Dec 14, 2015 - technique at our institution over a 38-month period. SICH was defined .... Online supplementary video 1 i
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Ischemic stroke
ORIGINAL RESEARCH
Comparison of clinical outcomes in patients with acute ischemic strokes treated with mechanical thrombectomy using either Solumbra or ADAPT techniques Josser E Delgado Almandoz,1 Yasha Kayan,1 Mark L Young,2 Jennifer L Fease,1 Jill M Scholz,1 Anna M Milner,1 Timothy H Hehr,2 Pezhman Roohani,2 Maximilian Mulder,3 Ronald M Tarrel2 ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ neurintsurg-2015-012122) 1
Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA 2 Division of Vascular Neurology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA 3 Division of Critical Care Medicine, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA Correspondence to Dr Josser E Delgado Almandoz, Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN 55407, USA;
[email protected] Received 15 October 2015 Revised 8 November 2015 Accepted 16 November 2015
ABSTRACT Purpose To compare rates of symptomatic intracranial hemorrhage (SICH) and good clinical outcome at 90 days in patients with ischemic strokes from anterior circulation emergent large vessel occlusions (ELVO) treated with mechanical thrombectomy using either Solumbra or A Direct Aspiration first-Pass Thrombectomy (ADAPT) techniques. Methods We compared clinical characteristics, procedural variables, and clinical outcomes in patients with anterior circulation ELVOs treated with mechanical thrombectomy using either a Solumbra or ADAPT technique at our institution over a 38-month period. SICH was defined using the SITS-MOST criteria. A good clinical outcome was defined as a modified Rankin Scale score of 0–2 at 90 days. Results One hundred patients were included, 55 in the Solumbra group and 45 in the ADAPT group. Patients in the ADAPT group had higher National Institutes of Health Stroke Scale (NIHSS) (19.2 vs 16.8, p=0.02) and a higher proportion of internal carotid artery terminus thrombi (42.2% vs 20%, p=0.03) than patients in the Solumbra group. Patients in the ADAPT group had a trend toward a lower rate of SICH than patients in the Solumbra group (2.2% vs 12.7%, p=0.07). Patients in the ADAPT group had a significantly higher rate of good clinical outcome at 90 days than patients in the Solumbra group (55.6% vs 30.9%, p=0.015). Use of the ADAPT technique (OR 6 (95% CI 1.0 to 31.2), p=0.049) was an independent predictor of a good clinical outcome at 90 days in our cohort. Conclusions In our cohort, the ADAPT technique was associated with significantly higher good clinical outcomes at 90 days in patients with acute ischemic stroke due to anterior circulation ELVOs treated with mechanical thrombectomy.
INTRODUCTION To cite: Delgado Almandoz JE, Kayan Y, Young ML, et al. J NeuroIntervent Surg Published Online First: [please include Day Month Year] doi:10.1136/ neurintsurg-2015-012122
Recent landmark randomized controlled trials have shown that, for patients with acute ischemic strokes due to anterior circulation emergent large vessel occlusions (ELVO), clinical outcomes are improved when best medical management including intravenous tissue plasminogen activator (IV-tPA) administration, if appropriate, is followed as soon as possible by mechanical thrombectomy.1–5 Hence,
this strategy is now considered the standard of care in this patient population.6 However, debate still exists in the neurointerventional community regarding what constitutes the safest and most effective technique for performing mechanical thrombectomy.7 8 The two principal mechanical thrombectomy techniques involve the use of stent-retrievers such as the Solitaire FR device (Medtronic Neurovascular, Irvine, California, USA)9–11 or the Trevo device (Stryker Neurovascular, Fremont, California, USA),12 13 or direct aspiration at the face of the thrombus using A Direct Aspiration first-Pass Thrombectomy (ADAPT) technique with a large-bore aspiration catheter such as the 5 Max ACE or ACE 64 catheters (Penumbra, Alameda, California, USA).14–16 Furthermore, stent-retrievers can be used in conjunction with either proximal flow arrest in the cervical vasculature with a balloon guide catheter17 or direct aspiration at the face of the thrombus at the time of thrombectomy (Solumbra technique).18–20 The purpose of this study is to compare rates of successful recanalization, symptomatic intracranial hemorrhage (SICH), and clinical outcomes at 90 days in a consecutive cohort of patients with anterior circulation ELVOs who underwent mechanical thrombectomy using either the Solumbra or ADAPT techniques at a comprehensive stroke center.
METHODS Our study was approved by our hospital’s institutional review board and conducted in compliance with the Health Insurance Portability and Accountability Act. We analyzed our prospectively maintained institutional neurointerventional database to examine the radiological and clinical outcomes in patients with anterior circulation ELVOs who were treated with mechanical thrombectomy using either the Solumbra or ADAPT techniques at our institution between 31 March 2012 and 11 June 2015.
Medical record review We recorded baseline patient and radiological characteristics, procedural variables, periprocedural complications, and clinical outcomes at 90 days in a
Delgado Almandoz JE, et al. J NeuroIntervent Surg 2015;0:1–6. doi:10.1136/neurintsurg-2015-012122
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Ischemic stroke consecutive cohort of patients with ELVOs treated with mechanical thrombectomy at our institution during the study period. The patient cohort was divided into two groups: (1) patients who underwent mechanical thrombectomy using the Solumbra technique (Solumbra group); and (2) patients who underwent mechanical thrombectomy using the ADAPT technique with Solumbra salvage if needed (ADAPT group).
ADAPT technique
Mechanical thrombectomy exclusion criteria Institutional exclusion criteria for mechanical thrombectomy were: (1) mild stroke symptoms, defined as an admission National Institutes of Health Stroke Scale (NIHSS) score
