Article Figures & Data
- Figure 1
*Clinical thrombectomy pathway. Patients who had contraindications to thrombolysis were given oral antiplatelets (aspirin or clopidogrel, if aspirin intolerance) before thrombectomy, unless fully anticoagulated. The indications and contraindications were for guidance, with final treatment decisions made by the responsible clinician. BA, basilar artery; HT1, haemorrhagic transformation 1; HT2, haemorrhagic transformation 2; INR, International Normalised Ratio; iv Aspirin, intravenous aspirin at a dose of 500mg; ICA, internal carotid artery; MT, mechanical thrombectomy; M1, proximal segment of the middle cerebral artery; M2, Sylvain Segment of the middle cerebral artery; NIHSS, National Institutes of Health Stroke Scale; PCA, posterior cerebral artery; SAH, subarachnoid haemorrhage; VA, vertebral artery.
- Table 1
Baseline demographics and clinical details
All thrombectomies
(n=565)Thrombectomies with stenting
(n=102)Stent
(n=102)No stent
(n=463)P value Aspirin
(n=49)No aspirin (n=53) P value Thrombolysis
(n=76)No thrombolysis (n=26) P value Age (years) median (IQR) 67 (57–72) 70 (60–77) 0.004* 68 (55–75) 66 (57–70) 0.40* 62 (55.75–71) 68.5 (60–78) 0.03* Male sex (n (%)) 70 (69%) 233 (50%) 0.001† 27 (55%) 43 (81%) 0.009† 60 (79%) 10 (38%) 0.0003† Hypertension
(n (%))51 (50%) 234 (51%) 1† 21 (43%) 30 (57%) 0.23† 36 (47%) 15 (58%) 0.50† Atrial fibrillation
(n (%))4 (4%) 153 (33%) <0.001† 2 (4%) 2 (4%) 1† 2 (3%) 2 (8%) 0.27† Hyperlipidaemia
(n (%))27 (26%) 124 (27%) 1† 10 (20%) 17 (32%) 0.27† 19 (25%) 8 (31%) 0.75† Diabetes (n (%)) 18 (18%) 70 (15%) 0.63† 7 (14%) 11 (21%) 0.55† 15 (20%) 3 (12%) 0.55† Previous stroke/TIA (n (%)) 13 (13%) 69 (15%) 0.69† 7 (14%) 6 (11%) 0.88† 9 (12%) 4 (15%) 0.73† Thrombolysis
(n (%))76 (75%) 354 (76%) 0.77† 34 (69%) 42 (79%) 0.36† NA NA NA NIHSS at baseline (median (IQR)) 18 (13–23) 18 (14–22) 0.87* 19 (15–23) 18 (9–23) 0.22* 19(14-23) 15.5 (10–22.5) 0.20* Anterior circulation (n (%)) 94 (92%) 416 (90%) 0.60† 45 (92%) 49 (92%) 1† 70 (92%) 24 (92%) 1† Posterior circulation (n (%)) 8 (8%) 47 (10%) 0.60† 4 (8%) 4 (8%) 1† 7 (8%) 2 (8%) 1† Onset to groin time (min)
(median (IQR))269 (195–343) 261 (201–332) 0.93* 277 (204–359) 260 (195–325) 0.36* 253 (195–322.5) 287 (195–500) 0.30* Onset to lysis time (min)
(median (IQR))123 (90–160) 135 (105–182) <0.001* 115 (90–152) 123 (94–168) <0.001* 123(90-160) na na Collateral score
(n (%))1† 0.11† Level 1 17 (44%) 17 (41%) 29 (49%) 5 (24%) Level 2 17 (44%) 19 (46%) 24 (41%) 12 (57%) Level 3 5 (12%) 5 (13%) 6 (10%) 4 (19%) ASPECTS score 7 (6.75–9) 8 (6–9) 0.88* 8 (6–9) 7 (7–9) 1* *Mann-Whitney U test.
†Z-test.
‡Fisher’s exact test.
ASPECTS, The Alberta Stroke Programme Early CT Score; NIHSS, National Institutes for Health Stroke Scale score; TIA, Transient ischemic attack.
