Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in 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.

Refining the Tmax malignant profile in large ischemic core patients receiving endovascular treatment

BACKGROUND AND PURPOSE

A significant proportion of patients with large ischemic core volume (LICV) have poor outcome despite successful recanalization. We aimed to assess the optimal cutoff for hypoperfusion volume, defined as Tmax > 6-seconds lesion size, to identify a malignant profile in LICV patients and predict poor functional outcome after endovascular treatment (EVT).

MATERIALS AND METHODS

Sixty-six consecutive LICV with multimodal CT study protocol within 24 h from onset. A receiver operating characteristic curve analysis was used to identify the optimal Tmax > 6-seconds lesion volume cutoff to define a malignant profile. Logistic regression was used to evaluate the predictive value of malignant profile for poor functional outcome (defined as modified Rankin Scale 4-6 at 3 months).

RESULTS

Tmax > 6-seconds volume had good discriminative ability for poor clinical outcome (AUC 0.85; 95 % CI 0.74-0.92). The best cut-off value for poor outcome was ≥160 mL (84 % sensitivity, 85 % specificity, 89 % positive predictive value, 80 % negative predictive value) and represented our definition of malignant profile. Among the 66 included patients, 39 (59 %) had poor functional outcome, of whom 29 (74.3 %) showed a malignant profile. The presence of malignant profile (OR = 9.11, 95 %CI = 2.78-29.80) and unsuccessful recanalization status (OR = 3.51, 95 %CI = 1.01-12.72) were independently associated with poor functional outcome in LICV patients. Patients with malignant profile showed higher hemorrhagic transformation (p = 0.026) and mortality (p = 0.013) rates compared to patients without malignant profile.

CONCLUSIONS

Tmax > 6-seconds lesion volume ≥160 mL identified the malignant profile and predicts unfavorable outcome in LICV patients undergoing EVT within 24-hours from stroke onset.

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.

Innovating stroke care: A performance study of the ALGO smart pump in smart static mode

INTRODUCTION

While revascularization rates have improved for mechanical thrombectomy (MT) in acute ischemic stroke, advancements in aspiration pumps have been limited. The ALGO Smart Pump (Von Vascular, Sunrise, FL) is a small on-field, operator-driven pump offering two aspiration modes: Adaptive Pulsatile Aspiration (APA™) Mode and a continuous 'Static' mode. This study evaluates the performance of the ALGO Smart Pump's Static Mode compared to a commercially available aspiration pump.

METHODS

Operators performed aspiration thrombectomy in a flow model with ALGO and the Penumbra ENGINE (Penumbra, Alameda, CA) using medium (ID.036-.057") to large (ID.068-.071) bore aspiration catheters. Primary endpoint was complete clot ingestion (CCI), defined as the full ingestion of the clot within the catheter or pump's canister, without any clot at the catheter tip or evidence of embolization to new territories (ENT). Secondary endpoints included first pass recanalization, ENT and total aspiration time.

RESULTS

When comparing all catheters, ALGO Smart Pump achieved CCI in 154 of 180 thrombectomies (85.6 %) compared to Penumbra ENGINE achieving CCI in 136 of 180 thrombectomies (75.6 %). The CCI rate between pump types across all catheters was statistically significant (p = 0.008), favoring ALGO pump. There was no difference between pump type on aspiration time.

CONCLUSION

The ALGO Smart Pump may represent an alternative in MT, with potential higher effectiveness compared to existing available aspiration pumps with additional user-friendly benefits including a sterile, smaller, on-field apparatus.

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.

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.

Effect of metabolic disorders on reactive gliosis and glial scarring at the early subacute phase of stroke in a mouse model of diabetes and obesity

