Factors Associated with Poor Outcomes in Patients Undergoing Endovascular Therapy for Acute Ischemic Stroke due to Large-Vessel Occlusion in Acute Anterior Circulation: A Retrospective Study

Endovascular Therapy and Outcomes Among Patients With Very Large Ischemic Core Stroke

Importance

The association of endovascular therapy (EVT) with outcomes is unclear for patients with very low Alberta Stroke Program Early Computed Tomography Score (ASPECTS) within 24 hours of stroke onset.

Objective

To explore the association of EVT with functional and safety outcomes among patients with ASPECTS of 0 to 2 scored with noncontrast computed tomography.

Design, Setting, and Participants

This cohort study used data from an ongoing, prospective, observational, nationwide registry including all patients treated at 38 stroke centers in China with an occlusion in the internal carotid artery or M1 or M2 segment of the middle cerebral artery within 24 hours of witnessed symptom onset. Patients with ASPECTS of 0 to 2 between November 1, 2021, and February 8, 2023, were included in analysis. Data were analyzed October to November 2023.

Exposures

EVT vs standard medical treatment (SMT).

Main Outcomes and Measures

The primary outcome was favorable functional outcome, defined as modified Rankin Scale score (mRS) of 0 to 3, at 90 days. Safety outcomes included symptomatic intracerebral hemorrhage (sICH) within 48 hours and mortality at 90 days.

Results

A total of 245 patients (median [IQR] age, 71 [63-78] years; 118 [48%] women) with ASPECTS of 0 to 2 were included, of whom 111 patients (45.1%) received SMT and 135 patients (54.9%) received EVT. The EVT group had significantly greater odds of favorable functional outcome at 90 days than the SMT group (30 patients [22.2%] vs 11 patients [9.9%]; P = .01; adjusted odds ratio [aOR], 3.07 [95% CI, 1.29-7.31]; P = .01). Patients in the EVT group, compared with the SMT group, had significantly greater odds of any ICH (56 patients [41.5%] vs 16 patients [11.4%]; P < .001; aOR, 4.27 [95% CI, 2.19-8.35]; P < .001) and sICH (24 patients [17.8%] vs 1 patient [0.9%]; P < .001; aOR, 23.07 [95% CI, 2.99-177.79]; P = .003) within 48 hours. There were no differences between groups for 90-day mortality (80 patients [59.3%] vs 59 patients [53.2%]; P = .34; aOR, 1.38 [95% CI, 0.77-2.47]; P = .28). The results remained robust in the propensity score-matched analysis.

Conclusions and Relevance

In this cohort study of patients with very low ASPECTS based on NCCT within 24 hours of stroke onset, those treated with EVT had higher odds of a favorable functional outcome compared with those who received SMT. Randomized clinical trials are needed to assess these findings.

The Relevance of Reperfusion Stroke Therapy for miR-9-3p and miR-9-5p Expression in Acute Stroke-A Preliminary Study

Reperfusion stroke therapy is a modern treatment that involves thrombolysis and the mechanical removal of thrombus from the extracranial and/or cerebral arteries, thereby increasing penumbra reperfusion. After reperfusion therapy, 46% of patients are able to live independently 3 months after stroke onset. MicroRNAs (miRNAs) are essential regulators in the development of cerebral ischemia/reperfusion injury and the efficacy of the applied treatment. The first aim of this study was to examine the change in serum miRNA levels via next-generation sequencing (NGS) 10 days after the onset of acute stroke and reperfusion treatment. Next, the predictive values of the bioinformatics analysis of miRNA gene targets for the assessment of brain ischemic response to reperfusion treatment were explored. Human serum samples were collected from patients on days 1 and 10 after stroke onset and reperfusion treatment. The samples were subjected to NGS and then validated using qRT-PCR. Differentially expressed miRNAs (DEmiRNAs) were used for enrichment analysis. Hsa-miR-9-3p and hsa-miR-9-5p expression were downregulated on day 10 compared to reperfusion treatment on day 1 after stroke. The functional analysis of miRNA target genes revealed a strong association between the identified miRNA and stroke-related biological processes related to neuroregeneration signaling pathways. Hsa-miR-9-3p and hsa-miR-9-5p are potential candidates for the further exploration of reperfusion treatment efficacy in stroke patients.

