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

Baseline neurological deficit and argatroban plus alteplase in acute ischemic stroke: A post hoc analysis of ARAIS trial

BACKGROUND

The ARAIS trial didn't demonstrate argatroban significantly improve functional outcome at 90 days in acute ischemic stroke. We conducted post hoc analysis of ARAIS to investigate whether baseline neurological deficit was associated with outcomes.

METHODS

Patients without endovascular therapy who met screening criteria as protocol and completed argatroban treatment were enrolled and classified into two subgroups according to NIHSS score at admission. Primary outcome was excellent functional outcome at 90 days, defined as mRS score of 0 to 1. Early neurological deterioration (END), defined as an increase of ≥4 in the NIHSS score from baseline within 48 hours, was investigated as secondary outcome. Compared with alteplase alone, we investigated treatment effect of argatroban plus alteplase on outcomes in subgroups and interaction with subgroups.

RESULTS

A total of 675 patients from full analysis set were included: 390 were assigned into NIHSS score <10 subgroup and 285 into NIHSS score ≥10 subgroup. For primary outcome, there was similar treatment effect between argatroban plus alteplase and alteplase alone in NIHSS score ≥10 subgroup (adjusted RD, 5.8%; 95% CI, -6.0% to 17.5%; P = 0.33) and in NIHSS score <10 subgroup (adjusted RD, -1.4%; 95% CI, -9.9% to 7.1%; P = 0.75), and no significant interaction (P = 0.43). Occurrence of early neurological deterioration within 48 hours were significantly lower in NIHSS score ≥10 subgroup, compared with NIHSS score <10 subgroup (P = 0.006).

CONCLUSION

Among patients with NIHSS score ≥10, argatroban plus alteplase could safely reduce END within 48 hours.

Endovascular Thrombectomy for Large Ischemic Strokes with ASPECTS 0-2: a Meta-analysis of Randomized Controlled Trials

PURPOSE

Randomized controlled trials (RCTs) demonstrated a treatment effect of endovascular thrombectomy in acute ischemic stroke with large infarct, commonly defined as an Alberta Stroke Program Early CT Score (ASPECTS) of 3-5. However, data on endovascular thrombectomy in patients with very low ASPECTS of 0-2 remain scarce.

METHODS

We conducted a systematic review and meta-analysis of RCTs comparing endovascular thrombectomy versus medical treatment alone in acute ischemic anterior circulation stroke with very large infarct, defined as ASPECTS of 0-2. The primary outcome was the shift toward better functional outcomes on the 90-day modified Rankin Scale (mRS). Random effects meta-analysis was performed using the generic inverse variance method.

RESULTS

Literature research identified four RCTs which evaluated the treatment effect of endovascular thrombectomy for large infarcts and provided a subgroup analysis of the mRS shift in patients with ASPECTS of 0-2. The pooled analysis showed a significant shift toward better 90-day mRS scores in favor of endovascular thrombectomy (pooled odds ratio, 1.62, 95% confidence interval, 1.29-2.04, P < 0.001).

CONCLUSION

This meta-analysis suggests a treatment effect of endovascular thrombectomy in specific patients with very low ASPECTS of 0-2, challenging the use of ASPECTS for treatment selection in acute ischemic stroke due to large vessel occlusion. An individual patient meta-analysis of RCTs would strengthen evidence in the treatment of patients with ASPECTS of 0-2.

Endovascular therapy in patients with a large ischemic volume at presentation: An aggregate patient-level analysis

INTRODUCTION

Recently, four randomized controlled trials (RCTs) have demonstrated the benefits of mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) caused by anterior large vessel occlusion (LVO) and a large ischemic core at baseline (LIC). The purpose of this study was to investigate the features influencing the clinical outcome and the benefits of mechanical thrombectomy in this subgroup.

METHODS

We conducted a multicenter retrospective aggregate cohort study of patients with AIS-LVO and a LIC, assessed with quantitative core volume measures, treated with MT between 2012 and 2019. The data were queried through four registries, including patients with core volumes ≥50cc. Multivariable logistic regression models were employed to determine factors independently associated with clinical outcomes in patients with successful recanalization (modified-Thrombolysis-in-Cerebral-Infarction-score, mTICI=2b-3) and unsuccessful recanalization group (mTICI=0-2a). The primary endpoint was a favorable functional outcome at day-90, defined as a modified Rankin scale (mRS) of 0-3, accounting for the inherent severity of AIS with baseline LIC. Secondary outcomes included functional independence (mRS 0-2) at day-90, mortality, and symptomatic Intracranial Hemorrhage (sICH).

RESULTS

A total of 460 patients were included (mean age 66±14.2 years; 39.6 % females). The mean baseline NIHSS was 20±5.2, and the core volume was 103.2±54.6 ml. Overall, 39.8 % (183/460) of patients achieved a favorable outcome at day-90 (mRS 0-3). Successful recanalization was significantly associated with a more frequent favorable outcome (aOR, 4.79; 95 %CI, 2.73-8.38; P<0.01) and functional independence (P<0.01). This benefit remained significant in older patients and in patients with cores above 100cc. At 90 days, 147/460 patients (32 %) were deceased, with successful recanalization significantly associated with less frequent mortality (OR, 0.34; 95 %CI, 0.22-0.53; P<0.01). The rate of sICH was 17.4 % and did not differ significantly between groups.

CONCLUSIONS

In this large, pooled-cohort study of AIS-LVO patients with infarct cores over 50cc at baseline, we demonstrated that successful recanalization was associated with a better functional outcome, lower mortality, and similar rates of symptomatic intracranial hemorrhage for a wide spectrum of patients.

Large vessel occlusion detection by non-contrast CT using artificial ıntelligence

INTRODUCTION

Computer vision models have been used to diagnose some disorders using computer tomography (CT) and magnetic resonance (MR) images. In this work, our objective is to detect large and small brain vessel occlusion using a deep feature engineering model in acute of ischemic stroke.

METHODS

We use our dataset. which contains 324 patient's CT images with two classes; these classes are large and small brain vessel occlusion. We divided the collected image into horizontal and vertical patches. Then, pretrained AlexNet was utilized to extract deep features. Here, fc6 and fc7 (sixth and seventh fully connected layers) layers have been used to extract deep features from the created patches. The generated features from patches have been concatenated/merged to generate the final feature vector. In order to select the best combination from the generated final feature vector, an iterative selector (iterative neighborhood component analysis-INCA) has been used, and this selector has chosen 43 features. These 43 features have been used for classification. In the last phase, we used a kNN classifier with tenfold cross-validation.

RESULTS

By using 43 features and a kNN classifier, our AlexNet-based deep feature engineering model surprisingly attained 100% classification accuracy.

CONCLUSION

The obtained perfect classification performance clearly demonstrated that our proposal could separate large and small brain vessel occlusion detection in non-contrast CT images. In this aspect, this model can assist neurology experts with the early recanalization chance.

Stenting with dual-layer CGuard stent in acute sub-occlusive carotid artery stenosis and in tandem occlusions: a monocentric study

PURPOSE

Double-layer design carotid stents have been cast in a negative light since several investigations reported high rates of in-stent occlusions, at least in the acute setting of tandem occlusions. CGuard is a new generation double-layered stent that was designed to prevent periinterventional embolic events. The aim of this study was to analyze the safety and efficacy of the CGuard in emergent CAS and for the acute treatment of tandem occlusions in comparison with the single-layer Carotid Wallstent (CWS) system.

METHODS

All patients who underwent CAS with CGuard or CWS after intracranial mechanical thrombectomy (MT) between 11/2018 and 12/2022 were identified from our local thrombectomy registry. Clinical, interventional and neuroimaging data were analyzed. Patency of the stent was assessed within 72 h. Intracranial hemorrhage and modified Rankin score (mRS) at discharge were the main endpoints.

RESULTS

In total, 86 stent procedures in 86 patients were included (CWS: 44, CGuard: 42). CGuard had a lower, but not statistically significant rate (p = 0.431) of in-stent occlusions (n = 2, 4.8%) when compared to the CWS (n = 4, 9.1%). Significant in-stent stenosis was found in one case in each group. There was no statistically significant difference in functional outcome at discharge between the two groups with a median mRS for CGuard of 2 (IQR:1-5) vs. CWS 3 (IQR:2-4).

CONCLUSION

In our series, the rate of in-stent occlusions after emergent CAS was lower with the dual-layer CGuard when compared to the monolayer CWS. Further data are needed to evaluate the potential benefit of the design in more detail.

Safety and efficacy of tirofiban combined with intravenous thrombolysis and endovascular treatment in acute large vessel occlusion stroke

OBJECTIVE

This study assesses the safety and efficacy of tirofiban for patients with large vessel occlusion stroke after intravenous thrombolysis.

METHODS

This study data was from SUSTAIN, DEVT, and RESCUE BT trials. According to whether the use of tirofiban who underwent endovascular treatment and preceding intravenous thrombolysis was divided into the tirofiban group and the no-tirofiban group. The safety outcomes were symptomatic intracranial hemorrhage, any intracranial hemorrhage within 48 h, and 3-month mortality. The efficacy outcome was defined as a score of 0-2 on the modified Rankin Scale scores at 3 months.

RESULTS

A total of 372 patients with intravenous thrombolysis were included in these SUSTAIN, DEVT, and RESCUE BT trials. Adjusted multivariate analysis showed that tirofiban with intravenous thrombolysis was not associated with symptomatic intracranial hemorrhage (aOR, 0.87; 95 % CI, 0.49-1.57; P=0.65), any intracranial hemorrhage within 48 h (aOR, 1.00; 95 % CI, 0.60-1.66; P=1.00), 3-month mortality (aOR, 1.10; 95 % CI, 0.56-2.19; P=0.78) and 3-month modified Rankin Scale scores 0-2 (aOR, 0.72; 95 % CI, 0.42-1.25; P=0.25) in patients with acute large vessel occlusion. In the subgroup analysis, we found that tirofiban was not recommended for females (aOR, 0.34; 95 % CI, 0.12-0.93), baseline Alberta Stroke Program Early CT Score≤9 (aOR, 0.37; 95 % CI, 0.18-0.76), and cardiogenic embolism (aOR, 0.36; 95 % CI, 0.14-0.97).