It is well recognized that type II Diabetes (T2D) and overweight/obesity are established risk factors for stroke, worsening also their consequences. However, the underlying mechanisms by which these disorders aggravate outcomes are not yet clear limiting the therapeutic opportunities. To fill this gap, we characterized, for the first time, the effects of T2D and obesity on the brain repair mechanisms occurring 7 days after stroke, notably glial scarring. In the present study, by performing a 30-minute middle cerebral artery occlusion (MCAO) on db/db (obese diabetics mice) and db/+ (controls) mice, we demonstrated that obese and diabetic mice displayed larger lesions (i.e. increased infarct volume, ischemic core, apoptotic cell number) and worsened neurological outcomes compared to their control littermates. We then investigated the formation of the glial scar in control and db/db mice 7 days post-stroke. Our observations argue in favor of a stronger and more persistent activation of astrocytes and microglia in db/db mice. Furthermore, an increased deposition of extracellular matrix (ECM) was observed in db/db vs control mice (i.e. chondroitin sulfate proteoglycan and collagen type IV). Consequently, we demonstrated for the first time that the db/db status is associated with increased astrocytic and microglial activation 7 days after stroke and resulted in higher deposition of ECM within the damaged area. Interestingly, the injury-induced neurogenesis appeared stronger in db/db as shown by the labeling of migrating neuroblast. This increase appeared correlated to the larger size of lesion. It nevertheless raises the question of the functional integration of the new neurons in db/db mice given the observed dense ECM, known to be repulsive for neuronal migration. Carefully limiting glial scar formation after stroke represents a promising area of research for reducing neuronal loss and limiting disability in diabetic/obese patients.

Intravenous tenecteplase for acute ischemic stroke between 4.5 and 6 h of onset (EXIT-BT2): Rationale and Design

RATIONALE

To date, the benefit of intravenous thrombolysis for acute ischemic stroke (AIS) patients without advanced neuroimaging selection is confined to within 4.5 h of onset. Our phase II EXIT-BT (Extending the tIme window of Thrombolysis by ButylphThalide up to 6 h after onset) trial suggested the safety, feasibility, and potential benefit of intravenous tenecteplase (TNK) in AIS between 4.5 and 6 h of onset. The EXIT-BT2 trial is a pivotal study undertaken to confirm or refute this signal.

AIM

To investigate the efficacy and safety of TNK for AIS between 4.5 and 6 h of onset with or without endovascular treatment.Sample size estimates:A maximum of 1440 patients are required to test the superiority hypothesis with 80% power according to a two-sided 0.05 level of significance, stratified by age, sex, history of diabetes, location of vessel occlusion, baseline National Institute of Health stroke scale score, stroke etiology, and plan for endovascular treatment.

DESIGN

EXIT-BT2 is a prospective, randomized, open-label, blinded assessment of endpoint (PROBE), and multi-center study. Eligible AIS patients between 4.5 and 6 h of onset are randomly assigned 1:1 into a TNK group or control group. The TNK group will receive TNK (0.25 mg/kg, a single bolus over 5-10 s, maximum 25 mg). The control group will receive standard medical care in compliance with national guidelines for acute ischemic stroke. Both groups will receive standard stroke care from randomization to 90 days after stroke onset according to national guidelines.

OUTCOME

The primary efficacy endpoint is excellent functional outcome, defined as a modified Rankin Scale score 0-1 at 90 days after randomization, while the primary safety endpoint is symptomatic intracerebral hemorrhage, defined as National Institutes of Health Stroke Scale score increase ⩾4 caused by intracranial hemorrhage within 24 (-6/+12) h after randomization.

CONCLUSIONS

The results of EXIT-BT2 may determine whether intravenous TNK has a favorable risk/benefit profile in AIS between 4.5 and 6 h of onset.

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.

Adjunctive intra-arterial tenecteplase after successful endovascular thrombectomy in patients with large vessel occlusion stroke (POST-TNK): Study rationale and design

RATIONALE

Adjunct intra-arterial alteplase has been shown to potentially improve clinical outcomes in patients with large vessel occlusion (LVO) stroke who have undergone successful endovascular thrombectomy. Tenecteplase, known for its enhanced fibrin specificity and extended activity duration, could potentially enhance outcomes in stroke patients after successful reperfusion when used as an adjunct intra-arterial therapy.

AIM

To explore the safety and efficacy of intra-arterial tenecteplase after successful endovascular thrombectomy in patients with LVO stroke.

SAMPLE SIZE

To randomize 498 participants 1:1 to receive intra-arterial tenecteplase or no intra-arterial adjunctive thrombolysis therapy.

METHODS AND DESIGN

An investigator-initiated, prospective, randomized, open-label, blind-endpoint multicenter clinical trial. Eligible patients with anterior circulation LVO stroke presenting within 24 h from symptom onset (time last known well) and excellent to complete reperfusion (expanded Thrombolysis In Cerebral Infarction (eTICI) scale 2c-3) at endovascular thrombectomy are planned to be randomized.

OUTCOMES

The primary outcome is freedom from disability (modified Rankin Scale, mRS, of 0-1) at 90 days. The primary safety outcomes are mortality through 90 days and symptomatic intracranial hemorrhage within 48 h.

