Effect of Mechanical Thrombectomy Without vs With Intravenous Thrombolysis on Functional Outcome Among Patients With Acute Ischemic Stroke: The SKIP Randomized Clinical Trial

STAY-HOME: Endovascular Thrombectomy for Patients With Prestroke Disability

Thrombectomy significantly improves clinical outcomes in patients with large vessel occlusion. However, the foundational trials used restrictive criteria, excluding patients with prestroke disability and included a few elderly patients (>80 years old). In addition, results from registries demonstrated conflicting results. We propose that there is equipoise for the elderly and prestroke disability to undergo thrombectomy and that trials are urgently required to guide treatment.

Acute ischemic stroke patient factors associated with poor outcomes in patients with favorable collaterals and successful thrombectomy

OBJECTIVES

Favorable arterial collaterals are correlated to favorable outcomes after endovascular thrombectomy (EVT), but many patients still have unfavorable outcomes despite favorable collaterals and successful reperfusion. We determined factors associated with favorable outcome in patients with good collaterals who had successful EVT.

MATERIALS AND METHODS

In a post hoc analysis of the prospective CRISP 2 study, we identified patients with good collaterals (Tan≥2) and successful reperfusion (TICI 2b-3). Favorable (mRS 0-2) and unfavorable outcome (mRS 3-6) groups were compared to identify clinical, imaging, and treatment predictors of favorable outcome.

RESULTS

92 patients were included. 33.7 % had favorable outcomes. There were no differences in sex (52 % females versus 54 % females; p = 0.821) or age (71 years [IQR 56-79] versus 68 years [IQR 57-79]; p = 0.859) in favorable versus unfavorable groups, respectively. Favorable outcome patients had more frequent intravenous thrombolysis (52 % versus 23 %; p = 0.006), shorter EVT procedures (27 min [IQR 23-40] versus 46 min ([IQR 27-64], and lower baseline NIHSS (12 [IQR 9-15] versus 16 [IQR 12-20]; p = 0.006). There were no differences in the frequency of TICI 3 rates (48 % vs. 38 %; p = 0.325) or first pass effect between the two groups (61 % vs. 57 %; p = 0.719). In a multivariable regression analysis, pre-stroke mRS 1 versus 0 versus (OR 0.15 [95 % CI: 0.03-0.78]; p = 0.024), pre-stroke mRS ≥3 versus 0 (OR 0.04 [95 % CI: 0.002-0.94]; p = 0.046), intravenous thrombolysis administration (OR 3.27 [95 % CI: 1.04-10.33]; p = 0.043) and EVT procedure time (OR for every 5 min 0.98 [95 % CI: 0.81-0.98]; p = 0.022) were modifiable predictors of favorable outcomes.

CONCLUSIONS

Among patients with good collaterals and successful reperfusion following EVT, favorable outcomes were associated with lower baseline mRS, intravenous thrombolysis administration, and shorter EVT procedure times.

Comparison of thrombectomy alone versus bridging thrombolysis in a US population using regression discontinuity analysis

The role of intravenous thrombolysis (IVT) in combination with endovascular thrombectomy (EVT) for the treatment of large vessel occlusion acute ischemic stroke has been evaluated exclusively outside the US, in randomized clinical trials which failed to demonstrate non-inferiority of skipping IVT. Because practice patterns and IVT dosing differ within the US, and prior observational US-based cohorts suggested improved clinical outcomes in patients who received IVT before EVT, a US-based evaluation is needed. This is a quasi-experimental study of a large US cohort using a regression discontinuity design (RDD) that enables the estimation of causal effects when randomization is not feasible. In this multi-center prospective cohort of patients undergoing EVT, we observed a sharp drop (65%) in the probability of receiving IVT at the cutoff of IVT eligibility time window while there were no significant differences in potential confounders including age, NIHSS, and ASPECTS at the cutoff. We found no association between IVT treatment and functional independence (mRS 0-2) at 90-days in patients undergoing EVT, nor in the secondary outcomes of excellent outcomes (mRS 0-1) at 90 days, mortality, symptomatic intracranial hemorrhage, first pass reperfusion, or final reperfusion.

Endovascular thrombectomy plus intravenous thrombolysis versus endovascular thrombectomy alone for large ischemic stroke

BACKGROUND

Endovascular thrombectomy (EVT) is the gold standard for eligible acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). A few trials studied EVT in AIS-LVO with large ischemic infarcts. We investigated the impact of intravenous thrombolysis (IVT) on EVT outcomes in those patients.

METHODS

We conducted a meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist and Cochrane Handbook of Systematic Reviews and Interventions. We searched 4 databases and performed our analysis utilizing a pooled risk ratio (RR) with a 95% confidence interval (CI).

RESULTS

Three studies investigated EVT with and without IVT in AIS-LVO patients with large ischemic infarcts. Regarding the modified Rankin Scale (mRS) score of 0-2 at 3 months, there was a statistically significant difference favoring EVT plus IVT (RR: 1.48, 95%CI: 1.27, 1.72, P < 0.00001). In respect of mRS score of 0-3, the analysis also favored EVT plus IVT (RR: 1.25, 95%CI: 1.11, 1.41, P = 0.0003). Regarding early neurological improvement (ENI) at 24 and 36 hours, our analysis favored EVT plus IVT (RR: 1.16, 95%CI: 1.01, 1.34, P = 0.03). In terms of mortality, our analysis favored EVT plus IVT (RR: 0.88, 95%CI: 0.77, 1, P = 0.04). There was no difference between the two groups across different types of intracranial hemorrhage (ICH).

CONCLUSION

Our results showed a beneficial impact of IVT on the outcomes of EVT in AIS-LVO patients with large ischemic infarcts in terms of functional outcomes and ENI. IVT was also associated with a lower mortality rate but not with an increased risk of ICH. Larger studies are needed to corroborate such results.

Intravenous Tenecteplase before Thrombectomy in Stroke

BACKGROUND

The safety and efficacy of treatment with intravenous tenecteplase before endovascular thrombectomy in patients with acute ischemic stroke due to large-vessel occlusion remain uncertain.

METHODS

In this open-label trial conducted in China, we randomly assigned patients with acute ischemic stroke due to large-vessel occlusion who had presented within 4.5 hours after onset and were eligible for thrombolysis to receive either intravenous tenecteplase followed by endovascular thrombectomy or endovascular thrombectomy alone. The primary outcome was functional independence (a score of 0 to 2 on the modified Rankin scale; range, 0 to 6, with higher scores indicating more severe disability) at 90 days. Secondary outcomes included successful reperfusion before and after thrombectomy. Safety outcomes included symptomatic intracranial hemorrhage within 48 hours and death within 90 days.

RESULTS

A total of 278 patients were randomly assigned to the tenecteplase-thrombectomy group and 272 to the thrombectomy-alone group. Functional independence at 90 days was observed in 147 patients (52.9%) in the tenecteplase-thrombectomy group and in 120 patients (44.1%) in the thrombectomy-alone group (unadjusted risk ratio, 1.20; 95% confidence interval, 1.01 to 1.43; P = 0.04). A total of 6.1% of the patients in the tenecteplase-thrombectomy group and 1.1% of those in the thrombectomy-alone group had successful reperfusion before thrombectomy, and 91.4% and 94.1%, respectively, had successful reperfusion after thrombectomy. Symptomatic intracranial hemorrhage within 48 hours occurred in 8.5% of the patients in the tenecteplase-thrombectomy group and in 6.7% of those in the thrombectomy-alone group; mortality at 90 days was 22.3% and 19.9%, respectively.

CONCLUSIONS

Among patients with acute ischemic stroke due to large-vessel occlusion who had presented within 4.5 hours after onset, the percentage of patients with functional independence at 90 days was higher with intravenous tenecteplase plus endovascular thrombectomy than with endovascular thrombectomy alone. (Funded by the Chongqing Science and Health Joint Medical Research Project and others; BRIDGE-TNK ClinicalTrials.gov number, NCT04733742.).

Advances in treatments for acute ischemic stroke

Acute ischemic stroke is a leading global cause of death and disability. Intravenous thrombolysis was the first acute treatment developed for ischemic strokes. First with alteplase and now with tenecteplase, intravenous thrombolysis has remained a cornerstone of acute ischemic stroke management. In large vessel occlusions, endovascular thrombectomy has become the standard of care in acute stroke management for anterior and posterior circulation strokes. The boundaries for these treatments have expanded, which has improved outcomes in patients who were previously ineligible. This review summarizes the latest advances in interventions for acute ischemic stroke, extending beyond existing guidelines and review articles to explore emerging strategies and treatments currently under investigation.

Thrombolysis for acute ischaemic stroke: development and update

Thrombolytic therapy is a cornerstone in managing acute ischaemic stroke, marking significant advancements in treatment. Various generations of thrombolytics play crucial roles in different strategies, including intravenous thrombolysis, bridging therapy and thrombolysis beyond the conventional time window. The continuous development of thrombolytics has brought notable improvements. Compared to first-generation urokinase, second-generation alteplase and third-generation tenecteplase offer significant pharmacological advantages, such as enhanced fibrin specificity and longer half-lives. Tenecteplase demonstrates non-inferiority to alteplase regarding efficacy and safety, with the added benefit of a more convenient administration method. Ongoing trials continue to reveal additional evidence. Furthermore, other thrombolytic agents, including reteplase and non-immunogenic recombinant staphylokinase, are gaining increasing interest in the medical community. This review examines the structural characteristics, pharmacological properties, efficacy and safety profiles of these thrombolytic drugs. It also provides a detailed analysis of the performance of thrombolytic therapy in different acute ischaemic stroke patient subgroups, aiming to trace the evolution of these treatments and compare their effectiveness in acute ischaemic stroke. The goal is to offer a scientific basis for clinical practices and future development of thrombolytic therapies.

IGF2BP1 exacerbates neuroinflammation and cerebral ischemia/reperfusion injury by regulating neuronal ferroptosis and microglial polarization

BACKGROUND

Cerebral ischemia/reperfusion (I/R) injury induces neuronal ferroptosis and microglial phenotypic shifts, driving post-ischemic neurological deficits. This study examines the regulatory role of the N6-methyladenosine (m6A) reader insulin-like growth factor 2 mRNA-binding protein 1 (IGF2BP1) in coordinating these pathological processes through Keap1/Nrf2 signaling.

METHODS

Cerebral I/R injury was modeled in C57BL/6 mice via middle cerebral artery occlusion (MCAO) and in hippocampal neurons and microglia through oxygen-glucose deprivation/reperfusion (OGD/R). Pro-inflammatory microglial polarization was induced by LPS/IFN-γ stimulation. IGF2BP1's functional impacts were assessed through knockdown and overexpression approaches, with mechanistic evaluations focusing on ferroptosis biomarkers, microglial polarization states, and Keap1/Nrf2 pathway activity. A microglia-neuron co-culture system elucidated cellular crosstalk mechanisms.