- Table 2
Complications and outcomes in patients who were stented during thrombectomy with or without intraoperative aspirin
All thrombectomies (n=565) Thrombectomies with stenting (n=102) Stent
(n=102)No stent
(n=463)P value Aspirin
(n=49)No aspirin (n=53) P value Thrombolysis in cerebral infarct score ≥2b (n (%)) 92 (90%) 414 (90%) 0.96* 43 (88%) 49 (92%) 0.51* NIHSS at 7 days median (IQR) 10 (3–20) 6 (2–16) 0.08† 5 (2–17) 15 (4–32) 0.03† NIHSS difference baseline to 7 days median (IQR) 6 (-3–13) 9 (1–14) 0.02† 8 (1–16) 3 (-9–8) 0.003† Infarction at 24 hours (n (%)) 79 (77%) 331 (72%) 0.27* 35 (71%) 44 (83%) 0.25* Malignant middle cerebral artery syndrome (n (%)) 6 (6%) 36 (8%) 0.65* 1 (2%) 5 (9%) 0.21‡ Hemicraniectomy (n (%)) 2 (2%) 9 (2%) 1‡ 1 (2%) 1 (2%) 1‡ Symptomatic intracerebral haemorrhage (n (%)) 11 (11%) 30 (7%) 0.19* 2 (4%) 9 (17%) 0.08* Subarachnoid haemorrhage (n (%)) 10 (10%) 42 (9%) 0.97* 6 (12%) 4 (7%) 0.51‡ Stroke within 90 days (n (%)) 0 (0.0%) 9 (2%) 0.37‡ 0 (0.0%) 0 (0.0%) 1‡ Death at 90 days (n (%)) 22 (22%) 76 (16%) 0.27* 10 (20%) 12 (23%) 0.97* mRS 0–2 at 90 days (n (%)) 44 (43%) 221 (48%) 0.46* 25 (51%) 19 (36%) 0.18* *Z-test.
†Mann-Whitney U test.
‡Fisher’s exact test.
NIHSS, National Institutes for Health Stroke Scale score.
- Table 3
Complications and outcomes in stented patients in relation to aspirin and thrombolysis
Aspirin given intraoperatively (n=49) No aspirin given intraoperatively (n=53) Thrombolysed
(n=34)Not thrombolysed
(n=15)P value Thrombolysed
(n=42)Not thrombolysed
(n=11)P value Thrombolysis in cerebral infarct score ≥2b (n (%)) 33 (97%) 10 (67%) 0.008* 39 (93%) 10 (90%) 1* NIHSS at 7 days median (IQR) 5 (2–14) 16 (2–36) 0.09† 15 (3–34) 15(5–21) 0.63† NIHSS difference baseline to 7 days median (IQR) 12 (4–18) 7 (-7–10) 0.01† 4 (-6–9) 2 (–12–4) 0.24† Infarction at 24 hours (n (%)) 26 (76%) 9 (60%) 0.31* 34 (81%) 10 (91%) 0.67* Malignant middle cerebral artery syndrome (n (%)) 0 (0%) 1 (7%) 0.31* 5 (12%) 0 (0%) 0.57* Hemicraniectomy (n (%)) 0 (0%) 1 (7%) 0.31* 1 (2%) 0 (0%) 1* Symptomatic intracerebral haemorrhage (n (%)) 1 (3%) 1 (6%) 1* 4 (10%) 5 (46%) 0.01* Subarachnoid haemorrhage (n (%)) 4 (12%) 2 (13%) 1* 2 (5%) 2 (18%) 0.19* Stroke within 90 days (n (%)) 0 (0%) 0 (0%) 1* 0 (0%) 0 (0%) 1* Death at 90 days (n (%)) 4 (12%) 6 (40%) 0.05* 8 (19%) 4 (36%) 0.24* mRS 0–2 at 90 days (n (%)) 20 (59%) 5 (33%) 0.18‡ 16 (38%) 3 (27%) 0.73* *Fisher’s exact test.
†Mann-Whitney U test.
‡Z-test.
mRS, modified Rankin Scale; NIHSS, National Institutes for Health Stroke Scale score.
- Table 4
Studies of emergent stenting during mechnical thrombectomy with details of the use of intraprocedural antiplatelet agents.
