Two-Year Outcome after Endovascular Treatment for Acute Ischemic Stroke

Endovascular thrombectomy for acute ischaemic stroke with established large infarct (TENSION): 12-month outcomes of a multicentre, open-label, randomised trial

BACKGROUND

Long-term data showing the benefits of endovascular thrombectomy for stroke with large infarct are scarce. The TENSION trial showed the safety and efficacy of endovascular thrombectomy in patients with ischaemic stroke and large infarct at 90 days. We aimed to investigate the safety and efficacy at 12 months of endovascular thrombectomy in patients who were enrolled in the TENSION trial.

METHODS

TENSION was an open-label, blinded endpoint, randomised trial done at 40 hospitals across Europe and one hospital in Canada. We included patients (aged ≥18 years) with acute ischaemic stroke due to large vessel occlusion in the anterior circulation and who had a large infarct, as indicated by an Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) of 3-5 on standard-of-care stroke imaging. We randomly assigned patients (1:1) to receive either endovascular thrombectomy with medical treatment or medical treatment only up to 12 h from stroke onset. The primary outcome was functional outcome across the entire range of the modified Rankin Scale at 90 days. Here, we report the prespecified 12-month follow-up analyses for functional outcome (using the simplified modified Rankin Scale questionnaire), quality of life (using the Patient-Reported Outcomes Measurement Information System 10-item [PROMIS-10] and EQ-5D questionnaires), post-stroke anxiety and depression (using the Patient Health Questionnaire-4 [PHQ-4]), and overall survival. Outcomes (except survival) were assessed in the intention-to-treat population; the survival analysis was based on treatment received. This trial is registered with ClinicalTrials.gov, NCT03094715, and is completed.

FINDINGS

We enrolled patients between July 17, 2018, and Feb 21, 2023, when the trial was stopped early for efficacy. 253 patients were randomly assigned, 125 (49%) to endovascular thrombectomy and 128 (51%) to medical treatment only. Median follow-up was 8·36 months (IQR 0·02-12·00). Endovascular thrombectomy was associated with a shift in the distribution of scores on the modified Rankin Scale towards better functional outcome at 12 months (adjusted common odds ratio 2·39 [95% CI 1·47-3·90]). Endovascular thrombectomy was also associated with a better quality of life compared with medical treatment only, as reflected by median scores on the EQ-5D questionnaire index (0·7 [IQR 0·4-0·9] vs 0·4 [0·2-0·7]), median scores for health status on the EQ-5D questionnaire visual analogue scale (50 [IQR 35-70] vs 30 [5-60]), and median global physical health scores on the PROMIS-10 questionnaire (T-score 39·8 [IQR 37·4-50·8] vs 37·4 [32·4-44·9]); although there was not enough evidence to suggest a difference between groups in global mental health scores on PROMIS-10 (41·1 [IQR 36·3-48·3] vs 38·8 [31·3-44·7]) or the numbers of patients reporting anxiety (13 [22%] of 58 vs 15 [42%] of 36) and depression (18 [31%] vs 18 [50%]) on PHQ-4. Overall survival was slightly better in the endovascular thrombectomy group compared with medical treatment only (adjusted hazard ratio 0·70 [95% CI 0·50-0·99]).

INTERPRETATION

In patients with acute ischaemic stroke from large vessel occlusion with established large infarct, compared with medical treatment only, endovascular thrombectomy was associated at 12 months after stroke with better functional outcome, quality of life, and overall survival. These findings suggest that the benefits of endovascular thrombectomy in patients with an ischaemic stroke and a large infarct are sustained in the long term and support the use of endovascular thrombectomy in these patients.

FUNDING

European Union Horizon 2020 Research and Innovation Programme.

Collateral-based selection for endovascular treatment of acute ischaemic stroke in the late window (MR CLEAN-LATE): 2-year follow-up of a phase 3, multicentre, open-label, randomised controlled trial in the Netherlands

BACKGROUND

The MR CLEAN-LATE trial provided evidence for the safety and efficacy of endovascular treatment for acute ischaemic stroke within the late window (after 6-24 h) in patients who were preselected based on the presence of collateral flow on CT angiography. We aimed to evaluate clinical outcomes 2 years after randomisation.

METHODS

MR CLEAN-LATE was a phase 3, multicentre, open-label, blinded-endpoint, randomised controlled trial conducted at 18 stroke intervention centres in the Netherlands. If endovascular treatment could be initiated within 6-24 h of symptom onset or last seen well, patients (aged 18 years or older) with an acute ischaemic stroke due to a large vessel occlusion in the anterior circulation and at least some collateral flow in the affected middle cerebral artery territory on CT angiography were randomly assigned (1:1) to either endovascular treatment with best medical treatment (endovascular treatment group) or best medical treatment alone (control group). Web-based randomisation, stratified by centre, was performed with the use of permuted blocks (block size eight to 20). The researchers who collected clinical outcomes and analysed the results were masked to treatment allocation; treating physicians, local investigators, and patients were aware of the received treatment. The primary outcome of MR CLEAN-LATE was the modified Rankin Scale (mRS) score at 90 days after randomisation. For this 2-year prespecified analysis, the primary outcome was mRS score at 2 years (minus 3 months to plus 6 months). Primary and safety analyses were performed based on the modified intention-to-treat principle, and included patients who provided (deferred) consent or died before consent could be obtained. Missing data were handled with multiple imputation by chained equations. The trial is completed and is registered at ISRCTN, ISRCTN19922220.

