Acute stroke with major intracranial vessel occlusion: Characteristics of cardioembolism and atherosclerosis-related in situ stenosis/occlusion

Emergent Large Vessel Occlusion due to Intracranial Stenosis: Identification, Management, Challenges, and Future Directions

This comprehensive literature review focuses on acute stroke related to intracranial atherosclerotic stenosis (ICAS), with an emphasis on ICAS-large vessel occlusion. ICAS is the leading cause of stroke globally, with high recurrence risk, especially in Asian, Black, and Hispanic populations. Various risk factors, including hypertension, diabetes, hyperlipidemia, smoking, and advanced age lead to ICAS, which in turn results in stroke through different mechanisms. Recurrent stroke risk in patients with ICAS with hemodynamic failure is particularly high, even with aggressive medical management. Developments in advanced imaging have improved our understanding of ICAS and ability to identify high-risk patients who could benefit from intervention. Herein, we focus on current management strategies for ICAS-large vessel occlusion discussed, including the use of perfusion imaging, endovascular therapy, and stenting. In addition, we focus on strategies that aim at identifying subjects at higher risk for early recurrent risk who could benefit from early endovascular intervention The review underscores the need for further research to optimize ICAS-large vessel occlusion treatment strategies, a traditionally understudied topic.

Acute Vertebrobasilar Artery Occlusion with Underlying Atherosclerosis: Balloon Angioplasty Combined with Tirofiban as Initial Salvage Therapy

OBJECTIVE

The optimal rescue endovascular treatment for patients with intracranial atherosclerotic stenosis in acute vertebrobasilar artery occlusion is not well established. We investigated the safety and efficacy of balloon angioplasty combined with tirofiban as the initial rescue strategy in these patients.

METHODS

We retrospectively analyzed the records of 41 patients admitted between January 2014 and September 2022, with vertebrobasilar artery atherosclerotic occlusion. Balloon angioplasty in combination with tirofiban was used as the first-line salvage therapy after the failure of mechanical thrombectomy. The technical success rate, recanalization outcome, procedure-related complications, symptomatic intracranial hemorrhage, and functional outcome at 90 days were reviewed.

RESULTS

Recanalization with a modified Thrombolysis in Cerebral Infarction grade of 2b-3 was achieved in 38 of the 41 patients (92.7%). Acute stents were deployed in 5 patients who did not achieve successful reperfusion after balloon angioplasty. Six patients (14.6%, 6/41) underwent stent angioplasty in the stable stage for severe residual stenosis detected on follow-up imaging. There was no procedure-related complication. Hemorrhagic transformation was detected on follow-up imaging in 11 patients (26.8%), while no symptomatic intracranial hemorrhage was recorded. Good functional outcome rate was 31.7% (13/41).

CONCLUSIONS

Balloon angioplasty combined with intravenous tirofiban administration is a safe and effective salvage therapy in patients with acute atherosclerotic occlusion of the vertebrobasilar artery.

Negative susceptibility vessel sign might be predictive of complete reperfusion in patients with acute basilar artery occlusion managed with thrombectomy

OBJECTIVES

Negative susceptibility vessel sign (SVS) on pre-thrombectomy MRI has been linked to fibrin-rich thrombus and difficult retrieval in anterior ischemic stroke. However, its impact in posterior circulation-large vessel occlusion stroke (PC-LVOS) has not yet been elucidated. We aim to investigate the relationship of SVS parameters with stroke subtypes and their influence on angiographic and functional outcomes.

METHODS

Prospective thrombectomy registries at two-comprehensive stroke centers were retrospectively reviewed between January 2015 and December 2019 for consecutive MRI-selected patients with PC-LVOS. Two groups were assigned by two independent readers, based on the presence or absence of the SVS (SVS +, SVS -) on MRI-GRE sequence. Multivariate logistic regression analysis was utilized to study primarily the impact of the SVS on the rate of complete recanalization (defined as mTICI 2c/3) at the final series following endovascular thrombectomy (EVT) and whether or not it might influence the efficacy of the frontline EVT strategy. Secondarily, we studied whether the absence of the SVS was predictive of the rate of 90-day functional independence (defined as mRS score < 2). Lastly, both qualitative (SVS +, SVS-) and quantitative (SVS length and diameter) parameters of the SVS were analyzed in association with the puncture to recanalization interval and various stroke etiological subtypes based on TOAST criteria.

RESULTS

Among 1823 patients, 116 were qualified for final analysis (median age, 68 (59-75) years; male, 65%); SVS was detected in 62.9% (73/116) of cases. SVS length was an independent predictor of procedural duration (p = .01) whilst two-layered SVS was inversely associated with the atherosclerosis etiological subtype (aOR = 0.27, 95% CI 0.08-0.89; p = .03). Successful recanalization was achieved in 82% (60/73) vs. 86% (37/43), p = .80 of patients with SVS (+, -) respectively. Only in SVS (+), stentriever (RR 0.59 (0.4-0.88), p = .009), and contact-aspiration (RR 0.82 (0.7-0.96), p = .01) achieved a lower rate of successful recanalization compared to combined technique. SVS (-) was significantly associated with a higher rate of mTICI 2c/3 (aOR = 4.444; 95% CI 1.466-13.473; p = .008) and showed an indirect effect of 9% towards functional independence mediated by mTICI 2c/3.

CONCLUSION

SVS parameters in PC-LVOS might predict stroke subtype and indirectly influence the functional outcome by virtue of complete recanalization.

KEY POINTS

• Negative susceptibility vessel sign (SVS) in patients with basilar occlusion independently predict complete recanalization that indirectly instigated a 3-month favorable outcome following thrombectomy. • The longer the SVS, the higher likelihood of large artery atherosclerosis and the longer the thrombectomy procedure. • Two-layered SVS might be negatively associated with the presence of atherosclerosis, yet already-known limitations of TOAST classification and the absence of pathological analysis should be taken into consideration.

Assessment of thrombus using susceptibility-weighted filtered-phase images in patients with acute ischemic stroke

BACKGROUND AND PURPOSE

Recognizing the location and length of the thrombus responsible for large vessel occlusion in patients with acute ischemic stroke can facilitate effective endovascular recanalization therapy (ERT). We hypothesized that the aliasing or dipole effect produced by filtered-phase susceptibility-weighted imaging (SWI) would facilitate thrombus delineation.

METHODS

Of the patients with middle cerebral artery occlusion who underwent ERT, we screened those who underwent noncontrast CT (NCCT), multiphase CT angiography (mCTA), and SWI before the endovascular procedure. We used an arbitrary index termed measurement of equivalence in thrombus assessed by digital subtraction angiography (METAD) defined as having the same location as the thrombus observed in the digital subtraction angiography (DSA) and length differing by less than 5 mm. For NCCT, mCTA, SWI_m (magnitude), and SWI_p (phase), the length of the thrombus and METAD were assessed.

RESULTS

The mean lengths of the thrombi determined using NCCT, mCTA, SWI_m, SWI_p, and DSA were 14.03, 13.47, 13.89, 9.93, and 8.96 mm, respectively. The absolute agreement for thrombus length was excellent for SWI_p and DSA (intraclass correlation coefficient [ICC] = .96), moderate for SWI_m and DSA (ICC = .53), and poor for mCTA and DSA (ICC = .14). The METADs were 26.7%, 40.0%, 33.3%, and 73.3% for NCCT, mCTA, SWI_m, and SWI_p, respectively. The METADs for NCCT and SWI_p were significantly different (p = .045) and those for mCTA and SWI_m were not (p = .537 and .093, respectively).