DISCUSSION

The POST-TNK trial will evaluate the efficacy and safety of intra-arterial tenecteplase in patients with LVO stroke and excellent to complete reperfusion.

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.

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.

Low-profile mechanical thrombectomy devices for large vessel occlusion in pediatric ischemic stroke

BACKGROUND

Mechanical thrombectomy (MT) is a well-established treatment modality for large vessel occlusion (LVO) in adults, but there are limited data in the pediatric population. The rarity of the condition makes prospective trial design difficult, and therefore evaluation of MT devices and outcomes is sparse. In pediatric LVO cases, some newer devices may be appropriate for use in revascularization procedures. Furthermore, illustrative specific device-access combinations have rarely been presented in young patients under the age of 5 years.

METHODS

This was a single institution experience in intracranial MT procedures for pediatric acute ischemic stroke (AIS). A given procedure was included if there was an attempt at MT between 2015 and 2023.

RESULTS

Sixteen endovascular procedures were performed in 15 patients with AIS, with a mean age of 7.4 years; eight patients were <5 years of age. MT was attempted in 15/16 (93.7%) procedures, including 11 (73.3%) in the anterior circulation and four (26.7%) in the posterior circulation; one case recanalized after medical treatment. The most common MT techniques were combined aspiration with a stentriever (n=10, 66.7%) and aspiration alone (n=3, 20%). Traditional stentrievers (4-6 mm) were used in seven cases and low-profile stentrievers in four cases. Improved reperfusion was achieved in all low-profile stentriever cases. Reperfusion of modified Thrombolysis in Cerebral Infaction ≥2b was obtained in 73.3% of cases, including 72.7% of those in which a stentriever was used.

CONCLUSIONS

Low-profile thrombectomy devices may achieve similar revascularization results to other approaches in challenging clinical scenarios observed in younger children.

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.

Resolving distal vessel occlusions caused by migrated emboli utilizing a modified stent retrieval technique

BACKGROUND

We retrospectively evaluated the safety and effectiveness of a modified stent retrieval technique that controls the unsheathing level of the microcatheter in resolving distal vessel occlusions resulting from migrated emboli.

METHODS

From January 2016 to February 2022, a modified stent retrieval technique was applied to 24 of 445 patients with acute large vessel occlusion stroke in the anterior circulation, featuring secondary embolus migration into M2, M3, A2, or A3 branches. The coverage range was adjusted through partial re-sheathing of the stent retriever by the delivery microcatheter after full unsheathing. Primary and secondary recanalization rates were assessed using the modified thrombolysis in cerebral infarction (TICI) score.

RESULTS

After recanalizing the primary large vessel occlusions, secondary distal vessel occlusions occurred in 12, 6, 4, and 2 patients in the M2, M3, A2, and A3 branches, respectively. The modified TICI score was 2a and 2b in 8 and 16 patients, respectively, for primary large vessel occlusion. The first pass rate of secondary distal vessel occlusions was 70.8 %, and 23 of 24 patients achieved a final recanalization rate of at least TICI 2c at the migrated distal vessel occlusion (mean duration: 23.2 ± 14 min) without significant complications. At 3 months, 16 patients (66.7 %) achieved favorable functional outcomes (modified Rankin score, 0-2).

CONCLUSION

This simple, effective, modified technique demonstrated safety and efficacy in resolving distal vessel occlusion.

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.

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.

Preliminary results of mechanical thrombectomy with the novel Titan aspiration catheter in acute ischemic stroke patients

PURPOSE

The aim of this study was to reveal our preliminary experience related to the technical success and safety of the Titan aspiration catheter in acute ischemic stroke (AIS) patients.

METHODS

Forty-eight consecutive AIS patients (mean age 62.6 ± 13.8 years) treated with Titan aspiration catheter, using both the ADAPT technique or combined approach with a stent retriever, were included in the study. The primary outcome was successful recanalization (mTICI ≥ 2c-3), and the secondary outcomes were complication rates and 90th day clinical outcomes.

RESULTS

The mean NIHSS score of the patients was 14.63 ± 3.04, and the mean time from groin puncture to recanalization was 24.72 ± 12.48 min. Successful recanalization was achieved in 35 (72.91%) patients. Postprocedural symptomatic hemorrhage was seen in 5 patients (10.41%). Rate of good clinical outcomes on day 90 was 45.83%. There were 7 deaths (14.58%) in this study.

