Subscribe to RSS
Download PDF
DOI: 10.1055/s-0045-1809328
A Comparison of Outcome between Two Different Age Groups after Intravenous Thrombolysis for Acute Ischemic Stroke of Anterior Circulation: A Single-Center Experience of 500 Cases
Funding None.
Abstract
Objective
Mechanical thrombectomy (MT) alone or with intravenous thrombolysis (IVT) avoids disabilities in patients with acute ischemic stroke. The purpose of this study is to assess the outcome in two different age groups by combined technique (simultaneous stent retriever plus syringe aspiration) following thrombolysis in anterior circulation stroke and to analyze predictive factors.
Materials and Methods
We retrospectively studied all patients (n = 500) who had ≥ modified thrombolysis in cerebral infarction (mTICI)2b following Solitaire stent retriever MT following IVT. Patients with anterior circulation stroke were dichotomized based on whether younger or older than 50 years. We analyzed predictive factors for favorable clinical outcome and also evaluated the age-related adverse results, with focus on symptomatic intracerebral hemorrhage within 7 days, favorable outcome (modified Rankin scale [mRS] 0–2), and mortality at 3 months following procedure.
Results
Among a total of 500 patients, 144 patients were in the young age group (≤50 years) with a mean age of 37.10 years, and 356 patients were in the old age group (>50 years) with a mean age of 63.55 years. There was a significant association between these two groups in the etiologies, medical history, age, puncture to recanalization time, and adverse results. Similarly, patient age ≤50 years, National Institute of Health Stroke Scale score at admission < 15, Alberta Stroke Program Early CT Score >5, mTICI3, and onset to recanalization time < 4 hours were significantly predictive factors for a favorable outcome.
Conclusion
Our study shows that the combined technique after IVT for anterior circulation stroke in large vessels is safe and effective; however, younger age has a higher rate of favorable outcome with a lower mortality rate.
Keywords
combined technique - intravenous thrombolysis - anterior circulation stroke - Solitaire stent - outcomeIntroduction
Acute ischemic stroke (AIS) caused by large vessels occlusion (LVO) is also one of the major causes of death and disabilities.[1] Therefore, re-establishment of blood flow is necessary as early as possible to prevent morbidity and mortality. Revascularization following intravenous thrombolysis (IVT) or mechanical thrombectomy (MT) in AIS patients with LVOs is a significant predictive factor for functional outcome.[2] IVT with recombinant tissue plasminogen activator (rt-PA) has become standard therapy with better clinical results for 20 years;[3] however, effectiveness of IVT is confined due to time frame where it should be given within 4.5 hours of onset of symptoms having no history of recent surgery/active bleeding/blood coagulation disorder as well as lower rate of recanalization in AIS with LVO.[4] The effectiveness in clinical outcome by using the newest generation thrombectomy device, called as stent retriever, in AIS because of LVO is superior compared with systemic thrombolysis alone, and has been described in a series of large-scale randomized trials.[5] However, the application of IVT by rt-PA within 4.5 hours after symptom onset in AIS caused by LVO and (MT has become a standard of care with significant reduction in mortality and disabilities.[5] [6] Furthermore, longer stent retriever MT may cause higher friction and shearing forces, leading to damage to the vessel's wall or tearing of perforators, and postprocedural complications have been reported in literature.[7] [8] However, it has been described that age was independent for MT, age directly affected the clinical outcome.[9] Older people tend to have more significant comorbidities such as atherosclerosis, hypertension (HTN), diabetes mellitus (DM), which alter brain plasticity, arterial collateral network, and self-recovering system.[10] [11] These predictive factors may lead to vascular remodeling, which can cause technical difficulties, and procedure time has been reported.[12] The purpose of this study was to assess the safety and efficacy of the combined technique with Solitaire (Medtronic, Irvine, California, United States) stent in anterior circulation stroke in two different age groups as well as to analyze predictive factors for outcome.