CONCLUSIONS

The SWI_p was best matched with the DSA for the measurement of the lengths and locations of thrombi. The use of pre-thrombectomy SWI_p imaging for acute ischemic stroke may facilitate a successful ERT strategy.

Outcome after endovascular treatment for acute ischemic stroke by underlying etiology: Tertiary experience and meta-analysis

Objective

To investigate the effect of two major etiologies [intracranial atherosclerotic stenosis (ICAS) and cardioembolism (CE])] on outcomes of acute ischemic stroke (AIS) patients due to large vessel occlusion (LVO) after endovascular thrombectomy (EVT).

Methods

Anterior circulation AIS patients receiving EVT were retrospectively analyzed. Clinical and laboratory data were collected. Clinical outcomes including favorable outcome (90-day modified Rankin Scale 0-2), mortality, intracranial hemorrhage (ICH) and symptomatic ICH (sICH) were compared. A systematic review and meta-analysis was also performed.

Results

A total of 302 AIS patients were included and divided into the ICAS group (86 patients) and the CE group (216 patients). Patients in the ICAS group were younger (62[18.0] vs. 68[19.0] years, p < 0.001), more likely to have smoking (52.3% vs. 26.9%, p < 0.001) and drinking (52.3% vs. 23.1%, p < 0.001) history, and more frequently required rescue therapy (80.2% vs. 4.6%, p < 0.001) compared to the CE group. However, favorable outcome (aOR 0.722, 95%CI 0.372-1.402, p = 0.336) and mortality (aOR 1.522, 95%CI 0.606-3.831, p = 0.371) were not significantly different between the two groups before and after adjustment. The incidence of sICH and ICH were comparable between the two groups before and after adjustment. Systematic review and meta-analysis consisted of 8 eligible studies (7 previous studies and this current study), incorporating 552 ICAS patients and 1,402 CE patients. Favorable outcome was slightly more likely in the ICAS group compared to the CE group (54.2% vs. 46.3%, OR 1.40, 95%CI 1.00-1.96, I ² = 53.2%). Moreover, the ICAS group had a lower rate of mortality (14.3% vs. 22.2%, OR 0.63, 95%CI 0.46-0.87, I ² = 0.0%) and ICH (19.5% vs. 31.9%, OR 0.60, 95%CI 0.42-0.84, I ² = 0.0%) than the CE group, while the two groups were similar in sICH rate (5.9% vs. 6.7%, OR 0.94, 95%CI 0.55-1.60, I ² = 6.3%).

Conclusion

Etiology was not considered as an important factor in functional outcome, despite the differences in baseline characteristics and technical EVT approach. The current study of anterior circulation AIS-LVO patients supports that outcomes for those with ICAS are not significantly different from those with CE.

Novel predictors and a predictive model of cerebrovascular atherosclerotic ischemic stroke based on clinical databases

BACKGROUND AND PURPOSE

Early identification of cerebrovascular atherosclerotic ischemic stroke is necessary for accurate treatment and clinical research.

AIMS

To identify novel predictors and build a predictive model of ischemic strokes due to cerebrovascular atherosclerosis.

METHOD

MIMIC-IV database was used to search for clinical data of patients with ischemic stroke. Included patients were divided into two groups according to their etiologies. Univariate and multivariate logistic regressions were used to build the predictive model, and the model reliability parameters were calculated. The cut-off value for the model was selected according to the Youden index. Clinical data from the Neurovascular Center of Changhai Hospital were used to verify the predictive model.

RESULTS

Logistical regressions showed a positive correlation between advanced age, peripheral atherosclerosis, history of transient ischemia, and the diagnosis of ischemic strokes due to cerebrovascular atherosclerosis. The history of atrial fibrillation, levels of the National Institutes of Health Stroke Scale, serum potassium, and activated partial thromboplastin time were negatively correlated to the diagnosis of cerebrovascular atherosclerotic ischemic stroke. The predictive model was constructed from logistic regression results, and the area under the curve was 0.764. The cut-off value for the model was set at 0.089 to achieve the highest Youden index, with sensitivity and specificity of 75.9% and 64.1%. Clinical verification of the model revealed that the sensitivity and specificity of the model were 52.5% and 93.0% respectively.

CONCLUSION

The efficacy of the predictive model was acceptable as an aid in predicting cerebrovascular atherosclerotic ischemic stroke.

Early diagnosis of intracranial atherosclerotic large vascular occlusion: A prediction model based on DIRECT-MT data

AIMS

This study aimed to build a prediction model to early diagnose intracranial atherosclerosis (ICAS)-related large vascular occlusion (LVO) in acute ischemic stroke patients before digital subtractive angiography.

METHODS

Patients enrolled in the DIRECT-MT trial (NCT03469206) were included in our secondary analysis and distributed into ICAS-LVO and non-ICAS-LVO groups. We also retrieved demographic data, medical histories, clinical characteristics, and pre-operative imaging data. Hypothesis testing was used to compare data of the two groups, and univariate logistic regression was used to identify the predictors of ICAS-LVO primarily. Then, we used multivariate logistic regression to determine the independent predictors and formulate the prediction model. Model efficacy was estimated by the area under the receiver operating characteristic (ROC) curve (AUC) and diagnostic parameters generated from internal and external validations.

RESULTS

The subgroup analysis included 45 cases in the ICAS-LVO group and 611 cases in the non-ICAS-LVO group. Variates with p < 0.1 in the comparative analysis were used as inputs in the univariate logistic regression. Next, variates with p < 0.1 in the univariate logistic regression were used as inputs in the multivariate logistic regression. The multivariate logistic regression indicated that the atrial fibrillation history, hypertension and smoking, occlusion located at the proximal M1 and M2, hyperdense artery sign, and clot burden score were related to the diagnosis of ICAS-LVO. Then, we constructed a prediction model based on multivariate logistics regression. The sensitivity and specificity of the model were 84.09 and 74.54% in internal validation and 73.11 and 71.53% in external validation.

CONCLUSION

Our current prediction model based on clinical data of patients from the DIRECT-MT trial might be a promising tool for predicting ICAS-LVO.

Clinical Effect of Digital Subtraction Angiography Combined with Neurointerventional Thrombolysis for Acute Ischemic Cerebrovascular Disease and Its Influence on Vascular Endothelial Function and Oxidative Stress

Objective

Ischemic cerebrovascular disease is a commonly seen vascular disorder in clinical practice. Given the difficulty of drug therapy to achieve ideal curative effects, interventional therapy has gradually become the preferred treatment for the disease. This research primarily discusses the short-term efficacy of digital subtraction angiography- (DSA-) guided neurointerventional thrombolysis for acute ischemic cerebrovascular disease (AICVD) and its influence on vascular endothelial function (VEF) and oxidative stress (OS).

Methods

All the clinical data of 162 patients diagnosed with AICVD and treated between June 2019 and December 2021 were collected and analyzed retrospectively. They were assigned to two cohorts according to the difference in interventional methods: a conventional group (CG) given recombinant tissue plasminogen activator (rt-PA) therapy and an observation group (OG) intervened by DSA-guided neurointerventional thrombolysis. The two groups were compared with respect to short-term treatment efficacy, the National Institutes of Health Stroke Scale (NIHSS) score, cerebral hemodynamics, and VEF and OS indexes.

