent MT, and data in patients treated with MT alone owing to contraindications to IVT are limited. Objective To compare consecutive patients treated with MT alone or with preceding IVT in a large tertiary neurointerventional center, with special emphasis on contraindications to IVT. Methods Retrospective analysis of 283 consecutive patients with acute ischemic stroke treated with MT in a tertiary neurovascular center over 14 months. Data on characteristics of periprocedural times, recanalization rate, complications, and long-term functional outcome were collected prospectively. Results Information on prior IVT and functional outcome was available in 250 patients. Mean (SD) follow-up period was 5.7 (5.1) months and 105 (42%) patients received both IVT and MT. No significant differences were found in successful recanalization rates (Thrombolysis in Cerebral Infarction (TICI) 2b/3, 73.8% vs 73.1, p=0.952), complication rates, and long-term favorable outcome (modified Rankin Scale 0–2, 35.2% vs 40%, p=0.444) between patients receiving MT plus IVT and those receiving MT alone. A favorable outcome in patients directly treated with MT alone who were eligible for IVT was achieved in 48.2%. Thrombectomy was safe and resulted in a favorable outcome in 32% of patients with absolute contraindications to IVT. Conclusions Preceding use of IVT was not an independent predictor of favorable outcome in patients with acute stroke treated with MT and complication rates did not differ whether or not IVT was used. MT is safe and achieved a favorable outcome in one-third of patients with stroke ineligible for IVT.

https://jnis.bmj.com/content/neurintsurg/9/3/229.full.pdf

Comparison of outcome and interventional complication rate in patients with acute stroke treated with mechanical thrombectomy with and without bridging thrombolysis.

Background and purpose In contrast to anterior circulation stroke (ACS), there is no evidence from randomized trials that mechanical thrombectomy (MT) with modern stent retrievers or thromboaspiration is safe and effective in posterior circulation stroke (PCS) Methods The present analysis was based on the prospective multicentre Registry on Revascularization in Ischemic Stroke Patients (REVASK) in Germany Demographic data, periprocedural times and complications, recanalization rates, and functional outcome at discharge and after 3 months were compared between 139 consecutive patients with PCS (849% basilar artery, 165% vertebral artery and 43% posterior cerebral artery occlusion) and 961 patients with ACS treated with MT Results Compared to ACS, PCS patients were significantly younger (65 vs 69 years, P = 0021) and had a lower median National Institutes of Health Stroke Scale (NIHSS) score at baseline (12 vs 15, P = 0024) Patients with PCS had a significantly longer time delay between symptom onset and both start and end of the MT procedure Successful recanalization and thrombectomy passes did not significantly differ between the two groups No symptomatic intracranial haemorrhage occurred in PCS compared to 3% in ACS (P = 0010) The median NIHSS score at discharge was 3 in PCS and 4 in ACS Favourable functional outcome at 3 months (modified Rankin Scale 0-2 380% vs 426%, P = 0392) and mortality (337% vs 308%, P = 0539) did not differ significantly between PCS and ACS Conclusions The study suggests that MT in PCS shows a lower risk of symptomatic intracranial haemorrhage and similar effectiveness compared to ACS PCS patients also seem to benefit from MT started beyond 6 h after symptom onset

Thrombectomy in posterior circulation stroke: differences in procedures and outcome compared to anterior circulation stroke in the prospective multicentre REVASK registry.

Ischemic stroke is one of the leading causes for death and disability worldwide. In patients with large space-occupying infarction, the subsequent edema complicated by transtentorial herniation poses a lethal threat. Especially in patients with malignant middle cerebral artery infarction, brain swelling secondary to the vessel occlusion is associated with high mortality. By decompressive craniectomy, a significant proportion of the skull is surgically removed, allowing the ischemic tissue to shift through the surgical defect rather than to the unaffected regions of the brain, thus avoiding secondary damage due to increased intracranial pressure. Several studies have shown that decompressive craniectomy reduces the mortality rate in patients with malignant cerebral artery infarction. However, this is done for the cost of a higher proportion of patients who survive with severe disability. In this review, we will describe the clinical and radiological features of malignant middle cerebral artery infarction and the role of decompressive craniectomy and additional therapies in this condition. We will also discuss large cerebellar stroke and the possibilities of suboccipital craniectomy.

/pdf/role-of-decompressive-craniectomy-in-ischemic-stroke-4winbbda46.pdf

Role of Decompressive Craniectomy in Ischemic Stroke

Mechanical thrombectomy (MT) is a new evidence-based treatment option for large vessel occlusion in the anterior brain circulation. Using comprehensive administrative data from Germany, we analysed the nationwide development of intravenous thrombolysis (IVT) and MT in Germany between 2010 and 2016. We considered all documented cases (n = 1,515,634) with a main diagnosis of the ICD-10-GM code I63 (ischemic stroke) and identified specific stroke recanalization therapy by using the corresponding Operating and Procedure Key for systemic thrombolysis and mechanical thrombectomy out of the DRG statistics. Regional analyses are based on data from the 413 German administrative districts and cities and the obligatory quality reports of all hospitals. We distinguished between rates of MT related to place of residence of patients and place of treatment. Coded ischemic strokes increased by 10.2% from 2010 (n = 206.688) to 2016 (n = 227.687). The rate of IVT increased from 8.9% in 2010 to 14.9% in 2016 and the rate of MT increased from 0.8% in 2010 to 4.7% in 2016 with a strong increase in 2015 and 2016. There was a high regional variability of MT according to place of residence of patients between 0 and 11.2% in 2016 with significant lower treatment rates in rural compared to urban areas (3.8 vs 5.4%). Mean age of patients treated with MT increased from 67.8 years in 2010 to 73.3 years in 2016 and almost reached the mean age of IVT treated patients (74.4 years). The number of hospitals coding MT increased from 91 to 193 from 2010 to 2016, but 80% of all MT procedures were performed in neurointerventional centers with ≥50 procedures/year in 2016. The rate of IVT in patients with acute ischemic stroke in Germany continues to rise and has reached 14.9% nationwide. The increase of MT is even more pronounced and was triggered by the evidence after publication of the MT randomized trials. There is still a high regional variability with significant lower MT rates in rural areas.