CONCLUSION

Tirofiban combined with intravenous thrombolysis in patients with acute large vessel occlusion may be safe. Further studies need to confirm the effectiveness of tirofiban after intravenous thrombolysis in different stroke etiology.

Safety and efficacy of mechanical thrombectomy for acute ischemic stroke with volume over 50 mL and significant perfusion mismatch

Background

This study aims to address the safety and efficacy of mechanical thrombectomy (MT) in acute ischemic stroke with an established infarction equal to or >50 mL with a significant difference between penumbra and established infarction detected by perfusion cerebral computed tomography (CT) with the Rapid® system.

Methods

This was a retrospective case-control study. Patients diagnosed with established and extensive ischemic stroke, defined by an ischemic volume equal to or >50 mL on CT or magnetic resonance imaging perfusion using the RAPID® system, were examined. The intervention group received endovascular interventional treatment with or without recombinant tissue plasminogen activator (rt-PA) in addition to standard therapy, and the control group received conservative treatment with or without rt-PA plus standard therapy.

Results

A total of 59 patients were enrolled, including 38 in the intervention group and 21 in the control group. Baseline characteristics were similar between groups. Patient National Institutes of Health Stroke Scale at discharge was significantly different between the control (median 30, interquartile range [IQR] 13) and intervention group (median 8, IQR 14) (P < 0.001). Modified Rankin scale (mRS) scores were significantly different at discharge between intervention (median mRS 2, IQR 3) and controls (median mRS 5, IQR 1) (P = 0.002). These mRS differences remained significant at 90 days, with median (IQR) values of 2 (2.75) and 5 (1), respectively (P < 0.001).

Conclusion

MT is safe and effective for large-core ischemic strokes with significant perfusion mismatch, leading to better functional outcomes without significant complications compared to the best medical treatment.

System-level trends in ischemic stroke admissions after adding endovascular stroke capabilities in community hospitals

BACKGROUND

There is substantial interest in adding endovascular stroke therapy (EST) capabilities in community hospitals. Here, we assess the effect of transitioning to an EST-performing hospital (EPH) on acute ischemic stroke (AIS) admissions in a large hospital system including academic and community hospitals.

METHODS

From our prospectively collected multi-institutional registry, we collected data on AIS admissions at 10 hospitals in the greater Houston area from January 2014 to December 2022: one longstanding EPH (group A), three community hospitals that transitioned to EPHs in November 2017 (group B), and six community non-EPHs that remained non-EPH (group C). Primary outcomes were trends in total AIS admissions, large vessel occlusion (LVO) and non-LVO AIS, and tissue plasminogen activator (tPA) and EST use.

RESULTS

Among 20 317 AIS admissions, median age was 67 (IQR 57-77) years, 52.4% were male, and median National Institutes of Health Stroke Scale (NIHSS) was 4 (IQR 1-10). During the first 12 months after EPH transition, AIS admissions increased by 1.9% per month for group B, with non-LVO stroke increasing by 4.2% per month (P<0.001). A significant change occurred for group A at the transition point for all outcomes with decreasing rates in admissions for AIS, non-LVO AIS and LVO AIS, and decreasing rates of EST and tPA treatments (P<0.001).

CONCLUSION

Upgrading to EPH status was associated with a 2% per month increase in AIS admissions during the first year post-transition for the upgrading hospitals, but decreasing volumes and treatments at the established EPH. These findings quantify the impact on AIS admissions in hospital systems with increasing EST access in community hospitals.

Development of a new scale for self-reported procedural patient comfort during endovascular therapy for acute stroke

INTRODUCTION

In stroke patients with acute large vessel occlusion, endovascular therapy (EVT) may be performed with or without sedation. Our aim is to describe self-reported intraprocedural comfort in patients undergoing EVT depending on sedation type.

METHODS

We performed a prospective observational single-center study of patients undergoing EVT. Patients were systematically interviewed on the day following intervention using a structured questionnaire addressing five domains (nausea/vomiting, pain of any kind, physical discomfort, emotional discomfort, and medical team interaction). Each domain scored 0 to 2 points for a maximum total of 10 points (a higher score indicating greater discomfort). In addition, satisfaction with procedural comfort was rated on a visual analog scale (VAS), and patients reported whether they would have preferred more, less, or the same amount of sedation. Patients who underwent EVT without sedation (local anesthesia, LA) were compared to those who received procedural sedation (conscious sedation, CS).

RESULTS

Seventy-seven questionnaires were completed: 37 (48%) patients underwent EVT with CS while 40 (52%) were treated under LA. Median scores on the self-reported discomfort scale (1[0-2] vs 1[0-2], p = 0.70) and mean scores on VAS (76 ± 25 vs 81 ± 24, p = 0.37) were similar between the CS and the LA group. The proportion of patients who were satisfied with the adopted sedation strategy was similar between groups.

CONCLUSION

EVT without prior sedation seems to be well tolerated. Systematic self-evaluation of patient comfort appears feasible and may become integrated into routine clinical care. Patient-oriented outcomes should be included in future trials of sedation during thrombectomy.

Involvement of Subinsular Territory Stroke as Predictor of Outcome after Successful Endovascular Recanalization of Left Middle Cerebral Artery Occlusion

Subinsular stroke (subIS) can occur between the penetrating middle cerebral artery (MCA) branches, which clinical and radiological findings sometimes encounter in patients after the recanalization of left proximal MCA occlusion. However, no supportive data are available to clarify this relationship. This study investigated whether the involvement of subIS can impact outcomes after successful reperfusion therapy. Data from 152 consecutive patients who underwent endovascular thrombectomy between 2019 and 2023 were collected. A 3-month functional independence defined as a modified Rankin Scale 0-2 (primary outcome) and influencing factors were analyzed retrospectively. Recanalization was achieved in 35 patients, of whom 11 (31%) developed subIS. Patients with subIS were older in age (81 vs. 75; p < 0.05), had lower apparent diffusion coefficient (ADC) values on admission (0.52 vs. 0.62; p < 0.001), and higher modified Rankin Scale (mRS) scores (4 vs. 2; p < 0.001) than those without subIS. In a multivariate analysis, subIS was independently associated with a worse functional outcome (odds ratio: 10.5, p = 0.02). The cut-off value of the ADCs was 0.52 with a sensitivity and specificity of 70% and 64%, respectively. Subinsular ischemic lesions contribute to poor functional independence in patients after the successful recanalization of left MCA occlusion. The attenuation of the ADC value in these territories could be a valuable predictor of the outcome.

Severity, Outcomes, and their Secular Changes in 33,870 Ischemic Stroke Patients with Atrial Fibrillation in a Hospital-Based Registry: Japan Stroke Data Bank

AIM

Severity, functional outcomes, and their secular changes in acute atrial fibrillation (AF)-associated stroke patients were determined.

METHODS

Acute ischemic stroke patients with AF in a hospital-based, multicenter, prospective registry from January-2000 through December-2020, were compared with those without AF. The co-primary outcomes were the initial severity assessed by the NIH Stroke Scale (NIHSS) score and favorable outcome assessed by the modified Rankin Scale scores 0-2 at hospital discharge.

RESULTS

Of the 142,351 patients studied, 33,870 had AF. AF patients had higher NIHSS scores (median 9 vs. 3, adjusted coefficient 5.468, 95% CI 5.354-5.582) than non-AF patients. Favorable outcome was less common in AF patients than in non-AF patients in the unadjusted analysis (48.4% vs. 70.4%), but it was more common with adjustment for the NIHSS score and other factors (adjusted OR 1.110, 95% CI 1.061-1.161). In AF patients, the NIHSS score decreased throughout the 21-year period (adjusted coefficient -0.088, 95% CI -0.115 - -0.061 per year), and the reduction was steeper than in non-AF patients (P＜0.001). In AF patients, favorable outcome became more common over the period (adjusted OR 1.018, 95% CI 1.010-1.026), and the increase was steeper than in non-AF patients (P＜0.001); the increase was no longer significant after further adjustment by reperfusion therapy.

CONCLUSIONS

Initial stroke severity became milder and functional outcomes improved in AF patients over the 21-year period. These secular changes were steeper than in non-AF patients, suggesting that AF-associated stroke seemed to reap more benefit of recent development of stroke care than stroke without AF.

A Randomized Trial on Hemodynamic Optimization of Cerebral Perfusion after Successful Endovascular Therapy in Patients with Acute Ischemic Stroke (HOPE)

INTRODUCTION

In patients with acute ischemic stroke (AIS) secondary to intracranial large vessel occlusion, optimal blood pressure (BP) management following endovascular treatment (EVT) has not yet been established. The randomized trial on Hemodynamic Optimization of Cerebral Perfusion after Successful Endovascular Therapy in Patients with Acute Ischemic Stroke (HOPE) (clinicaltrials.gov id: NCT04892511) aims to demonstrate whether hemodynamic optimization using different systolic BP targets following EVT according to the degree of final recanalization, is more effective than currently recommended BP management in improving functional outcomes of patients with AIS.

METHODS

HOPE is an investigator-initiated multicenter clinical trial with randomized allocation, open-label treatment, and blinded endpoint evaluation (PROBE). Patients with an anterior circulation AIS within 24 h of symptom onset, treated with EVT, and showing successful recanalization (mTICI ≥2b) at the end of the procedure, are equally allocated (1:1) to hemodynamic optimization according to the study protocol versus BP management according to current guidelines (≤180/105 mm Hg). The protocol includes two different targets of systolic BP depending on the recanalization status (mTICI = 2b: 140-160 mm Hg; mTICI = 2c/3: 100-140 mm Hg). The protocol is applied within the first 72 h and includes BP lowering as well as vasopressor therapies when needed. The primary outcome is the proportion of favorable outcome (modified Rankin Scale [mRS] 0-2) at 90 days. Secondary outcomes include the shift on the mRS score, neurological deterioration, symptomatic intracerebral hemorrhage, and mortality.