CONCLUSION

The aspiration thrombectomy method is increasingly being used in AIS cases due to its rapid patency rate and its relatively easy application. Because of technological advances, newer aspiration catheters have been improved and are commercially available. Our preliminary results showed that the Titan aspiration catheter could be a useful tool both with the ADAPT technique and the combined approach. Additionally, the fact that the device is offered as a kit may be important in terms of cost-effectiveness.

Stroke Hospitalization Administration & Monitoring: Routine or COVID-19 Care (SHAMROCC)

Background

Monitoring stroke patients in critical-care units for 24 h after thrombolysis or endovascular thrombectomy is considered standard of care in current guidelines but is not evidence-based. Due to the COVID-19 pandemic, our center adopted a targeted protocol in April 2021 with 24-h critical-care monitoring no longer being guaranteed for stroke patients receiving reperfusion treatment. We aim to compare the incidence and timing of complications during the year under the targeted approach compared to prior years when the standard of care was followed.

Methods

We conducted a single-center retrospective cohort study. We analyzed data from stroke patients treated with thrombolysis and/or endovascular thrombectomy in 2019 (pre-COVID-19, standard of care), 2020 (during COVID-19, standard of care) and 2021 (during COVID-19, targeted protocol). Data extracted included demographics, the nature and timing of complications within the first 24 h, and the unit at the time of complication.

Results

Three hundred forty-nine patients were included in our study: 78 patients in 2019, 115 patients in 2020, and 156 patients in 2021. In 2021, 32% of patients experienced at least 1 complication within the first 24 h compared to 34% in 2020 and 27% in 2019. In 2021, 33% of patients admitted to critical-care units had a complication compared to 29% in non-critical care units. In 2021, 70% of complications had occurred by hour 8 compared to 49% in 2020 and 29% in 2019.

Conclusions

The incidence and timing of complications did not significantly worsen under the targeted approach compared to prior years and were not associated with hospital location.

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.

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.

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.

Navigating the waters of acute minor stroke therapies: a systematic review and network meta-analysis

BACKGROUND

Although acute minor stroke often presents with mild symptoms, such as unilateral limb weakness, mild aphasia, dizziness, or mild cognitive impairment, untreated outcomes could be poor, and optimal treatment methods are still debated.

OBJECTIVES

We aimed to identify the optimum treatment for minor strokes with a network meta-analysis.

METHODS

Studies from Embase, Ovid, and Cochrane Library were considered. Randomized controlled trials and prospective cohort studies on ischemic stroke with a National Institutes of Health Stroke Scale score no more than 5, explicit intravenous thrombolysis, or antiplatelet therapy were included. Efficacy outcome was measured by 3-month modified Rankin scale (mRS), with primary outcome defined as mRS score of 0 to 1 and secondary outcome defined as mRS score of 0 to 2. Safety outcomes included symptomatic intracranial hemorrhage (sICH) and mortality at 3 months.

RESULTS

Nine studies encompassing 10 665 patients were meta-analyzed. Aspirin plus clopidogrel (n = 4283) was more strongly associated with primary outcome than aspirin (n = 2128; odds ratio [OR], 1.26; 95% CI, 1.04∼1.54) and recombinant tissue plasminogen activator (rt-PA; n = 1840; OR, 1.23; 95% CI, 1.00∼1.50). Aspirin plus clopidogrel (n = 3933) also had a lower sICH risk than rt-PA (n = 2538; OR, 0.11; 95% CI, 0.04∼0.30) and tenecteplase (n = 194; OR, 0.15; 95% CI, 0.03∼0.68), as well as a lower mortality than aspirin alone (n = 830; OR, 0.27; 95% CI, 0.10∼0.71). Patients treated with aspirin (n = 815) also had a lower sICH risk than rt-PA (n = 2538; OR, 0.20; 95% CI, 0.04∼0.95).

CONCLUSION

Dual antiplatelet therapy based on aspirin and clopidogrel offers balanced efficacy and safety, positioning it as a potentially optimal treatment for minor stroke. rt-PA showed comparable efficacy, while its associated risks were more pronounced.

