Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials

Safe Endovascular Recanalization of Internal Carotid Artery Occlusion Using Retrograde Aspiration Angiography

OBJECTIVE

Cerebral infarction, resulting from acute internal carotid artery (ICA) occlusion, typically manifests with a wide ischemic area and severe symptoms. Mechanical thrombectomy proves effective within 24 hours of disease onset and in less ischemic infarction core. However, in cases with well-developed collateral flow and mild symptoms, conservative treatment is initially selected. If symptoms worsen or ipsilateral hemisphere perfusion decreases, superficial temporal artery-middle cerebral artery anastomosis is considered. Revascularization therapy may also be effective. Contralateral angiography allows for ipsilateral blood flow verification once complete revascularization is achieved, albeit with potential treatment-related complications. Here, we describe retrograde angiography using an intermediate catheter (IMC) and contralateral contrast injection to achieve safer revascularization.

METHODS

We present 10 acute ICA occlusion cases caused by thromboembolism, arteriosclerosis, carotid artery stent occlusion, or embolic stroke of undetermined source. Employing bilateral femoral artery puncture, one catheter was guided to the occluded ICA, while another was positioned for diagnostic purposes in the contralateral ICA or vertebral artery. The IMC was navigated through the occluded vessel, with contralateral imaging performed during aspiration. The catheter was gradually retracted to confirm the extent of occlusion and recognize recanalization.

RESULTS

Recanalization was successfully achieved in all cases. Symptomatic ischemic complication and hyperperfuison was not seen in all cases. No cases were decreased modified Rankin scale after treatment.

CONCLUSIONS

Advancements in IMC technology facilitate distal catheter guidance to the ICA, even in proximal occlusion. Combining this technique with contralateral imaging allows us to confirm the extent of occlusion and recanalization status without antegrade imaging, making recanalization therapy safer.

Endovascular therapy versus medical management in isolated posterior cerebral artery acute ischemic stroke: A multinational multicenter propensity score-weighted study

BACKGROUND

Despite the proven effectiveness of endovascular therapy (EVT) in acute ischemic strokes (AIS) involving anterior circulation large vessel occlusions, isolated posterior cerebral artery (PCA) occlusions (iPCAo) remain underexplored in clinical trials. This study investigates the comparative effectiveness and safety of EVT against medical management (MM) in patients with iPCAo.

METHODS

This multinational, multicenter propensity score-weighted study analyzed data from the Multicenter Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy (MAD-MT) registry, involving 37 centers across North America, Asia, and Europe. We included iPCAo patients treated with either EVT or MM. The primary outcome was the modified Rankin Scale (mRS) at 90 days, with secondary outcomes including functional independence, mortality, and safety profiles such as hemorrhagic complications.

RESULTS

A total of 177 patients were analyzed (88 MM and 89 EVT). EVT showed a statistically significant improvement in 90-day mRS scores (OR = 0.55, 95% CI = 0.30-1.00, p = 0.048), functional independence (OR = 2.52, 95% CI = 1.02-6.20, p = 0.045), and a reduction in 90-day mortality (OR = 0.12, 95% CI = 0.03-0.54, p = 0.006) compared to MM. Hemorrhagic complications were not significantly different between the groups.

CONCLUSION

EVT for iPCAo is associated with better neurological outcomes and lower mortality compared to MM, without an increased risk of hemorrhagic complications. Nevertheless, these results should be interpreted with caution due to the study's observational design. The findings are hypothesis-generating and highlight the need for future randomized controlled trials to confirm these observations and establish definitive treatment guidelines for this patient population.

Profile of antiplatelet regimens for emergent carotid stenting in tandem occlusion. Systematic review and meta-analysis

AIM

To investigate the optimum antiplatelet therapy regimen (APTR) for emergent carotid artery stenting following mechanical thrombectomy (MT) in stroke patients with tandem occlusion.

METHODS

A literature search was performed on Pubmed/OVID/Cochran's CENTRAL database for studies from 2015 to 2022. Patient characteristics, antiplatelet regimen type, mTICI, 90 days-mRS, acute in-stent thrombosis (AIST), mortality, intracranial hemorrhage (ICH), and sample size were recorded. Exclusion criteria were non-English literature, sample size < 5 patients, other anticoagulant/antiplatelet therapy, and 100 % stent insertion in one study arm. The studies were assessed using MINORS/GRADE. Meta-analysis and meta-regression with a random effects model were performed. The outcomes were: 90 days-mRS, death, AIST and ICH RESULTS: Five-hundred-twenty-four studies were retrieved. After applying the exclusion criteria, the final population included 19/534 studies (3.6 %) for 880 patients (46.3 per article). I^2 and Q's Cochrane were 86.4 % and 132.5 for mRS, 19.9 % and 17.5 for death, 0 % and 9.4 for acute in-stent thrombosis and 62.1 % and 39.7 for intra-cranial haemorrhages, respectively. Patients in the aspirin subgroup had a significantly lower rate of functional independence (mRS≤2) than those in the DAPT subgroup (47 % [CI95 % 42.0 %-52.0 %] vs. 61.9 % [CI95 % 50.8-72.9]; p=0.0007;OR 0.75[CI95 % 0.56-1.01], p=0.06). DAPT significantly decreased the death rate compared with aspirin (8.6 % [CI95 % 5.3 %-11.9 %] vs. 16.7 % [CI95 11.1 %-22.2 %]; p=0.0012). Anti-GPIIb/IIIa demonstrated a trend of increasing the probability of mortality versus DAPT (OR 1.88[CI95 % 0.93-3.86], p=0.08. No significant differences were observed between AIST and ICH in the treatment groups.

CONCLUSION

DAPT may increases the chance of obtaining an mRS score ≤2 and reduces mortality.

Combined Selective Endovascular Brain Hypothermia with Edaravone Dexborneol versus Edaravone Dexborneol Alone for Endovascular Treatment in Acute Ischemic Stroke (SHE): Protocol for a Multicenter, Single-Blind, Randomized Controlled Study

INTRODUCTION

Selective endovascular brain hypothermia has been proposed as a potential neuroprotective strategy; however, its effectiveness is still not well established. The primary objective of this trial is to investigate the efficacy and safety of selective endovascular brain hypothermia with edaravone dexborneol for endovascular treatment in acute ischemic stroke (AIS).

METHODS

The SHE study is a multicenter, single-blind, randomized controlled clinical trial. Patients with acute anterior circulation ischemic stroke who received endovascular treatment within 24 h after stroke onset and achieved successful recanalization will be enrolled and centrally randomized into combined selective endovascular brain hypothermia with edaravone dexborneol or edaravone dexborneol alone groups in a 1:1 ratio (n = 564). Patients allocated to the hypothermia group will receive 300 mL cool saline at 4°C through guiding catheter (30 mL/min) into target vessel within 3 min after recanalization and then receive edaravone dexborneol (edaravone dexborneol 15 mL + NS 100 mL ivgtt bid for 10-14 days) within 24 h after admission. The control group will receive 300 mL 37°C saline (30 mL/min) infused into target vessel through guiding catheter and then receive edaravone dexborneol. All patients enrolled will receive standard care according to current guidelines for stroke management. The primary outcome is the proportion of functional independence, defined as a mRS score of 0-2 at 90 days after randomization.

CONCLUSION

This is a randomized clinical trial with a large sample size to compare combined selective endovascular brain hypothermia and edaravone dexborneol with edaravone dexborneol alone in patients with acute anterior ischemic stroke. The SHE trial aims to provide further evidence of the benefit of selective endovascular brain hypothermia in AIS patients who received endovascular treatment.

Prognostic impact of intracranial arteriosclerosis subtype after endovascular treatment for acute ischaemic stroke

BACKGROUND AND PURPOSE

The influence of intracranial arteriosclerosis (ICAR) on acute ischaemic stroke (AIS) prognosis is unclear. This study explored its impact, focusing on ICAR subtypes categorized by intracranial carotid artery calcification (ICAC) patterns: intimal or atherosclerotic versus internal elastic lamina calcification or non-atherosclerotic. The aim was to determine their effect on AIS prognosis in patients undergoing endovascular treatment (EVT).

METHODS

This prospective cohort study included consecutive AIS patients with anterior circulation large vessel occlusion undergoing EVT. ICAC, the hallmark of ICAR, was assessed using non-contrast computed tomography to quantify volume and establish the predominant ICAR subtype. The primary outcome was long-term functional outcome, measured by the 90-day modified Rankin Scale score. Secondary outcomes included first-pass effect, revascularization degree, symptomatic intracranial haemorrhage and 24-h infarct volume. Multivariate-adjusted linear and logistic regression models were used to assess the association of ICAC volume and subtype with these outcomes.

RESULTS

From January 2021 to February 2022, 181 patients were included, of whom 172 (95%) had ICAC. Internal elastic lamina calcification was the predominant subtype in 103 (57%), intimal in 52 (29%) and mixed in 17 (9%). The intimal or atherosclerotic ICAC pattern was linked to poorer functional outcomes (adjusted odds ratio 2.12, 95% confidence interval [CI] 1.10-4.09), decreased first-pass effect probability (adjusted odds ratio 0.42, 95% CI 0.21-0.84) and higher infarct volume (adjusted β value 22.11, 95% CI 0.55-43.67).

CONCLUSIONS

A predominant intimal ICAC subtype, linked to underlying atherosclerosis, correlated with larger infarct volume and poorer 90-day functional outcomes in EVT-treated AIS patients. Intracranial atherosclerosis appears to be a relevant factor hampering clinical benefits post-EVT.

Transcranial doppler (TCD) in predicting outcomes following successful mechanical thrombectomy of large vessel occlusions in anterior circulation: a systematic review and meta-analysis

BACKGROUND

Transcranial Doppler (TCD) is a non-invasive, bedside tool that allows for real-time monitoring of the patient's hemodynamic status following mechanical thrombectomy (MT). This systematic review and meta-analysis aims to evaluate the predictive value of TCD parameters following successful MT (Thrombolysis in Cerebral Infarction 2b-3).

METHODS

In July 2024, we searched PubMed, Embase, and Scopus, to identify observational studies in which TCD parameters were measured within 48 hours of MT. Using random-effects models, we compared four TCD parameters (mean flow velocity (MFV), MFV index, pulsatility index (PI), and peak systolic velocity (PSV) among groups with vs without hemorrhagic transformation (HT) and favorable vs poor functional recovery (modified Rankin Scale 0-2 vs 3-6).