CONCLUSION

The HOPE trial will provide new information on the safety and efficacy of different BP targets following EVT according to the degree of final recanalization in patients with AIS.

Artificial intelligence software for assessing brain ischemic penumbra/core infarction on computed tomography perfusion: A real-world accuracy study

BACKGROUND

With the increasingly extensive application of artificial intelligence (AI) in medical systems, the accuracy of AI in medical diagnosis in the real world deserves attention and objective evaluation.

AIM

To investigate the accuracy of AI diagnostic software (Shukun) in assessing ischemic penumbra/core infarction in acute ischemic stroke patients due to large vessel occlusion.

METHODS

From November 2021 to March 2022, consecutive acute stroke patients with large vessel occlusion who underwent mechanical thrombectomy (MT) post-Shukun AI penumbra assessment were included. Computed tomography angiography (CTA) and perfusion exams were analyzed by AI, reviewed by senior neurointerventional experts. In the case of divergences among the three experts, discussions were held to reach a final conclusion. When the results of AI were inconsistent with the neurointerventional experts' diagnosis, the diagnosis by AI was considered inaccurate.

RESULTS

A total of 22 patients were included in the study. The vascular recanalization rate was 90.9%, and 63.6% of patients had modified Rankin scale scores of 0-2 at the 3-month follow-up. The computed tomography (CT) perfusion diagnosis by Shukun (AI) was confirmed to be invalid in 3 patients (inaccuracy rate: 13.6%).

CONCLUSION

AI (Shukun) has limits in assessing ischemic penumbra. Integrating clinical and imaging data (CT, CTA, and even magnetic resonance imaging) is crucial for MT decision-making.

Comparative Effectiveness of Intravenous Thrombolysis plus Mechanical Thrombectomy versus Mechanical Thrombectomy Alone in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

INTRODUCTION

The treatment of acute ischemic stroke due to large artery vessel occlusion experienced a dramatic development within the last decade. This meta-analysis investigates the effectiveness of bridging therapy (BT) versus mechanical thrombectomy (MT) alone in treating acute ischemic stroke.

METHODS

Two independent reviewers assessed two-arm clinical trials from Scopus, PubMed, Web of Science, and the Cochrane Library up to January 2024. Data extraction and quality were evaluated using the ROBINS-2 tool. Our primary outcomes were improvement in NIHSS scores and 90-day modified Rankin Scale (mRS) score.

RESULTS

This meta-analysis, which included 2,638 participants from 8 randomized controlled trials, found that BT resulted in a greater improvement in NIHSS scores from baseline compared to endovascular treatment alone (mean difference [MD] 0.96, 95% confidence interval [CI]: [0.73-1.20], p < 0.00001). Additionally, BT group achieved successful recanalization more frequently before and after thrombectomy. Thrombectomy alone hat a shorter time from stroke onset to groin puncture compared to BT (MD 9.91, 95% CI: [4.31-15.52], p = 0.005). Functional outcomes, mortality rates, symptomatic intracerebral hemorrhage rates, and long-term recovery metrics, such as Barthel index and modified Rankin Scale scores, were comparable between both treatment approaches.

CONCLUSION

BT is superior to endovascular treatment alone based on NIHSS score improvement and successful reperfusion rates before and after thrombectomy. Despite MT alone demonstrating a shorter time from stroke onset to groin puncture (MD of 9.91 min), it did not contribute to greater NIHSS improvement at 24 h and 7 days. Further trials with larger sample sizes are warranted to enhance precision in clinical guidance.

A New Fibrin-Heparine Coated Self-Expanding Stent for the Rescue Treatment of Intracranial Stenosis-a Multicentric Study

INTRODUCTION

Rescue intracranial stenting is necessary to provide sufficient recanalization after mechanical thrombectomy (MT) in patients with acute large vessel occlusions (LVO) due to an underlying intracranial atherosclerotic disease (ICAD). The CREDO heal is a novel stent that provides a potentially lower thrombogenicity due to surface modification. We present the first multicentric experience with the CREDO heal for acute rescue stenting.

METHODS

Data of 81 patients who underwent rescue stenting after MT at 12 centers in Germany and Spain were prospectively collected and retrospectively evaluated.

RESULTS

Final mTICI 2b‑3 was reached in 95.1% after median two MT maneuvers and stenting. Four periprocedural complications resulted in clinical deterioration (4.9%). Intraparenchymal hemorrhage occurred in one patient (1.2%) and functional independence at FU was reached by 42% of the patients. Most interventions were performed under Gp IIb/IIIa inhibitors.

CONCLUSION

CREDO heal was effective and safe in our case series. However, more data is needed to define the optimal antithrombotic regime. The use under single antiplatelet medication is not supported by our study.

Trevo 3 Mm and/or AXS Catalyst 5 for the Treatment of Medium Distal Vessel Occlusion Stroke-results from the ASSIST Registry

BACKGROUND

The effect of endovascular therapy (EVT) on the outcome of stroke patients with a medium distal vessel occlusion (MDVO) is unclear. We report the results of MDVO patients treated with the 3 mm Trevo stent retriever (SR) and/or the AXS Catalyst 5 distal access catheter.

METHODS

Data was derived from a prospective, multicenter global registry (ASSIST registry) which enrolled patients treated with operator preferred EVT technique at 71 sites from January 2019 to January 2022. Three techniques were assessed: SR classic, direct aspiration, and a combined approach. Additional inclusion criteria were (a) EVT performed with the 3 mm Trevo SR and/or AXS Catalyst 5 distal access catheter on the first pass and (b) an occlusion of the M2 segment or M3 segment of the middle cerebral artery or the A1, A2 or A3 segment of the anterior cerebral artery. The primary outcome was achieving an expanded Thrombolysis in Cerebral Infarction (eTICI) score of 2c or 3 on the first pass, with the primary technique as adjudicated by core lab. The primary clinical outcome measure was a 90-day modified Rankin Scale (mRS) score of 0-2.

RESULTS

A total of 155 patients (10.4% of the ASSIST population) were included. Most patients had an M2 occlusion (93.5%). First pass eTICI reperfusion was achieved in 43.1% of the patients. No modifying effect of the frontline technique was found. The rate of mRS 0-2 (overall 65.0%) did not significantly differ between groups.

CONCLUSION

The data suggests that the Trevo 3 mm SR and/or the AXS Catalyst 5 may be an option to treat medium distal vessel occlusion, but more data is needed to demonstrate safety and efficacy in this patient cohort. Further improvements are needed regarding materials and techniques to improve reperfusion results in this patient cohort in the future.

Remote Teleproctoring with the TEGUS System for Mechanical Thrombectomy in a Non-Comprehensive Stroke Center: Initial Preliminary Data On Clinical Experience

PURPOSE

Mechanical thrombectomy (MT) is typically performed by experienced neurointerventional radiologists. However, logistical and geographic limitations often hinder access to rapid MT. This study reports the first clinical experience using TEGUS teleproctoring to support MT conducted by general interventional radiologists (IR) at non-comprehensive stroke centers, compared to on-site proctoring outcomes.

METHODS

The Arnau de Vilanova Hospital in Spain used to transfer stroke patients requiring MT to a comprehensive Stroke Center 160 km away. To overcome COVID-19 mobility restrictions, the Tegus Teleproctoring System was installed. Before teleproctoring, the general interventional radiologist underwent six months of neurointerventional training at a primary stroke center. From April 2021 to May 2023, general IR conducted MT either with on-site proctor supervision or teleproctoring support. We aim to compare clinical outcome of patients receiving MT according to proctoring method.

RESULTS

During the study, 49 MTs were performed: 15 with TEGUS teleproctoring and 34 with on-site proctoring. Both groups had similar baseline characteristics, except for NIHSS scores (Tegus 9 [IQR 6-20] vs 18 [IQR 12-22], p = 0.034). No significant differences were found in door-to-revascularization time (82 ± 28.2 vs 84 ± 26.4) min, p = (0.895). The final mTICI distribution and 90-day mRS scores were comparable after adjusting by stroke severity. There were no reports of symptomatic intracranial hemorrhage in either group.

CONCLUSION

This study shows the feasibility of Tegus remote teleproctoring during emergent cases of MT in a remote hospital. It could improve the learning curve of interventional radiologists with limited experience in MT, and lower the territorial inequity associated to MT.

Success with incrementally faster times to endovascular therapy (SWIFT-EVT): A systematic review and meta-analysis

BACKGROUND

A major systematic review and meta-analysis assessing trial data through 2014 (the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials, HERMES) demonstrated that particularly over the initial six hours of acute ischemic stroke (AIS), rapid performance of endovascular therapy (EVT) markedly improves outcomes. The current analysis, Success with Incrementally Faster Times to EVT (SWIFT-EVT), aimed to provide an updated metric summarizing latest estimates for modified Rankin Scale (mRS) improvements accrued by streamlining time to EVT.

METHODS

A systematic review and meta-analysis was conducted using electronic databases. Eligible studies reported a time-benefit slope with times from AIS onset (or time last known normal) to EVT commencement; the predictor was onset-to-groin (OTG) time. Primary and secondary outcomes were 90-day functional independence (mRS 0-2) and 90-day excellent function (mRS 0-1), respectively.

RESULTS

Five studies were included. Results showed increased change of good outcome with each hour of pre-EVT time savings for mRS 0-2 for 0-270' (OR 1.25, 95 % CI 1.16-1.35, I2 40 %) and 271-360' time frame (1.22, 95 % CI 1.12-1.33, I2 58 %). For the studies assessing mRS 0-1, estimates were found appropriate for both the 0-270' time frame (OR 1.34, 95 % CI 1.19-1.51, I2 27 %) and the 271-360' time frame (OR 1.20, 95 % CI 1.03-1.38, I2 60 %).

