Longer Thrombectomy Times Increase Mortality Risk and Stroke Care Costs

 What this means is that followup interventions need to be prioritized to get survivors fully recovered.  Change the failed status quo! Or is everyone in stroke completely BRAIN DEAD and willing to live with failure?

Longer Thrombectomy Times Increase Mortality Risk and Stroke Care Costs

Puncture to recanalization time was significantly associated with discharge outcome, wherein each 15-minute increase was linked to a higher likelihood of death or hospice discharge. Patients with acute ischemic stroke who experience longer puncture to recanalization (PTR) times during thrombectomy have worse outcomes and greater acute care costs. These findings were published in Stroke: Vascular and Interventional Neurology Researchers conducted a retrospective analysis of 721 patients who underwent mechanical thrombectomy for large vessel occlusion at a high-volume neuroendovascular practice between January 2011 and June 2020. The researchers examined the effect of PTR time on immediate poststroke disposition and associated costs. The analysis included patients with successful reperfusion (modified Thrombolysis in Cerebral Infarction≥2B) and excluded those with missing data or those with extreme time outliers. Patients were categorized into 4 discharge groups: transfer to acute or subacute rehabilitation, home or home with physical therapy (PT), in-hospital death or hospice, and long-term care placement. The researchers employed a multinomial logistic regression model to assess how incremental increases in PTR time influenced these outcomes. [R]educing procedural time should be prioritized not only to improve individual patient outcomes but also to support institutional cost efficiency and inform national stroke care policies. The median PTR time was 34.7 minutes, and the cohort was 50% women, with a mean age of 67.0 years. Most patients (95%) presented with anterior circulation occlusions. Common comorbidities included hypertension (78.8%), hyperlipidemia (51.5%), atrial fibrillation (38.4%), and diabetes (29.3%). At discharge, 54.2% of patients were transferred to rehabilitation, 21.9% were discharged home or home with PT, 18.7% died or were transitioned to hospice, and 5.1% required long-term care placement. There was a significant association between PTR and discharge disposition (P= .003). Each 15-minute increase in PTR was linked to a 2% to 4.6% higher likelihood of death or hospice discharge and a 1.5% to 2.5% lower likelihood of being discharged home or home with PT. In adjusted analyses, longer PTR was independently associated with greater odds of death or hospice disposition (odds ratio [OR], 1.020; 95% CI, 1.008-1.032;P=.001). From an economic standpoint, every 15-minute increase in PTR was associated with an average increase in direct acute care costs of $190.04 per stroke episode (95% CI, $184.74-$196.20;P<.001). When extrapolated to an estimated 39,000 annual thrombectomies nationwide, the researchers estimated a $7.4 million annual increase in acute stroke care costs for each 15-minute increase in mean PTR (95% CI, $7.2–$7.7 million). Study limitations include a single-center design, exclusion of patients with incomplete data, and reliance on modeled cost estimates that did not capture postacute or indirect costs. “These results suggest that procedural speed remains a crucial determinant of clinical outcome, and reducing procedural time should be prioritized not only to improve individual patient outcomes but also to support institutional cost efficiency and inform national stroke care policies,” the study authors concluded.  Disclosures: This research was supported by Microvention. Multiple study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.

Editorial: Ischemic stroke management: From symptom onset to successful reperfusion and beyond

Since you're not even talking about 100% recovery. I guess you don't give a flying fuck about what survivors want!  GET THE HELL OUT OF STROKE AND LET  BETTER PERSONS IN!

Measure recovery and results, NOT groin puncture time or reperfusion. I'd fire everyone involved in this.

“What's measured, improves.” So said management legend and author Peter F. Drucker 

 

Editorial: Ischemic stroke management: From symptom onset to successful reperfusion and beyond

Peter B. Sporns^1,2*, Johanna M. Ospel¹ and Marios-Nikos Psychogios¹

• ¹Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland
• ²Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Editorial on the Research Topic
Ischemic stroke management: From symptom onset to successful reperfusion and beyond

Introduction

Fast and complete reperfusion of the occluded vessel territory is the key to every revascularization therapy in stroke patients, no matter if treated with alteplase or endovascular thrombectomy (EVT) (1–4). However, there is room for substantial improvement in time efficiency and techniques to achieve reperfusion [(3, 5), Advani]. This introduction of the Research Topic “Ischemic Stroke Management: From Symptom Onset to Successful Reperfusion and Beyond” left room for a wide variety of topics for articles, which is reflected by a large number of high-quality articles published in this Research Topic (59). The predefined areas of interest included—but were not limited to—the one-stop management of ischemic stroke patients in the angio-suite, novel methods of pre-hospital patient triage, new procedural techniques and software solutions for effective patient triage, clinical consequences of improved time metrics and prediction of functional outcomes following hyperacute reperfusion therapies. The aim of the Research Topic was to investigate the impact of logistical and procedural improvements on the success of reperfusion and the clinical outcome of ischemic stroke patients.