Predicting clinical outcome in posterior circulation large-vessel occlusion patients with endovascular recanalisation: the GNC score

BACKGROUND AND PURPOSE

Acute ischaemic strokes caused by posterior circulation large-vessel occlusions (pc-LVOs) are associated with particularly poor prognoses, including significant disability and mortality rates. This study sought to develop and validate a novel scoring system for predicting functional outcomes in pc-LVO cases following successful endovascular recanalisation.

METHODS

We derived a predictive model from the DETECT-China cohort and externally validated it using the DETECT2-China dataset. Poor outcome was defined as a modified Rankin Scale score of 4-6 at 90 days. Cerebral circulation time (CCT), measured via digital subtraction angiography (DSA), served as a key predictor. Multivariable logistic regression was employed to construct the scoring system.

RESULTS

The training cohort comprised 92 patients, of whom 52 (56.5%) experienced poor outcomes. Multivariate analysis identified prolonged CCT (adjusted OR (aOR) 1.365; 95% CI 1.105 to 1.686; p=0.004), elevated admission National Institutes of Health Stroke Scale (NIHSS) (aOR 1.235; 95% CI 1.120 to 1.363; p<0.001) and higher blood glucose levels (aOR 1.345; 95% CI 1.023 to 1.769; p=0.034) as independent predictors. These variables were integrated into the GNC score (Glucose-NIHSS-CCT). The GNC score demonstrated excellent predictive performance for clinical outcome, good discrimination and calibration in this cohort, as well as the bootstrap validation. Importantly, the excellent performance of this score was further validated in DETECT2-China.

CONCLUSIONS

This is the first report that CCT based on DSA is an independent prognostic marker in pc-LVO patients with successful recanalisation post-endovascular treatment. The GNC score, incorporating readily available clinical and angiographic parameters, offers a reliable tool for outcome prediction in this high-risk population.

Fibrinogen depletion and the risk of intracerebral hemorrhage following endovascular mechanical thrombectomy

BackgroundIntravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are the standard of care for select stroke patients with acute large vessel occlusion (LVO). Fibrinogen levels may drop after IVT, and a significant decrease in fibrinogen is associated with an increased risk of intracranial hemorrhage (ICH). Our pilot study aimed to explore the relationship between fibrinogen levels and the development of ICH in MT-treated patients and whether bridging with IVT further increases that risk.MethodsThis is a prospective pilot study that enrolled adults presenting with a diagnosis of LVO stroke and eligible to receive MT with or without IVT between April 2020 and May 2023. Fibrinogen levels were drawn before treatment with IVT or MT and immediately following MT.ResultsForty-one patients were enrolled. Median age was 68 years [interquartile range 56-79], 58.5% were females and 56.1% were black. Nineteen patients (46.3%) were treated with MT + IVT, and 22 (53.6%) were treated with MT-only. There was no difference in baseline characteristics between the two groups. Baseline fibrinogen levels were similar between MT + IVT and MT-only groups [391 vs. 352 mg/dL, p = 0.4]. Post MT, the MT + IVT group had lower fibrinogen levels compared to the MT-only group [224 vs. 303 mg/dL, p < 0.001]. Similarly, there was a significant change between baseline and follow-up levels in the MT + IVT vs. MT-only group [106 vs. 39.5 mg/dL, p = 0.001]. Eight patients (19.5%) developed ICH; 5 (26.3%) in the MT + IVT group and 3 (13.6%) in the MT-only group. No significant differences were seen in baseline, follow-up, or change in fibrinogen levels between patients who developed ICH and those who did not. However, when stratified by treatment group, postintervention fibrinogen levels were significantly lower in patients who developed an ICH in the MT + IVT group compared to those without ICH in the MT group (200 vs. 301 mg/dL, p = 0.006). There was also a negative correlation between the change in fibrinogen levels and the rate of first-pass recanalization (Spearman CC -0.33, p = 0.03).ConclusionThis pilot study's preliminary data showed an association between fibrinogen depletion and hemorrhagic transformation in MT-treated patients. Since intracerebral hemorrhage is the most dire side effect in stroke treatment, fibrinogen monitoring in patients undergoing MT after IVT may help identify patients with an increased risk of ICH. Larger, prospective, and multicenter studies are needed to confirm these findings and if fibrinogen repletion should be considered for dysfibrinogenemia.

