Effect of Endovascular Treatment Alone vs Intravenous Alteplase Plus Endovascular Treatment on Functional Independence in Patients With Acute Ischemic Stroke: The DEVT Randomized Clinical Trial

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.).

Comparing Early National Institutes of Health Stroke Scale Versus 90-Day Modified Rankin Scale Outcomes in Acute Ischemic Stroke Trials: A Systematic Review and Analysis

BACKGROUND

Early National Institutes of Health Stroke Scale (NIHSS) assessment may provide practical benefits over 90-day modified Rankin Scale (mRS), but it is unclear how it compares in adjudicating randomized clinical trial (RCT) results in acute ischemic stroke.

METHODS AND RESULTS

We searched Ovid Medline (inception to April 1, 2023) and included RCTs of acute therapies for acute ischemic stroke with data for both 90-day mRS and NIHSS within 7 days. Primary outcome was agreement between trial results (classified as positive, negative, or neutral) based on 24-hour NIHSS and 90-day mRS scores. We additionally assessed agreement for 2-hour, 48-hour, 72- to 96-hour, and 5- to 7-day NIHSS scores. We aimed to validate our findings using individual patient data from the ESCAPE (Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke) and ESCAPE-NA1 (Safety and Efficacy of Nerinetide [NA-1] in Subjects Undergoing Endovascular Thrombectomy for Stroke) RCTs. We included 116 trials (44 387 patients), contributing 165 NIHSS assessments. The 24-hour NIHSS scores resulted in the same classification as 90-day mRS scores in 61/73 (83.6%) trials (Cohen's kappa, 0.64 [95% CI: 0.45-0.83] and Gwet's agreement coefficient 1, 0.79 [95% CI: 0.67-0.90]). Agreement was not statistically different by timing of NIHSS assessments (range 75%-100%, P=0.33). Individual patient data showed higher agreement for assessments between 48 hours and 7 days, varying by NIHSS dichotomization cutoffs (NIHSS score, 0-2; 2 hours, 56.6%; 24 hours, 66.6%; 48 hours, 71.8%; 5-7 days: 76.5%, P<0.01; NIHSS score, 0-7; 2 hours, 72.8%; 24 hours, 80.5%; 48 hours, 83.1%; 5-7 days: 84.7%, P<0.01).

CONCLUSIONS

The 24-hour NIHSS scores aligned with 90-day mRS scores in 84% of RCT results, indicating intermediate-to-good agreement. However, individual patient data showed that early NIHSS risks misclassifying around 1/4 patients. These data contribute to a better understanding of the nuances of early NIHSS score as an outcome in acute ischemic stroke RCTs.

Systematic Review and Network Meta-Analysis of the Effects of Plant Extracts on Cognitive Function and Quality of Life in Stroke Patients

In recent years, numerous researchers have focused on plant extracts derived from traditional medicines to treat stroke, as these extracts may improve patients' cognitive function and quality of life. This study aims to evaluate the effects of nine distinct plant extracts ( Ginkgo biloba extract, Ginsenosides, Berberine, St. John's Wort extract, Resveratrol, Gastrodin, Crocus sativus L., Moringa oleifera Seed extract, and Panax Notoginseng Saponins) on cognitive function and quality of life in stroke patients. This study seeks to conduct a network meta-analysis to assess the impact of these plant extracts on cognitive function and quality of life in stroke patients. Researchers systematically searched the Embase, PubMed, Cochrane Library, and Web of Science databases from database inception through October 2024 searched for randomized controlled trials (RCTs) exclusively(no language restrictions). The selected studies were evaluated for methodological quality via the Cochrane bias risk assessment tool, and data analysis software was used to analyze the data accordingly. The primary outcome measures included the following assessment scales: National Institute of Health Stroke Scale (NIHSS), Modified Rankin Scale (mRS), Activities of Daily Living Scale (ADLs), Barthel Index (BI), Montreal Cognitive Assessment (MOCA), and Mini-Mental State Examination (MMSE). Treatment effects were ranked based on probability values derived from the surface under the cumulative ranking curve (SUCRA). Moreover, cluster analysis was applied to evaluate the effects of plant extracts on six scales that reflect cognitive function and quality of life in patients. After screening, 48 eligible randomized controlled trials were included, covering 6599 stroke patients and evaluating nine different plant extract treatments. Specifically, results from 33 trials were included in the NIHSS score, 10 in the mRS score, 11 in the ADL score, 11 in the BI score, nine in the MMSE score, and eight in the MOCA score. Findings indicate that St. John's Wort extract (SUCRA 71.2%) was the most effective in reducing NIHSS scores, Berberine (SUCRA 84.1%) was most effective in reducing mRS scores, and St. John's Wort extract (SUCRA 99.1%) showed the highest efficacy in enhancing ADL scores. Ginsenosides were the most effective in improving Barthel Index (SUCRA 74.7%), MMSE (SUCRA 93%), and MOCA (SUCRA 79.7%) scores. The NMA indicates that, compared to placebo, St. John's Wort extract, Berberine, and Ginsenosides can enhance cognitive function and improve quality of life in stroke patients. This study provides valuable insights into using plant extracts for stroke treatment, potentially guiding clinical practice, but there are some unavoidable limitations to our study, including heterogeneity, differences in extraction methods of plant extracts, and lack of consideration of social support systems and dose effects. Future longer follow-up, larger samples, and more methodologically rigorous randomized controlled trials are recommended to clearly establish the effects of different dosages on cognitive function and quality of life in stroke patients.