CONCLUSIONS

Each hour saved from AIS onset to EVT start is associated with a 22-25 % increased odds of achieving functional independence, a useful metric to inform patient-specific and systems planning decisions.

"Insights into vessel perforations during thrombectomy: Characteristics of a severe complication and the effect of thrombolysis"

INTRODUCTION

Thrombectomy complications remain poorly explored. This study aims to characterize periprocedural intracranial vessel perforation including the effect of thrombolysis on patient outcomes.

PATIENTS AND METHODS

In this multicenter retrospective cohort study, consecutive patients with vessel perforation during thrombectomy between January 2015 and April 2023 were included. Vessel perforation was defined as active extravasation on digital subtraction angiography. The primary outcome was modified Rankin Scale (mRS) at 90 days. Factors associated with the primary outcome were assessed using proportional odds models.

RESULTS

459 patients with vessel perforation were included (mean age 72.5 ± 13.6 years, 59% female, 41% received thrombolysis). Mortality at 90 days was 51.9% and 16.3% of patients reached mRS 0-2 at 90 days. Thrombolysis was not associated with worse outcome at 90 days. Perforation of a large vessel (LV) as opposed to medium/distal vessel perforation was independently associated with worse outcome at 90 days (aOR 1.709, p = 0.04) and LV perforation was associated with poorer survival probability (HR 1.389, p = 0.021). Patients with active bleeding >20 min had worse survival probability, too (HR 1.797, p = 0.009). Thrombolysis was not associated with longer bleeding duration. Bleeding cessation was achieved faster by permanent vessel occlusion compared to temporary measures (median difference: 4 min, p < 0.001).

DISCUSSION AND CONCLUSION

Vessel perforation during thrombectomy is a severe and frequently fatal complication. This study does not suggest that thrombolysis significantly attributes to worse prognosis. Prompt cessation of active bleeding within 20 min is critical, emphasizing the need for interventionalists to be trained in complication management.

Iron changes within infarct tissue in ischemic stroke patients after successful reperfusion quantified using QSM

PURPOSE

For nearly half of patients who undergo Endovascular Thrombectomy following ischemic stroke, successful recanalisation does not guarantee a good outcome. Understanding the underlying tissue changes in the infarct tissue with the help of biomarkers specific to ischemic stroke could offer valuable insights for better treatment and patient management decisions. Using quantitative susceptibility mapping (QSM) MRI to measure cerebral iron concentration, this study aims to track the progression of iron within the infarct lesion after successful reperfusion.

METHODS

In a prospective study of 87 ischemic stroke patients, successfully reperfused patients underwent MRI scans at 24-to-72 h and 3 months after reperfusion. QSM maps were generated from gradient-echo MRI images. QSM values, measured in parts per billion (ppb), were extracted from ROIs defining the infarct and mirror homolog in the contralateral hemisphere and were compared cross-sectionally and longitudinally.

RESULTS

QSM values in the infarct ROIs matched those of the contralateral ROIs at 24-to-72 h, expressed as median (interquartile range) ppb [0.71(-7.67-10.09) vs. 2.20(-10.50-14.05) ppb, p = 0.55], but were higher at 3 months [10.68(-2.30-21.10) vs. -1.27(-12.98-9.82) ppb, p < 0.001]. The infarct QSM values at 3 months were significantly higher than those at 24-to-72 h [10.41(-2.50-18.27) ppb vs. 1.68(-10.36-12.25) ppb, p < 0.001]. Infarct QSM at 24-to-72 h and patient outcome measured at three months did not demonstrate a significant association.

CONCLUSION

Following successful endovascular reperfusion, iron concentration in infarct tissue, as measured by QSM increases over time compared to that in healthy tissue. However, its significance warrants further investigation.

Predictors of favorable functional outcomes for elderly patients undergoing endovascular thrombectomy for acute ischemic stroke

PURPOSE

The aim of this study was to identify factors that predict favorable functional outcomes in elderly patients with large-vessel occlusion acute ischemic stroke (LVO-AIS) who underwent mechanical thrombectomy (MT).

METHODS

We conducted a retrospective observational study using the prospectively maintained Bigdata Observatory for Stroke of China (BOSC) to identify eligible patients who underwent MT for LVO-AIS at four comprehensive stroke centers between August 2019 and February 2022. Inclusion criteria included patients aged 80 years or older with a baseline modified Rankin Scale (mRS) 0-2, baseline National Institutes of Health Stroke Scale (NIHSS) > 6, baseline Alberta Stroke Program Early CT Score (ASPECTS) > 6 who received treatment within 24 h from symptom onset. Pertinent demographic, clinical, and procedural variables were collected. Multivariable regression analyses were performed to identify predictors of favorable long-term functional outcomes, defined as mRS 0-2 at 90 days.

RESULTS

A total of 63 patients were included in the study with a mean age of 83 years. Patients with previous diagnosis of atrial fibrillation were more likely to have a favorable functional outcome (OR 2.09, 95% CI 2.09-407.33, p = 0.012), while a higher baseline NIHSS was associated with a less favorable functional outcome (OR 0.64, 95% CI 0.46-0.89, p = 0.007). In addition, there was an observed trend suggesting an association between higher baseline ASPECTS and favorable functional outcomes. This association did not reach statistical significance (OR 2.49, 95% CI 0.94-6.54, p = 0.065).

CONCLUSION

In this study, we identified factors that predicted a favorable functional outcome in elderly LVO-AIS patients undergoing MT. A higher baseline NIHSS decreased the odds of mRS 0-2 at 90 days, whereas a history of atrial fibrillation increased the odds of a favorable functional outcome. These results emphasize the complex relationship between clinical factors and functional recovery in this vulnerable population.

Anaesthesia modality on endovascular therapy outcomes in patients with large infarcts: a post hoc analysis of the ANGEL-ASPECT trial

OBJECTIVES

Endovascular therapy (EVT) now penetrates the once obscure realm of large infarct core volume acute ischaemic stroke (LICV-AIS). This research aimed to investigate the potential correlation between different anaesthetic approaches and post-EVT outcomes in LICV-AIS patients.

METHODS

Between October 2020 and May 2022, the China ANGEL-Alberta Stroke Programme Early CT Score (ASPECT) trial studied patients with LICV-AIS, randomly assigning them to the best medical management (BMM) or BMM with EVT. This post hoc subgroup analysis categorised subjects receiving BMM with EVT into general anaesthesia (GA) and non-GA groups based on anaesthesia type. We applied multivariable logistic regression to evaluate the relationship between anaesthesia during EVT and patient functional outcomes, as measured by the modified Rankin scale (mRS), in addition to the occurrence of complications. Further adjustment for selection bias was achieved through propensity score matching (PSM).

RESULTS

In total, 230 patients with LICV-AIS were enrolled (GA 84 vs Non-GA 146). No significant difference was observed between the two groups in terms of the proportion of patients who achieved an mRS score of 0-2 at 90 days (27.4% for the GA group vs 31.5% for the non-GA group, p=0.51). However, the GA group had significantly longer median surgical times (142 min vs 122 min, p=0.03). Furthermore, GA was associated with an increased risk of postoperative pneumonia (adjusted OR 2.03, 95% CI 1.04 to 3.98). The results of PSM analysis agreed with the results of the multivariate regression analysis. No significant difference in intracranial haemorrhage incidence or mortality rate was observed between the groups.

CONCLUSION

This post hoc analysis of subgroups of the ANGEL-ASPECT trial suggested that there may be no significant association between the choice of anaesthesia and neurological outcomes in LICV-AIS patients. However, compared with non-GA, GA prolongs the duration of EVT and is associated with a greater postoperative pneumonia risk.

TRIAL REGISTRATION NUMBER

NCT04551664.

Trends in performance of thrombectomy for acute ischemic stroke patients in teaching and non-teaching hospitals

OBJECTIVES

The value of thrombectomy in patients with acute ischemic stroke cannot be understated. As such, whether these patients get access to this treatment can significantly impact their disease outcomes. We analyzed the trends in thrombectomy adoption between teaching and non-teaching hospitals in the United States, and their impact on overall patient care.

MATERIALS AND METHODS

We conducted a retrospective analysis of hospital admissions in the Nationwide Inpatient Sample with a diagnosis of acute ischemic stroke between 2012 and 2020. We compared the annual total number and proportion of patients undergoing thrombectomy between teaching and non-teaching hospitals, and their corresponding outcomes.

RESULTS

A total of 3,823,490 and 1,875,705 patients were admitted to teaching and non-teaching hospitals during the study duration, respectively. The proportion of patients who underwent thrombectomy increased from 1.60 % to 7.02 % (p-value for trend p < 0.001) in teaching hospitals and from 0.32 % to 2.20 % (p-value trend p < 0.001) in non-teaching hospitals. The absolute increase in the number of acute ischemic stroke patients undergoing thrombectomy was highest in teaching hospitals particularly those with large bed size, an increase from 3635 patients in 2012 to 24,730 patients in 2020. Higher rates of intravenous thrombolysis and patient transfer prior to thrombectomy were seen in teaching hospitals compared with non-teaching hospitals.

CONCLUSIONS

The study highlights disparities between teaching and non-teaching hospitals, with teaching hospitals showing a disproportionately higher rate of thrombectomy adoption in acute ischemic stroke patients. Further studies are needed to understand the barriers to the adoption of thrombectomy in non-teaching hospitals.

High plasma BNP concentration associates with clinical outcome after mechanical thrombectomy: Post hoc analysis of SKIP

OBJECTIVES

Heart failure may result in reduced brain perfusion, limiting the blood flow needed to achieve clinical recovery. We investigated whether plasma levels of brain natriuretic peptide (BNP), a biological marker of heart failure, were related to clinical outcomes after mechanical thrombectomy (MT).