Direct Exposure to Outdoor Air Pollution Worsens the Functional Status of Stroke Patients Treated with Mechanical Thrombectomy

Background The effect of air pollutants on the functional status of stroke patients in short-term follow-up is unknown. The aim of this study was to evaluate the effect of air pollution occurring in the stroke period and during hospitalization on the functional status of patients undergoing mechanical thrombectomy (MT). Methods Our study included stroke patients for which the individual-level exposure to ambient levels of O3, CO, SO2, NO2, PM2.5, and PM10 during the acute stroke period was assessed. The correlations between the air pollutants' concentration and the patients' functional state were analyzed. A total of 499 stroke patients (mean age: 70) were qualified. Results The CO concentration at day of stroke onset was found to be significant regarding the functional state of patients on the 10th day (OR 0.014 95% CI 0-0.908, p = 0.048). The parameters which increased the risk of death in the first 10 days were as follows: NIHSS (OR 1.27; 95% CI 1.15-1.42; p < 0.001), intracranial bleeding (OR 4.08; 95% CI 1.75-9.76; p = 0.001), and SO2 concentration on day 2 (OR 1.21; 95% CI 1.02-1.47; p = 0.03). The parameters which increased the mortality rate within 90 days include age (OR 1.07; 95% CI 1.02-1.13; p = 0.005) and NIHSS (OR 1.37; 95% CI 1.19-1.63; p < 0.001). Conclusions Exposure to air pollution with CO and SO2 during the acute stroke phase has adverse effects on the patients' functional status. A combination of parameters, such as neurological state, hemorrhagic transformation, and SO2 exposure, is unfavorable in terms of the risk of death during a hospitalization due to stroke. The risk of a worsened functional status of patients in the first month of stroke rises along with the increase in particulate matter concentrations within the first days of stroke.

Safety and efficacy of intravenous thrombolysis in patients with acute ischemic stroke taking direct oral anticoagulants prior to stroke: a meta-analysis

BACKGROUND

To assess the safety and efficacy of intravenous thrombolysis (IVT) in patients with acute ischemic stroke (AIS) taking direct oral anticoagulants (DOACs) prior to stroke.

METHODS

Literature was searched in PubMed, Cochrane Library, and Embase until March 13, 2023. The primary outcome was symptomatic intracranial hemorrhage (sICH). Secondary outcomes included excellent outcome (modified Rankin Scale [mRS] 0-1), functional independence (mRS 0-2), and mortality. Odds ratios (OR) with 95% confidence intervals (CI) were estimated using a random-effects model.

RESULTS

Five non-randomized studies included 239,879 patients with AIS treated with IVT, with 3400 (1.42%) taking DOACs prior to stroke. The rates of sICH did not differ statistically between patients taking DOACs and those not taking anticoagulants (unadjusted OR 0.98; 95% CI 0.67-1.44; P = 0.92; adjusted OR 0.81; 95% CI 0.64-1.03; P = 0.09). Patients taking DOACs had significantly higher adjusted rates of excellent outcome (adjusted OR 1.22; 95% CI 1.06-1.40; P < 0.01) and functional independence (adjusted OR 1.25; 95% CI 1.10-1.42; P < 0.01) at discharge than those not taking anticoagulants. No significant difference was observed in mortality and other efficacy outcomes between groups after adjustment.

CONCLUSION

The meta-analysis indicated that taking DOACs prior to stroke does not significantly increase the risk of sICH in selected patients with AIS treated with IVT. Furthermore, the benefits of IVT in selected patients taking DOACs appear to be comparable to those not taking anticoagulants. Further research is warranted to confirm the findings.

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.

Endovascular treatment for ischemic stroke patients with and without atrial fibrillation, and the effects of adjunctive pharmacotherapy: a narrative review

INTRODUCTION

Endovascular thrombectomy (EVT) is associated with good clinical outcomes in patients with ischemic stroke, but the impact of EVT on clinical outcomes in patients with ischemic stroke with and without atrial fibrillation (AF), and the effect of adjunctive pharmacological therapies with EVT, remains unclear.

