Randomized assessment of rapid endovascular treatment of ischemic stroke

Endovascular therapy versus best medical care for acute ischemic stroke with distal medium vessel occlusion: a systematic review and meta-analysis

BACKGROUND

With the refinement of catheter technology, distal medium vessel occlusions (DMVOs) are now viewed as amenable to endovascular treatment (EVT) but its efficacy and safety remains unclear in AIS patients with DMVO.

METHODS

We conducted a systematic search of PubMed, Embase databases and Cochrane Library up to December 2023 using keywords to identify studies comparing EVT versus BMT in AIS with DMVOs. The assessed clinical outcomes were excellent functional outcome, good functional outcome, 90-day mortality, symptomatic intracranial hemorrhage (sICH), and early neurological improvement (ENI) after treatment.

RESULTS

Overall, 31 studies were included. There were no significant differences in excellent functional outcome (OR: 1.21, 95% CI: 0.99-1.47), good functional outcome (OR: 1.03, 95% CI: 0.82-1.30) and 90-day mortality (OR: 1.17, 95% CI: 0.84-1.62). Additionally, EVT led to higher sICH (OR: 1.64, 95% CI: 1.09-2.47) and better ENI (OR: 1.50, 95% CI: 1.02-2.19) compared to BMT. In individuals with M2 occlusion receiving EVT showed better excellent functional outcomes (OR: 1.48, 95% CI: 1.07-2.03). Those patients with PCA occlusion showed no significant difference in functional outcomes. In individuals with ACA occlusion, EVT resulted in reduced functional independence (OR: 0.55, 95% CI: 0.31-0.98). For NIHSS < 6, BMT achieved better functional independence compared to EVT (OR: 0.71, 95% CI: 0.51-0.98) and EVT showed higher sICH (OR: 3.44, 95% CI: 1.42-8.31).

CONCLUSION

For patients with AIS and DMVO occlusion, EVT fails to improve functional prognosis while increasing sICH incidence. More randomized controlled trials are needed in the future to confirm these results.

Study on the Prognostic Factors Related to Endovascular Treatment of Acute Basilar Artery Occlusion Within 24 Hours of Onset

BACKGROUND

To evaluate the prognostic effect of endovascular treatment (EVT) in patients with acute base artery occlusion (ABAO) within 24 h of onset, and analyze the factors related to prognosis.

METHODS

A retrospective analysis was conducted on all ABAO patients who received EVT within 24 h of onset in the neurology department of Baotou Central Hospital in Inner Mongolia from May 2016 to October 2022. Good prognosis was defined as a Modified Rankin Scale (mRS) score of 0-3 and poor prognosis mRS score of 4-6 at 90 day follow-up, and factors related to prognosis were analyzed.

RESULTS

Among the 77 patients included in the analysis, 68 patients (88.3%) achieved recanalization (modified thrombolysis in cerebral infarction, mTICI 2b/3 grade). Thirty eight patients (49.4%) achieved an overall good prognosis. In univariate analysis, age, baseline Glasgow Coma Scale (GCS), baseline National Institutes of Health Stroke Scale (NIHSS), posterior circulation Acute Stroke Prognostic Early CT score (pc ASPECTS), preoperative intravenous thrombolysis, and mTICI2b-3 were factors affecting good prognosis. Multivariate analysis showed that shorter onset to puncture time (OR 0.069; 95% CI, 0.009-0.519; p = 0.009), lower NIHSS (OR 1.179; 95% CI, 1.019-1.364; p = 0.027), and higher pc ASPECTS (OR 0.489, 95% CI, 0.250-0.959, p = 0.037) were factors influencing good prognosis in this study.

CONCLUSIONS

In summary, endovascular treatment for patients with acute basilar artery occlusion is safe and effective, but EVT may achieve better prognosis within 6 h of onset. The shorter time from onset to puncture at admission, lower baseline NIHSS score, and higher baseline pc-ASPECTS are factors affecting the good prognosis of patients at 90 days.

Analysis of factors associated with prognosis after successful thrombectomy after posterior circulation stroke

PURPOSE

With the continuous improvement of mechanical thrombectomy (MT) technology, the success rate of vascular recanalization has been significantly improved, and some patients still have poor prognosis based on vascular recanalization. This study aims to find clinical factors affecting prognosis after vascular recanalization and find valuable predictors.

METHODS

We followed up patients who underwent posterior circulation thrombectomy for up to 180 days. Using univariate and multivariate logistic regression, we identified prognostic factors related to functional outcomes or survival. Cox analysis was further applied to determine the optimal cutoff values for these factors.

RESULTS

Modified Thrombolysis in Cerebral Infarction (mTICI) and NIHSS (24 h), as independent prognostic factors, provide a reliable indication of patients' prognostic status within 90 days. Additionally, a lower Posterior Circulation Alberta Stroke Program Early CT Score (pc-ASPECTs) score and a higher NIHSS (24 h) score are closely associated with patients' 90-day survival status.

CONCLUSION

Retrospective analysis after thrombectomy showed that NIHSS (24 h) was a key independent prognostic factor for the rehabilitation prognosis and death of patients, which was helpful for clinical decision-making and postoperative care.

Two-stage convolutional neural network for segmentation and detection of carotid web on CT angiography

BACKGROUND

Carotid web (CaW) is a risk factor for ischemic stroke, mainly in young patients with stroke of undetermined etiology. Its detection is challenging, especially among non-experienced physicians.

METHODS

We included patients with CaW from six international trials and registries of patients with acute ischemic stroke. Identification and manual segmentations of CaW were performed by three trained radiologists. We designed a two-stage segmentation strategy based on a convolutional neural network (CNN). At the first stage, the two carotid arteries were segmented using a U-shaped CNN. At the second stage, the segmentation of the CaW was first confined to the vicinity of the carotid arteries. Then, the carotid bifurcation region was localized by the proposed carotid bifurcation localization algorithm followed by another U-shaped CNN. A volume threshold based on the derived CaW manual segmentation statistics was then used to determine whether or not CaW was present.

RESULTS

We included 58 patients (median (IQR) age 59 (50-75) years, 60% women). The Dice similarity coefficient and 95th percentile Hausdorff distance between manually segmented CaW and the algorithm segmented CaW were 63.20±19.03% and 1.19±0.9 mm, respectively. Using a volume threshold of 5 mm3, binary classification detection metrics for CaW on a single artery were as follows: accuracy: 92.2% (95% CI 87.93% to 96.55%), precision: 94.83% (95% CI 88.68% to 100.00%), sensitivity: 90.16% (95% CI 82.16% to 96.97%), specificity: 94.55% (95% CI 88.0% to 100.0%), F1 measure: 0.9244 (95% CI 0.8679 to 0.9692), area under the curve: 0.9235 (95%CI 0.8726 to 0.9688).

CONCLUSIONS

The proposed two-stage method enables reliable segmentation and detection of CaW from head and neck CT angiography.

Endovascular Thrombectomy for Ischemic Stroke With Large Infarct

Endovascular thrombectomy (EVT) is a safe and effective treatment for acute ischemic stroke caused by large vessel occlusion. However, earlier randomized trials of endovascular thrombectomy did not include many patients with large infarctions, leading to their exclusion from this treatment. Recent randomized trials have shown that endovascular thrombectomy is superior to medical management alone in improving functional outcomes in ischemic stroke cases with large infarcts. This commentary provides an overview of these trials and discusses important considerations for implementing these results into clinical practice.

Endovascular therapy in patients with acute intracranial non-terminal internal carotid artery occlusion (ICA-I)

BACKGROUND

Acute intracranial occlusion of the internal carotid artery (ICA) can be distinguished into (a) occlusion of the terminal ICA, involving the proximal segments of the middle or anterior cerebral artery (ICA-L/-T) and (b) non-terminal intracranial occlusions of the ICA with patent circle of Willis (ICA-I). While patients with ICA-L/-T occlusion were included in all randomized controlled trials on endovascular therapy (EVT) in anterior large vessel occlusion, data on EVT in ICA-I occlusion is scarce. We thus aimed to evaluate effectiveness and safety of EVT in ICA-I occlusions in comparison to ICA-L/-T occlusions.

METHODS

A large international multicentre cohort was searched for patients with intracranial ICA occlusion treated with EVT between 2014 and 2023. Patients were stratified by ICA occlusion pattern, differentiating ICA-I and ICA-L/-T occlusions. Baseline factors, technical (modified thrombolysis in cerebral infarction (mTICI) scale) and functional outcomes (modified Rankin scale [mRS] at 3 months) as well as rates of (symptomatic) intracranial hemorrhage ([s]ICH) were analyzed.

RESULTS

Of 13,453 patients, 1825 (13.6%) had isolated ICA occlusion. ICA-occlusion pattern was ICA-I in 559 (4.2%) and ICA-L/-T in 1266 (9.4%) patients. Age (years: 74 vs 73), sex (female: 45.8% vs 49.0%) and pre-stroke functional independency (pre-mRS ⩽ 2: 89.9% vs 92.2%) did not differ between the groups. Stroke severity was lower in ICA-I patients (NIHSS at admission: 14 [7-19] vs 17 [13-21] points). EVT was similarly successful with respect to technical (mTICI2b/3: 76.1% (ICA-I) vs 76.6% (ICA-L/-T); aOR 1.01 [0.76-1.35]) and functional outcome (mRS ordinal shift cOR 1.01 [0.83-1.23] in adjusted analyses. Rates of ICH (18.9% vs 34.5%; aOR 0.47 [0.36-0.62] and sICH (4.7% vs 7.3%; aOR 0.58 [0.35-0.97] were lower in ICA-I patients.

CONCLUSION

EVT might be performed safely and similarly successful in patients with ICA-I occlusions as in patients with ICA-L/-T occlusions.

STAY-HOME: Endovascular Thrombectomy for Patients With Prestroke Disability

Thrombectomy significantly improves clinical outcomes in patients with large vessel occlusion. However, the foundational trials used restrictive criteria, excluding patients with prestroke disability and included a few elderly patients (>80 years old). In addition, results from registries demonstrated conflicting results. We propose that there is equipoise for the elderly and prestroke disability to undergo thrombectomy and that trials are urgently required to guide treatment.

The Mediating Effect of Intracranial Hemorrhage Status on the Relationship between the INR and Mortality in Patients with Ischemic Stroke

INTRODUCTION

The international normalized ratio (INR) is a biomarker of coagulopathy. The objective of this study was to assess the relationship between the INR and clinical outcomes in patients with large vessel occlusion (LVO) stroke who received endovascular therapy.