Materials and Methods
Patient Selection
We retrospectively studied all patients (n = 500) who had ≥ modified thrombolysis in cerebral infarction (mTICI)2b following Solitaire stent retriever MT after IVT with AIS caused by LVO of anterior circulation between January 2015 and January 2024 ([Fig. 1]). Among consecutive patients, those who have been initiated IVT within 4.5 hours after onset were included. Additionally, we limited this study to LVO of intracranial internal carotid artery, proximal middle cerebral artery (M1/M2), and proximal anterior cerebral artery (A1/A2) established using cerebral DSA. Patient with age younger than 18 years, posterior circulation stroke, as well as postthrombectomy < mTICI2b grade were excluded from this study. Patient's data included age, sex, medical history, history of antithrombotic medications, National Institute of Health Stroke Scale (NIHSS) score assessed by neurologist at emergency department, and etiology of AIS, which was classified based on the Trial of Org 10172 in Acute Stroke Treatment.[13] Procedural variables included Alberta Stroke Program Early CT Score (ASPECTS) on admission based on brain computed tomography scan, site of vascular occlusion, and onset to puncture (OTP) defined as the time from stroke onset to puncture time. Two age groups were dichotomized, young age group (age ≤50 years) and old age group (age >50 years) and compared with variables. Postprocedural variables included puncture to recanalization (PTR) time defined as the time from puncture time to recanalization, and score of mTICI after thrombectomy. Outcome measures included postprocedural hemorrhage within 7 days, decompressive hemicraniectomy within 7 days, favorable outcome (modified Rankin scale [mRS] 0–2) at 3 months, and mortality at 3 months. Favorable outcome was defined as mRS ≤2 and unfavorable outcome as mRS >2 at 3 months. This is a retrospective study, so informed consent was taken from the institute as well as from all participants included in this study. This study was approved by local Institutional Review Board.
Procedure
All procedures were performed by single neurointerventionalist under general anesthesia. Prior to MT, all patients were administered rt-PA intravenously within 4.5 hours of stroke onset at a maximum dose of 0.9 mg/kg by a neurologist according to the conventional guidelines.[14] MT was performed using second-generation stent retriever (4 × 40 mm—Solitaire, Medtronic). A 6-Fr, 90-cm Shuttle sheath (Cook Medical, Bloomington, Indiana, United States) was used as the guiding catheter. A distal access catheter, Navien 5F, 0.058Inch (EV3, Medtronic) was used. Microcatheter, Phenom 21 (Medtronic) was advanced to the target location with the support of microwire, Synchro select, 0.0014 Inch (Stryker Neurovascular, United States). Microwire was removed, and the Solitaire stent was advanced and placed at the occlusion site for 5 minutes. The stent was retrieved with simultaneous aspiration from the distal access catheter (by a 50-mL syringe).[15] After each pass of device recanalization, status was assessed based on the mTICI score and noted as per inclusion criteria.
Statistical Analysis
Patients were dichotomized by age based on whether they were younger or older than 50 years at the time of intervention. All data are expressed as mean and standard deviation or median and range for continuous variables and number of patients with percentage for categorical variables, where appropriate. Comparative analyses between patients who achieved favorable and unfavorable outcomes as well as baseline characteristics, clinical variables, and clinical outcomes between the two age groups were performed using the Student's t-test, chi-square test, and Fisher's exact test, as appropriate. Statistical analyses were performed using SPSS 26.0 for Windows (SPSS Inc.; Chicago, Illinois, United States). A p-value of less than 0.05 was considered statistically significant.
Results
There were 500 patients who had ≥mTICI2b following IVT and Solitaire stent retriever (size 4 × 40 mm) MT between January 2015 and January 2024. There were 59.03% male and 40.97% female in the young age group, and 56.18% male and 43.82% female in the old age group. Major vascular risk factors were: HTN (59.02%), DM (50.69%), dyslipidemia (47.22%), coronary artery diseases (36.80%), and smoking (31.25%) in young age group; and dyslipidemia (79.21%), DM (76.40%), HTN (74.43%), coronary artery diseases (51.68%), and smoking (46.91%) in old age group in which there was significant association between the two groups (p = 0.0004). There was a significant association of stroke etiologies with these two age groups (p = 0.0090), where large vessels atherosclerosis/cardioembolic origin were 42.36%/23.62% and 40.45%/28.09% in the young and old age groups, respectively. PTR time was significantly different between these two age groups (p < 0.0001), where mean time was 24.45 and 32.81 minutes in the young and old age groups, respectively ([Table 1]).
