Posterior circulation ASPECTS on diffusion-weighted MRI can be a powerful marker for predicting functional outcome

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

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

European stroke organisation and European society for minimally invasive neurological therapy guideline on acute management of basilar artery occlusion

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

Futile recanalization in patients with basilar artery occlusion: assessment of the underlying etiology and the role of perfusion imaging

BACKGROUND

Futile recanalization (FR) after endovascular therapy (EVT) is common in basilar artery occlusion (BAO). The purpose of this study was to investigate the predictors of FR in the posterior circulation with an emphasis on the role of perfusion imaging and its relation to the underlying etiology.

METHODS

We included BAO patients who had pretreatment perfusion imaging and successful recanalization after EVT. Patients were dichotomized into futile and non-futile groups according to the favorable functional outcome at 90 days (modified Rankin Scale (mRS) 0-3). Perfusion abnormalities were assessed using an automated software for Tmax volume measurement and identification of hypoperfusion area based on Tmax>6 s involvement of the pons-midbrain-thalamus (PMT), cerebellum, and temporo-occipital lobe.

RESULTS

Of the 134 enrolled patients, the incidence of FR was 47.8% (64/134). Multivariate logistic analysis showed that a higher National Institutes of Health Stroke Scale (NIHSS) score on admission (adjusted OR (aOR) 1.066; 95% CI 1.011 to 1.125), a longer onset-to-recanalization time (aOR 1.002; 95% CI 1.001 to 1.004), incomplete recanalization (aOR 3.909; 95% CI 1.498 to 10.200), and PMT hypoperfusion (aOR 4.444; 95% CI 1.203 to 16.415) were independent predictors of FR. In patients with embolic occlusion of etiology, PMT hypoperfusion was associated with FR (aOR 8.379; 95% CI 1.377 to 50.994), whereas intracranial atherosclerotic stenosis (ICAS)-related occlusion was not (p=0.587).

CONCLUSIONS

In patients with BAO, the likelihood of FR is associated with PMT hypoperfusion on pretreatment perfusion imaging. In particular, PMT hypoperfusion may be used as an imaging predictor of FR in patients with embolic cause of BAO.

Derivation and Validation of a Scoring System for Predicting Poor Outcome After Posterior Circulation Ischemic Stroke in China

BACKGROUND AND OBJECTIVES

Guidelines for posterior circulation ischemic stroke (PCIS) treatment are lacking and outcome prediction is crucial for patients and clinicians. We aimed to develop and validate a prognostic score to predict the poor outcome for patients with PCIS.

METHODS

The score was developed from a prospective derivation cohort named the Third China National Stroke Registry (August 2015-March 2018) and validated in a spatiotemporal independent validation cohort (December 2017-March 2023) in China. Patients with PCIS with acute infarctions defined as hyperintense lesions on diffusion-weighted imaging were included in this study. The poor outcome was measured as modified Rankin scale (mRS) score 3-6 at 3 months after PCIS. Multivariable logistic regression analysis was used to identify predictors for poor outcome. The prognostic score, namely PCIS Outcome Score (PCISOS), was developed by assigning points to variables based on their relative β-coefficients in the logistic model.

RESULTS

The PCISOS was derived from 3,294 patients (median age 62 [interquartile range (IQR) 55-70] years; 2,250 [68.3%] men) and validated in 501 patients (median age 61 [IQR 53-68] years; 404 [80.6%] men). Among them, 384 (11.7%) and 64 (12.8%) had poor outcome 3 months after stroke in respective cohorts. Age, mRS before admission, NIH Stroke Scale on admission, ischemic stroke history, infarction distribution, basilar artery, and posterior cerebral artery stenosis or occlusion were identified as independent predictors for poor outcome and included in PCISOS. This easy-to-use integer scoring system identified a marked risk gradient between 4 risk groups. PCISOS performed better than previous scores, with an excellent discrimination (C statistic) of 0.80 (95% CI 0.77-0.83) in the derivation cohort and 0.81 (95% CI 0.77-0.84) in the validation cohort. Calibration test showed high agreement between the predicted and observed outcomes in both cohorts.

DISCUSSION

PCISOS can be applied for patients with PCIS with acute infarctions to predict functional outcome at 3 months post-PCIS. This simple tool helps clinicians to identify patients with PCIS with higher risk of poor outcome and provides reliable outcome expectations for patients. This information might be used for personalized rehabilitation plan and patient selection for future clinical trials to reduce disability and mortality.

Early neurological changes following endovascular therapy for acute stroke due to intracranial atherosclerotic disease

BACKGROUND

Endovascular therapy (EVT) reduces functional disability in patients with acute large vessel occlusion (LVO). However, the early neurological change after EVT may be limited in patients with intracranial atherosclerotic disease (ICAD).

METHODS

We analyzed the Japanese Registry of NeuroEndovascular Therapy (JR-NET) 4 which was a retrospective, nationwide, multicenter registry of patients with LVO between 2015 and 2019. We compared the early neurological change, efficacy and safety of EVT for acute LVO in ICAD and other etiologies. The primary outcome was NIHSS improvement ≥10 points, and secondary outcome were NIHSS worsening ≥4 points 7 days after EVT, effective reperfusion rate, 30-day functional outcomes, and safety outcomes.

RESULTS

Among the 6710 enrolled patients, 610 (9.1%) had ICAD. The ICAD group was younger (mean 72.0 vs. 75.8 years) and predominantly male (63.4% vs. 56.0%), had lower NIHSS scores before EVT (median 16 vs. 18), and underwent percutaneous transluminal angioplasty and stenting more frequently (43.0% vs. 4.4%, 12.3% vs. 4.4%). In the ICAD group, NIHSS improvement was significantly lower (adjusted odds ratio (aOR) [95% confidence interval (95%CI)] 0.52 [0.41-0.65]), NIHSS worsening was significantly higher (aOR [95%CI] 1.76 [1.31-2.34]), and effective reperfusion was significantly lower (aOR [95%CI] 0.47 [0.36-0.60]). Fewer patients with ICAD had modified Rankin scale 0-2 at 30 days (aOR [95%CI] 0.60 [0.47-0.77]). The risk of acute reocclusion was more prominent in the ICAD group (aOR [95%CI] 4.03 [1.98-8.21]).

CONCLUSIONS

Improvement in neurological severity after EVT was lower in patients with LVO and ICAD.

Efficacy of Endovascular Thrombectomy in Acute Basilar Artery Occlusion with Low PC-ASPECTS: A Nationwide Prospective Registry-Based Study

OBJECTIVE

We evaluated the efficacy of endovascular thrombectomy (EVT) on the functional outcome of patients with acute basilar artery occlusion and low posterior circulation acute stroke prognosis early computed tomography score (PC-ASPECTS).

METHODS

We identified patients with acute ischemic stroke due to basilar artery occlusion and PC-ASPECTS of 6 or less, presenting within 24 h between August 2008 and April 2022. The primary outcome was a favorable functional outcome, defined as a modified Rankin Scale (mRS) score of 0-3 at 90 days. The secondary outcomes included an mRS score of 0-2, a favorable shift in the ordinal mRS scale, the occurrence of symptomatic intracranial hemorrhage (sICH), and mortality at 90 days. We compared the outcome of patients treated with EVT and those without EVT, using the inverse probability of treatment weighting methods.

RESULTS

Out of 566 patients, 55.5% received EVT. In the EVT group, 106 (33.8%) achieved favorable outcomes, compared to 56 patients (22.2%) in the conservative group. EVT significantly increased the likelihood of achieving a favorable outcome compared to conservative treatment (relative risk [RR] 1.39, 95% confidence interval [CI], 1.11-1.74, p = 0.004). EVT was associated with a favorable shift in the mRS (RR 1.85, 95% CI, 1.49-2.29, p < 0.001) and reduced mortality without an increase in the risk of sICH. It did not have an impact on achieving an mRS score of 0-2.

INTERPRETATION

Patients with acute basilar artery occlusion and a PC-ASPECTS of 6 or less might benefit from EVT without an increasing sICH. ANN NEUROL 2024;95:788-799.

Impact of prodromal symptoms on the prognosis of patients with basilar artery occlusion treated with mechanical thrombectomy

INTRODUCTION

Even with reperfusion therapies, the prognosis of patients with basilar artery occlusion (BAO) related stroke remains poor. We aimed to test the hypothesis that the presence of prodromal symptoms, an easily available anamnestic data, is a key determinant of poor functional outcome.

PATIENTS AND METHODS

Data from patients with BAO treated in Lille, France, with mechanical thrombectomy (MT) between 2015 and 2021 were prospectively collected. The presence of prodromal symptoms was defined by previous transient neurological deficit or gradual progressive clinical worsening preceding a secondary sudden clinical worsening. We compared the characteristics of patients with and without prodromal symptoms. We built multivariate logistic regression models to study the association between the presence of prodromal symptoms and functional (mRS 0-3 and mortality), and procedural (successful recanalization and early reocclusion) outcomes.

RESULTS

Among the 180 patients, 63 (35%) had prodromal symptoms, most frequently a vertigo. Large artery atherosclerosis was the predominant cause of stroke (41.3%). The presence of prodromal symptoms was an independent predictor of worse 90-day functional outcome (mRS 0-3: 25.4% vs 47.0%, odds ratio (OR) 0.39; 95% confidence interval (CI) 0.16-0.86) and 90-day mortality (OR 2.17; 95% CI 1.02-4.65). Despite similar successful recanalization rate, the proportion of early basilar artery reocclusion was higher in patients with prodromal symptoms (23.8% vs 5.6%, p = 0.002).

DISCUSSION AND CONCLUSION

More than one third of BAO patients treated with MT had prodromal symptoms, especially patients with large-artery atherosclerosis. Clinicians should systematically screen for prodromal symptoms given the poor related functional outcome and increased risk of early basilar artery reocclusion.

Clinical evaluation of mechanical thrombectomy for patients with posterior circulation occlusion: A retrospective study

OBJECTIVE

Although consensus has been reached regarding the use of mechanical thrombectomy for acute large anterior circulation occlusion, its effectiveness in patients with posterior circulation occlusion remains unclear. This study aimed to establish the determining factors for good clinical outcomes of mechanical thrombectomy for posterior circulation occlusion.

METHODS

We extracted cases of acute large vessel occlusion (LVO) in the posterior circulation from a database comprising 536 patients who underwent mechanical thrombectomy at our hospital between April 2015 and March 2021.