Looking at the studies published in this Research Topic and starting with pre-hospital triage optimization Cabal et al. report that their new prehospital triage test (FAST PLUS) yielded significant reductions of onset-to-groin times in patients receiving EVT, meaning that median onset-to-groin times reduced from 213 to 142 min in their cohort from the Czech Republic. Weissenborn et al. analyzed workflow and outcome metrics of stroke patients undergoing EVT in their German tertiary stroke center as a starting point for optimization. In their analysis, they found several factors leading to a delay in treatment (i.e., medical treatment of a hypertensive crisis, epileptic fits, vomiting, or agitation, repeated brain imaging, and transfer from other hospitals). Hence, they concluded that analyses of workflow and treatment results should be carried out regularly to identify the potential for optimization of operational procedures and selection criteria for patients who could benefit from EVT (Weissenborn et al.).

At least as important as prehospital triage and procedural optimization are the technical results of the thrombectomy procedure itself (5, 6). Thus, various articles in this Research Topic investigated technical and procedural developments. In their retrospective study, Guenego et al. described the impact of clot shape on successful middle cerebral artery M1-segment endovascular reperfusion and found that clot shape as determined on T2^* imaging, appears to be a predictor of successful reperfusion after EVT because angulated and bifurcating clots were associated with poorer rates of successful reperfusion. Moreover, Candel et al. found that the size of stent retriever matters in acute M1 occlusions treated with aspiration-assisted mechanical thrombectomy. A longer stent retriever with a larger nominal diameter achieved a higher complete and successful first pass effect and higher successful reperfusion compared to a shorter stent retriever (Candel et al.). Another analysis by Etter et al. found that application of a new coating to the delivery wire of the Trevo retriever, with the new device being called the “Trevo NXT” stent retriever, was an effective and safe tool for EVT that could be more easily deployed and was especially effective when used for combined approaches. When looking at the definition for successful recanalization of the thrombectomy procedure, Yoo et al. reported that in their international multicenter trial, first-pass excellent reperfusion (defined as TICI 2c-3), was the technical revascularization endpoint that best predicted functional independence and concluded that this should be an angiographic endpoint for future trials, further consolidating prior evidence from published studies.

Previous studies have shown that histological thrombus composition impacts procedural and technical outcomes of EVT, that thrombus composition is associated with stroke etiology and that the thrombus composition itself can be predicted from admission imaging (7–11). In this issue, Eto et al. report that atherosclerotic components in retrieved thrombi might provide useful clues for diagnosing stroke pathogenesis. Their investigation of the association between onset-to-imaging time and radiological thrombus characteristics suggested that elapsed time from stroke onset plays a limited role in the interpretation of radiological thrombus characteristics and their effect on treatment results and should therefore not confound imaging-based thrombus analysis, at least in the early time window (Tolhuisen et al.). Regarding the visualization of thrombus content, LaGarange et al. reported that MicroCT can be used as an indicator for red blood cells-rich composition of clots, and a combination of MicroCT and electron microscopy revealed further valuable information with regard to clot composition.

Regarding the ongoing debate of intravenous thrombolysis plus EVT vs. EVT alone, Maier et al. report that in patients included in the German Stroke Registry, bridging IVT improved rates of successful reperfusion and long-term functional outcome in mothership patients with anterior circulation large vessel occlusion, which is in line with the results of the recently published SWIFT DIRECT trial. This was further confirmed by a meta-analysis concluding that bridging thrombolysis provides more benefits than EVT alone in terms of clinical functional outcomes without compromising safety in AIS patients with LVOs (Li et al.).

Furthermore, several studies in this article collection further investigated indication criteria in special populations, which were not represented by randomized trials. For example, Kastrup et al. reported that in dependent patients, EVT led to less patients with poor outcomes and smaller infarcts compared to intravenous thrombolysis alone.