RESULTS

Eleven studies comprising 1432 patients (59% male; mean age range: 63-73 years) were included. The MFV and MFV index were higher in patients with HT (Hedges' g=0.42 and 0.54, P=0.015 and 0.005, respectively). Patients with MFV index ≥1.3 showed a higher risk of all HT (RR 1.97; 95% confidence interval (CI) 1.28 to 3.03, P=0.002), symptomatic HT (RR 4.68; 95% CI 1.49 to 14.65, P=0.008), and poor functional status at 90 days (RR 1.65; 95% CI 1.27 to 2.14, P=0.029), respectively. There was no difference in mean PSV (P=0.1) and PI (P=0.3) among groups with and without HT.

CONCLUSION

This study underscores the prognostic value of the MFV index in predicting HT, symptomatic HT, and poor functional recovery after successful MT in the anterior circulation. Large-scale, multi-center studies are necessary to confirm these findings and to validate the MFV index as a reliable predictor for improving post-thrombectomy care.

Comparison of Thrombolysis In Cerebral Infarction (TICI) 2b and TICI 3 reperfusion in endovascular therapy for large ischemic anterior circulation strokes

BACKGROUND

Landmark thrombectomy trials have provided evidence that selected patients with large ischemic stroke benefit from successful endovascular therapy, commonly defined as incomplete (modified Thrombolysis In Cerebral Infarction (mTICI) 2b) or complete reperfusion (mTICI 3). We aimed to investigate whether mTICI 3 improves functional outcomes compared with mTICI 2b in large ischemic strokes.

METHODS

This retrospective multicenter cohort study was conducted to compare mTICI 2b versus mTICI 3 in large ischemic strokes in the anterior circulation. Patients enrolled in the German Stroke Registry between 2015-2021 were analyzed. Large ischemic stroke was defined as an Alberta Stroke Program Early CT Score (ASPECTS) of 3-5. Patients were matched by final mTICI grade using propensity score matching. Primary outcome was the 90-day modified Rankin Scale (mRS) score.

RESULTS

After matching, 226 patients were included. Baseline and imaging characteristics were balanced between mTICI 2b and mTICI 3 patients. There was no shift on the mRS favoring mTICI 3 compared with mTICI 2b in large ischemic strokes (adjusted common odds ratio (acOR) 1.12, 95% confidence interval (95% CI) 0.64 to 1.94, P=0.70). The rate of symptomatic intracranial hemorrhage was higher in mTICI 2b than in mTICI 3 patients (12.6% vs 4.5%, P=0.03). Mortality at 90 days did not differ between mTICI 3 and mTICI 2b (33.6% vs 37.2%; adjusted OR 0.69, 95% CI 0.33 to 1.45, P=0.33).

CONCLUSIONS

In endovascular therapy for large ischemic strokes, mTICI 3 was not associated with better 90-day functional outcomes compared with mTICI 2b. This study suggests that mTICI 2b might be warranted as the final angiographic result, questioning the benefit/risk ratio of additional maneuvers to seek for mTICI 3 in large ischemic strokes.

TRIAL REGISTRATION NUMBER

NCT03356392.

Temporal progression of functional independence after mechanical thrombectomy in acute vertebrobasilar artery occlusions

BACKGROUND

Neurological recovery after endovascular treatment (EVT) for large vessel occlusion stroke often has diverse timelines. Understanding the temporal progression of functional independence after EVT, especially delayed functional independence (DFI) and highly delayed functional independence (HDFI), in patients who do not improve early is essential for prognostication and rehabilitation. We aimed to analyze the prevalence and predictors of DFI and HDFI after EVT in acute vertebrobasilar artery occlusions (VBAO).

METHODS

Patients with VBAO who received EVT in China were retrospectively enrolled. Early functional independence (EFI) was defined as a modified Rankin Scale (mRS) score of 0-2 at discharge. The incidence and predictors of DFI (mRS score 0-2 at 90 days in non-EFI patients) and HDFI (mRS score 0-2 at 1 year in non-DFI patients) were analyzed.

RESULTS

2422 patients met the study criteria. EFI was observed in 20% (483) of patients. Among non-EFI patients, DFI was observed in 21% (395/1880). HDFI was observed in 13% (191/1439) of non-DFI patients. Younger age (P=0.006), lower pre-EVT National Institutes of Health Stroke Scale (NIHSS) score (P<0.001), higher posterior circulation-Alberta Stroke Program Early CT Score (PC-ASPECTS) (P=0.012), and absence of symptomatic intracranial hemorrhage (sICH) (P<0.001) were predictors of DFI. Predictors of HDFI were younger age (P<0.001) and lower pre-EVT NIHSS score (P<0.001).

CONCLUSION

A considerable proportion of patients have DFI and HDFI. The independent predictors of DFI were younger age, lower pre-EVT NIHSS score, higher PC-ASPECTS, and absence of sICH. Predictors of HDFI included younger age and lower pre-EVT NIHSS score.

Microvascular reperfusion during endovascular therapy: the balance of supply and demand

BACKGROUND

Endovascular therapy (EVT) has revolutionized the treatment of acute stroke, but large vessel recanalization does not always result in tissue-level reperfusion. Cerebral blood flow (CBF) is not routinely monitored during EVT. We aimed to leverage diffuse correlation spectroscopy (DCS), a novel transcranial optical imaging technique, to assess the relationship between microvascular CBF and post-EVT outcomes.

METHODS

Frontal lobe CBF was monitored by DCS in 40 patients undergoing EVT. Baseline CBF deficit was calculated as the percentage of CBF impairment on pre-EVT CT perfusion. Microvascular reperfusion was calculated as the percentage increase in DCS-derived CBF that occurred with recanalization. The adequacy of reperfusion was defined by persistent CBF deficit, calculated as: baseline CBF deficit - microvascular reperfusion. A good functional outcome was defined as 90-day modified Rankin Scale score ≤2.

RESULTS

Thirty-six of 40 patients achieved successful recanalization, in whom microvascular reperfusion in itself was not associated with infarct volume or functional outcome. However, patients with good functional outcomes had a smaller persistent CBF deficit (median 1% (IQR -11%-16%)) than patients with poor outcomes (median 28% (IQR 2-50%)) (p=0.02). Smaller persistent CBF deficit was also associated with smaller infarct volume (p=0.004). Multivariate models confirmed that persistent CBF deficit was independently associated with infarct volume and functional outcome.

CONCLUSIONS

CBF augmentation alone does not predict post-EVT outcomes, but when microvascular reperfusion closely matches the baseline CBF deficit, patients experience favorable clinical and radiographic outcomes. By recognizing inadequate reperfusion, bedside CBF monitoring may provide opportunities to personalize post-EVT care aimed at CBF optimization.

Effects of reperfusion grade and reperfusion strategy on the clinical outcome: Insights from ESCAPE-NA1 trial

BACKGROUND

We evaluated the association of reperfusion quality and different patterns of achieved reperfusion with clinical and radiological outcomes in the ESCAPE NA1 trial.

METHODS

Data are from the ESCAPE-NA1 trial. Good clinical outcome [90-day modified Rankin Scale (mRS) 0-2], excellent outcome (90-day mRS0-1), isolated subarachnoid hemorrhage, symptomatic hemorrhage (sICH) on follow-up imaging, and death were compared across different levels of reperfusion defined by expanded Treatment in Cerebral Infarction (eTICI) Scale. Comparisons were also made between patients with (a) first-pass eTICI 2c3 reperfusion vs multiple-pass eTICI 2c3; (b) final eTICI 2b reperfusion vs eTICI 2b converted-to-eTICI 2c3; (c) sudden reperfusion vs gradual reperfusion if >1 pass was required. Multivariable logistic regression was used to test associations of reperfusion grade and clinical outcomes.

RESULTS

Of 1037 included patients, final eTICI 0-1 was achieved in 46 (4.4%), eTICI 2a in 76 (7.3%), eTICI 2b in 424 (40.9%), eTICI 2c in 284 (27.4%), and eTICI 3 in 207 (20%) patients. The odds for good and excellent clinical outcome gradually increased with improved reperfusion grades (adjOR ranging from 5.7-29.3 and 4.3-17.6) and decreased for sICH and death. No differences in outcomes between first-pass versus multiple-pass eTICI 2c3, eTICI 2b converted-to-eTICI 2c3 versus unchanged eTICI 2b and between sudden versus gradual eTICI 2c3 reperfusion were observed.

CONCLUSION

Better reperfusion degrees significantly improved clinical outcomes and reduced mortality, independent of the number of passes and whether eTICI 2c3 was achieved suddenly or gradually.

Comprehensive analysis of the impact of procedure time and the 'golden hour' in subpopulations of stroke thrombectomy patients

OBJECTIVE

To evaluate the effect of procedure time on thrombectomy outcomes in different subpopulations of patients undergoing endovascular thrombectomy (EVT), given the recently expanded indications for EVT.

METHODS

This multicenter study included patients undergoing EVT for acute ischemic stroke at 35 centers globally. Procedure time was defined as time from groin puncture to successful recanalization (Thrombolysis in Cerebral Infarction score ≥2b) or abortion of procedure. Patients were stratified based on stroke location, use of IV tissue plasminogen activator (tPA), Alberta Stroke Program Early CT score, age group, and onset-to-groin time. Primary outcome was the 90-day modified Rankin Scale (mRS) score, with scores 0-2 designating good outcome. Secondary outcome was postprocedural symptomatic intracranial hemorrhage (sICH). Multivariate analyses were performed using generalized linear models to study the impact of procedure time on outcomes in each subpopulation.

RESULTS

Among 8961 patients included in the study, a longer procedure time was associated with higher odds of poor outcome (mRS score 3-6), with 10% increase in odds for each 10 min increment. When procedure time exceeded the 'golden hour', poor outcome was twice as likely. The golden hour effect was consistent in patients with anterior and posterior circulation strokes, proximal or distal occlusions, in patients with large core infarcts, with or without IV tPA treatment, and across age groups. Procedures exceeding 1 hour were associated with a 40% higher sICH rate. Posterior circulation strokes, delayed presentation, and old age were the variables most sensitive to procedure time.

CONCLUSIONS

In this work we demonstrate the universality of the golden hour effect, in which procedures lasting more than 1 hour are associated with worse clinical outcomes and higher rates of sICH across different subpopulations of patients undergoing EVT.