RESULTS

Fifty-two patients who underwent mechanical thrombectomy for LVO in the posterior circulation were identified. Five patients with simultaneous occlusion of the anterior and posterior circulation were excluded; finally, 47 patients were included in this study. The median patient age was 78 years, and 36% of the patients were women. The median National Institutes of Health Stroke Scale (NIHSS) score on admission was 31, the median posterior circulation-Alberta Stroke Program Early Computed Tomography Score (pc-ASPECTS) was 8, and the median Basilar Artery on Computed Tomography Angiography (BATMAN) score was 6. The rate of good recanalization (Thrombolysis in Cerebral Infarction scale grades 2b and 3) was 96%, and a good prognosis (modified Rankin Scale score of 0-2 at 90 days) was achieved in 19 patients (40%). The median pc-ASPECTS was significantly higher in the good prognosis group than in the poor prognosis group (10 vs. 7; p = 0.007). The median NIHSS score at presentation was significantly lower in the good prognosis group than in the poor prognosis group (17 vs. 34; p = 0.02). The median BATMAN score was significantly higher in the good prognosis group than in the poor prognosis group (8 vs. 3.5; p = 0.0002). Multivariate analysis showed that an NIHSS score ≦ 20 at presentation was the only independent factor for good prognoses.

CONCLUSION

The prognosis of mechanical thrombectomy for posterior circulation LVO was better in patients with lower NIHSS scores at presentation.

Posterior circulation cerebral infarction: A review of clinical, imaging features, management, and outcomes

Objective

This narrative review discusses posterior circulation cerebral infarcts (PCCI) and provides an update given recent randomized trials in the management of basilar artery occlusion (BAO). We examine clinical characteristics, imaging protocols, management updates, and outcomes of PCCI.

Methods

The following databases were searched: MEDLINE, Scopus, Google Scholar, and Web of Science for articles on PCCI. We included randomized trials and observational studies in humans. We also reviewed relevant references from the literature identified.

Results

PCCI and BAO is associated with high morbidity and mortality. Early assessment and accurate diagnosis of PCCI remains a clinical challenge. Neuroimaging advances have improved early detection, but barriers remain due to costs and availability. Recent randomized trials provide new insights for BAO patients and support the efficacy of endovascular thrombectomy.

Discussion

PCCI requires specific diagnostic and management that is distinct from anterior circulation stroke. While further studies are needed in varied populations and in the subset of BAO patients presenting with milder deficits, growing randomized data support the treatment of BAO patients with endovascular thrombectomy.

Basilar artery occlusion: A review of clinicoradiologic features, treatment selection, and endovascular techniques

Basilar artery occlusion (BAO) is an infrequent but often fatal subtype of stroke. Predicting outcomes and selecting patients for endovascular therapy (EVT) remains challenging. Advances in neuroimaging and the development of prognostic scoring systems have augmented clinical decision-making over time. Recent randomized trials, BEST (Basilar Artery Occlusion Endovascular Intervention vs. Standard Medical Treatment), BASICS (Basilar Artery International Cooperation Study), BAOCHE (Basilar Artery Occlusion CHinese Endovascular Trial) and ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion), compared EVT and medical management for patients with BAO. These trials yielded mixed results. The former two suggested unclear benefit while the latter two supported a benefit of EVT. While all had limitations, most providers agree caution should be exercised when excluding patients from EVT who may stand to benefit. Further studies are therefore needed to determine the effectiveness, safety, selection criteria, and optimal technical approach for EVT among patients with BAO. Hyperacute-phase advanced imaging can offer several benefits to aid decision making. It is reasonable to exclude patients with low National Institutes of Health Stroke Scale (NIHSS), large imaging-proven cores, and evidence of perforator occlusion by branch atheromatous disease. Herein, we review the clinical presentation, imaging work-up, treatments, and clinical outcomes for BAO, while highlighting knowledge gaps in treatment selection and technique.

Neuroimaging Modalities Used for Ischemic Stroke Diagnosis and Monitoring

Strokes are one of the global leading causes of physical or mental impairment and fatality, classified into hemorrhagic and ischemic strokes. Ischemic strokes happen when a thrombus blocks or plugs an artery and interrupts or reduces blood supply to the brain tissue. Deciding on the imaging modality which will be used for stroke detection depends on the expertise and availability of staff and the infrastructure of hospitals. Magnetic resonance imaging provides valuable information, and its sensitivity for smaller infarcts is greater, while computed tomography is more extensively used, since it can promptly exclude acute cerebral hemorrhages and is more favorable speed-wise. The aim of this article was to give information about the neuroimaging modalities used for the diagnosis and monitoring of ischemic strokes. We reviewed the available literature and presented the use of computed tomography, CT angiography, CT perfusion, magnetic resonance imaging, MR angiography and MR perfusion for the detection of ischemic strokes and their monitoring in different phases of stroke development.

Effect of edaravone on symptomatic intracranial hemorrhage in patients with acute large vessel occlusion on apixaban for non-valvular atrial fibrillation

BACKGROUND

Edaravone administration was associated with lower incidence of symptomatic intracranial hemorrhage (sICH) in patients with acute large vessel occlusion (LVO). However, its protective effect on sICH in patients with LVO who receive direct oral anticoagulants for non-valvular atrial fibrillation (NVAF) is uncertain.

OBJECTIVES

To explore the effect of edaravone administration on the incidence of sICH in patients with acute LVO receiving apixaban for NVAF.

METHODS

A Japanese multicenter registry of apixaban on clinical outcome of the patients with LVO or stenosis (ALVO study) included patients who were admitted within 24 h after stroke onset and were received apixaban within 14 days of stroke onset. Patients were divided into two groups according to edaravone administration (Edaravone and No-Edaravone groups). The incidence of sICH within one year and infarct growth before apixaban administration were compared between these groups.

RESULTS

Of the 686 enrolled patients, 622 were included and edaravone was administered to 407 (65.4%). The incidences of sICH in Edaravone and No-Edaravone groups were 1.3% and 5.0%, respectively (p = 0.01). The inverse probability of treatment-weighting (IPTW) hazard ratio (HR) (95% confidence interval [CI]) of Edaravone group for sICH within one year was 0.36 (0.15-0.80) compared to No-Edaravone group. The incidences of infarct growth in Edaravone and No-Edaravone groups were 35.3% and 42.0%, respectively (p = 0.13). IPTW HR (95% CIs) for infarct growth was 0.76 (0.60-0.97).

CONCLUSIONS

Edaravone administration was associated with a lower incidence of sICH in patients with LVO and NVAF who administrated apixaban.

Outcomes of Endovascular Treatment versus Standard Medical Treatment for Acute Ischemic Stroke with Basilar Artery Occlusion: A Systematic Review and Meta-Analysis

BACKGROUND

Although endovascular treatment (EVT) is beneficial for large vessel occlusion in anterior circulation stroke, whether these benefits exist for basilar artery occlusion (BAO) remains unclear. This systematic review and meta-analysis compared the outcomes of patients with BAO undergoing EVT and standard medical treatment (SMT).

METHODS

The PubMed, Embase, and Cochrane Library databases were searched for eligible randomized control trials (RCTs) and non-RCTs involving patients with acute ischemic stroke and BAO undergoing EVT or SMT. The following outcomes were assessed: 90-day functional outcomes (favorable outcome and functional independence: modified Rankin scale [mRS] score of 0-3 or 0-2, respectively), mortality, and symptomatic intracranial hemorrhage (sICH) incidence. The summary effect sizes were determined as risk ratios (RRs) through the Mantel-Haenszel method with a random-effects model.

RESULTS

Four RCTs and four non-RCTs were included. Compared with SMT, EVT resulted in a higher proportion of patients with 90-day mRS scores of 0-3 (RR: 1.54 [1.16-2.06] in RCTs and 1.88 [1.11-3.19] in non-RCTs), a higher proportion of patients achieving functional independence (90-day mRS score of 0-2; RR: 1.83 [1.07-3.12] and 1.84 [0.97-3.48], respectively), a lower risk of mortality (RR: 0.76 [0.65-0.89] and 0.72 [0.62-0.83], respectively), and a higher sICH risk (RR: 5.98 [2.11-16.97] and 4.95 [2.40-10.23], respectively). Severe neurological deficits, intravenous thrombolysis, and higher posterior circulation Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS) were associated with EVT benefits.

CONCLUSION

In patients with BAO, EVT results in superior functional outcomes, lower mortality risk, and higher sICH risk than does SMT, independent of age and sex. Higher National Institutes of Health Stroke Scale scores, intravenous thrombolysis, and higher pc-ASPECTSs before treatment are associated with greater benefits from EVT.

Clinical outcome and outcome prediction of octogenarians with acute basilar artery occlusion and endovascular stroke treatment compared to younger patients

Background and aims

Octogenarians are underrepresented in recently published studies that showed the benefit of endovascular stroke treatment (EST) for patients with acute basilar artery occlusion (BAO). We aimed to compare the clinical outcome of octogenarians with BAO and EST compared to younger patients (YPs) and identify independent outcome predictors.

Methods

This is a retrospective, single-center analysis of patients treated for BAO with EST from January 2013 until June 2021 in a tertiary stroke center. Octogenarians (80-89 years) were compared to YPs. A study endpoint was a favorable clinical outcome as per the modified Rankin Scale (mRS 0-3), 90 days after stroke onset. The study groups were compared using univariate analysis, and a multivariable logistic regression analysis was performed to define independent predictors for favorable and unfavorable (mRS 5-6) clinical outcomes.

Results

In this study cohort, 74/191 (38.7%) octogenarians had a higher pre-stroke mRS [median, interquartile range (IQR): 2, 1-3 octogenarians vs. 0, 0-1 YP, p < 0.001] and a comparable National Institutes of Health Stroke Scale (NIHSS) before EST (median, IQR: 21, 10-38 vs. 20, 8-35 in YP, p = 0.487). They showed a comparable rate of favorable outcome (mRS 0-3, 90 days, 23.0 vs. 25.6% in YP, p = 0.725), but were less often functionally independent (mRS 0-2: 10.8% in octogenarians vs. 23.0% in YP, p = 0.049). The rate of unfavorable clinical outcome was comparable (mRS 5-6, n = 40, 54.1% in octogenarians vs. n = 64, 54.7% in YP, p = 0.831). A baseline NIHSS was an independent predictor for clinical outcome in YPs [e.g., for unfavorable clinical outcome: odds ratio (OR) 1.061, confidence interval (CI) 1.027-1.098, p = 0.005] and for favorable clinical outcome in octogenarians. Pre-stroke mRS predicted favorable outcomes in octogenarians (OR 0.54, CI 0.30-0.90, p = 0.0291), while age predicted unfavorable outcomes in YPs (OR 1.045, CI 1.011-1.086, p = 0.0137).

