UNASSIGNED: The relationship between the early hemodynamic consequences of acute pulmonary embolism (PE) and short-term morbidity and mortality has long been recognized. The mortality incidence and other complications after high-risk (massive) PE, the most severe category of the disease, are summarized in this meta-analysis.
UNASSIGNED: A systematic review and meta-analysis of studies reporting on patients with massive PE indexed by PubMed and the Cochrane Library over a 10-year period (2010-2020) was conducted. Studies with adequate information to specify a cohort of patients with high-risk PE defined by the American Heart Association and European Society of Cardiology criteria and their clinical outcomes were included. Incidences were calculated as weighted averages with 95% CIs.
UNASSIGNED: A total of 27 publications spanning 1517 patients were identified that met the search criteria for high-risk PE. In-hospital all-cause mortality averaged 28.3% (95% CI, 20.9%-37.0%) in patients at high risk, comparable to the 30-day all-cause mortality of 30.2% (95% CI, 22.3%-39.6%). In-hospital major bleeding was 13.8% (95% CI, 9.3%-20.0%), and intracranial hemorrhage was reported in 3.6% (95% CI, 2.2%-5.9%). The risk of bias in publications was graded as low-to-moderate, with substantial heterogeneity among the studies.
UNASSIGNED: This systematic review and meta-analysis provided low-quality to moderate-quality evidence documenting mortality, major bleeding, and other complications in patients meeting the American Heart Association and European Society of Cardiology criteria for high-risk PE. This information was used to inform the design of the FLowTriever for Acute Massive Pulmonary Embolism (FLAME) study (NCT04795167), a study evaluating an advanced therapy for patients with high-risk PE.

BACKGROUND: Mechanical Thrombectomy (MT) is an efficacious treatment for severe acute ischemic stroke patients. However, access to MT is limited in many parts of the world, partly due to economic barriers. The purpose of this systematic review is to provide an updated frame about the socioeconomic impact of MT.
METHODS: To carry out this systematic review we used the PRISMA guidelines. We included scientific articles analyzing the socioeconomic impact of MT for acute ischemic stroke, in which MT was compared to best medical therapy (BMT). The online databases of Pubmed, Scopus and Web of Science were used as main sources of information. To carry out the comparative analysis, the incremental cost-effectiveness ratio (ICER) was used, relating the cost to quality-adjusted life-year (QALY). Risk of bias was assessed with the Consensus Health Economic Criteria (CHEC) and the Consolidated Health Economic Evaluation Reporting Standards (CHEERS).
RESULTS: Eight hundred thirty-two studies were identified in this systematic review. As a result, studies that used cost-effectiveness analysis show that MT saves costs in the long term and cost-utility analysis show that the cost per QALY is reasonable with a mean ICER value of $14242.36/QALY.
CONCLUSIONS: MT has a favorable socioeconomic impact, as derived from cost-effectiveness and cost-utility analyses. Therefore, public policies should encourage the implementation of MT for stroke patients around the world.

UNASSIGNED: To demonstrate the technical aspects of the novel Penumbra Indigo Lightning Flash System (Penumbra, Inc.) for mechanical thrombectomy of pulmonary embolism (PE).
UNASSIGNED: The novel Penumbra Lightning Flash catheter is a 16 French (F) sheath-compatible device designed for advanced thrombectomy, especially in the pulmonary arteries. This device has large thrombus burden removal capacity; however, technical nuances are necessary to accomplish more with efficacy pulmonary embolism management. Access sites, pulmonary arteries catheterization technique, thrombectomy device navigation and mechanism of action are described thoroughly.
UNASSIGNED: Penumbra Indigo Lightning Flash system for mechanical thrombectomy as other catheter-directed treatments (CDTs) represents a major advance in contemporary PE management. With favorable safety profile and efficacy, CDTs have become an integral component of the multidisciplinary approach to PE care.
CONCLUSIONS: The article highlights the Penumbra Indigo Lightning Flash System as a significant advancement in mechanical thrombectomy for pulmonary embolism (PE). By detailing technical aspects and procedural nuances, it supports clinicians for improvement in endovascular PE management. The system\'s integration into multidisciplinary care represents a major step forward, providing an effective alternative to traditional therapies, particularly for high-risk PE patients. This innovation promises to enhance patient outcomes in contemporary PE management.

UNASSIGNED: Mechanical thrombectomy is a time-sensitive treatment, with rapid initiation and reduced delays being associated with better patient outcomes. Several systematic reviews reported on various interventions to address delays. Hence, we performed an umbrella review of systematic reviews to summarise the current evidence.
UNASSIGNED: Medline, Embase, Cochrane Library and JBI were searched for published systematic reviews. Systematic Reviews that detailed outcomes related to time-to-thrombectomy or functional independence were included. Methodological quality was assessed using the JBI critical appraisal tool by two independent reviewers.
UNASSIGNED: A total of 17 systematic reviews were included in the review. These were all assessed as high-quality reviews. A total of 13 reviews reported on functional outcomes, and 12 reviews reported on time-to-thrombectomy outcomes. Various interventions were identified as beneficial. The most frequently reported beneficial interventions that improved functional and time-related outcomes included: direct-to-angio-suite and using a mothership model (compared to drip-and-ship). Only a few studies investigated other strategies including other pre-hospital and teamwork strategies.
UNASSIGNED: Overall, there were various strategies that can be used to reduce delays in the delivery of mechanical thrombectomy with different effectiveness. The mothership model appears to be superior to the drip-and-ship model in reducing delays and improving functional outcomes. Additionally, the direct-to-angiosuite approach appears to be beneficial, but further research is required for broader implementation of this approach and to determine which groups of patients would benefit the most.

