الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Despite 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 well-selected 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. Evaluate the efficacy and safety of mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion. 2. Identify predictors of functional independence and predictors of complications and three months mortality following mechanical thrombectomy. This prospective cohort study, a registered trial (NCT03608644), was carried out at Assiut University stroke center, collaborating with Ain Shams University stroke center, Egypt. Eighty-eight patients who met inclusion criteria for MT [forty-four patients in group 1 (MT group from Ain Shams university stroke center where MT is available) and forty-four patients in group 2 (MM group from Assiut university stroke center where MT is not available)] with anterior circulation AIS were recruited between first January 2019 to end of December 2019. Inclusion criteria were: Adult patients (≥18 years, National Institutes of Health Stroke Scale score (NIHSS) ≥ 6, presented within 6 hours from the onset, and presented with large vessel occlusion (LVO) of the internal carotid artery (ICA) middle cerebral artery (MCA) M1 segment, or both. The Medical Ethical Review Board of Assiut and Ain Shams University approved the study- approval number 17200215, and we obtained informed consent from the patients and/ or their relatives. 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 [215]. 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. Patients in 1 (MT group) underwent MT plus standard of care Patients in group 2 (MM group) received standard of care without MT. 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 average MAP and the attempts number, procedure duration, and the inserted carotid stent (if performed). The recanalization status was assessed using AOL and by mTICI, and successful recanalization was defined as AOL score 2 or 3 and mTICI grade 2b or Stander 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. Also, we assessed rates of three months mortality. The main findings of our study are summarized as follows. Predictors of functional independence. NIHSS at presentation remained a significant independent predictor of long-term functional outcomes after MM (p = .010) and after MT (p=.009). Successful recanalization as detected by mTICI (p = .0001) remained significant independent predictors of good long-term functional outcome (mRS) after MT. Predictors of complications (unsuccessful recanalization Successful recanalization occurred in 81.8% when evaluated by AOL and 63.6% according to evaluation by mTICI. High NIHSS at presentation (p= .001), number of attempts (p = .030), and using distal access catheter (p = .052) remained significant independent predictors associated with unsuccessful recanalization as assisted by mTICI. Predictors of complications (development of sICH). High NIHSS at presentation (p = .049) remained a significant independent predictor for developing sICH after MT. Predictors of three months mortality. Duration of the procedure (p = .010) remained a significant independent predictive factor of three months mortality after MT. early and late outcomes of both groups (MT) and (MM) Early recovery was recorded in 28.4% and was significantly higher among MT than MM patients, while good functional outcomes after three months, according to mRS, were recorded in 42% of patients and were significantly higher among patients with MT than those with MM, On other hands, we could detect no significant difference between patients of both groups regarding the development of sICH or three months mortality.
Impact of IV rtPA on patients who underwent MT and who received MM alone.
The current study found no differences between patients who received IV rtPA and those who did not revive it regarding different aspects of outcomes among both groups