Kate A. Hentschel, Badih Daou, Nohra Chalouhi, Robert M. Starke, Shannon Clark, Ashish Gandhe, Pascal Jabbour, Robert Rosenwasser and Stavropoula Tjoumakaris
Mechanical thrombectomy is standard of care for the treatment of acute ischemic stroke. However, limited data are available from assessment of outcomes of FDA-approved devices. The objective of this study is to compare clinical outcomes, efficacy, and safety of non–stent retriever and stent retriever thrombectomy devices.
Between January 2008 and June 2014, 166 patients treated at Jefferson Hospital for Neuroscience for acute ischemic stroke with mechanical thrombectomy using Merci, Penumbra, Solitaire, or Trevo devices were retrospectively reviewed. Primary outcomes included 90-day modified Rankin Scale (mRS) score, recanalization rate (thrombolysis in cerebral infarction [TICI score]), and incidence of symptomatic intracranial hemorrhages (ICHs). Univariate analysis and multivariate logistic regression determined predictors of mRS Score 3–6, mortality, and TICI Score 3.
A total of 99 patients were treated with non–stent retriever devices (Merci and Penumbra) and 67 with stent retrievers (Solitaire and Trevo). Stent retrievers yielded lower 90-day NIH Stroke Scale scores and higher rates of 90-day mRS scores ≤ 2 (22.54% [non–stent retriever] vs 61.67% [stent retriever]; p < 0.001), TICI Score 2b–3 recanalization rates (79.80% [non–stent retriever] vs 97.01% [stent retriever]; p < 0.001), percentage of parenchyma salvaged, and discharge rates to home/rehabilitation. The overall incidence of ICH was also significantly lower (40.40% [non–stent retriever] vs 13.43% [stent retriever]; p = 0.002), with a trend toward lower 90-day mortality. Use of non–stent retriever devices was an independent predictor of mRS Scores 3–6 (p = 0.002), while use of stent retrievers was an independent predictor of TICI Score 3 (p < 0.001).
Stent retriever mechanical thrombectomy devices achieve higher recanalization rates than non–stent retriever devices in acute ischemic stroke with improved clinical and radiographic outcomes and safety.
Nohra Chalouhi, Badih Daou, Toshimasa Okabe, Robert M. Starke, Richard Dalyai, Cory D. Bovenzi, Eliza Claire Anderson, Guilherme Barros, Adam Reese, Pascal Jabbour, Stavropoula Tjoumakaris, Robert Rosenwasser, Walter K. Kraft and Fred Rincon
Cerebral vasospasm (cVSP) is a frequent complication of aneurysmal subarachnoid hemorrhage (aSAH), with a significant impact on outcome. Beta blockers (BBs) may blunt the sympathetic effect and catecholamine surge associated with ruptured cerebral aneurysms and prevent cardiac dysfunction. The purpose of this study was to investigate the association between preadmission BB therapy and cVSP, cardiac dysfunction, and in-hospital mortality following aSAH.
This was a retrospective cohort study of patients with aSAH who were treated at a tertiary high-volume neurovascular referral center. The exposure was defined as any preadmission BB therapy. The primary outcome was cVSP assessed by serial transcranial Doppler with any mean flow velocity ≥ 120 cm/sec and/or need for endovascular intervention for medically refractory cVSP. Secondary outcomes were cardiac dysfunction (defined as cardiac troponin-I elevation > 0.05 μg/L, low left ventricular ejection fraction [LVEF] < 40%, or LV wall motion abnormalities [LVWMA]) and in-hospital mortality.
The cohort consisted of 210 patients treated between February 2009 and September 2010 (55% were women), with a mean age of 53.4 ± 13 years and median Hunt and Hess Grade III (interquartile range III–IV). Only 13% (27/210) of patients were exposed to preadmission BB therapy. Compared with these patients, a higher percentage of patients not exposed to preadmission BBs had transcranial Doppler-mean flow velocity ≥ 120 cm/sec (59% vs 22%; p = 0.003). In multivariate analyses, lower Hunt and Hess grade (OR 3.9; p < 0.001) and preadmission BBs (OR 4.5; p = 0.002) were negatively associated with cVSP. In multivariate analysis, LVWMA (OR 2.7; p = 0.002) and low LVEF (OR 1.1; p = 0.05) were independent predictors of in-hospital mortality. Low LVEF (OR 3.9; p = 0.05) independently predicted medically refractory cVSP. The in-hospital mortality rate was higher in patients with LVWMA (47.4% vs 14.8%; p < 0.001).
The study data suggest that preadmission therapy with BBs is associated with lower incidence of cVSP after aSAH. LV dysfunction was associated with higher medically refractory cVSP and in-hospital mortality. BB therapy may be considered after aSAH as a cardioprotective and cVSP preventive therapy.