Results

The short-term efficacy was better in OG (93.98%) than in CG (82.28%). After treatment, the NIHSS score decreased in both cohorts with obvious differences within the group at different time points, and the posttreatment NIHSS score was lower in OG as compared to CG. OG had higher Q m and V m while lower W v, Z cv, and R v than CG. Higher endothelial-dependent flow-mediated dilatation (FMD) was observed in OG, as well as lower ankle-brachial index (ABI) and pulse wave velocity (PWV). And the posttreatment MDA was lower while SOD, GSH-Px, and TAC were higher in OG compared with those on CG. All the above differences were of statistical significance (P < 0.05).

Conclusions

DSA-guided neurointerventional thrombolysis is highly effective in the treatment of AICVD, which can not only effectively improve patients' neurological function and cerebral hemodynamics but also mitigate VEF injury and help to alleviate patients' OS.

Efficacy and safety of direct balloon angioplasty in the treatment of large atherosclerotic stroke

OBJECTIVE

Based on the unclear safety and effectiveness of direct balloon angioplasty as a first-line treatment for patients with acute ischemic stroke caused by large artery atherosclerosis (LAA), our paper would center on investigating the safety and effectiveness of this novel strategy.

PATIENTS AND METHODS

A consecutive series of acute ischemic stroke patients due to intracranial atherosclerosis and short thrombus who underwent thorough direct balloon angioplasty from October 2019 to March 2021 were enrolled. The primary end point included arterial recanalization (modified Thrombolysis in Cerebral Infarction [mTICI]: 2b-3), and 90-day functional independence (modified Rankin Scale[mRS]: 0-2). The secondary end point was symptomatic intracerebral hemorrhage (sICH) and perioperative restenosis and re-occlusion of offending vessel.

RESULTS

68 patients were included. Mean time from onset to groin puncture was 342.5 min and 50 min for groin puncture to successful recanalization. 61 (89.7%) patients achieved successful recanalization and 41 (60.3%) acquired functional independence. 11 (16.0%) patients experienced ICH and only 3 (4.4%) for sICH. 8 (11.8%) patients developed symptomatic restenosis or re-occlusion within seven days after the operation. In addition, 16 (23.5%) patients received rescue stenting and 3 (18.8%) of this subgroup appeared immediate intra-stent thrombosis.

CONCLUSION

Direct balloon angioplasty may be a safe and effective method for the treatment of stroke caused by intracranial large arteriosclerosis occlusion.

The length of susceptibility vessel sign predicts early neurological deterioration in minor acute ischemic stroke with large vessel occlusion

Background

Patients with acute large vessel occlusion (LVO) presenting with minor stroke are at risk of early neurological deterioration (END). The present study aimed to evaluate the frequency and potential predictors of END in patients with medical management and LVO presenting with minor stroke. The relationship between SVS length and END was also investigated.

Methods

This was a prospective multicenter study. Consecutive patients were collected with anterior circulation. LVO presented with minor stroke [National Institutes of Health Stroke Scale (NIHSS) ≤ 4] within 24 h following onset. END was defined as a deterioration of NIHSS ≥4 within 24 h, without parenchymal hemorrhage. The length of the susceptibility vessel sign (SVS) was measured using the T2* gradient echo imaging.

Results

A total of 134 consecutive patients with anterior circulation LVO presenting with minor stroke were included. A total of 27 (20.15%) patients experienced END following admission. Patients with END exhibited longer SVS and higher baseline glucose levels compared with subjects lacking END (P < 0.05). ROC curve analysis indicated that the optimal cutoff point SVS length for END was SVS ≥ 9.45 mm. Multivariable analysis indicated that longer SVS [adjusted odds ratio (aOR), 2.03; 95% confidence interval (CI), 1.45–2.84; P < 0.001] and higher baseline glucose (aOR,1.02; 95% CI, 1.01–1.03; P = 0.009) levels were associated with increased risk of END. When SVS ≥ 9.45 mm was used in the multivariate logistic regression, SVS ≥ 9.45 mm (aOR, 5.41; 95%CI, 1.00–29.27; P = 0.001) and higher baseline glucose [aOR1.01; 95%CI, 1.00–1.03; P = 0.021] were associated with increased risk of END.

Conclusions

END was frequent in the minor stroke patients with large vessel occlusion, whereas longer SVS and higher baseline glucose were associated with increased risk of END. SVS ≥ 9.45 mm was a powerful independent predictor of END.

Efficacy and Safety of a Novel Thrombectomy Device in Patients With Acute Ischemic Stroke: A Randomized Controlled Trial

Purpose: The Tonbridge stent is a novel retriever with several design improvements which aim to achieve promising flow reperfusion in the treatment of acute ischemic stroke (AIS). We conducted a randomized controlled, multicenter, non-inferiority trial to compare the safety and efficacy of the Tonbridge stent with the Solitaire FR. Methods: AIS patients aged 18-85 years with large vessel occlusion in anterior circulation who could undergo puncture within 6 h of symptom onset were included. Randomization was performed on a 1:1 ratio to thrombectomy with either the Tonbridge stent or the Solitaire FR. The primary efficacy endpoint was successful reperfusion using a modified thrombolysis in cerebral infarction score (mTICI) of 2b/3. Safety outcomes were symptomatic intracranial hemorrhage (sICH) within 24 ± 6 h and all-cause mortality within 90 days. A clinically relevant non-inferiority margin of 12% was chosen as the acceptable difference between groups. Secondary endpoints included time from groin puncture to reperfusion, National Institutes of Health Stroke Scale (NIHSS) score at 24 h and at 7 days, and a modified Rankin Scale (mRS) score of 0-2 at 90 days. Results: A total of 220 patients were enrolled; 104 patients underwent thrombectomy with the Tonbridge stent and 104 were treated with the Solitaire FR. In all test group patients, the Tonbridge was used as a single retriever without rescuing by other thrombectomy devices. Angioplasty with balloon and/or stent was performed in 26 patients in the Tonbridge group and 16 patients in the Solitaire group (p = 0.084). Before angioplasty, 86.5% of those in the Tonbridge group and 81.7% of those in the Solitaire group reached successful reperfusion (p = 0.343). Finally, more patients in the Tonbridge group achieved successful reperfusion (92.3 vs. 84.6%, 95% CI of difference value 0.9-16.7%, p < 0.0001). There were no significant differences on sICH within 24 ± 6 h between the two groups. All-cause mortality within 90 days was 13.5% in the Tonbridge group and 16.3% in the Solitaire group (p = 0.559). We noted no significant differences between groups on the NIHSS at either 24 h or 7 days and the mRS of 0-2 at 90 days. Conclusion: The trial indicated that the Tonbridge stent was non-inferior to the Solitaire FR within 6 h of symptom onset in cases of large vessel occlusion stroke. Clinical Trial Registration:ClinicalTrials.gov, number: NCT03210623.