RESULTS

MCAO-operated mice demonstrated upregulated IGF2BP1 expression accompanied by neuronal apoptosis and microglial M1 polarization. IGF2BP1 silencing significantly attenuated OGD/R-induced neuronal ferroptosis, evidenced by reduced iron overload (Fe2+), lipid peroxidation (MDA), and reactive oxygen species (ROS) alongside restored glutathione (GSH) levels, while concurrently enhancing GPX4 activity through Keap1/Nrf2 pathway regulation. This intervention further shifted microglial polarization toward the M2 phenotype, effectively mitigating neuroinflammatory responses. Importantly, the neuroprotective effects of IGF2BP1 knockdown were abolished upon Keap1 overexpression. Co-culture experiments revealed that IGF2BP1-depleted microglia suppressed neuronal ferroptosis via phenotypic reprogramming. In vivo validation confirmed that IGF2BP1 knockdown ameliorated neurological deficits and reduced ferroptosis markers in MCAO-challenged mice.

CONCLUSION

IGF2BP1 serves as a critical regulator of cerebral I/R injury by exacerbating neuronal ferroptosis and sustaining detrimental microglial activation. These findings nominate IGF2BP1 inhibition as a promising strategy for ischemic stroke intervention.

Endovascular thrombectomy with versus without intravenous thrombolysis for acute ischaemic stroke

RATIONALE

Acute ischaemic stroke is a major cause of death and disability worldwide. Once diagnosed, treatment is generally limited to intravenous thrombolysis (IVT), endovascular thrombectomy, or both. Intravenous thrombolysis has theoretical benefits (enhancing reperfusion, dissolving smaller thrombi) and harms (delaying time to endovascular intervention, allergic reaction, increased bleeding risk).

OBJECTIVES

To assess the effects of endovascular thrombectomy with IVT versus without IVT on functional independence (defined as a modified Rankin Scale score (mRS) < 3) within 90 days in people with acute ischaemic stroke.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Scopus, LILACS, Google Scholar, the International HTA database, and two trial registries to November 2023.

ELIGIBILITY CRITERIA

We included randomised controlled trials of adults with acute ischaemic stroke who received endovascular therapy and were randomised to either intravenous thrombolysis within 4.5 hours or a control.

OUTCOMES

Outcomes were: functional independence (mRS score < 3), excellent functional outcome (mRS score < 2), mortality, asymptomatic intracranial haemorrhage, symptomatic intracranial haemorrhage, successful revascularisation (thrombolysis in cerebral infarction (TICI) grades 2b to 3), and complete revascularisation (TICI grade 3 only), within 90 days.

RISK OF BIAS

We used the Cochrane RoB 2 tool to assess the following potential sources of bias for each outcome: bias arising from the randomisation process; bias due to deviations from intended interventions; bias due to missing outcome data; bias in measurement of the outcome; and bias in selection of the reported result.

SYNTHESIS METHODS

We pooled outcome data using the random-effects model and performed meta-analyses using the Mantel-Haenszel method. We assessed the statistical heterogeneity of pooled data by visually inspecting forest plots to consider the direction and magnitude of effects, and used the Chi2 test and I2 statistic to quantify the heterogeneity. We used GRADE to assess the certainty of evidence.

INCLUDED STUDIES

We included six studies, with a total of 2336 participants (1166 control and 1170 intervention). The mean age was 71 years. There were 1034 women and 1302 men. Four studies used alteplase 0.9 mg/kg, one study used alteplase 0.6 mg/kg, and one study used either alteplase 0.9 mg/kg or tenecteplase 0.25 mg/kg. There were no important variations in the outcomes reported across studies.

SYNTHESIS OF RESULTS

All six studies were at overall low risk of bias for each outcome. There was probably little to no difference in functional independence between the IVT and control groups (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.92 to 1.14; P = 0.62; 6 studies, 2336 participants; moderate-certainty evidence). There was no evidence of a difference in excellent functional outcome between the IVT and control groups (RR 0.99, 95% CI 0.92 to 1.05; P = 0.67; 6 studies, 2336 participants; high-certainty evidence). There was no evidence of a difference in mortality between the IVT and control groups (RR 0.94, 95% CI 0.78 to 1.14; P = 0.54; 6 studies, 2336 participants; high-certainty evidence). There was no evidence of a difference in asymptomatic intracranial haemorrhage between the IVT and control groups (RR 1.13, 95% CI 1.00 to 1.29; P = 0.06; 6 studies, 2334 participants; high-certainty evidence). There was probably little to no difference in symptomatic intracranial haemorrhage between the IVT and control groups (RR 1.20, 95% CI 0.84 to 1.70; P = 0.31; 6 studies, 2336 participants; moderate-certainty evidence). There was a higher rate of successful revascularisation with IVT over control (RR 1.04, 95% CI 1.01 to 1.08; P = 0.008; 6 studies, 2326 participants; high-certainty evidence). There was a higher rate of complete revascularisation with IVT over control (RR 1.14, 95% CI 1.02 to 1.28; P = 0.02; 5 studies, 2037 participants; high-certainty evidence). Limitations included: differences in inclusion and exclusion criteria between studies (e.g. age thresholds, pre-existing comorbidities or baseline functional status, time periods, diagnostic imaging, specific vessels); specific endovascular device used; thrombolysis medication and dose; and potential conflict of interest, as multiple study authors reported receiving funding or fees from pharmaceutical companies. For functional independence, assessed as an mRS score < 3 within 90 days, we downgraded the certainty of evidence by one level due to a high I2 value, indicating that heterogeneity may be substantial for this outcome. For symptomatic intracranial haemorrhage within 90 days, we downgraded the certainty of evidence by one level because the 95% CI included both important benefits and important harms.

AUTHORS' CONCLUSIONS

The evidence does not currently support a clear benefit or harm for routine intravenous thrombolysis amongst people receiving endovascular thrombectomy. Amongst participants receiving endovascular thrombectomy, IVT did not demonstrate evidence of a difference in functional independence, excellent functional outcome, mortality, and asymptomatic intracranial haemorrhage, or symptomatic intracranial haemorrhage, when compared with no IVT. However, IVT did result in a higher rate of successful and complete revascularisation when compared with no IVT. Future research should include more high-quality trials to further evaluate the role of intravenous thrombolysis in people receiving endovascular thrombectomy to provide more robust data and further narrow the confidence intervals. Future research should also identify whether time- and person-specific factors influence the effect of IVT amongst those receiving endovascular thrombectomy.

FUNDING

None REGISTRATION: Gottlieb M, Carlson JN, Westrick J, Peksa GD. Endovascular thrombectomy with versus without intravascular thrombolysis for acute ischaemic stroke. Cochrane Database of Systematic Reviews. 2024;2:1465-1858.

Direct mechanical thrombectomy vs. intravenous alteplase plus mechanical thrombectomy in acute ischemic stroke with anterior circulation tandem occlusions

Background and purpose

Tandem occlusion is a significant risk factor for poor outcomes following intravenous thrombolysis. The necessity of bridging therapy [intravenous thrombolysis prior to mechanical thrombectomy (MT)] for patients with tandem occlusion remains controversial. This study assessed the safety and efficacy of direct MT vs. bridging therapy in patients with tandem occlusions in the anterior circulation.

Methods

This retrospective study enrolled patients with anterior circulation tandem occlusions treated with either direct mechanical thrombectomy (MT-alone group) or intravenous alteplase thrombolysis followed by MT (bridging group) between January 2019 and March 2022. The primary outcome was prespecified as a favorable outcome [modified Rankin Scale (mRS) score of 0-2] at 90 days. Secondary outcomes included successful reperfusion, overall mortality at 90 days, and rates of symptomatic intracranial hemorrhage (SICH) and asymptomatic intracranial hemorrhage (aSICH).

Results

A total of 110 patients were enrolled, with 49 in the MT-alone group and 61 in the bridging group. A favorable outcome (mRS score of 0-2) at 90 days was achieved in 25 patients (51.0%) in the MT-alone group and in 34 patients (55.7%) in the bridging group, showing no significant difference between the groups, with an adjusted odds ratio (aOR) of 1.17 (95% CI, 0.47-2.90; P = 0.743). The incidence of aSICH was higher in the bridging group than in the MT-alone group [31.1% vs. 14.3%; aOR, 2.86 (95% CI, 1.04-7.88); P = 0.042]. Rates of successful reperfusion, overall mortality at 90 days, and SICH were similar between the groups. Multivariate analysis showed that a lower baseline National Institutes of Health Stroke Scale (NIHSS) score (P = 0.005), intraprocedural tirofiban administration (P = 0.012), and internal carotid artery stent implantation (P = 0.040) were associated with a favorable outcome at 90 days.

Conclusion

This study found no evidence that prior intravenous thrombolysis affects clinical or imaging outcomes in patients with acute ischemic stroke due to anterior circulation tandem occlusions after endovascular thrombectomy. Bridging therapy may be associated with an increased rate of aSICH. Intraprocedural tirofiban administration, stent implantation, and a lower baseline NIHSS score were associated with favorable outcomes.

Effect of intravenous alteplase before endovascular therapy for atherothrombotic stroke-related large vessel occlusion: subanalysis of the RESCUE AT-LVO registry

BACKGROUND

Whether intravenous thrombolysis (IVT) should be administered prior to endovascular therapy (EVT) in patients with atherothrombotic stroke-related large vessel occlusion (AT-LVO) remains unclear. This study aimed to assess the efficacy and safety of IVT administered before EVT in this patient population.

METHODS

We analysed the data from a multicentre registry of patients who underwent EVT for AT-LVO. Patients were categorised based on presumed mechanism of occlusion: in situ occlusion (intracranial group) or embolism from cervical artery occlusion/stenosis (tandem group). We compared the efficacy and safety of IVT before EVT in patients who received IVT (IVT stratum) and those who did not (non-IVT stratum). The primary outcome was a modified Rankin Scale score of 0-2 at 90 days.

RESULTS

Among the 336 patients in the intracranial group, 99 patients underwent IVT. The rate of favourable functional outcomes did not differ between IVT and non-IVT strata (51.1% vs 47.6%; adjusted ORs (aORs) (95% CI), 1.18 (0.66 to 2.09)); whereas any intracranial haemorrhage (ICH) (10.1% vs 3.8%; aOR, 2.98 (1.01 to 9.26)) and mortality at 90 days (6.4% vs 1.3%; aOR, 4.66 (1.02 to 26.73)) were significantly higher in the IVT stratum. Among the 233 patients in the tandem group, 88 patients underwent IVT, with no significant differences in efficacy or safety outcomes between the strata.

CONCLUSION

In patients with AT-LVO, IVT before EVT did not improve outcomes and was associated with increased risk of ICH and mortality in those with in situ intracranial occlusion. IVT before EVT may not be recommended in patients with atherosclerotic intracranial occlusions.

