Thrombolysis in Cerebral Infarction Grade 2C or 3 Represents a Better Outcome than 2B for Endovascular Thrombectomy in Acute Ischemic Stroke: A Network Meta-Analysis

Significance of atherosclerotic plaque location in recanalizing non-acute long-segment occlusion of the internal carotid artery

To investigate the significance of atherosclerotic plaque location in hybrid surgery comprising both endovascular recanalization approaches and carotid endarterectomy for symptomatic atherosclerotic non-acute long-segment occlusion of the internal carotid artery (ICA), 162 patients were enrolled, including 120 (74.1%) patients in the proximal plaque group and 42 (25.9%) in the distal plaque group. Surgical recanalization was performed in all patients, with successful recanalization in 119 (99.2%) patients in the proximal and 39 (92.9%) in the distal plaque group. The total successful recanalization rate was 97.5% (158/162) with a failure rate of 2.5% (4/162). Periprocedural complications occurred in 5 (4.2% or 5/120) patients in the proximal plaque group, including neck infection in two (1.7%), recurrent nerve injury in 1 (0.8%), and laryngeal edema in 2 (1.7%), and 2 (4.8%) in the distal plaque group, including femoral puncture infection in 2 (4.8%). No severe complications occurred in either group. Univariate analysis showed plaque location was a significant (P = 0.018) risk factor for successful recanalization, and multivariate analysis indicated that the plaque location remained a significant independent risk factor for recanalization success (P = 0.017). In follow-up 6-48 months after the recanalization surgery, reocclusion occurred in two (2.8%) patients in the proximal plaque group and 4 (13.3%) in the distal plaque group. In conclusion, although hybrid surgery achieves similar outcomes in patients with ICA occlusion caused by either proximal or distal atherosclerotic plaques, plaque location may be a significant risk factor for successful recanalization of symptomatic non-acute long-segment ICA occlusion.

Modeling diffusion-weighted imaging lesion expansion between 2 and 24 h after endovascular thrombectomy in acute ischemic stroke

PURPOSE

Diffusion-weighted imaging (DWI) lesion expansion after endovascular thrombectomy (EVT) is not well characterized. We used serial diffusion-weighted magnetic resonance imaging (MRI) to measure lesion expansion between 2 and 24 h after EVT.

METHODS

In this single-center observational analysis of patients with acute ischemic stroke due to large vessel occlusion, DWI was performed post-EVT (< 2 h after closure) and 24-h later. DWI lesion expansion was evaluated using multivariate generalized linear mixed modeling with various clinical moderators.

RESULTS

We included 151 patients, of which 133 (88%) had DWI lesion expansion, defined as a positive change in lesion volume between 2 and 24 h. In an unadjusted analysis, median baseline DWI lesion volume immediately post-EVT was 15.0 mL (IQR: 6.6-36.8) and median DWI lesion volume 24 h post-EVT was 20.8 mL (IQR: 9.4-66.6), representing a median change of 6.1 mL (IQR: 1.5-17.7), or a 39% increase. There were no significant associations among univariable models of lesion expansion. Adjusted models of DWI lesion expansion demonstrated that relative lesion expansion (defined as final/initial DWI lesion volume) was consistent across eTICI scores (0-2a, 0.52%; 2b, 0.49%; 2c-3, 0.42%, p = 0.69). For every 1 mL increase in lesion volume, there was 2% odds of an increase in 90-day mRS (OR: 1.021, 95%CI [1.009, 1.034], p < 0.001).

CONCLUSION

We observed substantial lesion expansion post-EVT whereby relative lesion expansion was consistent across eTICI categories, and greater absolute lesion expansion was associated with worse clinical outcome. Our findings suggest that alternate endpoints for cerebroprotectant trials may be feasible.

Potential Approach to Quantifying the Volume of the Ischemic Core in Truncated Computed Tomography Perfusion Scans: A Preliminary Study

OBJECTIVE

This study aimed to provide an alternative approach for quantifying the volume of the ischemic core (IC) if truncation of computed tomography perfusion (CTP) occurs in clinical practice.