Abbreviations: ACA, anterior cerebral artery; ASPECTS, Alberta Stroke Program Early CT Score; ICA, internal carotid artery; IQR, interquartile range; MCA, middle cerebral artery; mTICI, modified thrombolysis in cerebral infarction; NIHSS, National Institute of Health Stroke Scale; SD, standard deviation; TICI, thrombolysis in cerebral infarction.
There was a significant association of age between functional and nonfunctional outcomes (p < 0.0292). Younger age had 69.44% of favorable outcome and 30.56% of unfavorable outcome, and older age had 58.98% of favorable outcome and 41.02% of unfavorable outcome. The NIHSS score at admission was significantly associated with functional outcome. The NIHSS score less than 15 at admission had 57.20% of favorable outcome compared with NIHSS score more than 15 (38.60%). The ASPECTS having less than 5 had 59.85% of favorable outcome and 40.115% of unfavorable outcome, and ASPECTS more than 5 had 41.50% of favorable outcome and 58.50% of unfavorable outcome. Onset to recanalization time was significantly associated with outcome (p <0.0001) ([Table 2]).
Abbreviations: ACA, anterior cerebral artery; ASPECTS, Alberta Stroke Program Early CT Score; ICA, internal carotid artery; IVT, intravenous thrombolysis; CA, middle cerebral artery; MT, mechanical thrombectomy; mTICI, modified thrombolysis in cerebral infarction; NIHSS, National Institute of Health Stroke Scale; TICI, thrombolysis in cerebral infarction.
We did not find device-related problem in all cases. The procedural and clinical outcomes were not significantly associated with age groups (p = 0.0806). Symptomatic intracerebral hemorrhage (ICH) within 7 days of procedure was found 15.97 and 25.56% in the young and old age groups, respectively, where 10.42% in the young age group and 11.52% in the old age group underwent decompressive surgery within 7 days after the procedure. Functional outcome at 90 days was noted as 79.86 and 69.10% in the young age group and the old age group, respectively. Similarly, mortality at 90 days was 6.9 and 10.95% in the young and the old age groups, respectively ([Table 3]).
Abbreviations: DHC, decompressive hemicraniectomy; ICH, intracerebral hemorrhage; mRS, modified Rankin scale.
Discussion
In this present study, we found that AIS of LVO in anterior circulation treated with combined technique following IVT by rt-PA was safe and effective. Eight randomized trials have demonstrated the value of MT in addition to IVT for AIS patients harboring an LVO in anterior circulation,[16] where majority of patient enrolled in these trials had received IV rt-PA before MT in which IVT is not contradicted. However, the matter of whether MT without prior IVT is better or worse than combined treatment is now matter of strong debate.[16] Many arguments have been advanced in favor of pretreatment with IVT, including the opportunity of an early reperfusion or even in case of failure of MT, and possible reopening of distal occluded vessels after MT.[17] Solitaire 4 × 40 had better recanalization rate, and similarly, 58.7 to 88.0% of rate of recanalization were reported in the literature using stent retriever MT.[5] [7] Furthermore, longer or oversized Solitaire stent may cause more friction and result in trauma to vessels' wall as well as straighten the vessels during device retrieval.[18] However, we did not notice more friction and traumatic injuries while using Solitaire 4 × 40 in our study. Solitaire 2 Fr 4 × 40 is laser-cut, closed-cell, nitinol stent specifically designed to retrieve larger clots and negotiate tortuous anatomies where it can be difficult to achieve an exact stent placement to cover the clot in large vessels AIS.[7]
In the MR CLEAN Registry, a prospective survey from the Netherlands, ∼10% of patients treated with endovascular therapy were young patients with LVO, where 9.61% of patients were young, 18 to 49 years old, and 90.39% of older patients, >50 years,[10] which is lower than our data of 22.8% of young patients (144/500). AIS caused by cardioembolic causes (40.28%) was found to be significantly higher in young age than older age (31.74%), and large artery atherosclerosis (42.98%) was found to be significantly higher in older age than younger age (36.11%) (p = 0.0431), which is consistent with other study where cardioembolic causes was most common causes of stroke caused by embolic stroke of undermined source in young age followed by carotid dissection.[10] Dyslipidemia (79.21%) was more common risk factor for AIS followed by DM (76.40%) and HTN (74.43%) in older age group, while HTN (59.02%) was more common in younger age group followed by smoking history (50.69%) and dyslipidemia (47.22%) (p = 0.0007) in our study. Likewise, HTN was found to be more common followed by hypercholesterolemia in both young and older age groups (p < 0.001),[10] which is inconsistent with a study where AF ischemic heart diseases were more common in the older age and where smoking was more common in the younger age group and where smoking was more common in the younger age group.[19] The median NIHSS score at admission was 12 in the younger age group and 14 in the older age group, but no significant differences (p = 0.3493) were noted. Our finding was almost similar to the report of the previous studies where the median NIHHS score 13 to 14 in the younger age group and 15 to 16 in the older age group have been described.[10] [20]