The relation between aortic arch branching types and the location of large vessel occlusion in cardioembolic stroke

Cardiac embolism is the leading etiology of ischemic strokes. There are arguments about the left-right propensity of cardioembolic strokes.This study aimed to reveal the relationship between the different aortic arch types and the location of large vessel occlusion (LVO) in cardioembolic stroke.We retrospectively identified all patients with acute ischemic stroke admitted to our comprehensive stroke center who had medium- to high-risk cardioembolicsources according to the TOAST classification.Only those with LVO and available images of the aortic arch were included. Patients were classified into 3 groups according to the aortic arch types: Type I (n = 44), Type II (n = 105), Type III (n = 36).The thrombus was divided into large thrombus or small thrombus based on the location of LVO.Overall, left-sided strokes (50.8%) were almost equal to right-sided (49.2%). There was a growing tendency for the percentage of left-sided infarcts with advancement of the aortic arch types either in the total cases or in the atrial fibrillation cases, with no statistical difference between the 3 aortic arch types.In type III aortic arch, left-sided strokes (69.0%) were twice than right-sided (31%) in large thrombus (P < 0.05), while right-sided strokes (85.7%) were more common than left-sided (14.3%) in small thrombus (P < 0.05).Conversely, in type Ⅰ and II aortic arches, left-sided strokes were more common than right-sided in small thrombus, while right-sided strokes were more common than left-sided in large thrombus (P < 0.05). The left-right propensity of cardioembolic stroke is related to the proximity of clot lodging in different aortic arch types.

Large vessel cardioembolic stroke and embolic stroke of undetermined source share a common profile of matrix metalloproteinase-9 level and susceptibility vessel sign length

BACKGROUND

Embolic stroke of undetermined source (ESUS) accounts for up to 25% of ischemic strokes. Identification of biomarkers that could improve the prediction of stroke subtype and subsequently of stroke prevention still remains a major issue.

METHODS

The HIBISCUS-STROKE cohort includes ischemic stroke patients with large vessel occlusion treated with mechanical thrombectomy following admission magnetic resonance imaging. Presence and length of susceptibility vessel sign (SVS) were assessed by gradient-recalled echo T2*-weighted imaging. Matrix metalloproteinase-9 (MMP-9) was measured on sera collected at admission. A multiple logistic regression model was performed to detect independent markers distinguishing cardioembolic (CE) from large-artery atherosclerosis (LAA) subtype.

RESULTS

A total of 147 patients were included, of them the etiology was distributed as follows: 86 (58.5%) CE, 26 (17.7%) LAA, and 35 (23.8%) ESUS. The optimal cutoff for differentiating CE from LAA subtype was 14.5 mm for SVS length (sensitivity, 79.7%; specificity, 72.7%) and 1110 ng/ml for admission MMP-9 level (sensitivity, 85.3%; specificity, 52.2%). Multivariate analysis revealed that current smoking (odds ratio [OR] 0.07, 95% confidence interval [CI] 0.01-0.93), tandem occlusion (OR 0.01, 95% CI 0.01-0.21), SVS length (OR 0.78, 95% CI 0.63-0.97), and admission MMP-9 level (OR 0.99, 95% CI 0.99-1.00) were inversely associated with CE subtype. SVS length and MMP-9 level did not differ between ESUS and CE subtypes.

CONCLUSION

SVS length and admission MMP-9 level may improve the prediction of CE subtype whose profile is close to ESUS, thus suggesting a common cardiac embolic source.

Differences between proximal and distal M1 occlusions after mechanical thrombectomy

PURPOSE

Whether M1 occlusions proximal (pM1) and distal (dM1) to the lenticulostriate perforators result in different clinical outcomes after mechanical thrombectomy (MT) is unknown. We retrospectively compared the clinical outcomes and baseline characteristics of patients with these two types of occlusions.

METHODS

From March 2010 to May 2019, we performed MT for 141 M1 occlusions, including pM1 occlusions (n = 58) and dM1 occlusions (n = 83).

RESULTS

Good clinical outcomes (modified Rankin Scale score 0 to 2) were achieved in 28 out of 58 (48.3%) patients with pM1 occlusions and 46 out of 83 (55.4%) patients with dM1 occlusions without significance (p = 0.493). Cardioembolic occlusions represented 19 out of 58 (32.6%) pM1 occlusions and 53 out of 83 (63.9%) dM1 occlusions, and atherosclerotic occlusions represented 37 out of 58 (63.8%) pM1 occlusions and 27 out of 83 (32.5%) dM1 occlusions, with significance (p = 0.001). Rescue treatments, such as balloon angioplasty or stenting, were needed more for pM1 occlusions than dM1 occlusions (21 out of 58 (36.2%) vs. 8 out of 83 (9.8%), p < 0.001). The multivariable logistic regression analysis demonstrated that the need for rescue treatment was associated with pM1 occlusions (adjusted odds ratio; 3.804, 95% confidence interval; 1.306-11.082, p = 0.014).

CONCLUSIONS

In our series, pM1 and dM1 occlusions did not significantly differ in good clinical outcomes. Our study also showed that pM1 occlusions were more strongly associated with atherosclerotic occlusions, while dM1 occlusions were more strongly associated with cardioembolic occlusions, and rescue treatments were needed more often for pM1 occlusions than dM1 occlusions.

Predictive Value of the Alberta Stroke Program Early CT Score (ASPECTS) in the Outcome of the Acute Ischemic Stroke and Its Correlation with Stroke Subtypes, NIHSS, and Cognitive Impairment

OBJECTIVES

This study is aimed at correlating ASPECTS with mortality and morbidity in patients with acute middle cerebral artery territory infarction and at determining the cutoff value of ASPECTS that may predict the outcome.

METHODS

150 patients diagnosed with acute middle cerebral artery territory infarction were involved in this study. Risk factors, initial NIHSS, and GCS were determined. An initial or follow-up noncontrast CT brain was done and assessed by ASPECTS. Outcomes were determined by mRS during the follow-up of cases after 3 months. Correlations of ASPECTS and outcome variables were done by Spearman correlation. Logistic regression analysis and ROC curve were done to detect the cutoff value of ASPECTS that predicts unfavorable outcomes.

RESULTS

The most common subtypes of ischemic strokes were lacunar stroke in 66 patients (44%), cardioembolic stroke in 39 patients (26%), and LAA stroke in 30 cases (20%). The cardioembolic stroke had a statistically significant lower ASPECT score than other types of ischemic strokes (P < 0.05). Spearman correlation showed that lower ASPECTS values (worse outcome) were more in older patients and associated with lower initial GCS. ASPECTS values were inversely correlated with initial NIHSS, inpatient stay, inpatient complications, mortality, and mRS. The ASPECTS cutoff value determined for the prediction of unfavorable outcomes was equal to ≤7. The binary logistic regression analysis detected that patients with ASPECTS ≤ 7 were significantly associated with about fourfold increased risk of poor outcomes (OR 3.95, 95% CI 2.09-11.38, and P < 0.01).

CONCLUSIONS

ASPECTS is a valuable and appropriate technique for the evaluation of the prognosis in acute ischemic stroke. Patients with high ASPECTS values are more likely to attain favorable outcomes, and the cutoff value of ASPECTS is a strong predictor for unfavorable outcomes. This trial is registered with ClinicalTrials.gov NCT04235920.