METHODS

Baseline CTP and follow-up diffusion-weighted imaging (DWI) data from 88 patients with stroke were retrospectively collected. CTP source images (CTPSI) from the unenhanced phase to the peak arterial phase (CTPSI-A) or the peak venous phase (CTPSI-V) were collected to simulate the truncation of CTP in the arterial or venous phases, respectively. The volume of IC on CTPSI-A (V CTPSI-A ) or CTPSI-V (V CTPSI-V ) was defined as the volume of the brain tissue with >65% reduction in attenuation compared with that of the normal tissue. The volume of IC on the baseline CTP (V CTP ) was defined as a relative cerebral blood flow of <30% of that in the normal tissue. The volume of the posttreatment infarct on the follow-up DWI (V DWI ) image was manually delineated and calculated. One-way analysis of variance, Bland-Altman plots, and Spearman correlation analyses were used for the statistical analysis.

RESULTS

V CTPSI-A was significantly higher than V DWI ( P < 0.001); however, no significant difference was observed between V CTP and V DWI ( P = 0.073) or between V CTPSI-V and V DWI ( P > 0.999). The mean differences between V DWI and V CTPSI-V , V DWI and V CTP , and V DWI and V CTPSI-A were 1.70 mL (limits of agreement [LoA], -56.40 to 59.70), 8.30 mL (LoA, -40.70 to 57.30), and -68.10 mL (LoA, -180.90 to 44.70), respectively. Significant correlations were observed between V DWI and V CTP ( r = 0.68, P < 0.001) and between V DWI and V CTPSI-V ( r = 0.39, P < 0.001); however, no significant correlation was observed between V DWI and V CTPSI-A ( r = 0.20, P = 0.068).

CONCLUSIONS

V CTPSI-V may be a promising method for quantifying the volume of the IC if truncation of CTP occurs.

Predictors of mTICI 2c/3 over 2b in patients successfully recanalized with mechanical thrombectomy

OBJECTIVE

For patients presenting with acute ischemic stroke (AIS) caused by large vessel occlusions (LVO), mechanical thrombectomy (MT) is the treatment standard of care in eligible patients. Modified Thrombolysis in Cerebral Infarction (mTICI) grades of 2b, 2c, and 3 are all considered successful reperfusion; however, recent studies have shown achieving mTICI 2c/3 leads to better outcomes than mTICI 2b. This study aims to investigate whether any baseline preprocedural or periprocedural parameters are predictive of achieving mTICI 2c/3 in successfully recanalized LVO patients.

METHODS

We conducted a retrospective multicenter cohort study of consecutive patients presenting with AIS caused by a LVO from 1 January 2017 to 1 January 2023. Baseline and procedural data were collected through chart review. Univariate and multivariate analysis were applied to determine significant predictors of mTICI 2c/3.

RESULTS

A total of 216 patients were included in the study, with 159 (73.6%) achieving mTICI 2c/3 recanalization and 57 (26.4%) achieving mTICI 2b recanalization. We found that a higher groin puncture to first pass time (OR = 0.976, 95%CI: 0.960-0.992, p = 0.004), a higher first pass to recanalization time (OR = 0.985, 95%CI: 0.972-0.998, p = 0.029), a higher admission NIHSS (OR = 0.949, 95%CI: 0.904-0.995, p = 0.031), and a lower age (OR = 1.032, 95%CI: 1.01-1.055, p = 0.005) were associated with a decreased probability of achieving mTICI 2c/3.

INTERPRETATION

A lower groin puncture to first pass time, a lower first pass to recanalization time, a lower admission NIHSS, and a higher age were independent predictors of mTICI 2c/3 recanalization.

Predictors of parenchymal hematoma and clinical outcome after mechanical thrombectomy in patients with large ischemic core due to large vessel occlusion: a retrospective multicenter study

BACKGROUND

The aim of our study was to find predictors of parenchymal hematoma (PH) and clinical outcome after mechanical thrombectomy (MT) in patients with large vessel occlusion (LVO) and baseline large infarct.

METHODS

The databases of 16 stroke centers were retrospectively screened for patients with anterior circulation LVO and baseline Alberta Stroke Program Early CT Score (ASPECTS) ≤5 that received MT. Procedural parameters, including the number of passes during first and second technique of MT, were recorded. Outcome measures were occurrence of PH type 2 and any type of PH after MT, and the 90-day modified Rankin Scale (mRS) score of 0-3 and 0-2.