FINDINGS

Between Feb 2, 2018, and Jan 27, 2022, 535 patients were randomly assigned in the MR CLEAN-LATE trial, of whom 502 (94%) gave deferred consent and comprised the modified intention-to-treat population (255 in the endovascular treatment group and 247 in the control group). 261 (52%) patients were female and 241 (48%) were male. Data for mRS score at 2 years were available for 226 (89%) patients in the endovascular treatment group and for 202 (82%) patients in the control group. The median mRS score at 2 years was 4 (IQR 2-6) in the endovascular treatment group and 6 (2-6) in the control group. The endovascular treatment group demonstrated a shift towards better functional outcomes on the mRS (adjusted common odds ratio 1·41 [95% CI 1·00-1·99]; p=0·049). All-cause mortality at 2 years was 34% (87 of 255) in the endovascular treatment group and 41% (101 of 247) in the control group (adjusted hazard ratio 0·81 [95% CI 0·60-1·08]; p=0·15). Major vascular events (ie, transient ischaemic attack, ischaemic stroke, haemorrhagic stroke, and cardiac events) were reported between 90 days and 2 years in 23 patients in the endovascular treatment group and 13 patients in the control group.

INTERPRETATION

Our results show that the effectiveness of late-window (after 6-24 h) endovascular treatment in improving clinical outcomes is sustained for up to 2 years in a population preselected based on the presence of collateral flow on CT angiography. This finding might be important for prompting further evaluations of cost-effectiveness, health-care policy development, and clinical decision making.

FUNDING

The Dutch Organization for Health Research and Health Innovation (ZonMW), Collaboration for New Treatments of Acute Stroke Consortium, Dutch Heart Foundation, Stryker, Medtronic, Cerenovus, Health Holland Top Sector Life Sciences & Health, and the Netherlands Brain Foundation.

Thrombectomy in young adults with embolic stroke of undetermined source: Analysis of the Young ESUS study

OBJECTIVES

Embolic Stroke of Undetermined Source (ESUS) is a distinct stroke entity that disproportionately affects young adults. We sought to describe characteristics, workup and outcomes of young adult ESUS patients who underwent thrombectomy, and compare outcomes to those reported in different age groups.

MATERIALS AND METHODS

Young-ESUS is a multicenter longitudinal cohort study that enrolled consecutive patients aged 21-50 years at 41 stroke centers in 13 countries between 2017- 2019. Between-group comparisons were performed using Wilcoxon rank sum test for continuous variables or Fisher's exact test for binary variables. Distribution of functional outcomes after thrombectomy for our young adult cohort versus pediatric and older adult cohorts reported in the literature were described using the Kruskal-Wallis test.

RESULTS

Of 535 patients enrolled in Young-ESUS, 65 (12.1%) were treated with endovascular thrombectomy. Patients who underwent thrombectomy were more likely to undergo in-depth cardiac testing than those who did not, but cardiac abnormalities were not detected more often in this group. Among thrombectomy patients, 35/63 (55.6%) had minimal to no functional disability at follow up. When adjusted for age, stroke severity and IV alteplase, the odds of achieving favorable outcome did not differ between treated versus untreated patients.

CONCLUSIONS

Thrombectomy is not rare in young adults with ESUS. Despite extensive workup, cardiac abnormalities were not more prevalent in the thrombectomy group. More research to determine optimal workup, etiologic factors and favorable outcome of stroke across the lifespan is needed.

Statistical analyses of ordinal outcomes in randomised controlled trials: a scoping review

BACKGROUND

Randomised controlled trials (RCTs) aim to estimate the causal effect of one or more interventions relative to a control. One type of outcome that can be of interest in an RCT is an ordinal outcome, which is useful to answer clinical questions regarding complex and evolving patient states. The target parameter of interest for an ordinal outcome depends on the research question and the assumptions the analyst is willing to make. This review aimed to provide an overview of how ordinal outcomes have been used and analysed in RCTs.

METHODS

The review included RCTs with an ordinal primary or secondary outcome published between 2017 and 2022 in four highly ranked medical journals (the British Medical Journal, New England Journal of Medicine, The Lancet, and the Journal of the American Medical Association) identified through PubMed. Details regarding the study setting, design, the target parameter, and statistical methods used to analyse the ordinal outcome were extracted.

RESULTS

The search identified 309 studies, of which 144 were eligible for inclusion. The most used target parameter was an odds ratio, reported in 78 (54%) studies. The ordinal outcome was dichotomised for analysis in 47 ( 33 % ) studies, and the most common statistical model used to analyse the ordinal outcome on the full ordinal scale was the proportional odds model (64 [ 44 % ] studies). Notably, 86 (60%) studies did not explicitly check or describe the robustness of the assumptions for the statistical method(s) used.

CONCLUSIONS

The results of this review indicate that in RCTs that use an ordinal outcome, there is variation in the target parameter and the analytical approaches used, with many dichotomising the ordinal outcome. Few studies provided assurance regarding the appropriateness of the assumptions and methods used to analyse the ordinal outcome. More guidance is needed to improve the transparent reporting of the analysis of ordinal outcomes in future trials.

Cost and Utility Estimates per Modified Rankin Scale Score up to 2 Years Post Stroke: Data to Inform Economic Evaluations From a Societal Perspective

OBJECTIVES

Model-based health economic evaluations of ischemic stroke are in need of cost- and utility estimates related to relevant outcome measures. This study aims to describe societal cost- and utility estimates per modified Rankin Scale (mRS)-score at different time points within 2 years post stroke.

METHODS

Included patients had a stroke between 3 months and 2.5 years ago. mRS and EQ-5D-5L were scored during a telephone interview. Based on the interview date, records were categorized into a time point: 3 months (3M; 3-6 months), 1 year (Y1; 6-18 months), or 2 years (Y2; 18-30 months). Patients completed a questionnaire on healthcare utilization and productivity losses in the previous 3 months. Initial stroke hospitalization costs were assessed. Mean costs and utilities per mRS and time point were derived with multiple imputation nested in bootstrapping. Cost at 3 months post stroke were estimated separately for endovascular treatment (EVT)-/non-EVT-patients.

