Background and aim The clinical importance and management of vasospasm as a complication during endovascular stroke treatment(EVT)has not been well studied.We sought to investigate current expert opinions in neurointe...Background and aim The clinical importance and management of vasospasm as a complication during endovascular stroke treatment(EVT)has not been well studied.We sought to investigate current expert opinions in neurointervention and therapeutic strategies of iatrogenic vasospasm during EVT.Methods We conducted an anonymous international online survey(4 April 2023 to 15 May 2023)addressing treatment standards of neurointerventionalists(NIs)practising EVT.Several illustrative cases of patients with vasospasm during EVT were shown.Two study groups were compared according to the NI’s opinion regarding the potential influence of vasospasm on patient outcome after EVT using descriptive analysis.Results In total,534 NI from 56 countries responded,of whom 51.5%had performed>200 EVT.Vasospasm was considered a complication potentially influencing the patient’s outcome by 52.6%(group 1)whereas 47.4%did not(group 2).Physicians in group 1 more often added vasodilators to their catheter flushes during EVT routinely(43.7%vs 33.9%,p=0.033)and more often treated severe large-vessel vasospasm with vasodilators(75.3%vs 55.9%;p<0.001),as well as extracranial vasospasm(61.4%vs 36.5%,p<0.001)and intracranial medium-vessel vasospasm(27.1%vs 11.2%,p<0.001),compared with group 2.In case of a large-vessel vasospasm and residual and amenable medium-vessel occlusion during EVT,the study groups showed different treatment strategies.Group 2 continued the EVT immediately more often,without initiating therapy to treat the vasospasm first(9.6%vs 21.1%,p<0.001).Conclusion There is disagreement among NIs about the clinical relevance of vasospasm during EVT and its management.There was a higher likelihood of use of preventive and active vasodilator treatment in the group that perceived vasospasm as a relevant complication as well as differing interventional strategies for continuing an EVT in the presence of a large-vessel vasospasm.展开更多
Background Randomised controlled trials with perfusion selection have shown benefit of endovascular treatment(EVT)for ischaemic stroke between 6 and 24 hours after symptom onset or time last seen well.However,outcomes...Background Randomised controlled trials with perfusion selection have shown benefit of endovascular treatment(EVT)for ischaemic stroke between 6 and 24 hours after symptom onset or time last seen well.However,outcomes after EVT in these late window patients without perfusion imaging are largely unknown.We assessed their characteristics and outcomes in routine clinical practice.Methods The Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry,a prospective,multicentre study in the Netherlands,included patients with an anterior circulation occlusion who underwent EVT between 2014 and 2017.CT perfusion was no standard imaging modality.We used adjusted ordinal logistic regression analysis to compare patients treated within versus beyond 6.5 hours after propensity score matching on age,prestroke modified Rankin Scale(mRS),National Institutes of Health Stroke Scale,Alberta Stroke Programme Early CT Score(ASPECTS),collateral status,location of occlusion and treatment with intravenous thrombolysis.Outcomes included 3-month mRS score,functional independence(defined as mRS 0-2),and death.Results Of 3264 patients who underwent EVT,106(3.2%)were treated beyond 6.5 hours(median 8.5,IQR 6.9-10.6),of whom 93(87.7%)had unknown time of stroke onset.CT perfusion was not performed in 87/106(80.2%)late window patients.Late window patients were younger(mean 67 vs 70 years,p<0.04)and had slightly lower ASPECTS(median 8 vs 9,p<0.01),but better collateral status(collateral score 2-3:68.3%vs 57.7%,p=0.03).No differences were observed in proportions of functional independence(43.3%vs 40.5%,p=0.57)or death(24.0%vs 28.9%,p=0.28).After matching,outcomes remained similar(adjusted common OR for 1 point improvement in mRS 1.04,95%CI 0.56 to 1.93).Conclusions Without the use of CT perfusion selection criteria,EVT in the 6.5-24-hour time window was not associated with poorer outcome in selected patients with favourable clinical and CT/CT angiography characteristics.randomised controlled trials with lenient inclusion criteria are needed to identify more patients who can benefit from EVT in the late window.展开更多