METHODS

The RESCUE BT trial was a multicenter, randomized, double-blind, placebo-controlled clinical trial involving 948 stroke patients from 55 centers across China. We extracted INR data and related data from the BT database, with outcome measures comprising intracranial hemorrhage (ICH) and 90-day mortality. Logistic regression analysis was conducted to examine the associations between the INR and clinical outcomes in the entire patient cohort and across different stratified subgroups.

RESULTS

A total of 885 patients met the study criteria, with 672 exhibiting a normal INR and 213 showing an elevated INR. Multivariable analysis indicated that an elevated INR was linked to an increased risk of ICH (OR 1.65, 95% confidence interval CI 1.17-2.33, P =0.005) and 90-day mortality (OR 1.78, 95% CI 1.17-2.70, P =0.007). Mediation analysis indicated that the association between the INR and 90-day mortality risk was partially mediated by ICH status, with the mediation effect contributing 11.4% to the overall relationship. Subgroup analyses revealed no significant differences between the different subgroups (P for interaction > 0.05). In patients receiving tirofiban, an elevated INR was more strongly associated with an increased 90-day mortality rate (OR 7.75, 95% CI 1.42-42.33, P =0.018).

CONCLUSION

Our findings underscore the critical importance of INR monitoring in patients with LVO stroke undergoing endovascular treatment (EVT). The association between the INR and 90-day mortality was mediated through ICH status. The use of tirofiban strengthened the associated between an elevated INR and a higher 90-day mortality rate. These insights offer valuable guidance for optimizing patient outcomes.

TRIAL REGISTRATION

URL: http://www.chictr.org.cn ; ChiCTR-INR-17014167.

Factors and outcomes associated with National Institutes of Health stroke scale scores in acute ischemic stroke patients undergoing thrombectomy in United States

BACKGROUND AND PURPOSE

The National Institutes of Health Stroke Scale (NIHSS) is the standard for assessing neurological deficits in acute ischemic stroke patients undergoing thrombectomy. However, data on NIHSS scores in patients undergoing thrombectomy at national-level studies in the United States are lacking.

METHODS

Acute ischemic stroke patients admitted between 2018 and 2021 were identified using ICD-10-CM codes from the Nationwide In-patient Sample, with NIHSS scores categorized into specific strata (0-9, 10-19, 20-29, 30-42). We analyzed the effect of NIHSS scores on in-hospital mortality, routine discharge without palliative care (based on discharge disposition), and length and costs of hospitalization after adjusting for potential confounders.

RESULTS

The NIHSS score strata among 108,990 acute ischemic stroke patients undergoing thrombectomy were: NIHSS score 0-9 (29.6 %), 10-19 (40.6 %), 20-29 (26.4 %), and 30-42 (3.4 %). Patients in the Midwest and West regions (adjusted odds ratio [adjusted OR] = 1.51, p = 0.002 and adjusted OR = 1.63, p < 0.001, respectively), those treated in rural hospitals (adjusted OR = 1.35, p = 0.009) and those who were self-pay (adjusted OR = 1.51, p = 0.048) had higher odds of being in higher NIHSS score strata. Patients in higher NIHSS score strata (NIHSS score 10-19, 20-29, and 30-42 had significantly lower odds of discharge home without palliative care (adjusted OR= 0.50, 0.32, and 0.22 respectively, all p < 0.001) and higher odds of in-hospital mortality (adjusted OR = 1.51, 2.30, and 3.80 respectively, all p < 0.001) compared to those in NIHSS score strata of 0-9. Patients in higher NIHSS score strata had significantly higher hospital stays and higher hospitalization costs.

CONCLUSIONS

We provide a comprehensive national-level analysis of NIHSS scores in acute ischemic stroke patients undergoing thrombectomy which may assist in understanding variations in outcomes and resource utilizations in United States.

The presence of a ghost infarct core is associated with fast core growth in acute ischemic stroke

INTRODUCTION

The overestimation of ischemic core volume by CT perfusion (CTP) is a critical concern in the selection of candidates for reperfusion therapy. This phenomenon is termed a ghost infarct core (GIC). Core growth rate (CGR) is an indicator of ischemic severity. We aimed to elucidate the association between GIC and CGR.

PATIENTS AND METHODS

Consecutive patients with acute ischemic stroke who underwent mechanical thrombectomy in our institute from March 2017 to July 2022 were enrolled. The initial ischemic core volume (IICV) was measured by pretreatment CTP, and the final infarct volume (FIV) was measured by diffusion-weighted imaging. A GIC was defined by IICV minus FIV > 10 ml. The CGR was calculated by dividing the IICV by the time from onset to CTP. Univariable analysis and a multivariable logistic regression model were used to evaluate the association between GIC-positive and CGR.

RESULTS

Of all 91 patients, 21 (23.1%) were GIC-positive. The GIC-positive group had higher CGR (14.2 [2.6-46.7] vs 4.8 [1.6-17.1] ml/h, p = 0.02) and complete recanalization (n = 15 (71.4%) vs 29 (41.4%), p = 0.02) compared to the GIC-negative group. On receiver-operating characteristic curve analysis, the optimal cutoff point of CGR to predict GIC-positive was 22 ml/h (sensitivity, 0.48; specificity, 0.85; AUC, 0.67). Multivariable logistic regression analysis showed that CGR ⩾ 22 ml/h (OR 6.44, 95% CI [1.59-26.10], p = 0.01) and complete recanalization (OR 3.72, 95% CI [1.14-12.08], p = 0.02) were independent predictors of GIC-positive.

CONCLUSIONS

A GIC was associated with fast CGR in acute ischemic stroke. Overestimation of the initial ischemic core may be determined by core growth speed.

Outcomes of different anesthesia techniques in nonagenarians treated with mechanical thrombectomy for anterior circulation large vessel occlusion: An inverse probability weighting analysis

INTRODUCTION

There is a lack of evidence for the optimal type of anesthesia technique in patients ⩾ 90 years with acute ischemic stroke undergoing mechanical thrombectomy (MT) as this subgroup of patients was often excluded or under-represented in previous trials. We aimed to compare outcomes between general anesthesia (GA) and non-GA techniques in patients ⩾ 90 years with large vessel occlusion (LVO) undergoing MT.

PATIENTS AND METHODS

Our study included patients ⩾ 90 years with anterior circulation LVO, NIHSS ⩾ 6, ASPECTS ⩾ 5 consecutively treated with MT within 6 h after stroke onset in three thrombectomy capable centers between January 1st, 2016 and March 30th, 2023. Inverse probability weighting (IPW) was used to reduce bias by indication of the anesthesia type on study outcomes. We used a weighted ordinal robust logistic regression analysis to explore the primary outcome of modified Rankin Scale (mRS) shift at 90 days in GA versus non-GA treated patients. Secondary outcomes included 90-day mortality, symptomatic intracranial hemorrhage (sICH) and TICI score of 2b, 2c, or 3.ResultsWe included 139 patients ⩾ 90 years treated with MT, 62 were in GA group and 77 in non-GA group. There was a significant shift for worse mRS scores at 90-day in non-GA treated patients (cOR 3.65, 95% CI 1.77-7.77, p = 0.001). The weighted logistic regression showed that non-GA technique was an independent predictor of 90-day mortality (OR 7.49, 95% CI 2.00-28.09; p = 0.003).

CONCLUSION

Our study indicated that nonagenarians with acute ischemic stroke treated with MT without GA have a worse prognosis than their counterparts undergoing MT with GA. Further studies in larger cohorts are warranted to evaluate the optimal type of anesthesia in this patient population.

Prehospital stroke scales outperform National Institutes of Health Stroke Scale in predicting large vessel occlusion in a large academic telestroke network

IntroductionPrehospital telestroke evaluations may improve stroke triage compared to paramedic-applied large vessel occlusion scales, but ambulance-based video National Institutes of Health Stroke Scale assessments are challenging. The accuracy of telestroke-administered large vessel occlusion scales has not been investigated, so we sought to evaluate this further.MethodsThis retrospective study included all in-hospital telestroke encounters in a large academic telestroke network from 2019 to 2020. We retrospectively calculated seven large vessel occlusion scales using the in-hospital telestroke National Institutes of Health Stroke Scale (Rapid Arterial oCclusion Evaluation, Cincinnati Stroke Triage Assessment Tool, Field Assessment Stroke Triage for Emergency Destination, 3-Item Stroke Scale, Prehospital Acute Stroke Severity, Vision-Aphasia-Neglect, and Gaze-Face-Arm-Speech-Time). Diagnostic performance was assessed via sensitivity, specificity, negative predictive value, positive predictive value, positive likelihood ratio, negative likelihood ratio, and accuracy using established scale thresholds. These results were compared to the National Institutes of Health Stroke Scale at thresholds of 6, 8, and 10. The area under curve was calculated using c-statistics by treating scales as continuous variables.ResultsA total of 625 patients were included; 111 (17.8%) patients had an anterior large vessel occlusion, 118 (18.9%) patients had any large vessel occlusion, and 182 (29.1%) patients had stroke mimic diagnosis. The mean age (SD) was 67.9 (15.9), 48.3% were female, and 93.4% were white. The Mean National Institutes of Health Stroke Scale (SD) was 14.9 (8.4) for patients with anterior large vessel occlusion, 4.7 (5.0) for patients with non-large vessel occlusion ischemic stroke, and 4.4 (5.8) for stroke mimic (p < 0.001). Compared to the National Institutes of Health Stroke Scale, Field Assessment Stroke Triage for Emergency Destination, and Rapid Arterial oCclusion Evaluation scales demonstrated higher accuracy and area under curve for large vessel occlusion detection.DiscussionBoth the Field Assessment Stroke Triage for Emergency Destination and Rapid Arterial oCclusion Evaluation scales outperformed the National Institutes of Health Stroke Scale for large vessel occlusion detection in patients evaluated by in-hospital telestroke. These scales may be valid alternatives to the National Institutes of Health Stroke Scale examination in this setting.

Endovascular treatment in patients with acute ischemic stroke presenting beyond 6 h after symptom onset: An international multicenter cohort study of the EVA-TRISP collaboration

INTRODUCTION

After positive findings in clinical trials the time window for endovascular thrombectomy (EVT) for patients with an acute ischemic stroke has been expanded up to 24 h from symptom onset or last seen well (LSW). We aimed to compare EVT patients' characteristics and outcomes in the early versus extended time window and to compare outcomes with the DAWN and DEFUSE 3 trial results.

PATIENTS AND METHODS

Consecutive EVT patients from 16 mostly European comprehensive stroke centers from the EVA-TRISP cohort were included. We compared rates of 90-day good functional outcomes (Modified Rankin Scale 0-2), symptomatic intracranial hemorrhage (sICH), and 90-day mortality between patients treated in the early (<6 h after onset or LSW) versus extended (6-24 h after onset or LSW) time windows.