RESULTS

1106 patients were included from 18 Dutch centers. At each time point, higher mRS-scores were associated with increasing average costs and decreasing average utility. Mean societal costs at 3M ranged from €11 943 (mRS 1, no EVT) to €55 957 (mRS 5, no EVT). For Y1, mean costs in the previous 3 months ranged from €885 (mRS 0) to €23 215 (mRS 5), and from €1655 (mRS 0) to €22 904 (mRS 5) for Y2. Mean utilities ranged from 0.07 to 0.96, depending on mRS and time point.

CONCLUSIONS

The mRS-score is a major determinant of costs and utilities at different post-stroke time points. Our estimates may be used to inform future model-based health economic evaluations.

Early neurological deterioration in patients with acute ischemic stroke is linked to unfavorable cerebral venous outflow

INTRODUCTION

Early neurological deterioration (END) is associated with poor outcomes in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). Causes of END after mechanical thrombectomy (MT) include unsuccessful recanalization and reperfusion hemorrhages. However, little is known about END excluding the aforementioned causes. We aimed to investigate factors associated with unexplained END (ENDunexplained) with regard to the cerebral collateral status.

PATIENTS AND METHODS

Multicenter retrospective study of AIS-LVO patients with successful MT (mTICI 2b-3). On admission CT angiography (CTA), pial arterial collaterals and venous outflow (VO) were assessed using the modified Tan-Scale and the Cortical Vein Opacification Score (COVES), respectively. ENDunexplained was defined as an increase in NIHSS score of ⩾ 4 within the first 24 hours after MT without parenchymal hemorrhage on follow-up imaging. Multivariable regression analyses were performed to examine factors of ENDunexplained and unfavorable functional outcome (modified Rankin Scale score 3-6).

RESULTS

A total of 620 patients met the inclusion criteria. ENDunexplained occurred in 10% of patients. While there was no significant difference in pial arterial collaterals, patients with ENDunexplained exhibited more often unfavorable VO (81% vs. 53%; P < 0.001). Unfavorable VO (aOR [95% CI]; 2.56 [1.02-6.40]; P = 0.045) was an independent predictor of ENDunexplained. ENDunexplained was independently associated with unfavorable functional outcomes at 90 days (aOR [95% CI]; 6.25 [2.06-18.94]; P = 0.001).

DISCUSSION AND CONCLUSION

Unfavorable VO on admission CTA was associated with ENDunexplained. ENDunexplained was independently linked to unfavorable functional outcomes at 90 days. Identifying AIS-LVO patients at risk of ENDunexplained may help to select patients for intensified monitoring and guide to optimal treatment regimes.

Long term for patients with futile endovascular reperfusion after stroke

AIMS

With the progress of thrombectomy technology, the vascular recanalization rate of patients with stroke has been continuously improved, but the proportion of futile recanalization (FR) is still quite a few. The long-term prognosis and survival of patients with FR and its influencing factors remain unclear.

METHODS

Consecutive patients who received endovascular treatment (EVT) for ischemic stroke were enrolled between 2013 and 2021 from a single-center prospectively registry study. We evaluated the long-term outcome of these patients by Kaplan-Meier survival analysis, and the multivariable logistic regression curve was performed to analyze influencing factors.

RESULTS

Among 458 patients with FR, 56.4% of patients survived at 1 year, and 50.4% at 2 years. In the multivariate regression analysis, age, premorbid modified Rankin Scale (mRS), National Institutes of Health Stroke Scale (NIHSS), posterior circulation infarct, general anesthesia, symptomatic intracerebral hemorrhage (sICH), and decompressive craniectomy were found to be related to unfavorable outcomes in long-term. Age, premorbid mRS, NIHSS, general anesthesia, and sICH were predictors of long-term mortality.

CONCLUSIONS

Futile recanalization accounts for a large proportion of stroke patients after thrombectomy. This study on the long-term prognosis of such patients is beneficial to the formulation of treatment plans and the prediction of therapeutic effects.

Endovascular thrombectomy plus medical care versus medical care alone for large ischaemic stroke: 1-year outcomes of the SELECT2 trial

BACKGROUND

Multiple randomised trials have shown efficacy and safety of endovascular thrombectomy in patients with large ischaemic stroke. The aim of this study was to evaluate long-term (ie, at 1 year) evidence of benefit of thrombectomy for these patients.

METHODS

SELECT2 was a phase 3, open-label, international, randomised controlled trial with blinded endpoint assessment, conducted at 31 hospitals in the USA, Canada, Spain, Switzerland, Australia, and New Zealand. Patients aged 18-85 years with ischaemic stroke due to proximal occlusion of the internal carotid artery or of the first segment of the middle cerebral artery, showing large ischaemic core on non-contrast CT (Alberta Stroke Program Early Computed Tomographic Score of 3-5 [range 0-10, with lower values indicating larger infarctions]) or measuring 50 mL or more on CT perfusion and MRI, were randomly assigned, within 24 h of ischaemic stroke onset, to thrombectomy plus medical care or to medical care alone. The primary outcome for this analysis was the ordinal modified Rankin Scale (range 0-6, with higher scores indicating greater disability) at 1-year follow-up in an intention-to-treat population. The trial is registered at ClinicalTrials.gov (NCT03876457) and is completed.

FINDINGS

The trial was terminated early for efficacy at the 90-day follow-up after 352 patients had been randomly assigned (178 to thrombectomy and 174 to medical care only) between Oct 11, 2019, and Sept 9, 2022. Thrombectomy significantly improved the 1-year modified Rankin Scale score distribution versus medical care alone (Wilcoxon-Mann-Whitney probability of superiority 0·59 [95% CI 0·53-0·64]; p=0·0019; generalised odds ratio 1·43 [95% CI 1·14-1·78]). At the 1-year follow-up, 77 (45%) of 170 patients receiving thrombectomy had died, compared with 83 (52%) of 159 patients receiving medical care only (1-year mortality relative risk 0·89 [95% CI 0·71-1·11]).