Antegrade Blood Flow on 4-Dimensional Computed Tomography Angiography Predict Stroke Subtype in Patients With Acute Large Artery Occlusion

Background

The purpose of this study was to determine whether the presence of antegrade blood flow was related to stroke subtype in patients with acute intracranial large artery occlusion.

Methods and Results

The prospectively collected data for consecutive patients who had occlusion of the unilateral M1 segment of the middle cerebral artery with or without internal carotid artery and received reperfusion therapy were retrospectively reviewed. Stroke causes were determined according to the Trial of ORG 10172 in Acute Stroke Treatment standard. We defined antegrade flow as early opacification at the distal interface of the clot with subsequent distal extension on 4‐dimensional computed tomography angiography. A total of 387 large artery occlusion patients were analyzed (229 men and 158 women; mean age, 71±14 years), including 77 (19.9%) with large artery atherosclerosis (LAA), 206 (53.2%) with cardioembolism, and 104 (26.9%) with undetermined causes. Antegrade flow was found in 206 (53.2%) patients, and 181 (46.8%) presented with retrograde flow. The rate of antegrade flow was much higher in patients with LAA than in those with cardioembolism (85.7% versus 42.2%, P<0.001). Multivariable logistic regression revealed that presence of antegrade flow was significantly associated with cuse of LAA after adjusting for confounding factors, when setting cardioembolism as reference (odds ratio, 5.650; 95% confidence interval, 2.451–13.158; P<0.001). The sensitivity, specificity, and positive and negative predictive values of the antegrade flow for predicting LAA were 43.1%, 91.5%, 85.7%, and 57.8%, respectively.

Conclusions

Using 4‐dimensional computed tomography angiography, antegrade flow can be identified in more than half of acute anterior large artery occlusion patients and occurs more frequently in those with LAA as the cause of stroke.

Current knowledge of large vascular occlusion due to intracranial atherosclerosis: focusing on early diagnosis

Intracranial atherosclerosis (ICAS)-related large vascular occlusion (LVO) was an intractable subtype of acute ischemic stroke (AIS), which always needed rescue angioplasty and stenting and complicated the procedure of endovascular recanalization. Diagnosing ICAS-LVO accurately and early was helpful for both clinical treatment and trials. Digital subtraction angiography (DSA) was unable to provide an early and rapid diagnosis of ICAS-LVO based on current studies. A variety of pre-DSA methods had been used to distinguish ICAS-LVO with other subtypes of ischemic stroke, such as medical histories, clinical presentations, computed tomography or angiography (CT/CTA), and magnetic resonance imaging (MRI/MRA). This article briefly reviewed the status quo of the diagnosis and treatment of ICAS-LVO and summarized early diagnostic methods of ICAS-LVO from different aspects.

Cortical Microinfarcts Associated With Worse Outcomes in Patients With Acute Ischemic Stroke Receiving Endovascular Treatment

BACKGROUND AND PURPOSE

We aimed to evaluate the impact of cortical microinfarcts (CMIs) on functional outcome after endovascular treatment in patients with acute ischemic stroke.

METHODS

In a multicenter registration study for RESCUE-RE (a registration study for Critical Care of Acute Ischemic Stroke After Recanalization), eligible patients with large vessel occlusion stroke receiving endovascular treatment, who had undergone 3T magnetic resonance imaging on admission or within 24 hours after endovascular treatment were analyzed. We evaluated the presence and numbers of CMIs with assessment of axial T1, T2-weighted images, and fluid-attenuated inversion recovery images. The primary outcome was functional dependence or death defined as modified Rankin Scale scores of 3 to 6 at 90 days. Secondary outcomes included early neurological improvement, any intracranial hemorrhage, symptomatic intracranial hemorrhage, and mortality. We investigated the independent associations of CMIs with the outcomes using multivariable logistic regression in overall patients and in subgroups.

RESULTS

Among 414 patients (enrolled from July 2018 to May 2019) included in the analyses, 96 (23.2%) patients had at least one CMI (maximum 6). Patients with CMI(s) were more likely to be functionally dependent or dead at 90 days, compared with those without (55.2% versus 37.4%; P<0.01). In multivariable logistic regression analyses, presence of CMI(s) (adjusted odds ratio, 1.78 [95% CI, 1.04-3.07]; P=0.04) and multiple CMIs (CMIs ≥2; adjusted odds ratio, 7.41 [95% CI, 2.48-22.17]; P<0.001) were independently, significantly associated with the primary outcome. There was no significant difference between subgroups in the associations between CMI presence and the primary outcome.

CONCLUSIONS

Acute large vessel occlusion stroke patients receiving endovascular treatment with CMI(s) were more likely to have a poor functional outcome at 90 days, independent of patients' characteristics. Such associations may be dose-dependent. Registration: URL: http://www.chictr.org.cn; Unique identifier: ChiCTR1900022154.

Laquinimod Protects Against TNF-α-Induced Attachment of Monocytes to Human Aortic Endothelial Cells (HAECs) by Increasing the Expression of KLF2

Introduction

As a worldwide health issue, the treatment and prevention of atherosclerosis present an important goal. Increased levels of proinflammatory cytokines such as TNF-α-associated chronic inflammatory response cause endothelial cells to lose their ability to regulate vascular function. Lipid-laden immune cells are recruited to the endothelium where they adhere to the endothelial wall and invade the intimal space, thereby leading to the development of atherosclerotic lesions, fatty plaques, and thickening of the arterial wall. In the present study, for the first time, we investigated the effects of laquinimod, an immunomodulatory agent used for the treatment of multiple sclerosis, on human aortic endothelial in a TNF-α-induced atherosclerotic microenvironment. At present, the mechanism of action of laquinimod is not well defined.

Methods

The effects of laquinimod on the gene expression of IL-6, MCP-1, VCAM-1, E-selectin, and KLF2 were measured by real-time PCR. ELISA assay was used to determine protein secretion and expression. Phosphorylation of ERK5 and the protein level of KLF2 were measured by Western blot analysis. The attachment of monocytes to endothelial cells was assayed by calcein-AM staining and fluorescent microscopy.

Results

Our findings demonstrate that laquinimod reduced the expression of key inflammatory cytokines and chemokines, including IL-6, MCP-1, and HMGB1. We further demonstrate that laquinimod significantly reduced the attachment of monocytes to endothelial cells, which is mediated through reduced expression of the cellular adhesion molecules VCAM-1 and E-selectin. Here, we found that laquinimod could significantly increase the expression of KLF2 through activation of ERK5 signaling. The results of our KLF2 knockdown experiment confirm that the effects of laquinimod observed in vitro are dependent on KLF2 expression.

Conclusion

Together, these findings suggest a potential antiatherosclerotic capacity of laquinimod. Further research will elucidate the underlying mechanisms.

Differences in Safety and Efficacy of Endovascular Treatment for Acute Ischemic Stroke : A Propensity Score Analysis of Intracranial Atherosclerosis-Related Occlusion versus Embolism

PURPOSE

The prognosis after endovascular treatment (EVT) of acute arterial occlusions due to intracranial atherosclerotic disease (ICAD) may differ from those due to embolism. The aim was to evaluate whether safety and efficacy of EVT differ among patients with middle cerebral artery (MCA) M1 occlusion from ICAD or embolism.