Helicopter Emergency Medical Services as a Tool for Prehospital Emergency Rescue in Northern Italy

OBJECTIVE

Stroke is a time-sensitive condition in which timely intervention is crucial for optimal outcomes. Advances in stroke management, including extended time windows for thrombolysis and mechanical thrombectomy, highlight the need for efficient patient centralization. This study explores the newly adopted stroke algorithm for patient centralization in Lombardy, Italy, and evaluates the potential for helicopter emergency medical services (HEMS) to improve access to timely care.

METHODS

Data regarding stroke rescue missions were retrieved from SAS-AREU database. Geospatial maps were created using QGIS (Open Source Geospatial Foundation (OSGeo), Chicago, IL) 3.30, with travel times calculated using Google Maps data. Population density was retrieved from Geoportal Lombardia. Area with road travel time to a Hub hospital >60 minutes were identified as potential HEMS priority settings.

RESULTS

In 2024, 11,822 patients rescued by the Regional Agency for Emergency and Urgency were given the "stroke code." HEMS was used in 214 cases, covering a median distance of 49.3 km with a median rescue time of 77 minutes. The study identified areas with road travel times exceeding 60 minutes, highlighting northern Lombardy's mountainous regions and areas with low population density as high priority areas for HEMS intervention. The analysis also revealed an unexpected advantage for air transport in some plain areas, despite viable road access.

CONCLUSION

Geospatial mapping is a valuable tool for identifying areas where HEMS can reduce response times. The integration of HEMS into stroke care algorithms enhances timely interventions, ensuring that patients are centralized within recommended time windows, improving outcomes, and addressing geographic and infrastructural challenges.

Fibrinogen depletion and the risk of intracerebral hemorrhage following endovascular mechanical thrombectomy

BackgroundIntravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are the standard of care for select stroke patients with acute large vessel occlusion (LVO). Fibrinogen levels may drop after IVT, and a significant decrease in fibrinogen is associated with an increased risk of intracranial hemorrhage (ICH). Our pilot study aimed to explore the relationship between fibrinogen levels and the development of ICH in MT-treated patients and whether bridging with IVT further increases that risk.MethodsThis is a prospective pilot study that enrolled adults presenting with a diagnosis of LVO stroke and eligible to receive MT with or without IVT between April 2020 and May 2023. Fibrinogen levels were drawn before treatment with IVT or MT and immediately following MT.ResultsForty-one patients were enrolled. Median age was 68 years [interquartile range 56-79], 58.5% were females and 56.1% were black. Nineteen patients (46.3%) were treated with MT + IVT, and 22 (53.6%) were treated with MT-only. There was no difference in baseline characteristics between the two groups. Baseline fibrinogen levels were similar between MT + IVT and MT-only groups [391 vs. 352 mg/dL, p = 0.4]. Post MT, the MT + IVT group had lower fibrinogen levels compared to the MT-only group [224 vs. 303 mg/dL, p < 0.001]. Similarly, there was a significant change between baseline and follow-up levels in the MT + IVT vs. MT-only group [106 vs. 39.5 mg/dL, p = 0.001]. Eight patients (19.5%) developed ICH; 5 (26.3%) in the MT + IVT group and 3 (13.6%) in the MT-only group. No significant differences were seen in baseline, follow-up, or change in fibrinogen levels between patients who developed ICH and those who did not. However, when stratified by treatment group, postintervention fibrinogen levels were significantly lower in patients who developed an ICH in the MT + IVT group compared to those without ICH in the MT group (200 vs. 301 mg/dL, p = 0.006). There was also a negative correlation between the change in fibrinogen levels and the rate of first-pass recanalization (Spearman CC -0.33, p = 0.03).ConclusionThis pilot study's preliminary data showed an association between fibrinogen depletion and hemorrhagic transformation in MT-treated patients. Since intracerebral hemorrhage is the most dire side effect in stroke treatment, fibrinogen monitoring in patients undergoing MT after IVT may help identify patients with an increased risk of ICH. Larger, prospective, and multicenter studies are needed to confirm these findings and if fibrinogen repletion should be considered for dysfibrinogenemia.