BACKGROUND: Physician transfer is an alternate option to patient transfer for expedient performance of mechanical thrombectomy in patients with acute ischemic stroke.
RESULTS: We conducted a systematic review to identify studies that evaluate the effect of physician transfer in patients with acute ischemic stroke who undergo mechanical thrombectomy. A search of PubMed, Scopus, and Web of Science was undertaken, and data were extracted. A statistical pooling with random-effects meta-analysis was performed to examine the odds of reduced time interval between stroke onset and recanalization, functional independence, death, and angiographic recanalization. A total of 12 studies (11 nonrandomized observational studies and 1 nonrandomized controlled trial) were included, with a total of 1894 patients. Physician transfer was associated with a significantly shorter time interval between stroke onset and recanalization with a pooled mean difference estimate of -62.08 (95% CI, -112.56 to -11.61]; P=0.016; 8 studies involving 1419 patients) with high between-study heterogeneity in the estimates (I2=90.6%). The odds for functional independence at 90 days were significantly higher (odds ratio, 1.29 [95% CI, 1.00-1.66]; P=0.046; 7 studies with 1222 patients) with physician transfer with low between-study heterogeneity (I2=0%). Physician transfer was not associated with higher odds of near-complete or complete angiographic recanalization (odds ratio, 1.18 [95% CI, 0.89-1.57; P=0.25; I2=2.8%; 11 studies with 1856 subjects).
CONCLUSIONS: Physician transfer was associated with a significant reduction in the mean of time interval between symptom onset and recanalization and increased odds for functional independence at 90 days with physician transfer compared with patient transfer among patients who undergo mechanical thrombectomy.

BACKGROUND: Mechanical thrombectomy represents a mainstay of management for acute ischemic stroke in the setting of large vessel occlusion. However, there are no clinical practice guidelines defining the role of thrombectomy at the extremes of age. In this scoping review, we aimed to summarize the existing medical and neurosurgical literature pertaining to mechanical thrombectomy in nonagenarians. The PubMed database was queried using the following terms and relevant citations assessed: \"thrombectomy nonagenarian,\" \"thrombectomy age 90,\" \"stroke nonagenarian,\" and \"ischemic stroke thrombectomy.\" Common measurable outcomes, including mortality, modified Rankin scale (mRS) score, and thrombolysis in cerebral infarction (TICI) scale score, were utilized to compare results.
CONCLUSIONS: Thrombectomy was shown to improve functional outcomes in all eight of the studies included in the analysis. Mortality was assessed in only two reported studies, and thrombectomy was shown to provide a mortality benefit in 1 study among patients for whom first-pass reperfusion was achieved. Other outcomes of reported interest included greater early neurologic recovery at discharge and improved functional outcomes at 90 days among nonagenarians who underwent thrombectomy as compared to those who received thrombolytic therapy alone. Nonagenarians with good functional status at baseline were the most likely to have favorable outcomes.
CONCLUSIONS: Mechanical thrombectomy improves outcomes among nonagenarians presenting with acute ischemic stroke due to large vessel occlusion. Further large-scale prospective studies are warranted to optimize patient selection and develop clinical practice guidelines specific to this important patient demographic.

There is limited evidence on the outcomes and safety of mechanical thrombectomy (MT) among patients with acute ischemic stroke (AIS) in the context of cardiac diseases. Our study reviews MT in AIS within the context of cardiac diseases, aiming to identify existing and emerging needs and gaps. PubMed and Scopus were searched until December 31, 2023, using a combination of cardiological diseases and \"mechanical thrombectomy\" or \"endovascular treatment\" as keywords. Study design included case reports/series, observational studies, randomized clinical trials, and meta-analyses/systematic reviews. We identified 943 articles, of which 130 were included in the review. Results were categorized according to the cardiac conditions. MT shows significant benefits in patients with atrial fibrillation (n=139) but lacks data for stroke occurring after percutaneous coronary intervention (n=2) or transcatheter aortic valve implantation (n=5). MT is beneficial in AIS attributable to infective endocarditis (n=34), although functional benefit may be limited. Controversy surrounds the functional outcomes and mortality of patients with AIS with heart failure undergoing MT (n=11). Despite technical challenges, MT appears feasible in aortic dissection cases (n=4), and in patients with left ventricular assist device or total artificial heart (n=10). Data on AIS attributable to congenital heart disease (n=4) primarily focus on pediatric cases requiring technical modifications. Treatment outcomes of MT in patients with cardiac tumors (n=8) vary because of clot consistency differences. After cardiac surgery stroke, MT may improve outcomes with early intervention (n=13). Available data outline the feasibility of MT in patients with AIS attributable to large-vessel occlusion in the context of cardiac diseases.