Intravenous administration of muse cells improves cerebral ischemia outcome via immunomodulation in the spleen

Ischemic stroke is a leading cause of disability and death globally. Stem cell therapies are emerging as a frontier for enhancing post-stroke recovery, with Muse cells-a subclass of pluripotent stem cells-demonstrating considerable promise. Muse cells are notable not only for their potential in cell replacement but also for their role in modulating immune responses following cerebral infarction. In the present study, we administered Muse cells intravenously to mice after inducing a stroke via distal middle cerebral artery occlusion. We evaluated motor outcomes, splenocyte populations, cytokine profiles, and gene expression 2 weeks after inducing stroke. Additionally, comparisons were drawn between outcomes in splenectomized mice and those receiving adoptive splenocyte transfer to discern the specific influence of the spleen on treatment efficacy. Our findings revealed that Muse cell therapy facilitates motor recovery, an effect that is compromised in the absence of the spleen. Spleens in treated mice exhibited a shift in neutrophil counts, increased cytokine activity, and a notable uptick in the expression of genes related to protein folding. These insights affirm the potential therapeutic effect of Muse cells in post-stroke treatment strategies, with their efficacy attributed, at least in part, to immunomodulatory pathways involving the spleen.

Phosphatidylserine: A Novel Target for Ischemic Stroke Treatment

Over the past 40 years, research has heavily emphasized stroke treatments that directly target ischemic cascades after stroke onset. Much attention has focused on studying neuroprotective drugs targeting one aspect of the ischemic cascade. However, the single-target therapeutic approach resulted in minimal clinical benefit and poor outcomes in patients. Considering the ischemic cascade is a multifaceted and complex pathophysiological process with many interrelated pathways, the spotlight is now shifting towards the development of neuroprotective drugs that affect multiple aspects of the ischemic cascade. Phosphatidylserine (PS), known as the "eat-me" signal, is a promising candidate. PS is involved in many pathophysiological changes in the central nervous system after stroke onset, including apoptosis, inflammation, coagulation, and neuronal regeneration. Moreover, PS might also exert various roles in different phases after stroke onset. In this review, we describe the synthesis, regulation, and function of PS under physiological conditions. Furthermore, we also summarize the different roles of PS after stroke onset. More importantly, we also discuss several treatment strategies that target PS. We aim to advocate a novel stroke care strategy by targeting PS through a translational perspective.

Endovascular thrombectomy after anterior circulation large vessel ischemic stroke: an updated meta-analysis

BACKGROUND

Endovascular thrombectomy (EVT) has emerged as the established standard of care for the treatment of anterior circulation large-vessel occlusion (LVO). However, its benefits remain unclear in specific patient populations. Herein, we present an updated systematic review and meta-analysis aimed at thoroughly assessing the effectiveness and safety of combining EVT with medical treatment (MT) compared with MT alone.

METHODS

This systematic review was performed in accordance with the PRISMA guideline. The MEDLINE, Embase, and Cochrane databases were systematically searched to identify relevant articles published until December 30, 2023. The inclusion criteria restricted articles to randomized clinical trials (RCTs). We pooled odds ratios (OR) and their respective 95% confidence intervals (CIs).

RESULTS

Fifteen RCTs involving 3897 patients were included in the study. EVT plus MT was associated with a significant reduction in disability at 90 days (OR = 1.91, [1.61-2.26]), improved functional independence (modified Rankin Scale [mRS] 0-2) (OR = 2.19 [1.81-2.64]), excellent functional outcomes (mRS 0-1) (OR = 2.37, [1.45-3.87]), improved independent ambulation (mRS 0-3) (OR = 2.17, [1.75-2.69]), and higher rates of partial/complete recanalization (OR = 2.18, [1.66-2.87] compared with EVT. Efficacy outcomes for both large and small infarct cores were statistically favorable following EVT. Safety outcomes showed comparable rates, except for intracerebral and subarachnoid hemorrhage, which favored MT alone.

CONCLUSION

This meta-analysis supports the use of EVT plus MT as the standard of care for acute ischemic stroke patients with LVO of any infarct core size, as it offers substantial improvements in functional outcomes and recanalization. Safety considerations, particularly the risk of hemorrhage, warrant careful patient selection. These findings provide valuable insights for optimizing stroke management protocols and enhancing patient outcomes.

Clinical and subclinical acute brain injury caused by invasive cardiovascular procedures

Over the past 50 years, the number and invasiveness of percutaneous cardiovascular procedures globally have increased substantially. However, cardiovascular interventions are inherently associated with a risk of acute brain injury, both periprocedurally and postprocedurally, which impairs medical outcomes and increases health-care costs. Current international clinical guidelines generally do not cover the area of acute brain injury related to cardiovascular invasive procedures. In this international Consensus Statement, we compile the available knowledge (including data on prevalence, pathophysiology, risk factors, clinical presentation and management) to formulate consensus recommendations on the prevention, diagnosis and treatment of acute brain injury caused by cardiovascular interventions. We also identify knowledge gaps and possible future directions in clinical research into acute brain injury related to cardiovascular interventions.

Association between basal ganglia infarction and hemorrhagic transformation after mechanical thrombectomy in acute ischemic stroke: insights from the DIRECT-MT trial

BACKGROUND

Acute ischemic stroke (AIS) often leads to significant morbidity and mortality. Mechanical thrombectomy (MT) is an effective intervention for large vessel occlusion strokes. However, hemorrhagic transformation (HT) remains a critical post-procedural complication. This study investigates the relationship between basal ganglia infarction (BGI) and the risk of HT, particularly focusing on hemorrhagic infarction (HI) and parenchymal hematoma (PH).

METHODS

Data from the DIRECT-MT trial were analyzed. Patients were categorized based on the presence of BGI identified on initial non-contrast CT. HT was classified into HI and PH following the Heidelberg criteria. Multivariate logistic regression, propensity score matching (PSM), and inverse probability of treatment weighting (IPTW) were used to assess the association between BGI and HT.

RESULTS

Among 607 patients, 273 had BGI. BGI was associated with a higher risk of HT, specifically PH. The incidence of PH in the BGI group was 20% compared with 11% in the non-BGI group. Adjusted analyses, including PSM and IPTW, confirmed the significant association between BGI and PH with an adjusted odds ratio (aOR) of 2.51 (95% CI 1.49 to 4.22, P<0.001). However, no significant association was found between BGI and HI.

CONCLUSIONS

BGI significantly increases the risk of PH following MT for AIS, underscoring the need for tailored therapeutic strategies in managing these patients. No significant correlation was observed between BGI and HI. Future research should explore the underlying mechanisms and validate these findings across diverse populations to improve patient outcomes.

Can the clot meniscus and claw signs predict thrombectomy and clinical outcomes in patients with stroke? A systematic review and meta-analysis

BACKGROUND

The angiographic shape of an occlusion, like the clot meniscus sign and the claw sign, has been reported to potentially impact the recanalization rate and clinical outcome in patients undergoing mechanical thrombectomy for acute ischemic strokes.

METHOD

Following PRISMA guidelines, a systematic literature search was conducted across PubMed, Scopus, Embase and Web of Science databases. Patients were grouped into clot meniscus/claw sign positive and negative groups based on the definitions obtained from each study. Primary outcomes included technical success, with a meta-analysis performed using a random-effects model to calculate proportions and odds ratios (OR) with 95% confidence intervals (Cl).

RESULTS

We included seven studies recruiting 1572 patients. The results indicated that the positive and negative groups had comparable first-pass effect (OR 1.95; 95% CI 0.76 to 5.01; P=0.167) and final recanalization (OR 1.36; 95% CI 0.81 to 2.27; P=0.248) rates. However, the rate of having a favorable functional outcome was significantly higher in the positive group than in the negative sign group (OR 1.91; 95% CI 1.25 to 2.92; P<0.003). Within the sign-positive population, the use of contact aspiration was associated with a significantly higher rate of recanalization compared with using a stent retriever (OR 0.18; 95% CI 0.07 to 0.49; P<0.001). This result did not translate into a clinical impact, as both stent retriever and contact aspiration showed comparable rates of functional independence at 3 months (OR 0.22; 95% CI 0.02 to 2.33; P=0.210).

CONCLUSION

The presence of the clot meniscus/claw sign is not associated with recanalization outcomes after thrombectomy. However, it might be a good sign to predict which thrombectomy technique might be associated with better recanalization, although current evidence may need further confirmation.

Predicting Futile Recanalization After Endovascular Thrombectomy for Patients With Stroke With Large Cores: The SNAP Score

BACKGROUND AND OBJECTIVES

We aimed to develop and validate a prediction score for futile recanalization (FR) for large vessel occlusion (LVO) presenting low Alberta Stroke Program Early Computed Tomography Score (ASPECTS) for patients who underwent endovascular thrombectomy (EVT).

METHODS

Patients with anterior circulation LVO with low ASPECTS (<6) who underwent successful EVT (modified treatment in cerebral ischemia score ≥2b) from Stroke Thrombectomy and Aneurysm Registry were retrospectively analyzed. FR was defined as 90-day modified Rankin Scale (mRS) scores ≥4 despite successful EVT. Multivariable logistic regression was used to identify independent predictors of FR, and they were used to create a clinical score. The performance of the score was assessed by receiver operating characteristic curve analyses.

RESULTS

Of 219 patients, 170 and 49 patients were randomly assigned to the training and validation cohort, respectively. Independent predictors of FR identified in the training cohort were used to construct the SNAP score: site of occlusion (middle cerebral artery = 0, internal carotid artery = 1), National Institutes of Health Stroke Scale score at admission (≤10 = 0, 10 to 19 = 1, ≥20 = 2), age (<75 = 0, ≥75 = 2), and prestroke mRS score (0-3). Receiver operating characteristic curve analyses of the SNAP score in the training and validation cohorts showed areas under the curve of 0.79 (95% CI 0.72-0.86) and 0.79 (95% CI 0.65-0.92) for predicting FR, respectively. A SNAP score ≥5 had a positive predictive value of 92.1% [95% CI 78.8%-97.3%] for FR.

CONCLUSION

The SNAP score may be useful in predicting FR after EVT in low-ASPECTS patients with LVO. It can provide patients, family members, and physicians with reliable outcome expectations among patients with acute ischemic stroke with large infarcts.