Impact of bridging intravenous thrombolysis and infarct core growth rate on early neurological improvement in patients with acute anterior circulation ischemic stroke and mechanical thrombectomy

PurposeThe aim of this study is to assess the impact of bridging intravenous thrombolysis (IVT), infarct core growth rate (ICGR) and their interaction on neurological outcomes in patients undergoing endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) with anterior large vessel occlusion (LVO).MethodsPatients undergoing EVT due to anterior LVO (ICA to M2 branches) between 2018 and 2022 in a tertiary care center were included. Patient's baseline characteristics, peri-procedural factors of EVT and neurological outcomes were retrospectively analyzed. ICGR was determined by infarct core volume on perfusion CT divided by the time from stroke onset to imaging. Endpoints included early neurological improvement (ENI), defined as NIHSS reduction of ≥8 points after 24 h or NIHSS < 2 at discharge, and intracranial hemorrhage (ICH) on CT at 24 h.ResultsOf 205 patients, 128 (62.4%) received bridging IVT. Neither bridging IVT, ICGR, nor their interaction was significantly associated with ENI or ICH occurrence. Factors significantly associated with ENI included short groin puncture to reperfusion time (OR = 0.98, CI 0.97-0.99, p < 0.001), low pre-stroke mRS (OR = 0.76, CI 0.65-0.89, p = 0.001), and high baseline CT ASPECTS (OR = 1.15, CI 1-1.31, p = 0.049). Factors associated with reduced odds of ICH were short symptom onset to admission time (OR = 1, CI 0.998-1, p = 0.021), short groin puncture to reperfusion time (OR = 1.01, CI 1-1.02, p = 0.039), and complete reperfusion (OR 0.89, CI 0.81-0.97, p = 0.009).ConclusionNeither bridging intravenous thrombolysis, infarct core growth rate, nor their interaction significantly impacted early neurological improvement or intracranial hemorrhage rate.

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.

Construction and validation of a predictive model for poor long-term prognosis in severe acute ischemic stroke after endovascular treatment based on LASSO regression

Objective

We aimed at establishing a predictive model for poor long-term prognosis (3 months post-treatment) following endovascular treatment (EVT) for severe acute ischemic stroke (AIS) and evaluating its predictive performance.

Methods

The patients with severe AIS (NIHSS score ≥ 16) who received EVT were divided into a modeling group (178 patients), an internal validation group (76 patients), and an external validation group (193 patients). Internal and external validation were performed using cross-validation. Poor long-term prognosis was defined as a modified Rankin Scale (mRS) score > 2 at 3 months after the stroke. Univariate analysis and LASSO regression were used to select risk factors, and a logistic regression model was established to create a nomogram. The model's performance and clinical applicability were evaluated using the area under the receiver operating characteristic (ROC) curve (AUC), calibration curves, and decision curves.

Results

Five predictive factors were identified: baseline NIHSS score (OR = 1.096, 95% CI: 1.013-1.196, p = 0.0279), symptomatic intracranial hemorrhage (OR = 6.912, 95% CI: 1.758-46.902, p = 0.0156), time from puncture to reperfusion (OR = 1.015, 95% CI: 1.003-1.028, p = 0.0158), age (OR = 1.037, 95% CI: 1.002-1.076, p = 0.0412), which were found to be risk factors for poor long-term prognosis after EVT for severe AIS. Collateral circulation was identified as a protective factor (OR = 0.629, 95% CI: 0.508-0.869, p = 0.0055). Based on these five factors, a nomogram was constructed to predict poor long-term prognosis after EVT. The ROC curve showed that the AUC for predicting poor long-term prognosis was 0.7886 (95% CI: 0.7225-0.8546) in the modeling group, 0.8337 (95% CI: 0.7425-0.9249) in the internal validation group, and 0.8357 (95% CI: 0.7793-0.8921) in the external validation group. The calibration curve and clinical decision curve demonstrated good consistency and clinical utility of the model.

Conclusion

The predictive model for poor long-term prognosis following EVT for severe AIS has accurate predictive value and clinical application potential.

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.

CT-Based Intrathrombus and Perithrombus Radiomics for Prediction of Prognosis after Endovascular Thrombectomy: A Retrospective Study across 2 Centers

BACKGROUND AND PURPOSE

Complications from endovascular thrombectomy (EVT) can negatively affect clinical outcomes, making the development of a more precise and objective prediction model essential. This research aimed to assess the effectiveness of radiomics features derived from presurgical CT scans in predicting the prognosis post-EVT in patients with acute ischemic stroke.

MATERIALS AND METHODS

This investigation included 336 patients with acute ischemic stroke from 2 medical centers from March 2018 to March 2024. The participants were split into a training cohort of 161 patients and a validation cohort of 175 patients. Patient outcomes were rated with the mRS: 0-2 for good, 3-6 for poor. A total of 428 radiomics features were derived from intrathrombus and perithrombus regions in noncontrast CT and CTA images. Feature selection was conducted using a least absolute shrinkage and selection operator regression model. The efficacy of 8 different supervised learning models was assessed using the area under the curve (AUC) of the receiver operating characteristic curve.

RESULTS

Among all models tested in the validation cohort, the logistic regression algorithm for the combined model achieved the highest AUC (0.87; 95% CI, 0.81-0.92), outperforming other algorithms. The combined use of radiomics features from both the intrathrombus and perithrombus regions significantly enhanced diagnostic accuracy over models using features from a single region (0.81 versus 0.70, 0.77), highlighting the benefit of integrating data from both regions for improved prediction.

CONCLUSIONS

The findings suggest that a combined radiomics model based on CT serves as a potent approach to assessing the prognosis following EVT. The logistic regression model, in particular, proved to be both effective and stable, offering critical insights for the management of stroke.

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.