AREAS COVERED

The goal of this narrative review is to provide an overview of studies which have examined: 1) associations between EVT and outcomes for patients following ischemic stroke, 2) associations between EVT and outcomes for patients following ischemic stroke with and without AF , including function, reperfusion, hemorrhage, and mortality, 3) the effect of adjunctive pharmacological therapies peri- and post-thrombectomy, and 4) integration of prehospital care on endovascular treatment outcomes.

EXPERT OPINION

There is little evidence from randomized controlled trials on the effect of AF on stroke outcomes following EVT and the safety and efficacy of AF treatment in the peri-EVT such as tirofiban or Intravenous thrombolysis with Non-vitamin K Antagonist Oral Anticoagulant. The available evidence from observational studies on AF and EVT outcomes is inconsistent, but factors such as procedural EVT devices, the center volume, clinician experience, stroke recognition, and inclusion criteria of studies have all been associated with poorer clinical outcomes. Enhancing the clinical network among prehospital and hospitals will facilitate direct transfer to EVT centers, reducing stroke onset to EVT time and optimizing stroke outcomes.

Cerebral Circulation Time After Thrombectomy: A Potential Predictor of Outcome After Recanalization in Acute Stroke

Background

Despite successful recanalization, up to half of patients with acute ischemic stroke caused by large‐vessel occlusion treated with endovascular treatment (EVT) do not recover to functional independence. We aim to evaluate the role of cerebral circulation time (CCT) as outcome predictor after EVT.

Methods and Results

We retrospectively enrolled consecutive patients with acute ischemic stroke–large‐vessel occlusion undergoing EVT. Three categories of CCT based on digital subtraction angiography were studied: CCT of the stroke side, CCT of the healthy side), and change of CCT of the stroke side versus CCT of the healthy side. Dramatic clinical recovery was defined as a 24‐hour National Institutes of Health Stroke Scale score ≤2 or ≥8 points drop. A modified Rankin Scale score ≤2 at 3 months was considered a favorable outcome. Logistic regression analysis was performed to evaluate the prediction of CCT on prognosis. One hundred patients were enrolled, of which 38 (38.0%) experienced a dramatic clinical recovery and 43 (43.0%) achieved a favorable outcome. Logistic regression analysis found that shorter change of CCT of the stroke side versus CCT of the healthy side and CCT of the stroke side were independent positive prognostic factors for dramatic clinical recovery (odds ratio [OR], 0.189; P=0.033; OR, 0.581; P=0.035) and favorable outcomes (OR, 0.142; P=0.020; OR, 0.581; P=0.046) after adjustment for potential confounders. A model including the change of CCT of the stroke side versus CCT of the healthy side also had significantly higher area under the curve values compared with the baseline model in patients with dramatic clinical recovery (0.780 versus 0.742) or favorable outcome (0.759 versus 0.713).

Conclusions

To our knowledge, this is the first report that CCT based on digital subtraction angiography data exhibits an independent predictive performance for clinical outcome in patients with acute ischemic stroke–large‐vessel occlusion after EVT. Given that this readily available CCT can provide alternative perfusion information during EVT, a prospective, multicenter trial is warranted.

Passing Extracranial Artery Occlusion by Intermediate Catheter With Expanding Microballoon (PEACE): A Novel Endovascular Therapy in Acute Tandem Occlusion Stroke

PURPOSE

Endovascular treatment of atherosclerotic tandem occlusions in acute ischemic stroke (AIS) is a matter of debate. This article reports a single-center experience using an intermediate catheter with microballoon for treatment of tandem occlusions.

METHODS

A total of 151 AIS patients with large vessel occlusion received endovascular therapy and a consecutive series of patients (n = 26) who suffered from tandem cervical intracranial occlusions were treated using the Passing Extracranial Artery Occlusion by Intermediate Catheter with Expanding Microballoon (PEACE) technique. Intracranial recanalization was achieved by aspiration or stent retriever and then emergency stenting was performed for extracranial internal carotid artery (ICA) lesion. Demographic, clinical characteristics, procedural details of endovascular therapy, and prognosis outcome were assessed. The outcomes of tandem occlusion group were compared with isolated intracranial occlusion group (n = 122) and previous studies.