RESULTS

In total, 408 patients were available for analysis. A higher number of passes in the second technique was predictive of PH type 2 (odds ratio (OR) - 3.204, 95% confidence interval (CI) 1.140 to 9.005), whereas procedure conducted under general anesthesia was associated with lower risk (OR 0.127, 95% CI 0.002 to 0.808). The modified thrombolysis in cerebral infarction grade 2c-3 was associated with the mRS score 0-3 (OR 3.373, 95% CI 1.891 to 6.017), whereas occurrence of PH type 2 was predictive of unfavorable outcome (OR 0.221, 95% CI 0.063 to 0.773). Similar results were found for the mRS score 0-2 outcome measure.

CONCLUSION

In patients with large ischemic core, a higher number of passes during MT and procedure not conducted under general anesthesia are associated with increased rate of PH type 2, that negatively impact the clinical outcome. Our data outline a delicate balance between the need of a complete recanalization and the risk of PH following MT.

Excellent Recanalization and Small Core Volumes Are Associated With Favorable AM-PAC Score in Patients With Acute Ischemic Stroke Secondary to Large Vessel Occlusion

Objective

To assess pretreatment and interventional parameters as predictors of favorable Activity Measure for Post-Acute Care (AM-PAC) scores for optimal discharge planning.

Design

In this prospectively collected, retrospectively reviewed multicenter study from 9/1/2017 to 9/22/2022, patients were dichotomized into favorable and unfavorable AM-PAC. Multivariate logistic regression and receiver operator characteristics analyses were performed for the identified significant variables. A P value of ≤.05 was significant.

Setting

Hospitalized care.

Participants

In total, 229 patients (mean ±SD 70.65 ±15.2 [55.9% women]) met our inclusion criteria. Inclusion criteria were (a) computed tomography (CT) angiography confirmed LVO from 9/1/2017 to 9/22/2022; (b) diagnostic CT perfusion; and (c) available AM-PAC scores.

Interventions

None.

Main Outcome Measures

Favorable AM-PAC, defined as a daily activity score ≥19 and basic mobility score of ≥17.

Results

Patients with favorable AM-PAC were younger (61.3 vs 70.7, P<.001), had lower admission glucose (mean, 124 vs 136, P=.042), lower blood urea nitrogen (mean, 15.59 vs 19.11, P<.001), and lower admission National Institutes of Health Stroke Scale (NIHSS) (mean, 10.58 vs 16.15, P<.001). No differences in sex were noted. Multivariate regression analyses revealed age, admission NIHSS, relative cerebral blood flow (rCBF) <30% volume, and modified thrombolysis in cerebral infarction (mTICI) score to be independent predictors of favorable AM-PAC (P<.047 for all predictors). The combined model revealed an area under the curve (AUC) of 0.83 (IQR 0.75-0.86).

Conclusion

Excellent recanalization, smaller core volumes, younger age, and lower stroke severity independently predict favorable outcomes as measured by AM-PAC.

No-reflow phenomenon following stroke recanalization therapy: Clinical assessment advances: A narrative review

The no-reflow phenomenon (NRP) after successful vascular recanalization in acute ischemic stroke (AIS) has become a major cause of poor clinical prognosis and ineffective recanalization. However, there is currently no clear definition or unified clinical assessment method for the NRP. Therefore, it is urgent to clarify the clinical evaluation criteria for the NRP and develop new no-reflow evaluation techniques so that remedial treatment can be applied to AIS patients suffering from the NRP. In this brief review, a variety of NRP assessment methods and defining criteria for clinical practice are presented.

First-pass effect in posterior acute ischemic stroke undergoing endovascular thrombectomy: A systematic review and meta-analysis

OBJECTIVES

First-pass effect (FPE) has been shown to be a predictor of favorable clinical outcomes following endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) in the anterior circulation. Literature regarding FPE for posterior circulation AIS is sparse; we conducted a systematic review and meta-analysis to explore FPE in posterior circulation stroke undergoing EVT.

MATERIALS AND METHODS

We conducted a systematic review of the English literature in PubMed, Embase, Scopus, and Web of Science. FPE was defined as thrombolysis in cerebral infarction (TICI) 2c-3 and modified FPE (mFPE) was defined as TICI 2b-3 in one pass. Definitions of non-FPE and non-mFPE varied among studies. The primary outcome of interest was modified Rankin Scale (mRS) 0-2. Secondary outcomes of interest were mRS 0-3, symptomatic intracranial hemorrhage (sICH), and mortality. We calculated odds ratios (OR) and corresponding 95% confidence intervals (CI). Heterogeneity was assessed with Q statistic and I2 test.