A Visualized Nomogram to Predict the Risk of Acute Ischemic Stroke Among Patients With Cervical Artery Dissection

Background

Acute ischemic stroke (AIS) is a significant global health concern, with cervical artery dissection (CAD) being a notable yet frequently overlooked cause, particularly in young adults. Despite advancements in imaging technologies, there remains a deficiency in effective methodologies for the prompt identification of AIS attributable to CAD. This research aims to create a predictive model combining clinical, imaging, and laboratory data to improve risk stratification and guide timely interventions.

Methods

Between 2019 and 2024, patients diagnosed with CAD were enrolled in the study. Nomogram models were constructed utilizing a two-step methodological approach. Initially, the least absolute shrinkage and selection operator (LASSO) regression analysis was utilized to improve variable selection. Subsequently, logistic regression analysis was conducted to develop an estimation model using the significant indicators identified by the LASSO. The model's accuracy was evaluated using the application of receiver operating characteristic (ROC) curves, calibration curves, decision curve analyses, and clinical impact curves. The model underwent internal validation through bootstrap resampling with 1,000 iterations.

Results

In the cohort of 102 patients, 75 individuals with CAD experienced had an acute ischemic stroke. This cohort was characterized by a significantly older median age (42 years vs 51 years, p=0.041) and a comparable proportion of males (78.7% vs 74.1%,p=0.825). The analysis identified hyperlipidemia (aOR=0.19, 95% CI=0.040-0.893, p=0.036), lumen occlusion (aOR=5.41, 95% CI=1.236-23.648, p=0.025), a lower lymphocyte-to-monocyte ratio (LMR) (aOR=0.68, 95% CI=0.476-0.797, p=0.038), and higher systemic immune-inflammation index (SII) (aOR=1.01, 95% CI=1.001-1.016, p=0.026) are independent factors linked to ischemic stroke in CAD patients. The predictive model showed strong performance with an AUC of 0.870 (95% CI=0.789-0.950) under the ROC curve. Decision curve analysis (DCA) indicated that the constructed nomogram was clinically applicable, with a risk threshold ranging from 9% to 95%.

Conclusion

This study developed a dynamic and visualized nomogram model for the precise prediction of stroke risk in patients with CAD, exhibiting robust performance, calibration, and clinical utility. Future multi-center studies are anticipated to further substantiate its clinical applicability.

Development and validation of a prognostic nomogram for predicting poor outcomes following intravenous rt-PA in patients with acute ischemic stroke

Background

Intravenous administration of recombinant tissue plasminogen activator (rt-PA) within 4.5 h of symptom onset is a standard treatment for acute ischemic stroke (AIS). However, certain patients continue to develop unfavorable outcomes despite timely rt-PA therapy. Identifying those at high risk is essential for developing individualized care plans and establishing appropriate follow-up.

Methods

This retrospective study included AIS patients treated with intravenous rt-PA at 0.9 mg/kg at our center. Outcomes at three months were evaluated using the modified Rankin Scale (mRS). Patients with mRS scores ≤2 were considered to have favorable outcomes, and those with scores >2 were considered to have poor outcomes. Univariable analysis and stepwise logistic regression were used to identify independent predictors of poor prognosis, and a nomogram was subsequently developed. The model's discriminative power was assessed with area under the receiver operating characteristic curves (AUC-ROC), and its calibration was examined using calibration plots. Decision curves and clinical impact curves were applied to determine clinical utility.

Results

Among 392 enrolled patients, 77 had poor outcomes three months after rt-PA therapy. Fibrinogen (Fg), baseline NIHSS, and a history of hypertension emerged as independent predictors of poor prognosis. The nomogram achieved an AUC of 0.948 (95% CI [0.910-0.985]), with sensitivity of 0.900 and specificity of 0.916 in the training dataset, and an AUC of 0.959 (95% CI [0.907-1.000]), with sensitivity of 0.943 and specificity of 0.947 in the validation dataset. Calibration plots demonstrated close agreement between predicted and observed probabilities, and decision curves indicated a wide range of net benefit threshold probabilities.

Conclusions

This nomogram, incorporating baseline NIHSS, Fg, and a history of hypertension, accurately predicts poor three-month outcomes in AIS patients treated with intravenous rt-PA. Its ease of use may facilitate early risk stratification and assist clinicians in formulating more targeted management strategies and follow-up protocols for patients likely to experience unfavorable outcomes.

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.

Impact of cerebral collateral recycle status on clinical outcomes in elderly patients with endovascular stroke treatment

BACKGROUND

Elderly patients are at high risk of acute ischemic stroke caused by large vessel occlusion (AIS-LVO) and usually suffer disability and fatality from stroke even after receiving endovascular treatment (EVT). Previous studies lacked the knowledge of comprehensive cerebral collateral for elderly patients. Hence, we explore the role of cerebral collateral recycle (CCR) status in clinical outcomes in a real-world setting among elderly AIS-LVO patients undergoing EVT.

METHODS

This was a multicenter retrospective cohort study. Computed tomographic angiography (CTA) at admission was applied to evaluate cerebral venous outflow profiles by the Cortical Vein Opacification Score (COVES) and pial arterial collaterals by the Tan scale. According to the status of cerebral collaterals, enrolled patients were divided into the poor, moderate, and favorable CCR groups. The primary outcome was functional independence (90-day modified Rankin Scale score 0-2).