MATERIALS AND METHODS

Data were analyzed from stroke patients with internal carotid or middle cerebral artery occlusion enrolled in the SKIP trial for whom plasma level of BNP was evaluated on admission. Favorable outcome was defined as a modified Rankin scale score of 0-2 at 3 months.

RESULTS

Among 169 patients (median age, 74 years; 62% men, median National Institutes of Health Stroke Scale score, 18), 104 (62%) achieved favorable outcomes. Median plasma BNP level was lower in the favorable outcome group (124.1 pg/mL; interquartile range [IQR], 62.1-215.5 pg/mL) than in the unfavorable outcome group (198.0 pg/mL; IQR, 74.8-334.0 pg/mL; p=0.005). In multivariate regression analysis, the adjusted odds ratio for BNP for favorable outcomes was 0.971 (95% confidence interval, 0.993-0.999; p=0.048). At 3 months after onset, the favorable outcome rate was lower in the ≥186 pg/mL group (45%) than in the <186 pg/mL group (72%; p=0.001). This significant difference remained regardless of the presence of atrial fibrillation (AF), with rates of 47% and 76%, respectively, in AF patients (p=0.003) and 33% and 68%, respectively, in patients without AF (p=0.046).

CONCLUSION

High plasma BNP concentration appears associated with unfavorable outcomes after MT.

Post-endovascular therapy contrast extravasation in the mesial temporal region on dual-energy CT is associated with outcome in acute ischemic stroke patients

PURPOSE

Pre- and post-endovascular treatment (EVT) imaging may aid in predicting functional outcomes in acute middle cerebral artery (MCA) ischemic stroke. Low post-EVT contrast extravasation (CE)-ASPECTS is associated with poor functional outcomes. Besides the MCA regions included in the ASPECTS score, CE may be seen in the mesial temporal (MT) region. In this study, we investigated the frequency and prognostic implication of MT-CE in acute ischemic stroke patients.

METHODS

Patients with an acute ischemic stroke due to anterior large vessel occlusion who received EVT and post-EVT DECT between 2010 and 2019 were included. Iodine overlay maps of DECT were assessed for the occurrence of CE, using the ASPECTS for occurrence in the MCA region and, calculating a CE-ASPECTS, for whether the MT region was involved. Multivariable linear and logistic regression were used to assess the relationship between involvement of MT-CE and 24-48h NIHSS, mRS, and mortality on a multiple imputed dataset. All models were adjusted significant variables in univariate analyses and for total CE-ASPECTS.

RESULTS

501/651 patients met the inclusion criteria. MT-CE occurred in 97 (19 %) patients, and was more often present in patients with internal carotid artery occlusions. MT-CE was associated with higher NIHSS scores at 24-hours (aβ 2.2, 95 % CI 0.09-4.31), with increased risk of higher mRS scores (acOR 1.88, 95 % CI 1.16-3.06), and with increased risk of mortality (aOR 2.12, 95 % CI 1.16-3.86).

CONCLUSION

MT-CE is a common finding on post-EVT DECT and is an independent predictor for worse functional outcomes.

Role of intracranial bone marrow mesenchymal stem cells in stroke recovery: A focus on post-stroke inflammation and mitochondrial transfer

Stem cell therapy has become a hot research topic in the medical field in recent years, with enormous potential for treating a variety of diseases. In particular, bone marrow mesenchymal stem cells (BMSCs) have wide-ranging applications in the treatment of ischemic stroke, autoimmune diseases, tissue repair, and difficult-to-treat diseases. BMSCs can differentiate into multiple cell types and exhibit strong immunomodulatory properties. Although BMSCs can regulate the inflammatory response activated after stroke, the mechanism by which BMSCs regulate inflammation remains unclear and requires further study. Recently, stem cell therapy has emerged as a potentially effective approach for enhancing the recovery process following an ischemic stroke. For example, by regulating post-stroke inflammation and by transferring mitochondria to exert therapeutic effects. Therefore, this article reviews the therapeutic effects of intracranial BMSCs in regulating post-stroke inflammation and mitochondrial transfer in the treatment of stroke, providing a basis for further research.

Trends and Progress in Neuroendovascular Treatment in Japan: Japanese Registry of Neuroendovascular Therapy (JR-NET) 4. Main Report

We reported the main results of the Japanese Registry of Neuroendovascular Therapy (JR-NET) 4, a nationwide surveillance of therapy (NET) in Japan from January 2015 to December 2019. JR-NET 4 registered consecutive patients who underwent NETs by Japan Society of Neuroendovascular Therapy (JSNET) -certified specialists. The primary endpoint was functional independence (mRS score of 0-2) at 30 days post-NET, with secondary endpoints focusing on technical success and major adverse events within 30 days.A total of 63,230 patients and 60,354 NET procedures from 166 participating centers were analyzed. During the study period, NET cases have consistently increased, with an increase in the proportion of elderly patients. A significant trend shift was observed in the distribution of NET procedures, with endovascular treatment for acute ischemic stroke that showed a dramatic increase in 5 years. This trend aligns with key randomized clinical trials from 2015 that presented the efficacy of this treatment. Clinical outcomes at 30 days posttreatment revealed that endovascular treatment for acute ischemic stroke and other NETs maintained safety and effectiveness despite varying prevalence of functional independence between target diseases. The study also observed a steady increase in emergency treatment cases, reflecting the increase in acute ischemic stroke, a time-sensitive medical condition.This comprehensive surveillance highlights the trend of NET practices in Japan, driven by clinical evidence and advancements in treatment devices. Although these findings were specific to Japan, they offer valuable insights into the broader trends in NETs and acute stroke care.

Stent Retriever AssIsted Lysis Technique with Tirofiban: A Potential Bailout Alternative to Angioplasty and Stenting

BACKGROUND AND PURPOSE

Angioplasty and stent placement have been described as a bailout technique in individuals with failed thrombectomy. We aimed to investigate Stent retriever AssIsted Lysis (SAIL) with tirofiban before angioplasty and stent placement.

MATERIALS AND METHODS

Patients from 2 comprehensive stroke centers were reviewed (2020-2023). We included patients with failed thrombectomy and/or underlying intracranial stenosis who received SAIL with tirofiban before the intended angioplasty and stent placement. SAIL consisted of deploying a stent retriever through the occluding lesion to create a bypass channel and infuse 10 mL of tirofiban for 10 minutes either intra-arterially or IV. The stent retriever was re-sheathed before retrieval. The primary end points were successful reperfusion (expanded TICI 2b-3) and symptomatic intracerebral hemorrhage. Additional end points included 90-day mRS 0-2 and mortality.

RESULTS

After a median of 3 (interquartile range, 2-4) passes, 44 patients received the SAIL bridging protocol with tirofiban, and later they were considered potential candidates for angioplasty and stent placement bailout (43.2%, intra-arterial SAIL). Post-SAIL successful reperfusion was obtained in 79.5%. A notable residual stenosis (>50%) after successful SAIL was observed in 45.7%. No significant differences were detected according to post-SAIL: successful reperfusion (intra-arterial SAIL, 80.0% versus IV-SAIL, 78.9%; P = .932), significant stenosis (33.3% versus 55.0%; P = .203), early symptomatic re-occlusion (0% versus 8.0%; P = .207), or symptomatic intracerebral hemorrhage (5.3% versus 8.0%; P = .721). Rescue angioplasty and stent placement were finally performed in 15 (34.1%) patients (intra-arterial SAIL 21.0% versus IV-SAIL 44%; P = .112). At 90 days, mRS 0-2 (intra-arterial SAIL 50.0% versus IV-SAIL 43.5%; P = .086) and mortality (26.3% versus 12.0%; P = .223) were also similar.

CONCLUSIONS

In patients with stroke in which angioplasty and stent placement are considered, SAIL with tirofiban, either intra-arterial or IV, seems to safely induce sustained recanalization, offering a potential alternative to definitive angioplasty and stent placement.

Should they stay or should they go? Stroke transfers across a hospital network pre- and post-implementation of an automated image interpretation and communication platform

BACKGROUND

A key decision facing nonthrombectomy capable (spoke) hospitals is whether to transfer a suspected large vessel occlusion (LVO) patient to a comprehensive stroke center (CSC). In a retrospective cohort study, we investigated the rate of transfers resulting in endovascular thrombectomy (EVT) and associated costs before and after implementation of an artificial intelligence (AI)-based software.

METHODS

All patients with a final diagnosis of acute ischemic stroke presenting across a five-spoke community hospital network in affiliation with a CSC were included. The Viz LVO (Viz.ai, Inc.) software was implemented across the spokes with image sharing and messaging between providers across sites. In a cohort of patients before (pre-AI, December 2018-October 2020) and after (post-AI, October 2020-August 2022) implementation, we compared the EVT rate among ischemic stroke patients transferred out of our health system to the CSC. Secondary outcomes included the EVT rate based on spoke computed tomography angiography (CTA) and estimated transfer costs.

RESULTS

A total of 3113 consecutive eligible patients (mean age 71 years, 50% female) presented to the spoke hospitals with 162 transfers pre-AI and 127 post-AI. The rate of transfers treated with EVT significantly increased (32.1% pre-AI vs. 45.7% post-AI, p = 0.02). There was a sharp increase in CTA use post-AI at the spoke hospitals for all patients and transfers that likely contributed to the increased EVT transfer rate, but prior spoke CTA use alone was not sufficient to account for all improvement in EVT transfer rate (37.2% pre-AI vs. 49.2% post-AI, p = 0.12). In a binary logistic regression model, the odds of an EVT transfer in the intervention period were 1.85 greater as compared to preintervention (adjusted odds ratio 1.85, 95% confidence interval 1.12-3.06). The decrease in non-EVT transfers resulted in an estimated annual benefit of $206,121 in spoke revenue and $119,921 in payor savings (all US dollars).