RESULTS

Seven studies with 417 patients in the mFPE group, 942 in the non-mFPE group, 545 in the FPE group, and 1023 in the non-FPE group were included. Overall, FPE was associated with greater rates of 90-day mRS 0-2 (OR= 2.78, 95% CI= 2.11-3.65; P-value< 0.001) and mRS 0-3 (OR= 2.67, 95% CI= 1.98-3.60; P-value< 0.001); however, there was significant heterogeneity among studies for both mRS 0-2 (I2= 69%; P-value< 0.001) and mRS 0-3 (I2= 69%; P-value< 0.001). FPE and non-FPE were associated with similar rates of sICH (OR= 0.65, 95% CI= 0.40-1.07; P-value= 0.09), and no heterogeneity was observed (I2= 0%; P-value= 0.95). FPE was associated with lower rates of mortality (OR= 0.44, 95% CI= 0.33-0.58; P-value< 0.001), although heterogeneity was observed (I2= 58%; P-value= 0.01).

CONCLUSIONS

FPE is associated with favorable clinical outcomes in patients undergoing EVT for posterior circulation AIS. Future studies should work to further quantify the impact of FPE on outcomes in the posterior circulation.

Factors predicting good prognosis of failed intra-arterial thrombectomy cases: A retrospective study

Intra-arterial thrombectomy (IAT) has been increasingly applied in the treatment of acute ischemic stroke (AIS) due to large-vessel occlusion, and many related studies have been published. However, limited studies on the prognosis of failed-IAT patients are available. In this study, factors that can predict a good prognosis in patients with failed IAT were studied. Among patients who visited our hospital between January 2016 and September 2022 and underwent IAT, we retrospectively analyzed those with failed IAT. A univariate analysis was performed on the radiological features, medical histories, and other patient characteristics expected to affect the prognosis, and a multivariate analysis was performed on some of these factors. In univariate analysis, a good collateral channel on susceptibility-weighted imaging (SWI), modified thrombolysis in cerebral infarction (mTICI) 2A recanalization, and the pre-procedural modified Rankin scale (mRS) were statistically significant. In the multivariate analysis, good collateral channels on SWI and computed tomography angiography (CTA) and mTICI 2A recanalization were statistically significant. Factors that can predict a good prognosis in patients with failed IAT include good leptomeningeal collateral channels evaluated by CTA and SWI and mTICI 2A recanalization.

Identifying ex vivo acute ischemic stroke thrombus composition using electrochemical impedance spectroscopy

BACKGROUND

Intra-procedural characterization of stroke thromboemboli might guide mechanical thrombectomy (MT) device choice to improve recanalization rates. Electrochemical impedance spectroscopy (EIS) has been used to characterize various biological tissues in real time but has not been used in thrombus.

OBJECTIVE

To perform a feasibility study of EIS analysis of thrombi retrieved by MT to evaluate: (1) the ability of EIS and machine learning to predict red blood cell (RBC) percentage content of thrombi and (2) to classify the thrombi as "RBC-rich" or "RBC-poor" based on a range of cutoff values of RBC.

METHODS

ClotbasePilot was a multicentric, international, prospective feasibility study. Retrieved thrombi underwent histological analysis to identify proportions of RBC and other components. EIS results were analyzed with machine learning. Linear regression was used to evaluate the correlation between the histology and EIS. Sensitivity and specificity of the model to classify the thrombus as RBC-rich or RBC-poor were also evaluated.

RESULTS

Among 514 MT,179 thrombi were included for EIS and histological analysis. The mean composition in RBC of the thrombi was 36% ± 24. Good correlation between the impedance-based prediction and histology was achieved (slope of 0.9, R²  =  0.53, Pearson coefficient  =  0.72). Depending on the chosen cutoff, ranging from 20 to 60% of RBC, the calculated sensitivity for classification of thrombi ranged from 77 to 85% and the specificity from 72 to 88%.