RESULTS

We included 9313 patients, of which 6876 were treated in the early and 2437 in the extended time window. National Institutes of Health Stroke Scale (NIHSS) score at presentation was lower in patients treated in the extended time window (median 13 [IQR 7-18] vs 15 [IQR 9-19], p < 0.001). The percentage of patients with good functional outcome was slightly lower in the extended time window (37.4% vs 42.2%, p < 0.001). However, rates of successful recanalization, sICH, and mortality were similar. Good functional outcome rates after EVT were slightly lower for patients in the extended window in the EVA-TRISP cohort as compared to DAWN and DEFUSE 3.

DISCUSSION AND CONCLUSION

According to this large multicenter cohort study reflecting daily clinical practice, EVT use in the extended time window appears safe and effective.

Brain remodeling in stroke patients: A comprehensive review of mechanistic and neuroimaging studies

Stroke-induced brain remodeling involves a complex interplay of neurovascular components, including endothelial cells, microglia, astrocytes, and pericytes, which collectively contribute to the restoration of brain function. These processes are crucial for repairing the blood-brain barrier, regulating inflammation, and promoting neurogenesis. This review examines the mechanisms underlying brain remodeling and the role of advanced neuroimaging techniques-such as functional MRI (fMRI), positron emission tomography (PET), functional near-infrared spectroscopy (fNIRS), and functional ultrasound (fUS)-in assessing these changes. We also discuss various therapeutic approaches aimed at enhancing brain remodeling, including pharmacological agents, stem cell therapy, and rehabilitation strategies that target neurovascular repair and functional recovery. Despite significant progress, challenges remain in translating imaging insights into effective treatments. Future research should focus on integrating multiple imaging modalities to provide a comprehensive view of neurovascular changes and refining therapeutic interventions to optimize recovery and functional outcomes in stroke patients.

Dual-Energy CT-Based Assessment of Thrombotic Heterogeneity for Predicting Stroke Source and Response to Machine Thrombectomy: A Step Toward Visualization Thrombus Treatment

The viability of using thrombus heterogeneity (TH) data derived from dual-energy CT (DECT) as a visual thrombotic biomarker is unclear. The first aim of this study is to develop a quantitative measure of TH on DECT and test its performance for predicting the stroke source (cardiogenic vs. non-cardiogenic) and clinical outcomes (functional status assessed by the modified Rankin Scale score at 90 days) following machine thrombectomy (MT). The second aim is to associate thrombus subregions with the thrombus composition to facilitate visualization of thrombus constituents. Radiomics data are extracted from the whole thrombus and subregions in CT/DECT to construct predictive models. The performances of all models are evaluated and compared in the validation and comparative cohorts. Histopathologic analysis is performed to correlate the subregion data with the actual thrombus composition. This study included 221 and 255 participants who underwent DECT and CT examinations, respectively. DECT outperformed CT in predicting stroke source and clinical outcomes, with the TH-related models showing the highest performance in the validation and comparative cohorts. Thrombus composition is correlated with the different CT/DECT-based subregions, with DECT-habitat_c showing the strongest association. Thrombus subregion analyses may help visualize the related constituents.

Functional outcomes in pediatric large vessel occlusion treated with endovascular treatment: results from Chinese Pediatric Ischemic Stroke Registry, a multicenter, prospective registry study

BACKGROUND AND PURPOSE

Endovascular treatment (EVT) has become the standard of care for selected adult patients with large vessel occlusion (LVO), but its efficacy in pediatric patients remains limited. This study aimed to assess the clinical outcomes of EVT in pediatric patients with LVO and compare it with medical management.

METHODS

The Chinese Pediatric Ischemic Stroke Registry (CPISR) is a multicenter, prospective observational study. Eighty-five centers across 20 provinces in China reported functional outcomes for children aged between 28 days and 18 years presenting with arterial ischemic stroke (AIS) caused by LVO who received either EVT or medical treatment. The primary outcome was the pediatric modified Rankin Scale (mRS) score at 90 days. Secondary outcomes included excellent outcome (pediatric mRs 0-1), favorable outcome (pediatric mRs 0-2) and 90-day mortality. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were employed to address imbalances across groups. A meta-analysis integrating the currently available evidence was performed to systematically compare the two groups.

RESULTS

In this study, 64 patients with LVO were finally included in this analysis. After PSM, EVT was associated with increased odds of improved shift pediatric mRS scores (OR 3.20, 95% CI 1.03 to 9.97) and excellent outcome (OR 10.0, 95% CI 1.10 to 90.59). There was no significant difference in 90-day mortality between EVT and medical management groups (OR 1.70, 95% CI 0.10 to 28.43). Meta-analysis also demonstrated the superiority of EVT over medical treatment, showing better mRS shift at 90 days (OR 2.56, 95% CI 1.44 to 4.54), a high possibility of excellent outcome (OR 4.44, 95% CI 1.90 to 10.33) and favorable outcome (OR 2.16, 95% CI 1.15 to 4.05).

CONCLUSION

This matched-control study and meta-analysis showed that EVT was associated with better functional outcomes in pediatric patients with LVO. These findings support the use of EVT as a treatment approach for pediatric patients with LVO.

Endovascular thrombectomy for large ischemic strokes: meta-analysis of six multicenter randomized controlled trials

BACKGROUND

Six randomized controlled trials have concluded their investigations on the efficacy and safety of endovascular thrombectomy (EVT) for patients with large infarcts.To synthesize the results from six trials which met the inclusion criteria (RESCUE-Japan LIMIT, ANGEL-ASPECT, SELECT2, TESLA, TENSION, and LASTE) to provide high-level evidence and guide providers on optimizing EVT treatment decisions for patients presenting with large ischemic strokes seen on initial imaging.

METHODS

Study and patient characteristics of the six included trials were collected, and 90-day modified Rankin Scale (mRS) outcomes were tabulated. Generalized odds ratios (OR) of mRS score shift and utility-weighted mRS values were calculated for each study. Random-effects models were used to pool study outcomes.

RESULTS

922 patients received EVT, and 924 received medical management. Most patients had Alberta Stroke Program Early CT (ASPECT) scores of 3 to 5 and intracranial occlusion in the internal carotid artery (ICA) or the first segment of the middle cerebral artery (M1). EVT was significantly superior to medical management in terms of likelihood of better mRS score, functional independence (mRS score 0-2), and independent walking (mRS score 0-3) at 90 days, representing numbers needed to treat of 4.7 (95% CI 3.7 to 6.6), 7.1 (95% CI 5.6 to 9.6), and 10.6 (95% CI 8.2 to 14.8), respectively. EVT was not significantly associated with higher risk of symptomatic intracranial hemorrhage (1.7% (95% CI -0.32% to 3.72%), P=0.10). There was significant inter-study heterogeneity in mortality risk, which might have been due to differences in treatment time windows.

CONCLUSIONS

This study provides strong evidence that EVT is effective for patients presenting within 6 hours of stroke onset, ASPECT scores of 3 to 5, and intracranial ICA or proximal M1 occlusion. Use of EVT beyond 6 hours or for more distal occlusions requires further investigation.

Post-thrombectomy rehabilitation strategies and 90-day outcomes in acute ischemic stroke patients enrolled in randomized controlled trials: A systematic review and meta-analysis

BackgroundThe post-thrombectomy recovery phase has significant influence on long-term patient outcomes. Our study aims to explore the effect of post-thrombectomy rehabilitation strategies on modified Rankin Scale (mRS) at 90-day.MethodsA search of PubMed, Scopus, Web of Science, ClinicalTrials.gov, and the Cochrane Library from inception to April 2024. Randomized controlled trials (RCTs) were included and assessed for quality using the Cochrane risk of bias tool. The rehabilitation strategies were divided into three groups: as per institutional care, as per national guideline, or not specified. We performed meta-regression to identify the association between rehabilitation strategy used and 90-day outcome defined using mRS.Results23 RCTs were included with 6649 patients (mean age 67 and 26% of patients were men). Rehabilitation "as per institutional care" was the most common (52%, 95% confidence interval (CI):31%-72%), followed by "as per national guidelines" (17%, 95% CI:5%-39%). We found statistically significant variations in proportions of rehabilitation strategies (F(2,97) = 0.035, p = 0.01). A two-proportion z-test indicated a borderline significant difference between "as per institutional care" (52%) and "as per national guidelines" (17%) (χ2(1) = 3.52, p = 0.06). In meta-regression, rehabilitation strategies used in the RCT significantly influenced the proportion of patients enrolled in the RCT who achieved mRS 0-2 at 90 days post-thrombectomy (QM (df = 1) = 5.06, p = 0.025). Trials using rehabilitation "as per institutional care" (log odds ratio (OR) = 0.64, 95% CI [0.42, 0.87], p < 0.01) and those using rehabilitation "as per national guidelines" (log odds ratio = 0.58, 95% CI [0.07-1.08], p = 0.02) were associated with statistical significantly higher odds of having higher proportion of patients with mRS 0-2 at 90 days.ConclusionsThere is variation in rehabilitation strategies utilized post-thrombectomy which influences functional outcomes at 90 days. Rehabilitation protocols should be standardized in RCTs evaluating thrombectomy in acute ischemic stroke patients.

The NeVa stent-retriever - a single-centre real-world experience

Stent-retriever-based mechanical thrombectomy (MT) is an effective treatment for acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). First-pass effect (FPE) is one most powerful predictors of positive outcomes in LVO AIS patients treated with MT. We performed an independent central reader review of our prospectively maintained database to identify all patients treated first with the NeVa stent retriever at our single high-volume Comprehensive Stroke Centre.Overall, 89 patients met our inclusion criteria. The median age was 73 yrs (range 28-88; 52% male). The median presentation NIHSS was 16 (range 5-30) and 49% received IV tPA prior to MT. 93% of target occlusions were in the anterior circulation (n = 83) with a median ASPECT score on plain CT of 8 (range 5-10). A Balloon Guide Catheter (BGC) was used in 80% of cases and a distal aspiration catheter was used in all cases. Longer NeVa models (≥29 mm) were used in 89% of cases. FPE was demonstrated in 57% of cases (eTICI score of ≥2c) with modified FPE demonstrated in 65.1% of cases (eTICI score of ≥2b (67%)). A final eTICI score of ≥2c was achieved in 87% of cases. Good functional outcome (mRS ≤2) was achieved in 40% of patients (n = 81).The NeVa stent-retriever has a very high rate of FPE and final recanalization in this real-world cohort of patients from the NeVa One registry. These results are higher than those previously published and may support longer NeVa device use with a BGC and proximal aspiration to optimize FPE.

