الفهرس 
ACUTE ISCHEMIC STROKEOnly 14 pages are availabe for public view
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Abstract
D
espite significant advances in stroke treatment and risk reduction over the past decade, stroke remains the second leading cause of death worldwide; the majorities (87%) of strokes are ischemic, and between one-quarter and one-half of these strokes are due to LVO. These blockages are often refractory to IV rtPA, and are associated with high rates of morbidity and mortality without endovascular intervention. Several RCTs have recently demonstrated the effectiveness of new MT devices over IV rtPA of AIS treatment. MT is now considered the gold standard in treating patients with certain anterior (proximal middle cerebral artery and internal carotid artery) occlusions who present within 6 hours of stroke onset. The guidelines extended the eligibility of MT after the results of DEFUSE 3 and DAWN trials up to 16 and 24 h, respectively in wellselected patients with clinical/imaging mismatch.
Even with rapidly increasing procedural volumes and overall improved clinical outcomes, emergent thrombectomy remains a challenging and high-risk procedure with a considerable (up to 39%) mortality rate. Predicting these patients at high risk of unfavorable outcomes and adjusting therapeutic strategies accordingly can greatly improve patient outcomes.
Therefore, this study aims to:
1. Compare between the stent retriever in comparison to aspiration thrombectomy according to the proportion of patients with successful revascularization defined as a modified Thrombolysis in Cerebral Infarction score of 2b or 3 at the end of all endovascular procedures, duration of procedure and number of trials.
2. Identify predictors of functional independence and predictors of complications and following mechanical thrombectomy.
This prospective cohort study, was carried out at Ain Shams University stroke center, collaborating with Nasr city health insurance hospital, Egypt.
One hundred patients with anterior circulation AIS who met inclusion criteria for MT were recruited between the first of March 2020 and to end of March 2023, We classified the patients into two groups.
1. group one includes 50 patients treated with Stent retriever Thrombectomy
2. group two includes 50 patients treated with Aspiration Thrombectomy
Inclusion criteria were: Age >18 years, The National Institutes of Health Stroke Scale score (NIHSS) of ≥6, Cerebral infarction in the anterior circulation (internal carotid artery, M1, MCA, or both) proven by CTA or MRA, The Alberta stroke program early CT scores (ASPECT) ≥6, Patients who received or did not receive IV thrombolysis before mechanical thrombectomy, The time from onset of stroke to arrival to an emergency unit is less than 6 hours.
Patients who had a history of old stroke with a disability of more than 2 as evaluated by an mRS were excluded from the analysis. Also, patients or their relatives can request to be removed from the study at any point.
All patients were subjected to demographic, clinical, stroke risk factors, imaging, and procedural data evaluation and analysis.
All Patients underwent immediate brain CT for exclusion of cerebral hemorrhage and detection of early ischemic signs and scored it using the ASPECTS.
Also, vascular imaging with CTA to ensure the presence of LVO and the localization of occluded artery.
All patients may receive IV rtPA within 4.5 hours from the onset of stroke symptoms.
EVT was performed under sedation or general anesthesia. Via 8F femoral introducer sheath in the femoral artery, an 8F guide catheter was advanced into the carotid artery. Moreover, we evaluate the collateral grade using ASITN/SIR scale. We used two techniques in MT stent retriever and direct aspiration techniques or both. The data during the procedure were collected and analyzed, including the attempts number, procedure duration. The recanalization status was assessed using TICI, and successful recanalization was defined as TICI grade 2b or 3.
Standard of care includes antiplatelet therapy, BP management, stroke unit care, complication prevention, and rehabilitation. Outcome evaluation All patients underwent computed tomography or magnetic resonance imaging 24 hours after MT to assess hemorrhagic complications
In addition, we assessed early recovery, which was defined as A decrease of 8 or more points of NIHSSs at 24 h or NIHSS of less than or equal 2 points at discharge. And we assessed the mRS at 90 days during face-to-face interviews or telephone conversations with the patient or relatives. Good functional outcome (functional independence) was defined as mRS scores from 0 to 2 at 90 days.
The main findings of our study are summarized as follows:
The present study showed that both direct aspiration and stent retriever thrombectomy were safe and effective in treatment of acute ischemic stroke with similar success rate.
The unfavorable outcome was associated with older age, higher NIHSS at presentation, elevated CT ASPECT and the incidence of symptomatic intracerebral hemorrhage. There was positive correlation between recanalization TICI with CT aspect. As well we find negative correlation between recanalization TICI with NIHSS at presentation.
The incidence of symptomatic intracerebral hemorrhage was associated with higher NIHSS at presentation.
Our results show no differences regarding outcomes between patients receiving IV rtPA and patients not receiving it after AIS caused by LVO.
Although MT now it has become state-funded, it is still not widespread.
RECOMMENDATIONS
So we also recommended that:
• Both contact aspiration and stent retriever thrombectomy are safe and effective in treatment of acute ischemic stroke due to large vessel occlusion.
• Contact aspiration is faster, cheaper and relatively easier. So we recommend it as a first line strategy in our developing country. It can be followed by stent retrievers in case of failure.
• Decrease the duration of thrombectomy procedure and decrease number of attempts as much as possible to improve the outcome.
• Trying to achieve complete recanalization TICI 3 rather than 2 b as much as possible as this will reduce infarct growth and improve post-thrombectomy functional independence.
• Further comparative studies with larger sample size and longer follow-up are needed to confirm our results and to identify more risk factors of adverse events.
LIMITATIONS
• The current study there was some limitations.
• First, relatively small sample size as it represents only the experience of centers.
• Second, only two types of stent retrievers and one type of aspiration catheters were used for thrombectomy. Other types of devices need to be tested.
• Third, we used regular guiding not balloon guiding catheters (BGC) as it is not available in Egypt. The use of BGC has an impact on achieving good recanalization and better first passes effect.