CONCLUSION

Combination of EIS and machine learning can reliably predict the RBC composition of retrieved ex vivo AIS thrombi and then classify them into groups according to their RBC composition with good sensitivity and specificity.

Predictors of outcome after endovascular treatment for tandem occlusions: a single center retrospective analysis

BACKGROUND

The endovascular treatment procedure in tandem occlusions (TO) is complex compared to single occlusion (SO) and optimal management remains uncertain. The aim of this study was to identify clinical and procedural factors that may be associated to efficacy and safety in the management of TO and compare functional outcome in TO and SO stroke patients.

METHODS

This is a retrospective single center study of medium (MeVO) and large vessel occlusion (LVO) of the anterior circulation. Clinical, imaging, and interventional data were analyzed to identify predictive factors for symptomatic intracranial hemorrhage (sICH) and functional outcome after endovascular treatment (EVT) in TO. Functional outcome in TO and SO patients was compared.

RESULTS

Of 662 anterior circulation stroke patients with MeVO and LVO stroke, 90 (14%) had TO. Stenting was performed in 73 (81%) of TO patients. Stent thromboses occurred in 8 (11%) patients. Successful reperfusion with modified thrombolysis in cerebral infarction (mTICI) ≥ 2b was achieved in 82 (91%). SICH occurred in seven (8%). The strongest predictors for sICH were diabetes mellitus and number of stent retriever passes. Good functional clinical outcome (mRS ≤ 2) at 90-day follow up was similar in TO and SO patients (58% vs 59% respectively). General anesthesia (GA) was associated with good functional outcome whereas hemorrhage in the infarcted tissue, lower mTICI score and history of smoking were associated with poor outcome.

CONCLUSIONS

The risk of sICH was increased in patients with diabetes mellitus and those with extra stent-retriever attempts. Functional clinical outcomes in patients with TO were comparable to patients with SO.

Validation of the Charlotte large artery occlusion endovascular therapy outcome score using Viz.ai-derived cerebral blood volume index

BACKGROUND

The Charlotte large artery occlusion endovascular therapy outcome score (CLEOS) predicts poor 90-day outcomes for patients presenting with internal carotid artery (ICA) or middle cerebral artery (MCA) occlusions. It incorporates RAPID-derived cerebral blood volume (CBV) index, a marker of collateral circulation. We validated the predictive ability of CLEOS with Viz.ai-processed computed tomography perfusion (CTP) imaging.

METHODS

The original CLEOS derivation cohort was compared to a validation cohort consisting of all ICA and MCA thrombectomy patients treated at a large health system with Viz.ai-processed CTP. Rates of poor 90-day outcome (mRS 4-6) were compared in the derivation and validation cohorts, stratified by CLEOS. CLEOS was compared to previously described prediction models using area under the curve (AUC) analyses. Calibration of CLEOS was performed to compare predicted risk of poor outcomes with observed outcomes.

RESULTS

One-hundred eighty-one patients (mean age 66.4 years, median NIHSS 16) in the validation cohort were included. The validation cohort had higher median CTP core volumes (24 vs 8 ml) and smaller median mismatch volumes (81 vs 101 ml) than the derivation cohort. CLEOS-predicted poor outcomes strongly correlated with observed outcomes (R2 = 0.82). AUC for CLEOS in the validation cohort (0.72, 95% CI 0.64-0.80) was similar to the derivation cohort (AUC 0.75, 95% CI 0.70-0.80) and was comparable or superior to previously described prognostic models.

CONCLUSIONS

CLEOS can predict risk of poor 90-day outcomes in ICA and MCA thrombectomy patients evaluated with pre-intervention, Viz.ai-processed CTP.

Groin Puncture to Recanalization Time May Be a Strong Predictor of mTICI 2c/3 over mTICI 2b in Patients with Large Vessel Occlusions Successfully Recanalized with Mechanical Thrombectomy