Conclusion

Octogenarians with acute BAO eligible for EST are as likely to achieve a favorable outcome as YPs, and the rate of death or severe disability is comparable. The admission NIHSS is an independent predictor for favorable and unfavorable outcomes in YP and for favorable outcomes in octogenarians. In this study cohort, pre-stroke mRS predicted favorable outcomes in octogenarians while age predicted an unfavorable outcome in YPs.

Effect of massive cerebellar infarction on the outcomes of patients with acute basilar artery occlusion during hospitalization after endovascular treatment: A retrospective study

Acute basilar artery occlusion (ABAO) after endovascular treatment (EVT) is often associated with a poor prognosis, particularly in patients with cerebellar infarction who may develop malignant cerebellar edema. The present study aimed to investigate how massive cerebellar infarction (MCI) affects hospitalization outcomes in ABVO patients who undergo EVT. We conducted a retrospective study of ABVO patients who underwent EVT at our hospital between September 2017 and September 2022. MCI was diagnosed using imaging techniques, and various prognostic scores were assessed during hospitalization to examine the relationship between MCI and these outcomes. We identified 42 ABAO patients, of whom 22 (52.4%) had MCI. Patients with MCI had a higher modified Rankin Scale (mRS) score at discharge compared to those without MCI (4.36 ± 1.14 vs 3.05 ± 1.85, P = .042, odds ratio [OR] (95% confidence interval [CI]) = 1.093 (0.083, 2.103)), and a lower Glasgow Coma Scale score (6.59 ± 4.0 vs 10.10 ± 5.07, P = .036, OR (95% CI) = -3.444 (-6.518, -0.369)). MCI was identified as an independent risk factor for an extremely poor prognosis (mRS ≥ 5) at discharge (P = .036, OR (95% CI) = 15.531 (1.603, 313.026)) and for no improvement in mRS score compared to onset (P = .013, OR (95% CI) = 0.025 (0.001, 0.274)). Additionally, an extremely poor prognosis was independently associated with stent implantation, EVT duration, and body mass index, while mRS score improvement was correlated with EVT duration and pulmonary infection. MCI in ABAO patients is a significant independent risk factor for a poor prognosis at discharge and no improvement in function score compared to onset. Early diagnosis and intervention are necessary to improve outcomes, particularly in high-risk populations.

Imaging predictors of clinical outcomes after endovascular treatment in MRI-selected patients with acute basilar artery occlusion

PURPOSE

We aimed to investigate the impact of baseline infarct area and collateral status (CS), which are imaging predictors of clinical outcome following stroke, after endovascular treatment (EVT) in MRI-selected patients with acute basilar artery occlusion (BAO).

METHODS

Patients with acute BAO who underwent EVT within 24 h after stroke from December 2013 to February 2021 were included in this retrospective, multicenter, observational study. The baseline infarct area was evaluated by the posterior circulation of Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS) using diffuse-weighted imaging (DWI), and CS was assessed by measuring the computed tomography angiography of the basilar artery (BATMAN) score and the posterior circulation collateral score (PC-CS) using magnetic resonance angiography (MRA). A Good outcome was defined as a modified Rankin scale score ≤ 3 at 3 months. For each imaging predictor, a multivariate logistic regression analysis was performed to evaluate its impact on good outcomes.

RESULTS

A total of 86 patients were analyzed, and 37 (43.0%) had a good outcome. The latter showed significantly higher pc-ASPECTS than those without good outcomes. In multivariate analyses, a pc-ASPECTS ≥ 7 was significantly associated with good outcomes (OR, 2.98 [95% CI, 1.10-8.13], P = 0.032), while PC-CS ≥ 4 (OR, 2.49 [95% CI, 0.92-6.74], P = 0.073) and BATMAN score ≥ 5 (OR, 1.51 [95% CI, 0.58-3.98], P = 0.401) were not.

CONCLUSIONS

In MRI-selected patients with acute BAO, pc-ASPECTS on DWI was an independent predictor of clinical outcomes after EVT, while the MRA-based CS assessments were not.

The Value of Interdisciplinary Collaboration in Lateral Medullary Syndrome Rehabilitation: A Case Report

Wallenberg's syndrome, also known as lateral medullary syndrome (LMS), is a neurological condition resulting from damage to the lateral portion of the medulla oblongata. We present a case of a 64-year-old man with Wallenberg's syndrome who presented for acute rehabilitation after sustaining a cerebrovascular accident (CVA). As seen in our patient, common symptoms of LMS include difficulty swallowing, hoarseness, ipsilateral weakness, and ipsilateral loss of sensation or numbness. Although the prognosis following infarction is often good, dysfunction in swallowing is one of the key deficits that have a long-term impact on patient quality of life. We aim to emphasize the significance of the interdisciplinary approach to achieving favorable health outcomes in patients with LMS.

Early-versus-Late Endovascular Stroke Treatment: Similar Frequencies of Nonrevascularization and Postprocedural Cerebrovascular Complications in a Large Single-Center Cohort Study

BACKGROUND AND PURPOSE

Endovascular treatment of acute ischemic stroke is now performed more frequently in the late window in radiologically selected patients. However, little is known about whether the frequency and clinical impact of incomplete recanalization and postprocedural cerebrovascular complications differ between early and late windows in the real world.

MATERIALS AND METHODS

We retrospectively reviewed all patients with acute ischemic stroke receiving endovascular treatment within 24 hours from 2015 to 2019 and included in the Acute STroke Registry and Analysis of Lausanne. We compared rates of incomplete recanalization and postprocedural cerebrovascular complications (parenchymal hematoma, ischemic mass effect, and 24-hour re-occlusion) in the early (<6 hours) versus late window (6-24 hours, including patients with unknown onset) populations and correlated them with the 3-month clinical outcome.

RESULTS

Among 701 patients with acute ischemic stroke receiving endovascular treatment, 29.2% had late endovascular treatment. Overall, incomplete recanalization occurred in 56 patients (8%), and 126 patients (18%) had at least 1 postprocedural cerebrovascular complication. The frequency of incomplete recanalization was similar in early and late endovascular treatment (7.5% versus 9.3%, adjusted P =.66), as was the occurrence of any postprocedural cerebrovascular complication (16.9% versus 20.5%, adjusted P = .36). When analyzing single postprocedural cerebrovascular complications, rates of parenchymal hematoma and ischemic mass effect were similar (adjusted P = .71, adjusted P = .79, respectively), but 24-hour re-occlusion seemed somewhat more frequent in late endovascular treatment (4% versus 8.3%, unadjusted P = .02, adjusted P = .40). The adjusted 3-month clinical outcome in patients with incomplete recanalization or postprocedural cerebrovascular complications was comparable between early and late groups (adjusted P = .67, adjusted P = .23, respectively).

CONCLUSIONS

The frequency of incomplete recanalization and of cerebrovascular complications occurring after endovascular treatment is similar in early and well-selected late patients receiving endovascular treatment. Our results demonstrate the technical success and safety of endovascular treatment in well-selected late patients with acute ischemic stroke.

Risk factors and prognosis of early neurological deterioration in patients with posterior circulation cerebral infarction

BACKGROUND

The incidence, risk factors, and pathogenesis of early neurological deterioration (END) in posterior circulation stroke are still unclear. In this study, we aimed to determine the risk factors and prognosis of END in patients with acute posterior circulation cerebral infarction.

METHODS

Acute posterior circulation ischemic stroke patients who had completed neuroimaging within 72 h of onset were selected from a prospective registry study Demographic characteristics, physiological data, medical history, laboratory data, in-hospital evaluation, neurological severity and TOAST classification, treatment, and the modified Rankin Scale (mRS) score of patients were assessed. Early neurological deterioration was defined as an increase of 2 points in the National Institutes of Health Stroke Scale score between the baseline and 72 h evaluation. Favorable and poor outcomes were defined as mRSs of 02 and≥ 3, respectively, at 3 months. The incidence and risk factors were evaluated by univariate and multivariate regression analysis (step-back method).

RESULTS

The analysis included 455 subjects with an acute posterior circulation non-cardiac ischemic stroke, 330 (72.53 %) of them male, with an average age of 63.12 ( ± 10.14) years and with 47 (10.33 %) having END. The results of univariate and multivariate logistic regression analysis showed that BATMAN scores ≥ 5 (OR: 0.1, 95 % CI: 0.02-0.53, P < 0.01), large artery atherosclerosis (OR: 11.55, 95 % CI: 4.18-31.93, P < 0.01), vascular stenosis > 50 % (OR: 2.44, 95 % CI: 1.1-5.42, P = 0.029), reperfusion therapy (OR: 4.21, 95 % CI: 1.66-10.64, P < 0.01), and the distribution of pontine lesions (OR: 5.66, 95 % CI: 2.39-13.44, P < 0.01) were significantly associated with END. Patients with END had a lower rate of favorable outcomes at discharge and long-term follow-up (P < 0.001), regardless of whether they received reperfusion therapy.

CONCLUSION

The lesion distribution of the pons, the progression of temporo-occipital lobe lesions, and large arterial atherosclerosis are independent risk factors of END that might predict a poor short- and long-term prognosis.

Impact of thrombocytopenia on hemorrhagic complications after endovascular therapy for acute large vessel occlusion: Sub-analysis of RESCUE-Japan registry 2

BACKGROUND

Endovascular treatment (EVT) for patients with large vessel occlusion (LVO) and concurrent thrombocytopenia raises concerns about hemorrhagic complications. We examined the association between thrombocytopenia and clinical outcomes after EVT.

METHODS

This is a sub-analysis of the RESCUE-Japan Registry 2, a nationwide registry that enrolled 2420 consecutive acute LVO patients. We evaluated the clinical outcomes in patients who underwent EVT according to their platelet count on admission (Moderate/Severe, < 100 × 10⁹ /L; Mild, 100 to ≤150 × 10⁹/L; Normal, ≥ 150 × 10⁹/L). The outcomes included any and symptomatic intracranial hemorrhage (ICH) after EVT, and modified Rankin Scale (mRS) at 90 days.