INTERPRETATION

In patients with ischaemic stroke due to a proximal occlusion and large core, thrombectomy plus medical care provided a significant functional outcome benefit compared with medical care alone at 1-year follow-up.

FUNDING

Stryker Neurovascular.

Cerebral blood volume index can predict the long-term prognosis after endovascular thrombectomy in patients with acute ischemic stroke due to large vessel occlusion

Long-term prognosis and factors influencing endovascular therapy (EVT) remain unclear. This study aimed to investigate the association between computed tomography perfusion (CTP) parameters and long-term prognosis of patients with acute ischemic stroke (AIS) treated with EVT. Patients with AIS due to large vessel occlusion treated with EVT were prospectively included for a 1-year follow-up. All patients and their data were grouped based on the hypoperfusion intensity ratio (HIR, ＜0.3 vs. ≥ 0.3) and cerebral blood volume (CBV) index (＞0.7 vs. ≤ 0.7). The primary outcome was favorable prognosis, defined as a modified Rankin Scale (mRS) score of 0-2. Multivariate logistic regression was used to analyze factors influencing long-term favorable prognosis. Of 69 patients included, 35 (50.7 %) achieved mRS 0-2 at one year. A favorable prognosis was observed predominantly in patients with higher CBV index (75.0 % vs. 34.1 %, p= 0.001) and lower HIR (72.0 % vs. 38.6 %, p=0.008). In the multivariate logistic regression, CBV index (odds ratio (OR) = 4.362; 95 % confidence interval (CI): 1.052, 18.082; p = 0.042), baseline National Institutes of Health Stroke Scale (NIHSS) score (OR = 0.913; 95 % CI: 0.836, 0.997; p = 0.044), and symptomatic intracranial hemorrhage (sICH) (OR = 0.089; 95 % CI: 0.009, 0.925; p = 0.043) were independently associated with a long-term favorable prognosis. The CBV index may serve as a predictor of the long-term prognosis of patients treated with EVT. The novel finding is that the baseline NIHSS score and sICH were associated with long-term prognosis.

Cost-effectiveness of Direct Transfer to Angiography Suite of Patients With Suspected Large Vessel Occlusion

BACKGROUND AND OBJECTIVES

Patients with acute ischemic stroke due to large vessel occlusion (LVO) deemed eligible for endovascular thrombectomy (EVT) are transferred from the emergency room to the angiography suite to undergo the procedure. Recently, the strategy of direct transfer of patients with suspected LVO to the angiography suite (DTAS) has been shown to improve functional outcomes. This study aims to evaluate the cost-effectiveness of the DTAS strategy vs initial transfer of patients with suspected LVO (Rapid Arterial Occlusion Evaluation score >4 and NIH Stroke Scale >10) to the emergency room (ITER).

METHODS

A decision-analytic Markov model was developed to estimate the cost-effectiveness of the DTAS strategy vs the ITER strategy from a Dutch health care perspective with a 10-year time horizon. The primary outcome was the incremental cost-effectiveness ratio (ICER) using Dutch thresholds of $59,135 (€50,000) and $94,616 (€80,000) per quality-adjusted life year (QALY). Uncertainty of input parameters was assessed using 1-way sensitivity analysis, scenario analysis, and probabilistic sensitivity analysis.

RESULTS

The DTAS strategy yielded 0.65 additional QALYs at an additional $16,089, resulting in an ICER of $24,925/QALY compared with the ITER strategy. The ICER varied from $27,169 to $38,325/QALY across different scenarios. The probabilistic sensitivity analysis showed that the DTAS strategy had a 91.8% and 97.0% likelihood of being cost-effective at a decision threshold of $59,135/QALY and $94,616/QALY, respectively.

DISCUSSION

The cost-effectiveness of the DTAS strategy over ITER is robust for patients with suspected LVO. Together with recently published clinical results, this means that implementation of the DTAS strategy may be considered to improve the workflow and outcome of EVT.

A systematic review and meta-analysis of health utility values among patients with ischemic stroke

Purpose

Ischemic stroke (IS) has a considerable impact on the health-related quality of life (HRQoL) of patients. A systematic review was conducted to summarize and synthesize the HRQoL reported from IS patients.

Methods

An electronic search was performed in PubMed, Web of Science, ScienceDirect, Embase, and Cochrane Library databases from inception to February 2022 for studies measuring utility values in IS patients. Basic information about the studies, patient characteristics, measurement of the utility values, and utility values were extracted and summarized. Utility values were pooled according to the time of evaluation, and disease severity was classified with modified Rankin Scale (mRS) scores. The quality of the studies was assessed according to key criteria recommended by the National Institute for Health and Care Excellence.

Results

A total of 39 studies comprising 30,853 participants were included in the study. Measured with EQ-5D-3L, the pooled utility values were 0.42 [95% confidential interval (CI): 0.13 to 0.71], 0.55 (95% CI: 0.43 to 0.68), 0.65 (95% CI: 0.52 to 0.78), 0.60 (95% CI: 0.43 to 0.78), and 0.67 (95% CI: 0.60 to 0.74) for patients diagnosed with IS within 1, 3, 6, 12, and 24 months or above among poststroke patients. Four studies reported utility values classified by mRS scores where synthesized estimates stratified by mRS scores ranged from 0.91 (95% CI: 0.85 to 0.97) for patients with an mRS score of 1 to-0.04 (95% CI:-0.18 to 0.11) for those with an mRS score of 5. As for the health dimension profiles, usual activity was the most impacted dimension, while self-care was the least impacted one.

Conclusion

This study indicated that the utility values in IS patients kept increasing from stroke onset and became relatively stabilized at 6 months poststroke. Health utility values decreased significantly as mRS scores increased. These results facilitate economic evaluations in utility retrieval and selection. Further exploration was required regarding the factors that affect the HRQoL of IS patients.