Our study showed that mortality rate was significantly higher in older patients (16.01%, 57/356) compared with younger patients (6.9%, 11/144), and favorable outcome, mRS 0 to 2 was 69.10% (246/356) in older patients and 79.86% (115/144) in younger patients at 90 days. Symptomatic ICH was found to be lower (15.97% [23/144]) in young age group as compared with older age group (25.56% [91/356]) (p = 0.0497). Shi et al described no significant association between younger patients and older patients (>50 years) with AIS with regard to good clinical outcome, successful reperfusion, mortality and symptomatic ICH,[21] [22] which is contrast with another study where mortality and symptomatic ICH were significantly lower in younger age group with similar reperfusion rate.[10] Similarly, we observed that there was no significant association between these two age groups with reperfusion grading (mTICI2b/2c and mTICI3) after MT (p = 0.1121). Furthermore, our younger age group with AIS had more favorable outcome and lower mortality rate compared with older age group, which is consistent to other studies where 61 to 87%[11] [14] [23] [24] of favorable outcomes and 7 to 12%[10] [25] of mortality in younger patients have been reported. Our mortality rate was lower than a study done by Li et al where mortality rate was 32.3% (21/113) in young patients (<50 years) with AIS with LVO following MT.[19] Elder people tend to have more comorbidities such as HTN, DM, atherosclerosis, as well as natural aging process with decreasing immunity which may hamper in elasticity of brain or arterial collateral circulation and ability to recover.[10] These explanations are consistent with our findings, such as arterial HTN, DM, coronary artery diseases, dyslipidemia; previous stroke history and use of antithrombotic drugs were significantly higher in older patients compared with younger patients in this present study, which may be major reasons for poor functional outcome and more mortality in older age patients.
Combined technique after IVT for AIS with LVO is also safe and effective in older patients; however, age is significant predictor of functional outcome following MT.[26] The HERMES study described better outcomes of patients treated with MT versus medical therapy at 3 months follow-up and revealed that older patients populations get benefit even more from MT than younger patients.[9] But, younger age was significantly associated with higher rate (69.44%, 11/144) of favorable outcome compared with older patients (58.98%, 210/356) (p = 0.0292) in our study. The rates of recanalization are higher in young patients and may lead to high favorable outcome, which may be due to less tortuosity of arterial anatomy and atherosclerosis in younger populations.[27] Furthermore, risk factors for stroke, etiologies, frequency of stent pass, and vascular occlusion site were not found to be significant predictive factor for outcome. The NIHSS score less than 15 at admission was found to be significantly associated with 57.20% (123/215) of favorable outcome and 42.79% (92/215) of unfavorable outcome as compared with NIHSS score more than 15 at admission; and NIHSS score more than 15 at admission was found to be directly related with higher unfavorable outcome (61.40%, 174/285) and low favorable outcome (38.60%, 110/285) (p < 0.0001). Similarly, ASPECTS were also significantly differences with favorable and unfavorable outcomes (p < 0.0001), where ASPECTS more than 5 were found to be significant predictor for high favorable outcome (59.85%, 155/259) as compared with ASPECTS less than 5. Our findings are deferent with other study, where NIHSS and ASPECTS were independent predictors of favorable outcome.[28] Campbell et al described that great benefit and good outcome can be obtained from patients with AIS having NIHSS score ≤15 as compared with stroke patients with NIHSS score >20.[29] We also noted that onset to recanalization time was directly associated with outcome. Onset to recanalization time (ORT) < 4 hours or > 4 hours were found to be significant differences with more favorable outcome and unfavorable outcome (p < 0.0001). There was higher favorable outcome when ORT less than 4 hours (68.38%, 212/310) compared with ORT > 4 hours (35.26%, 67/190). Similar to our results, symptoms onset to recanalization or reperfusion were strongly associated with more favorable outcome with loss of significant treatment by 6 hours have been described in the MR CLEAN trail.[30] Earlier recanalization after MT following IVT may lead to earlier reperfusion of ischemic/penumbra brain which may positively impact on favorable outcome in patients with AIS caused by LVO. A higher mTICI grade, mTICI3, was found to be significantly associated with more favorable outcome as compared with mTICI2b/c (p = 0.0013) in our study.