CONCLUSIONS

The implementation of an automated image interpretation and communication platform was associated with increased CTA use, more transfers treated with EVT, and potential economic benefits.

Endovascular therapy in acute ischemic stroke with poor reperfusion is associated with worse outcomes compared with best medical management: a HERMES substudy

BACKGROUND

Functional outcomes in patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO) undergoing endovascular treatment (EVT) with poor reperfusion were compared with patients with AIS-LVO treated with best medical management only.

METHODS

Data are from the HERMES collaboration, a patient-level meta-analysis of seven randomized EVT trials. Baseline characteristics and functional outcomes (modified Rankin Scale (mRS) score at 90 days) were compared between patients with poor reperfusion (defined as modified Thrombolysis in Cerebral Infarction Score 0-1 on the final intracranial angiography run as assessed by the central imaging core laboratory) and patients in the control arm with multivariable logistic ordinal logistic regression adjusted for pre-specified baseline variables.

RESULTS

972 of 1764 patients from the HERMES collaboration were included in the analysis: 893 in the control arm and 79 in the EVT arm with final mTICI 0-1. Patients with poor reperfusion who underwent EVT had higher baseline National Institutes of Health Stroke Scale than controls (median 19 (IQR 15.5-21) vs 17 (13-21), P=0.011). They also had worse mRS at 90 days compared with those in the control arm in adjusted analysis (median 4 (IQR 3-6) vs median 4 (IQR 2-5), adjusted common OR 0.59 (95% CI 0.38 to 0.91)). Symptomatic intracranial hemorrhage was not different between the two groups (3.9% vs 3.5%, P=0.75, adjusted OR 0.94 (95% CI 0.23 to 3.88)).

CONCLUSION

Poor reperfusion after EVT was associated with worse outcomes than best medical management, although no difference in symptomatic intracranial hemorrhage was seen. These results emphasize the need for additional efforts to further improve technical EVT success rates.

Basilar artery occlusion management: An international survey of gender influence on management

BACKGROUND

The superiority of endovascular thrombectomy (EVT) over medical management was not established in two early basilar artery occlusion (BAO) randomized controlled trials. Despite this, many clinicians recommended EVT for acute BAO under certain circumstances. This paper aims to compare physicians' diagnostic and management strategies of BAO according to gender.

METHODS

From January to March 2022 an international survey was conducted regarding management strategies in acute BAO. We compared responses between clinicians by identifying gender. Questions were designed to examine clinical and imaging parameters influencing management of patients with BAO.

RESULTS

Among the 1245 respondents from 73 countries, 311 (25.0%) identified as female. This figure was 13.6% amongst interventionists. Geographically, female respondents were lowest in Asia (14.5%) and North America (23.9%). The proportion of respondents identifying as female was consistent regardless of their years of experience. Female respondents were more likely to choose time of onset as time of first estimated stroke like symptom (48.0% vs. 38.5%, p < .01), were less likely to favor thrombectomy in the V4 segment of vertebrobasilar artery occlusions (31.5% vs. 43.3%, p < .01), and were less likely to find it acceptable to enroll all patients who met trial criteria in the standard medical treatment arm of a clinical trial (41.2% vs. 47.0%, p = .01). Male respondents were more likely to agree that thrombolysis would not alter their decision on proceeding with EVT (93.7% vs. 88.3%, p < .01).

CONCLUSIONS

Female clinicians appear to be significantly underrepresented in stroke medicine. This is most pronounced amongst interventionists and in Asia. Although male and female opinions were closely aligned on many aspects of BAO management, differences in opinion were observed in a number of significant areas which influence decision making.

European Stroke Organisation (ESO) and European Society for Minimally Invasive Neurological Therapy (ESMINT) guideline on acute management of basilar artery occlusion

The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology.Although BAO accounts for only 1-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five representing the European Society of Minimally Invasive Neurological Therapy (ESMINT)) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements.First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (although in small numbers) in IVT trials. Non-randomized studies of IVT-only cohorts showed a high proportion of favorable outcomes. Expert Consensus suggests using IVT up to 24 hours unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared with BMT alone within 6 and 6-24 hours from last seen well. In both time windows, we observed a different effect of treatment depending on a) the region where the patients were treated (Europe vs Asia), b) on the proportion of IVT in the BMT arm, and c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with a National Institutes of Health Stroke Scale (NIHSS) score below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT+BMT over BMT alone (this is based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS score below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT+BMT over BMT alone in proximal and middle locations of BAO compared with distal location. While recommendations for patients without extensive early ischemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 hours after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty).

Clinical and radiographic outcomes after mechanical thrombectomy in medium-vessel posterior cerebral artery occlusions: Subgroup analysis from STAR

BACKGROUND

Whereas mechanical thrombectomy (MT) has become standard-of-care treatment for patients with salvageable brain tissue after acute stroke caused by large-vessel occlusions, the results of MT in patients with medium-vessel occlusions (MEVOs), particularly in the posterior cerebral artery (PCA), are not well known.

METHODS

Using data from the international Stroke Thrombectomy and Aneurysm Registry (STAR), we assessed presenting characteristics and clinical outcomes for patients who underwent MT for primary occlusions in the P2 PCA segment. As a subanalysis, we compared the PCA MeVO outcomes with STAR's anterior circulation MeVO outcomes, namely middle cerebral artery (MCA) M2 and M3 segments.

RESULTS

Of the 9812 patients in STAR, 43 underwent MT for isolated PCA MeVOs. The patients' median age was 69 years (interquartile range 61-79), and 48.8% were female. The median NIH Stroke Scale score was 9 (range 6-17). After recanalization, 67.4% of patients achieved successful recanalization (modified treatment in cerebral infarction score [mTICI] ≥ 2b), with a first-pass success rate of 44.2%, and 39.6% achieved a modified Rankin score of 0-2 at 90 days. Nine patients (20.9%) had died by the 90-day follow-up. In comparison with M2 and M3 MeVOs, there were no differences in presenting characteristics among the three groups. Patients with PCA MeVOs were less likely to undergo intra-arterial thrombolysis (4.7% PCA vs. 10.1% M2 vs. 16.2% M3, p = 0.046) or to achieve successful recanalization (mTICI ≥ 2b, 67.4%, 86.7%, 82.3%, respectively, p < 0.001); however, there were no differences in the rates of successful first-pass recanalization (44.2%, 49.8%, 52.3%, respectively, p = 0.65).

CONCLUSIONS

We describe the STAR experience performing MT in patients with PCA MeVOs. Our analysis supports that successful first-pass recanalization can be achieved in PCA MEVOs at a rate similar to that in MCA MeVOs, although further study and possible innovation may be necessary to improve successful PCA MeVO recanalization rates.

Endovascular treatment effect in vertebrobasilar artery occlusion patients with posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) <6

BACKGROUND

Endovascular treatment (EVT) has revolutionized the standard treatment of vertebrobasilar artery occlusion (VBAO) with moderate infarct core, but its effectiveness in patients with a low posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) is unclear. This study aimed to assess EVT effects in VBAO patients with pc-ASPECTS <6.

METHODS

This retrospective study enrolled patients with VBAO within 24 hours of the estimated occlusion time at 65 stroke centers in a nationwide registration in China. The primary outcome was a favorable shift in the modified Rankin Scale (mRS) at 90 days. The secondary outcomes included a favorable outcome (mRS 0-3) and functional independence (mRS 0-2). Propensity score matching and inverse probability of treatment weighting were used to compare the outcomes of patients treated with EVT and those with best medical management.

RESULTS

A total of 431 patients with VBAO and pc-ASPECTS <6 were included. EVT was associated with a favorable shift in the mRS score at 90 days (OR 1.72, 95% CI 1.19 to 2.5), a higher probability of a favorable outcome (OR 1.66, 95% CI 1.02 to 2.74), and improved functional independence (OR 1.76, 95% CI 1.06 to 2.96). EVT also significantly reduced the risk of 90-day mortality (OR 0.62, 95% CI 0.40 to 0.96), but increased the risk of symptomatic intracranial hemorrhage (OR 2.76, 95% CI 1.06 to 8.58).

CONCLUSION

The results of this study suggest that EVT may be a safe and effective treatment option for patients with VBAO and pc-ASPECTS <6. Further studies are needed to investigate the effect of EVT in patients with pc-ASPECTS <6 and to identify patients who may benefit from EVT.

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.

Acute myocardial infarction and ischaemic stroke: differences and similarities in reperfusion therapies-a review

Acute ST-elevation myocardial infarction (STEMI) and acute ischaemic stroke (AIS) share a number of similarities. However, important differences in pathophysiology demand a disease-tailored approach. In both conditions, fast treatment plays a crucial role as ischaemia and eventually infarction develop rapidly. Furthermore, in both fields, the introduction of fibrinolytic treatments historically preceded the implementation of endovascular techniques. However, in contrast to STEMI, only a minority of AIS patients will eventually be considered eligible for reperfusion treatment. Non-invasive cerebral imaging always precedes cerebral angiography and thrombectomy, whereas coronary angiography is not routinely preceded by non-invasive cardiac imaging in patients with STEMI. In the late or unknown time window, the presence of specific patterns on brain imaging may help identify AIS patients who benefit most from reperfusion treatment. For STEMI, a uniform time window for reperfusion up to 12 h after symptom onset, based on old placebo-controlled trials, is still recommended in guidelines and generally applied. Bridging fibrinolysis preceding endovascular treatment still remains the mainstay of reperfusion treatment in AIS, while primary percutaneous coronary intervention is the strategy of choice in STEMI. Shortening ischaemic times by fine-tuning collaboration networks between ambulances, community hospitals, and tertiary care hospitals, optimizing bridging fibrinolysis, and reducing ischaemia-reperfusion injury are important topics for further research. The aim of this review is to provide insights into the common as well as diverging pathophysiology behind current reperfusion strategies and to explore new ways to enhance their clinical benefit.