Cost-effectiveness of tenecteplase versus alteplase for acute ischemic stroke

INTRODUCTION

Alteplase is widely used as an intravenous thrombolytic drug in acute ischemic stroke (AIS). Recently however, tenecteplase, a modified form of tissue plasminogen activator, has been shown to increase early recanalization rate and has proven to be non-inferior with a similar safety profile compared to alteplase. This study aims to evaluate the cost-effectiveness of 0.25 mg/kg tenecteplase versus 0.9 mg/kg alteplase for intravenous thrombolysis in AIS patients from the Dutch healthcare payer perspective.

METHODS

A Markov decision-analytic model was constructed to assess total costs, total quality-adjusted life year (QALY), an incremental cost-effectiveness ratio, and incremental net monetary benefit (INMB) of two treatments at willingness-to-pay (WTP) thresholds of €50,000/QALY and €80,000/QALY over a 10-year time horizon. One-way sensitivity analysis, probabilistic sensitivity analysis, and scenario analysis were conducted to test the robustness of results. Clinical data were obtained from large randomized controlled trials and real-world data.

RESULTS

Treatment with tenecteplase saved €21 per patient while gaining 0.05 QALYs, resulting in INMB of €2381, clearly rendering tenecteplase cost-effective compared to alteplase. Importantly, tenecteplase remained the cost-effective alternative in all scenarios, including AIS patients due to large vessel occlusion (LVO). Probabilistic sensitivity analysis proved tenecteplase to be cost-effective with a 71.0% probability at a WTP threshold of €50,000/QALY.

CONCLUSIONS

Tenecteplase treatment was cost-effective for all AIS patients (including AIS patients with LVO) compared to alteplase. The finding supports the broader use of tenecteplase in acute stroke care, as health outcomes improve at acceptable costs while having practical advantages, and a similar safety profile.

Budget impact of endovascular treatment for acute ischaemic stroke patients in the Netherlands for 2015-2021

INTRODUCTION

Endovascular treatment (EVT) has been proven to be both effective and cost-effective for patients with acute ischaemic stroke. We investigated the budget impact of large-scale implementation of EVT for acute ischaemic stroke patients in the Netherlands for 2015-2021.

METHODS

An analysis was performed from a healthcare perspective as a preplanned substudy of the Multicenter Randomized Clinical trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN). Estimated yearly costs during follow-up after stroke for patients who had or had not been treated with EVT as add-on to usual care were linked to numbers of new patients retrieved from 2 Dutch registries of EVT that started after the last inclusion in MR CLEAN (2014). Aggregated costs and costs per care sector were calculated based on prevalence using a population dynamic tool.

RESULTS

From 2015, the yearly number of new acute ischaemic stroke patients receiving EVT increased almost threefold, from 812 in 2015 to 2,370 in 2021. The introduction of EVT plus usual care resulted in estimated net annual savings that increased from € 2.9 million in 2015 to € 58 million in 2021.

CONCLUSION

Offering EVT as add-on to usual care for acute ischaemic stroke patients was increasingly cost saving from a national healthcare perspective but affected distinct healthcare sectors differently.

In vivo imaging of cerebral glucose metabolism informs on subacute to chronic post-stroke tissue status - A pilot study combining PET and deuterium metabolic imaging

Recanalization therapy after acute ischemic stroke enables restoration of cerebral perfusion. However, a significant subset of patients has poor outcome, which may be caused by disruption of cerebral energy metabolism. To assess changes in glucose metabolism subacutely and chronically after recanalization, we applied two complementary imaging techniques, fluorodeoxyglucose (FDG) positron emission tomography (PET) and deuterium (2H) metabolic imaging (DMI), after 60-minute transient middle cerebral artery occlusion (tMCAO) in C57BL/6 mice. Glucose uptake, measured with FDG PET, was reduced at 48 hours after tMCAO and returned to baseline value after 11 days. DMI revealed effective glucose supply as well as elevated lactate production and reduced glutamate/glutamine synthesis in the lesion area at 48 hours post-tMCAO, of which the extent was dependent on stroke severity. A further decrease in oxidative metabolism was evident after 11 days. Immunohistochemistry revealed significant glial activation in and around the lesion, which may play a role in the observed metabolic profiles. Our findings indicate that imaging (altered) active glucose metabolism in and around reperfused stroke lesions can provide substantial information on (secondary) pathophysiological changes in post-ischemic brain tissue.

The Charlotte Large Artery Occlusion Endovascular Therapy Outcome Score Predicts Poor Outcomes 1 Year After Endovascular Thrombectomy

OBJECTIVE

We evaluated the ability of several outcome prognostic scales to predict poor 1-year outcomes and mortality after endovascular thrombectomy.

METHODS

In this retrospective analysis from the stroke registry of a large integrated health system, consecutive patients presenting from August 2020 to September 2021 with an anterior circulation large-vessel occlusion stroke treated with endovascular thrombectomy were included. Multivariable logistic regression was performed to determine the ability of each scale to predict the primary outcome (1-year modified Rankin Scale [mRS] score of 4-6) and the secondary outcome (1-year mortality). Area under the curve analyses were performed for each scale.

RESULTS

In 237 included patients (mean age 68 [±15] years; median National Institutes of Health Stroke Scale score 16 [11-21]), poor 1-year outcomes were present in 116 patients (49%) and 1-year mortality was 34%. The CLEOS (Charlotte Large Artery Occlusion Endovascular Therapy Outcome Score), which incorporates age, baseline National Institutes of Health Stroke Scale score, initial glucose level, and computed tomography perfusion cerebral blood volume index, had a significant association with poor 1-year outcomes (per 25-point increase; odds ratio, 1.0134; P = 0.02). CLEOS and PRE (Pittsburgh Response to Endovascular Therapy) were both significantly associated with 1-year mortality. Area under the curve values were comparable for CLEOS, PRE, Houston Intra-Arterial Therapy 2, and Totaled Health Risks in Vascular Events to predict 1-year mRS score 4-6 and mortality. Only 1 of 18 patients with CLEOS ≥690 had a 1-year mRS score of 0-3.