Mechanical Thrombectomy for Large Ischemic Stroke: A Critical Appraisal of Evidence From 6 Randomized Controlled Trials

Recently, 6 randomized trials evaluated the efficacy and safety of endovascular thrombectomy in patients with large core stroke. This review examines the differences in clinical and imaging eligibility and their impact on the interpretation of evidence and potential neuroimaging workflow. Pending results of a planned patient-level meta-analysis, it also evaluates clinical outcomes and thrombectomy treatment effect across those trials, overall and within selected clinical and imaging subgroups most relevant to clinical practice. Additionally, the implications of extending thrombectomy eligibility to patients with large core stroke on stroke systems of care and societal benefits are discussed.

Endovascular thrombectomy in late-window stroke: Do perfusion imaging and large infarcts really matter? A systematic review and meta-analysis of 10 randomized clinical trials

BACKGROUND

Several randomized trials have evaluated the benefits of endovascular thrombectomy (EVT) for anterior circulation large vessel occlusion strokes presenting beyond 6 hours of the last known well (LKW). We aimed to synthesize the results from these trials to provide high-level evidence regarding EVT treatment for patients presenting in the late window.

METHODS

A systematic search was conducted through four electronic databases, with no language restriction. Binary outcomes were analyzed using the risk ratio (RR) and 95 % confidence interval (CI), while continuous outcomes were analyzed using the standardized mean difference (SMD) and 95 % CI.

RESULTS

Out of 2824 patients from 10 trials comparing EVT plus BMT and BMT alone among patients with AIS who presented beyond 6 hours of LKW, 1871 patients (n = 981 EVT, n = 890 BMT) were included in the analysis. The results showed benefits toward the EVT than BMT alone in Modified Rankin Scale (mRS) 0-1 (RR= 1.84, 95 %CI= 1.4- 2.4), mRS 0-2 (RR= 2.3, 95 %CI= 1.5- 2.1), and mRS 0-3 (RR= 1.64, 95 %CI= 1.3- 1.63) at three months. No significant difference between EVT and BMT alone groups was found when analyzing either 90-day mortality or symptomatic intracranial hemorrhage. Subgroup analysis showed that there was no significant difference between patients with large core stroke and patients with non-large core stroke in 90-day mRS 0-2 (RR= 3.6 vs 2.37, P-value=0.26). Findings did not show significant difference between perfusion vs non-perfusion imaging modalities in 90-day mRS 0-2 and mortality.

CONCLUSION

These findings strengthen the previous evidence for the benefits of EVT over medical treatment in managing patients with stroke, even with large ischemic regions in the late time window.

Predictive role of a combined model for futile recanalization in acute ischemic stroke: a retrospective cohort study

Objective

There is a lack of data regarding patients with acute ischemic stroke caused by large vessel occlusions (LVOs) undergoing mechanical thrombectomy (MT) and their predictors of futile recanalization (FR). We sought to investigate the predictors of FR in patients with AIS-LVO undergoing mechanical thrombectomy.

Method

A retrospective analysis was conducted on 229 acute AIS patients who received MT, after eliminating the 31 patients not meet the requirements. The patients were categorized into the FR group and the useful recanalization (UR) group. Multivariate logistic regression analysis was used to explore the factors that influence FR after mechanical thrombectomy. ROC curve was used to plot the ability to predict FR after MT, and then the combined model was constructed and evaluate the predictive ability of this model to FR.

Results

198 patients who achieved successful recanalization were included in the analysis, of whom 124 experienced UR and 74 experienced FR. Patients with FR had higher Baseline NIHSS; they were more frequently on hypertension history and had longer door-to-puncture time (DPT) and door-to-recanalization time (DRT). Multivariable regression analysis showed that the hypertension history, Admission NIHSS, Admission DBP, Admission blood glucose, ischemic core, and DPT were associated with an increased probability of FR. The combined model was better than the models alone in predicting the risk of FR.

Conclusion

Admission blood pressure, admission NIHSS scores, admission DBP, ischemic core and DPT are independent risk factors for FR after MT in patients with AIS, and the combined model established by them has high predictive efficacy for FR risk after MT.

In Which Cases Is Additional Direct Surgery Useful for Mechanical Thrombectomy Failure?

Clinical evidence for adding direct surgery to the management of patients with large vessel occlusion after mechanical thrombectomy failure is limited. We investigated which patients would benefit from the additional surgery. We retrospectively examined factors influencing mechanical thrombectomy success and the outcomes of patients receiving additional direct surgery. Direct surgery was performed in patients younger than 75 years with modified Rankin Scale 0-2 and with Diffusion-Weighted Imaging-Clinical mismatch in the middle cerebral artery area on post-mechanical thrombectomy magnetic resonance imaging. To convert the hyperdense artery sign into an objective index, the ratio of the occluded to the normal vessel in Hounsfield Units was calculated (defined as the hyperdense artery sign ratio). A total of 152 patients were included in this study; the median patient age was 77.0 years; 13 patients (8.5%) had posterior circulation occlusion, and effective recanalization was confirmed in 124 patients (82.8%). Multivariable analysis showed the factors significantly associated with successful recanalization to be male gender (p = 0.0020) and a higher hyperdense artery sign ratio (p = 0.0012). The cut-off value of the hyperdense artery sign ratio was 1.05. Additional direct surgery was performed in 6 of 28 patients with mechanical thrombectomy failure. In 5 of these patients, recanalization was not successful even with direct embolectomy, and bypass was added. Patients who underwent direct surgery had better modified Rankin Scale scores at discharge than those who did not (p = 0.0405). The hyperdense artery sign ratio was a predictor of mechanical thrombectomy success; if the hyperdense artery sign ratio was less than 1.05, mechanical thrombectomy was often unsuccessful, and an early conversion to direct surgery was deemed beneficial.

Clinical impact of gradient echo MRI versus CT in detecting hemorrhagic transformation after mechanical thrombectomy

PURPOSE

Hemorrhagic transformation (HT) following mechanical thrombectomy (MT) is a critical concern in the management of ischemic stroke patients. While both CT and MRI are used to detect HT, the clinical implications of discrepancies between these modalities remain unclear. This study aims to investigate the clinical implications of discordant findings between gradient echo MRI and CT in detecting HT after MT.

METHODS

In this retrospective study, patients who underwent MT for ischemic stroke between 2016 and 2023 were analyzed. Patients were categorized into two groups based on imaging results: CT negative and MRI positive versus CT positive and MRI positive.

RESULTS

A total of 286 patients were included in the study, with 104 in the CT negative and MRI positive group and 182 in the CT positive and MRI positive group. More patients in the CT negative and MRI positive group were started on antithrombotic medications in less than 2 days compared to the patients in the CT positive and MRI positive group (47.3% vs. 34.5%; OR: 1.94, 95% CI: 0.88-4.27, p = 0.09) and still exhibited significantly higher rates of good functional outcomes (mRS 0-2) at discharge (OR: 3.27, 95% CI: 1.03-10.36, p = 0.04). Additionally, the CT negative and MRI positive group had a lower, though not statistically significant, likelihood of readmission for diagnosis of intracranial hemorrhage (ICH) within 30 days (0% vs. 2.7%, p = 0.16).

CONCLUSION

Gradient echo MRI can detect subtle hemorrhages not seen on CT, and both modalities offer complementary insights. In our cohort of MRI-positive patients, those with CT-negative findings had better functional outcomes and earlier antithrombotic resumption without increased risk of ICH readmission. These results suggest that in select scenarios, a negative CT may help inform safe antithrombotic management, though this does not diminish the diagnostic value of MRI. Further prospective studies are warranted to establish thresholds for MRI findings and refine clinical protocols post-MT.

Endovascular Treatment of Acute Large Vessel Occlusion in the Anterior and Posterior Circulation

Endovascular treatment (EVT) has been strongly recommended as a first-line treatment for acute ischemic strokes (AIS) caused by large vessel occlusion (LVO). To evaluate the efficacy, safety, and predictors of favorable outcomes of EVT for LVO-caused AIS in both the anterior and posterior circulations, consecutive patients who had undergone EVT for AISs caused by LVO were retrospectively enrolled, and the clinical data, symptomatic intracranial hemorrhage (sICH), modified Rankin Scale (mRS) score, and mortality at 90 days were analyzed. In total, 231 patients were enrolled with a mean age of 63.25 ± 11.48 years, including 167 (72.29%) patients with anterior circulation occlusion (ACO) and 64 (27.71%) patients with posterior circulation occlusion (PCO) treated with EVT. The median baseline National Institutes of Health Stroke Scale (NIHSS) Score on admission was 17 (12-20). The median time from symptom onset to recanalization (OTR) was 380 (307.5-461) minutes. Successful recanalization was achieved in 90.04% of patients. At 3-month follow-up, 118 (51.08%) patients had favorable clinical outcomes (mRS 0-2), with a mortality rate of 18.61% (43/231). Younger age (p = 0.001), a lower baseline NIHSS score (p < 0.001), a higher recanalization rate (p = 0.018), and shorter OTR time (p = 0.026) were significant independent risk factors for favorable outcomes. Compared to patients with ACO, PCO patients had a lower favorable outcome rate (p = 0.049) and a higher mortality rate (p < 0.001). In conclusion, EVT is safe and effective for patients with LVO-caused AIS, and younger age, lower baseline NIHSS scores, a higher recanalization rate, and shorter OTR time are independent risk factors for favorable outcomes. PCO patients may have worse clinical outcomes and a higher mortality rate than ACO patients.

Automated Emergent Large Vessel Occlusion Detection Using Viz.ai Software and Its Impact on Stroke Workflow Metrics and Patient Outcomes in Stroke Centers: A Systematic Review and Meta-analysis

The implementation of artificial intelligence (AI), particularly Viz.ai software in stroke care, has emerged as a promising tool to enhance the detection of large vessel occlusion (LVO) and to improve stroke workflow metrics and patient outcomes. The aim of this systematic review and meta-analysis is to evaluate the impact of Viz.ai on stroke workflow efficiency in hospitals and on patients' outcomes. Following the PRISMA guidelines, we conducted a comprehensive search on electronic databases, including PubMed, Web of Science, and Scopus databases, to obtain relevant studies until 25 October 2024. Our primary outcomes were door-to-groin puncture (DTG) time, CT scan-to-start of endovascular treatment (EVT) time, CT scan-to-recanalization time, and door-in-door-out time. Secondary outcomes included symptomatic intracranial hemorrhage (ICH), any ICH, mortality, mRS score < 2 at 90 days, and length of hospital stay. A total of 12 studies involving 15,595 patients were included in our analysis. The pooled analysis demonstrated that the implementation of the Viz.ai algorithm was associated with lesser CT scan to EVT time (SMD -0.71, 95% CI [-0.98, -0.44], p < 0.001) and DTG time (SMD -0.50, 95% CI [-0.66, -0.35], p < 0.001) as well as CT to recanalization time (SMD -0.55, 95% CI [-0.76, -0.33], p < 0.001). Additionally, patients in the post-AI group had significantly lower door-in door-out time than the pre-AI group (SMD -0.49, 95% CI [-0.71, -0.28], p < 0.001). Despite the workflow metrics improvement, our analysis did not reveal statistically significant differences in patient clinical outcomes (p > 0.05). Our results suggest that the integration of the Viz.ai platform in stroke care holds significant potential for reducing EVT delays in patients with LVO and optimizing stroke flow metrics in comprehensive stroke centers. Further studies are required to validate its efficacy in improving clinical outcomes in patients with LVO.