RESULTS

As compared to isolated intracranial occlusion groups, only a few patients suffered from atrial fibrillation (7.7% vs 38.5%, p<0.01) in tandem occlusions group. A larger proportion of patients (61.5% vs 29.5%) had tandem occlusions in which extracranial ICA occlusion was combined with intracranial terminus occlusion in ICA (p<0.01). 46.2% of tandem occlusions patients achieved intracranial recanalization by aspiration alone versus 15.6% in patients with isolated intracranial occlusion (p<0.01). In tandem occlusion patients treated with PEACE, 92.3% achieved successful reperfusion (thrombolysis in cerebral infarct [TICI] ≥2b). The median time from puncture to recanalization was 51 minutes (interquartile range [IQR], 41-66). 67.6% favorable functional prognosis (modified Rankin score [mRS], 0-2) was seen, with 11.5% mortality and 3.8% of symptomatic intracerebral hemorrhage (sICH) at 90 days. These outcomes are all consistent or better than previously reported studies performed for tandem occlusion.

CONCLUSIONS

Endovascular therapy using the PEACE technique with intermediate catheter and lined expanding microballoon is safe, efficient, and fast in the treatment of atherosclerotic tandem occlusion patients.

Clinical and Non-Clinical Determinants of the Effect of Mechanical Thrombectomy and Post-Stroke Functional Status of Patients in Short and Long-Term Follow-Up

To date, inconsistent results evaluating the effect of parameters on mechanical thrombectomy (MT) outcomes in stroke-patients have been published. This study aimed to identify the key parameters for functional status after MT in stroke-patients in short and long-term follow-up.

METHOD

The study analysis focused on the relevance of selected clinical and non-clinical parameters to the functional status of the patients after MT.

RESULTS

417 stroke-patients (mean age 67.8 ± 13.2 years) were qualified. Atrial fibrillation, and leukocytosis were significant for the neurological status on the first day of stroke (p = 0.036, and p = 0.0004, respectively). The parameters with the strongest effect on the functional status on day 10 were: age (p = 0.009), NIHSS (p = 0.002), hyperglycemia (p = 0.009), the result in TICI (p = 0.046), and first pass effect (p = 0.043). The parameters with the strongest effect on the functional status on day 365 were: age and NIHSS on the first day of stroke (p = 0.0002 and 0.002, respectively). Leukocytosis and the neurological status at baseline were key parameters associated with ICB after MT (p = 0.007 and p = 0.003, respectively).

CONCLUSIONS

Age and neurological status in the ultra-acute phase of stroke are crucial for the functional status in short and long-term observations of patients treated with mechanical thrombectomy. Atrial fibrillation, hyperglycemia, and inflammatory state are relevant to the short-term post-stroke functional status. First pass effect and the degree of post-interventional reperfusion are important technical parameters to the short-term functional status. Neurological status and white blood count during the acute phase are associated with a high rate of post-procedural intracranial bleeding.

Prognostic Role of Chronic Rhinosinusitis in Acute Ischemic Stroke Patients Undergoing Mechanical Thrombectomy

Background: The aim of the study was to assess the relevance of chronic rhinosinusitis (CRS) CT features to the efficacy of mechanical thrombectomy (MT) in patients with acute ischemic stroke. Methods: This study included 311 patients qualified for MT in whom the CRS features were assessed based on a CT scan, according to the Lund-Mackay (L-M) score. Clinical, inflammatory parameters, patients neurological (NIHSS) and functional status (mRS), and recanalisation efficacy (TICI) were compared between patients with mild lesions (L-M score 0–3 points)-group 1, and patients with more severe lesions (L–M score 4–24)-group 2. Results: There was a significant difference in the NIHSS on day seven after stroke onset-10 points in group 1 and 14 points in group 2, p = 0.02. NIHSS ≤ 6 points on day seven was found in 41.9% of patients in group 1, and in 27.5% in group 2, p = 0.042. There were no significant differences in mRS score and in the TICI score. L-M score, lipid abnormalities and CRP were factors associated with NIHSS ≥ 7 points on day 7. Conclusions: The CT features of CRS may be used as a prognostic tool for early prognosis assessment in stroke patients.