Intravenous thrombolysis before endovascular treatment in acute vertebrobasilar occlusions: Pooled analysis of the French and German Stroke Registries

INTRODUCTION

Whether intravenous thrombolysis (IVT) provides additional benefit in eligible patients with acute vertebrobasilar occlusion who undergo endovascular treatment (EVT) remains an open question.

PATIENTS AND METHODS

We conducted a pooled analysis using data from two national stroke registries, the ETIS registry in France and GSR-ET registry in Germany. Patients who underwent EVT for vertebral and/or basilar artery occlusions from January 2015 to December 2023 were included. The primary efficacy outcome was a favorable shift toward better functional outcomes on modified Rankin Scale (mRS) scores at 90 days. Safety outcomes included 90-days mortality and symptomatic haemorrhagic transformation (sICH). Comparisons between IVT + EVT and direct EVT groups were made combining inverse propensity score matching, probability of treatment weighting (IPTW) and regression models.

RESULTS

Among 2028 patients treated during the study period, 797 (39.2%) received IVT before EVT, while 1231 (60.7%) had EVT alone. After IPTW matching, we compared 211 patients treated with IVT + EVT to 260 direct EVT patients. Patients in the IVT + EVT group had a favorable shift across the 90-day mRS distribution (common aOR 1.43 per 1-point mRS improvement, 95% CI 1.01-2.04; p = 0.046), higher odds of 90-day favorable functional outcome (aOR 1.56, 95% CI 1.00-2.44; p = 0.049) and lower odds of 90-day mortality (aOR 0.62, 95% CI 0.39-0.99; p = 0.045). IVT was not associated with increased risk of sICH (aOR 1.65, 95% CI 0.62-4.35; p = 0.313).

DISCUSSION

This registry-based study suggests a potential benefit of IVT before EVT in eligible patients with vertebrobasilar occlusions. Conclusion: Randomized clinical trials are necessary to confirm these findings and to validate the benefits of IVT in this clinical context.

Advances in endovascular thrombectomy for the treatment of acute ischemic stroke

INTRODUCTION

Acute ischemic stroke (AIS) is the second leading cause of death and one of the leading causes of long-term disability globally. Endovascular thrombectomy (EVT) has revolutionized treatment for large vessel occlusion (LVO), providing 20% increase in post-stroke functional independence compared to intravenous thrombolysis (IVT) alone. Despite its proven efficacy, EVT is underutilized. While it is suitable for at least 15-20% of AIS patients, its mean adoption ranges from less than 1% to 7% in different areas.

AREAS COVERED

This review highlights key findings from pivotal randomized controlled trials and real-world data, focusing on patient selection criteria, advancements in thrombectomy devices, and procedural innovations. A comprehensive literature search was performed using PubMed, Scopus, EMBASE and the Cochrane Library for relevant randomized controlled trials and observational studies.

EXPERT OPINION

Disparity in access to EVT requires strategic investments in healthcare systems and international multidisciplinary collaboration. Enhancing geographic coverage with thrombectomy-capable centers and optimizing prehospital triage systems are essential. Bridging the gap between treatment capability and real-world implementation is critical to improving global AIS outcomes.

Treatment with Manganese Porphyrin, MnTnBuOE-2-PyP5+, Suppressed the Activation of Macrophages in a Mouse Intracerebral Hemorrhage

Background: Manganese porphyrin, MnTnBuOE-2-PyP5+ (BMX-001), improves neurologic deficits in experimental ischemic stroke and has the potential to serve as an adjunct with thrombolysis or thrombectomy in stroke patients. In 10-30% of stroke patients following thrombolysis, the hemorrhagic transformation, associated with iron release, occurs. This study aimed to examine the neurologic outcome following the BMX-001 treatment in a mouse intracerebral hemorrhage (ICH) model with relevance to prospective ischemic stroke clinical trials. Methods: Twenty C57Bl6 mice were randomly assigned to groups after surgery and received vehicle or BMX-001 treatment immediately following stereotaxic left striatum collagenase injection. Post-ICH body weight, the Corner test, neurological deficit score, and Rotarod test were examined. Six sham surgery mice serve as a control group. At 72 h, the brain histological evaluation was performed, including hemorrhage size, Prussian blue staining, and the activation of macrophages. Data were collected by a researcher who was blind to groups. Results: No significant difference in body weight, neurological deficits, and hemorrhage size was found between groups. However, BMX-001 reduced the number of macrophages in the hemorrhagic area (48 ± 10 in vehicle, 33 ± 8 in BMX-001, p = 0.008) and the number of cells stained with Prussian blue-an indicator of iron released during hemorrhage (65 ± 22 in vehicle and 41 ± 15 in BMX-001, p = 0.027). Conclusions: The results support the safe use of BMX-001 in stroke patients in combination with thrombolysis or thrombectomy and, moreover, indicate the beneficial anti-inflammatory effect of BMX-001, alike to that previously reported in stroke studies of analogous, similarly redox-active, Mn porphyrins.

Intravenous thrombolysis before endovascular treatment versus endovascular treatment alone for patients with large vessel occlusion and carotid tandem lesions: individual participant data meta-analysis of six randomised trials

BACKGROUND

For patients with large vessel occlusion and carotid tandem lesions, the best treatment approach is not clear. Intravenous thrombolysis in addition to endovascular treatment might increase the risk of intracranial haemorrhage and decrease effectiveness in this cohort, particularly for patients receiving acute carotid stenting. In an individual participant data meta-analysis of six randomised controlled trials (RCTs), no clear benefit was seen of intravenous thrombolysis in patients with large-vessel occlusion stroke who were eligible for direct endovascular treatment. We aimed to assess whether the presence of carotid tandem lesions would modify the safety and efficacy of intravenous thrombolysis in patients who could directly undergo endovascular treatment, in a prespecified secondary subgroup analysis of this individual participant data meta-analysis.

METHODS

We previously did a systematic review and individual participant data meta-analysis of six RCTs comparing intravenous thrombolysis plus endovascular treatment with endovascular treatment alone in patients with anterior circulation stroke presenting directly at centres capable of endovascular treatment. The principal investigators of the six identified trials provided individual participant data for 2313 patients, which we pooled. The primary outcome was functional outcome, as measured by 90-day modified Rankin Scale score. Heterogeneity of treatment effect was assessed in the intention-to-treat population using ordinal regression models, with interaction terms for treatment and carotid tandem lesions, followed by a mixed-effects meta-analysis. A sensitivity analysis included only patients who received acute carotid stenting. The study is registered with PROSPERO, CRD42023411986.

FINDINGS

Of the 2313 patients who were included in the individual patient data meta-analysis, 2267 (98%) had data for carotid tandem lesions, of whom 1136 were assigned intravenous thrombolysis plus endovascular treatment and 1131 were assigned endovascular treatment alone. 340 patients had carotid tandem lesions (161 intravenous thrombolysis plus endovascular treatment, 179 endovascular treatment alone) and 1927 did not have tandem lesions (975 intravenous thrombolysis plus endovascular treatment, 952 endovascular treatment alone). The median age of patients was 71 years (IQR 62-78); 1003 (44·2%) patients were female and 1264 (55·8%) were male. Compared with endovascular treatment alone, the addition of intravenous thrombolysis did not improve functional outcome in patients with tandem lesions (adjusted common odds ratio [acOR] 1·00, 95% CI 0·62-1·62) or in those without tandem lesions (1·17, 0·99-1·37). No significant heterogeneity of treatment effect was observed between patients with tandem lesions and those without (ratio of odds ratios 0·81, 95% CI 0·48-1·37; pinteraction=0·44). Intracranial haemorrhage rates in patients with tandem lesions were similar for those receiving intravenous thrombolysis plus endovascular treatment (58 [37%] of 155) and for those receiving endovascular treatment alone (65 [38%] of 172; acOR 0·95, 95% CI 0·59-1·54). Rates of symptomatic haemorrhage in patients with tandem lesions were also similar (six [4%] of 159 for those receiving intravenous thrombolysis plus endovascular treatment vs ten [6%] of 179 for those receiving endovascular treatment alone; 0·81, 0·28-2·30). The sensitivity analysis including only patients who received acute carotid stenting showed similar results to the primary analysis.

INTERPRETATION

The findings of this prespecified secondary analysis of an individual patient data meta-analysis show that, in patients with carotid tandem lesions, the addition of intravenous thrombolysis to endovascular treatment was not associated with an increase in the risk of bleeding or with modification of functional outcome. These data suggest that the presence of tandem lesions should not solely influence the decision to administer intravenous thrombolysis to patients who can directly undergo endovascular treatment.

FUNDING

Stryker, Boehringer Ingelheim, and Amsterdam University Medical Centers, University of Amsterdam.

Intravenous tenecteplase bridging reperfusion ameliorates cerebral ischemia/reperfusion injury by improving microvascular circulation in rats

BACKGROUND

Endovascular thrombectomy (EVT) alone was not demonstrated to be noninferior to intravenous alteplase bridging EVT in acute large vessel occlusion stroke. Using the cerebral ischemia/reperfusion (I/R) injury model, intravenous tenecteplase (TNK) was administrated after ischemia, followed by reperfusion at various time points.

OBJECTIVES

To investigate whether intravenous TNK bridging EVT vs EVT alone could improve I/R injury, and this effect may be associated with the time from TNK to reperfusion.

METHODS

Rats received intravenous TNK (1.4 mg/kg) or vehicle (sterile water) 1.0 hours after middle cerebral artery occlusion, followed by reperfusion after 0.5 or 1.0 hours following TNK. Neurological deficit scores, infarct volume, and brain edema were measured 24 hours after middle cerebral artery occlusion. Microthrombi were determined by immunofluorescence staining for CD31+/fibrinogen+ and CD31+/thrombocyte+. Inflammatory cell infiltration in the ischemic brain region was determined by flow cytometry.

RESULTS

Compared with vehicle, TNK significantly reduced neurological deficit scores, brain infarction, neuroinflammation, and blood-brain barrier disruption, and significantly reduced intravascular fibrin and platelet deposition and brain inflammatory cell infiltration in the penumbra of I/R rats. Furthermore, a better beneficial trend was found in TNK bridging reperfusion at 0.5 hours after TNK compared with TNK bridging reperfusion at 1.0 hours after TNK.

CONCLUSION

Our results demonstrate that intravenous TNK bridging reperfusion produced neuroprotective action through dissolving microvascular thrombus and alleviating inflammatory cell infiltration to improve microcirculation, with the result of maintaining blood-brain barrier integrity and inhibiting neuroinflammation, and the neuroprotective benefit may be associated with the time from TNK to reperfusion.