METHODS

A database review was conducted to identify EVT patients with acute MCA M1 occlusion from November 2013 to December 2018.The patients were divided into the ICAD group and embolic group according to the etiology of occlusion. Using propensity score analysis, patients with ICAD-related occlusion and embolism underwent 1:1 matching. Angiographic results, complications, and clinical outcomes were compared.

RESULTS

A total of 217 patients (ICAD: 51; embolism: 166) were identified. After propensity score matching, 45 patients with ICAD-related occlusion and 45 with embolism were matched. All baseline covariates except atrial fibrillation were statistically indistinguishable. The rate of successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] 2b-3) was similar between the two groups, while the rate of mTICI 3 in the ICAD group was higher. No statistical difference was observed in the rate of postprocedural intracranial hemorrhage. The rate of favorable outcome (modified Rankin Scale [mRS] ≤2) and mortality at 90 days was comparable.

CONCLUSION

This propensity score analysis demonstrated that the EVT patients with acute ICAD-related MCA M1 occlusion had similar angiographic and clinical outcomes compared to those with M1 embolism on a similar baseline condition.

Effect of direct angioplasty therapy on acute middle cerebral artery occlusion with good leptomeningeal collateral

OBJECTIVE

The objective of this study was to investigate and discuss the effect of direct angioplasty therapy on acute middle cerebral artery occlusion (MCAO) patients with good leptomeningeal collateral circulation in 4.5 h.

PATIENTS AND METHODS

We retrospectively reviewed our acute ischemic stroke database from January 2017 to January 2019, then selected consecutive patients with evidence of the proximal M1 segments of MCAO and good leptomeningeal collateral who have received angioplasty or mechanical thrombectomy (MT). The baseline characteristics and outcome of patients was statistical analysis, included age, gender and risk factors, baseline national institutes of health stroke scale (NIHSS) scores, preoperative alberta stroke programme early CT (ASPECT) score, time from door to needle, time of door to puncture, endovascular procedure time, 7d NIHSS score and the modified treatment in cerebral infarction (m-TICI) 2b or 3, symptomatic hemorrhage, average hospital stays, modified rankin scale (mRS) score 0-2 at 3-month and mortality. All the thrombi were analyzed by histopathology. All statistical analysis was done with t-test for continuous data and χ2 test for binary data.

RESULTS

A total of 93 patients were included (direct angioplasty = 41 (44.1 %), MT = 52 (55.9 %)). There was no significant difference in baseline data between the two groups. The difference in the time of door to recanalization, the time of puncture to recanalization, symptomatic hemorrhage, and average hospital stays were significantly different between groups (P < 0.05). The other agents were not significantly different between groups (P > 0.05 each). Histopathological analysis showed all thrombi contained different amounts of platelets, fibrinogen, white blood cell, and red blood cell.

CONCLUSION

Direct angioplasty therapy on acute MCAO with good leptomeningeal collateral may help to shorten the time of surgery, reduce symptomatic hemorrhage, and hospital stay.

Assessment of the value of 3D-DSA combined with neurointerventional thrombolysis in the treatment of senile cerebrovascular occlusion

Assessment of the value of three-dimensional digital subtraction angiography (3D-DSA) combined with neurointerventional thrombolysis in the treatment of senile cerebrovascular occlusion was investigated. A total of 129 patients with senile cerebrovascular occlusion admitted to the Affiliated Hospital of Zunyi Medical University from August 2015 to September 2017 were collected. Among them, 69 patients who underwent neurointerventional catheter thrombolysis under 3D-DSA were included in the study group, and 60 patients treated with neurointerventional thrombolysis were the control group. The levels of inflammatory cytokines IL-6, IL-1β and IL-8 in the two groups were measured by enzyme linked immunosorbent assay (ELISA) before treatment (T0), 7 days (7d) after treatment (T1) and 14 days (14d) after treatment (T2). The score of the National Institute of Health Stroke Scale and the clinical efficacy of patients in the two groups were compared before and after treatment, and Barthel index (BI) was used for investigation before and after treatment. The recurrence rate of disease in the two groups within 1 year was recorded. At T1, IL-6, IL-1β and IL-8 in the study group were significantly lower than those in the control group (P<0.05). The NIHSS score in the study group was lower than that in the control group after treatment (P<0.05). The BI score in the study group was significantly higher than that in the control group after treatment (P<0.05). After the prognostic follow-up, the disease recurrence rate of the study group was significantly lower than that of the control group (P<0.05). In conclusion, 3D-DSA combined with neurointerventional thrombolysis can significantly reduce the expression of inflammatory cytokines and improve the quality of life in patients with cerebrovascular occlusion, which has a high clinical value.

Impact of basal ganglia damage after successful endovascular recanalization for acute ischemic stroke involving lenticulostriate arteries

OBJECTIVE

Regional ischemic vulnerability of the brain reportedly differs between the cortex and basal ganglia and has been poorly assessed in the setting of endovascular mechanical thrombectomy. This study was conducted to determine the fate of an ischemic basal ganglia and its contribution to the clinical outcome after successful endovascular recanalization for acute ischemic stroke with large vessel occlusion involving the lenticulostriate arteries.

METHODS

Clinical and radiological findings were retrospectively analyzed in consecutive patients with acute ischemic stroke characterized by large vessel occlusion involving the lenticulostriate arteries. Mechanical thrombectomy was performed in all patients using a stent retriever. The fate of ischemic basal ganglia based on location (lentiform nucleus, caudate nucleus, and internal capsule) and insular cortex was assessed according to the Alberta Stroke Programme Early CT Score (ASPECTS).

RESULTS

Of 170 patients with large intracranial vessel occlusion who achieved successful endovascular recanalization, defined as a thrombolysis in cerebral infarction grade of ≥ 2B, involvement of the lenticulostriate arteries was seen in 55 patients (internal carotid artery, n = 35; proximal middle cerebral artery, n = 20). Preoperative infarction was detected in the lentiform nucleus (66.7%), internal capsule (11.1%), and caudate nucleus (33.3%), all of which showed secondary advancement despite successful recanalization (85.4%, 27.3%, and 54.5%, respectively; p < 0.05). Lenticulostriate arteries with a lateral proximal and/or medial proximal origin significantly affected the development of mature infarction in the lentiform nucleus. Postoperative hemorrhagic transformation was detected in 25 of 55 patients, mostly in the lentiform nucleus. Involvement of insular ribbon infarction was significantly high in patients with hemorrhagic transformation in the basal ganglia. Age, initial National Institutes of Health Stroke Scale (NIHSS) score, initial ASPECTS, postoperative ASPECTS, postoperative infarction in the insular ribbon, and lesions in the middle cerebral artery area (M1-M6) were significantly different between patients with good and poor modified Rankin Scale scores. Interestingly, no differences were detected in postoperative infarction or hemorrhagic transformation in the basal ganglia. Multivariate analysis showed that only age (p = 0.02, OR 0.88) and the initial NIHSS score (p = 0.01, OR 0.86) independently affected favorable clinical outcomes.

CONCLUSIONS

The basal ganglia are vulnerable and readily develop secondary infarction and hemorrhagic transformation despite successful recanalization. However, this does not have a significant impact on the clinical outcome of acute ischemic stroke with large vessel occlusion involving the lenticulostriate arteries.