RESULTS

Of 1268 patients who underwent EVT, the Moderate/Severe and Mild groups consisted of 41 (3.2%), and 193 (15.2%) patients. Any ICH occurred in 37%, 35%, and 24% of Moderate/Severe, Mild, and Normal group patients, respectively, and the adjusted ORs (95% CIs) were 1.50 (0.71-3.18) for Moderate/Severe and 1.87 (1.28-2.73) for Mild, compared to the Normal group (p for trend = 0.004). Symptomatic ICH increased with the severity of thrombocytopenia (9.8% vs 3.6% vs 2.1%), and adjusted ORs were 4.43 (1.16-17.0) in Moderate/Severe and 1.85 (0.71-4.86) in Mild (p for trend = 0.10). Mortality was significantly associated with the severity of thrombocytopenia (p for trend = 0.005), and adjusted ORs were 3.26 (1.29-8.26) in the Moderate/Severe and 2.76 (1.58-4.84) in the Mild groups.

CONCLUSIONS

Thrombocytopenia in LVO patients was not rare and associated with the incidence and manifestation of ICH after EVT.

Prognostic value of pretreatment diffusion-weighted imaging score for acute basilar artery occlusion with successful endovascular recanalization

PURPOSE

The aim of this study is to test the prognostic value of a diffusion-weighted imaging (DWI) score in acute basilar artery occlusion (ABAO) with successful recanalization.

METHODS

The DWI-based pons-midbrain and thalamus (PMT) score was developed to assess posterior circulation infarcts. We test its prognostic value and compare it with other two established scales, the DWI-based posterior circulation acute stroke prognosis Early CT score (PC-ASPECTS) and brain stem score (BSS). A retrospective cohort of consecutive ABAO patients with pretreatment magnetic resonance imaging and successful recanalization (defined as modified Thrombolysis in Cerebral Infarction 2b-3) were analyzed. A favorable outcome was defined as a 90-day modified Rankin Scale (mRS) score of 2 or less. The prognostic performance of three scales was estimated by receiver operating characteristic (ROC) curve analyses.

RESULTS

One hundred and sixteen eligible patients (mean age, 59.1 ± 11.7 [standard deviation]; 96 [82.8%] man) were included and evaluated. Between favorable (mRS ≤ 2) and unfavorable groups, the baseline PMT score (median [interquartile range], 3 [1-4] versus 6 [5-8]; P < 0.001) differs significantly. ROC curve analyses showed the PMT score had the best prognostic value for favorable outcome (area under the curve, PMT versus BSS versus PC-ASPECTS = 0.80 versus 0.72 versus 0.68, P = 0.010). Multivariate logistic regression analyses showed baseline National Institute of Health stroke scale (OR, 0.90 [95%CI, 0.86-0.95], P = 0.004) and PMT score < 5 (OR, 17.83 [95%CI, 3.91-81.19], P < 0.001) were independent prognostic factors of favorable outcome.

CONCLUSIONS

The PMT score seems to predict clinical outcome of ABAO patients with successful recanalization.

Treatment Outcomes of Mechanical Thrombectomy in Patients with Acute Posterior Circulation Stroke

Objective  The benefits of mechanical thrombectomy (MT) in patients with acute posterior circulation stroke remain unclear. Currently, there is no evidence from randomized control trials to show the safety and effectiveness of MT in patients with posterior circulation stroke. This study was to evaluate the treatment outcomes of MT in posterior circulation stroke patients enrolling in our hospital during 2010 to 2020. Materials and Methods  Between January 2010 and December 2020, 66 patients with acute posterior circulation stroke underwent MT. Data collected and analyzed included demographics, comorbidity, National Institutes of Health Stroke Scale (NIHSS), procedure time, site of occlusion, presence of posterior communicating artery (PCoA), endovascular technique, and modified Rankin Scale (mRS). Good clinical outcome was defined by mRS at 2 or less at 90 days after MT. Statistical Analysis  Variables with normal distribution were reported with mean ± standard deviation, meanwhile those with nonnormal distribution were demonstrated with median and range. Fisher's exact test for categorical variables or Mann-Whitney U test for continuous variables was performed. Multivariate logistic regression analysis with binary logistic regression method was used analyze the association between the prognosis factor and good outcome. Statistical significance was defined when p -value less than 0.05. Results  The mean age of patients was 65.2 years with male predominance. The median NIHSS was 18.5. Successful recanalization (modified thrombolysis in cerebral infarction 2b-3) was achieved in 61/66 cases (92.42%) and postprocedure symptomatic intracerebral hemorrhage occurred in 5/66 cases (7.60%). Successful recanalization with good clinical outcome was obtained from 30 of 61 cases (49.18%); it was also associated with distal basilar artery occlusion ( p  = 0.035) and PCoA patency presence ( p  = 0.024). Our study showed the correlation between good treatment outcomes with initial NIHSS less than 20, intravenous recombinant tissue-type plasminogen activator, pre-MT magnetic resonance imaging Q5 brain, and contact aspiration MT technique. Conclusion  MT is beneficial to patients with posterior circulation stroke. A good clinical outcome was significantly associated with distal basilar artery occlusion and PCoA patency presence within a group of successful recanalization.

Outcome of endovascular treatment in acute basilar artery occlusion with National Institutes of Health Stroke Scale score 10-19

OBJECTIVE

Authors of this study aimed to investigate the efficacy and safety of endovascular treatment (EVT) versus standard medical treatment (SMT) alone in patients with acute basilar artery occlusion (BAO) and moderate deficit (National Institutes of Health Stroke Scale [NIHSS] score 10-19).

METHODS

Patients with moderate deficit caused by acute BAO in the period from January 2014 to May 2019 were included in the study. The patients were divided into groups based on treatment: EVT plus SMT group or SMT-alone group. The primary outcome was favorable functional outcome (modified Rankin Scale score 0-3) at 90 days, and safety outcomes were symptomatic intracerebral hemorrhage (sICH) and mortality at 90 days.

RESULTS

A total of 173 patients had moderate deficits, 128 of whom had been treated with EVT and 45 with SMT alone. EVT was associated with a significant higher proportion of 90-day favorable outcomes compared with SMT (adjusted odds ratio [aOR] 4.09, 95% CI 1.39-12.04, p = 0.011). Younger age (aOR 0.96, 95% CI 0.92-0.99, p = 0.017), absence of diabetes mellitus (aOR 0.35, 95% CI 0.12-0.99, p = 0.048), higher baseline posterior circulation Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS; aOR 1.48, 95% CI 1.07-2.05, p = 0.018), and modified Thrombolysis in Cerebral Infarction (mTICI) score of 2b-3 (aOR 15.15, 95% CI 3.07-74.72, p = 0.001) were independent factors for a favorable outcome in the EVT group. Rates of mortality and sICH were comparable in the EVT and SMT groups.

CONCLUSIONS

EVT leads to improved outcomes compared to those with SMT alone. Younger age, absence of diabetes mellitus, higher baseline pc-ASPECTSs, and mTICI score of 2b-3 were associated with better functional outcome in the EVT group.

A visualized nomogram to online predict futile recanalization after endovascular thrombectomy in basilar artery occlusion stroke

Background and purpose

Futile recanalization occurs in a significant proportion of patients with basilar artery occlusion (BAO) after endovascular thrombectomy (EVT). Therefore, our goal was to develop a visualized nomogram model to early identify patients with BAO who would be at high risk of futile recanalization, more importantly, to aid neurologists in selecting the most appropriate candidates for EVT.

Methods

Patients with BAO with EVT and the Thrombolysis in Cerebral Infarction score of ≥2b were included in the National Advanced Stroke Center of Nanjing First Hospital (China) from October 2016 to June 2021. The exclusion criteria were lacking the 3-month Modified Rankin Scale (mRS), age &lt;18 years, the premorbid mRS score &gt;2, and unavailable baseline CT imaging. Potential predictors were selected for the construction of the nomogram model and the predictive and calibration capabilities of the model were assessed.

Results

A total of 84 patients with BAO were finally enrolled in this study, and patients with futile recanalization accounted for 50.0% (42). The area under the curve (AUC) of the nomogram model was 0.866 (95% CI, 0.786–0.946). The mean squared error, an indicator of the calibration ability of our prediction model, was 0.025. A web-based nomogram model for broader and easier access by clinicians is available online at https://trend.shinyapps.io/DynNomapp/.

Conclusion

We constructed a visualized nomogram model to accurately and online predict the risk of futile recanalization for patients with BAO, as well as assist in the selection of appropriate candidates for EVT.

The safety and effectiveness of endovascular treatment for patients with vertebrobasilar artery occlusions: according to the BEST and BASICS criteria

Background:

Whether endovascular treatment (EVT) is safe and effective for vertebrobasilar artery occlusion (VBAO) is yet incompletely understood. Two RCTs, the endovascular treatment versus standard medical treatment for vertebrobasilar artery occlusion (BEST) trail and the Basilar Artery International Cooperation Study (BASICS), concentrating on this field were recently reported.

Objective:

We use real-world registry data of VBAO to compare the outcome of EVT inside and outside the inclusion and exclusion criteria of the BEST and BASICS study to testify the feasibility of the selection paradigms of VBAO in these trials.

Methods:

Consecutive patients with VBAO receiving EVT involving 21 stroke centers were retrospectively included. The safety outcomes [3-month mortality, symptomatic intracranial hemorrhage (sICH), and effectiveness outcomes (the proportion of 3-month functional independence (mRS of 0–2) and favorable outcome (mRS of 0–3)] were compared between VBAO patients who meet or failed to meet the BEST/BASICS selection criteria for EVT.

Results:

Our study cohort consisted of 577 VBAO patients who underwent EVT. Of them, 446 patients had pc-ASPECTS ≧8. Successful reperfusion (mTICI 2b or 3) was achieved in 85.4% (n = 493). There were 418 patients fulfilling the BEST criterion for EVT and 194 fulfilling the BASICS criterion. Regression analysis indicated that adherence to BEST or BASICS criterion for EVT was not independently related to most of the safety and effectiveness outcome except that adherence to BEST was significantly associated with the 3-month favorable outcome (OR_BEST: 1.742, 95% CI: 1.087–2.790). However, when we put pc-ASPECTS into both criteria with a cut-off value of 8, meeting both BEST criterion plus pc-ASPECTS and BASICS criterion plus pc-ASPECTS was independently related to 3-month functional independence (OR_BEST: 1.687, 95% CI: 1.077–2.644; OR_BASIC: 1.653, 95% CI: 1.038–2.631) and favorable outcome (OR_BEST: 2.280, 95% CI: 1.484–3.502; OR_BASIC: 2.153, 95% CI: 1.372–3.378).