Advances in treatments for acute ischemic stroke

Acute ischemic stroke is a leading global cause of death and disability. Intravenous thrombolysis was the first acute treatment developed for ischemic strokes. First with alteplase and now with tenecteplase, intravenous thrombolysis has remained a cornerstone of acute ischemic stroke management. In large vessel occlusions, endovascular thrombectomy has become the standard of care in acute stroke management for anterior and posterior circulation strokes. The boundaries for these treatments have expanded, which has improved outcomes in patients who were previously ineligible. This review summarizes the latest advances in interventions for acute ischemic stroke, extending beyond existing guidelines and review articles to explore emerging strategies and treatments currently under investigation.

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Thrombectomy Selection in the Large Core Era: Implications for Regional Transfers

PURPOSE OF REVIEW

This review aims to evaluate recent advances in large core stroke management with a focus on diagnostic imaging protocols to select patients for endovascular therapy.

RECENT FINDINGS

Recent randomized controlled trials have shown that thrombectomy can lead to favorable outcomes in patients with large infarcts, contradicting previous assumptions that thrombectomy was not indicated in such patients due to higher risks and very low benefits. Although mechanical thrombectomy remains the gold standard of medical treatment for large vessel occlusions with demonstrated salvageable brain tissue, analysis of the results of recent randomized trials in patients with large ischemic stroke should help us expand patient selection, optimize timing, and explore different management modalities to improve the outcomes of therapy in these patients.

Interaction of brain imaging features and effects of intensive blood pressure lowering after endovascular treatment for acute ischaemic stroke: the pre-specified secondary analyses of ENCHANTED2/MT trial

Background

The second Enhanced Control of Hypertension and Thrombectomy Stroke Study (ENCHANTED2/MT) was terminated early when the intensive blood pressure lowering to a systolic level of 120 mm Hg or lower, compared to 140-180 mm Hg, was harmful in patients who received successful endovascular therapy for acute ischaemic stroke due to large-vessel occlusion. We aimed to determine the interaction of key brain imaging features and the effect of treatment on clinical outcomes.

Methods

ENCHANTED2/MT was a prospective, randomised, open-label, blinded-endpoint, controlled trial that aimed to assess the effectiveness of different intensities of blood pressure control on the functional independence in patients who had received successful endovascular therapy for acute ischaemic stroke from large-vessel occlusion at 44 hospitals in China between July 20, 2020 and March 7, 2022. In these pre-specified secondary analyses, neuroradiologists reviewed the baseline brain images of participants (computerised tomography [CT], CT with angiography [CTA] and digital subtraction angiography [DSA]) blind to treatment allocation, to determine the degree of cerebral infarction on the Alberta Stroke Program Early CT Score (ASPECTS), collateral status according to modified TAN score, and degree of reperfusion on the expanded Treatment In Cerebral Infarction (eTICI) scale. The primary outcome was functional independence, according to the distribution of scores on the modified Rankin scale (range 0 [no symptoms] to 6 [death]) at 90 days. Multivariable logistic regression analysis was done according to the modified intention-to-treat principle in all participants with available outcome data. ENCHANTED2/MT is registered with ClinicalTrials.gov, NCT04140110.

Findings

Of 816 participants in the trial, in whom 407 were assigned to more intensive blood pressure lowering and 409 were assigned to less intensive blood pressure lowering treatment, there were 533, 372, and 757 participants with available data for ASPECTS, collateral flow, and eTICI analyses, respectively. Intensive blood pressure lowering was associated with worse functional independence in participants with complete reperfusion (eTICI 3: adjusted odds ratio [aOR] 1.51, 95% CI 1.14-2.02) but not in those with incomplete reperfusion (eTICI 2b/c: aOR 1.29, 95% CI 0.73-2.28), without significant interaction (pinteraction = 0.82). There was no significant interaction between blood pressure treatment and ASPECTS (0-5 vs. 6-10: aOR 1.27, 95% CI 0.77-2.11 vs. aOR 1.37, 95% CI 0.91-2.07; pinteraction = 0.14) on functional independence. However, more intensive blood pressure lowering treatment was associated with worse functional independence in participants with poor collateral status (aOR 1.99, 95% CI 1.11-3.57) compared to those with good collateral status (aOR 0.87, 95% CI 0.53-1.45), with a moderate level of interaction (pinteraction = 0.037).

Interpretation

Our study indicates that collateral status may help identify patients at risk from intensive blood pressure lowering treatment to a systolic target of 120 mm Hg or lower, in patients undergoing endovascular therapy for acute ischaemic stroke from large-vessel occlusion.

Funding

The Shanghai Hospital Development Center; National Health and Medical Research Council of Australia; Medical Research Foundation (MRF) of the UK; AstraZeneca; China Stroke Prevention; Shanghai Changhai Hospital, Science and Technology Commission of Shanghai Municipality; Takeda China; Hasten Biopharmaceutic; Genesis Medtech; Penumbra.

Comparative effectiveness of intra-arterial thrombolysis vs. mechanical thrombectomy: a literature review

Background

Acute ischemic stroke (AIS) remains one of the leading causes of morbidity and mortality worldwide. Time is the single most critical factor in the management of patients presenting with AIS, where re-opening of occluded blood vessels is paramount. Intra-arterial thrombolysis (IAT) and mechanical thrombectomy (MT) are two such therapies employed to reestablish cerebrovascular blood flow in patients with AIS. This review compares both IAT and MT according to their efficacy, safety profiles, recanalization rates, clinical outcomes, and adverse procedural events.

Methods

Study abstraction from electronic search databases comprising PubMed/MEDLINE, ResearchGate, and the National Library of Medicine was used. Screening and selection of relevant articles were comprehensively conducted for this review. Direct comparisons between IAT and MT in terms of variables including recanalization rates, clinical outcomes, and adverse procedural events were warranted for study inclusion. Research determined to exhibit insufficient data or without comparable groups were subsequently excluded.

Results

MT was prompter when executing procedures than IAT, achieving greater rates of recanalization. Both interventions displayed similar results regarding rates of symptomatic intracranial hemorrhage (sICH) and mortality. Despite current available data indicating MT to demonstrate more efficiency as a procedure, further research is needed to examine IAT in light of specific patient demographics, clinical presentation, and circumstances.

Conclusion

This review elucidated that MT often takes less time peri-procedurally, achieving greater success in revascularization compared with that of IAT. Regarding mortality and sICH rates, IAT and MT comparison showed equivocal results. Thus, while making therapeutic decisions, it is important to consider the unique clinical features of each patient as well as the timing of interventions in order to maximize treatment outcomes.

Endovascular thrombectomy for large-core stroke: a meta-analysis with trial sequential analysis

Recent studies have reported that endovascular thrombectomy (ET) may improve neurological outcomes in large-core stroke.We performed a systematic review and meta-analysis to compare the pooled efficacy and safety of ET and of the best medical treatment among patients with large-core stroke.We searched the PubMed/MEDLINE, Scopus, and Cochrane databases from inception to November 2023. The inclusion criteria were randomized controlled trials (RCTs) comparing ET and the best medical treatment available among patients with large-core stroke (Alberta Stroke Program Early Computed Tomography Score [ASPECTS] < 6 or ischemic core > 50 mL on perfusion imaging) within 24 hours of symptom onset.We included 6 RTCs comprising 1,887 patients (ET group: n = 945). Endovascular thrombectomy was associated with good neurological outcomes (odds ratio [OR]: 2.92; 95% confidence interval [95%CI]: 2.17-3.93), or independent walking (OR: 2.22; 95%CI: 1.72-2.86). Trial sequential analysis confirmed a robust statistical significance for good neurological outcomes favoring ET. Endovascular thrombectomy was associated with higher risks of developing intracranial bleeding (OR: 2.65; 95%CI: 1.35-5.22) and symptomatic intracranial bleeding (OR: 1.83; 95%CI: 1.14-2.94). There were no differences between the groups regarding mortality or decompressive craniectomy. Patients submitted to non-contrast computed tomography (CT) with CT angiography (CTA) scans were analyzed separately and showed good neurological outcomes, comparable to those of the patients submitted to other imaging modalities (OR: 3.24; 95%CI: 1.52-6.92).Endovascular thrombectomy was associated with good neurological outcomes and independent walking in patients with large-core acute ischemic stroke. However, it was also associated with an increased risk of developing intracranial bleeding. Non-contrast head CT with CTA scans may be appropriate for screening patients to undergo ET.

Assessment of collaterals on multiphase CTA in stroke patients with a large vessel occlusion: an interrater and intrarater agreement study

PURPOSE

The assessment of collateral circulation is an important prognostic factor in patients with stroke due to large vessel occlusion. The results of a recent trial suggested that collateral status could even be used for thrombectomy decision making in patients with late window acute ischemic stroke. However, the reliability of collateral assessment is uncertain. We sought to assess the interrater and intrarater agreement of collateral assessment using multiphase CT angiography.

METHODS

Two junior and two senior raters in stroke neurology, diagnostic neuroradiology, and interventional neuroradiology evaluated 60 multiphase CT scans of acute ischemic stroke and scored the presence of collaterals as follows: poor (< 50% collaterals), moderate (≥ 50% but < 100% collaterals), and good (100% collaterals), using the contralateral hemisphere for reference. Agreement was assessed through Fleiss kappa scoring for the global scale and for various dichotomizations.

RESULTS

The overall interrater agreement for the assessment of collaterals on Multiphase CTA was moderate, with higher agreement found among diagnostic neuroradiologists. Dichotomizing the agreement scale into "poor/moderate vs. good" and "poor vs. moderate/good" greatly increased the interrater agreement among all specialties, especially in the latter scenario. Similarly, global intrarater agreement of CTA collateral images was determined to be moderate to substantial, with improvement after dichotomization.

CONCLUSION

Interrater and intrarater agreement for the global collateral scale was modest, with improvement after dichotomization. Our work suggests that this scale can be reliably used in clinical practice after dichotomization.