Mechanical thrombectomy (MT) is an important therapeutic option in the management of acute ischemic stroke (AIS) caused by large vessel occlusions (LVO). While achieving a modified thrombolysis in cerebral infarction (mTICI), grades of 2b, 2c, and 3 are all considered successful recanalization; recent literature suggests that mTICI grades of 2c/3 are associated with superior outcomes than 2b. The aim of this preliminary study is to determine whether any baseline or procedural parameters can predict whether successfully recanalized patients achieve an mTICI grade of 2c/3 over 2b. Consecutive patients from 9/2019 to 10/2021 who were successfully recanalized following MT for confirmed LVO were included in the study. Baseline and procedural data were collected through manual chart review and analyzed to ascertain whether any variables of interest could predict mTICI 2c/3. A total of 47 patients were included in the preliminary study cohort, with 35 (74.5%) achieving an mTICI score of 2c/3 and 12 (25.5%) achieving an mTICI score of 2b. We found that a lower groin puncture to recanalization time was a strong, independent predictor of TICI 2c/3 (p = 0.015). These findings emphasize the importance of minimizing procedure time in achieving superior reperfusion but must be corroborated in larger scale studies.

Continuing early mTICI 2b recanalization may improve functional outcome but is associated with a higher risk of intracranial hemorrhage

Background

Successful reperfusion (mTICI 2c/3) and low number of passes are key determinants for good clinical outcome in acute large vessel occlusion. While final mTICI 2c/3 reperfusion is superior to partial reperfusion (mTICI 2b) it remains unclear if this is also true for the subgroup of patients with early mTICI 2b (achieved in ≤2 retrieval attempts) reperfusion who are secondarily improved to mTICI 2c/3. This study was designed to examine if early mTICI2b should be continued or stopped during mechanical thrombectomy (MT).

Methods

Nine hundred and thirteen ischemic stroke patients who received MT were retrospectively analyzed. Angiography runs following each recanalization attempt were scored for mTICI. The patients with early mTICI 2b reperfusions were dichotomized in “TICI2b-stopped” (MT withdrawal after mTICI 2b was achieved with first or second retrieval) and “TICI2b-continued” (MT was continued after mTICI 2b was achieved with first or second retrieval). Functional outcome was obtained after 90 days using the modified Rankin scale (mRS90).

Results

Of 362 Patients with a M1-occlusion, 100 patients fulfilled the inclusion criteria with an early mTICI 2b. 78/100 patients were included in the “TICI2b-stopped” group and 22/100 patients were in the “TICI2b-continued” group. Of these 22 patients, none had a final mTICI score lower than 2b and 11 patients had a final mTICI score of 2c/3. Regarding good functional outcome at mRS90, “TICI2b-continued” showed by trend a slight advantage of 40.1 vs. 35.6% in “TICI2b-stopped” but in multivariate logistic regression analysis adjusted for confounders, no significant difference was found between the two groups (OR 0.75, 95% CI 0.19–2.87, p = 0.67). Symptomatic intracranial hemorrhage was significantly higher in “TICI2b-continued” compared to “TICI2b-stopped” (31.8 vs. 10.3%, p = 0.031).

Conclusion

Successfully improving an early mTICI 2b to mTICI 2c/3 reperfusion is possible in a substantial number of patients and might improve functional outcome. However, an increase in symptomatic intracranial hemorrhage (SICH) due to further retrieval attempts may diminish the potential functional benefit to continue early mTICI 2b. To support this finding, further investigation with more power is needed to account for the low number of events regarding SICH.

Short-term Montreal Cognitive Assessment predicts functional outcome after endovascular therapy

Background

The previous studies have shown that cognition in patients 4–8 weeks after stroke can predict early functional outcomes after stroke. The analyses of data from the REVASCAT trial proved that stent thrombectomy improves post-morbid wiring test outcomes in patients with AIS compared with drug therapy. However, few studies focus on the relationship between cognitive impairment and functional outcomes in patients undergoing endovascular treatment.

Methods

A total of 647 participants registered from stroke centers. Stroke severity was evaluated by National Institutes of Health stroke scale (NIHSS). The functional status was estimated by modified Rankin scale (mRS). The cognitive impairment was assessed by trained neurologists at 14 (±4) and 90 (±7) days after stroke onset using the Montreal Cognitive Assessment (MoCA). A MoCA score of less than 26 was considered post-stroke cognitive impairment (PSCI).