Management of dropped head syndrome: a systematic review and single-arm meta-analysis

Dropped Head Syndrome (DHS) is a rare condition marked by severe neck extensor muscle weakness, leading to a chin-on-chest deformity caused by pathological kyphosis. This study aims to evaluate the efficacy of conservative versus surgical treatments for DHS. A systematic search of PubMed, Embase, and ScienceDirect was conducted for studies on DHS treatments. Outcomes included total/partial improvement, success, and failure rates. Statistical analyses were performed using R software and the "meta" package. We identified 1,252 articles, with 19 studies and 472 patients included. Of these, 134 (28.4%) underwent surgery and 338 (71.6%) received conservative treatment. Partial improvement after conservative treatment was 59% (95% CI 32.76-83.03%; I² = 78%), with total improvement at 4.45% (95% CI 0.01-13.21%; I² = 84%). Success rates were 6.73% (95% CI 0.74-16.16%; I² = 82%), and failure was 100% (95% CI 99.28-100%; I² = 78%). For surgical treatment, total improvement was 100% (95% CI 99.57-100%; I² = 18%), and success was also 100% (95% CI 98.37-100%; I² = 0%), with low heterogeneity. Only two surgical patients failed (95% CI 0.00-1.63%; I² = 0%). Conservative treatment was ineffective in achieving functional recovery and horizontal gaze. Surgical treatment is the preferred option for treating DHS and should be considered a disease-modifying therapy.

Clinical and neurophysiological predictors of the functional outcome in right-hemisphere stroke

OBJECTIVE

The aim of the present study is to examine the relationship between EEG measures and functional recovery in right-hemisphere stroke patients.

METHODS

Participants with stroke (PS) and neurologically unimpaired controls (UC) were enrolled. At enrolment, all participants were assessed for motor and cognitive functioning with specific scales (motricity index, trunk control test, Level of Cognitive Functioning, and Functional Independence Measure (FIM). Moreover, EEG data were recorded. At discharge, participants were re-tested with the FIM RESULTS: Powers in the delta, theta, alpha, and beta bands and connectivity within the fronto-parietal network were compared between groups. Then, the between-group discriminative EEG measures and the motor/cognitive scales were used to feed a machine learning algorithm to predict FIM scores at discharge and the length of hospitalization (LoH). Higher delta, theta, and beta and impaired connectivity were found in PS compared to UC. Moreover, motor/cognitive functioning, beta power, and fronto-parietal connectivity predicted the FIM score at discharge and the LoH (accuracy=73.2 % and 85.2 % respectively).

CONCLUSIONS

Results show that the integration of motor/cognitive scales and EEG measures can reveal the rehabilitative potentials of PS predicting their functional outcome and LoH.

SIGNIFICANCE

Synergistic clinical and electrophysiological models can support rehabilitative decision-making.

Intraarterial Thrombolysis as an Adjunct to Thrombectomy in Acute Ischemic Stroke: Current Status and Future Prospects

BACKGROUND AND PURPOSE

Intraarterial thrombolysis (IAT) has been sporadically used as an adjunct to mechanical thrombectomy (MT) in acute ischemic stroke patients for nearly two decades to improve distal arterial and microvascular perfusion even in patients with near complete or complete recanalization.

METHODS

We provide an overall narrative review that includes a systematic review and meta-analysis of two randomized controlled trials (RCTs), Chemical Optimization of Cerebral Embolectomy and Endovascular Recanalization in Patients with Acute Posterior Circulation Arterial Occlusion, to identify current and future implications. Risk ratios (RRs) were calculated from RCTs using a fixed-effects model. We identified 10 ongoing or planned RCTs after a search on clinicaltrials.gov and other sources, of which eight are in China, one in Europe, and one in Australia.

RESULTS

A previous meta-analysis of 16 (predominantly observational) studies involving 7572 MT-treated patients had identified 14% higher odds of functional independence (modified Rankin scale [mRS] 0-2) at 90 days in patients treated with IAT. In the current analysis of 321 patients who underwent MT in RCTs, 165 were randomized to IAT and 156 were in the control group. The RR of achieving an mRS score of 0-1 at 90 days postrandomization was higher in patients treated with IAT compared with the control group (absolute increase of 12.87%, RR = 1.39, 95% confidence interval [CI] 1.04-1.86). The rate of symptomatic intracerebral hemorrhage (sICH) within 24 h was slightly higher (absolute increase of 1.64%, RR = 0.95, 95% CI 0.07-13.30) in patients treated with IAT. The ongoing RCTs have sample sizes ranging from 80 to 498 that can identify very large minimal clinically important differences (MCIDs) (13%-20% increase) in primary outcomes, but smaller MCIDs (<10%) that can still result in practice changes with interventions associated with low cost and complexity and are easy to implement, such as IAT, will not be identified.

CONCLUSIONS

Observational studies and recent RCTs suggest a potential benefit of IAT in improving functional outcomes among patients post-MT, although the potentially increased risk of sICH, inadequate sample sizes, and lack of data from the United States need to be considered. A large, definitive, and generalizable RCT is required to establish the therapeutic value and safety profile of IAT prior to widespread incorporation into routine practice.

Effectiveness and safety of bridging therapy and endovascular therapy in patients with large cerebral infarctions: from ANGEL-ASPECT

BACKGROUND AND PURPOSE

The benefits of thrombolytic therapy before endovascular thrombectomy in cases of acute ischaemic stroke, with a large infarction volume, remain unclear. This analysis aims to evaluate the effectiveness and safety of bridging therapy and endovascular therapy among patients with large cerebral infarctions.

METHODS

In this post-hoc analysis of the multicentre prospective study of ANGEL-ASPECT (Acute Anterior Circulation Large Vessel Occlusive Patients with a Large Infarct Core), participants were divided into two groups: an endovascular therapy group and a bridging therapy group. The primary outcome was the modified Rankin Scale (mRS) score at 90 days. The primary safety outcome was symptomatic intracranial haemorrhage. Ordinal logistic regression was performed to compare the primary endpoint between the two groups. Subgroup analyses were conducted to further explore potential risk factors associated with the outcomes.

RESULTS

122 patients were included, of whom 77 (63%) underwent endovascular therapy and 45 (37%) underwent bridging therapy. The median scores on mRS at 90 days of the bridging therapy group and the endovascular therapy group were 3 (2-5) and 4 (2-6), with no significant differences (common OR 1.36; 95% CI 0.71 to 2.61). Symptomatic intracranial haemorrhage was reported in three patients who were in the endovascular and bridging therapy groups (relative risk (RR) 1.71; 95% CI 0.36 to 8.12). The mortality between two groups did not differ (RR 0.75; 95% CI 0.37 to 1.54).

CONCLUSIONS

Our study indicated that endovascular therapy alone might be a viable option for patients with large cerebral infarctions, displaying no noticeable disparity in outcomes compared with bridging therapy.

MicroRNAs Associated with Parenchymal Hematoma After Endovascular Mechanical Reperfusion for Acute Ischemic Stroke in Rats

Background/Objectives: Hemorrhagic transformation after endovascular thrombectomy predicts poor outcomes in acute ischemic stroke with large-vessel occlusion. The roles of microRNAs (miRNAs) in the pathogenesis of parenchymal hematoma (PH) after endovascular thrombectomy still remain unclear. This study aimed to investigate the miRNA and mRNA regulatory network associated with PH after mechanical reperfusion in an animal stroke model and an oxygen-glucose deprivation/reoxygenation (OGD/R) model. Methods: Twenty-five miRNAs were assessed in a mechanical reperfusion-induced hemorrhage transformation model in rats under hyperglycemic conditions receiving 5 h middle cerebral artery occlusion. The differentially expressed miRNAs associated with PH were assessed in a neuron, astrocyte, microglia, brain microvascular endothelial cell (BMEC), and pericyte model of OGD/R. The predicted target genes of the differentially expressed miRNAs were further assessed in the animal model. The miRNA-mRNA regulatory network of PH was established. Results: Thirteen down-regulated miRNAs (miRNA-29a-5p, miRNA-29c-3p, miRNA-126a-5p, miRNA-132-3p, miRNA-136-3p, miRNA-142-3p, miRNA-153-5p, miRNA-218a-5p, miRNA-219a-2-3p, miRNA-369-5p, miRNA-376a-5p, miRNA-376b-5p, and miRNA-383-5p) and one up-regulated miRNA (miRNA-195-3p) were found in the rat peri-infarct with PH after mechanical reperfusion. Of these 14 PH-related miRNAs, 10 were significantly differentially expressed in at least two of the five neuron, astrocyte, microglia, BMEC, and pericyte models after OGD/R, consistent with the animal stroke model results. Thirty-one predicted hub target genes were significantly differentially expressed in the rat peri-infarct with PH after mechanical reperfusion. Forty-nine miRNA-mRNA regulatory axes of PH were revealed, and they were related to the mechanisms of inflammation, immunity, oxidative stress, and apoptosis. Conclusions: Fourteen miRNAs were associated with PH after mechanical reperfusion in the rat stroke and the OGD/R models. Simultaneously differentially expressed miRNAs and related genes in several cells of the neurovascular unit may serve as valuable targets for PH after endovascular thrombectomy in acute ischemic stroke.

Effect of Intravenous Alteplase Before Endovascular Thrombectomy on Outcome After Unsuccessful Recanalization in the DIRECT-MT Trial

BACKGROUND

There are still some patients with acute anterior circulation large vessel occlusion stroke experienced unsuccessful recanalization after endovascular thrombectomy (EVT). The efficacy of intravenous alteplase before thrombectomy for such patients is unknown. We performed this study to investigate whether prior intravenous alteplase could affect the outcome of patients with unsuccessful recanalization.

METHODS

This is a post-hoc analysis of the DIRECT-MT trial (direct intraarterial thrombectomy in order to revascularize acute ischemic stroke patients with large vessel occlusion efficiently in Chinese Tertiary Hospitals: a multicenter randomized clinical trial). Patients with final extended thrombolysis in cerebral infarction score of 0-2a were included. Patients with successful recanalization (modified treatment in cerebral ischemia 2b-3) or could not be assessed for modified treatment in cerebral ischemia were excluded. The primary outcome was the 90-day modified Rankin Scale (mRS) score, while secondary outcomes included 90-day functional independence (mRS 0-2), recanalization (modified arterial occlusive lesion) rates at 24-72 hours by computed tomography angiography, infarction volume on computed tomography, and rates of symptomatic intracranial hemorrhage and asymptomatic intracranial hemorrhage.

RESULTS

Among 656 randomized patients, 92 patients with unsuccessful recanalization were included, of which 55 patients underwent EVT alone (EVT group) and 37 patients underwent EVT preceded by intravenous alteplase (combination group). No statistically significant difference in the 90-day mRS score was observed between the 2 groups (adjusted common odds ratio = 1.65; 95% confidence interval, 0.76 to 3.59). The volume of infarction, the proportion of 90-day functional independence, recanalization rates at 24-72 hours, rates of symptomatic intracranial hemorrhage, and rates of asymptomatic intracranial hemorrhage were similar in both groups.