Observational Studies Paper Number stented/total cases Indication Centres NIHSS before
MT
(median)Territory TICI ≥2 Key outcome mRS≤2 Symptomatic intracranial haemorrhage Antiplatelet choice Thrombolysis Mortality at 3 months Behme et al 2 170/170 ES Multi (4) 15 Carotid 77% 36% 9% Eptifibatide or tirofiban or aspirin 500 intravenous and clopidogrel via nasogastric tube 72% 19% (discharge) Papanagiotou et al 4 322/482 ES Multi 16 Carotid 81.1% 55.0% 7.1% Variable intravenous aspirin, intravenous GP IIb/IIIa Inh, clopidogrel
heparin62% 11.2% Zhu et al TITAN registry5 256/295 ES Multi ND Carotid 83.1% 57.9% 5.1% All below 60% 9.5% 4.4% Antiplatelet and lysis (136) 8.6% Antiplatelet alone (92) 9.0% Lysis alone (11) 0% Neither (7) Anadani et al TITAN Registry6 205/205 ES Multi ND Carotid 81% 56.6% 5.9% Type of antiplatelet regime not reported 60% 12.7% Hadler et al 7 73/548 xx Single xx Carotid xx 40.6% 16% Tirofiban, dual antiplatelet therapy 65.8% 28.1% Chang et al 8 48/148 RS Multi 14 Carotid, M1 64.6% 39.6% 16.7% GP IIb/IIIa Inh and /or antiplatelets 46% intravenous, 15% ia 12.5% Stracke et al 9 210/210 RS Multi 13 Any 82.9% 44.8% 10.5% At least one agent, detail not fully reported 31% 18.5% Delvoye et al 25 60/218 ES Single 16 Carotid ND 58.1% 9.3% Aspirin intravenous 250 mg (43) or 53.5% 18.6% 12 37.5% 25% abciximab 0.25 mg/kg (8) 50.0% 37.5% 17 33.3% 11.1% Bolus and infusion (9) 33.3% 11.1% Peng et al 26 90/339 RS Multi (16) 17 Anterior circulation ND 36.4% 13.6% Tirofiban Yes 31.9% Schaefer et al 27 26/122 RS Single 15* ND ND ND 3.6% ND 39% 36% (discharge) Mohamedan et al 28 107/499 RS Multi (14) 16 Carotid ND 34.6% 7.5% Not specified 29% intravenous 2% ia 29.9% Ingleton et al 102/565 RS Single 18 Carotid, VA 90% 43% 11% All 102 (100%) 75% 22% 19 88% 51% 4% Aspirin 500 mg intravenous in 49 (48%) 69% 20% 18 92% 51% 4% No asprin l in 53 (52%) 79% 23% Metanalyses and systematic Reviews Paper Number stented/total cases Indication Centres NIHSS before
MT
(median)Territory TICI ≥2 Key outcome mRS≤2 Symptomatic intracranial haemorrhage Antiplatelet choice Thrombolysis Mortality at 3 months Dufort et al 29 1635 ES Meta-analysis of 16 studies ND Anterior circulation ND 53.7% 8.3% Variable Not specified 13.4% Paul et al 30 129 ES Pooled analysis ND Any 100% ND 6.2% IV cangrelor 23.4% ND Sadeh-Gonik et al 31 338 ES Meta-analysis of 14 studies 16* Anterior circulation 76% 53% 7% Not specified 65% 14% Maingard et al 32 365 RS Meta-analysis of 12 studies 16* Anterior circulation 35.7% 48.5% 9.7% Tirofioban, heparin, abciximab, aspirin, clopidogrel, 35.7% 21.9% Sivan-Hoffman et al 33 193 ES Meta-analysis of 11 studies 2010–2015 17* Carotid 63.8% 44% 7% Not specified 54% 13% Cai et al 34 774/1595 ES Meta-analysis of 15 studies ND Any 78.5% 37.8%† 8.3%† Not specified 31.8% median 22.5%** Observational studies including 20 or more patients and meta-analyses of emergent or rescue stenting after mechanical thrombectomy.
*Study used mean as measure of NIHSS baseline, TICI.
†Total number of participants is 1595. The total number of stented patients is 774. Percentages were calculated, where information available in tables and figures.
BA, basilar artery; ES, emergent stenting; GP IIb/IIIa Inh, glycoprotein IIb/IIIa inhibitors; M1, proximal segment of the middle cerebral artery; mRS, modified Rankin Scale ; MT, mechanical thrombectomy; ND, not disclosed within article; NIHSS, National Institutes of Health Stroke Scale; RS, rescue stenting; TICI, thrombolysis in cerebral infarct; VA, vertebral artery; xx, unavailable.
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