Influence of the thrombectomy parameters on the efficacy in the acute stroke with large vessel occlusion treatment

Acute ischemic stroke (AIS) is an acute impairment of brain function caused by a central nervous system focal injury of a vascular origin. The cause is a sudden blockage of blood flow to the brain neural tissue caused by arterial occlusion. AIS is the second most common primary cause of death in Europe, accounting for 9% of deaths in men and 12% of deaths in women annually. Moreover, mortality within the first month after the incident is around 30%. Half of the survivors lose their independence in everyday life, as it is the leading cause of long-term disability. From a socio-economic point of view, AIS represents a major public health burden worldwide, mainly due to the high hospitality rate of severely disabled patients and consequently high costs of rehabilitation and medical care. The main goals of AIS treatment are the recanalization of occluded blood vessels and potential reperfusion of remained viable brain tissue. Until 2015, the only proven reperfusion technique was the application of recombinant tissue plasminogen activator (IV tPA) administered less than 4.5 hours from symptom onset. However, several randomized controlled trials (RCTs) promoted an endovascular treatment approach and proved that mechanical thrombectomy (MT) is safe and effective for the treatment of anterior circulation large vessel occlusion (ACLVO), in comparison with traditional AIS treatment. Although MT is currently an accepted standard of care, there are still a lot of pending questions to be clarified. For instance, issues about widening MT indications, best technique, practical organization, minimal required imaging, type of anesthesia, patient triage and transport, the best management of tandem occlusion (TO), and the influence of the clot composition on retrieval efficacy need to be additionally clarified in future. Another major issue is the applicability of RCTs results achieved in the well-organized centers and in highly-controlled settings, compared to a real-world situation, especially in developing country medical systems which are dealing with lack of trained personnel, shortage of appropriate financial and material support, lower basic health level of the population, etc. Therefore, this dissertation aimed to evaluate the influence of different thrombectomy parameters on the treatment of AIS in Belgrade and Toulouse cohort study populations.\nMaterial and methods: This double center observational cohort study with the pragmatic care trial context for AIS patients treated with MT included data from 284 patients at Toulouse University prospective stroke registry and data from 82 patients at The Clinical Center of Serbia prospective stroke registry. Clinical and radiological data collection of treated cases were from January 2015 to January 2017 at Toulouse University center, and from January 2018 to January 2020 at The Clinical Center of Serbia. Moreover, additional collected data related to the anesthesia management during MT procedure in the Toulouse mono-center cohort were for the period from January 2014 until July 2016. The eligible cases were selected using the following inclusion criteria: (1) verified ACLVO by computed tomography (CT) angiography or magnetic resonance (MR) angiography; (2) MT initiated within the 6 hours from symptoms onset regardless of the use of intravenous recombinant tissue plasminogen activator (IV tPA). On the other hand, the exclusion criteria were as follows: (1) presence of intracranial hemorrhage (on MR or CT); (2) absence of the ACLVO; (3) small artery occlusion (distal from M2 division of the middle cerebral artery) or in the territory of posterior circulation (vertebrobasilar distribution); (4) MT initiated after 6 hours from symptom onset; (5) age below 18 years. From prospective stroke databases of both centers, several parameters were collected: clinical data (age, gender, pre-treatment National Institutes of Health Stroke Scale (NIHSS) score, side of occlusion, level of occlusion, use of IV tPA, and type of anesthesia), time metrics (time of stroke onset, time of arrival at the stroke center, time of imaging, time of arrival in the angio-suite, time of arterial puncture (AP) and time of recanalization/last image), imaging data (on MR or CT),the Alberta Stroke Program Early CT Score (ASPECTS) was calculated on\ndiffusion-weighted imaging (DWI) or CT to assess the extent of the ischemic core, endovascular treatment data and angiographic outcome on modified thrombolysis in cerebral infarction (mTICI) score, and safety and clinical outcomes (complications and intracranial hemorrhage, stroke severity measured on the NIHSS at 24h, the degree of disability assessed on modified...

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