The different clinical value of susceptibility vessel sign in acute ischemic stroke patients under different interventional therapy: A systematic review and meta-analysis

Acute ischemic stroke (AIS) subtype, one of the most important factors for selecting therapeutic strategies, is difficult to be accurately diagnosed at admission sometimes. The magnetic susceptibility effect of deoxygenated hemoglobin in red thrombi appeared as hypointense signals in magnetic resonance imaging (MRI) scans. The prognostic value of susceptibility vessel sign (SVS) for stroke subtype, recanalization and outcomes in AIS patients will be comprehensively determined in the present study. A comprehensive search of databases was conducted including the PubMed, Embase, and Cochrane Library from inception up to August 2017. Statistical tests were performed to check for heterogeneity and publication bias. Subgroup and sensitivity analysis were also conducted to evaluate the robustness of the conclusions. Overall, 21 studies including 1832 patients were identified. The presence of SVS was significantly associated with cardioembolic stroke than absence of SVS (RR = 1.53, 95% CI = 1.30-1.81, p < 0.001). The patients with SVS were less likely to achieve recanalization (RR = 0.70, 95% CI = 0.56-0.88, p = 0.002) and poor functional outcome (RR = 1.68, 95% CI = 1.44-1.97, p < 0.001) after intravenous thrombolysis (IVT), whereas it was similar between two group after endovascular treatment (EVT) (p = 0.990 and p = 0.335). The SVS length was smaller in recanalization group than that in non-recanalization group (RR = -0.49, 95% CI = -0.72 to -0.27, p < 0.001), however, no significant difference between SVS width and recanalization rate was found. The presence of SVS appears to be a stronger predictor of cardioembolic stroke. Furthermore, the SVS was associated with a decreasing recanalization rate and poor outcome in AIS patients after IVT but not after EVT. Which offered a practical information to select optimal therapeutic strategies for stroke patients with SVS though the level of evidence seems to be quite shaky.

Solitaire Stent Permanent Implantation as an Effective Rescue Treatment for Emergency Large Artery Occlusion

BACKGROUND

In this study, we present our experiences on the feasibility of rescue permanent Solitaire stent placement for failed mechanical thrombectomy (MT) and our protocol to avoid ineffective stent placement.

METHODS

We retrospectively evaluated the data for consecutive patients admitted into the Second Affiliated Hospital of Wenzhou Medical University and 2 collaboration hospitals from August 2014 to May 2018 for emergency large artery occlusion. The baseline clinical characteristics and radiologic assessment, interventional data, clinical outcome, and angiographic follow-up data were assessed. Notably, we introduced our protocol for antegrade flow assessment before Solitaire stent detachment to ensure an effective stent implantation.

RESULTS

Thirty-nine patients (mean age, 68.1 years, mean preprocedural National Institute of Health Scale Score, 22.1) were included, in which 34 patients had anterior circulation large artery occlusion and 5 patients had posterior circulation large artery occlusion. The MT attempts ranged from 1-5 (3.6 on average). The mean onset-to-puncture time was 4.8 hours (ranging from 2.1-7.8 hours) and the mean procedure time was 87.4 minutes (ranging from 32-124 minutes). Modified thrombolysis in cerebral infarction 2b-3 reperfusions were noted in all cases. The immediate, average postprocedure stenosis rate was 25.3%, and the average stenosis rate at the 3-month angiographic follow-up was 34.7% (data from 15 patients). Three patients died. Nineteen (48.7%) patients had good outcome (modified Rankin Scale, mRS ≤2) at the 3-month follow-up.

CONCLUSIONS

Permanent Solitaire stent placement might be a feasible therapy for patients with MT-failed emergency large artery occlusion. For a successful revascularization, careful antegrade flow assessment before stent detachment is critical.

Differences in characteristics and outcomes after endovascular therapy: A single-center analysis of patients with vertebrobasilar occlusion due to underlying intracranial atherosclerosis disease and embolism

BACKGROUND

Therapeutic strategies and outcomes vary with stroke subtypes for patients with acute vertebrobasilar occlusion (VBAO). This study aimed to compare characteristics and outcomes of VBAO due to intracranial atherosclerotic disease (ICAD) and embolisms and identify baseline predictors of ICAD.

METHODS

Patients with VBAO who received endovascular therapy (EVT) were retrospectively analyzed. Participants fulfilling the criteria were classified as the ICAD group (focal stenosis of >70%, or fixed stenosis >50% in addition to either flow and perfusion impairment on angiography or an evident reocclusion tendency) and the embolism group (defined as no evidence of focal significant stenosis after thrombolysis or thrombectomy). Baseline characteristics and outcomes after EVT were compared between the two groups, and logistic regression was performed to explore the factors associated with ICAD.

RESULTS

Among the 133 patients enrolled, 95 (71.4%) patients were categorized in the ICAD group, and 38 (28.6%) in the embolism group. A history of atrial fibrillation (odds ratio (OR) 0.142; 95% confidence interval (CI) (0.028-0.707), p = 0.017), distal basilar artery occlusion (OR 0.107; 95% CI (0.040-0.289), p < 0.001) and V4 segment occlusion (OR 3.423; 95% CI (1.172-9.999), p = 0.024) were independently associated with ICAD. Patients with VBAO due to ICAD had a lower rate of recanalization (81.1% vs 100%, p = 0.004), but the 90-day good clinical outcome was comparable (41.1% vs 50.0%, p = 0.347).

CONCLUSIONS

The occlusion sites and a history of atrial fibrillation might be helpful in predicting ICAD in patients with VBAO. Patients with ICAD who were treated by EVT had a lower rate of recanalization but comparable 90-day good outcomes.

Assessment of veins in T2*-weighted MR angiography predicts infarct growth in hyperacute ischemic stroke

BACKGROUND AND PURPOSE

T2*-weighted magnetic resonance angiography (SWAN) detects hemodynamic insufficiency as hypointense areas in medullary or cortical veins. We therefore investigated whether SWAN can help predict ischemic penumbra-like lesions in patients with acute ischemic stroke (AIS).

MATERIALS AND METHODS

Magnetic resonance imaging (MRI) records-including SWAN, diffusion-weighted imaging (DWI), and magnetic resonance angiography (MRA)-of consecutive patients with major vessel occlusion within 6 h from AIS onset were analyzed. Acute recanalization was defined as an arterial occlusive lesion score of 2-3. A modified Alberta Stroke Program Early CT Score (mASPECTS) was used to evaluate ischemic areas revealed by SWAN and DWI. SWAN- and DWI-based mASPECTSs were calculated, and correlations between DWI-SWAN mismatches with final infarct lesions or clinical outcomes were evaluated.

RESULTS

Among the 35 patients included in this study, we confirmed cardioembolic stroke in 26, atherothrombotic stroke in 4, and unknown stroke etiology in 5. Overall, recanalization was achieved in 23 patients, who showed a higher follow-up DWI-based mASPECTS and lower modified Rankin Scale (mRS) score at 90 days than patients without recanalization. Initial SWAN- and follow-up DWI-based mASPECTSs were significantly higher for atherothrombotic stroke than for cardioembolic stroke. Of 12 patients without recanalization, DWI-SWAN mismatch was significantly correlated with infarct growth. Patients with recanalization showed no such correlation. In the assessment of clinical outcome, follow-up DWI-based mASPECTS and patient's age were significantly correlated with mRS at 90 days after stroke. A multivariate logistic regression analysis revealed that the follow-up DWI-based mASPECTS was independently associated with a favorable outcome 90 days after stroke.