Conclusion:

Our study indicated that, based on real-world data of EVT, adherence to BEST or BASICS criterion for EVT was not independently associated with the safety and effectiveness outcome except that adherence to BEST was significantly related to the 3-month favorable outcome. However, the BEST or BASICS selection criterion and pc-ASPECTS ≧8 might be better paradigms for EVT patient selection.

Predictors of ischemic events in patients with unilateral extracranial vertebral artery dissection: A single-center exploratory study

Objective

Extracranial vertebral artery dissection (EVAD) is one of the main causes of stroke in young and middle-aged patients. However, the diagnosis is challenging. This study aimed to identify the characteristics of EVAD on color duplex ultrasonography (CDU) and high-resolution magnetic resonance imaging (hrMRI), hoping to improve the accuracy and determine the relative contribution of vessel findings and clinical factors to acute ischemic events.

Methods

Patients with unilateral EVAD were recruited and divided into ischemia and non-ischemia groups. Clinical features of patients and the lesion location; a variety of signs which indicate dissection, including the presence of an intimal flap, double lumen, intramural hematoma, dissecting aneurysm, intraluminal thrombus, and irregular lumen; and other quantitative parameters of each dissected segment on CDU and hrMRI were reviewed, respectively. Multiple logistic regression was performed to explore the association between clinical, imaging characteristics, and ischemic events in patients with unilateral EVAD.

Results

Ninety-six patients with unilateral EVAD who met the inclusion criteria were enrolled during a six-year period. Overall, 41 cases (42.7%) were confirmed as ischemic stroke (n = 40) or transient ischemic attack (n = 1) during the 48 h after the onset of symptoms. Men, infections during the last week, and smoking were more common in the ischemia group. Intraluminal thrombus and occlusion on CDU were more prevalent in patients with cerebral ischemia than in those without (36.6 vs. 5.5%; p < 0.001, and 39.0 vs. 9.1%; p = 0.001, respectively). On hrMRI, intraluminal thrombus and occlusion were also more frequent in the ischemia group than in the non-ischemia group (34.1 vs. 5.5%; p < 0.001, and 34.1 vs. 9.1%; p = 0.003, respectively). In addition, lesion length on hrMRI was significantly longer for patients with ischemia (81.5 ± 41.7 vs. 64.7 ± 30.8 mm; p = 0.025). In multivariable logistic regression analysis, male gender, infections during the last week, and the presence of intraluminal thrombus on CDU and hrMRI were independently associated with acute ischemic events.

Conclusion

Male sex, infections during the last week, and the presence of intraluminal thrombus due to dissection are associated with an increased risk of ischemic events in patients with unilateral EVAD.

Association between anemic status on admission and clinical outcomes of acute large vessel occlusion

BACKGROUND

Anemia is a frequently observed condition, but its clinical impact on large vessel occlusion (LVO) remains unclear. We examined the association between anemic status on admission and clinical outcomes of LVO in a real-world setting.

METHODS

We conducted a post-hoc analysis of the RESCUE-Japan Registry 2, a nationwide registry which enrolled 2408 consecutive patients with LVO who were admitted within 24 h of onset. The patients were classified into anemia (<11 g/dL) and no-anemia (≥11 g/dL) groups according to their hemoglobin level on admission. The primary outcome was defined as a modified Rankin Scale of 0-2 at day 90.

RESULTS

Among the 2373 patients with available baseline hemoglobin data, 307 (13.0%) were classified in the anemia group. Anemia was associated with a lower likelihood of the primary outcome (adjusted odds ratio [OR]: 0.68; 95% confidence interval [CI]: 0.47-0.98) and higher mortality within 90 days (adjusted OR: 1.48; 95% CI: 1.01-2.17). Subgroup analyses showed that the likelihood of achieving the primary outcome between the two groups was different between men and women (P for interaction = 0.049), those with Alberta Stroke Program Early CT Score (ASPECTS) <6 and ASPECTS ≥6 (P for interaction = 0.02), and those with National Institute of Health Stroke Scale (NIHSS) ≥16 and NIHSS < 16 (P for interaction = 0.005).

CONCLUSIONS

Anemic state on admission was associated with poorer clinical outcomes of LVO in real-world clinical practice. The effects of anemic status were larger in LVO patients with lower NIHSS or higher ASPECTS.

Prehospital stroke notification and endovascular therapy for large vessel occlusion: a retrospective cohort study

The impact of prehospital notification by emergency medical services (EMS) on outcomes of endovascular therapy (EVT) for large vessel occlusion (LVO) remains unclear. We therefore explored the association between prehospital notification and clinical outcomes after EVT. In this single-center retrospective study from 2016 through 2020, we identified all LVO patients who received EVT. Based on the EMS's usage of a prehospital stroke notification system, we categorized patients into two groups, Hotline and Non-hotline. The primary outcome was good neurological outcome at 90 days; other time metrics were also evaluated. Of all 312 LVO patients, the proportion of good neurological outcomes was 94/218 (43.1%) in the Hotline group and 8/34 (23.5%) in the Non-hotline group (adjusted odds ratio 2.86; 95% confidence interval 1.12 to 7.33). Time from hospital arrival to both tissue plasminogen activator and to groin puncture were shorter in the Hotline group (30 (24 to 38) min vs 48(37 to 65) min, p < 0.001; 40 (32 to 54) min vs 76 (50 to 97) min, p < 0.001), respectively. In conclusion, prehospital notification was associated with a reduction in time from hospital arrival to intervention and improved clinical outcomes in LVO patients treated with EVT.

Endovascular Treatment for Posterior Circulation Stroke: Ways to Maximize Therapeutic Efficacy

The efficacy of endovascular treatment (EVT) in patients with posterior circulation stroke has not been proven. Two recent randomized controlled trials failed to show improved functional outcomes after EVT for posterior circulation stroke (PC-EVT). However, promising results for two additional randomized controlled trials have also been presented at a recent conference. Studies have shown that patients undergoing PC-EVT had a higher rate of futile recanalization than those undergoing EVT for anterior circulation stroke. These findings call for further identification of prognostic factors beyond recanalization. The significance of baseline clinical severity, infarct volume, collaterals, time metrics, core-penumbra mismatch, and methods to accurately measure these parameters are discussed. Furthermore, their interplay on EVT outcomes and the potential to individualize patient selection for PC-EVT are reviewed. We also discuss technical considerations for improving the treatment efficacy of PC-EVT.

Posterior Circulation ASPECTS on CT Angiography Predicts Futile Recanalization of Endovascular Thrombectomy for Acute Basilar Artery Occlusion

Background

Acute basilar artery occlusion (BAO) is the most potentially disastrous outcome and has a high risk of recurrence stroke in posterior circulation infarction (PCI). However, the rate of futile recanalization remains high despite successful recanalization. The objective of this study was to investigate 90 days functional outcomes among patients with BAO who underwent endovascular thrombectomy (EVT) and to identify the risk factors associated with futile recanalization.

Methods

We retrospectively analyzed 72 patients with acute BAO who received EVT from January 2018 to June 2021. CT angiography source images posterior circulation Acute Stroke Prognosis Early CT Score (CTA-SI pc-ASPECTS) evaluated the extensive hypoattenuation in patients with BAO. Futile recanalization defined an modified Rankin Scale (mRS) of 3-6 at 90 days despite a successful recanalization. Logistic regression analysis was performed to investigate the predictors of futile recanalization.

Results

Our sample included a total of 55 eligible patients. Patients with poor outcomes showed that the pc-ASPECTS score was lower in patients with poor outcomes than that in patients with good outcomes (P = 0.017). Longer time from symptoms onset-to-the puncture (P = 0.014) and elevation of leucocytes (P = 0.012) were associated with poor outcomes. The multivariable logistic analysis showed that pc-ASPECTS and onset-to-puncture time (OPT) were independent predictors of futile recanalization.

Conclusions

This study suggested that pc-ASPECTS and OPT are independent predictors of futile recanalization after EVT in patients with BAO. The lower pc-ASPECTS score and longer puncture time will have a poor clinical outcome.

Imaging-based outcome prediction in posterior circulation stroke

BACKGROUND AND PURPOSE

We developed a machine learning model to allow early functional outcome prediction for patients presenting with posterior circulation (pc)-stroke based on CT-imaging and clinical data at admission. The proposed algorithm utilizes quantitative information from automated multidimensional assessments of posterior circulation Acute Stroke Prognosis Early CT-Score (pc-ASPECTS) regions. Discriminatory power was compared to predictions based on conventional pc-ASPECTS ratings.

METHODS

We retrospectively analyzed non-contrast CTs and clinical data of 172 pc-stroke patients. 90 days outcome was dichotomized into good and poor using modified Rankin Scale (mRS) cut-offs. Predictive performance was assessed for outcome differentiation at mRS 2, 3, 4 and survival prediction (mRS ≤ 5) using random forest algorithms. Results were compared to conventional pc-ASPECTS and clinical parameters. Models were evaluated in a nested fivefold cross-validation approach.

RESULTS

Receiver operating characteristic areas under the curves (ROC-AUCs) of the test sets using conventionally rated pc-ASPECTS reached 0.63 for mRS ≤ 4 to 0.68 for mRS ≤ 5 and 0.73 for mRS ≤ 5 to 0.85 for mRS ≤ 2 if clinical data were considered. Pure imaging-based machine learning classifier ROC-AUCs were lowest for mRS ≤ 4 (0.81) and highest for mRS ≤ 5 (0.87). The combined clinical data and machine learning-based model had the highest predictive performance with ROC-AUCs reaching 0.90 for mRS ≤ 2.

CONCLUSION

Machine learning-based evaluation of pc-ASPECTS regions predicts functional outcome of pc-stroke patients with higher accuracy than conventional assessments. This could optimize triage for additional diagnostics and allocation of best possible medical care and might allow required arrangements of the social environment at an early point of time.