/pdf/distribution-and-evolution-of-acute-interventional-ischemic-3aho1ictkj.pdf

Distribution and evolution of acute interventional ischemic stroke treatment in Germany from 2010 to 2016

Interdisziplinäres neurovaskuläres Netzwerk

Die mechanische Thrombektomie (MT) stellt eine evidenzbasierte Therapieform bei Patienten mit akutem Hirninfarkt dar. Eine flachendeckende qualitative Bereitstellung der MT fur alle infrage kommenden Patienten innerhalb der kurzest moglichen Zeit stellt eine grose Herausforderung dar. Analyse der bundesweiten MT-Versorgungsrealitat anhand einer regionalisierten und klinikbezogenen Auswertung. Administrative Versorgungsdaten wurden anhand der DRG-Statistiken und der strukturierten Qualitatsberichte der Krankenhauser fur die Berichtsjahre 2010 und 2014 ausgewertet. Bezogen auf die Fallzahlen von Patienten mit akutem Hirninfarkt wurden die Raten und Veranderungen an systemischer Thrombolyse (STL) und MT in den 413 Kreisen und kreisfreien Stadten analysiert. Die Rate an rekanalisierenden Behandlungen ist im Zeitraum von 2010 zu 2014 bundesweit gestiegen (STL-Rate von 8,0 auf 11,6 %; MT-Rate von 0,7 auf 2,3 %). Je nach Wohnort des Patienten ergaben sich dabei hohe Streubreiten (STL = 3,4–26,7 %; MT = 0–7,4 %). Im Jahr 2014 wurden 5526 MT bei 244.757 Hirninfarkten kodiert. Insgesamt wurden 134 Krankenhausern mit mehr als 2 MT/Jahr ermittelt. 21 % aller MT wurden in nur 7 Kliniken mit >100 MT/Jahr durchgefuhrt. In 308 (75 %) der 413 Regionen wurde keine MT durchgefuhrt. Durch ein enges Netz an zertifizierten Stroke-Units mit flachendeckender Verfugbarkeit der STL sind in Deutschland ausgezeichnete strukturelle Voraussetzungen zur Behandlung von Patienten mit akutem Hirninfarkt etabliert. Bezogen auf das Ziel einer ubiquitaren Verfugbarkeit der MT ist noch Optimierungsbedarf erkennbar. Trotz Zunahme der Anzahl an Kliniken mit der Moglichkeit zur MT, ist ein Trend hin zu Interventionszentren mit uberregionalem Einzugsgebiet festzustellen.

[Availability of mechanical thrombectomy for acute stroke : Analysis of the health care reality in Germany].

Hintergrund: In der Akutbehandlung des ischamischen Schlaganfalls sind fur die Thrombolyse und die Stroke-Unit-Behandlung positive Effekte auf den Krankheitsverlauf nachgewiesen. Datenanalysen zeigen, dass die Behandlungsquoten regional stark variieren und meist unter einer erstrebenswerten Versorgungsquote bleiben. In das Verfahren der mechanischen Rekanalisierung wird viel Hoffnung gesetzt, auch wenn randomisierte Studien zu Komplikationen und Outcome bisher fehlen. Im Ruhrgebiet haben sich 27 neurologische und 9 neuroradiologische Kliniken zum „Neurovaskularen Netz Ruhr“ (NNR) zusammengeschlossen, um die genannten Therapiemodalitaten moglichst vielen Patienten verfugbar zu machen. Methoden: Darstellung der Aktivitaten zur Bildung eines uberregionalen neurovaskularen Netzwerks zur Verbesserung der Versorgungsqualitat akuter Schlaganfallpatienten, insbesondere zur flachendeckenden Bereitstellung spezifischer Behandlungsmoglichkeiten. Ergebnisse: Vier Faktoren der strukturierten Netzwerkbildung werden identifiziert und dargestellt: Diskussion: Unterschiedliche Konzepte regionaler Versorgungsstrukturen versuchen die Lyserate zu erhohen und das Potenzial interventioneller Behandlungsansatze fur moglichst viele Patienten umzusetzen. Neben der Zentrumsbildung mit maximaler Expertise konnen moglicherweise auch Netzwerke, die auf die Optimierung der Behandlungsstrukturen und Patientenflusse abzielen, dies realisieren. Die Versorgungsstruktur im Ruhrgebiet mit vielen neurologischen und neuroradiologischen Kliniken ermoglicht eine modellhafte Vernetzung durch einheitliche Fachstandards und strukturelle Masnahmen zur flachendeckenden und durchgangigen Bereitstellung interventioneller Verfahren. Die Bewertung der durchgefuhrten Masnahmen wird eine uberregionale prospektive Datenakquisition erbringen.

Das „Neurovaskuläre Netz Ruhr“

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[Availability of mechanical thrombectomy for acute stroke : Analysis of the health care reality in Germany].

Das „Neurovaskuläre Netz Ruhr“