Study Of Endovascular Treatment Strategies And Clinical Models Development After Acute Large Vessel Occlusion Stroke

Background and Objectives Current evidence does not agree on the merits of direct thrombectomy(DT)and bridging thrombectomy(BT)in treating acute anterior circulation large vessel occlusive stroke.The purpose of this study was to compare the safety and efficacy of direct thrombectomy(DT)and bridging thrombectomy(BT)in treating patients with acute ischemic stroke due to carotid T occlusion.Materials and Methods Patients with acute ischemic stroke diagnosed with carotid-T occlusion and receiving endovascular therapy(bridging thrombotomy or direct thrombotomy)were retrospectively enrolled at four senior advanced stroke centers from January 2015 to September 2018.Patients were divided into the bridging thrombectomy group and direct thrombectomy group according to whether intravenous thrombolysis were administrated.We collected and analyzed the age,gender,cerebrovascular disease risk factors,emergency blood glucose,stroke etiology classification,the national institutes of health stroke scale(NIHSS)scores and the Alberta stroke operation early acute stroke CT(ASPECT)score,clot burden score(CBS),the grade of American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology(ASITN/SIR)classification,operation time intervals,pass times of thrombectomy,rescue treatment,successful recanalization,Multivariate Logistic regression model was used to predict independent risk factors for prognosis.Results A total of 111 patients with acute ischemic stroke due to carotid T occlusion were included in this study.Among them,57 cases were divided into DT group and 54 cases were divided into BT group.In terms of time intervals,patients in the BT group had a longer imaging to puncture(ITP)time,a higher symptom onset to puncture(OTP)time,and a longer symptom onset to successful recanalization(OTR)time than those in DT group.The incidence of intracranial hemorrhage(ICH)in BT group was higher than that in the DT group(59.3% in BT group vs 40.4% in DT group,X2=3.966,P=0.046).After adjustment for confounding factors,intravenous thrombolysis was not significantly associated with 90-day favorable outcome,successful recanalization rate,90-day mortality,but may increase the incidence of intracranial hemorrhage(OR=2.492,95%CI,1.005--6.180,P=0.049).Patients in the poor outcome group had a higher NIHSS scores on admission than that in the favorable group Clot burden score in the poor outcome group was higher than that in the favorable outcome group.Patients in the favorable outcome group achieved higher e TICI 2B-3 than patients in the poor outcome group(92.1% vs.72.6%,X2=5.786,P=0.016).The rate of intracranial hemorrhage in poor outcome group(64.4% in the poor outcome group vs 21.1% in the favorable outcome group,X2 = 18.770,P < 0.001),the proportion of symptomatic intracranial hemorrhage(20.5% in the poor outcome group vs 2.6% in the favorable outcome group,X2 = 6.503,P = 0.011),the proportion of the asymptomatic intracranial hemorrhage(43.8% in the poor outcome group vs 18.4% in the favorable outcome group,X2 = 7.083,P = 0.008)were higher than that in the favorable outcome group.After adjustment for confounding factors,higher ASPECT score,low NIHSS score,and successful recanalization were associated with favorable outcomes.Symptomatic intracranial hemorrhage and asymptomatic intracranial hemorrhage were the independent risk factors for poor outcome.In multivariate regression analysis,intravenous thrombolysis was not an independent risk factor for poor prognosis(OR=1.458,95%CI,0.516-4.121).Conclusions In patients with acute ischemic stroke due to carotid T occlusion,there is no difference in favorable outcome,successful recanalization,90-day mortality between patients treated with direct thrombectomy and patients treated with bridging thrombectomy.Multivariate analysis adjusted for confounding factors indicated that bridging thrombectomy may increase the incidence of intracerebral hemorrhage in carotid T occlusion patients.Higher ASPECT score,low NIHSS score,and successful recanalization were associated with favorable outcome,while symptomatic intracranial hemorrhage and asymptomatic intracranial hemorrhage were independent risk factors for poor prognosis.However,since this study was a retrospective study,the results still need to be verified by further prospective randomized clinical trials.Background and Objectives Malignant cerebral edema(MCE)is a serious adverse event in acute anterior circulation large vessel occlusion stroke(LVOS)stroke patients treated with endovascular thrombectomy(EVT).MCE can increase intracranial pressure and accelerate the deterioration of nerve function,thereby reducing the benefit of EVT.The purpose of this study was to establish a nomogram to predict the risk of MCE after EVT.We hoped that the nomogram could help identify high-risk patients in clinical practice and increase the proportion of patients with good functional outcome.Materials and Methods We retrospectively enrolled patients from two stroke centers who were diagnosed with anterior circulation LVOS and received EVT.MCE was defined as midline shift > 5 mm at the septum pellucidum or pineal gland with obliteration of the basal cisterns or the need for early decompressive hemicraniectomy.We performed multivariable logistic regression model to establish the most suitable nomogram model,and used the area under the receiver operating characteristic curve(AUC-ROC)and Hosmer-Lemeshow test to evaluate the nomogram model about the discrimination and calibration ability of the nomogram.Results: A total of 370 patients(mean age: 67.2±11.9,male: 56.8%)were included in the final analysis,of which 71 patients(19.2%)developed MCE after EVT.After adjusting for confounding factors,age(OR: 0.960,95% CI: 0.934-0.987,P = 0.004),baseline National Institutes of Health Stroke Scale(NIHSS)score(OR: 1.076,95% CI: 1.016-1.140,P = 0.013),collateral circulation(grade 1 vs grade 0: OR: 0.360,95% CI: 0.176-0.763,P = 0.005,grade 2 vs grade 0: OR: 0.127,95 % CI:0.051-0.315,P <0.001),blood glucose level(OR: 1.180,95% CI: 1.086-1.281,P <0.001),and recanalization status(2b-3 vs.0-2a,or: 0.352,95% CI: 0.185-0.669,P = 0.001)were included in the nomogram.There was no obvious collinearity between these variables.The AUC-ROC of the nomogram was 0.805 [95% confidence interval,95% CI(0.750-0.860)].The Hosmer-Lemeshow goodness-of-fit test indicated that the nomogram had a good calibration ability(p=0.681).The occurrence of MCE is also the main predictor of poor functional prognosis after EVT(OR: 13.489,95% CI: 3.322-54.771,P<0.001).Conclusions Acute anterior circulation LVOS patients receiving EVT had a high incidence of MCE.MCE was associated with a poor 90-day functional outcome.The nomogram model was established with age,baseline NIHSS score,blood glucose level,collateral circulation and postoperative recanalization status.The nomogram had a good discrimination and calibration ability.We hoped that the nomogram could help identify high-risk patients in clinical practice.