Repeated reperfusion treatment in recurrent ischemic stroke: A retrospective single-center case series

Data regarding repeated reperfusion therapy (rRT) in acute ischemic stroke (AIS), including intravenous thrombolysis and endovascular treatment (EVT), are quite poor. To date, there are only few case reports and five larger studies on repeated EVT. We aimed to report our single-center experience and describe different clinical scenarios of recurrent AIS with emergent large vessel occlusion (LVO), for which the decision-making process could be challenging in the emergency setting. We retrospectively reviewed 765 consecutive AIS patients with LVO, who underwent reperfusion procedures at our comprehensive stroke center, from 2014 to 2020, and identified rRT patients. We identified and reviewed the medical records of eight patients (1.05%), who repeated reperfusive treatment for recurrent stroke within 30 days (early arterial reocclusion, EAR) and after 30 days (late arterial reocclusion, LAR). We assigned collected data to three clinical scenarios, each divided into EAR and LAR cases. All patients had recurrent emergent LVO in the same vessel territory previously affected, both in EAR and LAR patients. A good clinical outcome has been achieved in EAR patients (modified Rankin Score ≤ 2). Artery-to-artery embolic mechanism was more common in the EAR group, while LAR was more frequently associated with cardioembolic source. RRT appears to be an effective treatment option for recurrent LVO, and it should not be withheld in carefully selected patients. EVT should be considered, including aspiration-only and stenting procedures in patients with AIS and recurrent LVO after previous reperfusive treatments, even after a very short time.

Predictive value of DWI posterior-circulation lesion volume for 90-day clinical outcome after endovascular treatment of acute basilar artery occlusion: a retrospective single-center study

PURPOSE

The relationship between posterior-circulation lesion volume (PCLV) and clinical outcomes is poorly investigated. We aimed to analyze, in patients with acute basilar artery occlusion (ABAO), if pre-endovascular treatment (EVT) PCLV was a predictor of outcomes.

METHODS

We analyzed consecutive MRI selected, endovascularly treated ABAO patients. Baseline PCLV was measured in milliliters on apparent diffusion-coefficient map reconstruction. Univariable and multivariable logistic models were used to test if PCLV was a predictor of 90-day outcomes. After the received operating characteristic (ROC) analysis, the optimal cut-off was determined to evaluate the prognostic value of PCLV.

RESULTS

A total of 110 ABAO patients were included. The median PCLV was 4.4 ml (interquartile range, 1.3-21.2 ml). Successful reperfusion was achieved in 81.8% of cases after EVT. At 90 days, 31.8% of patients had a modified Rankin scale ≤ 2, and the mortality rate was 40.9%. PCLV was an independent predictor of functional independence and mortality (odds ratio [OR]:0.57, 95% confidence interval [CI], 0.34-0.93 and 1.84, 95% CI, 1.23-2.76, respectively). The ROC analysis showed that a baseline PCLV ≤ 8.7 ml was the optimal cut-off to predict the 90-day functional independence (area under the curve [AUC] = 0.68, 95% CI, 0.57-0.79, sensitivity 88.6%, and specificity 49.3%). In addition, a PCLV ≥ 9.1 ml was the optimal cut-off for the prediction of 90-day mortality (AUC = 0.71, 95% CI, 0.61-0.82, sensitivity 80%, and specificity 60%).

CONCLUSIONS

Pre-treatment PCLV was an independent predictor of 90-day outcomes in ABAO. A PCLV ≤ 8.7 and ≥ 9.1 ml may identify patients with a higher possibility to achieve independence and a higher risk of death at 90 days, respectively.

Cerebral blood volume index as a predictor of functional independence after basilar artery thrombectomy

BACKGROUND AND PURPOSE

The role of CT perfusion (CTP)in the evaluation of acute basilar artery occlusion (aBAO) patients undergoing endovascular thrombectomy (EVT) is unclear. We investigated the association of individual CTP parameters with functional outcomes in aBAO patients undergoing EVT.

METHODS

A health system's prospectively collected code stroke registry was used in this retrospective analysis of aBAO patients treated with EVT presenting between January 2017 and February 2021 with pre-EVT CTP. The primary outcome measure was modified Rankin Scale (mRS) score 0-2 at 90 days. Factors with a univariate association (p < .05) with mRS 0-2 were combined in a multivariable regression model to determine independent predictors of 90-day favorable functional outcome.

RESULTS

Forty-six subjects, with median age 67 years and median National Institutes of Health Stroke Scale 16, were included, of whom 17 (37%) achieved mRS 0-2 at 90 days. In the multivariable logistic regression model, CTP cerebral blood volume (CBV) index (per 0.1-point increase, odds ratio = 1.843; 95% confidence interval: 1.039, 3.268; p-value .0365) was independently associated with a favorable 90-day outcome.

CONCLUSIONS

CBV index was independently associated with a favorable 90-day outcome in aBAO patients treated with EVT, a novel finding in this patient population. CBV index may assist in treatment and prognosis discussions and inform future studies investigating the role of CTP in aBAO.

Novel Diffusion-Weighted Imaging Score Showed Good Prognostic Value for Acute Basilar Artery Occlusion Following Endovascular Treatment: The Pons-Midbrain and Thalamus Score

BACKGROUND AND PURPOSE

Prognostic factors for outcome of endovascular treatment remains to be investigated in patients with acute basilar artery occlusion. We aimed to assess the prognostic value of a novel pretreatment diffusion-weighted imaging score: The Pons-Midbrain and Thalamus (PMT) score.

METHODS

Eligible patients who underwent endovascular treatment due to acute basilar artery occlusion were reviewed. The PMT score was a diffusion-weighted imaging-based semiquantitative scale in which the infarctions of pons, midbrain, and thalamus were fully considered. The PMT score was assessed as well as the posterior circulation Acute Stroke Prognosis Early Computed Tomography Score and Brain Stem Score. Good outcomes were defined as a modified Rankin Scale score of ≤3 at 90-day and successful reperfusion as Thrombolysis in Cerebral Infarction grades 2b/3. The associations between baseline clinical parameters and good outcomes were evaluated with logistic regression.

RESULTS

A total of 107 patients with pretreatment magnetic resonance imaging were included in this cohort. The baseline PMT score (median [interquartile range], 3 [1-5] versus 7 [5-9]; P<0.001) and Brain Stem Score (median [interquartile range], 2 [1-4] versus 3 [2-5]; P=0.001) were significantly lower in good outcome group; the posterior circulation Acute Stroke Prognosis Early Computed Tomography Score was higher in good outcome group without statistical significance. As a result of receiver operating characteristic curve analyses, the posterior circulation Acute Stroke Prognosis Early Computed Tomography Score showed poor prognostic accuracy for good outcome (area under the curve, 0.60 [95% CI, 0.49-0.71]; P=0.081); The baseline PMT score showed significantly better prognostic accuracy for 90-day good outcome than the Brain Stem Score and National Institutes of Health Stroke Scale (area under the curve, 0.80 versus 0.68 versus 0.78, P=0.003). In addition, favorable PMT score <7 (odds ratio, 22.0 [95% CI, 6.0-80.8], P<0.001), Brain Stem Score <3 (odds ratio, 4.65 [95% CI, 2.05-10.55], P<0.001) and baseline National Institutes of Health Stroke Scale <23 (odds ratio, 8.0 [95% CI, 2.5-25.6], P<0.001) were associated with improved good outcome.

CONCLUSIONS

In patients with acute basilar artery occlusion following endovascular treatment, the pretreatment diffusion-weighted imaging based PMT score showed good prognostic value for clinical outcome.

Time-outcome relationship in acute large-vessel occlusion exists across all ages: subanalysis of RESCUE-Japan Registry 2

Early reperfusion after endovascular thrombectomy is associated with an improved outcome in ischemic stroke patients; however, the time dependency in elderly patients remains unclear. We investigated the time–outcome relationships in different age subgroups. Of 2420 patients enrolled in the RESCUE-Japan Registry 2 study, a study based on a prospective registry of stroke patients with acute cerebral large-vessel occlusion at 46 centers, we analyzed the data of 1010 patients with successful reperfusion after endovascular therapy (mTICI of 2b or 3). In 3 age subgroups (< 70, 70 to < 80, and ≥ 80 years), the mRS scores at 90 days were analyzed according to 4 categories of onset-to-reperfusion time (< 180, 180 to < 240, 240 to < 300, and ≥ 300 min). In each age subgroup, the distributions of mRS scores were better with shorter onset-to-reperfusion times. The adjusted common odds ratios for better outcomes per 1-category delay in onset-to-reperfusion time were 0.66 (95% CI 0.55–0.80) in ages < 70 years, 0.66 (95% CI 0.56–0.79) in ages 70 to < 80 years, and 0.83 (95% CI 0.70–0.98) in ages ≥ 80 years. Early reperfusion was associated with better outcomes across all age subgroups. Achieving early successful reperfusion is important even in elderly patients.

Impact of Procedure Time on Clinical Outcomes of Patients Who Underwent Endovascular Therapy for Acute Ischemic Stroke

BACKGROUND AND PURPOSE

The time from onset to reperfusion is associated with clinical outcomes in acute ischemic stroke due to large vessel occlusion (LVO); nevertheless, the time limit of the continuing procedure remains unclear. We analyzed the relationship between procedure time and clinical outcomes in patients with LVO who underwent endovascular treatment (EVT).

METHODS

We assessed 1,247 patients who underwent EVT for LVO. Data were obtained from our multicenter registry, and patients were included if data on procedure time were available. Multivariate analysis was performed to assess the impact of procedure time on clinical outcomes using the following parameters: favorable outcome (the modified Rankin score of 0-2 at 90 days), mortality within 90 days, symptomatic intracranial hemorrhage within 72 h after stroke onset, and procedure-related complications.

RESULTS

The rate of favorable outcomes linearly decreased with increasing procedure time, but there was no linear relationship between procedure time and other outcomes. The adjusted odds ratio for 30-minute delay in procedure time was 0.76 (95% confidence interval, 0.68-0.84) for favorable outcome, 1.15 (0.97-1.36) for mortality, 1.08 (0.87-1.33) for symptomatic intracranial hemorrhage, and 0.92 (0.75-1.16) for complications. Significant interactions in the effect of procedure time on favorable outcome were observed between the subgroups stratified by age (≥75 or <75 years). Younger patients had a greater deleterious effect of delayed reperfusion.

CONCLUSIONS

Increasing procedure time was associated with less favorable outcomes, but not with the rate of mortality, symptomatic intracerebral hemorrhage, or complications in our cohort.

Status of In-Hospital Acute Ischemic Stroke Treated by Mechanical Thrombectomy

Objective

To elucidate the current state of in-hospital acute ischemic stroke under the introduction of acute-phase mechanical thrombectomy.