Rapid Assay Diagnostic for Acute Stroke Recognition (RADAR): study protocol for a diagnostic accuracy study

INTRODUCTION

Large-vessel occlusion (LVO) stroke is effectively treated by time-critical thrombectomy, a highly specialised procedure only available in a limited number of centres. Many patients with suspected stroke are admitted to their nearest hospital and require transfer to access treatment, with resulting delays. This study is evaluating the accuracy of a new rapid portable test for LVO stroke which could be used in the future to select patients for direct admission to a thrombectomy centre.

METHODS AND ANALYSIS

Rapid Assay Diagnostic for Acute Stroke Recognition (RADAR) is a prospective observational cohort study taking place in stroke units in England. Participants are adults with a new suspected stroke with at least one face, arm or speech (FAST) symptom(s) and known onset within 6 hours or last known to be well 6-24 hours ago. The index test ('LVOne test' (Upfront Diagnostics)), consists of two portable lateral flow assays which use fingerprick capillary blood to detect d-dimer and glial fibrillary acidic protein concentrations. Reference standards comprise independently adjudicated standard CT/MRI brain±CT/MR angiography with senior clinician opinion to establish: ischaemic stroke±LVO; intracerebral haemorrhage; transient ischaemic attack; stroke mimic. Analyses will report sensitivity, specificity and negative and positive predictive values for identification of LVO stroke. Powered using a primary analysis population (≥2 FAST symptoms and known onset within 6 hours), 276 participants will detect a test specificity of 92%. The broader total study population which allows evaluation of the test for milder symptoms and unknown onset times is estimated to be 552 participants.

ETHICS AND DISSEMINATION

Ethical (North East-Newcastle & North Tyneside 2 Research Ethics Committee (reference: 23/NE/0043), Health Research Authority and participating National Health Service Trust approvals are granted. Consent is required for enrolment. Dissemination of results will include presentations at conferences, publication in journals and plain English summaries.

TRIAL REGISTRATION NUMBER

ISRCTN12414986.

Normative connectome-based analysis of sensorimotor deficits in acute subcortical stroke

The interrelation between acute ischemic stroke, persistent disability, and uncertain prognosis underscores the need for improved methods to predict clinical outcomes. Traditional approaches have largely focused on analysis of clinical metrics, lesion characteristics, and network connectivity, using techniques such as resting-state functional magnetic resonance imaging (rs-fMRI) and diffusion tensor imaging (DTI). However, these methods are not routinely used in acute stroke diagnostics. This study introduces an innovative approach that not only considers the lesion size in relation to the National Institutes of Health Stroke Scale (NIHSS score), but also evaluates the impact of disrupted fibers and their connections to cortical regions by introducing a disconnection value. By identifying fibers traversing the lesion and estimating their number within predefined regions of interest (ROIs) using a normative connectome atlas, our method bypasses the need for individual DTI scans. In our analysis of MRI data (T1 and T2) from 51 patients with acute or subacute subcortical stroke presenting with motor or sensory deficits, we used simple linear regression to assess the explanatory power of lesion size and disconnection value on NIHSS score. Subsequent hierarchical multiple linear regression analysis determined the incremental value of disconnection metrics over lesion size alone in relation to NIHSS score. Our results showed that models incorporating the disconnection value accounted for more variance than those based solely on lesion size (lesion size explained 44% variance, disconnection value 60%). Furthermore, hierarchical regression revealed a significant improvement (p < 0.001) in model fit when adding the disconnection value, confirming its critical role in stroke assessment. Our approach, which integrates a normative connectome to quantify disconnections to cortical regions, provides a significant improvement in assessing the current state of stroke impact compared to traditional measures that focus on lesion size. This is achieved by taking into account the lesion's location and the connectivity of the affected white matter tracts, providing a more comprehensive assessment of stroke severity as reflected in the NIHSS score. Future research should extend the validation of this approach to larger and more diverse populations, with a focus on refining its applicability to clinical assessment and long-term outcome prediction.

A systematic review of the socioeconomic impact of mechanical thrombectomy for acute ischemic stroke

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.

Bridging thrombolysis before endovascular therapy is associated with better outcomes in patients with large infarction core

BACKGROUND

This study investigates the efficacy and safety of bridging intravenous thrombolysis (IVT) before endovascular therapy (EVT) compared with EVT alone in patients with large infarction core.

METHODS

We conducted a comprehensive search of PubMed, EMBASE, and the Cochrane Library from January 2015 to June 2024. Included studies involved patients with acute ischemic stroke with an Alberta Stroke Program Early CT Score of ≤5 or an ischemic core volume of ≥50 mL. Studies were required to provide either 90-day modified Rankin Scale (mRS) score, reperfusion, symptomatic intracranial hemorrhage (sICH), or 90-day mortality.

RESULTS

Nine observational studies with 2641 patients were analyzed. The IVT+EVT group had a higher rate of 90-day functional independence (mRS 0-2; OR 1.56, 95% CI 1.31 to 1.87; adjusted OR (aOR) 1.43, 95% CI 1.21 to 1.68) and 90-day functional outcome (mRS 0-3; OR 1.34, 95% CI 1.11 to 1.62; aOR 1.18, 95% CI 1.02 to 1.37) compared with EVT alone. There was no significant difference in successful reperfusion (OR 1.01, 95% CI 0.62 to 1.64; aOR 1.07, 95% CI 0.74 to 1.54) and 90-day mortality (OR 0.86, 95% CI 0.73 to 1.02; aOR 0.89, 95% CI 0.77 to 1.04) between the two groups. Moreover, patients who received IVT+EVT had a higher rate of sICH (OR 1.30, 95% CI 1.03 to 1.64; aOR 2.21, 95% CI 1.22 to 4.01).

CONCLUSIONS

In patients with large infarction core, bridging IVT before EVT is associated with favorable functional outcomes compared with EVT, even though bridging therapy entails a higher risk of sICH. Further trials are needed to confirm these findings.

Estimating the replicability of highly cited clinical research (2004-2018)

INTRODUCTION

Previous studies about the replicability of clinical research based on the published literature have suggested that highly cited articles are often contradicted or found to have inflated effects. Nevertheless, there are no recent updates of such efforts, and this situation may have changed over time.

METHODS

We searched the Web of Science database for articles studying medical interventions with more than 2000 citations, published between 2004 and 2018 in high-impact medical journals. We then searched for replications of these studies in PubMed using the PICO (Population, Intervention, Comparator and Outcome) framework. Replication success was evaluated by the presence of a statistically significant effect in the same direction and by overlap of the replication's effect size confidence interval (CIs) with that of the original study. Evidence of effect size inflation and potential predictors of replicability were also analyzed.

RESULTS

A total of 89 eligible studies, of which 24 had valid replications (17 meta-analyses and 7 primary studies) were found. Of these, 21 (88%) had effect sizes with overlapping CIs. Of 15 highly cited studies with a statistically significant difference in the primary outcome, 13 (87%) had a significant effect in the replication as well. When both criteria were considered together, the replicability rate in our sample was of 20 out of 24 (83%). There was no evidence of systematic inflation in these highly cited studies, with a mean effect size ratio of 1.03 [95% CI (0.88, 1.21)] between initial and subsequent effects. Due to the small number of contradicted results, our analysis had low statistical power to detect predictors of replicability.

CONCLUSION

Although most studies did not have eligible replications, the replicability rate of highly cited clinical studies in our sample was higher than in previous estimates, with little evidence of systematic effect size inflation. This estimate is based on a very select sample of studies and may not be generalizable to clinical research in general.

Extending mechanical thrombectomy service provision to 24/7: a break-even analysis

BACKGROUND

Comprehensive stroke centres across England have developed investment proposals, showing the estimated increases in mechanical thrombectomy (MT) treatment volume that would justify extending the standard hours to a 24/7 service provision. These investment proposals have been developed taking a financial accounting perspective, that is by considering the financial revenues from tariff income. However, given the pressure put on local health authorities to provide value for money services, an affordability question emerges. That is, at what additional MT treatment volume the additional treatment costs are offset by the additional health economic benefits, that is quality-adjusted life years (QALYs) and societal cost savings, generated by administering MT compared to standard care.

METHODS

A break-even analysis was conducted to identify the additional MT treatment volume required. The incremental hospital-related costs associated with the 24/7 MT extension were estimated using information and parameters from four relevant business cases. The additional societal cost savings and health benefits were estimated by adapting a previously developed Markov chain-based model.

RESULTS

The additional hospital-related annual costs for extending MT to a 24/7 service were estimated at a mean of £3,756,818 (range £1,847,387 to £5,092,788). On average, 750 (range 246 to 1,571) additional eligible stroke patients are required to be treated with MT yearly for the proposed 24/7 service extension to be affordable from a health economic perspective. Overall, the additional facility and equipment costs associated with the 24/7 extension would affect this estimate by 20%.

CONCLUSIONS

These findings support the ongoing debate regarding the optimal levels of MT treatment required for a 24/7 extension and respective changes in hospital organisational activities. They also highlight a need for a regional-level coordination between local authorities and hospital administrations to ensure equity provision in that stroke patients can benefit from MT and that the optimal MT treatment volume is reached. Future studies should contemplate reproducing the presented analysis for different health service provision settings and decision making contexts.

Evaluation of the knowledge, attitude and practice towards ischaemic stroke among healthcare workers in neurology and neurosurgery department: a cross-sectional study in Shaanxi province, China

OBJECTIVES

Healthcare workers play an important role in the timely recognition and treatment of patients who had an ischaemic stroke. However, their knowledge, attitude and practice (KAP) towards ischaemic stroke have not been well studied. This study aimed to assess the KAP towards ischaemic stroke among healthcare workers in the neurology and neurosurgery department in Shaanxi province, China.

DESIGN

Cross-sectional study.

SETTING

Medical centres in Shaanxi province.