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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MESH Headings Collapse

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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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The Effectiveness of Deep Learning in the Differential Diagnosis of Hemorrhagic Transformation and Contrast Accumulation After Endovascular Thrombectomy in Acute Ischemic Stroke Patients

Objectives: Differentiation of hyperdense areas on non-contrast computed tomography (NCCT) images as hemorrhagic transformation (HT) and contrast accumulation (CA) after endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) patients are critical for early antiplatelet and anticoagulant therapy. This study aimed to predict HT and CA on initial NCCT using deep learning. Material and Methods: This study was conducted between January and December 2024. The study included 556 images of 52 patients (21 female and 31 male) who underwent EVT due to AIS, with hyperdense areas observed in the NCCT examination within the first 24 h post-EVT. The evaluated images were labeled as 'contrast accumulation' and 'hemorrhagic transformation'. These labeled images were trained with nine different models under a convolutional neural network (CNN) architecture using a large dataset, such as ImageNet. These models are DenseNet201, InceptionResNet, InceptionV3, NASNetLarge, ResNet50, ResNet101, VGG16, VGG19 and Xception. After training the CNN models, their performance was evaluated using accuracy, loss, validation accuracy, validation loss, F1 score, Receiver Operating Characteristic (ROC) Curve, confusion matrix, confidence interval, and p-value analysis. Results: The models trained in the study were derived from 556 images in data sets obtained from 52 patients; 186 images in training data for CA and 186 images training data for HT (with an increase to 558 images), 115 images used for validation data, and 69 images were compared using test data. In the test set, the Area Under the Curve (AUC) metrics showing sensitivity and specificity values under different cutoff points for the models were as follows: DenseNet201 model AUC = 0.95, InceptionV3 model AUC = 0.93, NasNetLarge model AUC = 0.89, Xception model AUC = 0.91, Inception_ResNet model AUC = 0.84, Resnet50 and Resnet101 models AUC = 0.74. The InceptionV3 model demonstrates the best performance with an F1 score of 0.85. Recall scores generally ranged between 0.62 and 0.85. Conclusions: In our study, hyperdensity areas in initial NCCT images obtained after EVT in AIS patients were successfully differentiated from HT and CA with high accuracy using CNN architectures. Our findings may enable the early identification of patients who would benefit from anticoagulation or antiplatelet therapy to prevent re-occlusion or progression after EVT.

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.

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.

Advances in endovascular thrombectomy for the treatment of acute ischemic stroke

INTRODUCTION

Acute ischemic stroke (AIS) is the second leading cause of death and one of the leading causes of long-term disability globally. Endovascular thrombectomy (EVT) has revolutionized treatment for large vessel occlusion (LVO), providing 20% increase in post-stroke functional independence compared to intravenous thrombolysis (IVT) alone. Despite its proven efficacy, EVT is underutilized. While it is suitable for at least 15-20% of AIS patients, its mean adoption ranges from less than 1% to 7% in different areas.

AREAS COVERED

This review highlights key findings from pivotal randomized controlled trials and real-world data, focusing on patient selection criteria, advancements in thrombectomy devices, and procedural innovations. A comprehensive literature search was performed using PubMed, Scopus, EMBASE and the Cochrane Library for relevant randomized controlled trials and observational studies.

EXPERT OPINION

Disparity in access to EVT requires strategic investments in healthcare systems and international multidisciplinary collaboration. Enhancing geographic coverage with thrombectomy-capable centers and optimizing prehospital triage systems are essential. Bridging the gap between treatment capability and real-world implementation is critical to improving global AIS outcomes.

Trends in reperfusion treatments, functional outcomes and mortality for first-ever ischaemic stroke in Norway from 2014 to 2021: The Norwegian Stroke Registry

INTRODUCTION

Acute ischaemic stroke (AIS) treatment has undergone major changes in the last decades with regards to reperfusion treatment with intravenous thrombolysis (IVT) and mechanical thrombectomy (MT). We analysed temporal trends in reperfusion treatment, functional outcomes and mortality among patients with first-ever AIS.

PATIENTS AND METHODS

We included 45,686 first-ever AIS patients registered in the Norwegian Stroke Registry from 2014 to 2021. Temporal trends in reperfusion therapy, functional outcome defined by modified Rankin Scale (mRS) score at 90 days and mortality were assessed in age-and sex-adjusted logistic regression models and in analyses stratified by age and reperfusion treatment.