Methods

The study included 18 consecutive patients with in-hospital cerebral infarction who underwent thrombectomy between April 2014 and March 2020 at St. Marianna University School of Medicine Yokohama City Seibu Hospital. We analyzed the primary disease, department responsible for treatment, modified Rankin Scale (mRS) scores before onset and on discharge, status of onset, treatment course, and so on.

Results

The mean age was 79.9 (66-93) years. There were nine females. The admission methods included scheduled admission in 5 patients and non-scheduled admission in 13 patients. The primary diseases consisted of malignant tumors in five patients and heart disease in four patients. The departments responsible for treatment consisted of the Department of Digestive Surgery for six patients and Department of Cardiology for three patients. The mRS score before admission was evaluated as 0-2 in 15 patients and 3-5 in 3 patients. The embolism was evaluated as cardiogenic in 14 patients. Antithrombotic therapy was discontinued before the onset of cerebral infarction in three patients. The mean interval from onset or last well known (LWK) until CT/MRI and puncture was 88.4 and 157.6 minutes. The median Alberta stroke program early CT score (ASPECTS; minimum-maximum) was 8 (2-10). Tissue plasminogen activator (t-PA) was administered to five patients. Concerning the degree of recanalization, the thrombolysis in cerebral infarction (TICI) grade was evaluated as 1 to 2a in 2 patients and 2b to 3 in 16. In the latter, the mean interval from onset or final onset-free confirmation until recanalization was 197.7 minutes. mRS score on discharge was evaluated as 0-2 in four patients, 3-5 in nine, and 6 in five patients. The mortality was related to a primary disease requiring admission in three patients.

Conclusion

In-hospital onset cerebral infarction was markedly influenced by the primary disease requiring admission. Even when favorable recanalization was achieved, the number of patients with a favorable outcome was small.

Posterior circulation acute stroke prognosis early CT scores in predicting functional outcomes: A meta-analysis

Background and purpose

Patients with posterior circulation acute ischemic stroke exhibit varied clinical presentations and functional outcomes. Whether posterior circulation acute stroke prognosis early computed tomography scores (PC-ASPECTS) predict unfavorable functional outcomes (UFO) for patients treated with different therapeutic regimens is unclear.

Methods

According to PRISMA guidelines, we performed a systematic search of electronic databases for studies assessing the functional outcomes of posterior circulation acute ischemic stroke using baseline PC-ASPECTS. The following three scales of PC-ASPECTS were retrieved: UFO prediction by using PC-ASPECTS per score decrease, UFO prediction by using binary PC-ASPECTS with a cut-off value, and the difference in PC-ASPECTS between patients with unfavorable and favorable functional outcomes. Moreover, a subgroup analysis was conducted for patients treated with intra-arterial endovascular treatment (IA-EVT) only. Sensitivity analysis with different definition of UFO and image modalities were also conducted.

Results

In total, 25 studies were included. In scale 1, PC-ASPECTS significantly predicted UFO (odds ratio [OR]: 1.66 per score decrease, 95% confidence interval [CI]: 1.32–2.07). In scale 2, binary PC-ASPECTS with a cut-off value between 6 and 9 significantly predicted UFO (OR: 3.91, 95% CI: 2.54–6.01). In scale 3, patients with UFO had lower PC-ASPECTS than those with favorable outcomes (standardized mean difference [SMD]: −0.67, 95% CI: −0.8 to −0.55). For patients treated with IA-EVT only, the scales demonstrated consistent results. Sensitivity analysis showed PC-ASPECTS significantly predicted UFO in both definitions of modified Rankin Scale ≥ 3 and ≥ 4, and magnetic resonance imaging was preferred imaging modality for PC-ASPECTS evaluation.

Conclusion

Baseline PC-ASPECTS is effective in predicting UFO for patients with posterior circulation acute ischemic stroke treated with different therapeutic regimens.

Early recurrent ischemic events after mechanical thrombectomy: effect of post-treatment intracranial hemorrhage

OBJECTIVE

Patients with intracranial hemorrhages (ICH) after mechanical thrombectomy (MT) may have a higher risk of early recurrent embolism (ERE) because of delayed initiation of anticoagulants. We assessed the rate of ischemic events in the early period after MT and the association with post-MT ICH.

METHODS

Patients who underwent MT in our institute were retrospectively reviewed. ERE was defined as recurrent ischemic stroke and systemic embolism within 14 days after MT. The association between ERE and parenchymal hematoma (PH) was assessed. Multivariable regression analysis and inverse probability of treatment weighting was used to adjust for differences in baseline characteristics between patients with and without PH.

RESULTS

A total of 307 patients (median age, 78 years; female, 47%; median baseline National Institutes of Health Stroke Scale score, 19) were included. ERE was observed in 12 of 307 patients (8 strokes, 4 systemic embolisms; 3.9%). Median time from MT to ERE was 6.5 days (IQR, 3-8 days). PH occurred in 21 patients (6.8%). Median time from MT to initiating oral anticoagulants was longer in patients with PH (8 days) than in those without (3 days) (p < 0.01). In both unweighted and weighted multivariable analysis, PH was significantly associated with an increased risk of ERE (unweighted odds ratio, 10.60; 95% CI, 2.66-42.23; weighted odds ratio, 12.34; 95% CI, 2.49-61.07).

CONCLUSIONS

ERE occurred in about 4% of patients after MT. PH after MT was associated with delayed initiation of oral anticoagulants and an increased risk of recurrent ischemic events.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov . Unique identifier: NCT02251665.

Multimodal CT pc-ASPECTS in infratentorial stroke: diagnostic and prognostic value

BACKGROUND AND PURPOSE

Diagnosis of posterior circulation stroke may be challenged. National Institutes of Health Stroke Scale (NIHSS) and brain imaging (non-contrast brain computed tomography-CT) are used for diagnosis; evaluation on posterior circulation stroke remains a limit of NIHSS, and the value of non-contrast CT (NCCT) is limited due to artifacts caused by the bones of the base of the skull. We tested the validity and prognostic value of posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) in patients with posterior circulation stroke.

METHODS

Pc-ASPECTS allots the posterior circulation 10 points. We studied 50 patients with posterior circulation stroke. We applied pc-ASPECTS to NCCT, CT angiography, and CT Perfusion. We evaluated the correlation of pc-ASPECT with outcome parameters for stroke.

RESULTS

Out of 50 patients, CTP showed abnormalities in 34 cases. The pc-ASPECT score calculated on brain CT and on the brain CT + angio CT had a sensibility of 24%, calculated on brain CT, angio CT and CTPerfusion gain a sensibility of 72%. Pc-ASPECT MTT resulted to be the more reliable parameter: outcome given by NIHSS score at discharge, mRS at discharge, and at 3 months was more severe in patients with Pc-ASPECT MTT alteration. Outcome given by NIHSS score at discharge and mRS at discharge and 1 at 3 months was more severe in patients with higher NIHSS score at admission.

CONCLUSION

We evaluated the usefulness of pc-ASPECTS on CTP in predicting functional outcome in acute posterior circulation stroke that appears to be a powerful marker for predicting functional outcome.

Values of Baseline Posterior Circulation Acute Stroke Prognosis Early Computed Tomography Score for Treatment Decision of Acute Basilar Artery Occlusion

BACKGROUND AND PURPOSE

This study aimed to analyze the impact of baseline posterior circulation Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS) on the efficacy and safety of endovascular therapy (EVT) for patients with acute basilar artery occlusion.

METHODS

The BASILAR was a nationwide prospective registry of consecutive patients with a symptomatic and radiologically confirmed acute basilar artery occlusion within 24 hours of symptom onset. We estimated the effect of standard medical therapy alone (SMT group) versus SMT plus EVT (EVT group) for patients with documented pc-ASPECTS on noncontrast CT, both as a categorical (0-4 versus 5-7 versus 8-10) and as a continuous variable. The primary outcomes included favorable functional outcomes (modified Rankin Scale ≤3) at 90 days and mortality within 90 days.

RESULTS

In total, 823 cases were included: 468 with pc-ASPECTS 8 to 10 (SMT: 71; EVT: 397), 317 with pc-ASPECTS 5 to 7 (SMT: 85; EVT: 232), and 38 with pc-ASPECTS 0 to 4 (SMT: 13; EVT: 25). EVT was associated with higher rate of favorable outcomes (adjusted relative risk with 95% CI, 4.35 [1.30-14.48] and 3.20 [1.68-6.09]; respectively) and lower mortality (60.8% versus 77.6%, P=0.005 and 35.0% versus 66.2%, P<0.001; respectively) than SMT in the pc-ASPECTS 5 to 7 and 8 to 10 subgroups. Continuous benefit curves also showed the superior efficacy and safety of EVT over SMT in patients with pc-ASPECTS ≥5. Furthermore, the prognostic effect of onset to puncture time on favorable outcome with EVT was not significant after adjustment for pc-ASPECTS (adjusted odds ratio, 0.98 [95% CI, 0.94-1.02]).

CONCLUSIONS

Patients of basilar artery occlusion with pc-ASPECTS ≥5 could benefit from EVT. The baseline pc-ASPECTS appears more important for decision making and predicting prognosis than time to EVT. Registration: URL: http://www.chictr.org.cn. Unique identifier: ChiCTR1800014759.

Age and discharge modified Rankin score are associated with 90-Day functional outcome after basilar artery occlusion treated with endovascular therapy

INTRODUCTION

Prognostic factors for functional outcome after basilar artery occlusion (BAO) treated with modern endovascular therapy (EVT) are sparse. We investigated the association between clinical characteristics, readily available imaging variables, and outcome in BAO patients treated with EVT.

METHODS

Retrospective analysis from a large healthcare system's prospectively collected code stroke registry of acute BAO patients treated with EVT between January 2017-January 2020. The primary outcome measure was a favorable 90-day modified Rankin score (mRS) of 0-2.

RESULTS

65 patients (median age 67 years, 57% male, median NIHSS 16) met the study inclusion criteria. Thrombolysis in Cerebral Infarction (TICI) 2 b-3 revascularization was achieved in 57/65 patients (88%) with a median time to revascularization of 445 minutes [IQR 302-840]. Ninety-day good outcome was seen in 35% (23/65) of patients. In a univariate analysis, age, history of ischemic stroke, baseline NIHSS, BAO site, and discharge mRS were associated with significant differences between the good and poor outcome groups. A multivariable logistic regression analysis demonstrated an independent association with 90-day good outcome and younger age (per 1-year, OR 0.79, 95% CI 0.64, 0.98) and good discharge mRS (0-2) (OR > 999.99, 95% CI 13.26, > 999.99).