CONCLUSIONS

CLEOS can predict poor 1-year outcomes and mortality for patients with anterior circulation large-vessel occlusion using prethrombectomy variables.

Endovascular thrombectomy in young patients with stroke

BACKGROUND

Endovascular treatment (ET) is standard of care in patients with acute ischemic stroke due to large vessel occlusion, but data on ET in young patients remain limited.

AIM

We aim to compare outcomes for young stroke patients undergoing ET in a matched cohort.

METHODS

We analyzed patients from an observational multicenter cohort with acute ischemic stroke and ET, the German Stroke Registry-Endovascular Treatment trial. Baseline characteristics, procedural parameters, and functional outcome at 90 days were compared between young (<50 years) and older (⩾50 years) patients with and without nearest-neighbor 1:1 propensity score matching.

RESULTS

Out of 6628 acute ischemic stroke patients treated with ET, 363 (5.5%) were young. Young patients differed with regard to prognostic outcome characteristics. Specifically, National Institutes of Health Stroke Scale (NIHSS) at admission was lower (median 13, interquartile range (IQR) 8-17 vs. 15, IQR 9-19, p < 0.001), and prestroke dependence was less frequent (2.9% vs. 12.2%, p < 0.001) than in older patients. Compared to a matched cohort of older patients, ET was faster (time from groin puncture to flow restoration, 35 vs. 45 min, p < 0.001) and intracranial hemorrhage was less frequent in young patients (10.0% vs. 25.9%, p < 0.001). Good functional outcome (modified Rankin Scale (mRS) 0-2) at 3 months was achieved more frequently in young patients (71.6% vs. 44.1%, p < 0.001), and overall mortality was lower (6.7% vs. 25.4%, p < 0.001). Among previously employed young patients (n = 177), 37.9% returned to work at 3-month follow-up, while 74.1% of the remaining patients were still undergoing rehabilitation.

CONCLUSION

Young stroke patients undergoing ET have better outcomes compared to older patients, even when matched for prestroke condition, comorbidities, and stroke severity. Hence, more liberal guidelines to perform ET for younger patients may have to be established by future studies.

Temporal lobe atrophy as a potential predictor of functional outcome in older adults with acute ischemic stroke

BACKGROUND

To explore whether temporal lobe atrophy predicts 3-month functional outcome in a population of patients with anterior circulation acute ischemic stroke (AIS) treated with mechanical thrombectomy (MT).

METHODS

We retrospectively selected patients > 65 years from our prospective endovascular stroke registry between June 2013 and August 2018. According to 3-month modified Rankin Scale (mRS), patients were divided in two groups, named good (mRS ≤ 2) and poor (mRS > 2) outcome. Measures of temporal lobe atrophy (i.e., interuncal distance [IUD], medial temporal lobe thickness [mTLT] and radial width of temporal horn [rWTH]) were assessed on pre-treatment CT scan. Cutoff values for good outcome were obtained for IUD, mTLT and rWTH by means of non-parametric ROC curve analysis. Multivariate analysis was performed to identify predictors of outcome. Ordinal shift analysis based on cutoff values was built to evaluate differences in 3-month mRS.

RESULTS

Among 340 patients, 130 (38.2%) had good and 210 (61.8%) had poor outcome. We found the following cutoff values for good outcome: < 25 mm for IUD, > 15 mm for mTLT and < 4 mm for rWTH. Lower IUD (OR 0.71; 95% CI 0.63-0.80; p < 0.0001) and rWTH (OR 0.73; 95% CI 0.61-0.87; p < 0.0001) and higher mTLT (OR 1.30; 95% CI 1.14-1.49; p < 0.0001) were independently associated with good outcome. Ordinal shift analysis based on cutoff values revealed significant differences in the rate of good outcome for rWTH (49 vs 27%; p < 0.0001), mTLT (52 vs 21%; p < 0.0001) and IUD (57 vs 17%; p < 0.0001).

CONCLUSIONS

Assessment of temporal lobe atrophy may predict functional outcome in patients with AIS treated with MT.

Safety and Efficacy of Tirofiban in Severe Ischemic Stroke Patients Undergoing Mechanical Thrombectomy

Tirofiban has recently shown encouraging efficacy and safety among acute ischemic stroke (AIS) patients with mechanical thrombectomy (MT). However, the benefits of tirofiban varied among studies depending on the patient’s condition, which was often not well analyzed. This study aimed to identify the characteristics of patients who may obtain the largest benefits from tirofiban. The efficacy endpoint was a favorable outcome defined as a modified Rankin Scale (mRS) score of 0~2 at 90 days. The safety endpoints were intracranial hemorrhage (ICH), symptomatic intracranial hemorrhage (sICH) and mortality at 90 days. Adjusted logistic regression analysis and subgroup analyses were utilized to investigate the factors associated with tirofiban and the outcome. All of 285 patients fit the inclusion criteria. Tirofiban was associated with a higher rate of favorable outcome (aOR 2.033, 95% CI, 1.002~4.123, p = 0.043) but not with an increased risk of ICH, sICH or mortality (p > 0.05). Moreover, subgroup analyses revealed that tirofiban was associated with favorable outcomes in patients with NIHSS > 14 (aOR 2.778, 95% CI 1.056~7.356, p = 0.038) but not in patients with NIHSS ≤ 14 (aOR 1.719, 95% CI 0.646~4.578, p = 0.278). No significant heterogeneity was found in the effect of tirofiban across the subgroups of age, sex, ASPECTS, time from onset to puncture, use of t-PA or stroke etiology (p for interaction > 0.05). The administration of tirofiban was associated with favorable outcomes in severe ischemic stroke patients, and further studies are needed to confirm this finding.