PARTICIPANTS

Healthcare workers in the neurology and neurosurgery department at Shaanxi province.

PRIMARY AND SECONDARY OUTCOME MEASURES

Demographic characteristics and KAP towards ischaemic stroke were collected by a self-designed questionnaire.

RESULTS

A total of 259 (96.6%) valid questionnaires were collected. Their mean KAP scores were 19.56±3.72 (total score: 23), 36.56±3.56 (total score: 40) and 27.45±3.00 (total score: 30), respectively. Multivariate logistic regression analysis demonstrated that education (bachelor's degree or above vs college or below: OR=2.704 (1.286-5.685), p=0.009), gender (female vs male: OR=0.401 (0.227-0.710), p=0.002) and professional title (intermediate vs no title: OR=0.280 (0.107-0.731), p=0.009) were independently associated with good knowledge; knowledge score (OR=1.266 (1.157-1.387), p<0.001) and hospital (private hospital vs public hospital: OR=0.544 (0.313-0.944), p=0.030) were independently associated with good attitude; and attitude score (OR=1.480 (1.326-1.652), p<0.001), gender (female vs male: OR=0.511 (0.264-0.993), p=0.047) and occupation (other healthcare workers vs physicians: OR=0.252 (0.129-0.495), p<0.001) were independently associated with good practice.

CONCLUSION

The healthcare workers in the neurology and neurosurgery department demonstrated a satisfactory KAP towards ischaemic stroke. Targeted and tailored training programmes might be an optional way to improve their practice.

Revascularization Therapies for Ischemic Stroke and Association With Risk of Epilepsy: A Danish Nationwide Register-Based Study

BACKGROUND

The association between stroke revascularization therapies and poststroke epilepsy is only sparsely investigated, and results are conflicting. The aim of this study is to investigate whether stroke revascularization therapies are associated with different risks of poststroke epilepsy.

METHODS AND RESULTS

We conducted a nationwide, register-based, propensity score-matched cohort study. We identified 40 816 patients admitted with a first ischemic stroke and no prior history of epilepsy in Denmark between January 1, 2011, and December 16, 2018. Of these, 6541 were treated with thrombolysis, 379 with thrombectomy, and 1005 with both thrombolysis and thrombectomy. The 3 treatment groups were each matched 1:1 to patients with stroke not treated with revascularization. Exact matching was done for sex, while propensity scores included information on stroke severity, cortical involvement, age, comorbidities, and socioeconomic parameters. Outcome was any diagnosis of epilepsy. We used Cox regressions to estimate adjusted hazard ratios (HRs) of epilepsy after ischemic stroke. Compared with matched patients with ischemic stroke not receiving revascularization treatment, patients who received thrombolysis alone had 32% lower risk of epilepsy (adjusted HR, 0.68 [95% CI, 0.57-0.81]) and patients who received thrombolysis and thrombectomy had 45% lower risk of epilepsy (adjusted HR, 0.55 [95% CI, 0.41-0.73]). Thrombectomy alone was not associated with significantly lower risk of epilepsy compared with matched patients with ischemic stroke not receiving revascularization therapy (adjusted HR, 0.78 [95% CI, 0.57-1.29]).

CONCLUSIONS

Thrombolysis alone and in combination with thrombectomy in ischemic stroke was associated with lower risk of epilepsy, whereas thrombectomy alone was not associated with lower risk of epilepsy.

Ensemble machine learning to predict futile recanalization after mechanical thrombectomy based on non-contrast CT imaging

OBJECTIVES

Despite successful recanalization after Mechanical Thrombectomy (MT), approximately 25 % of patients with Acute Ischemic Stroke (AIS) due to Large Vessel Occlusion (LVO) show unfavorable clinical outcomes, namely Futile Recanalization (FR). We aimed to use a Machine Learning (ML) Non-Contrast brain CT (NCCT) imaging predictive model to identify FR in patients undergoing MT.

MATERIALS & METHODS

Between July 2022 and December 2022, 70 consecutive patients with LVO undergoing a complete recanalization (eTICI 3) with MT within 8 h from onset at our Centre were analyzed. Two NCCT images per patient of middle cerebral artery vascular territory and patients' clinical characteristics were classified by the presence of ischemic features on 24 h NCCT after MT. Each slice was segmented with "Mazda" software ver.4.6 by placing a Region Of Interest (ROI) on the whole brain by two radiologists in consensus. A total of 381 features were extracted for each slice. The dataset was split into train and test set with a 70:30 ratio.

RESULTS

Eleven classification models were trained. An Ensemble Machine Learning (EML) model was obtained by averaging the predictions of models with accuracy on a test set >70 %, with and without patients' clinical characteristics. The EML model combined with clinical data showed an accuracy of 0.76, a sensitivity of 0.88, a specificity of 0.69 with a NPV of 0.90, a PPV of 0.64, with AUC of 0.84.

CONCLUSION

NCCT and ML analysis shows promise in predicting FR after complete recanalization following MT in AIS patients. Larger studies are required to confirm these preliminary results.

Intracranial artery calcification: Frequency, determinants, and modification of outcomes from endovascular thrombectomy

INTRODUCTION

Intracranial artery calcification (ICAC) is a common finding on computed tomography (CT) in patients presenting with large vessel occlusion acute ischemic stroke (LVO-AIS) and could serve as a useful biomarker of intracranial atherosclerosis and altered intracranial vessel pliability in patients undergoing endovascular thrombectomy (EVT).

METHODS

This was a retrospective cohort study analyzing consecutive patients undergoing CT head prior to EVT between 2016 and 2020. Extent of ICAC proximal to the target vessel was scored using a validated grading scale examining thickness and circumferential extent of calcifications. The relationship between 3 levels of ICAC burden and procedural, clinical, and safety outcomes was analyzed.

RESULTS

Among 86 patients meeting inclusion criteria, ICAC of any degree was present in 72.1 %. Median ICAC score was 3 [IQR 0-4]. There was a U-shaped association between ICAC score and successful reperfusion: 90.9 %, 65.7 %, and 94.4 % in the low, intermediate, and high ICAC score groups, respectively (p = 0.008). Use of rescue intervention, most often angioplasty and stenting, was greatest in the high ICAC score group: 3.0 % vs. 5.7 % vs. 22.2 % (p = 0.05). Functional independence at 90 days did not differ significantly among groups (41.7 % vs. 31.0 % vs. 15.4 %, p = 0.26), nor did rates of symptomatic intracranial hemorrhage (15.2 % vs. 14.3 % vs. 16.7 %, p = 0.97).

CONCLUSIONS

ICAC is seen on CT in nearly three-quarters of patients with LVO-AIS. Extent of ICAC has a U-shaped association with successful reperfusion, in part due to more frequent use of rescue interventions in patients with extensive ICAC.

Impact of intensive blood pressure lowering after multiple-attempt endovascular thrombectomy: A secondary analysis of the OPTIMAL-BP trial

BACKGROUND

Multiple attempts of thrombectomy have been linked to a higher risk of intracerebral hemorrhage and worsened functional outcomes, potentially influenced by blood pressure (BP) management strategies. Nonetheless, the impact of intensive BP management following successful recanalization through multiple attempts remains uncertain.

AIMS

This study aimed to investigate whether conventional and intensive BP managements differentially affect outcomes according to multiple-attempt recanalization (MAR) and first-attempt recanalization (FAR) groups.

METHODS

In this secondary analysis of the OPTIMAL-BP trial, which was a comparison of intensive (systolic BP target: <140 mm Hg) and conventional (systolic BP target = 140-180 mm Hg) BP managements during the 24 h after successful recanalization, we included intention-to-treat population of the trial. Patients were divided into the MAR and the FAR groups. We examined a potential interaction between the number of thrombectomy attempts (MAR and FAR groups) and the effect of BP managements on clinical and safety outcomes. The primary outcome was functional independence at 3 months. Safety outcomes were symptomatic intracerebral hemorrhage within 36 h and mortality within 3 months.

RESULTS

Of the 305 patients (median = 75 years), 102 (33.4%) were in the MAR group and 203 (66.6%) were in the FAR group. The intensive BP management was significantly associated with a lower rate of functional independence in the MAR group (intensive, 32.7% vs conventional, 54.9%, adjusted odds ratio (OR) = 0.33, 95% confidence interval (CI) = 0.12-0.90, p = 0.03). In the FAR group, the proportion of patients with functional independence was not significantly different between the BP managements (intensive, 42.5% vs conventional, 54.2%, adjusted OR = 0.73, 95% CI = 0.38-1.40). Incidences of symptomatic intracerebral hemorrhage and mortality rates were not significantly different according to the BP managements in both MAR and FAR groups.

CONCLUSIONS

Among stroke patients who received multiple attempts of thrombectomy, intensive BP management for 24 h resulted in a reduced chance of functional independence at 3 months and did not reduce symptomatic intracerebral hemorrhage following successful reperfusion.

Diagnosis and management of blunt cerebrovascular injuries: What you need to know

ABSTRACT

Blunt cerebrovascular injuries are not as rare as they were once thought to be-but they still have the same potential for disastrous outcomes. They may occur following any trauma, but more common with higher energy transfer mechanisms. If stroke occurs, prompt recognition and treatment offers the best chance for optimal outcome. Early diagnosis and provision of antithrombotic therapy may prevent strokes, so screening of asymptomatic patients is recommended. Herein we will present what you need to know to diagnose and manage blunt cerebrovascular injury.

Role of Stroke Scales and Scores in Cerebrovascular Disease

This article provides a comprehensive review of widely utilized stroke scales in both routine clinical settings and research. These scales are crucial for planning treatment, predicting outcomes, and helping stroke patients recover. They also play a pivotal role in planning, executing, and comprehending stroke clinical trials. Each scale presents distinct advantages and limitations, and the authors explore these aspects within the article. The authors' intention is to provide the reader with practical insights for a clear understanding of these scales, and their effective use in their clinical practice.