文摘Background and aim The clinical importance and management of vasospasm as a complication during endovascular stroke treatment(EVT)has not been well studied.We sought to investigate current expert opinions in neurointervention and therapeutic strategies of iatrogenic vasospasm during EVT.Methods We conducted an anonymous international online survey(4 April 2023 to 15 May 2023)addressing treatment standards of neurointerventionalists(NIs)practising EVT.Several illustrative cases of patients with vasospasm during EVT were shown.Two study groups were compared according to the NI’s opinion regarding the potential influence of vasospasm on patient outcome after EVT using descriptive analysis.Results In total,534 NI from 56 countries responded,of whom 51.5%had performed>200 EVT.Vasospasm was considered a complication potentially influencing the patient’s outcome by 52.6%(group 1)whereas 47.4%did not(group 2).Physicians in group 1 more often added vasodilators to their catheter flushes during EVT routinely(43.7%vs 33.9%,p=0.033)and more often treated severe large-vessel vasospasm with vasodilators(75.3%vs 55.9%;p<0.001),as well as extracranial vasospasm(61.4%vs 36.5%,p<0.001)and intracranial medium-vessel vasospasm(27.1%vs 11.2%,p<0.001),compared with group 2.In case of a large-vessel vasospasm and residual and amenable medium-vessel occlusion during EVT,the study groups showed different treatment strategies.Group 2 continued the EVT immediately more often,without initiating therapy to treat the vasospasm first(9.6%vs 21.1%,p<0.001).Conclusion There is disagreement among NIs about the clinical relevance of vasospasm during EVT and its management.There was a higher likelihood of use of preventive and active vasodilator treatment in the group that perceived vasospasm as a relevant complication as well as differing interventional strategies for continuing an EVT in the presence of a large-vessel vasospasm.
基金We acknowledge the support of the Netherlands Cardiovascular Research Initiative which is supported by the Dutch Heart Foundation,CVON2015-01:CONTRASTthe support of the Brain Foundation Netherlands(HA2015.01.06).
文摘Background Randomised controlled trials with perfusion selection have shown benefit of endovascular treatment(EVT)for ischaemic stroke between 6 and 24 hours after symptom onset or time last seen well.However,outcomes after EVT in these late window patients without perfusion imaging are largely unknown.We assessed their characteristics and outcomes in routine clinical practice.Methods The Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry,a prospective,multicentre study in the Netherlands,included patients with an anterior circulation occlusion who underwent EVT between 2014 and 2017.CT perfusion was no standard imaging modality.We used adjusted ordinal logistic regression analysis to compare patients treated within versus beyond 6.5 hours after propensity score matching on age,prestroke modified Rankin Scale(mRS),National Institutes of Health Stroke Scale,Alberta Stroke Programme Early CT Score(ASPECTS),collateral status,location of occlusion and treatment with intravenous thrombolysis.Outcomes included 3-month mRS score,functional independence(defined as mRS 0-2),and death.Results Of 3264 patients who underwent EVT,106(3.2%)were treated beyond 6.5 hours(median 8.5,IQR 6.9-10.6),of whom 93(87.7%)had unknown time of stroke onset.CT perfusion was not performed in 87/106(80.2%)late window patients.Late window patients were younger(mean 67 vs 70 years,p<0.04)and had slightly lower ASPECTS(median 8 vs 9,p<0.01),but better collateral status(collateral score 2-3:68.3%vs 57.7%,p=0.03).No differences were observed in proportions of functional independence(43.3%vs 40.5%,p=0.57)or death(24.0%vs 28.9%,p=0.28).After matching,outcomes remained similar(adjusted common OR for 1 point improvement in mRS 1.04,95%CI 0.56 to 1.93).Conclusions Without the use of CT perfusion selection criteria,EVT in the 6.5-24-hour time window was not associated with poorer outcome in selected patients with favourable clinical and CT/CT angiography characteristics.randomised controlled trials with lenient inclusion criteria are needed to identify more patients who can benefit from EVT in the late window.