To our knowledge, this is first study to examine the predictive factors for favorable and unfavorable outcomes as well as adverse results including mortality rate at 3 months in young (≤50 years) and old (>50 years) age patients with AIS caused by LVO in anterior circulation treated by combined technique after IVT. However, there are some limitations of our study: its retrospective design and relatively numbers of patients are not large enough. And also, sample sizes of the younger age groups were rather small as compared with older age groups. In addition to, this is a single-center study of observational character. Only inclusion of patients with mTICI >2b is also another limitation. We also could not describe the different score of mTICI after MT as well as analyze to evaluate its effect on functional outcome. This study should include onset to door, door to puncture along with PTR time to correlate with functional outcome. We also did not explain different local and systemic complications such as puncture site hematoma, deep vein thrombosis, pneumonia, pulmonary embolism, status of secondary vasospasm, and brain edema, which might also be causes of mortality in patients with AIS due to LVO after MT following IVT. Moreover, collateral circulation plays a pivotal role in maintaining viable brain tissue for a longer period and allowing a secondary path for reperfusion therapies, and has evolved as a prognostic factor to consider when selecting patients for acute ischemic treatments.[31] Collateral circulation status in patients who had a functional outcome needs to be studied, which was not described in our study.
Conclusion
In conclusion, combined technique after IVT for patients with AIS caused by LVO in anterior circulation is safe and effective. However, mortality rate is lower, and functional outcome is higher in younger age groups as compared with old age groups at 3 months following thrombectomy. Patient age ≤50 years, NIHSS score at admission< 15, ASPECTS >5, mTICI3, and onset to recanalization time < 4 hours were found to be significant predictive factors for functional outcome in our study.
Conflict of Interest
None declared.
Authors' Contributions
M.K. conceived and designed the study, he also contributed to data collection, manuscript writing, and drafting of the manuscript. G. R. was responsible for editing and providing technical feedback on design and analyses.
Ethical Approval
This is a retrospective study, so informed consent was taken from the institute as well as all included participants in this study. This study was approved by local Institutional Review Board.