CONCLUSIONS

We found no evidence that prior intravenous alteplase could affect the clinical or imaging outcome in patients with acute anterior circulation large vessel occlusion stroke and unsuccessful recanalization after EVT.

Treatment outcome of bridge mechanical thrombectomy with different IV-tPA dosages in the standard and extended time window in real-world practice

BACKGROUND

Differences of treatment outcome between full or reduced dose of tissue plasminogen activator (tPA) for bridge mechanical thrombectomy (MT) in the extended time window have not been clearly established. We aimed to present real-world results of bridge MT with different tPA dosages in the standard and extended windows.

MATERIALS AND METHODS

Patients with anterior circulation stroke treated with MT between 2017 and 2021 at two stroke referral centers were retrospectively reviewed. Bridge MT with tPA were categorized as full (0.9 mg/kg) or reduced (<0.9 mg/kg) dose. Standard window (SW) cohort was defined as MT performed within 6 h of acute ischemic stroke onset, while those beyond 6 h as the extended window (EW) cohort. 90 days Modified Rankin Scale (mRS) score, technical treatment success, in-hospital mortality, and post-treatment hemorrhage were analyzed.

RESULTS

A total of 423 patients met the inclusion criteria, 218 of which treated in the SW, while 205 treated in the EW. Within the SW cohort, the full-dose tPA group demonstrated a higher proportion of good functional outcome (GFO) at 90 days (mRS0-3) versus reduced (49% vs 21%, p = 0.0358). The overall GFO of SW was higher than that of the EW cohort (33% vs 20%, p = 0.0480). Within the EW cohort, GFO was similar between full and reduced dose groups. Successful reperfusion rate was lower in SW versus EW cohorts (39% vs 58%, p = 0.0199).

CONCLUSION

In real-world practice, the GFO of bridge MT is better than MT alone. The tPA dosage is not a determining factor of GFO in EW MT.

Safety and efficacy of bridging intravenous thrombolysis plus mechanical thrombectomy versus direct mechanical thrombectomy in different age groups of acute ischemic stroke patients

OBJECTIVE

To evaluate the safety and efficacy of bridging intravenous thrombolysis plus mechanical thrombectomy (MT) versus direct MT in different age groups of patients with acute ischemic stroke (AIS) secondary to large vessel occlusion (LVO) of the anterior circulation.

METHODS

Consecutive patients from the prospective endovascular stroke registry of the Comprehensive Stroke Center, University of Rome Tor Vergata, Italy, between January 2015 and June 2021 were retrospectively analyzed. Patients were divided into age groups (≤ 80 years old and > 80 years old); for each age group, they were further divided in the bridging therapy group and the direct MT group. We performed a propensity score analysis according to baseline characteristics. Safety outcomes were any intracerebral hemorrhage (ICH), symptomatic ICH (sICH) and 3-month mortality. Efficacy outcomes were successful recanalization (modified Thrombolysis in Cerebral Infarction, mTICI, score ≥ 2b) and 3-month functional independence (modified Rankin Scale, mRS, ≤ 2).

RESULTS

We included 761 AIS patients with anterior circulation LVO (mean age 73.5 ± 12.8 years; 44.8% males; mean baseline NIHSS 16 ± 5). After propensity score, there were 365 patients ≤ 80 years old (52% bridging therapy) and 187 patients > 80 years old (57% bridging therapy). In both age groups of patients, we found no statistically significant differences in the rates of any ICH, sICH, successful recanalization and 3-month mortality and functional independence between bridging therapy and direct MT groups.

CONCLUSION

In our population, safety and efficacy outcomes of bridging therapy versus direct MT did not differ in both AIS patients ≤ 80 and > 80 years old.

Understanding Noninferiority Trials: What Stroke Specialists Should Know

Noninferiority trials aim to prove that the efficacy, defined in terms of a key clinical outcome, of a new treatment is not meaningfully worse than that of an established active control. Noninferiority trials are important when other aspects of care can be improved, such as convenience, toxicity, costs, and safety (nonefficacy benefits). While the motivation for a noninferiority trial is straightforward, the design, execution, and interpretation of these trials is not a trivial task. Several safeguards that protect superiority trials from incorrect conclusions do not apply or even work in reverse for noninferiority trials. This review aims to provide stroke clinicians and researchers with a general overview of noninferiority trials and a deeper understanding of 10 pitfalls they should consider when designing and interpreting such trials.

Xiaoxuming decoction enhanced neuroprotection after cerebral ischemia/reperfusion via the JAK2/STAT3 signaling pathway based on UPLC/HRMS, network pharmacology and experimental validation

ETHNOPHARMACOLOGICAL RELEVANCE

Xiao-xu-ming decoction (XXMD), a prominent traditional Chinese medicinal formula historically revered for stroke treatment, demonstrates pronounced efficacy in ameliorating ischemic stroke injury.

AIM OF THE STUDY

This study aims to investigate the effects and mechanisms of XXMD on neuroprotection subsequent to cerebral ischemia/reperfusion in vivo and in vitro.

MATERIALS AND METHODS

Neurobehavioral test, TTC staining, HE staining and nissl staining were used to examine the neuroprotective effect of XXMD on cerebral ischemia-reperfusion injury induced by middle cerebral artery occlusion (MCAO) in rats. Additionally, we assessed cell viability and injury with CCK8 and lactate dehydrogenase (LDH) assays. The changes in neuronal ultra-structure were observed after oxygen-glucose deprivation and reoxygenation (OGD/R) by transmission electron microscopy (TEM). Network analysis combined with ultrahighperformance liquid chromatography-high resolution mass spectrometry (UPLC-HRMS) predicted the mechanism of XXMD on ischemic stroke injury. Furthermore, the expression of neuroplasticity-related proteins neurofilament 200 (NF200), microtubule-associated protein 2 (MAP2), postsynaptic density protein 95 (PSD95), synaptophysin (SYN), phosphorylated Janus kinase2 (p-JAK2), and phosphorylated signal transduction and activator of transcription 3 (p-STAT3) was evaluated by immunofluorescence staining and Western blot analyses.

RESULTS

XXMD significantly improved Ethology, infarct area and pathological changes after MCAO and reperfusion, reducing morphological and ultrastructural alterations and decreased cell viability in HT22 cells induced by OGD/R. Network pharmacology showed that 1153 compounds of XXMD were matched. The Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis demonstrated that XXMD treated ischemia stroke mainly regulating inflammation reaction-related signaling pathways, atherosclerosish-related signaling pathways. Molecular docking results showed that TP53, AKT1, STAT3, and IL6 are closely bound to the corresponding active ingredients. XXMD treatment significantly reversed the above alternations. XXMD or AG490 up-regulated the expression of neuroplasticity-associated proteins, and reduced phosphorylation of JAK2, STAT3 expression following OGD/R.

CONCLUSION

XXMD exerts neuroprotective effects by promoting neural plasticity via regulating the JAK2/STAT3 pathway, indicating a promising alternative therapeutic strategy for ischemic stroke.

Development of physiologically relevant synthetic thrombus for use in visual analysis of in vitro mechanical thrombectomy device testing

BACKGROUND

Ischemic stroke is a leading cause of death and significant long-term disability worldwide. Mechanical thrombectomy is emerging as a standard treatment for eligible patients. As clinical implementation of stent retrieval and aspiration thrombectomy increases, there is a need for physiologically relevant in vitro device efficacy testing. Critical to this testing is the development of standardized 'soft' and 'hard' synthetic blood clots that mimic the properties of human thrombi and are compatible with imaging technologies. Synthetic clots allow researchers to extract information regarding clot integration, model hemodynamics, and quantify the physics of thrombectomy.

METHODS

This work develops polyacrylamide and alginate-based synthetic clots that are compatible with particle image velocimetry (PIV) and radiographic imaging techniques while maintaining mechanical properties of 'soft' and 'hard' human clots. Dynamic mechanical analysis testing using an HR2-Rheometer demonstrates comparable mechanical properties to human clots previously tested by this research group and provided in existing literature.

RESULTS

The synthetic clots are formulated with either 0.5% w/v polyethylene microspheres for PIV visualization or 20% w/v barium sulfate for angiographic visualization, enabling real-time imaging of clot behavior during thrombectomy simulations. The soft formulation shows compressive and shear properties of ~12 kPa and 2-3 kPa, respectively. The hard clots are 3-4 times stiffer, with compressive and shear properties of 41-42 kPa and 8-9 kPa, respectively.

CONCLUSION

Standardized synthetic clots offer a platform for reproducible device testing. This provides a greater understanding of mechanical thrombectomy device efficacy, which may lead to quantifiable advances in device development and eventual improved clinical outcomes.

Thrombectomy versus combined thrombolysis for acute basilar artery occlusion: a secondary analysis of the ATTENTION trial

BACKGROUND

Few studies have compared the outcomes of bridging intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) with those of direct MT in patients with acute basilar artery occlusion (BAO). This study aimed to assess the efficacy and safety of direct endovascular treatment (EVT) and bridging IVT followed by EVT in Chinese patients with acute basilar artery occlusion BAO.

METHODS

This subanalysis derived from the prospective multicenter randomized controlled trial of the ATTENTION study, included 221 patients with acute BAO categorized into two groups based on whether they received bridging IVT before MT: MT alone or combined IVT+MT. The primary endpoint was the modified Rankin Scale (mRS) score distribution at 90 days. Secondary outcomes included mRS scores within different ranges (0-1, 0-2, and 0-3) at the 90-day point and National Institutes of Health Stroke Scale (NIHSS) scores at 24 hours and 3 days post-intervention. Safety outcomes encompassed intracranial hemorrhage incidence based on the Heidelberg classification criteria (any intracerebral hemorrhage) and mortality assessment at 90 days.

RESULTS

Direct and bridging IVT before EVT yielded similar primary outcomes. No significant difference in 90-day mRS scores (median, 4.5 vs 4; adjusted odds ratio (aOR), 0.95 [95% confidence interval (CI), 0.79 to 1.15]; p=0.624) was observed between the two groups. Regarding safety outcomes, no significant differences were observed between the groups in terms of death within 90 days or any intracranial hemorrhage within 24 hours.

CONCLUSIONS

In patients with acute BAO, those treated with bridging IVT before EVT did not demonstrate any advantages in enhanced safety and efficacy outcomes compared with those treated with direct EVT.

Bridging thrombolysis with tenecteplase versus endovascular thrombectomy alone for large-vessel anterior circulation stroke: a target trial emulation analysis

BACKGROUND

Whether bridging thrombolysis with tenecteplase is beneficial compared with thrombectomy alone in patients who had a stroke with large-vessel occlusion remains unclear.

