Imad Derraz

Importance: Reperfusion is a key factor for clinical outcome in patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT) for large-vessel intracranial occlusion. However, data are scarce on the association between the time from onset and reperfusion results. Objective: To analyze the rate of reperfusion after EVT started at different intervals after symptom onset in patients with AIS. Design, Setting, and Participants: We conducted a meta-analysis of individual patient data from 7 randomized trials of the Highly Effective Reperfusion Using Multiple Endovascular Devices (HERMES) group. This is a multicenter cohort study of the intervention arm of randomized clinical trials included in the HERMES group. Patients with anterior circulation AIS who underwent EVT for M1/M2 or intracranial carotid artery occlusion were included. Each trial enrolled patients according to its specific inclusion and exclusion criteria. Data on patients eligible but not enrolled (eg, refusals or exclusions) were not available. All analyses were performed by the HERMES biostatistical core laboratory using the pooled database. Data were analyzed between December 2010 and April 2015. Main Outcomes and Measures: Successful reperfusion was defined as a modified thrombolysis in cerebral infarction score of 2b/3 at the end of the EVT procedure adjusted for age, occlusion location, pretreatment intravenous thrombolysis, and clot burden score and was analyzed in relation to different intervals (onset, emergency department arrival, imaging, and puncture) using mixed-methods logistic regression. Results: Among the 728 included patients, with a mean (SD) age of 65.4 (13.5) years and of whom 345 were female (47.4%), decreases in rates of successful reperfusion defined as a thrombolysis in cerebral infarction score of 2b/3 were observed with increasing time from admission or first imaging to groin puncture. The magnitude of effect was a 22% relative reduction (odds ratio, 0.78; 95% CI, 0.64-0.95) per additional hour between admission and puncture and a 26% relative reduction (odds ratio, 0.74; 95% CI, 0.59-0.93) per additional hour between imaging and puncture. Conclusions and Relevance: Because the probability of reperfusion declined significantly with time between hospital arrival and groin puncture, we provide additional arguments for minimizing the intervals after symptom onset in anterior circulation acute ischemic stroke.

Background and Purpose: The efficiency of prehospital care chain response and the adequacy of hospital resources are challenged amid the coronavirus disease 2019 (COVID-19) outbreak, with suspected consequences for patients with ischemic stroke eligible for mechanical thrombectomy (MT). Methods: We conducted a prospective national-level data collection of patients treated with MT, ranging 45 days across epidemic containment measures instatement, and of patients treated during the same calendar period in 2019. The primary end point was the variation of patients receiving MT during the epidemic period. Secondary end points included care delays between onset, imaging, and groin puncture. To analyze the primary end point, we used a Poisson regression model. We then analyzed the correlation between the number of MTs and the number of COVID-19 cases hospitalizations, using the Pearson correlation coefficient (compared with the null value). Results: A total of 1513 patients were included at 32 centers, in all French administrative regions. There was a 21% significant decrease (0.79; [95%CI, 0.76–0.82]; P <0.001) in MT case volumes during the epidemic period, and a significant increase in delays between imaging and groin puncture, overall (mean 144.9±SD 86.8 minutes versus 126.2±70.9; P <0.001 in 2019) and in transferred patients (mean 182.6±SD 82.0 minutes versus 153.25±67; P <0.001). After the instatement of strict epidemic mitigation measures, there was a significant negative correlation between the number of hospitalizations for COVID and the number of MT cases ( R 2 −0.51; P =0.04). Patients treated during the COVID outbreak were less likely to receive intravenous thrombolysis and to have unwitnessed strokes (both P <0.05). Conclusions: Our study showed a significant decrease in patients treated with MTs during the first stages of the COVID epidemic in France and alarming indicators of lengthened care delays. These findings prompt immediate consideration of local and regional stroke networks preparedness in the varying contexts of COVID-19 pandemic evolution.

BACKGROUND: Chronic subdural hematoma (CSDH) is a common condition requiring surgical treatment; however, recurrence occurs in 15% of cases at 1 year. Middle meningeal artery (MMA) embolization has recently emerged as a promising treatment to prevent CSDH recurrence. OBJECTIVE: To investigate the effect of MMA embolization on hematoma volume resorption (HVR) after surgery in symptomatic patients. METHODS: From April 2018 to October 2018, participants with CSDH requiring surgery were prospectively randomized in a pilot study, and received either surgical treatment alone (ST group) or surgery and adjuvant MMA embolization (ST+MMAE group). The primary outcome was HVR measured on the 3 month CT scan compared with the immediate pre-embolization CT scan. Secondary outcomes were clinical recurrence of CSDH and safety measures. RESULTS: 46 patients were randomized and 41 of these achieved a 3 month follow-up . Twenty-one patients received MMA embolization. At 3 months, the HVR from postsurgical level was higher in the ST+MMAE group (mean difference 17.5 mL, 95% CI 3.87 to 31.16 mL; p=0.015). Two participants presented a CSDH recurrence (one in each group). One patient died (ST group). No MMA embolization-related adverse events were reported. CONCLUSION: The addition of MMA embolization to surgery led to an increase in CSDH resorption at 3 months. One recurrence of CSDH was reported in each group, and there were no treatment-related complications.

BACKGROUND: It is uncertain whether mechanical thrombectomy (MT) increases the probability of a good outcome (modified Rankin Scale (mRS) 0-2) in patients with Alberta Stroke Program Early CT Score (ASPECTS) 0-6. OBJECTIVE: To assess the impact of MT in patients with pretreatment ASPECTS 0-6. METHODS: According to PRISMA guidelines, we performed a systematic search of three databases for series of patients with ASPECTS 0-6 treated by MT. Random-effects meta-analysis was used to pool the following: rate of mRS 0-2 at 3 months follow-up, symptomatic intracranial hemorrhage (sICH), and mortality rates. RESULTS: We included 17 studies and 1378 patients with ASPECTS 0-6 (1194 MT, 184 medical management). The rate of mRS 0-2 was 30.1% and 3.2% after MT and medical management, respectively. MT gave higher odds of mRS 0-2 (OR 4.76, p=0.01). Patients with ASPECTS 6 and 5 had comparable rates of good outcome (37.7% and 33.3%, respectively). Overall, the rate of mRS 0-2 was 17.1% in patients with ASPECTS 0-4: 22.1% and 13.9% of patients with ASPECTS 4 and 0-3 were functionally independent, respectively. Successful recanalization (Thrombolysis in Cerebral Infarction grade 2b-3) gave higher odds of mRS 0-2 than unsuccessful reperfusion (OR 5.2, p=0.001). The MT group tended to have lower odds of sICH compared with the controls (OR 0.48, p=0.06). Patients aged <70 years had higher rates of mRS 0-2 than those aged >70 years (40.3% vs 16.2%). CONCLUSIONS: Patients with ASPECTS 0-6may benefit from MT. Successful reperfusion increases the probability of 3-month functional independence without increasing the risk of sICH. Patients with ASPECTS 5 and 6 have comparable outcomes. MT can still enable approximately one in four patients with ASPECTS 4 to be independent, whereas only 14% of subjects with ASPECTS 0-3 regain a good functional outcome.