Discussion and future challenges

The collection of articles in this Research Topic contributes to the continuous evolvement of further defining patient subgroups that will benefit from hyperacute reperfusion therapies. As an example, there are three currently ongoing randomized controlled trials investigating the benefit of EVT in patients with medium vessel occlusions (DISTAL, NCT05029414, ESCAPE-MeVO, NCT05151172, and DISCOUNT, NCT05030142). Defining imaging and clinical characteristics to identify potential EVT candidates within this patient subgroup will help to treat as many stroke patients as possible with the game-changing endovascular thrombectomy but, on the other hand, also help to prevent harming patients, who are very unlikely to benefit. Further logistic and procedural improvements will pave the way toward treating patients even more effectively and in the end find the optimal and fastest therapy for individual stroke patients.

Author contributions

All authors drafted and revised this editorial. All authors contributed to the article and approved the submitted version.

Effect of balloon guide catheter on clinical outcomes and reperfusion in Trevo thrombectomy

Wrong endpoints measured. Survivors don't give a shit about; 

1. groin puncture time

2. reperfusion time

3. first pass effect

4. number of passes 

Didn't even measure how close to 100% recovery survivors got. 

Effect of balloon guide catheter on clinical outcomes and reperfusion in Trevo thrombectomy

1. Thanh N Nguyen1,2,3,
2. Alicia C Castonguay4,
3. Raul G Nogueira5,
4. Diogo C Haussen5,
5. Joey D English6,
6. Sudhakar R Satti7,
7. Jennifer Chen8,
8. Hamed Farid9,
9. Candace Borders10,
10. Erol Veznedaroglu11,
11. Mandy J Binning11,
12. Ajit S Puri12,
13. Nirav A Vora13,
14. Ron F Budzik13,
15. Guilherme Dabus14,
16. Italo Linfante14,
17. Vallabh Janardhan15,
18. Amer Alshekhlee16,
19. Michael G Abraham17,
20. Randall C Edgell18,
21. M Asif Taqi19,
22. Ramy El Khoury20,
23. Maxim Mokin21,
24. Aniel Q Majjhoo22,
25. Mouhammed R Kabbani23,
26. Michael T Froehler24,
27. Ira Finch25,
28. Sameer A Ansari26,
29. Roberta Novakovic27,
30. Mohamad Abdalkader1,2,3,
31. Osama O Zaidat28

Author affiliations

Abstract

Introduction The Solitaire stent retriever registry showed improved reperfusion, faster procedure times, and better outcome in acute stroke patients with large vessel occlusion treated with a balloon guide catheter (BGC) and Solitaire stent retriever compared with a conventional guide catheter. The goal of this study was to evaluate whether use of a BGC with the Trevo stent retriever improves outcomes compared with a conventional guide catheter.

Methods The TRACK registry recruited 23 sites to submit demographic, clinical, and site adjudicated angiographic and outcome data on consecutive patients treated with the Trevo stent retriever. BGC use was at the discretion of the physician.

Results 536 anterior circulation patients (of whom 279 (52.1%) had BGC placement) were included in this analysis. Baseline characteristics were notable for younger patients in the BGC group (65.4±15.3 vs 68.1±13.6, P=0.03) and lower rate of hypertension (72% vs 79%, P=0.06). Mean time from symptom onset to groin puncture was longer in the BGC group (357 vs 319 min, P=0.06).Thrombolysis in Cerebral Infarction 2b/3 scores were higher in the BGC cohort (84% vs 75.5%, P=0.01). There was no difference in reperfusion time, first pass effect, number of passes, or rescue therapy. Good clinical outcome(What the fuck is your definition of this? Mine is 100% recovery.) at 3 months was superior in patients with BGC (57% vs 40%; P=0.0004) with a lower mortality rate (13% vs 23%, P=0.008). Multivariate analysis demonstrated that BGC use was an independent predictor of good clinical outcome (OR 2; 95% CI 1.3 to 3.1, P=0.001).

Conclusions In acute stroke patients presenting with anterior circulation large vessel occlusion, use of a BGC with the Trevo stent retriever resulted in improved reperfusion, improved clinical outcome, and lower mortality.

http://dx.doi.org/10.1136/neurintsurg-2018-014452