RESULTS

Among 860 AIS-LVO patients receiving EVT, a total of 338 elderly patients were included in the present study after strict screening. Compared with the poor CCR group, the moderate CCR group (31.1 % vs. 10.2 %; adjusted odds ratio[aOR] 3.80; 95 % confidence interval[CI] 1.71-8.44; P = 0.001) and the favorable CCR group (63.3 % vs. 10.2 %; aOR 8.49; 95 % CI 4.02-17.92; P < 0.001) both had a significantly higher rate of functional independence. In subgroup analysis, similar results were found in AIS-LVO patients with older age, large core infarction, or late time window.

CONCLUSION

The cerebral collateral status in elderly patients with AIS-LVO treated by EVT is a strong predictor of functional outcomes and more robust CCR means better outcomes.

Global Trends of Mechanical Thrombectomy in Acute Ischemic Stroke Over the Past Decade: A Scientometric Analysis Based on WOSCC and GBD Database

OBJECTIVE

To present a global overview of the current research landscape and emerging trends in mechanical thrombectomy for acute ischemic stroke (AIS) over the past decade.

METHODS

A thorough search was conducted on the Web of Science on May 20, 2024, focusing on original articles and reviews in English. Bibliometric tools were employed to make a network analysis and visual representation. Additionally, data on disability-adjusted life years, prevalence, and incidence of ischemic strokes were extracted from the Global Burden of Disease database.

RESULTS

A total of 7776 papers were included, indicating a steady increase from 169 to 1311 between 2014 and 2023. The United States led in core publications with 2887 papers. The incidence and disability-adjusted life years of ischemic stroke have continued to rise in Asia but have recently declined in North America and European countries. The University of Calgary emerged as the leading institution and Mayank Goyal was the most prolific author. Neurointerventional Surgery was the top contributing journal with 790 articles. The analysis identified 6332 keywords forming 5 clusters, with "mechanical thrombectomy" serving as the largest cluster, focusing mainly on interventional thrombectomy techniques for AIS. The term "tissue plasminogen activator" exhibited strong burst strength of 46.58. Keywords such as "injury", "diagnosis", "posterior circulation", and "severity" burst in 2020 and lasted until 2024.

CONCLUSIONS

Interest in mechanical thrombectomy for AIS was progressively increasing. Future research directions may include minimizing intraoperative injuries, refining diagnostic techniques, investigating interventions for posterior circulation, and tailoring thrombectomy strategies based on stroke severity and large vessel occlusion etiology.

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.

Infarct Growth in Patients with Emergent Large Vessel Occlusion Stroke Transferred for Endovascular Thrombectomy

INTRODUCTION

Patients with a large vessel occlusion (LVO) stroke who are transferred to a comprehensive stroke center (CSC) for endovascular thrombectomy (EVT) often experience infarct growth. We aimed to investigate the clinical predictors of fast infarct growth and its effect on clinical outcomes.

METHODS

We retrospectively collected EVT data of patients with LVO transferred to our center between March 14, 2019, and June 28, 2022. The absolute rate of Alberta Stroke Program Early Computed Tomography Score (ASPECTS) decay was defined as (ASPECTS primary CT - ASPECTS repeat CT)/elapsed hours. The ratio of relative ASPECTS deterioration was defined as (ASPECTS primary CT - ASPECTS repeat CT)/ASPECTS primary CT. In the primary analysis, the study population was dichotomized into absolute slow progressors and absolute fast progressors using the median absolute rate of ASPECTS decay. Secondary analysis was also conducted using the median relative ASPECTS deterioration ratio, and the study population was categorized into relative fast progressors and relative slow progressors. Favorable outcome was defined as a 90-day modified Rankin Scale (mRS) score ≤ 2.

RESULTS

We included 309 patients: median age 72 years (IQR 65-77); median National Institutes of Health Stroke Scale (NIHSS) 14 (IQR 11-18). The median absolute rate of ASPECTS decay was 0.42 points/hour and the median relative ASPECTS deterioration ratio was 11.1%. Overall, fast infarct growth was independently associated with worse 90-day outcome (absolute rate of ASPECTS decay: OR = 3.395; 95% CI 1.844-6.250; P < 0.001; relative ASPECTS deterioration ratio: OR = 3.754; 95% CI 2.050-6.873; P < 0.001). In multivariable analysis, fast infarct growth was independently associated with high admission NIHSS, proximal occlusions, and poor collateral status, while intravenous thrombolysis before transfer was negative with fast inter-hospital infarct growth.

CONCLUSIONS

For patients with LVO stroke who are transferred from a PSC to CSC for EVT, the infarct growth rate is highly variable and is strongly associated with 90-day outcomes. Initiation of intravenous bridging therapy before transfer may limit the infarct growth during inter-hospital transfer.

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.

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.

Chronic mitral regurgitation predicts acute heart failure and worse outcomes after endovascular treatment for large vessel occlusion stroke

BACKGROUND

Valvular diseases are widely recognized as important etiologies for large vessel occlusion stroke (LVO) but their impact on outcomes among patients with LVO receiving endovascular treatment (EVT) are less well delineated.