Post-procedural plasma D-dimer level may predict futile recanalization in stroke patients with endovascular treatment

OBJECTIVE

High d-dimer levels may increase the likelihood of unfavorable clinical outcomes in patients with acute ischemic stroke. However, the impacts of serum d-dimer levels on outcomes of reperfusion treatment in patients with acute ischemic stroke have not been evaluated. This study aims to assess a possible relationship between serum d-dimer and functional outcomes in stroke patients with endovascular treatment (EVT).

METHODS

Patients with acute ischemic stroke who underwent successful EVT were enrolled. Plasma d-dimer was measured before and within 6 h after endovascular procedures. Futile recanalization was defined as a modified Rankin Scale score of 3-6 at 90 days of stroke onset. Multivariable logistic regression analyses were performed to determine the relationships between d-dimer and futile recanalization.

RESULTS

Of the 161 enrolled patients, 78 (48.4 %) were classified as futile recanalization. After adjusting for potential confounders, high post-procedural d-dimer level was associated with futile recanalization (odds ratio, 1.25; 95 % CI, 1.05-1.51; P = 0.016). In patients with futile recanalization, change in serum d-dimer levels increased significantly after EVT (P < 0.001). Furthermore, change in d-dimer level after EVT was associated with futile recanalization (odds ratio, 1.33; 95 % CI, 1.11-1.65; P = 0.005) independently.

CONCLUSIONS

High post-procedural plasma d-dimer levels and a significant increase in d-dimer after EVT may predict futile recanalization in patients with acute ischemic stroke.

Automatic prediction of stroke treatment outcomes: latest advances and perspectives

Stroke is a major global health problem that causes mortality and morbidity. Predicting the outcomes of stroke intervention can facilitate clinical decision-making and improve patient care. Engaging and developing deep learning techniques can help to analyse large and diverse medical data, including brain scans, medical reports, and other sensor information, such as EEG, ECG, EMG, and so on. Despite the common data standardisation challenge within the medical image analysis domain, the future of deep learning in stroke outcome prediction lies in using multimodal information, including final infarct data, to achieve better prediction of long-term functional outcomes. This article provides a broad review of recent advances and applications of deep learning in the prediction of stroke outcomes, including (i) the data and models used, (ii) the prediction tasks and measures of success, (iii) the current challenges and limitations, and (iv) future directions and potential benefits. This comprehensive review aims to provide researchers, clinicians, and policy makers with an up-to-date understanding of this rapidly evolving and promising field.

Multiphase CTA vs. MRA collateral map for predicting functional outcomes after acute ischemic stroke

PURPOSE

To compare the prognostic abilities of multiphase CT angiography (mCTA) and multiphase MR angiography (MRA) collateral map in acute anterior circulation ischemic stroke.

METHODS

This secondary analysis of a prospective observational study included data from participants with acute ischemic stroke due to steno-occlusion of the internal carotid artery and/or middle cerebral artery within 8 h of symptom onset between January 1, 2016, and March 31, 2021. The intermethod agreement of the collateral scores (CSs) from mCTA and the collateral perfusion scores (CPSs) from the MRA collateral map was analyzed. Multiple logistic regression analyses were conducted to determine the prognostic value of mCTA and MRA collateral maps.

RESULTS

169 participants (106 men and 63 women, mean age 69 years ± 13) were included. The agreement between the CSs of mCTA and the CPSs of the MRA collateral map (weighted kappa = 0.44, 95% confidence interval [CI]: 0.37-0.52) of 168 participants was moderate. Younger age (Odds ratio [OR], 0.51; 95% CI, 0.34-0.76; p = 0.001), lower baseline NIHSS scores (OR, 0.89; 95% CI, 0.81-0.99; p = 0.024), CPS 4 (OR, 36.66; 95% CI, 1.79-750.29; p = 0.019) and CPS 5 (OR, 144.10; 95% CI, 1.11-18788.93; p = 0.046) on the MRA collateral map, and successful reperfusion (OR, 9.63; 95% CI, 3.00-30.94; p < 0.001) were independently associated with favorable functional outcomes.

CONCLUSIONS

Only the MRA collateral map demonstrated clinical prognostic value in acute anterior circulation ischemic stroke patients, demonstrating the superiority of the MRA collateral map over mCTA in collateral assessment.

Thrombectomy With Low ASPECTS: The Roles of Infarct Volume and Postacute Neurological Status

BACKGROUND

Recent randomized trials demonstrated the beneficial effect of endovascular therapy in patients with low Alberta Stroke Program Early CT Score. Despite large follow-up infarct volumes, a significantly increased rate of good functional outcomes was observed, challenging the role of infarct volume as a predictive imaging marker. This analysis evaluates the extent to which the effects of endovascular thrombectomy on functional outcomes are explained by (1) follow-up infarct volume and (2) early neurological status in patients with stroke with low Alberta Stroke Program Early CT Score.

METHODS

TENSION (Efficacy and Safety of Thrombectomy in Stroke With Extended Lesion and Extended Time Window) was a randomized trial conducted from February 2018 to January 2023 across 41 stroke centers. Two hundred fifty-three patients with ischemic stroke due to anterior circulation large vessel occlusion and Alberta Stroke Program Early CT Score of 3 to 5 were randomized to endovascular thrombectomy plus medical treatment or medical treatment alone. All patients with the availability of relevant data points were included in this secondary as-treated analysis. The primary outcome was the 90-day modified Rankin Scale score. Confounder-adjusted mediation analysis was performed to quantify the proportion of the treatment effect on a 90-day modified Rankin Scale score explained by (1) 24-hour follow-up infarct volume and (2) 24-hour National Institutes of Health Stroke Scale scores.

RESULTS

One hundred eighty-eight patients were included; thereof, 87 (46%) were female patients. Median age was 72 (interquartile range, 63-79) years. The endovascular thrombectomy cohort had a 20.5 (95% CI, 8.3-33.7) percentage points higher probability of achieving independent ambulation (modified Rankin Scale, 0-3) and a 24.2 (95% CI, 13.4-35.8) percentage points lower mortality at 90 days compared with medical treatment alone. The reduction in 24-hour follow-up infarct volume explained 30% of the treatment effect on functional outcomes, while the 24-hour National Institutes of Health Stroke Scale score explained 61%.

CONCLUSIONS

In patients with low Alberta Stroke Program Early CT Score, infarct volume demonstrated limited explanatory power for functional outcomes compared with the early neurological status, which may more effectively reflect factors such as the involvement of specific brain regions, disruption of structural networks, and selective neuronal loss.

Optimal Systolic Blood Pressure Control After Thrombectomy in Acute Ischemic Stroke: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVES

The optimal systolic blood pressure (SBP) control after endovascular thrombectomy (EVT) is unclear. This study aimed to determine whether intensive SBP control (<140 mmHg) within 24 h post-EVT, compared to conventional management (<180 mmHg), leads to a better functional outcome, defined as a modified Rankin Scale (mRS) score of 0-2 at 90 days.

METHODS

Following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, we searched databases (PubMed, Scopus, EMBASE, Google Scholar, Web of Science) for English language articles up to March 15, 2024. We included randomized controlled trials (RCTs) and observational studies comparing intensive versus conventional SBP control up to 24 h post-EVT. Studies without separate primary outcome data and case series/reports were excluded. The primary outcome was functional independence (mRS 0-2 at 90 days).

RESULTS

Twelve studies (n = 5152 patients; five RCTs and seven observational studies) were included, and a primary analysis of the RCTs, along with a secondary exploratory analysis of the observational studies were conducted. The analysis of RCTs favored conventional control for the primary outcome (risk ratio [RR]- 0.81; 95% confidence interval [CI]- 0.73-0.90; P < 0.0001). Mortality rates (RR- 1.14, 95% CI- 0.89-1.45; P = 0.29) and the risk of symptomatic intracranial hemorrhage (RR- 1.10, 95% CI- 0.77-1.58; P = 0.60) were similar in both groups. The secondary exploratory analysis of observational data favored the intensive arm for the primary outcome (RR- 1.28, 95% CI- 1.17-1.41; P < 0.00001).

CONCLUSIONS

Our primary analysis of RCTs showed that intensive control was associated with poorer functional outcomes, with no significant impact on mortality rate or the risk of symptomatic intracranial hemorrhage. Although observational studies suggested better outcomes with intensive control, we recommend conventional management based on Level 1 evidence from RCTs.PROSPERO Registration no - CRD42023463173.

Age-Specific Differences in Inflammatory Biomarkers and Their Impact on Futile Recanalization After Mechanical Thrombectomy: An Inverse Probability Weighting Analysis

BACKGROUND

Mechanical thrombectomy (MT) is the standard treatment for large vessel occlusion (LVO) stroke. However, a substantial proportion of patients experience poor functional outcomes despite successful reperfusion, namely futile recanalization (FR). This study aimed to evaluate the predictive value of inflammatory biomarkers, measured on admission and at 24 h, in identifying the risk of FR and to assess age-specific differences influencing this outcome.

METHODS

This international, multicenter, observational study included patients with anterior circulation LVO stroke treated with MT. Strict inclusion criteria were applied to minimize confounding factors related to inflammation. Inflammatory biomarkers were assessed at admission and 24 h post-procedure. Inverse probability weighting (IPW) was utilized to balance baseline characteristics between patients with FR and effective recanalization (ER). Least absolute shrinkage and selection operator (LASSO) regression was applied to identify independent predictors, and restricted cubic splines were used to determine optimal biomarker cut-offs.

RESULTS

Among 885 patients, 470 (53%) experienced FR. In multivariate analysis, 24-h CRP (OR 1.01, 95% CI 1.01-1.02, p = 0.018) and 24-h NLR (OR 1.11, 95% CI 1.02-1.22, p = 0.019) were significant predictors of FR, with cut-offs of 8.55 and 4.58, respectively. In patients aged < 80 years, 24-h CRP and NLR were most predictive (cut-offs: 17.09 and 5.59). In patients aged ≥ 80 years, admission SIRI emerged as the most significant predictor (OR 1.24, 95% CI 1.06-1.50, p = 0.015), with an optimal cut-off value of 2.53.

CONCLUSIONS

Inflammatory biomarkers exhibit significant predictive value for FR following MT, with distinct age-specific patterns. These findings underscore the importance of tailoring predictive models and interventions to optimize clinical outcomes.

Impact of Reperfusion Quality and Pass Number on Functional Outcomes in Acute Ischemic Stroke Patients Undergoing Mechanical Thrombectomy

OBJECTIVE

To compare functional outcomes between patients achieving good reperfusion (eTICI 2B) after a single pass and those requiring multiple passes to achieve excellent or complete reperfusion (eTICI 2C/3) in acute ischemic stroke (AIS) patients undergoing mechanical thrombectomy (MT).