Evaluation of Occluded Distal Vessels with Variable Flip-Angle 3-Dimensional Turbo Spin-Echo Magnetic Resonance Imaging Before Acute Mechanical Thrombectomy

OBJECTIVE

The aim of this study was to evaluate the course of occluded distal vessels before mechanical thrombectomy (MT) for acute large vessel occlusion (LVO) with non-contrast magnetic resonance imaging (MRI). The variable flip-angle three-dimensional turbo spin-echo (VRFA-3D-TSE) method was used to evaluate the course of occluded distal vessels quickly and clearly in acute LVO cases before MT.

METHODS

Patients with acute LVO who were indicated for MT between April 2021 and March 2022 were examined by the VRFA-3D-TSE method to evaluate the distal course of occluded vessels. We included internal carotid artery (ICA) occlusion, M1 occlusion of the middle cerebral artery, and basilar artery (BA) occlusion. Preoperative images were compared to the angiographic findings after recanalization or with follow-up magnetic resonance angiography, and the results were assessed by 2 endovascular treatment specialists as excellent, good, or poor imaging.

RESULTS

MT was performed in a total of 27 patients. There were 17 patients with intracranial occlusion of the ICA, M1, and BA. Occlusion was found in the intracranial ICA in 6 patients, the M1 in 7, and the BA in 4. VRFA-3D-TSE MRI was performed in all patients, and the imaging was rated (by the 2assessors) as excellent in 12 of 17 and 14 of 17 cases, good in 5 of 17 and 3 of 17 cases, and poor in 0 of 17 cases.

CONCLUSIONS

In patients with acute LVO, VRFA-3D-TSE MRI enabled rapid and good depiction of the course of occluded distal vessels before MT without the use of contrast medium.

New Strategies for Stroke Therapy: Nanoencapsulated Neuroglobin

Stroke is a global health and socio-economic problem. However, no efficient preventive and/or palliative treatments have yet been found. Neuroglobin (Ngb) is an endogen neuroprotective protein, but it only exerts its beneficial action against stroke after increasing its basal levels. Therefore, its systemic administration appears to be an efficient therapy applicable to stroke and other neurodegenerative pathologies. Unfortunately, Ngb cannot cross the blood-brain barrier (BBB), making its direct pharmacological use unfeasible. Thus, the association of Ngb with a drug delivery system (DDS), such as nanoparticles (NPs), appears to be a good strategy for overcoming this handicap. NPs are a type of DDS which efficiently transport Ngb and increase its bioavailability in the infarcted area. Hence, we previously built hyaluronate NPS linked to Ngb (Ngb-NPs) as a therapeutic tool against stroke. This nanoformulation induced an improvement of the cerebral infarct prognosis. However, this innovative therapy is still in development, and a more in-depth study focusing on its long-lasting neuroprotectant and neuroregenerative capabilities is needed. In short, this review aims to update the state-of-the-art of stroke therapies based on Ngb, paying special attention to the use of nanotechnological drug-delivering tools.

Five-Year Outcomes After Endovascular Treatment for Large Vessel Occlusion Stroke

Background

The long-term outcomes of acute large vessel occlusion (LVO) in anterior circulation treated by endovascular treatment (EVT) remains to be determined. The aim of this study was to assess the 5-year outcomes of patients with LVO who underwent EVT.

Methods

This study was an observational, nationwide registry of consecutive patients with acute LVO who received EVT in 28 comprehensive stroke centers in China. The primary outcome was the proportion of favorable outcome [modified Rankin Scale score (mRS) 0–2] at 5 years. Secondary outcomes included proportions of patients with excellent outcome (mRS 0–1), all-cause mortality and risk of stroke recurrence at 5 years.

Results

A total of 807 patients were included into the study and had 90-day follow-up data, 657 patients had 5-year follow-up data. At 90 days, 218 patients (27.0%) had an excellent outcome, 349 patients (43.2%) had a favorable functional outcome. 199 patients (24.7%) died. At 5 years, 190 patients (28.9%) had an excellent outcome, 261 patients (39.7%) had a favorable functional outcome, 317 patients (48.2%) died and 129 (28.2%) had stroke recurrence. Because of missing 5-year follow-up data, among available 269 patients who achieved functional independence at 90 days, 208 (77.3%) maintained favorable outcome, 19 (7.1%) had disability (mRS 3–5) and 42 (15.6%) died at 5 years. Furthermore, among available 189 patients with mRS 3–5 at 90 days, 53 (28.0%) patients achieved favorable functional outcome, 60 (31.7%) patients maintained unfavorable functional outcome and 76 (40.2%) patients died within 5 years. Multivariate analyses identified that younger age [odds ratio (OR): 0.96; 95% CI, 0.93–0.99; P = 0.009], lower mRS at 90 days (OR: 0.15; 95% CI, 0.10–0.23; P < 0.001) and absence of stroke recurrence (OR: 0.001; 95% CI, 0.000–0.006; P < 0.001) were significantly associated with favorable outcome at 5 years. Advanced age (OR: 1.06, 95% CI, 1.04–1.08; P < 0.001), higher mRS at 90 days (OR: 0.84; 95% CI, 0.73–0.98; P = 0.021) and atrial fibrillation (OR: 1.63; 95% CI, 1.02–2.60; P = 0.04) were independent factors for stroke recurrence.

Conclusion

Our results indicated that the beneficial effect of EVT in patients with acute LVO can be sustained during the course of at least 5 years. Reducing the risk of stroke recurrence by anticoagulation for atrial fibrillation may be a crucial strategy to improve long-term outcome.

Association of reperfusion success and emboli in new territories with long term mortality after mechanical thrombectomy

BACKGROUND

The degree of reperfusion is the most important modifiable predictor of 3 month functional outcome and mortality in ischemic stroke patients treated with mechanical thrombectomy. Whether the beneficial effect of reperfusion also leads to a reduction in long term mortality is unknown.