METHODS

This study was a post hoc exploratory analysis of the RESCUE-BT trial, DEVT trial and BASILAR prospective registry. Outcome measures included the modified Rankin Scale (mRS) score at 90 days, symptomatic intracranial hemorrhage, and post-stroke early acute heart failure (EAHF). Chronic significant mitral regurgitation (csMR) was defined as a long-existing mitral regurgitation (MR) with moderate-to-severe MR grade examined by the transthoracic echocardiography. Adjusted odds ratio (aOR) and 95% confidence interval (CI) were obtained by logistic regression models.

RESULTS

Among 2011 patients in these three studies, 837 individuals receiving EVT with available information for valvular status were included in this study. In all categories of chronic valvular disorders, only csMR was related to very poor outcomes (mRS 5-6, aOR 2.76 (95% CI 1.59 to 4.78), P<0.001). CsMR (aOR 7.65 (95% CI 4.33 to 13.49), P<0.001) was an independent predictor of post-stroke EAHF. Mediation analysis showed that csMR increased EAHF instead of reocclusion events or venous thrombosis mediated its effects on functional outcome (49.50% (95% CI 24.83% to 90.00%)). Identical results of csMR on clinical outcomes and post-stroke EAHF were detected in novel cohorts constructed by propensity score matching and sensitivity analysis.

CONCLUSION

Our study demonstrated that csMR was a mediator of heart-brain interaction associated with poor outcomes of LVO after EVT by increasing the frequency of post-stroke EAHF. Replication of these findings in a larger cohort is warranted.

The benefit of favorable venous outflow profiles is mediated through the reduced risk of intracranial hemorrhage in acute ischemic stroke patients undergoing endovascular treatment

BACKGROUND

Favorable venous outflow (VO) has been recognized as an independent predictor of excellent clinical outcomes in acute ischemic stroke caused by anterior circulation large vessel occlusion (AIS-LVO) patients who received endovascular treatment (EVT). However, the reasons why VO affects clinical outcomes have not been fully explained. In this study, we aimed to identify the potential mediators of VO affecting prognosis.

METHODS

We conducted a multicenter retrospective cohort study of consecutive patients with AIS-LVO who underwent EVT. Baseline computed tomographic angiography (CTA) was applied to assess VO by the Cortical Vein Opacification Score (COVES). The primary outcome was functional independence at 90 days (modified Rankin Scale (mRS) score of 0-2). Classifying subtypes of intracranial hemorrhage (ICH) to explore the relationship between ICH subtypes and VO. Multivariate logistic regression and causal mediation analyses were used to evaluate the relationship among VO, functional independence, and potential mediators.

RESULTS

Among 860 AIS-LVO patients undergoing EVT, a total of 515 patients were included in the present study after strict screening. In multivariate logistic regression analysis, favorable VO profiles (defined as COVES 3-6) were significantly associated with a lower incidence of ICH (24.2% vs 46.9%, adjusted odds ratio (aOR) 0.48, 95% confidence interval (CI) 0.30 to 0.77, P=0.002) and a higher proportion of functional independence (58.9% vs 15.0%, aOR 4.07, 95% CI 2.41 to 6.88, P<0.001). Mediation analysis showed that favorable VO profiles significantly reduced the incidence of parencuymal hematoma (PH) 2 accounting for 8.0% (95% CI 0.9% to 19.0%) of its beneficial effect on functional independence.

CONCLUSION

This study demonstrated the potential mediating effects of severe ICH for the beneficial effect of favorable VO on clinical prognosis among patients with AIS-LVO who underwent 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.

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.

Efficacy and safety of tirofiban in acute ischemic stroke patients with ideal reperfusion: A cohort study of LAA and CE subgroups

BACKGROUND AND OBJECTIVES

Despite achieving ideal reperfusion (eTICI = 3) through endovascular treatment (EVT), some acute ischemic stroke (AIS) patients still experience poor outcomes. This study aims to evaluate the efficacy and safety of tirofiban in AIS patients with ideal reperfusion, focusing on its effects in large artery atherosclerosis (LAA) and cardioembolic (CE) stroke.

METHODS

A total of 474 AIS patients from the RESCUE-BT database were included. Patients were assigned to either the tirofiban or placebo group based on the treatment received. The primary outcome was favorable functional recovery at 90 days (mRS ≤2), and safety outcomes included symptomatic intracranial hemorrhage (sICH) and 90-day mortality. Multivariable logistic regression was used to adjust for confounders, and subgroup and interaction analyses assessed tirofiban's efficacy in LAA and CE populations.

RESULTS

In the overall population that achieved ideal reperfusion, Tirofiban did not improve clinical outcomes and did not increase the risk of mortality or incidence of sICH (p > 0.05). However, subgroup analysis indicated potential clinical benefits for patients with higher NIHSS scores in the LAA group, especially in the subgroup with NIHSS scores >13 (adjusted OR 4.671, 95% CI [1.545, 14.122]). No significant differences were found in the CE group.

CONCLUSIONS

Tirofiban showed potential benefits for LAA patients with ideal reperfusion, especially those with NIHSS scores above 13. Careful patient selection is recommended.

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.