Multicenter clinical trial evaluating the safety and efficacy of mechanical thrombectomy using the Versi Retriever

BACKGROUND

This study aimed to elucidate the safety and efficacy of mechanical thrombectomy using the Versi Retriever in patients with acute ischemic stroke (AIS).

METHODS

This was a prospective, multicenter, single-arm study conducted at 10 institutes in Japan from December 2018 to March 2021 on mechanical thrombectomy using the Versi Retriever in patients with AIS. The primary efficacy outcome was the modified Rankin scale (mRS) 0-2 at 90 days after the procedure. The primary safety outcome was mortality within 90 days after the procedure.

RESULTS

Fifty-eight patients with a mean age of 72.7 years were enrolled in the study. The primary efficacy outcome of mRS 0-2 at 90 days was 62.0% (95% CI 47.2-75.3%) in patients within 8 hours of stroke onset. The rate of immediate reperfusion of Thrombolysis in Cerebral Infarction (TICI) grade 2b-3 using the Versi Retriever in three passes was 78.0% (64.0-88.5%). The rate of final reperfusion of TICI 2b-3 was 100% (92.9-100%). The primary safety outcome of mortality within 90 days was 8.0% (2.2-19.2%) in patients within 8 hours of AIS onset. The incidence of intracranial hemorrhage within 24 hours was 12.0% (4.5-24.3%) for symptomatic cases and 32.0% (19.5-46.7%) for asymptomatic cases.

CONCLUSION

The Versi Retriever proved to be a safe and effective option for mechanical thrombectomy in patients with AIS.

Mechanical thrombectomy practices in Europe: Insights from a survey of European neuroradiologists from the ESMINT

BACKGROUND AND PURPOSE

Mechanical thrombectomy (MT) has revolutionized the prognosis of acute ischemic stroke. Indications for MT are constantly expanding across countries, presenting healthcare professionals, and institutions with the challenge of offering MT to the entire population despite geographic constraints, while also training enough interventional neuroradiologists (INR) for this highly technical-level procedure. We aimed to provide an overview of current European MT practices and organizations in 2021.

MATERIALS AND METHODS

Members of the European Society of Minimally Invasive Neurological Therapy (ESMINT) were invited to complete two different online surveys from March to November 2021 to collect data on MT practice.

RESULTS

A total of 240 individual responses from INR (from 33 European countries) were received. These included information from 56 thrombectomy-capable stroke centers (TCSC) data (across 26 European countries). The mean number of INR per center was 3.8 ± 1.43, median 4 (IQR, 3-4.5). Half of the centers (28/56, 50.00%) performed less than 150 MT per year. Most INR used a balloon guide catheter in less than 50% of cases (160/240, 66.67%), and limited the number of recanalization attempts to six passes to restore flow (209/240, 87.08%). Additionally, 37.92% of the respondents (91/240, 37.92%) indicated that they already performed MT for distal occlusions (M3, M4) as part of their routine practice. Other details of the MT procedure, anesthetic management, and patient selection are also presented and discussed.

CONCLUSIONS

This European survey emphasizes the differences between TCSC and INR in modern thrombectomy practices. Even if most centers remain understaffed to meet current and future MT needs, most European TCSCs are actively training young INR.

The move to 24/7 mechanical thrombectomy provision for ischaemic stroke: an observational study of the impact on referrals, activity, procedural efficacy, and safety at a supra-regional centre

BACKGROUND

Health systems are striving to improve delivery of mechanical thrombectomy (MT) for ischaemic stroke. With the move to 24/7 provision, we aimed to assess (1) the change in referral and procedural frequency and timing, (2) reasons referrals did not proceed to MT, and (3) nocturnal procedural efficacy and safety.

METHODS

This was an observational study comparing 12-month data for an extended daytime service (2021/2022, hours, 0800-2000) to that for a 12-month period delivering 24/7 cover (2023-2024). Nocturnal and daytime outcomes (rate of recanalisation using modified TICI scoring), extent of postprocedural infarction (using ASPECTS grading), rate of early neurological improvement (using 24-h NIHSS change), 90-day mortality, and complicating symptomatic intracranial haemorrhage (SICH) in the latter period were compared.

RESULTS

Both referrals (432 to 851) and procedural caseload (191 to 403) approximately doubled with the move to 24/7 cover; 36% of procedures occurred overnight (n = 145). The dominant reasons for referrals not proceeding to MT were a large core infarct (n = 144) or absence of a large vessel occlusion on baseline imaging (n = 140). There were no significant differences in successful recanalisation (TICI 2B/3: 85.5% vs 87.1%, P = .233), rates of postprocedural ASPECTS≥7 (74.9% vs 75.8%, P = .987), early neurological improvement (NIHSS reduction ≥30%: 43.4% vs 42.4%, P = .917), 90-day mortality (19.6% vs 18.6%, P = .896), or SICH (1.9% vs 4.1%, P = .214) obtained for daytime vs nighttime hours.

CONCLUSION

24/7 MT provision has resulted in a rapid rise in the number of patients who may benefit from MT. This service can be provided with an acceptable safety profile during nighttime hours in a high-volume comprehensive UK centre.

Thrombectomy for patients with a large infarct core: a study-level meta-analysis with trial sequential analysis

Background

The effectiveness and safety of endovascular treatment compared with medical management alone regarding outcomes for patients with a large infarct core remain uncertain.

Objectives

To juxtapose the clinical outcomes of thrombectomy versus the best medical care in patients with a large infarct core.

Design

Systematic review and meta-analysis.

Data sources and methods

We conducted searches in PubMed, Cochrane, and Embase for articles published up until November 8, 2023. Randomized trials were selected for inclusion if they encompassed patients with large vessel occlusion and sizable strokes receiving thrombectomy. The primary outcome was functional outcomes at 3 months after pooling data using random-effects modeling. Safety outcomes included mortality at 3 months, symptomatic intracranial hemorrhage (SICH), and decompressive craniectomy. We performed a trial sequential analysis to balance type I and II errors.

Results

From 904 citations, we identified six randomized trials, involving a cohort of 1897 patients with a large ischemic region. Of these, 953 individuals underwent endovascular thrombectomy. At 3 months, thrombectomy was significantly correlated with better neurological prognosis, as evidenced by the increased odds of good functional outcomes (odds ratio (OR), 2.90; 95% confidence interval (CI), 2.08-4.05) and favorable functional outcomes (OR, 2.40; 95% CI, 1.86-3.09). Mortality rates did not demonstrably diminish as a consequence of the endovascular management (OR, 0.78; 95% CI, 0.58-1.06). However, the incidence of SICH was greater in the thrombectomy group compared to those with only medical treatment (5.5% vs 3.2%; OR, 1.77; 95% CI, 1.11-2.83). The application of trial sequential analysis yielded definitive evidence regarding favorable function outcomes and a shift in the distribution of modified Rankin scale scores at 3 months; however, others remained inconclusive.

Conclusion

The results from most of the included trials display consistency. Meta-analysis of these six randomized trials offers high-quality evidence that thrombectomy significantly mitigates disability in patients with a large infarction, while also increasing the risk of SICH.

Trial registration

PROSPERO, CRD42023480359.

Endovascular treatment in pediatric stroke: an individual patient pooled analysis on presentation, management and outcomes

BACKGROUND

This study aimed to perform a comprehensive pooled analysis of all published series involving pediatric patients with large vessel occlusion (LVO) undergoing endovascular treatment (EVT) to study the disease landscape including presentation, management, and outcomes.

METHODS

The data used in this study were pooled from published literature on EVT for pediatric stroke spanning from 1980 to 2023. The relevant articles were carefully reviewed, and only those reporting at least one case of pediatric LVO undergoing EVT were included. Furthermore, pediatric patients with LVO who received EVT from the Chinese Pediatric Ischemic Stroke Registry database were also included. The primary outcome for this study was the unfavorable outcome after stroke. The risk factors influencing the outcomes of patients with pediatric stroke treated with EVT were analyzed using Cox proportional hazards models.

RESULTS

A total of 221 pediatric patients who underwent EVT were included. During an average follow-up period of 6 months, 20.8% of patients had an unfavorable outcome. Multivariate Cox regression showed that patients with a higher Pediatric National Institutes of Health Stroke Scale (pedNIHSS) score (aHR=7.54, 95% CI 2.38 to 23.58) and unsuccessful reperfusion (aHR=5.84, 95% CI 2.86 to 11.93) were associated with an increased risk of unfavorable outcomes, while older age (aHR=0.27, 95% CI 0.09 to 0.82) was associated with a lower risk of unfavorable outcomes.

CONCLUSION

Following EVT treatment, a significant proportion of pediatric patients with LVO achieved favorable outcomes. However, factors such as the severity of the pedNIHSS score and unsuccessful reperfusion were found to be associated with a poorer prognosis.

High Hypoperfusion Intensity Ratio Is Independently Associated with Very Poor Outcomes in Large Ischemic Core Stroke

BACKGROUND

Recent advances have highlighted the efficacy of endovascular thrombectomy (EVT) in patients with large ischemic core stroke, yet a significant portion still experience very poor outcomes, defined as a 90-day modified Rankin Score (mRS) of 5-6. This study aims to investigate the hypoperfusion intensity ratio (HIR) as a prognostic imaging parameter for these outcomes.

METHODS

In a multicenter retrospective cohort study, data from consecutive patients undergoing EVT for acute ischemic stroke with large vessel occlusion (AIS-LVO) at two comprehensive stroke centers were analyzed. The study included patients with an Alberta Stroke Program Early CT Score (ASPECTS) of 5 or less and utilized pretreatment perfusion imaging to calculate HIR. The primary outcome was very poor outcomes (90 days mRS 5-6).

RESULTS

Among 102 patients included, 59 (57.8%) had very poor outcome (90 days mRS 5-6). Multivariable logistic regression analysis adjusting for multiple covariates including admission National Institutes of Health Stroke Scale (NIHSS) and EVT revealed that higher admission NIHSS (adjusted odds ratio [aOR] 1.224, 95% CI 1.089-1.374, p = 0.001) and HIR (aOR per 0.1 incremental change, 1.34, 95% CI 1.02-1.82, P = 0.042) were independently associated with very poor outcomes.

CONCLUSION

This study demonstrates that admission NIHSS and HIR are independently associated with very poor outcome (90 days mRS 5-6) in patients with large ischemic core strokes. These findings highlight the importance of collateral status and perfusion imaging in predicting outcomes in this patient population, suggesting a potential role for HIR in the triage and management of large core stroke patients.