Results

A total of 120 Patients who underwent endovascular therapy were included. The PSCI group had higher levels of age, men, educational status, atrial fibrillation, smoking, alcoholism, Alberta Stroke Program Early CT (ASPECT) score of the anterior circulation, and OTP time than the non-PSCI group (p < 0.05). In contrast, the 14-day MoCA score, 14-day NIHSS score, 3-month MoCA score, 3-month NIHSS score, 3-month mRS score, and 3-month EQ5D score were lower in those PSCI patients. The risk predictors of PSCI were age, sex, educational level, atrial fibrillation, smoking, alcoholism, ASPECT Score (anterior circulation), 14-day MoCA score, and 14-day NIHSS score. There were strong relationships between 3-month NIHSS and MoCA (r = –0.483, p < 0.001). Receiver operating characteristic (ROC) curve indicated that 14-day MoCA score, memory, abstraction, visuospatial/executive functions, attention, and language, played a significant role to predict PSCI [area under the curve (AUC) > 0.7]. It had predictive value for the 14-day visuospatial/executive functions to predict 3-month functional outcomes.

Conclusion

Early application of the MoCA in different cognitive regions could predict the PSCI and future functional outcomes, which is necessary to screen high-risk patients with poor prognosis and conduct an early intervention.

The CHA2DS2-VASc risk score predicts successful endovascular treatment in patients with acute ischemic stroke

OBJECTIVES

Acute ischemic stroke is a common cause of mortality and morbidity worldwide. Percutaneous endovascular intervention is an important treatment method in ischemic stroke. Endovascular procedure success is associated with the clinical outcome of the patients. The CHA2DS2-VASC score is an important score used to determine the risk of ischemic stroke in patients with atrial fibrillation. In our study, we aimed to evaluate the relationship between procedure success and CHA2DS2-VASC score in patients with acute ischemic stroke who underwent endovascular intervention.

MATERIALS AND METHODS

A total of 102 consecutive patients who underwent endovascular intervention with acute ischemic stroke were included in the study. The admission CHA2DS2-VASc scores of the patients were recorded. After the procedure, the relationship between the TICI score and the CHA2DS2-VASc score was evaluated.

RESULTS

CHA2DS2-VASc score was significantly higher in the group that resulted in unsuccessful endovascular intervention (2.78 ± 1.44, 5.02 ± 1.77 p < .001). Receiver-operating characteristics analysis revealed the cutoff value of CHA2DS2-VASc score ≥3 as a predictor of unsuccessful intervention with 76,6% sensitivity and 83,3% specificity, positive predictive value 50%, negative predictive value 84,6% (area under the curve [AUC]: 0.827,95% CI: 0.739-0.895, p < .001). In the multivariate analysis; atrial fibrillation ([β] = 4.201; [CI]: 1.251-14.103, p = .020), CHA2DS2-VASc score ([β] = 0.053; [CI]: 0.004-0.750, p = .030) were found independent predictors for unsuccessful intervention treatment.

CONCLUSIONS

In our study, we showed that the CHA2DS2-VASc score is associated with the success of endovascular intervention in patients with acute ischemic stroke who underwent percutaneous endovascular treatment.

Direct Endovascular Thrombectomy Alone vs. Bridging Thrombolysis for Patients with Acute Ischemic Stroke : A Meta-analysis

PURPOSE

Although the current guidelines recommend bridging thrombolysis (BT) therapy, which is intravenous thrombolysis (IVT) followed by endovascular thrombectomy (EVT), for patients with acute ischemic stroke from large vessel occlusion (AIS-LVO), the effectiveness and safety of IVT remain controversial. We performed a meta-analysis to demonstrate the non-inferiority of direct EVT alone (DEVT) compared to BT for the efficacy and safety in patients with AIS-LVO who were eligible for IVT.

METHODS

The literature was searched in big databases between 1 January 1990 and 1 April 2021. The search included both randomized clinical trials (RCTs) and nonrandomized studies (NRSs) that compared DEVT with BT for patients with AIS-LVO who were eligible for IVT (time from stroke onset ≤ 4.5 h). Only NRSs with good intergroup variable matching were included in the study. Outcomes measured included 90-day functional independence, mortality, symptomatic intracranial hemorrhage (sICH), and successful recanalization. The noninferiority margin for risk difference was set at 5% from the literature review.

RESULTS

Three RCTs (n = 1094) and four NRSs (n = 1366) were included in the meta-analysis. There were 1227 patients (49.9%) in the DEVT group and 1233 patients (50.1%) in the BT group. A statistically significant noninferiority of DEVT compared to BT was concluded in 90-day functional independence, mortality and successful reperfusion. Even in the sICH rate, DEVT group showed a superiority (risk difference, -2%; 95% confidence interval, -4 to -0.002%).