BACKGROUND: Since the efficacy and safety of endovascular thrombectomy (EVT) in patients with acute ischemic stroke with a large infarct area is still inconclusive, we sought to compare functional and neurological outcomes with the use of endovascular thrombectomy versus medical care alone.
METHODS: We searched MEDLINE (via PubMed), Embase, Cochrane Library, ClinicalTrials.gov, and the International Clinical Trials Registry Platform (ICTRP) to retrieve all the relevant randomized controlled trials (RCTs) on this topic. Review manager (RevMan) was used to perform meta-analyses using a random-effect model. Dichotomous outcomes were pooled using risk ratios (RR) with 95% confidence intervals (CIs).
RESULTS: Our meta-analysis included 6 RCTs with a total of 1665 patients. Most studies included patients with an ASPECTS score of 3-5. Our results demonstrate that endovascular thrombectomy significantly increased the rates of functional independence (mRS ≤ 2) (RR, 2.49; 95% CI, 1.89-3.29) and moderate neurological outcome (mRS ≤ 3) (RR, 1.90; 95% CI, 1.50-2.40) at 90 days. The benefit of EVT for these outcomes remained the same at 1-year follow-up. Endovascular thrombectomy was associated with increased rates of early neurological improvement (RR, 2.22; 95% CI, 1.53-3.22), excellent neurological recovery (mRS ≤ 1) (RR, 1.75; 95% CI, 1.02-3.03), and decreased rate of poor neurological recovery (mRS 4-6) (RR, 0.81; 95% CI, 0.76-0.86). No significant difference was found between the two groups regarding all-cause mortality (RR, 0.86; 95% CI, 0.72-1.02), decompressive craniectomy (RR, 1.32; 95% CI, 0.89-1.94), and the incidence of serious adverse effects (RR, 1.39; 95% CI, 0.83-2.32) between the two groups. Endovascular thrombectomy significantly increased the rates of any intracranial hemorrhage (RR, 1.94; 95% CI, 1.48-2.53) and symptomatic intracranial hemorrhage (RR, 1.73; 95% CI, 1.11-2.69).
CONCLUSIONS: Endovascular thrombectomy (EVT) significantly improves neurological and functional outcomes in patients who present within 6 hours of stroke onset with ICA and proximal M1 occlusions, and ASPECTS scores ranging from 3 to 5, compared to medical therapy alone, with an increased risk of symptomatic intracranial hemorrhage.

OBJECTIVE: Acute ischemic stroke (AIS) imposes a major healthcare burden, with the elderly population often underrepresented in clinical trials. This systematic review and network meta-analysis aims to evaluate the safety and efficacy of mechanical thrombectomy (MT) among octogenarians and nonagenarians with AIS due to large vessel occlusion (LVO).
METHODS: A systematic search was conducted using PubMed, Web of Science, and Scopus databases. Outcomes of interest were modified Rankin Scale (mRS) score of 0-2, thrombolysis in cerebral infarction (TICI) score of 2b-3, 90-day mortality, and symptomatic intracerebral hemorrhage (sICH). The study followed Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.
RESULTS: The analysis included 47 studies. Significantly lower rates of mRS score 0-2 were observed in nonagenarians (17.4 %) and octogenarians (21.3 %) compared to younger (40.2 %) patients (Odds Ratio (OR) = 3.30, 95 % Confidence Interval (CI):2.35-4.65 and OR = 2.47, 95 % CI: 2.07-2.94). 90-day mortality was significantly higher in nonagenarians (38.9 %) compared to octogenarians (25.4 %) and younger (14.0 %) patients (OR = 0.58, 95 % CI: 0.41-0.83 and OR = 0.31, 95 % CI: 0.21-0.44), and in octogenarians compared to younger patients (OR = 0.52, 95 % CI: 0.41-0.66). No significant differences were observed in TICI 2b-3 and sICH rates across groups.
CONCLUSIONS: Our findings indicate that MT is a viable treatment option for AIS due to LVO among octogenarians and nonagenarians, albeit with nuanced differences. Specifically, octogenarians had lower 90-day mortality rates compared to nonagenarians. These insights support the need for individualized treatment plans for elderly patients with AIS due to LVO and highlight the importance of including this demographic in future clinical trials.

Simultaneous occlusion of both middle cerebral arteries (MCAs) is very rare and usually devastating. Few case reports are available in the literature where bilateral thrombectomy was done simultaneously to remove the clot. High NIH stroke scale with a low level of consciousness can be a clue for the diagnosis. Timely intervention is necessary to decrease morbidity and mortality in these patients. We also reviewed the existing literature where mechanical thrombectomies were done for bilateral MCA stroke in PubMed, Google Scholar, Cochrane, and Embase. Herein, we report a case of 47-year-old female having rheumatic heart disease presented with simultaneous bilateral MCAs occlusion, treated with mechanical thrombectomies successfully.