Large ischemic core defined by visually assessed ASPECTS predicts functional outcomes comparably accurate to automated CT perfusion in the 6-24 h window

INTRODUCTION

Automated CT perfusion (aCTP) is commonly used to select patients with anterior circulation large vessel occlusion (aLVO) for endovascular treatment (EVT). The equivalence of visually assessed Non-contrast CT Alberta Stroke Program Early CT Scores (ASPECTS) and aCTP based selection in predicting favorable functional outcomes remains uncertain.

PATIENTS AND METHODS

Retrospective multicenter study of adult aLVO patients from the Swiss Stroke Registry (2014-2021) treated with EVT or best medical treatment 6-24 h after stroke onset. We assessed ASPECTS on non-contrast CT visually and ischemic core volumes on aCTP, defining ASPECTS 0-5 and aCTP CBF < 30% volumes ⩾50 mL as large ischemic cores. We used logistic regression to explore the association between CT modalities and favorable functional outcomes (modified Rankin Scale [mRS] score shift toward lower categories) at 3 months. Receiver operating characteristic (ROC) curve analysis compared the predictive accuracy of visually assessed ASPECTS and aCTP ischemic core for favorable outcomes (mRS 0-2) at 3 months.

RESULTS

Of 210 patients, 11.4% had ASPECTS 0-5, and 12.9% aCTP core volumes ⩾50 mL. Within the same model, ASPECTS but not aCTP core volumes were associated with favorable outcomes (ASPECTS: acOR 1.85, 95%CI 1.27-2.70, p = 0.001). The ROC curve analyses showed comparable diagnostic accuracy in predicting favorable functional outcomes (mRS 0-2) at 3 months (ROC areas: ASPECTS 0.80 [95%CI 0.74-0.86] vs aCTP core 0.79 [95%CI 0.72-0.85]).

DISCUSSION AND CONCLUSION

In patients with aLVO, visually assessed ASPECTS showed at least comparable accuracy to automatically generated CTP core volumes in predicting functional outcomes at 3 months.

Stroke: Evolution of newer treatment modalities for acute ischemic stroke

Acute ischemic stroke is one of the leading causes of morbidity and mortality worldwide. Restoration of cerebral blood flow to affected ischemic areas has been the cornerstone of therapy for patients for eligible patients as early diagnosis and treatment have shown improved outcomes. However, there has been a paradigm shift in the management approach over the last decade, and with the emphasis currently directed toward including newer modalities such as neuroprotection, stem cell treatment, magnetic stimulation, anti-apoptotic drugs, delayed recanalization, and utilization of artificial intelligence for early diagnosis and suggesting algorithm-based management protocols.

Evaluating post-thrombectomy effective connectivity changes in anterior circulation stroke

OBJECTIVE

Granger causal analysis (GCA) and amplitude of low-frequency fluctuation (ALFF) are commonly used to evaluate functional alterations in brain disorders. By combining the GCA and ALFF, this study aimed to investigate the effective connectivity (EC) changes in patients with acute ischemic stroke (AIS) and anterior circulation occlusion after mechanical thrombectomy (MT).

METHODS

Resting-state functional magnetic resonance imaging (rs-fMRI) data were collected from 43 AIS patients with anterior circulation occlusion within 1 week post-MT and 37 healthy controls. ALFF and GCA were calculated for each participant. Patients were further divided into groups based on prognosis and perfusion levels. The differences in ALFF and EC were compared between AIS patients and healthy controls and between subgroups of patients. Pearson correlations between EC, ALFF values, and clinical characteristics of patients were calculated.

RESULTS

Compared to healthy controls, post-MT, AIS patients exhibited significant ALFF increases in the left precuneus and decreases in the left fusiform gyrus and right caudate. Increased EC from the contralesional lingual gyrus, contralesional putamen, ipsilesional thalamus, and contralesional thalamus to the contralesional caudate was obsrved, while decrease in EC were found for contralesional caudate to the ipsilesional thalamus and medial superior frontal gyrus. EC differences were particularly notable between perfusion groups, with significantly lower EC in the poorly perfused group. EC values were also positively correlated with National Institutes of Health Stroke Scale (NIHSS) scores pre-MT.

INTERPRETATION

In AIS patients, the caudate nucleus was central to the observed EC changes post-MT, characterized by decreased outputs and increased inputs. These changes indicate functional remodeling within the cortico-basal ganglia-thalamic-cortical pathway.

Acupuncture and its role in the treatment of ischemic stroke: A review

Acupuncture is a traditional Chinese medicine therapy that is treatment by placing a needle or pressure in a specific position on the patient's skin. Although used in the treatment of various diseases, acupuncture is effective in the treatment of ischemic stroke (IS), and has made some progress in the mechanism of action of the treatment of this disease. IS is difficult to treat, and there is a high rate of disability. Drug therapy is usually the first line of treatment, but adjuvant therapy has outstanding efficacy in promoting the rehabilitation of the disease and preventing sequelae. Among them, acupuncture is getting more and more attention as a more popular treatment method. Therefore, this study excavates the high-quality randomized controlled trials and meta-analysis of acupuncture for IS in recent years to further summarize the efficacy of acupuncture for IS. In this review, we provide an overview of the current understanding of acupuncture and IS, and the current studies investigating the effectiveness of acupuncture in the treatment of IS.

Associations of arterial oxygen partial pressure with all‑cause mortality in critically ill ischemic stroke patients: a retrospective cohort study from MIMIC IV 2.2

BACKGROUND

As a supportive treatment, the effectiveness of oxygen therapy in ischemic stroke (IS) patients remains unclear. This study aimed to evaluate the relationships between arterial partial pressure of oxygen (PaO2) and both consciousness at discharge and all-cause mortality risk in ICU IS patients.

METHODS

Blood gas measurements for all patients diagnosed with IS were extracted from the MIMIC-IV database. Patients were classified into four groups based on their average PaO2 during the first ICU day: hypoxemia (PaO2 < 80 mmHg), normoxemia (PaO2 80-120 mmHg), mild hyperoxemia (PaO2 121-199 mmHg), and moderate/severe hyperoxemia (PaO2 ≥ 200 mmHg). The primary endpoint was 90-day all-cause mortality. Secondary outcomes included the level of consciousness at discharge, assessed by the Glasgow Coma Scale (GCS), and 30-day all-cause mortality. Multivariate Cox regression and Restricted cubic spline (RCS) analysis were used to investigate the relationship between mean PaO2 and mortality, and to assess the nonlinear association between exposure and outcomes.

RESULTS

This study included a total of 946 IS patients. The cumulative incidence of 30-day and 90-day all-cause mortality increased with decreasing PaO2 levels. RCS analysis revealed a nonlinear relationship between PaO2 and the risk of 30-day all-cause mortality (nonlinear P < 0.0001, overall P < 0.0001), as well as a nonlinear association between PaO2 and 90-day all-cause mortality (nonlinear P < 0.0001, overall P < 0.0001). The results remained consistent after excluding the small subset of patients who received reperfusion therapy. Sensitivity analysis indicated that the favorable impact on survival tends to increase with the extended duration of elevated PaO2.

CONCLUSIONS

For IS patients who do not receive reperfusion therapy or whose recanalization status is unknown, a lower PaO2 early during ICU admission is considered an independent risk factor for short-term and recent mortality. Adjusting respiratory parameters to maintain supraphysiological levels of PaO2 appears to be beneficial for survival, although this finding requires further validation through additional studies.

TRIAL REGISTRATION

Not applicable.

Enhancing Stroke Recognition: A Comparative Analysis of Balance and Eyes-Face, Arms, Speech, Time (BE-FAST) and Face, Arms, Speech, Time (FAST) in Identifying Posterior Circulation Strokes

Background/Objectives: Posterior circulation stroke (PCS) poses a diagnostic challenge due to the diverse and subtle clinical manifestations. While the FAST (Face, Arms, Speech, Time) mnemonic has proven effective in identifying anterior circulation stroke, its sensitivity to posterior events is less clear. Recently, the addition of Balance and Eyes to the mnemonic has been proposed as a more comprehensive tool for stroke recognition. Despite this, evidence directly comparing the effectiveness of BE-FAST and FAST in identifying PCS remains limited. Methods: A retrospective analysis was performed on stroke calls at a comprehensive stroke centre, Sydney, Australia. BE-FAST symptoms first assessed at an emergency department triage were recorded, along with automated acute computerised tomography perfusion (CTP) imaging findings. Haemorrhagic strokes were excluded from analysis. An ischaemic stroke diagnosis was confirmed 48-72 h later with magnetic resonance imaging (MRI) brain. The performance of 1. BE-FAST and FAST and 2. BE-FAST and CTP in the hyperacute detection of posterior circulation ischaemic stroke was compared. Results: Out of 164 identified ischaemic infarcts confirmed on MRIs, 46 were PCS. Of these, 27 were FAST-positive, while 45 were BE-FAST-positive. Overall, BE-FAST demonstrated a higher sensitivity compared to FAST in identifying PCS (97.8 vs. 58.7) but suffered from a lower specificity (10.0 vs. 39.8). Notably, 39.1% (n = 18) of patients with PCS would have been missed if only FAST were used. Furthermore, of the 26 PCS negative on CTP, 25 were BE-FAST-positive, and 14 were FAST-positive. Conclusions: The incorporation of Balance and Eye assessments into the FAST protocol improves PCS detection, although may yield more false positives.

Home and workforce reintegration one year after thrombectomy in acute stroke patients

INTRODUCTION

Endovascular thrombectomy (EVT) combined with intravenous thrombolysis is the current standard treatment for acute large-vessel occlusion stroke. Beyond clear clinical benefits in the acute and post-acute phases, comprehensive evaluations of long-term outcomes, including home and workforce reintegration, remain limited. This study aimed to assess home and workforce reintegration 1 year post-EVT in a cohort of acute stroke patients and explore their association with health-related quality of life (HRQoL).

PATIENTS AND METHODS

We conducted a prospective observational study of 404 patients undergoing EVT at a tertiary university medical center between October 2019 and December 2021. Patients' functional outcomes were evaluated using the modified Rankin Scale (mRS), and HRQoL was assessed via the European Quality of Life Five Dimension Scale (EQ-5D). Data on occupational and living status were collected through standardized telephone interviews at 3- and 12-months post-treatment.