CONCLUSIONS

Patients presenting with an acute BAO treated with modern EVT have a good 90-day outcome in over one-third of cases. Age and discharge mRS are independently associated with good 90-day outcome. Additional studies may focus on factors that can enhance discharge function after BAO, a novel prognostic indicator for favorable 90-day outcome in our study.

Acute ischemic stroke endovascular therapy

Endovascular therapy (EVT) has become the standard treatment for large-vessel occlusion (LVO) acute ischemic stroke (AIS). EVT is now indicated in patients up to 24h from their last known well, provided that the patient meets specific clinical and imaging criteria. Improvements in thrombectomy devices, techniques, and operator experience have allowed successful EVT of ICA terminus, M1-MCA occlusions as well as proximal M2-MCA, basilar artery occlusions, and revascularization of tandem lesions. Mechanical thrombectomy failures still occur due to several factors, however, highlighting the need for further device and technical improvements. An ongoing debate exists regarding the need for pre-EVT thrombolytic agents, thrombectomy techniques, distal occlusions, anesthesia methods, the role of advanced neuroimaging, the treatment of patients with larger infarct core, and those presenting with milder stroke symptoms. Many of these questions are the subject of current or upcoming clinical trials. This review aims to provide an outline and discussion about the established recommendations and emerging topics regarding EVT for LVO AIS.

Brain Imaging Findings and Response to Intravenous Thrombolysis in Posterior Circulation Stroke

INTRODUCTION

Intravenous thrombolysis (IVT) is a standard treatment for both anterior circulation ischaemic stroke (ACIS) and posterior circulation ischaemic stroke (PCIS). Our aim was to evaluate the predictors for a good clinical outcome and intracerebral haemorrhage (ICH) in patients undergoing posterior circulation IVT based on the initially performed CT or MR imaging.

METHODS

The study cohort consisted of 1643 consecutive patients with acute ischaemic stroke (1440 ACIS, 203 PCIS cases) who underwent IVT. ICH was classified according to the European Cooperative Acute Stroke Study (ECASS) I protocol. Clinical outcome was assessed using the modified Rankin scale (mRS). Early ischaemic signs and pre-existing structural signs were assessed.

RESULTS

Good clinical outcomes (mRS 0-1) were noted in 45.3% of patients with PCIS, with a mortality rate of 14.8%. ICH was noted in 8.3%, and a large haemorrhage was found in 2.4% of patients. Some early ischaemic signs and pre-existing structural signs on initial CT/MR imaging correlated significantly with the 90-day clinical outcome.

CONCLUSIONS

Early ischaemic signs and pre-existing structural signs should be considered during the assessment of patients with PCIS eligible for IVT. Tissue hypoattenuation on initial CT scans correlates with an increased risk of death. Similarly to anterior circulation, atrophy on initial MRI may negatively predict good clinical outcome in posterior circulation.

DWI cerebellar infarct volume as predictor of outcomes after endovascular treatment of acute basilar artery occlusion

BACKGROUND

Preprocedural predictors of outcome in patients with acute basilar artery occlusion (ABAO) who have undergone endovascular treatment (EVT) remain controversial. Our aim was to determine if pre-EVT diffusion-weighted imaging cerebellar infarct volume (CIV) is a predictor of 90-day outcomes.

METHODS

We analyzed consecutive MRI-selected endovascularly treated patients with ABAO within the first 24 hours after symptom onset. Successful reperfusion was defined as a modified Thrombolysis in Cerebral Infarction score of 2b-3. Using the initial MRI, baseline CIV was calculated in mL on an apparent diffusion coefficient map reconstruction (Olea Sphere software). CIV was analyzed in univariate and multivariable models as a predictor of 90-day functional independence (modified Rankin Scale (mRS) 0-2) and mortality. According to receiver operating characteristic (ROC) analysis, the optimal cut-off was determined by maximizing the Youden index to evaluate the prognostic value of CIV.

RESULTS

Of the 110 MRI-selected patients with ABAO, 64 (58.18%) had a cerebellar infarct. The median CIV was 9.6 mL (IQR 2.7-31.4). Successful reperfusion was achieved in 81.8% of the cases. At 90 days the proportion of patients with mRS ≤2 was 31.8% and the overall mortality rate was 40.9%. Baseline CIV was significantly associated with 90-day mRS 0-2 (p=0.008) in the univariate analysis and was an independent predictor of 90-day mortality (adjusted OR 1.79, 95% CI 1.25 to 2.54, p=0.001). The ROC analysis showed that a CIV ≥4.7 mL at the initial MRI was the optimal cut-off to discriminate patients with a higher risk of death at 90 days (area under the ROC curve (AUC)=0.74, 95% CI 0.61 to 0.87, sensitivity and specificity of 87.9% and 58.1%, respectively).

CONCLUSIONS

In our series of MRI-selected patients with ABAO, pre-EVT CIV was an independent predictor of 90-day mortality. The risk of death was increased for baseline CIV ≥4.7 mL.

Predictors of Very Poor Outcome after Mechanical Thrombectomy for Acute Basilar Artery Occlusion

Prognosis for patients with acute basilar artery occlusion (BAO) remains poor. Successful revascularization is a main predictor of favorable clinical outcomes after mechanical thrombectomy for BAO. However, even if mechanical thrombectomy is successful, some patients have a poor clinical outcome, including vegetative state and mortality. This study investigated the factors that are predictive of extremely poor clinical outcomes despite successful revascularization after mechanical thrombectomy for BAO.

We evaluated 35 consecutive patients who presented with acute ischemic stroke due to BAO and who were successfully treated with mechanical thrombectomy. A very poor outcome was defined as a modified Rankin Scale (mRS) score of 5 or 6 at 3 months after treatment. The associations between the clinical, imaging, procedural factors, and poor outcome were evaluated.

Using univariate analyses, there were significant differences in the preoperative National Institute of Health Stroke Scale (NIHSS) score (22.0 ± 9.0 vs. 30.5 ± 4.3, p <0.001), and infarct volume in brain stem (0.11 ± 0.19 cc vs. 2.55 ± 1.56 cc, p <0.001) between the control and very poor outcome groups. In receiver operating characteristic (ROC) curve analysis, the area under ROC curve of infarct volume in brain stem was 0.891 to predict very poor outcome.

Preoperative infarct volume in brain stem is strong predictor for very poor outcome. The infarct volume in brain stem is useful for deciding treatment indications.

Reasons for Failed Mechanical Thrombectomy in Posterior Circulation Ischemic Stroke Patients

Background and Purpose

To determine reasons for failed recanalization in mechanical thrombectomy (MT) of the posterior circulation.

Methods

Retrospective single center analysis of reasons for MT failure in the posterior circulation. Failed MTs were categorized according to the reason for procedure failure in failed vascular access, failed passage of the target vessel occlusion and MT failure after passing the occluded target vessel. Patient characteristics were compared between failed and successful MT.

Results

Patients with failed MT (30/218 patients, 13.8%) were categorized into futile vascular access (13/30, 43.3%), abortive passage of the target vessel occlusion (6/30, 20.0%) and MT failure after passing the vessel occlusion (11/30, 36.7%). In 188/218 (86.2%) successful MTs alternative vascular access, local intra-arterial (i.a.) thrombolysis and emergency stent-assisted PTA prevented 65 MT failures. Patients with failed MT showed a higher NIHSS at discharge, a higher pc-ASPECTS in follow-up imaging, a higher mRS 90 days after stroke onset and a high mortality rate of 77.0% (mRS at 90 days, median (IQR): 6 (6–6) vs. 4 (2–6) for successful MT, p-value < 0.001). Co-morbidities and stroke etiology were not different compared to sufficient recanalization with atherosclerotic disease as the leading stroke etiology in both groups.

Conclusion

Failure of MT in posterior circulation ischemic stroke patients is associated with a high mortality rate. Reasons for MT failure are diverse with futile vascular access and MT failure after passing the vessel occlusion as the leading causes. Alternative vascular access, local i.a. thrombolysis and stent-assisted PTA can prevent MT failure.

Predictors of Favorable Outcome after Endovascular Thrombectomy in MRI: Selected Patients with Acute Basilar Artery Occlusion

BACKGROUND AND PURPOSE

Clinical outcomes after endovascular treatment for acute basilar artery occlusions need further investigation. Our aim was to analyze predictors of a 90-day good functional outcome defined as mRS 0-2 after endovascular treatment in MR imaging-selected patients with acute basilar artery occlusions.

MATERIALS AND METHODS

We analyzed consecutive MR imaging-selected patients with acute basilar artery occlusions endovascularly treated within the first 24 hours after symptom onset. Successful and complete reperfusion was defined as modified TICI scores 2b-3 and 3, respectively. Outcome at 90 days was analyzed in univariate and multivariate analysis regarding baseline patient treatment characteristics and periprocedural outcomes.

RESULTS

One hundred ten patients were included. In 10 patients, endovascular treatment was aborted for failed proximal/distal access. Overall, successful reperfusion was achieved in 81.8% of cases (n = 90; 95% CI, 73.3%-88.6%). At 90 days, favorable outcome was 31.8%, with a mortality rate of 40.9%; the prevalence of symptomatic intracranial hemorrhage within 24 hours was 2.7%. The median time from symptom onset to groin puncture was 410 minutes (interquartile range, 280-540 minutes). In multivariable analysis, complete reperfusion (OR = 6.59; 95% CI, 2.17-20.03), lower pretreatment NIHSS (OR = 0.77; 95% CI, 0.64-0.94), the presence of posterior communicating artery collateral flow (OR = 2.87; 95% CI, 1.05-7.84), the absence of atrial fibrillation (OR = 0.18; 95% CI, 0.03-0.99), and intravenous thrombolysis administration (OR = 2.75; 95% CI, 1.04-7.04) were associated with 90-day favorable outcome.

CONCLUSIONS

In our series of MR imaging-selected patients with acute basilar artery occlusions, complete reperfusion was the strongest predictor of a good outcome. Lower pretreatment NIHSS, the presence of posterior communicating artery collateral flow, the absence of atrial fibrillation, and intravenous thrombolysis administration were associated with favorable outcome.