Association between coagulation activity and clinical and imaging outcomes in acute ischemic stroke patients - A sub-study of the MR CLEAN NO-IV trial

BACKGROUND

The MR CLEAN NO-IV trial showed neither superiority nor noninferiority of endovascular treatment (EVT) alone compared to intravenous thrombolysis (IVT; Alteplase) before EVT in acute ischemic stroke (AIS) patients with large vessel occlusion of the anterior circulation. Although the treatment effect is largely attributable to EVT, IVT may affect hypercoagulability during AIS.

AIMS

To investigate the association between activated coagulation and final infarct volume and clinical outcomes (modified Rankin Scale 3-6 and mortality 90 days post-EVT), and whether this effect is modified by IVT administration.

METHODS

Enzyme-linked immunosorbent assays were used to quantify activated coagulation markers (activated coagulation factor (F) XIIa-C1 esterase inhibitor (C1inh); FXIIa-antithrombin (AT), FXIa-C1inh, FXIa-AT, FIXa-AT, FXa-AT, T-AT, FVIIa-AT) in plasma samples obtained on admission (T0), 1 h post-EVT (T1) and 24 h post-EVT (T2). Multivariable regressions were performed to investigate the associations and effect modification.

RESULTS

In the total cohort of 116 patients, a significant increase at T1 was seen in FIXa-AT (p = .001), FXa-AT (p < .001), T-AT (p < .001), and FVIIa-AT (p = .012), while there was a significant increase at T2 in FXIIa-C1inh (p < .001). Similar results were seen in the IVT+EVT subgroup. The EVT alone subgroup showed a significant temporary increase at T1 in FXa-AT (p < .001) and T-AT (p = .014). Neither the enzyme:inhibitor complexes nor the interaction with IVT were significantly associated with the outcome measures.

CONCLUSION

Despite temporary significant increases in enzyme:inhibitor complexes in the IVT+EVT group, but not in the EVT alone group, there were no significant associations with final infarct volume and clinical outcomes.

Effusol ameliorates ischemic stroke by targeting NLRP3 protein to regulate NLRP3 inflammasome-mediated pyroptosis

BACKGROUND

The significance of pyroptosis as an inflammatory mode of death in ischemic stroke (IS) has attracted much attention in recent years. Effusol is a dihydrophenanthrene component extracted from Juncus effusus L.. Previous studies have found that Juncus effusus L. has a good inhibitory effect against microglia activation. However, it is not clear whether effusol inhibits microglia over-activation and attenuates its mediated microglia pyroptosis in the treatment of IS.

PURPOSE

The aim is to examine how effusol influences the initiation and activation stages of pyroptosis, as well as the NLRP3 inflammasome, resulting from microglial over-activation triggered post-IS.

METHODS

This study investigated the impact of effusol on neurological severity and edema to assess its neuroprotective effects in IS. Mechanistically, immunofluorescence and western blotting were applied to explore the initiation and activation of the NLRP3 inflammasome. Finally, we employed the NLRP3 specific inhibitor, molecular docking, drug affinity responsive target stability (DARTS), and cellular thermal shift assay (CETSA) to further explore the underlying targets of effusol.

RESULTS

Effusol mitigated IS-induced damage and downregulated the expression of inflammatory factors at the mRNA level, the protein levels of toll-like receptor 4 (TLR4), nuclear transcription factor NF-κB p65, and key components of the NLRP3 inflammasome. Effusol also mitigated mitochondrial damage by increasing ATP levels and decreasing mitochondrial membrane potential. Importantly, effusol targets NLRP3 protein to inhibit pyroptosis, thereby suppressing the hyperactivation of NLRP3 inflammasome.

CONCLUSIONS

Effusol may be protective against IS by targeting NLRP3 proteins to inhibit NLRP3 inflammasome activation-mediated pyroptosis. This finding provides a theoretical basis and a prospective drug candidate for the treatment of effusol in IS.

CTP-Derived venous outflow profiles correlate with tissue-level collaterals regardless of arterial collateral status

BACKGROUND AND PURPOSE

Tissue-level collaterals (TLC), which quantify the state of arterial blood flow transiting through cerebral ischemic tissue, have been shown to be related to the clinical outcomes of acute ischemic stroke (AIS), regardless of the arterial collateral status on computed tomography angiography(CTA). Herein, we investigated whether venous outflow (VO) profiles on computed tomographic perfusion (CTP) were linked to TLC, regardless of the arterial collateral status.

METHODS

Consecutive anterior circulation AIS patients with large vessel occlusion(LVO) undergoing thrombectomy in a retrospective cohort were evaluated between January 2021 and August 2023 at two comprehensive stroke centers. All patients underwent pretreatment noncontrast computed tomography (NCCT), computed tomography perfusion (CTP) and follow-up NCCT or head magnetic resonance imaging (MRI) within 72 h of endovascular treatment (EVT). The VO profile parameters were recorded based on time-density curve derived from the CTP, including the peak time of VO (PTV) and total VO time (TVT). As the quantitative index of TLC, hypoperfusion intensity ratio (HIR) ≦0.4 was considered favorable for TLC. The primary outcome was tissue-level collaterals (TLC), defined by the HIR. Logistic regression analysis was used to assess the association between VO characteristics and TLC, whereas receiver operating characteristic (ROC) analysis was used to evaluate the value of VO parameters in predicting favorable TLC.