RESULTS

Mean age was 73.8 years and 54.5% were men. The use of reperfusion treatment increased over time (IVT only from 15.5% to 18.1%; MT only from 0.4% to 2.8%; IVT + MT combined, from 0.9% to 3.4%). The proportion of patients achieving mRS 0-2 at 90 days increased from 64.2% to 68.1%. The 90-day mortality decreased from 11.7% to 10.5%. Improvement in 90-day functional outcome was most notable in patients receiving IVT, but was also observed in patients not receiving reperfusion treatment. Patients aged ⩾80 years showed improvement in functional outcome and reduced mortality rate, while less noticeable time trends were observed in patients <80 years.

DISCUSSION AND CONCLUSION

Reperfusion therapy for first-ever AIS increased significantly over time, concurrent with significant improvements in functional outcome and lower mortality rate. Improvements in outcome were more prominent in the older population. Improved outcome among non-reperfused patients suggest that factors other than reperfusion therapy contribute to these results.

Reliability of CT, DECT, and MRI for the diagnosis of hemorrhagic transformation after thrombectomy

INTRODUCTION

Computed Tomography (CT) is the main modality used for the diagnosis and classification of hemorrhagic transformation (HT) after thrombectomy, however its reliability has shown limitations. Dual-energy CT (DECT) and magnetic resonance imaging (MRI) have been suggested to enhance the reliability of HT detection and classification, but direct three-way comparison of these modalities is lacking. To measure and compare the reliability of CT, DECT and MRI for the diagnosis, classification, and therapeutic consequences of HT after thrombectomy.

PATIENTS AND METHODS

Between June 2017 and September 2019, 66 of 324 patients included in the BP-TARGET trial underwent CT, DECT and MRI scans within 36 h after thrombectomy. Seven readers, including three neurologists, two diagnostic, and two interventional neuroradiologists independently reviewed the images. They were asked for each patient and each imaging modality to score the presence of a hemorrhagic transformation (of any type), the type of hemorrhagic transformation according to the European Cooperative Acute Stroke Study (ECASS), and whether they would start the patient on antiplatelet based on the imaging finding. The readers repeated the same readings 1 month later. Interrater and intrarater agreement were measured using Kappa statistics.

RESULTS

There were frequent discrepancies between CT, DECT and MRI scans evaluations. The use of MRI led to an increased rate of HT diagnosis compared to CT and DECT scans. Interrater agreement for ECASS classification was only fair-to-moderate for all three imaging modalities but improved to a substantial level after dichotomization into 0/HI1/HI2 versus PH1/PH2. The interrater agreement for the decision to start antiplatelet therapy was substantial only with CT (κ = 0.636 [0.577-0.694]) and remained moderate with MRI and DECT.

CONCLUSION

In our study, the imaging modality influenced the diagnosis and classification of HT, the management of antiplatelet therapy, and the interrater and intrarater agreement. These findings may guide the choice of imaging modality in research or clinical settings.

Outcome Predictor Differences in Infratentorial and Supratentorial Ischemic Stroke

Acute ischemic stroke outcomes depend on various factors. We investigated whether the outcome-relevant factor (ORF) profiles differ between different vascular territories and different therapeutic strategies. In this retrospective study, we analyzed 410 comprehensive stroke center patients [median age of 70 years (IQR 57-80), 125 women (30%)] by analyzing five groups: all patients, patients with infratentorial infarctions only (n = 80), all patients with supratentorial infarctions (n = 330), patients with supratentorial infarctions without (n = 269), and with mechanical thrombectomy (n = 61). Outcomes were classified with the modified Rankin scale as ≤2 (good) or >2 (poor) after three months. The patient group with infratentorial strokes was compared to the group of patients with supratentorial strokes using the Kruskal-Wallis test or chi-squared statistics. Within each of the five stroke groups, univariate logistic regression analysis was used to identify the ORF of a poor outcome; if more than one ORF was identified, all identified factors were included in one multinomial logistic regression analysis model. Compared to the patients with supratentorial strokes, the patients with infratentorial stroke exhibited a less severe neurological deficit at entry and lower rates of ischemic heart disease, thrombolytic intervention, and cardio-embolism but a higher rate of large vessel disease. After multinomial logistic regression analysis, a poor outcome in the infratentorial group was associated with atrial fibrillation [odds ratio (OR) 13.73 (95% confidence interval 1.05-181.89), p = 0.04], estimated glomerular filtration rate [OR 0.96 (0.91-0.99)], p = 0.02], and marginally with diabetes mellitus [OR 7.69 (0.96-62.63), p = 0.05]. In all three supratentorial stroke groups, the neurological deficit as scored by the National Institute of Health Stroke Scale [OR 1.32 (1.22-1.44), p < 0.0001] was predominantly associated with a poor outcome, accompanied by age only in the group of all supratentorial strokes [OR 1.04 (1.01-1.08), p = 0.01]. In this cohort of mild to moderate stroke patients, the ORFs differed between the supra- and infratentorial stroke populations.