RESULTS

Of 357 patients with 12-month follow-up data, 33.6% had a favorable outcome (mRS 0-2). Among stroke survivors, the rate of home reintegration without nursing care was 42.1%, and workforce reintegration among previously employed patients was 43.3% at 12 months. Both outcomes were significantly associated with improved HRQoL. Lower neurological deficits and younger age were predictive of successful home and workforce reintegration.

DISCUSSION AND CONCLUSION

One year post-EVT, approximately 40%-50% of acute stroke patients successfully reintegrate into home and work settings. These findings underscore the need for ongoing support tailored to improving long-term reintegration and quality of life for stroke survivors.

DATA ACCESS STATEMENT

The data supporting the findings of the study are available from the corresponding author upon reasonable request and in accordance to European data privacy obligations.

The use of a (non-) balloon guide catheter in endovascular stroke treatment, a registry of real-life use and nationwide questionnaire

INTRODUCTION

Despite literature suggesting benefits of a balloon guide catheter (BGC) in stroke thrombectomy, BGCs are not routinely used. This study aimed to get insights in the use of a BGC and the reasons (not) to inflate the balloon.

METHODS

Data were used of the Maastricht Stroke Quality Registry (MaSQ-Registry), a prospective registry for quality purposes of stroke patients treated between September 2020-February 2023. Additionally, a Dutch nationwide questionnaire was sent among all stroke treating physicians of the Dutch Society of Interventional Radiology (NVIR). Information on the use and reasons for selecting a (non-)BGC and using the BGC was collected.

RESULTS

Out of 511 patients registered in the MaSQ-Registry, 458 were included. In 69% (n=317) of the patients a BGC was used; in 68% (n=214) the balloon was not inflated. In 95% of the posterior circulation occlusions a non-BGC was used. In total 47 treating physicians from sixteen stroke centers responded to the questionnaire. 51% (n=24) preferred a non-BGC and 30% (n=14) never used a BGC. 52% and 18% of the BGC-users estimated they inflate the balloon in 80-100% and 0-20% of the times, respectively. The main reasons reported for not inflating the balloon were when the BGC was occlusive (47%) or not placeable (34%) in the carotid artery.

CONCLUSION

This study shows variation in the use of (non-)BGC use with and without inflated balloon among treating physicians in the Netherlands, highlighting current limited consensus regarding the use of (non-)BGCs among stroke treating physicians.

Outcome and Risk of Poststroke Pneumonia in Patients with Acute Ischemic Stroke After Endovascular Thrombectomy: A Post Hoc Analysis of the DIRECT-MT Trial

BACKGROUND

In this study, we aimed to investigate the risk factors and impact of poststroke pneumonia (PSP) on mortality and functional outcome in patients with acute ischemic stroke (AIS) after endovascular thrombectomy (EVT).

METHODS

This was a post hoc analysis of a prospective randomized trial (Direct intraarterial thrombectomy in order to revascularize AIS patients with large-vessel occlusion efficiently in Chinese tertiary hospitals: a multicenter randomized clinical trial). Patients with AIS who completed EVT were evaluated for the occurrence of PSP during the hospitalization period and their modified Rankin Scale (mRS) scores at 90 days after AIS. Logistic regression analysis was conducted to investigate the independent predictors of PSP. Propensity score matching was conducted for the PSP and non-PSP groups by using the covariates resulting from the logistic regression analysis. The associations between PSP and outcomes were analyzed. The outcomes included 90-day poor functional outcome (mRS scores > 2), 90-day mortality, and early 2-week mortality.

RESULTS

A total of 639 patients were enrolled, of whom 29.58% (189) developed PSP. Logistic regression analysis revealed that history of chronic heart failure (unadjusted odds ratio [OR] 2.011, 95% confidence interval [CI] 1.026-3.941; P = 0.042), prethrombectomy reperfusion on initial digital subtraction angiography (OR 0.394, 95% CI 0.161-0.964; P = 0.041), creatinine levels at admission (OR 1.008, 95% CI 1.000-1.016; P = 0.049), and National Institutes of Health Stroke Scale at 24 h (OR 1.023, 95% CI 1.007-1.039; P = 0.004) were independent risk factors for PSP. With propensity scoring matching, poor functional outcome (mRS > 2) was more common in patients with PSP than in patients without PSP (81.03% vs. 71.83%, P = 0.043) at 90 days after EVT. The early 2-week mortality of patients with PSP was lower (5.74% vs. 12.07%, P = 0.038). But there was no statistically significant difference in 90-day mortality between the PSP group and non-PSP group (22.41% vs. 14.94%, P = 0.074). The survivorship curve also shows no statistical significance (P = 0.088) between the two groups.

CONCLUSIONS

Nearly one third of patients with AIS and EVT developed PSP. Heart failure, higher creatinine levels, prethrombectomy reperfusion, and National Institutes of Health Stroke Scale at 24 h were associated with PSP in these patients. PSP was associated with poor 90-day functional outcomes in patients with AIS treated with EVT.

Unfavorable neurological long-term outcome despite eTICI 3 - What are the predictors?

PURPOSE

Interventional stroke therapy has become standard treatment for patients with acute ischemic strokes. Complete reperfusion (eTICI 3) portrays the best possible technical outcome. The purpose of this study was to determine possible predictors for an unfavorable neurological long-term outcome (mRS 3-6) despite achieving the best possible treatment success.

METHODS

We evaluated 122 patients with stroke in the anterior circulation and complete reperfusion after mechanical thrombectomy (MT) between May 2010 and March 2020. We performed a binary logistic regression analysis with patient baseline data, stroke severity, comorbidities, premedication and treatment information as independent variables.

RESULTS

50 of the 122 patients included in our study showed a poor clinical outcome after 90 days (41 %). Multivariable logistic regression analysis showed that older age (p = 0.033), higher admission NIHSS (p=0.009), lower admission ASPECTS (p=0.005), a pre-existing cardiovascular disease (p=0.017), and multiple passes for complete reperfusion (p=0.030) had an independent impact on unfavorable outcome.

CONCLUSIONS

Older age, higher NIHSS upon admission, lower ASPECTS upon admission, cardiovascular comorbidities and multiple passes for complete reperfusion are predictors for poor neurological long-term outcome despite complete reperfusion.

Effect of INR on Outcomes of Endovascular Treatment for Acute Vertebrobasilar Artery Occlusion

Endovascular treatment (EVT) has been proven to be the standard treatment for acute vertebrobasilar artery occlusion (VBAO). This study aimed to analyze the effects of international normalized ratio (INR) indicators on outcomes in patients with acute VBAO treated with EVT. Dynamic data on INR in patients with VBAO who received endovascular treatment (EVT) at 65 stroke centers in China were retrospectively enrolled. Outcome measures included the modified Rankin Scale (mRS) score at 90 days and 1 year and symptomatic intracranial hemorrhage (sICH). The associations between elevated INR (INR > 1.1), INR variability (time-weighted variance of INR changes), and various clinical outcomes were analyzed in all patients and subgroups stratified by oral anticoagulation (OAC) by mixed logistic regression analysis. A total of 1825 patients met the study criteria, of which 1384 had normal INR and 441 had elevated INR. Multivariate analysis showed that elevated INR was significantly associated with poor functional outcomes (mRS 4-6) at 90 days (odds ratio [OR] 1.36, 95% confidence interval [CI] 1.08-1.72) and 1 year (OR 1.32, 95% CI 1.05-1.66), but was not associated with an increased risk of sICH (OR 1.00, 95% CI 0.83-1.20). Similar associations exist between INR variability and poor functional outcomes at 90 days (OR 2.17, 95% CI 1.09-4.30), 1 year (OR 2.28, 95% CI 1.16-4.46), and sICH (OR 1.11, 95% CI 0.93-1.33). Subgroup analyses further revealed that elevated INR and INR variability remained associated with poor functional outcomes in patients not receiving oral anticoagulation (OAC) therapy, while no significant associations were observed in OAC-treated patients, regardless of whether they were on warfarin or direct oral anticoagulants. Elevated INR and INR variability in VBAO patients treated with EVT were associated with poor functional outcomes. The mechanism underlying the association between elevated INR and poor functional outcomes might be attributed to the fact that elevated INR indirectly reflects the burden of comorbidities, which could independently worsen outcomes. These findings underscore the importance of a comprehensive and dynamic evaluation of INR levels in the management of VBAO patients receiving EVT, providing valuable insights for optimizing patient outcomes.

Decreased Quantitative Cerebral Blood Volume Is Associated With Poor Outcomes in Large Core Patients

BACKGROUND

Recent large core trials have highlighted the effectiveness of mechanical thrombectomy (MT) in acute ischemic stroke with large vessel occlusion. Variable perfusion-imaging thresholds and poor Alberta Stroke Program Early Computed Tomography Score reliability underline the need for more standardized, quantitative ischemia measures for MT patient selection. We aimed to identify the computed tomography perfusion parameter most strongly associated with poor outcomes in patients with acute ischemic stroke-large vessel occlusion with significant ischemic cores.

METHODS

In this study from 2 comprehensive stroke centers from 2 comprehensive stroke centers within the Johns Hopkins Medical Enterprise (Johns Hopkins Hospita-East Baltimore and Bayview Medical Campus) from July 29, 2019 to January 29, 2023 in a continuously maintained database, we included patients with acute ischemic stroke-large vessel occlusion with ischemic core volumes defined as relative cerebral blood flow <30% and ≥50 mL on computed tomography perfusion or Alberta Stroke Program Early Computed Tomography Score <6. We used receiver operating characteristics to find the optimal cutoff for parameters like cerebral blood volume (CBV) <34%, 38%, 42%, and relative cerebral blood flow >20%, 30%, 34%, 38%, and time-to-maximum >4, 6, 8, and 10 seconds. The primary outcome was unfavorable outcomes (90-day modified Rankin Scale score 4-6). Multivariable models were adjusted for age, sex, diabetes, baseline National Institutes of Health Stroke Scale, intravenous thrombolysis, and MT.

RESULTS

We identified 59 patients with large ischemic cores. A receiver operating characteristic curve analysis showed that CBV<42% ≥68 mL is associated with unfavorable outcomes (90-day modified Rankin Scale score 4-6) with an area under the curve of 0.90 (95% CI, 0.82-0.99) in the total and MT-only cohorts. Dichotomizing at this CBV threshold, patients in the ≥68 mL group exhibited significantly higher relative cerebral blood flow, time-to-maximum >8 and 10 seconds volumes, higher CBV volumes, higher HIR, and lower CBV index. The multivariable model incorporating CBV<42% ≥68 mL predicted poor outcomes robustly in both cohorts (area under the curve for MT-only subgroup was 0.87 [95% CI, 0.75-1.00]).