METHODS

This single-center retrospective cohort study included 301 AIS patients with large vessel occlusion who underwent MT between January 2018 and December 2022. Patients were categorized into single-pass eTICI 2B (n = 65) and multiple-pass eTICI 2C/3 (2-5 passes, n = 214; >5 passes, n = 22). Functional outcomes were assessed at 90 days using the modified Rankin Scale. Early neurological deterioration, adverse events, and safety outcomes were also analyzed.

RESULTS

No significant difference was observed in a 90-day functional independence between single-pass eTICI 2B and multiple-pass eTICI 2C/3 (47.7% vs. 41.5%, P = 0.39 for 2-5 passes; 27.3% vs. 41.5%, P = 0.24 for >5 passes). However, patients requiring more than 5 passes to achieve eTICI 2C/3 had significantly higher rates of early neurological deterioration (40.9% vs. 18.5%, P = 0.04) and adverse events (63.6% vs. 38.5%, P = 0.04). Mortality rates were similar between groups.

CONCLUSIONS

Our study suggests that achieving eTICI 2C/3 through multiple passes does not result in improved functional outcomes compared to single-pass eTICI 2B. Moreover, extended thrombectomy procedures may increase the risk of early neurological deterioration and adverse events, highlighting the need for careful procedural strategy in MT for AIS patients.

Non-routine thrombectomy in pediatric arterial ischemic stroke

PURPOSE

Unlike in adults, the indications and techniques for mechanical thrombectomy for arterial ischemic stroke (AIS) in children are not clearly established. The medical and interventional management of children with acute large vessel occlusion may entail the modification of the standardized management of this condition in adults. We present six cases of children who underwent non-routine thrombectomy for AIS.

METHODS

We retrospectively reviewed the records of children diagnosed with AIS between 2015 and 2023 and evaluated patient characteristics, procedural technical data, and final clinical outcomes. Procedures deviating from the current definition and indications for AIS treatment in adults as well as previously reported pediatric thrombectomy cases were defined as non-routine thrombectomy.

RESULTS

Seven non-routine thrombectomy procedures in six children were included in the study. The National Institutes of Health Stroke Scale scores on admission ranged from 4 to 35; no procedure-related mortality or major neurologic morbidity occurred. One child died of causes related to the initial severe heart failure and stroke; otherwise, all the children had a modified Rankin scale score of 0 to 1 at follow-up. Unique clinical and procedural features in our case series included presentation with acute stent occlusion (two children), bilateral simultaneous internal carotid artery occlusions associated with a unilateral tandem middle cerebral artery (MCA) occlusion (one child), MCA occlusion caused by thromboembolism of the atrial myxoma (one child), and very distal (one child) or delayed thrombectomy (two children).

CONCLUSION

Modifications to the standard medical and interventional algorithms may be required for mechanical thrombectomy in children.

CLINICAL SIGNIFICANCE

Referral centers specialized in pediatric neurology, pediatric anesthesia, and pediatric intervention are optimal for treating children using mechanical thrombectomy and for modifying the treatment, if required.

The Association of Cerebral Blood Flow Measured Using Extracranial Carotid Ultrasound with Functional Outcomes in Patients with Anterior Circulation Large Vessel Occlusion After Endovascular Thrombectomy-A Retrospective Study

Background: Endovascular mechanical thrombectomy (EVT) is regarded as the standard treatment for acute ischemic stroke with large vessel occlusion. Few studies have examined the evolution of cerebral flow after the acute stage of ischemic stroke. In this study, we examined the association of functional outcomes with cerebral blood flow by extracranial carotid sonography during the subacute phase after EVT and multiple prognostic variables. Methods: We conducted a single-center, retrospective, observational study between January 2018 and June 2023. Patients with acute stroke resulting from anterior circulation large vessel occlusion who underwent EVT were included. All patients underwent carotid sonography in the second week after EVT. Patients with fair (modified Rankin Scale [mRS]: 0-3) and poor outcomes (mRS: 4-6) were compared to determine the association between and identify the predictors of these factors and functional outcomes. Results: A total of 89 patients were included (female: 38 (42.7%); mean age: 69.45 ± 13.59 years). Multivariable logistic regression analysis revealed that three factors were independent predictors of fair outcomes: (1) the Alberta Stroke Program Early CT Score (odds ratio [OR]: 1.79; 95% confidence interval [CI]: 1.16-2.78; p = 0.009); (2) Thrombolysis in Cerebral Infarction 2b to 3 (OR: 4.91; 95%CI: 1.10-21.89; p = 0.037); (3) the ratio of treatment-side blood flow between the internal carotid artery and common carotid artery (QTI/QTC, OR: 45.35; 95% CI: 1.11-1847.51; p = 0.04). Conclusions: The ratio of QTI/QTC is a clinically relevant parameter as a potential predictor of favorable outcomes. This parameter can be used to formulate patient prognostic scores and help clinicians determine whether adequate cerebral perfusion is maintained during the subacute phase.

Mechanical thrombectomy failure in anterior circulation large vessel occlusion: an overview from the ROSSETTI registry

BACKGROUND

Although mechanical thrombectomy (MT) is an effective treatment for large vessel occlusion (LVO) with a high successful recanalization rate, MT failure (MTF) occurs in 10-15% of cases and is associated with unfavorable outcomes. However, little is known about the clinical, technical, and radiological reasons for MTF. We investigated the technical factors associated with MTF.

METHODS

We conducted a retrospective analysis of consecutive patients with anterior LVO prospectively included in the ongoing observational multicenter ROSSETTI registry. Patients were categorized according to the success (≥mTICI 2b) or failure (

RESULTS

We analyzed 4135 patients, including 325 patients (7.9%) with MTF. Patients in the MTF group had a significantly lower Alberta Stroke Program Early CT Score (ASPECTS) at baseline (8 (7-10) vs 9 (8-10)), longer time since last time seen well (279 min vs 262 min), increased MT procedure time (76 min vs 31 min), higher rate of complications (23% vs 4%), higher symptomatic intracerebral hemorrhage (21% vs 7.9%), higher 24 hour National Institutes of Health Stroke Scale score (19 vs 6), worse functional outcome at 3 months (modified Rankin Scale score 0-2, 15.6% vs 53%), and higher mortality (45% vs 20%). Four or more passes were an independent predictor of MTF (OR 3.46, 95% CI 2.58 to 4.63; P<0.001). None of the endovascular techniques demonstrated a higher likelihood of MTF.

CONCLUSION

In this study, MTF in anterior circulation LVO was associated with a high complication rate and worse outcomes.

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Key Words

• Brain
• Device
• Intervention
• Stroke
• Technique

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Affiliation(s)

Lluis Morales-Caba Interventional Neurorradiology, La Fe University and Polytechnic Hospital, Valencia, Spain
Josep Puig Radiology Department CDI and IDIBAPS, Hospital Clinic de Barcelona, Barcelona, Spain
Juan Manuel Sanchís Neuroradiology Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
Víctor Vázquez La Fe University and Polytechnic Hospital, Valencia, Spain
Mariano Werner Department of Radiology, Hospital Clinic de Barcelona, Barcelona, Spain
Guillem Dolz Neurointerventional Department CDI, Hospital Clinic de Barcelona, Barcelona, Spain
Marc Comas-Cufí Department of Computer Science, Applied Mathematics and Statistics, University of Girona, Girona, Spain
Pepus Daunis-I-Estadella Department of Computer Science, Applied Mathematics and Statistics, University of Girona, Girona, Spain
Pedro Vega Radiology, Hospital Universitario Central de Asturias, Oviedo, Spain
Eduardo Murias Radiology, Hospital Universitario Central de Asturias, Oviedo, Spain
Eva González Interventional Neuroradiology. Radiology, Hospital Universitario Cruces, Bilbao, Spain
Xabier Manso Interventional Neuroradiology. Radiology, Hospital Universitario Cruces, Bilbao, Spain
Fernando Delgado Diagnostic and Therapeutical Neuroradiology Unit, Hospital Reina Sofía, Córdoba, Spain
Carlos Martínez Neurorradiology, Hospital Universitario Reina Sofia, Cordoba, Spain
Carlos Pérez-García Interventional Neuroradiology, Hospital Clinico Universitario San Carlos, Madrid, Spain
Santiago Rosati Department of Radiology, Clinical San Carlos Hospital, Section of Interventional Neuroradiology, Madrid, Spain
Sebastian Remollo Interventional Neuroradiology Unit, Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Badalona, Spain Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
Carlos Castaño Interventional Neuroradiology Unit, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
Isabel Vielba-Gómez Stroke Unit, Department of Neurology, Hospital Universitario de Girona Doctor Josep Trueta, Girona, Spain
Tomàs Xuclà Stroke Unit, Department of Neurology, Hospital Universitario de Girona Doctor Josep Trueta, Girona, Spain
Lucia Aja Neuroradiology, Hospital Universitari de Bellvitge, Barcelona, Spain
Javier Martínez-Fernández Department of Radiology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
Yeray Aguilar Tejedor Radiology Department, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
Jose Carlos Mendez Interventional Neuroradiology Unit, Radiology, Hospital Ramón y Cajal, Madrid, Spain
José Carlos Rayón-Aledo Interventional Neuroradiology, Alicante General University Hospital, Alicante, Valenciana, Spain
Guillermo Parrilla Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
Víctor Cuba Radiology, Bellvitge University Hospital, Barcelona, Spain Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
Luis Hernán Vargas Department of Interventional Neuroradiology, Hospital Universitario de Salamanca, Salamanca, Spain
Antonio Doncel-Moriano Cubero Stroke Unit, Neurology, Hospital Clinic de Barcelona, Barcelona, Spain
Luis San Roman Neurointerventional Department CDI, Hospital Clinic de Barcelona, Barcelona, Spain
Jordi Blasco Neurointerventional Department CDI, Hospital Clinic de Barcelona, Barcelona, Spain
Fernando Aparici-Robles Sección Neurorradiología, Area Clinica, Imagen Médica, Hospital Politécnico y Universitario La Fe, Valencia, Spain

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Impact of socioeconomic deprivation on mechanical thrombectomy outcomes after acute ischaemic stroke: findings from a London-based multicentre study

BACKGROUND

Mechanical thrombectomy (MT) improves outcomes in patients who had an acute ischaemic stroke due to large vessel occlusion (LVO). However, socioeconomic status (SES) can influence recovery and prognosis. This study investigated the effect of SES, assessed via the Index of Multiple Deprivation (IMD), on MT outcomes in a multicentre London cohort.

METHODS

This retrospective study included patients with anterior circulation LVO treated with MT between 2021 and 2023 at three London hospitals. Patients were grouped into IMD1-5 (more deprived) and IMD6-10 (less deprived). Inverse probability weighting balanced baseline characteristics. Primary outcomes were 90-day functional independence (modified Rankin Scale (mRS) 0-2) and 90-day mRS shift. Secondary outcomes included recanalisation, early neurological changes, 90-day mortality, symptomatic intracerebral haemorrhage (sICH) and haemorrhagic transformation (HT). Subgroup analyses explored interactions between IMD and demographic or clinical factors. LASSO (Least Absolute Shrinkage and Selection Operator) regression identified predictors of functional independence, while receiver operating characteristic analysis evaluated IMD's predictive value.