-
References
- 1 Go AS, Mozaffarian D, Roger VL. et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Executive summary: heart disease and stroke statistics–2013 update: a report from the American Heart Association. Circulation 2013; 127 (01) 143-152
- 2 Fields JD, Lutsep HL, Smith WS. MERCI Multi MERCI Investigators. Higher degrees of recanalization after mechanical thrombectomy for acute stroke are associated with improved outcome and decreased mortality: pooled analysis of the MERCI and Multi MERCI trials. AJNR Am J Neuroradiol 2011; 32 (11) 2170-2174
- 3 The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333 (24) 1581-1587
- 4 Emberson J, Lees KR, Lyden P. et al; Stroke Thrombolysis Trialists' Collaborative Group. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 2014; 384 (9958): 1929-1935
- 5 Saver JL, Goyal M, Bonafe A. et al; SWIFT PRIME Investigators. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015; 372 (24) 2285-2295
- 6 Hacke W, Kaste M, Bluhmki E. et al; ECASS Investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359 (13) 1317-1329
- 7 Zibold F, Mordasini P, Mosimann P. et al. Safety of the Solitaire 4 × 40 mm stent retriever in the treatment of ischemic stroke. Cardiovasc Intervent Radiol 2018; 41 (01) 49-54
- 8 Naylor J, Thevathasan A, Churilov L. et al. Association between different acute stroke therapies and development of post stroke seizures. BMC Neurol 2018; 18 (01) 61
- 9 Goyal M, Menon BK, van Zwam WH. et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016; 387 (10029): 1723-1731
- 10 Brouwer J, Smaal JA, Emmer BJ. et al; MR CLEAN Registry Investigators†. Endovascular thrombectomy in young patients with stroke: a MR CLEAN registry study. Stroke 2022; 53 (01) 34-42
- 11 Wiegers EJA, Mulder MJHL, Jansen IGH. et al; MR CLEAN Trial and MR CLEAN Registry Investigators. MR CLEAN Trial and MR CLEAN Registry Investigators. Clinical and imaging determinants of collateral status in patients with acute ischemic stroke in MR CLEAN Trial and Registry. Stroke 2020; 51 (05) 1493-1502
- 12 Leischner H, Flottmann F, Hanning U. et al. Reasons for failed endovascular recanalization attempts in stroke patients. J Neurointerv Surg 2019; 11 (05) 439-442
- 13 Adams Jr HP, Bendixen BH, Kappelle LJ. et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993; 24 (01) 35-41
- 14 Maaijwee NA, Rutten-Jacobs LC, Schaapsmeerders P, van Dijk EJ, de Leeuw FE. Ischaemic stroke in young adults: risk factors and long-term consequences. Nat Rev Neurol 2014; 10 (06) 315-325
- 15 Humphries W, Hoit D, Doss VT. et al. Distal aspiration with retrievable stent assisted thrombectomy for the treatment of acute ischemic stroke. J Neurointerv Surg 2015; 7 (02) 90-94
- 16 Broderick JP, Palesch YY, Demchuk AM. et al; Interventional Management of Stroke (IMS) III Investigators. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 2013; 368 (10) 893-903
- 17 Tsivgoulis G, Alleman J, Katsanos AH. et al. Comparative efficacy of different acute reperfusion therapies for acute ischemic stroke: a comprehensive benefit-risk analysis of clinical trials. Brain Behav 2014; 4 (06) 789-797
- 18 Machi P, Jourdan F, Ambard D. et al. Experimental evaluation of stent retrievers' mechanical properties and effectiveness. J Neurointerv Surg 2017; 9 (03) 257-263
- 19 Li Z, Wu S, Liang F, Tan F, Li N, Bao M. Predictors of favorable outcome and mortality after endovascular thrombectomy in young Chinese patients with large vascular occlusions. Front Neurol 2023; 14: 1227642
- 20 Yeo LL-L, Chen VHE, Leow AS-T. et al. Outcomes in young adults with acute ischemic stroke undergoing endovascular thrombectomy: a real-world multicenter experience. Eur J Neurol 2021; 28 (08) 2736-2744
- 21 Shi J, Cao Y, You S. et al. Young stroke patients treated with intravenous thrombolysis have a more favorable outcome and mortality compared with older patients. Curr Neurovasc Res 2017; 14 (02) 141-148
- 22 Sallustio F, Koch G, Motta C. et al. Efficacy and safety of mechanical thrombectomy in older adults with acute ischemic stroke. J Am Geriatr Soc 2017; 65 (08) 1816-1820