CONCLUSIONS

For patients with AIS, DWI-SWAN mismatch might show penumbra-like lesions that would predict infarct growth without acute recanalization. Assessment of ischemic lesions from the venous side appears to be useful for considering the etiology and revascularization therapy.

Erythrocyte-Rich Thrombus Is Associated with Reduced Number of Maneuvers and Procedure Time in Patients with Acute Ischemic Stroke Undergoing Mechanical Thrombectomy

Background

Only few studies have investigated the relationship between the histopathology of retrieved thrombi and clinical outcomes. This study aimed to evaluate thrombus composition and its association with clinical, laboratory, and neurointerventional findings in patients treated by mechanical thrombectomy due to acute large vessel occlusion.

Methods

At our institution, 79 patients were treated by mechanical thrombectomy using a stent retriever and/or aspiration catheter between August 2015 and August 2016. The retrieved thrombi were quantitatively analyzed to quantify red blood cells, white blood cells, and fibrin by area. We divided the patients into two groups – a fibrin-rich group and an erythrocyte-rich group – based on the predominant composition in the thrombus. The groups were compared for imaging, clinical, and neurointerventional data.

Results

The retrieved thrombi from 43 patients with acute stroke from internal carotid artery, middle cerebral artery, or basilar artery occlusion were histologically analyzed. Erythrocyte-rich thrombi were present in 18 cases, while fibrin-rich thrombi were present in 25 cases. A cardioembolic etiology was significantly more prevalent among the patients with fibrin-rich thrombi than among those with erythrocyte-rich thrombi. Attenuation of thrombus density as shown on computed tomography images was greater in patients with erythrocyte-rich thrombi than in those with fibrin-rich thrombi. All other clinical and laboratory characteristics remained the same. Patients with erythrocyte-rich thrombi had a smaller number of recanalization maneuvers, shorter procedure times, a shorter time interval between arrival and recanalization, and a higher percentage of stent retrievers in the final recanalization procedure. The occluded vessels did not differ significantly.

Conclusions

In this study, erythrocyte-rich thrombus was associated with noncardioembolic etiology, higher thrombus density, and reduced procedure time.

The elevated lipoprotein-associated phospholipase A2 activity is associated with the occurrence and recurrence of acute cerebral infarction

There is a strong association between lipoprotein-associated phospholipase A2 (Lp-PLA2) levels and atherosclerosis-related diseases. The aim of this study was to investigate the role of Lp-PLA2 in the ischemic stroke and further offer clinical evidence that measuring Lp-PLA2 helps predict the risk of stroke occurrence and recurrence. A total of 328 hospitalized patients were recruited, including 179 cases of acute cerebral infarction (ACI) and 149 non-ACI controls. The serum level of Lp-PLA2 in ACI was significantly higher than non-ACI. The serum level of Lp-PLA2 in the recurrence of ACI was significantly higher than the nonrecurrence. The serum levels of Lp-PLA2 in large-artery atherosclerosis subtype were the highest among the subtypes of the Trial of Org 10172 in Acute Stroke Treatment and non-ACI controls. The level of Lp-PLA2 in large-artery atherosclerosis and the cardioembolism group was statistically significantly higher than that of the control cases. There was no statistically significant difference between the small-vessel occlusion group and the control cases. The present study confirmed that the elevated Lp-PLA2 level can be a risk factor for ischemic stroke in the Chinese population. The serum level of Lp-PLA2 may be a predictive factor for the recurrence of ACI.

Can clot density predict recanalization in acute ischemic stroke treated with intravenous tPA?

Stroke has become an absolute emergency that is treated by additional endovascular means or by replacing pharmacological options. Modern neuroradiological techniques such as computed tomography (CT) allow us to examine multiple parameters of the diseased brain. These focused on the parenchyma and hemodynamics for pretherapeutic decisions. However, it has become evident that the clot is the current target for interventional measures. Clot length is established as a marker for recanalization. The dense artery sign is known as an acute CT sign of stroke that is readily visible on acute nonenhanced CT. The rationale behind our study was to study if clot density might represent clot vulnerability or resistance to treatment. We conducted a prospective study of all consecutive stroke patients admitted to our hospital over 1 year, who presented with signs of acute middle cerebral artery stroke within the therapeutic window, and who underwent either intravenous or combined intravenous and intra-arterial thrombolysis. All patients were evaluated with a complete stroke CT protocol, transcranial color-coded duplex sonography monitoring, and clinical evaluation with the National Institutes of Health Stroke Scale (NIHSS) score. We measured clot length using planimetry on unenhanced CT and measured Hounsfield units in the clots on the same images. A total of 31 patients were included in the study (19 men, 12 women, aged 35–90 years). We found that patients with a longer clot on the unenhanced CT had a higher NIHSS score, confirming previous literature. However, we found that patients with a lower clot density recanalized to a more marked degree and had a better clinical outcome. Patients who did not recanalize had a higher clot density (49 Hounsfield units) than those who did recanalize (23 Hounsfield units). Overall, measuring the clot seems to be an important additional parameter to be taken into account. In our study, CT clot density seems to correlate with clinical outcome and recanalization. The higher density seems to represent a higher red blood cell content. This is evidence that clot composition could play a much more important role in acute stroke than thought until now and characterizing it with imaging may help in choosing the adequate treatment modality. Higher density seems to reflect erythrocyte content. Therefore, patients with a longer and denser clot may necessitate direct thrombectomy.

Prediction of Stroke Subtype and Recanalization Using Susceptibility Vessel Sign on Susceptibility-Weighted Magnetic Resonance Imaging

Supplemental Digital Content is available in the text.

Background and Purpose—

The susceptibility vessel sign (SVS) is a hypointense signal visualized because of the susceptibility effect of thrombi, sensitively detected on susceptibility-weighted magnetic resonance imaging. The relationship of SVS parameters with the stroke subtype and recanalization status after endovascular treatment remains uncertain.

Methods—

The data from 89 patients with acute stroke caused by anterior circulation infarcts who underwent susceptibility-weighted magnetic resonance imaging before endovascular treatment were examined. Independent reviewers, blinded to the stroke subtype and recanalization status, measured the SVS diameter, length, and estimated volume. The intra- and interrater agreements of the SVS parameters were assessed.

Results—

The SVS was identified in 78% of the patients. SVS was more commonly associated with cardioembolism than with noncardioembolism (P=0.01). The SVS diameter (P<0.01) and length (P=0.01) were larger in the cardioembolism group. The SVS diameter was larger in the recanalization group (thrombolysis in cerebral infarction ≥2b) than in the nonrecanalization group (P=0.04). Multivariable analysis revealed that the SVS diameter was an independent predictor of cardioembolism (adjusted odds ratio, 1.97; 95% confidence interval, 1.34–2.90; P<0.01). There was no significant association between the SVS volume and the recanalization status (adjusted odds ratio, 1.003; 95% confidence interval, 0.999–1.006; P=0.12). The optimal cutoff value of the SVS diameter for the cardioembolism was 5.5 mm (sensitivity, 45.6%; specificity, 93.8%).

Conclusions—

Increased SVS diameter on susceptibility-weighted magnetic resonance imaging may predict cardioembolism. No clear association was found between SVS volume and endovascular recanalization.