RESULTS

Among 1219 patients with acute LVO ischemic stroke treated with MT, 533 (43.7%) were in IMD1-5 and 686 (56.3%) in IMD6-10. IMD1-5 patients had lower odds of functional independence at 90 days (RR 0.79, 95% CI 0.70 to 0.90) and worse mRS shift (OR 1.29, 95% CI 1.06 to 1.58). They also had higher risks of sICH (RR 2.07, 95% CI 1.54 to 2.67) and HT (Risk Ratio 1.47, 95% CI 1.21 to 1.80). Subgroup analysis highlighted IMD's predictive importance in Asian or mixed ethnicity groups. A model incorporating IMD, age, sex, hypertension and National Institutes of Health Stroke Scale (area under the curve 0.656) demonstrated predictive accuracy for 90-day functional independence.

CONCLUSIONS

Lower SES correlates with worse outcomes and higher complications post-MT, even within a universal healthcare system. Addressing SES disparities could improve stroke care equity.

Factors of Difficult Guiding Catheter Access in Mechanical Thrombectomy for Acute Ischemic Stroke in the Anterior Circulation

Objective

Insertion of a guiding catheter (GC) system into the desired arterial site is crucial in mechanical thrombectomy (MT). This study assessed the factors of difficult GC access to the target carotid artery in patients with acute ischemic stroke in the anterior circulation.

Methods

In total, 174 patients who had undergone MT were retrospectively reviewed. The incidence of patients who could not undergo GC insertion to the target carotid artery, as well as the characteristics and outcomes of patients requiring a longer groin puncture-to-GC insertion time, were examined. The patients were divided into 3 groups based on the time from groin puncture to insertion into the target carotid artery: group A, within 10 min; group B, within 10-20 min; and group C, >20 min. In this study, the transfemoral catheter access was the primary option, and the approach site was changed based on the operator's discretion. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction grade ≥2B. A favorable outcome was defined as a modified Rankin Scale score of 0-2.

Results

Catheterization of the target carotid artery could not be performed in 8 (4.6%) patients, who were older and more likely to be female. The proportion of patients with a height ≤150 cm and the percentage of patients with a type III arch and/or tortuous common carotid artery (CCA) were high. The approach was changed in 4 (2.3%) patients, and GC insertion was successful in all cases. A significant difference was observed among the 3 groups in terms of age and the percentage of patients with a type III arch and/or CCA tortuosity and internal carotid artery occlusion. In addition, the time from groin puncture to recanalization significantly differed. The recanalization rate and the 90-day favorable outcome rate were significantly lower in patients with a groin puncture-to-GC insertion time >20 min.

Conclusion

We need to make an effort to insert the GC within 20 min while actively considering changes in the approach, particularly in older patients and those with a type III arch and/or tortuous CCA.

Outcomes of patients with heart failure after thrombectomy for ischemic stroke: A systematic review and meta-analysis

BackgroundMechanical thrombectomy (MT) is an effective treatment for acute ischemic stroke, but its outcomes in patients with heart failure (HF) are uncertain. Some studies suggest worse outcomes in these patients, while others show no significant differences in mortality or functional recovery.MethodsWe systematically searched the MEDLINE, Embase, and Cochrane databases until August 2024. Studies were included if they compared patients with HF to those without. All statistical analyses were carried out using R, version 4.1.1. A subanalysis examined outcomes in HF patients with reduced left ventricular ejection fraction (LVEF).ResultsWe included 3587 patients, of which 1187 (33.1%) were in the HF group. We found a significantly higher mortality (RR 2.01; 95% CI: 1.33-3.03; p < 0.01) and lower risk of favorable neurologic outcome (RR 0.76; 95% CI: 0.67-0.86; p < 0.01) at 90 days on HF group, without a notable difference in the occurrence of symptomatic intracranial hemorrhage (sICH) (RR 1.57; 95% CI: 0.98-2.51; p = 0.06) or recanalization success (RR 1.02; 95% CI: 0.98-1.07; p = 0.28). HF patients with reduced LVEF also showed higher mortality (RR 1.91; 95% CI: 1.05-3.49; p = 0.03) and worse functional outcomes (RR 0.83; 95% CI: 0.72-0.95; p < 0.01) compared to those without HF.ConclusionsHF patients undergoing MT for ischemic stroke may have worse functional outcomes and higher mortality at 90 days compared to non-HF patients despite similar rates of sICH and recanalization success. Our findings suggest that patients with HF may have a worse prognosis compared to those without HF following MT for ischemic stroke.

Scaling up thrombectomy care in transitioning health systems: a qualitative study of stroke centres in Canada

INTRODUCTION

Endovascular thrombectomy has shown significant benefits for patients with large-vessel ischaemic stroke. However, many countries face challenges establishing effective thrombectomy delivery systems, even when thrombolysis services are already in place. Moreover, there is limited research on implementing thrombectomy care delivery, particularly for scale-ups in low- and middle-income countries. This study identifies the key drivers of enhancing thrombectomy delivery systems in three Canadian regions and provides lessons for health systems in transition.

METHODS

A qualitative research design with a phenomenological approach was employed. From January to December 2022, at three comprehensive ischaemic stroke centres in Canada, we involved non-participant observation and in-depth interviews with 91 key informants, including care providers and administrators engaged in large-vessel stroke care. Guided by the Behaviour Change Wheel and Theoretical Domains Framework, the data were transcribed and analysed using thematic content analysis.

RESULTS

Three critical themes emerged. First, establishing a cohesive, goal-oriented, multidisciplinary patient care team with an egalitarian culture is vital. Second, integrating specific feedback data is essential for continuous quality improvement and for optimising workflow through collective leadership. Lastly, even with existing thrombolytic services, centralised regional planning and outreach to local thrombectomy implementers is necessary. Development must occur at stroke centres and their associated peripheral hospitals to build effective thrombectomy care delivery systems.

CONCLUSIONS

Enhancing thrombectomy care delivery systems requires a stepwise approach: first, establishing multidisciplinary teams at the micro-level; next, fostering collective leadership for continuous quality improvement at the meso-level and finally, coordinating regional outreach and centralised planning at the macro-level. The Canadian experience highlights the importance of addressing these interconnected levels and underscores the critical role of central planning and collaboration between policymakers and care providers. These strategies offer a structured pathway for improving stroke care globally, particularly in transitioning health systems.

Efects of Y-6 Sblingual Tablets for Paients with Acte Ischemic Stok (FUTURE): a phase II, randomised, double-blind, double-dummy, placebo-controlled, parallel trial

BACKGROUND

Acute ischaemic stroke, due to its high mortality and disability rates, imposes a significant economic and social burden worldwide. Typically, endovascular treatment within the therapeutic window is provided to salvage the ischaemic penumbra; however, even when recanalisation is successful during endovascular treatment, the clinical outcomes may still be disappointing. This highlights the necessity of further research, so as to discover better solutions to futile recanalisation and improve patient outcomes.

OBJECTIVE

To investigate the efficacy and safety of Y-6 sublingual tablets (cilostazol and dexborneol) compared with a placebo in the treatment of patients with acute ischaemic stroke caused by large vessel occlusion.

METHOD

The efficacy and safety of Y-6 sublingual tablets in patients with acute ischaemic stroke are evaluated in a phase II, randomised, double-blind, double-dummy, placebo-controlled, parallel clinical trial. Eligible patients having provided informed consent are randomised into five groups for a 28-day treatment period. The primary outcome is the percentage of patients achieving the modified Rankin Scale score of 0-1 at 90 days.

DISCUSSION

The EFfects of Y-6 SUblingual Tablets for PaTients with AcUte Ischemic StRokE trial assesses whether Y-6 sublingual tablets are effective and safe in improving the clinical outcomes of patients with acute ischaemic stroke caused by large vessel occlusion.

TRIAL REGISTRATION NUMBER

NCT06138834.

Quantitative Ischemic Lesions of Portable Low-Field Strength MRI Using Deep Learning-Based Super-Resolution

BACKGROUND

Deep learning-based synthetic super-resolution magnetic resonance imaging (SynthMRI) may improve the quantitative lesion performance of portable low-field strength magnetic resonance imaging (LF-MRI). The aim of this study is to evaluate whether SynthMRI improves the diagnostic performance of LF-MRI in assessing ischemic lesions.

METHODS

We retrospectively included 178 stroke patients and 104 healthy controls with both LF-MRI and high-field strength magnetic resonance imaging (HF-MRI) examinations. Using HF-MRI as the ground truth, the deep learning-based super-resolution framework (SCUNet) was pretrained using large-scale open-source data sets to generate SynthMRI images from LF-MRI images. Participants were split into a training set (64.2%) to fine-tune the pretrained SCUNet, and a testing set (35.8%) to evaluate the performance of SynthMRI. Sensitivity and specificity of LF-MRI and SynthMRI were assessed. Agreement with HF-MRI for Alberta Stroke Program Early Computed Tomography Score in the anterior and posterior circulation (diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography Score and diffusion-weighted imaging-posterior circulation Alberta Stroke Program Early Computed Tomography Score) was evaluated using intraclass correlation coefficients (ICCs). Agreement with HF-MRI for lesion volume and mean apparent diffusion coefficient (ADC) within lesions was assessed using both ICCs and Pearson correlation coefficients.

RESULTS

SynthMRI demonstrated significantly higher sensitivity and specificity than LF-MRI (89.0% [83.3%-94.6%] versus 77.1% [69.5%-84.7%]; P<0.001 and 91.3% [84.7%-98.0%] versus 71.0% [60.3%-81.7%]; P<0.001, respectively). The ICCs of diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography Score between SynthMRI and HF-MRI were also better than that between LF-MRI and HF-MRI (0.952 [0.920-0.972] versus 0.797 [0.678-0.876], P<0.001). For lesion volume and mean apparent diffusion coefficient within lesions, SynthMRI showed significantly higher agreement (P<0.001) with HF-MRI (ICC>0.85, r>0.78) than LF-MRI (ICC>0.45, r>0.35). Furthermore, for lesions during various poststroke phases, SynthMRI exhibited significantly higher agreement with HF-MRI than LF-MRI during the early hyperacute and subacute phases.

CONCLUSIONS

SynthMRI demonstrates high agreement with HF-MRI in detecting and quantifying ischemic lesions and is better than LF-MRI, particularly for lesions during the early hyperacute and subacute phases.