- 23 Yesilot Barlas N, Putaala J, Waje-Andreassen U. et al. Etiology of first-ever ischaemic stroke in European young adults: the 15 cities young stroke study. Eur J Neurol 2013; 20 (11) 1431-1439
- 24 Malik N, Hou Q, Vagal A. et al. Demographic and clinical predictors of leptomeningeal collaterals in stroke patients. J Stroke Cerebrovasc Dis 2014; 23 (08) 2018-2022
- 25 Szmygin M, Sojka M, Tarkowski P. et al. Predictors of favorable outcome after endovascular thrombectomy for acute ischemic stroke due to large vessel occlusion in young patients. Acta Radiol 2022; 63 (12) 1689-1694
- 26 Martini M, Mocco J, Turk A. et al. An international multicenter retrospective study to survey the landscape of thrombectomy in the treatment of anterior circulation acute ischemic stroke: outcomes with respect to age. J Neurointerv Surg 2020; 12 (02) 115-121
- 27 Chalouhi N, Tjoumakaris S, Starke RM. et al. Endovascular stroke intervention in young patients with large vessel occlusions. Neurosurg Focus 2014; 36 (01) E6
- 28 Marnat G, Gory B, Sibon I. et al; Endovascular Treatment in Ischemic Stroke (ETIS) Investigators. Mechanical thrombectomy failure in anterior circulation strokes: outcomes and predictors of favorable outcome. Eur J Neurol 2022; 29 (09) 2701-2707
- 29 Campbell BC, Hill MD, Rubiera M. et al. Safety and efficacy of Solitaire stent thrombectomy. Stroke 2016; 47 (03) 798-806
- 30 Bush CK, Kurimella D, Cross LJ. et al. Endovascular treatment with stent-retriever devices for acute ischemic stroke: a meta-analysis of randomized controlled trials. PLoS One 2016; 11 (01) e0147287
- 31 Anadani M, Finitsis S, Clarençon F. et al; ETIS Registry Investigators. Collateral status reperfusion and outcomes after endovascular therapy: insight from the Endovascular Treatment in Ischemic Stroke (ETIS) Registry. J Neurointerv Surg 2022; 14 (06) 551-557
Address for correspondence
Publication History
Article published online:
02 June 2025
© 2025. Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India
-
References
- 1 Go AS, Mozaffarian D, Roger VL. et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Executive summary: heart disease and stroke statistics–2013 update: a report from the American Heart Association. Circulation 2013; 127 (01) 143-152
- 2 Fields JD, Lutsep HL, Smith WS. MERCI Multi MERCI Investigators. Higher degrees of recanalization after mechanical thrombectomy for acute stroke are associated with improved outcome and decreased mortality: pooled analysis of the MERCI and Multi MERCI trials. AJNR Am J Neuroradiol 2011; 32 (11) 2170-2174
- 3 The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333 (24) 1581-1587
- 4 Emberson J, Lees KR, Lyden P. et al; Stroke Thrombolysis Trialists' Collaborative Group. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 2014; 384 (9958): 1929-1935
- 5 Saver JL, Goyal M, Bonafe A. et al; SWIFT PRIME Investigators. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015; 372 (24) 2285-2295
- 6 Hacke W, Kaste M, Bluhmki E. et al; ECASS Investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359 (13) 1317-1329
- 7 Zibold F, Mordasini P, Mosimann P. et al. Safety of the Solitaire 4 × 40 mm stent retriever in the treatment of ischemic stroke. Cardiovasc Intervent Radiol 2018; 41 (01) 49-54
- 8 Naylor J, Thevathasan A, Churilov L. et al. Association between different acute stroke therapies and development of post stroke seizures. BMC Neurol 2018; 18 (01) 61
- 9 Goyal M, Menon BK, van Zwam WH. et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016; 387 (10029): 1723-1731
- 10 Brouwer J, Smaal JA, Emmer BJ. et al; MR CLEAN Registry Investigators†. Endovascular thrombectomy in young patients with stroke: a MR CLEAN registry study. Stroke 2022; 53 (01) 34-42
- 11 Wiegers EJA, Mulder MJHL, Jansen IGH. et al; MR CLEAN Trial and MR CLEAN Registry Investigators. MR CLEAN Trial and MR CLEAN Registry Investigators. Clinical and imaging determinants of collateral status in patients with acute ischemic stroke in MR CLEAN Trial and Registry. Stroke 2020; 51 (05) 1493-1502