CONCLUSIONS

CBV<42% ≥68 mL most effectively forecasts poor outcomes in patients with large-core stroke, confirming its value alongside other parameters like time-to-maximum in managing acute ischemic stroke-large vessel occlusion.

Association between the serum glucose-to-potassium ratio and clinical outcomes in ischemic stroke patients after endovascular thrombectomy

Background and purpose

The baseline glucose-to-potassium ratio (GPR) is associated with poor outcomes in patients with acute brain injury and intracranial hemorrhage. However, the impact of serum GPR on clinical outcomes after endovascular thrombectomy (EVT) is unclear. This study aimed to evaluate the association between the GPR at admission and functional outcomes at 90 days after EVT.

Methods

We retrospectively reviewed our database for patients with acute ischemic stroke involving an anterior circulation large-vessel occlusion who received EVT between October 2019 and December 2021. The baseline serum GPR was measured after admission. The primary outcome was a 90-day poor outcome, which was defined as a modified Rankin scale score of 3-6.

Results

A total of 273 patients (mean age, 70.9 ± 11.9 years; 161 men) were finally included for analyses. During the 90-day follow-up, 151 patients (55.3%) experienced an unfavorable outcome. After adjusting for demographic characteristics and other potential confounders, the increased GPR was significantly associated with a higher risk of a 90-day poor outcome (odds ratio, 1.852; 95% confidence interval, 1.276-2.688, p = 0.001). Similar results were observed when the GPR was analyzed as a categorical variable. In addition, the restricted cubic spline observed a positive and linear association between the GPR and poor outcomes at 90 days (p = 0.329 for linearity; p = 0.001 for linearity).

Conclusion

Our study found that ischemic stroke patients with the higher GPR at admission were more likely to have an unfavorable prognosis at 3 months, suggesting that GPR may be a potential prognostic biomarker for ischemic stroke after EVT.

Impact of post-thrombectomy isolated subarachnoid hemorrhage on neurological outcomes in patients with anterior ischemic stroke - a retrospective single-center observational study

PURPOSE

We aimed to investigate the impact of post-thrombectomy isolated subarachnoid hemorrhage (i-SAH) and other types of intracranial hemorrhage (o-ICH) on patient's neurological outcomes.

METHODS

Stroke data from 2018 to 2022 in a tertiary care center were retrospectively analyzed. Patients with large vessel occlusion from ICA to M2 branch were included. Post-thrombectomy intracranial hemorrhages at 24 h were categorized with Heidelberg Bleeding Classification. Neurological impairment of patients was continuously assessed at admission, at 24 h, 48 h and 72 h, and at discharge. Predictors of i-SAH and o-ICH were assessed.

RESULTS

297 patients were included. i-SAH and o-ICH were found in 12.1% (36/297) and 11.4% (34/297) of patients. Overall, NIHSS of i-SAH patients at discharge were comparable to o-ICH patients (median 22 vs. 21, p = 0.889) and were significantly higher than in non-ICH patients (22 vs. 7, p < 0.001). i-SAH often resulted in abrupt deterioration of patient's neurological symptoms at 24 h after thrombectomy. Compared to non-ICH patients, the occurrence of i-SAH was frequently associated with worse neurological outcome at discharge (median NIHSS increase of 4 vs. decrease of 4, p < 0.001) and higher in-hospital mortality (41.7% vs. 23.8%, p = 0.022). Regardless of successful reperfusion (TICI 2b/3), the beneficial impact of thrombectomy appeared to be outweighed by the adverse effect of i-SAH. Incomplete reperfusion and shorter time from symptom onset to admission were associated with higher probability of i-SAH, whereas longer procedure time and lower baseline ASPECTS were predictive for o-ICH occurrence.

CONCLUSION

Post-thrombectomy isolated subarachnoid hemorrhage is a common complication with significant negative impact on neurological outcome.

Longitudinal changes in the US emergency department use of advanced neuroimaging in the mechanical thrombectomy era

PURPOSE

To describe ED neuroimaging trends across the time-period spanning the early adoption of endovascular therapy for acute stroke (2013-2018).

MATERIALS AND METHODS

We performed a retrospective, cross-sectional study of ED visits using the 2013-2018 National Emergency Department Sample, a 20% sample of ED encounters in the United States. Neuroimaging use was determined by Common Procedural Terminology (CPT) code for non-contrast head CT (NCCT), CT angiography head (CTA), CT perfusion (CTP), and MRI brain (MRI) in non-admitted ED patients. Data was analyzed according to sampling weights and imaging rates were calculated per 100,000 ED visits. Multivariate logistic regression analysis was performed to identify hospital-level factors associated with imaging utilization.

RESULTS

Study population comprised 571,935,906 weighted adult ED encounters. Image utilization increased between 2013 and 2018 for all modalities studied, although more pronounced in CTA (80.24/100,000 ED visits to 448.26/100,000 ED visits (p < 0.001)) and CTP (1.75/100,000 ED visits to 28.04/100,000 ED visits p < 0.001)). Regression analysis revealed that teaching hospitals were associated with higher odds of high CTA utilization (OR 1.88 for 2018, p < 0.05), while low-volume EDs and public hospitals showed the reverse (OR 0.39 in 2018, p < 0.05).

CONCLUSIONS

We identified substantial increases in overall neuroimaging use in a national sample of non-admitted emergency department encounters between 2013 and 2018 with variability in utilization according to both patient and hospital properties. Further investigation into the appropriateness of this imaging is required to ensure that access to acute stroke treatment is balanced against the timing and cost of over-imaging.

Diffusion tensor imaging and gray matter volumetry to evaluate cerebral remodeling processes after a pure motor stroke: a longitudinal study

BACKGROUND AND OBJECTIVES

Clinical factors are not sufficient to fix a prognosis of recovery after stroke. Pyramidal tract or alternate motor fiber (aMF: reticulo-, rubrospinal pathways and transcallosal fibers) integrity and remodeling processes assessable by diffusion tensor MRI (DTI) and voxel-based morphometry (VBM) may be of interest. The primary objective was to study longitudinal cortical brain changes using VBM and longitudinal corticospinal tract changes using DTI during the first 4 months after lacunar cerebral infarction. The second objective was to determine which changes were correlated to clinical improvement.

METHODS

Twenty-one patients with deep brain ischemic infarct with pure motor deficit (NIHSS score ≥ 2) were recruited at Purpan Hospital and included. Motor deficit was measured [Nine peg hole test (NPHT), dynamometer (DYN), Hand-Tapping Test (HTT)], and a 3T MRI scan (VBM and DTI) was performed during the acute and subacute phases.

RESULTS

White matter changes: corticospinal fractional anisotropy (FACST) was significantly reduced at follow-up (approximately 4 months) on the lesion side. FAr (FA ratio in affected/unaffected hemispheres) in the corona radiata was correlated to the motor performance at the NPHT, DYN, and HTT at follow-up. The presence of aMFs was not associated with the extent of recovery. Grey matter changes: VBM showed significant increased cortical thickness in the ipsilesional premotor cortex at follow-up. VBM changes in the anterior cingulum positively correlated with improvement in motor measures between baseline and follow-up.

DISCUSSION

To our knowledge, this study is original because is a longitudinal study combining VBM and DTI during the first 4 months after stroke in a series of patients selected on pure motor deficit. Our data would suggest that good recovery relies on spared CST fibers, probably from the premotor cortex, rather than on the aMF in this group with mild motor deficit. The present study suggests that VBM and FACST could provide reliable biomarkers of post-stroke atrophy, reorganization, plasticity and recovery.

CLINICALTRIALS

GOV IDENTIFIER

NCT01862172, registered May 24, 2013.

Prediction of Ischemic Stroke Functional Outcomes from Acute-Phase Noncontrast CT and Clinical Information

Background Clinical outcome prediction based on acute-phase ischemic stroke data is valuable for planning health care resources, designing clinical trials, and setting patient expectations. Existing methods require individualized features and often involve manually engineered, time-consuming postprocessing activities. Purpose To predict the 90-day modified Rankin Scale (mRS) score with a deep learning (DL) model fusing noncontrast-enhanced CT (NCCT) and clinical information from the acute phase of stroke. Materials and Methods This retrospective study included data from six patient datasets from four multicenter trials and two registries. The DL-based imaging and clinical model was trained by using NCCT data obtained 1-7 days after baseline imaging and clinical data (age; sex; baseline and 24-hour National Institutes of Health Stroke Scale scores; and history of hypertension, diabetes, and atrial fibrillation). This model was compared with models based on either NCCT or clinical information alone. Model-specific mRS score prediction accuracy, mRS score accuracy within 1 point of the actual mRS score, mean absolute error (MAE), and performance in identifying unfavorable outcomes (mRS score, >2) were evaluated. Results A total of 1335 patients (median age, 71 years; IQR, 60-80 years; 674 female patients) were included for model development and testing through sixfold cross validation, with distributions of 979, 133, and 223 patients across training, validation, and test sets in each of the six cross-validation folds, respectively. The fused model achieved an MAE of 0.94 (95% CI: 0.89, 0.98) for predicting the specific mRS score, outperforming the imaging-only (MAE, 1.10; 95% CI: 1.05, 1.16; P < .001) and the clinical information-only (MAE, 1.00; 95% CI: 0.94, 1.05; P = .04) models. The fused model achieved an area under the receiver operating characteristic curve (AUC) of 0.91 (95% CI: 0.89, 0.92) for predicting unfavorable outcomes, outperforming the clinical information-only model (AUC, 0.88; 95% CI: 0.87, 0.90; P < .001) and the imaging-only model (AUC, 0.85; 95% CI: 0.84, 0.87; P < .001). Conclusion A fused DL-based NCCT and clinical model outperformed an imaging-only model and a clinical-information-only model in predicting 90-day mRS scores. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Lee in this issue.