CONCLUSION

Evidence from RCTs and observational NRSs supports the use of DEVT (without IVT) as the first choice for treatment of patients with AIS-LVO within a time span of 4.5 h or less from stroke onset.

Clinical Significance of Hyperdense Area after Endovascular Therapy in Patients with Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

OBJECTIVE

We performed a systematic review and meta-analysis to investigate the clinical significance of hyperdense area after thrombectomy in patients with acute ischemic stroke (AIS).

METHODS

We searched Ovid MEDLINE(R) and Epub Ahead of Print, In-Process and other Non-Indexed, Cochrane Library Clinical Controlled Trials and Embase from inception to September 2020 and collected the cohort and case-control studies about the clinical significance of hyperdense area on different types of computed tomography (CT) after thrombectomy in patients with AIS. Outcomes were poor functional outcome (modified Rankin Scale [mRS] Score 3-6 at discharge or 90-day), mortality and subtypes of hemorrhage according to the European Cooperative Acute Stroke Study (ECASS).

RESULTS

1,999 patients from 16 studies were included in this meta-analysis. Pooled results indicated higher risk of symptomatic intracerebral hemorrhage (odds ratio [OR] = 3.02; 95% confidence interval [CI] 1.84-4.95; p < 0.0001, I2 = 0%) in patients with hyperdense area, and the subtype of parenchymal hematoma as well. There was also higher odds of poor functional outcome based on the mRS 3-6 at discharge or 90-day (OR = 1.92; 95% CI 1.35-2.73; p = 0.0003, I2 = 31%) and mortality (OR = 2.06; 95% CI 1.41-3.02; p = 0.0002, I2 = 0%) in patients with hyperdense area after thrombectomy compared with those without hyperdense area.

CONCLUSIONS

Our results indicated that the presence of hyperdense area on CT after thrombectomy was associated with high risk of symptomatic intracerebral hemorrhage, poor functional outcome, as well as mortality in patients with AIS. However, further studies were needed to confirm these results. The meta-analysis was conducted in adherence with the PRISMA Statement and was registered at the International Prospective Register of Systematic Reviews (CRD42020164165). To the best of our knowledge, this study is the first meta-analysis investigating the effect of hyperdense area after endovascular therapy in patients with AIS.

Effectiveness of very low profile thrombectomy device in primary distal medium vessel occlusion, as rescue therapy after incomplete proximal recanalization or following iatrogenic thromboembolic events

Background

Recent progress with smaller retrievers has expanded the ability to reach distal brain arteries. We herein report recanalization, bleeding complications and short-term clinical outcomes with the smallest currently known low profile thrombectomy device in patients with primary or secondary distal medium vessel occlusion (DMVO).

Methods

We performed a retrospective analysis of 115 patients receiving mechanical thrombectomy (MT) in DMVO using the extended Thrombolysis in Cerebral Infarction (eTICI), European Cooperative Acute Stroke Study (ECASS) II classification, The National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) scores at admission and discharge to evaluate outcomes. Patients were stratified into three groups: (1) primary isolated distal occlusion (n=34), (2) secondary distal occlusion after MT of a proximal vessel occlusion (n=71), or (3) during endovascular treatment of aneurysms or arteriovenous malformations (AVMs) (n=10).

Results

Successful distal recanalization, defined as an eTICI score of 2b67, 2c and 3, was achieved in 74.7% (86/115) of patients. More specifically, it was 70.5% (24/34), 73.2% (52/71), and 100% (10/10) of primary DMVO, secondary DMVO after proximal MT, and rescue MT during aneurysm or AVM embolization, respectively. Symptomatic intraparenchymal bleeding occurred in 6.9% (eight patients). In-hospital mortality occurred in 18.1% (19/105) of patients with stroke. The most common cause of death was large infarct, old age, and therapy limitation.

Conclusion

Direct or rescue MT of DMVO using a very low profile thrombectomy device is associated with a high rate of successful recanalization and a reasonable rate of symptomatic hemorrhagic complication, despite a risk of 18.1% hospital mortality in elderly patients. Further trials are needed to confirm our results and assess long-term clinical outcomes.