- 12 Leischner H, Flottmann F, Hanning U. et al. Reasons for failed endovascular recanalization attempts in stroke patients. J Neurointerv Surg 2019; 11 (05) 439-442
- 13 Adams Jr HP, Bendixen BH, Kappelle LJ. et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993; 24 (01) 35-41
- 14 Maaijwee NA, Rutten-Jacobs LC, Schaapsmeerders P, van Dijk EJ, de Leeuw FE. Ischaemic stroke in young adults: risk factors and long-term consequences. Nat Rev Neurol 2014; 10 (06) 315-325
- 15 Humphries W, Hoit D, Doss VT. et al. Distal aspiration with retrievable stent assisted thrombectomy for the treatment of acute ischemic stroke. J Neurointerv Surg 2015; 7 (02) 90-94
- 16 Broderick JP, Palesch YY, Demchuk AM. et al; Interventional Management of Stroke (IMS) III Investigators. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 2013; 368 (10) 893-903
- 17 Tsivgoulis G, Alleman J, Katsanos AH. et al. Comparative efficacy of different acute reperfusion therapies for acute ischemic stroke: a comprehensive benefit-risk analysis of clinical trials. Brain Behav 2014; 4 (06) 789-797
- 18 Machi P, Jourdan F, Ambard D. et al. Experimental evaluation of stent retrievers' mechanical properties and effectiveness. J Neurointerv Surg 2017; 9 (03) 257-263
- 19 Li Z, Wu S, Liang F, Tan F, Li N, Bao M. Predictors of favorable outcome and mortality after endovascular thrombectomy in young Chinese patients with large vascular occlusions. Front Neurol 2023; 14: 1227642
- 20 Yeo LL-L, Chen VHE, Leow AS-T. et al. Outcomes in young adults with acute ischemic stroke undergoing endovascular thrombectomy: a real-world multicenter experience. Eur J Neurol 2021; 28 (08) 2736-2744
- 21 Shi J, Cao Y, You S. et al. Young stroke patients treated with intravenous thrombolysis have a more favorable outcome and mortality compared with older patients. Curr Neurovasc Res 2017; 14 (02) 141-148
- 22 Sallustio F, Koch G, Motta C. et al. Efficacy and safety of mechanical thrombectomy in older adults with acute ischemic stroke. J Am Geriatr Soc 2017; 65 (08) 1816-1820
- 23 Yesilot Barlas N, Putaala J, Waje-Andreassen U. et al. Etiology of first-ever ischaemic stroke in European young adults: the 15 cities young stroke study. Eur J Neurol 2013; 20 (11) 1431-1439
- 24 Malik N, Hou Q, Vagal A. et al. Demographic and clinical predictors of leptomeningeal collaterals in stroke patients. J Stroke Cerebrovasc Dis 2014; 23 (08) 2018-2022
- 25 Szmygin M, Sojka M, Tarkowski P. et al. Predictors of favorable outcome after endovascular thrombectomy for acute ischemic stroke due to large vessel occlusion in young patients. Acta Radiol 2022; 63 (12) 1689-1694
- 26 Martini M, Mocco J, Turk A. et al. An international multicenter retrospective study to survey the landscape of thrombectomy in the treatment of anterior circulation acute ischemic stroke: outcomes with respect to age. J Neurointerv Surg 2020; 12 (02) 115-121
- 27 Chalouhi N, Tjoumakaris S, Starke RM. et al. Endovascular stroke intervention in young patients with large vessel occlusions. Neurosurg Focus 2014; 36 (01) E6
- 28 Marnat G, Gory B, Sibon I. et al; Endovascular Treatment in Ischemic Stroke (ETIS) Investigators. Mechanical thrombectomy failure in anterior circulation strokes: outcomes and predictors of favorable outcome. Eur J Neurol 2022; 29 (09) 2701-2707
- 29 Campbell BC, Hill MD, Rubiera M. et al. Safety and efficacy of Solitaire stent thrombectomy. Stroke 2016; 47 (03) 798-806
- 30 Bush CK, Kurimella D, Cross LJ. et al. Endovascular treatment with stent-retriever devices for acute ischemic stroke: a meta-analysis of randomized controlled trials. PLoS One 2016; 11 (01) e0147287
- 31 Anadani M, Finitsis S, Clarençon F. et al; ETIS Registry Investigators. Collateral status reperfusion and outcomes after endovascular therapy: insight from the Endovascular Treatment in Ischemic Stroke (ETIS) Registry. J Neurointerv Surg 2022; 14 (06) 551-557