Late time window endovascular treatment for acute ischemic stroke: rethinking the role of simplified imaging

OBJECTIVE

To assess safety and efficacy of endovascular treatment (EVT) in acute ischemic stroke (AIS)patients selected by ASPECTS within 6-24 h after onset.

METHODS

Patients were divided into early and late time window groups. Primary outcome was 90-day mRS 0-2, safety outcomes were 90-day any intracranial hemorrhage (ICH) and mortality. Univariate and multivariate analyses were conducted for the prediction of good outcome.

RESULTS

Of the 296 patients screened, 242 patients fulfilled the study criteria. Patients in the late time window group were younger, had lower baseline NIHSS scores and ASPECTS, a lower proportion of atrial fibrillation, a higher proportion of large-artery atherosclerosis, less received intravenous thrombolysis, and had a longer time from symptom onset to treatment. No difference in primary and safety outcomes: good outcome (42% vs. 50.5%, p = 0.188), ICH (26.1% vs. 20.6%, p = 0.311), and mortality (18% vs. 9.9%, p = 0.067). Multivariate analysis showed that age (OR = 0.977, 95%CI 0.955-0.999, p = 0.039), NIHSS score (OR = 0.905, 95%CI 0.858-0.953, p = 0.001), ASPECTS (OR = 1.242, 95%CI 1.004-1.538, p = 0.046), glucose (OR = 0.817, 95%CI 0.720-0.926, p = 0.002), platelet (OR = 1.005, 95% CI 1.000 -1.010, p = 0.031) and successful recanalization (OR = 5.037, 95%CI 1.137-22.318, p = 0.033) were independent predictors of good outcomes.

CONCLUSIONS

For late-window acute anterior-circulation LVO patients, those selected based on the ASPECTS exhibited comparable 90-day good outcomes and safety profiles to those in the early time window. This finding implies that ASPECTS could serve as a screening tool for patients in the late time window when undergoing EVT.

CLINICAL TRIAL

This is a clinical retrospective study. However, at the time when the study was initiated, clinical trial registration was not a mandatory requirement. Therefore, this trial was not registered.

Relevance of cervical internal carotid artery patency after thrombectomy in tandem occlusion. Are we missing an opportunity to revascularize?

BACKGROUND

Treatment options for cervical internal carotid artery (c-ICA) occlusion in tandem occlusions (TOs) include emergent carotid artery stenting (eCAS) and angioplasty. We attempted to determine the impact of c-ICA reocclusion on the risk of recurrent ischemic stroke (IS) and stroke-related death, as well as functional independence.

METHODS

Patients with TOs undergoing endovascular thrombectomy (EVT) from April 2016 to October 2024 were included. The primary outcome was the 90-day composite of recurrent IS and stroke-related death. Secondary outcomes included the rate of 90-day functional independence (modified Rankin Scale (mRS) 0-2) and mortality. We used binary logistic regression to explore the association between c-ICA reocclusion and the outcomes and to identify predictors of c-ICA reocclusion or future revascularization.

RESULTS

We included 163 patients, 85.9% with successful recanalization. Angioplasty and eCAS were performed in 70% and 19%, respectively. c-ICA reocclusion occurred in 22% at a median of 3.5 (0-41.7) days. c-ICA reocclusion increased the odds of recurrent IS or stroke-related death (adjusted OR (aOR) 2.90, 95% CI 1.07 to 8.30, P=0.036) and was associated with lower rates of independence (aOR 0.18, 95% CI 0.05 to 0.58, P=0.004). Among patients who did not undergo eCAS, c-ICA angioplasty (aHR 0.28, 95% CI 0.09 to 0.86, P=0.026) and residual stenosis (aHR 1.04, 95% CI 1.02 to 1.07, P<0.001) were independent predictors of reocclusion or future revascularization.

CONCLUSION

Maintaining c-ICA patency after EVT might be essential due to the association of reocclusion with recurrent IS, stroke-related death, and worse functional outcomes. Residual c-ICA stenosis and angioplasty are valuable predictors of c-ICA patency that can guide management during EVT.