METHODS

This is a causal inference study of observational data from the trials SWIFT DIRECT and EXTEND-IA TNK Parts 1 and 2 applying target trial emulation. We compared patients receiving thrombectomy alone to patients receiving tenecteplase 0.25 mg/kg or 0.40 mg/kg before thrombectomy. The primary outcome was functional independence (modified Rankin Scale (mRS) of 0-2) at 90 days. Secondary outcomes included improvement over the full ordinal mRS scale, freedom of disability (mRS 0-1), mortality and occurrence of symptomatic intracranial haemorrhage. The average causal treatment effect was estimated via inverse probability of treatment weighting and G-Computation. We calculated standardised risk differences (SRDs) and adjusted (common) ORs (a(c)ORs).

RESULTS

Of 377 patients included in the target trial, 187 received thrombectomy alone and 190 tenecteplase before thrombectomy. Tenecteplase before thrombectomy did not increase the probability of patients achieving functional independence (SRD 0.04 (95% CI -0.06 to 0.13)) but resulted in a significant improvement in the mRS overall (acOR 1.56 (95% CI 1.07 to 2.23)) and in a higher probability of freedom from disability (SRD 0.10 (95% CI 0.01 to 0.20)). The probability for improvement of functional outcomes was further increased in patients treated within 140 min after onset (ordinal mRS acOR 1.63 (95% CI 1.04 to 2.56)). No significant differences in safety outcomes were observed between the two groups.

CONCLUSION

Tenecteplase before thrombectomy compared with thrombectomy alone did not increase the probability of functional independence but resulted in significant improvement over the full mRS scale. This improvement was most evident in patients treated early.

Chinese stroke association guidelines on reperfusion therapy for acute ischaemic stroke 2024

BACKGROUND

Stroke remains a major global health challenge, with China experiencing a significant burden due to its high incidence and severe outcomes. Reperfusion therapies, such as intravenous thrombolysis and endovascular thrombectomy, have shown substantial benefits in improving early outcomes for ischaemic stroke. Recent clinical trials have validated the safety and efficacy of a broader range of thrombolytic agents and expanded the eligible patient populations for both intravenous thrombolysis and mechanical thrombectomy. This guideline aims to provide the latest evidence-based insights in the field of reperfusion therapy.

METHODS

The Chinese Stroke Association (CSA) established a writing group to develop updated guidelines on reperfusion therapy for acute ischaemic stroke. A comprehensive search of MEDLINE (via PubMed) was conducted up to 30 September 2024. Experts in the field of stroke engaged in extensive discussions, both online and offline, to evaluate the latest evidence. Each recommendation was graded using the CSA's class of recommendation and level of evidence in the Guideline Development Manual of the CSA.

RESULTS

This guideline, reviewed and approved by the CSA Guidelines Writing Group, outlines the criteria for patient selection for thrombolysis and thrombectomy and summarises the latest evidence on various thrombolytic drug options to support decision-making in reperfusion therapy. Additionally, the guideline includes green channel flow charts for intravenous thrombolysis and mechanical thrombectomy, designed to assist clinicians in optimising their clinical decisions.

CONCLUSION

This guideline updates the latest advancements in the field of reperfusion therapy for acute ischaemic stroke. It is anticipated that future clinical research will further advance areas such as innovative thrombolytic agents, expanded indications for thrombolysis and mechanical thrombectomy.

Acute DWI volume is a strong imaging predictor of favorable outcomes in patients with acute stroke and treated with mechanical thrombectomy

BACKGROUND

Infarct volume on diffusion-weighted imaging (DWI) is a promising imaging marker for clinical outcomes in patients with acute stroke treated with mechanical thrombectomy (MT), but its predictive value has not been well evaluated, especially in consecutive patients. The present study aimed to elucidate the relationship between infarct volume and its change and favorable functional outcomes in consecutive patients with acute stroke who underwent MT.

METHOD

Of patients with consecutive acute stroke who underwent MT from September 2014 through December 2019, those who were pre-morbidly independent were enrolled. Infarct volume on DWI was measured at admission (DWIinitial) and 24 h after admission (DWI24h) with semi-automated imaging software. Infarct growth (IG) was calculated as the difference between DWI24h and DWIinitial. Factors associated with a favorable outcome (mRS score 0-2) 3 months after stroke onset were assessed by multivariable analyses. Model performance was evaluated with the C-statistic.

RESULTS

A total of 251 patients (165 male [66 %], median age 75 [IQR 67-81] years, median NIHSS score 15 [7-21]) were enrolled in the present study. Multivariable logistic regression analysis showed that DWI24h (OR 0.74, 95 % CI 0.62-0.87 for every 10-mL increment) and IG (0.74, 0.62-0.88 for every 10-mL increment) were independently and negatively associated with a favorable outcome. These associations were observed in patients with diverse vessel occlusions. Adding DWI24h or IG to the conventional predictors of favorable outcomes improved predictive accuracy (p < 0.05).

CONCLUSION

DWI infarct volume 24 h after admission and IG can be strong imaging predictors of favorable outcomes after MT.

Risk of Symptomatic Intracranial Hemorrhage After Mechanical Thrombectomy in Randomized Clinical Trials: A Systematic Review and Meta-Analysis

BACKGROUND

Symptomatic intracranial hemorrhage (sICH) is the most dreaded complication after reperfusion therapy for acute ischemic stroke. We performed a meta-analysis of randomized controlled trials to estimate and compare risks of sICH after mechanical thrombectomy (MT) depending on the location of the large vessel occlusion, concomitant use of intravenous thrombolysis, timing of treatment, and core size.

METHODS

Randomized controlled trials were included, following a comprehensive search of different databases from inception to 1 March 2024. Random-effect models in a meta-analysis were employed to obtain the pooled risk ratios (RRs) and their corresponding 95% confidence intervals (95% CI) for sICH with MT, and were then compared to other reperfusion treatment regimens, including best medical treatment and intravenous thrombolysis (IVT).

RESULTS

MT in the anterior circulation was associated with a significantly higher risk of sICH as compared with no-MT (RR: 1.46; 95%CI: 1.03-2.07; p = 0.037). The risk of sICH was comparable between the MT and MT+IVT groups (RR: 0.77; 95%CI: 0.57-1.03; p = 0.079). There was no difference in sICH risk with MT as compared with no-MT within 6 h of last known well (RR: 1.14; 95%CI: 0.78-1.66; p = 0.485) and beyond that time (RR: 1.29; 95%CI: 0.80-2.08; p = 0.252); the risk of sICH was also comparable between MT conducted within 6 h of last known well and MT conducted beyond that time (p = 0.512). The sICH risk for MT in the posterior circulation (RR: 7.48; 95%CI: 2.27-24.61) was significantly higher than for MT in the anterior circulation (RR: 1.18; 95%CI: 0.90-1.56) (p = 0.003). MT was also associated with a significantly higher sICH risk than no-MT among patients with large core strokes (RR: 1.71; 95%CI: 1.09-2.66, p = 0.018).

CONCLUSIONS

When evaluating cumulative evidence from randomized controlled trials, the risk of sICH is increased after MT compared with patients not treated with MT. Yet, the difference is largely driven by the greater risk of sICH in patients treated with MT for posterior circulation occlusions and, to a lesser degree, large core strokes. Concomitant use of intravenous thrombolysis and the use of MT in the extended therapeutic window do not raise the risk of sICH.

Association of Alkaline Phosphatase Level with Futile Recanalization in Acute Ischemic Stroke Patients Treated with Endovascular Thrombectomy

OBJECTIVE

Nearly half of Acute Ischemic Stroke (AIS) patients failed to achieve favorable outcomes despite successful reperfusion treatment. This phenomenon is referred to as Futile Recanalization (FR). Screening patients at risk of FR is vital for stroke management. Previous studies reported the diagnostic value of alkaline phosphatase (ALP) levels in certain aspects of stroke prognosis. However, the association between serum ALP level and FR among AIS patients treated with thrombectomy remained unclear.

METHODS

We screened stroke patients who underwent thrombectomy at our center from January 2017 to June 2021, and those who achieved successful reperfusion (modified Thrombolysis in Cerebral Infarction score=3) were ultimately analyzed. Demographic information, vascular risk factors, and laboratory test results were collected at admission. The 3-month unfavorable outcome was defined as a modified Rankin Scale score of 3 to 6. The effect of ALP levels on FR was investigated with a logistic regression model.

RESULTS

Of 788 patients who underwent thrombectomy, 277 achieved successful reperfusion. Among them, 142 patients (51.3%) failed to realize favorable outcomes at 3 months. After adjusting for confounding variables, higher ALP levels (p =0.002) at admission were independently associated with unfavorable outcomes at three months. Adding ALP values to conventional risk factors improved the performance of prediction models for FR.

CONCLUSION

The current study found that the serum ALP levels at admission emerged as a potential biomarker for futile reperfusion in stroke patients undergoing thrombectomy. Further studies are warranted to confirm the clinical applicability of ALP level for futile recanalization prediction.

Predicting Functional Outcomes of Endovascular Thrombectomy in Acute Ischemic Stroke Using a Clinical-Radiomics Nomogram

BACKGROUND

Endovascular thrombectomy (EVT) is recommended for acute ischemic stroke due to large-vessel occlusion. However, approximately 50% of patients still experience poor outcomes after the procedure. This study aimed to assess whether a nomogram model that integrates computed tomography angiography radiomics features and clinical variables can predict EVT outcomes in patients with acute ischemic stroke.

METHODS

A total of 159 patients undergoing EVT were randomly divided into training and validation groups at a 7:3 ratio. A modified Rankin Scale score ≤ 2 at 90 days indicated a favorable outcome. We used univariate and multivariate logistic regression to identify analytic and radiomics predictors and create predictive models. Model performance was evaluated using the area under the curve, Hosmer-Lemeshow test, and decision curve analysis for discrimination, calibration, and clinical utility.

RESULTS

A 19-feature radiomics signature reached an area under the curve of 0.79. Combining it with age, baseline National Institutes of Health Stroke Scale score, diabetes, and statin use increased the area under the curve of the clinical-radiomics nomogram to 0.85. Both decision curve and calibration curve analyses showed strong performance.

CONCLUSIONS

Combining a radiomics nomogram with clinical predictors could effectively forecast EVT outcomes in patients with acute anterior circulation large vessel occlusion stroke.

Thrombectomy Failure and Associated Factors for Large-Vessel Occlusion Stroke

BACKGROUND

Ischemic stroke due to Large Vessel Occlusion (LVO) represents a critical and time-sensitive neurological emergency. Advancements in imaging technology and endovascular therapies have transformed the management of LVO. Nonetheless, thrombectomy failure diminishes the chances of patients achieving a favorable clinical outcome.

OBJECTIVE

We aimed to determine the factors influencing recanalization failure in order to optimize thrombectomy therapy along with enhancing patient outcomes.