Biomarkers for Early Detection of Stroke: A Systematic Review

Stroke remains a leading cause of mortality and disability worldwide. Identifying reliable biomarkers for stroke diagnosis and risk prediction could significantly improve patient outcomes through earlier intervention and better risk management. The objective of this systematic review is to systematically review recent studies investigating biomarkers for stroke diagnosis and risk prediction and to synthesize the most promising findings. We conducted a systematic review of 10 studies published between 2008 and 2023 that examined various biomarkers in relation to stroke. Studies were evaluated for quality using a simplified version of the Mixed Methods Appraisal Tool. The reviewed studies investigated a diverse array of biomarkers, including lipids, inflammatory markers, hemodynamic markers, microRNAs, metabolites, and neurodegenerative markers. Key findings include the following: (1) non-traditional lipid markers such as triglycerides and non-high-density lipoprotein cholesterol may be more predictive of stroke risk than low-density lipoprotein; (2) inflammatory markers, particularly IL-6, showed strong associations with stroke risk; (3) hemodynamic markers like midregional proatrial natriuretic peptide (MRproANP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) demonstrated potential in distinguishing stroke subtypes; (4) specific microRNAs (miR-125a-5p, miR-125b-5p, miR-143-3p) were upregulated in acute ischemic stroke; (5) metabolomic studies identified novel markers such as tetradecanedioate and hexadecanedioate associated with cardioembolic stroke; (6) neurodegenerative markers (total-tau, neurofilament light chain) were linked to increased stroke risk. This review highlights the potential of various biomarkers in improving stroke diagnosis and risk prediction. While individual markers show promise, a multi-marker approach combined with clinical variables appears most likely to yield clinically useful tools. Further large-scale validation studies are needed before these biomarkers can be implemented in routine clinical practice.

Outcomes of Mechanical Thrombectomy for Patients With Stroke Presenting With Low Alberta Stroke Program Early Computed Tomography Score in Early and Late Time Windows

BACKGROUND AND OBJECTIVES

This study aimed to compare outcomes of low Alberta Stroke Program Early Computed Tomography Score (ASPECTS) patients with stroke who underwent mechanical thrombectomy (MT) within 6 hours or 6 to 24 hours after stroke onset.

METHODS

A retrospective cohort study was conducted using data from a large multicenter international registry from 2013 to 2023. Patients with low ASPECTS (2-5) who underwent MT for anterior circulation intracranial large vessel occlusion were included. A propensity matching analysis was conducted for patients presented in the early (<6 hours) vs late (6-24 hours) time window after symptom onset or last known normal.

RESULTS

Among the 10 229 patients who underwent MT, 274 met the inclusion criteria. 122 (44.5%) patients were treated in the late window. Early window patients were older (median age, 74 years [IQR, 63-80] vs 66.5 years [IQR, 54-77]; P < .001), had lower proportion of female patients (40.1% vs 54.1%; P = .029), higher median admission National Institutes of Health Stroke Scale score (20 [IQR, 16-24] vs 19 [IQR, 14-22]; P = .004), and a higher prevalence of atrial fibrillation (46.1% vs 27.3; P = .002). Propensity matching yielded a well-matched cohort of 84 patients in each group. Comparing the matched cohorts showed there was no significant difference in acceptable outcomes at 90 days between the 2 groups (odds ratio = 0.90 [95% CI = 0.47-1.71]; P = .70). However, the rate of symptomatic ICH was significantly higher in the early window group compared with the late window group (odds ratio = 2.44 [95% CI = 1.06-6.02]; P = .04).

CONCLUSION

Among patients with anterior circulation large vessel occlusion and low ASPECTS, MT seems to provide a similar benefit to functional outcome for patients presenting <6 hours or 6 to 24 hours after onset.

Race, Ethnicity, and Gender Disparities in the Management and Outcomes of Critically Ill Adults with Acute Stroke

Racial, ethnicity and sex disparities are pervasive in the evaluation and acute care of ischemic stroke patients. Administration of intravenous thrombolysis and mechanical thrombectomy are the most critical steps in ischemic stroke treatment but compared to White patients, ischemic stroke patients from minority racial and ethnic groups are less likely to receive these potentially life-saving interventions. Sex and racial disparities in intracerebral hemorrhage or subarachnoid hemorrhage treatment have not been well studied.

Reperfusion therapies for ischemic stroke in dementia and cognitive impairment: A systematic review and meta-analysis

BACKGROUND

Endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT) have an unclear benefit in those with pre-stroke dementia or cognitive impairment, as these patients were often excluded from landmark stroke trials. We performed a systematic review and meta-analysis to assess the outcomes of IVT and EVT in these populations.

AIMS

Our systematic review, conforming to the Meta-Analysis of Observational Studies in Epidemiology guidelines, investigated studies on acute ischemic stroke patients with pre-stroke dementia or cognitive impairment treated with IVT or EVT. Primary outcome was favorable 90-day outcome (mRS 0-2). Secondary outcomes included 90-day mortality, symptomatic intracranial hemorrhage (SICH), and radiographic intracranial hemorrhage (ICH).

SUMMARY OF REVIEW

Nine articles were identified, with five observational studies of IVT use in patients with (n = 1078) and without dementia (n = 2805) being selected for the meta-analysis. There were no significant differences in favorable outcome (adjusted OR: 0.61, 95% CI 0.24-1.59), mortality (unadjusted OR: 1.19, 95% CI 0.86-1.64), ICH (unadjusted OR: 1.32, 95% CI 0.79-2.19), and symptomatic ICH (unadjusted OR: 0.94, 95% CI 0.70-1.25) for patients undergoing IVT with pre-stroke dementia versus those without. One EVT study (n = 615 with dementia vs n = 9600 without) found no significant differences in outcomes apart from an increased odds of ICH for those with pre-existing dementia (adjusted OR: 1.57, 95% CI 1.03-2.40). A pooled analysis of three IVT studies showed no significant association of cognitive impairment (n = 93 vs n = 211 without) with all assessed outcomes, whereas a study of EVT found that pre-stroke cognitive impairment was associated with poor 90-day outcomes (mRS 3-6).

CONCLUSION

These results suggest no substantial safety issues in the use of IVT or EVT for patients with pre-existing dementia or cognitive impairment compared to those without. However, the efficacy of these therapies in this demographic remains uncertain. Further rigorous studies that include a more nuanced outcome measurement approach are warranted.

REGISTRATION

URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42021240499.

Endovascular Stroke Thrombectomy for Patients With Large Ischemic Core: A Review

Importance

Recently, 6 randomized clinical trials-RESCUE-Japan-LIMIT (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism-Japan Large Ischemic Core Trial), ANGEL-ASPECT (Trial of Endovascular Therapy for Acute Ischemic Stroke With Large Infarct), SELECT2 (Trial of Endovascular Thrombectomy for Large Ischemic Strokes), TESLA (Thrombectomy for Emergent Salvage of Large Anterior Circulation Ischemic Stroke), TENSION (Endovascular Thrombectomy for Acute Ischemic Stroke With Established Large Infarct), and LASTE (Large Stroke Therapy Evaluation)-have concluded their investigations on the efficacy and safety of endovascular thrombectomy (EVT) for the treatment of patients with ischemic stroke, anterior-circulation large vessel occlusions, and large areas of ischemic changes defined as an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 5 or less. Overall, the results appeared to be positive, with 5 of the 6 trials meeting their primary efficacy end point, and 1 trial that was a near miss. However, questions remain regarding how these trial results should be interpreted and incorporated into routine clinical practice.

Observations

In this narrative review and analysis of published trials, important nuances of the available clinical data were identified, and important areas of lingering uncertainty were highlighted, including the efficacy and safety of EVT for patients with a low ASPECTS score in late treatment windows and those with large core volumes. Also emphasized was the possibly important role of advanced neuroimaging modalities such as perfusion and magnetic resonance imaging when making EVT treatment decisions for select patients with low ASPECTS scores.

Conclusions and Relevance

Recent trial data provide strong evidence that EVT is safe and effective for patients with anterior, large vessel-occlusion stroke and low ASPECTS scores who present within 6 hours from stroke onset. However, patient outcomes often remain poor despite EVT treatment. The efficacy and safety of EVT for patients with low ASPECTS scores who present beyond 6 hours of stroke onset remain uncertain, and the current trial data seem too scarce to justify forgoing advanced stroke imaging during this extended time window. Furthermore, the efficacy and safety of EVT for patients with large core volumes (100 mL or greater) or M2 occlusions (ie, occlusions of the second segment of the middle cerebral artery) remain uncertain. Future research to better identify patients likely to meaningfully respond to EVT is needed to further optimize the stroke triage process and health care resource utilization.

Hyper-Acute Stroke Systems of Care and Workflow

PURPOSE OF REVIEW

Recent stroke treatment advances have necessitated agile, broad-scale healthcare system redesign, to achieve optimal patient outcomes and access equity. Optimised hyperacute stroke care requires integrated pre-hospital, emergency department, stroke specialist, radiology, neurosurgical and endovascular neurointervention services, guided by a population-wide needs analysis. In this review, we survey system integration efforts, providing case studies, and identify common elements of successful initiatives.

RECENT FINDINGS

Different regions and nations have evolved varied acute stroke systems depending on geography, population density and workforce. However, common facilitators to these solutions have included stroke unit care as a foundation, government-clinician synergy, pre-hospital pathway coordination, service centralisation, and stroke data guiding system improvement. Further technological advantages will minimize the geographical distance disadvantages and facilitate virtual expertise redistribution to remote areas. Continued treatment advances necessitate an integrated, adaptable, population-wide trans-disciplinary approach. A well-designed clinician-led and government-supported system can facilitate hyperacute care and scaffold future system enhancements.

Hepatic Artery Thrombectomy after Orthotopic Liver Transplantation: A Stent Retriever and/or Aspiration-Guided Catheter Approach

Retransplantation has been the primary treatment for hepatic artery thrombosis (HAT) in patients with orthotopic liver transplant (OLT); however, because of scarcity of grafts, endovascular revascularization via mechanical thrombectomy offers an alternative to retransplantation should it provide similar long-term benefits. Data regarding a series of 8 patients with hepatic artery thrombectomies across 10 procedures (1 early HAT and 9 late HAT) utilizing stent retriever and/or suction catheter were collected. All had technically successful restoration of flow with stent placement of the anastomotic stenosis in 8 cases. Two patients required reintervention for HAT at 18 and 701 days after primary intervention, with the first dying from liver failure but with a patent hepatic artery on explant. One case had a procedure-related adverse event, hepatic artery dissection, Society of Interventional Radiology (SIR) adverse event classification of 2. Technical success was achieved in all procedures, demonstrating promise in effectively treating HAT in patients with OLT.