RESULTS

This study enrolled 221 eligible patients, among whom patients with favorable TLC were found to have a shorter PTV than patients with unfavorable TLC (12 s vs.16.5 s, P < 0.001) in univariable analysis. A shorter PTV was significantly associated with a favorable TLC (odds ratio [OR], 0.811; 95% confidence interval [CI], 0.709 to 0.927; P=0.002). Multivariable binary logistic stepwise regression analysis revealed that PTV was negatively correlated with TLC, regardless of the arterial collateral status was good (Good: OR, 0.777; 95%CI, 0.660-0.914; P=0.002; Poor: OR,0.729; 95%CI, 0.569-0.932; P=0.012). ROC analysis revealed that the PTV threshold for predicting favorable TLC was ≤13s, with an area under the curve (AUC), sensitivity, and specificity of 0.754, 0.728, and 0.699, respectively. The comprehensive predictor combined with PTV had an optimal predictive ability for TLC with an AUC of 0.894 (sensitivity=0.839, specificity=0.864).

CONCLUSION

Cerebral VO profiles in patients with anterior circulation AIS with LVO were related to TLC regardless of arterial collateral status, while PTV≤13s was a good predictor of favorable TLC.

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.

Association of Conscious Sedation With Dexmedetomidine and Outcome in Stroke Patients Undergoing Thrombectomy in the DEVT and RESCUE-BT Trials

BACKGROUND AND OBJECTIVES

Although dexmedetomidine (DEX) is widely administered during endovascular treatment (EVT) to enhance procedural adherence of patients with acute ischemic stroke (AIS) with large vessel occlusion, there is limited research on the association of DEX and outcomes among these patients. Hence, this study aimed to explore the safety and outcomes of DEX during conscious sedation (CS) in a real-world setting among patients undergoing EVT.

METHODS

This study was an individual patient-level pooled analysis of 2 multicenter randomized clinical trials RESCUE-BT and DEVT. This study included patients who underwent EVT because of occlusion of the internal carotid artery or middle cerebral artery. The DEX group included those receiving intraprocedural DEX for CS, whereas the patients without intraprocedural DEX sedation were categorized into the non-DEX group. The primary outcome was functional independence (modified Rankin Scale score of 0-2 at 90 days). Adjusted odds ratio (aOR) and 95% CI were obtained by logistic regression models.

RESULTS

A total of 728 patients were included in this study, of whom 308 (42.3%) were female. The median (interquartile range) age was 69 (59-76) years; the median baseline NIH Stroke Scale score was 16 (12-19). Compared with the non-DEX group, the DEX group had a significantly lower rate of functional independence (40.3% vs 51.3%; aOR 0.66; 95% CI 0.46-0.93; p = 0.019). There was a significantly higher rate of unstable procedural hemodynamics in the DEX group (9.7% vs 2.3%; aOR 4.60, 95% CI 2.12-9.99, p < 0.001). In subgroup analysis, similar results were found in intraprocedural DEX-treated patients when compared with local anesthesia or intraprocedural midazolam-treated patients, respectively.

DISCUSSION

There was a negative association between procedural DEX administration during CS and functional outcomes in patients with AIS receiving EVT in a real-world setting. A larger cohort is warranted to validate our findings.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that the use of DEX during EVT of AIS is associated with a worse outcome compared with other agents.

Effect of intravenous thrombolysis before endovascular therapy on outcomes in acute ischemic stroke with large core: a systematic review and meta-analysis

OBJECTIVE

To investigate the effect of intravenous thrombolysis (IVT) before endovascular therapy (EVT) on outcomes in acute ischemic stroke of large core.

METHODS

The studies comparing functional outcomes after EVT with and without IVT were systematically searched up to October 10th, 2023. Odds ratio (OR) was pooled using random effects model. Subgroup analysis was performed stratified by study design, country or region, study date, imaging methods and time window.

RESULTS

Thirteen studies were included, enrolling 1717 patients. The pooled rate of functional independence in patients receiving IVT + EVT was 26% (95% CI 20% - 33%), significantly higher than 18% (95% CI 15% - 20%) in those receiving EVT alone (OR 1.55, 95% CI 1.13-2.12, P = 0.006; I²= 23.9%). In subgroup analysis, prior IVT increased the probability of functional independence in retrospective studies (OR 1.97, 95% 1.47-2.63, P < 0.00001; I2 = 0). Non-Asian patients benefit from IVT before EVT for functional independence (OR 2.04, 95% 1.48-2.81, P < 0.0001; I2 = 0), but Asian patients did not (OR 1.45, 95% 0.90-2.35, p = 0.13; I2 = 0). The pooled rate of symptomatic intracranial hemorrhage in patients receiving IVT + EVT was 16% (95% CI 12% - 20%), inclining to be higher than 11% (95% CI 6% - 15%) in those receiving EVT alone without significant difference (OR 1.42, 0.83-2.41, P = 0.20; I²= 12%).

CONCLUSIONS

IVT before EVT might increase the probability of functional independence in non-Asian patients with large ischemic core. The results provided clinicians with additional information on selecting eligible patients for EVT.

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.

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.