METHODS

A retrospective analysis was performed employing consecutive LVO patients who underwent Endovascular Thrombectomy (EVT) in a tertiary comprehensive stroke center between January 2020 and June 2024. Recanalization failure (mTICI 0-2a) following thrombectomy was assessed using the Kolmogorov-Smirnov test, χ2 test, Fisher's exact test, and multivariable logistic regression to identify the related factors.

RESULTS

A total of 82 EVT patients were analyzed. The mean age was 58.20 years and 70.73% of the patients were male. The rate of recanalization failure was 61%. Multivariable logistic regression analysis with age-sex adjusted factors has revealed hypertension [aOR: 5.31 (95% CI: 1.23-22.77); p =0.025] and no IVT [aOR: 2.75 (95% CI: 1.06-7.14); p =0.037] to be independent predictors of recanalization failure in this study.

CONCLUSION

Hypertension and the absence of prior intravenous thrombolysis have been found to be significant contributing factors to the high rate of thrombectomy failure in large-vessel occlusion.

Bridging therapy versus direct endovascular thrombectomy in patients with established large infarct: a prospective cohort study

BACKGROUND

Whether patients with large core infarctions should undergo intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) is currently a subject of controversy. The study aimed to investigate the association of prior use of IVT with outcomes of EVT patients with large core infarctions.

MATERIALS AND METHODS

This prospective cohort included patients with acute large vessel occlusion and Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 0-5 from 38 stroke centers across China between November 2021 and February 2023. The primary outcome was defined as favorable functional outcomes, which is 90-day modified Rankin Scale (mRS) scores ranging from 0 to 3. Procedural outcomes included measures of successful and effective recanalization. Safety outcomes included the incidence of any intracranial hemorrhage (ICH), symptomatic ICH, and 90-day mortality.

RESULTS

Of 490 patients, 122 (24.5%) were treated with IVT before EVT. Bridging therapy and its transfer modes showed no association with any of the measured outcomes. Compared to direct EVT, bridging therapy was associated with a decreased risk of symptomatic ICH in very elderly patients and a decreased risk of any ICH in patients with admission NIHSS scores of 20 or higher. Additionally, early stroke severity may alter the odds of any ICH in patients with bridging therapy versus direct EVT (inverse probability weighting adjusted P value for interaction=0.003 and 0.007, respectively).

CONCLUSION

In large core infarction patients with high admission NIHSS or very elderly age, bridging therapy appears to have some advantages over direct EVT in reducing the risk of ICH.

Zuogui Pill Promotes Neurite Outgrowth by Regulating OPN/ IGF-1R/PTEN and Downstream mTOR Signaling Pathway

AIMS AND OBJECTIVES

Zuogui pill (ZGP) is the traditional Chinese medicine for tonifying kidney yin. Clinical and animal studies have shown that ZGP effectively enhances neurologic impairment after ischemic stroke, which may be related to promoting neurite outgrowth. This investigation aimed to prove the pro-neurite outgrowth impact of ZGP and define the underlying molecular pathway in vitro.

MATERIALS AND METHODS

The major biochemical components in the ZGP were investigated using UPLC-QTOF-MS. All-trans retinoic acid (ATRA) was employed to stimulate SH-SY5Y cells to develop into mature neurons, followed by oxygen-glucose deprivation and reoxygenation damage (OGD/R). Then the cells were supplemented with different concentrations of ZGP, and cell viability was identified by CCK-8. The neurites' outgrowth abilities were detected by wound healing test, while immunofluorescence staining of β-III-tubulin was used to label neurites and measure their length. Western blot was employed to discover the changes in protein levels.

RESULTS

ZGP improved the cell viability of differentiated SH-SY5Y cells following OGD/R damage, according to the CCK-8 assay. Concurrently, ZGP promoted neurite outgrowth and improved neurite crossing and migration ability. Protein expression analysis showed that ZGP upregulated the expression of GAP43, OPN, p-IGF-1R, mTOR, and p-S6 proteins but downregulated the expression of PTEN protein. Blocking assay with IGF-1R specific inhibitor Linstinib suggested IGF-1R mediated mTOR signaling pathway was involved in the pro-neurite outgrowth effect of ZGP.

CONCLUSION

This work illustrated the molecular mechanism underpinning ZGP's action and offered more proof of its ability to promote neurite outgrowth and regeneration following ischemic stroke.

Comparing the efficacy and safety of bridging therapy vs. monotherapy in patients with minor stroke: a meta-analysis

The two main therapeutic approaches for stroke treatment are endovascular thrombectomy, which involves mechanically removing the thrombus, and bridging therapy, which uses intravenous thrombolytics (IVT) prior to endovascular thrombectomy (EVT). This study aimed to compare monotherapy (EVT or IVT alone) with bridging therapy (IVT+EVT) in terms of efficacy and safety outcomes in patients with minor ischemic stroke. After a thorough screening, eight studies were included for qualitative synthesis and meta-analysis, comprising a total of 3,117 patients across the treatment arms. The main outcomes of interest were the efficacy of treatment modality, the rate of intracerebral hemorrhage (ICH), and mortality. In terms of functional outcomes measured by the Modified Rankin Score (mRs) 0-1, no significant difference was observed when comparing IVT monotherapy with bridging therapy (IVT+EVT), with an odds ratio of 0.79 (P = 0.41). However, IVT was associated with a decreased risk of symptomatic intracranial hemorrhage (sICH) compared to bridging therapy (OR = 0.51; P = 0.02), while EVT was associated with an increased risk of sICH compared to bridging therapy (OR = 8.33; P = 0.01). Mortality rates were comparable between IVT alone compared to bridging therapy and EVT alone compared to bridging therapy (P = 0.14). Although both treatment modalities share similar efficacy, there was a trend in favoring bridging therapy for mortality rates, but it was not statistically significant. Future randomized controlled trials and updated systematic reviews are needed within five to ten years to increase sample sizes and potentially identify statistically significant differences in mortality and other outcomes.

Association of primary and secondary hemostasis biomarkers with acute ischemic stroke outcome in patients undergoing thrombectomy, with or without thrombolytics: post hoc analysis of the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands-NO IV

BACKGROUND

Intravenous thrombolysis (IVT) using recombinant tissue plasminogen activator prior to endovascular thrombectomy treatment (EVT) failed to improve treatment effect in acute ischemic stroke (AIS) patients compared with EVT alone.

OBJECTIVES

We investigated whether primary and secondary hemostasis biomarkers are associated with the effect of intravenous thrombolytics on clinical and radiological outcomes after EVT.

METHODS

In the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN)-NO IV, AIS patients were randomized to receive IVT plus EVT or EVT alone. We measured hemostatic biomarkers before and 24 hours postreperfusion to determine changes in biomarkers and the association of the biomarkers with short term stroke severity on National Institutes of Health Stroke Scale score, long-term functional outcome (modified Rankin scale [mRS] score), post-EVT extended Thrombolysis in Cerebral Infarction score, and final infarct size.

RESULTS

This substudy included 214 of the 539 AIS patients who underwent IVT + EVT (n = 108/266) or EVT alone (n = 106/273). In the EVT group, low soluble glycoprotein VI (sGPVI) and high factor (F)VIII levels before treatment were associated with severe National Institutes of Health Stroke Scale score at 24 hours and poor mRS score at 90 days posttreatment, respectively. Also, in this group, sGPVI levels 24 hours after treatment were negatively associated with final infarct size. In the IVT + EVT group, high fibrinogen before treatment was associated with good extended Thrombolysis in Cerebral Infarction score, and low a disintegrin and metalloprotease with thrombospondin motif repeats 13 activity 24 hours posttreatment was associated with an unfavorable mRS score at 90 days.

CONCLUSION

Our findings suggest that patients with high FVIII and fibrinogen and low sGPVI levels might be the most suitable candidates for IVT + EVT and that patients with low a disintegrin and metalloprotease with thrombospondin motif repeats 13 activity might be suitable for EVT alone.

Understanding physician preferences about combined thrombolysis and thrombectomy in patients with large vessel occlusion: An international cross-sectional survey

BACKGROUND

A recently published individual participant-level meta-analysis found that EVT alone was not non-inferior to combined intravenous thrombolysis (IVT) and EVT. Our aim was to determine factors that influence physicians' treatment choice of IVT-alone versus EVT-alone versus a combined approach.

METHODS

We performed an international, structured, invite-only survey among physicians treating patients presenting with AIS. Respondents were asked 16 multiple choice questions. Fourteen questions involved the respondent being provided with a clinical scenario. In each scenario, a patient was presenting with an AIS with LVO, varying a single clinical or imaging feature.

RESULTS

A total of 282 stroke physicians (mean age 46 years, 75 % males) participated in the survey. In LVO stroke, eligible for both IVT and EVT, without other qualifiers, 220 (85.9 %) respondents chose to pursue a combined approach. For age over 80 years, 191 (74 %) participants opted for combined approach, which decreased to 121 (48.2 %) with dementia and 148 (57.4 %) if the patient was on dual anti-platelet therapy (DAPT). Of respondents choosing combination therapy in a patient above the age of 80, only 105 (56.8 %) would pursue the same in a patient with dementia. For imaging factors, 177 (72.8 %) opted for a combined approach for intracranial carotid occlusion, which decreased to 160 (65.3 %) in tandem occlusions. Overall, 88 (38 %) respondents agreed to the statement "I am uncomfortable with uncertainty in patient care".

CONCLUSIONS

In a typical patient with AIS due to LVO, most respondents still choose a combined revascularization approach but discrepancy in decision-making increases in complex scenarios.

Disrupting stroke-induced GAT-1-syntaxin1A interaction promotes functional recovery after stroke

Although stroke is a frequent cause of permanent disability, our ability to promote stroke recovery is limited. Here, we design a small-molecule stroke recovery promoting agent that works by dissociating γ-aminobutyric acid (GABA) transporter 1 (GAT-1) from syntaxin1A (Synt1A), a soluble N-ethylmaleimide-sensitive factor attachment protein receptor (SNARE) protein. Stroke induces an increase in GAT-1-Synt1A interaction in the subacute phase, a critical period for functional recovery. Uncoupling GAT-1-Synt1A reverses stroke-induced GAT-1 dysfunction and cortical excitability decline and enhances synaptic GABAergic inhibition and consequently cortical oscillations and network plasticity by facilitating the assembly of the SNARE complex at the synapse. Based on the molecular mechanism of GAT-1 binding to Synt1A, we design GAT-1-Synt1A blockers. Among them, ZLQ-3 exhibits the greatest potency. Intranasal use of ZLQ-3-1, a glycosylation product of ZLQ-3, substantially lessens impairments of sensorimotor and cognitive functions in rodent models. This compound, or its analogs, may serve as a promoting agent for stroke recovery.

Efficacy and Safety of Intravenous Tenecteplase Before Endovascular Thrombectomy for Acute Ischemic Stroke: The Multicenter, Randomized, BRIDGE-TNK Trial Protocol

BACKGROUND

Six randomized trials have not detected a difference between intravenous alteplase plus endovascular thrombectomy and endovascular thrombectomy alone in stroke. Tenecteplase, a recombinant human tenecteplase tissue-type plasminogen activator, is a genetically modified variant of alteplase. It is unclear whether the outcomes are different if alteplase is replaced with tenecteplase. This trial aims to determine whether intravenous tenecteplase within 4.5 hours of time last known well confers benefit in patients with acute ischemic stroke with large-vessel occlusion who undergo endovascular thrombectomy.

METHODS

BRIDGE-TNK (Thrombectomy With Versus Without rhTNK-tPA in Stroke) is an investigator-initiated, multicenter, prospective, randomized, open-label trial with blinded end point evaluation conducted at 40 thrombectomy-capable centers in China. This trial will randomize 544 patients with intravenous thrombolysis-eligible stroke (272 in each arm) with large-vessel occlusion within 4.5 hours of last known well to receive bridging intravenous tenecteplase with endovascular thrombectomy (tenecteplase-plus-thrombectomy group) or endovascular thrombectomy alone (thrombectomy-alone group). The primary outcome is the proportion of patients achieving functional independence, defined as a score of 0 to 2 on the modified Rankin Scale, at 90 days. Safety will be assessed via symptomatic intracranial hemorrhage at 48 hours and death at 90 days.

CONCLUSIONS

BRIDGE-TNK will provide important data on the role of intravenous tenecteplase before endovascular thrombectomy in patients with acute ischemic stroke with large-vessel occlusion who can be treated within 4.5 hours of last known well.

REGISTRATION

URL: https://clinicaltrials.gov. Unique identifier: NCT04733742.

Endovascular thrombectomy with or without intravenous alteplase in large-core ischemic stroke: a systematic review and meta-analysis

The role of bridging intravenous thrombolysis (IVT) with alteplase before endovascular thrombectomy (EVT) in treating large core ischemic stroke remains uncertain. We aimed to compare clinical outcomes and safety of EVT with or without bridging IVT in patients with anterior circulation large vessel occlusion (ACLVO) and baseline Alberta Stroke Program Early CT Score (ASPECTS) ≤ 5. We systematically searched PubMed, Web of Science, Cochrane Library, and Embase from inception until November 2023. The primary outcome was 90-day functional independence (modified Rankin Scale [mRS] 0-2). Secondary outcomes included 90-day independent ambulation (mRS 0-3), successful recanalization, any intracranial hemorrhage (ICH), symptomatic ICH (sICH) and 90-day mortality. A random-effects model was used for data pooling. Five high-quality studies, incorporating 2124 patients (41% treated with bridging IVT), were included. Across both unadjusted and adjusted analyses, no significant differences were found between the bridging IVT and EVT-alone groups in terms of functional independence (odds ratios [OR] = 1.36, 95% confidence interval [CI]: 0.90-2.07, P = 0.14; adjusted OR [aOR] = 1.19, 95% CI: 0.68-2.09, P = 0.53) or independent ambulation (OR = 1.14, 95% CI: 0.80-1.62, P = 0.47; aOR = 1.18, 95% CI: 1.00-1.39, P = 0.05) at 90 days. Furthermore, no differences were observed in successful recanalization, any ICH, sICH, and 90-day mortality between the two treatment groups. Bridging IVT exhibits similar functional and safety outcomes compared to EVT alone in ACLVO patients with baseline ASPECTS ≤ 5. Further research is warranted to confirm these findings.

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.

Optimizing Acute Ischemic Stroke Outcomes: The Role of Tenecteplase Before Mechanical Thrombectomy

PURPOSE

Acute ischemic stroke (AIS) is a life-threatening condition demanding prompt reperfusion to salvage brain tissue. Thrombolytic drugs, like tenecteplase (TNK), offer clot dissolution, but time constraints and contraindications limit their use. Mechanical thrombectomy (MT) revolutionized AIS treatment, especially for large vessel occlusions (LVO). Recent evidence suggests that administering TNK before MT improves recanalization and outcomes, challenging the dominance of alteplase.

METHODS

Relevant articles focusing on TNK before MT were retrieved from PubMed, Scopus, and Web of Science, looking for randomized controlled trials (RCT), clinical trials, and meta-analyses in humans until 2024.

FINDINGS

TNK, a genetically engineered thrombolytic, exhibits superior fibrin specificity and a longer half-life than alteplase. Clinical trials comparing TNK and alteplase before MT showcase enhanced recanalization, functional outcomes, and safety with TNK. Advanced neuroimaging aids patient selection, though its cost-effectiveness warrants consideration. Dosing studies favor a 0.25 mg/kg dose for efficacy and reduced complications. Clinical guidelines from various associations acknowledge TNK's potential as an alteplase alternative for AIS treatment, particularly for LVOs eligible for thrombectomy.

IMPLICATIONS

In conclusion, TNK emerges as a promising option for bridging therapy in AIS, displaying efficacy and safety benefits, especially when administered before MT. Its fibrin specificity, longer half-life, and potential for improved outcomes position TNK as a viable alternative to alteplase, potentially transforming the landscape of AIS treatment strategies. While limitations like small sample sizes and variations in protocols exist, future research should focus on large-scale RCT, subgroup analyses, and cost-effectiveness evaluations to further elucidate TNK's role in optimizing AIS management.

Impact of fasting blood glucose on prognosis after acute large vessel occlusion reperfusion: results from a multicenter analysis

Objective

To analyze the effect of fasting blood glucose levels after reperfusion of acute large vessel occlusion (ALVO) on patient functional prognosis.

Methods

Retrospectively included ALVO patients from three large stroke centers in China, all of whom achieved vascular reperfusion after mechanical thrombectomy or bridging thrombolysis. The prognosis scores of all patients at 90 ± 7 days post-recanalization were categorized into a good prognosis group (mRS 0-2) and a poor prognosis group (mRS 3-6). The relationship between mean blood glucose levels at 72 h post-recanalization and prognosis was explored using multivariable logistic regression analysis. Then we measured the area under the ROC curve for all factors to assess their predictive performance.

Results

(1) Totally 2,056 patients were included in the study, with 1,488 males and 568 females. There were 1,370 patients in the good prognosis group (mRS 0-2) and 686 in the poor prognosis group (mRS 3-6). (2) The two groups exhibited significant differences in terms of age, preoperative mRS score, history of diabetes, and mean fasting blood glucose (MFBG) (p < 0.001). (3) With 90-day mRS as the outcome variable, all independent variables were included in Univariate and multivariate regression analyses analysis, and the results showed that: age, preoperative mRS score, history of diabetes, and MFBG are all independent predictors of prognosis after recanalization of ALVO, with MFBG demonstrating a higher predictive power than the other factors (AUC = 0.644).

Conclusion

Various factors are correlated with the prognosis in patients who have undergone ALVO recanalization. Notably, the MFBG level demonstrates a significant predictive value for outcomes within the first 72 h following the recanalization procedure.

Bridging the Gap: Improving Acute Ischemic Stroke Outcomes with Intravenous Thrombolysis Prior to Mechanical Thrombectomy

BACKGROUND/OBJECTIVES

Current guidelines recommend intravenous thrombolysis (IVT) followed by mechanical thrombectomy (MT) for patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). This combined approach, known as bridging therapy (BT), is believed to increase the likelihood of a favorable functional outcome when administered within 4.5 h of symptom onset. However, the benefits of BT over direct mechanical thrombectomy (d-MT) remain debated. This study aimed to compare the outcomes of AIS-LVO patients undergoing MT within 6 h of symptom onset, with and without prior IVT.

METHODS

Within the prospective Transzlációs Idegtudományi Nemzeti Laboratórium (TINL) STROKE-registry, AIS-LVO patients admitted to the Department of Neurology, University of Pécs between February 2023 and June 2024 were investigated. The primary endpoint was the proportion of patients reaching functional independence at 90 days, defined as a modified Rankin Scale (mRS) score of 0-2. Secondary endpoints included clinical improvement at 72 h (National Institute of Health Stroke Scale [NIHSS] score of ≤1 or a change from baseline [ΔNIHSS] of ≥4) and successful recanalization (modified Thrombolysis in Cerebral Infarction [mTICI] score ≥ 2). Safety outcomes were evaluated based on thrombus migration and intracranial hemorrhage (ICH). Results were compared using linear and logistic regression analyses adjusted for baseline variables.

RESULTS

Of 82 patients, 51 (62.2%) received BT, while 31 (37.8%) underwent d-MT. The BT group showed a significantly higher rate of functional independence (45.7% vs. 17.2%, p = 0.014) and a lower 90-day mortality rate (13.7% vs. 35.5%, p = 0.029). Multivariate analysis revealed that IVT was independently associated with favorable functional outcomes (p = 0.011) and reduced mortality (p = 0.021). No significant differences were observed in terms of clinical improvement at 72 h, successful recanalization, thrombus migration, or hemorrhagic transformation between the groups.

CONCLUSIONS

This study supports current guidelines recommending BT for thrombectomy-eligible AIS-LVO patients, offering new insights into the ongoing clinical debate.

Futile recanalization after endovascular treatment in acute ischemic stroke with large ischemic core

BACKGROUND

Endovascular therapy (EVT) is the treatment of choice for acute ischemic stroke (AIS) with large vessel occlusion. However, in many patients, successful EVT recanalization does not correspond to a clinical improvement, called futile recanalization (FR). We aimed to identify stroke risk factors and patient characteristics associated with FR in AIS with large core infarct (LCI).

METHODS

A total of 137 patients with AIS with LCI treated by EVT at a single stroke center were retrospectively included from January 2016 to June 2023. LCI was defined by Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECT) < 6. Patient age, sex, modified Rankin Scale (mRS), National Institutes of Health Stroke Scale (NIHSS), time to treatment, risk factors, and radiologic findings were collected, and potential associations with FR were analyzed. FR was defined as successful reperfusion with modified Thrombolysis in Cerebral Infarction (mTICI) ≥ 2b but without functional independence at 90 days (mRS ≥ 3). A multivariate logistic regression analysis was conducted on the clinical characteristics of patients, based on the presence or absence of FR, and the factors influencing FR.

RESULTS

Of 137 patients, 120 showed successful recanalization (mTICI ≥ 2b). All patients were divided into FR (n = 80) and no FR (n = 40) groups. Older age (odds ratio [OR] 1.052, 95% confidence interval [CI] 1.002-1.105; p = 0.041), the higher the initial NIHSS score (OR 1.181, 95% CI 1.037-1.344; p = 0.012), and prior intravenous plasminogen activator (OR 0.310, 95% CI 0.118-0.813, p = 0.017) were independent influencing factors of FR.

CONCLUSIONS

The older age, the higher the initial NIHSS, and not receiving intravenous plasminogen activator were independently associated with FR in AIS with LCI. These factors could identify poor responders to EVT recanalization.