METHODS

Patients undergoing mechanical thrombectomy between January 2010 and December 2018 were included. The post-thrombectomy degree of reperfusion and emboli in new territories were core laboratory adjudicated. Reperfusion was evaluated according to the expanded Thrombolysis in Cerebral Infarction (eTICI) scale. Vital status was obtained from the Swiss population register. Adjusted hazard ratios (aHRs) using time split Cox regression models were calculated. Subgroup analyses were performed in patients with borderline indications.

RESULTS

Our study included 1264 patients (median follow-up per patient 2.5 years). Patients with successful reperfusion had longer survival times, attributable to a lower hazard of death within 0-90 days and for >90 days to 2 years (aHR 0.34, 95% CI 0.26 to 0.46; aHR 0.37, 95% CI 0.22 to 0.62). This association was homogeneous across all predefined subgroups (p for interaction >0.05). Among patients with successful reperfusion, a significant difference in the hazard of death was observed between eTICI2b50 and eTICI3 (aHR 0.51, 95% CI 0.33 to 0.79). Emboli in new territories were present in 5% of patients, and were associated with increased mortality (aHR 2.3, 95% CI 1.11 to 4.86).

CONCLUSION

Successful, and ideally complete, reperfusion without emboli in new territories is associated with a reduction in long term mortality in patients treated with mechanical thrombectomy, and this was evident across several subgroups.

Prognostication of ICU Patients by Providers with and without Neurocritical Care Training

BACKGROUND

Predictions of functional outcome in neurocritical care (NCC) patients impact care decisions. This study compared the predictive values (PVs) of good and poor functional outcome among health care providers with and without NCC training.

METHODS

Consecutive patients who were intubated for  ≥ 72 h with primary neurological illness or neurological complications were prospectively enrolled and followed for 6-month functional outcome. Medical intensive care unit (MICU) attendings, NCC attendings, residents (RES), and nurses (RN) predicted 6-month functional outcome on the modified Rankin scale (mRS). The primary objective was to compare these four groups' PVs of a good (mRS score 0-3) and a poor (mRS score 4-6) outcome prediction.

RESULTS

Two hundred eighty-nine patients were enrolled. One hundred seventy-six had mRS scores predicted by a provider from each group and were included in the primary outcome analysis. At 6 months, 54 (31%) patients had good outcome and 122 (69%) had poor outcome. Compared with other providers, NCC attendings expected better outcomes (p < 0.001). Consequently, the PV of a poor outcome prediction by NCC attendings was higher (96% [95% confidence interval [CI] 89-99%]) than that by MICU attendings (88% [95% CI 80-93%]), RES (82% [95% CI 74-88%]), and RN (85% [95% CI 77-91%]) (p = 0.047, 0.002, and 0.012, respectively). When patients who had withdrawal of life-sustaining therapy (n = 67) were excluded, NCC attendings remained better at predicting poor outcome (NCC 90% [95% CI 75-97%] vs. MICU 73% [95% CI 59-84%], p = 0.064). The PV of a good outcome prediction was similar among groups (MICU 65% [95% CI 52-76%], NCC 63% [95% CI 51-73%], RES 71% [95% CI 55-84%], and RN 64% [95% CI 50-76%]).

CONCLUSIONS

Neurointensivists expected better outcomes than other providers and were better at predicting poor functional outcomes. The PV of a good outcome prediction was modest among all providers.

Thrombectomy is a cost-saving procedure up to 24 h after onset

INTRODUCTION AND AIM

The treatment of ischemic stroke due to large-vessel occlusion has been revolutionized by mechanical thrombectomy (MT), as multiple trials have consistently shown improved functional outcomes compared to standard medical management both in the early and late time windows after symptom onset. However, MT is an interventional procedure that is more costly than best supportive care (BSC).

METHODS

We set out to study the cost-utility and budget impact of MT + BSC versus BSC alone for large-vessel occlusion using a combined decision tree and Markov model. The analysis was conducted from a Belgian payer perspective over a lifetime horizon, and health states were defined by the modified Rankin Scale (mRS). The treatment effect of MT + BSC combined clinical outcomes from all published early and late treatment window studies showing improved mRS after 90 days. Resource use and utilities were informed by an observational Belgian study of 569 stroke patients. Long-term mRS transitions were sourced from the Oxford Vascular study.

RESULTS

MT + BSC generated 1.31 additional quality-adjusted life years and resulted in cost savings of €10,216 per patient over lifetime. Deterministic sensitivity analyses demonstrated dominance of MT over a wide range of parameter inputs. In a Belgian setting, adding MT to BSC within an early time window for 1575 eligible stroke patients every year produced cost savings between €6.3 million (year 1) and €14.6 million (year 5), or a total cost saving of €56.2 million over 5 years.

CONCLUSION

Mechanical thrombectomy is a highly cost-effective treatment for ischemic stroke patients, providing quality-adjusted survival at lower health care cost, both when given in an early time window, as well as in a late time window.

Quantified health and cost effects of faster endovascular treatment for large vessel ischemic stroke patients in the Netherlands

BACKGROUND

The effectiveness of endovascular treatment (EVT) for large vessel occlusion (LVO) stroke severely depends on time to treatment. However, it remains unclear what the value of faster treatment is in the years after index stroke. The aim of this study was to quantify the value of faster EVT in terms of health and healthcare costs for the Dutch LVO stroke population.

METHODS

A Markov model was used to simulate 5-year follow-up functional outcome, measured with the modified Rankin Scale (mRS), of 69-year-old LVO patients. Post-treatment mRS was extracted from the MR CLEAN Registry (n=2892): costs per unit of time and Quality-Adjusted Life Years (QALYs) per mRS sub-score were retrieved from follow-up data of the MR CLEAN trial (n=500). Net Monetary Benefit (NMB) at a willingness to pay of €80 000 per QALY was reported as primary outcome, and secondary outcome measures were days of disability-free life gained and costs.

RESULTS

EVT administered 1 min faster resulted in a median NMB of €309 (IQR: 226;389), 1.3 days of additional disability-free life (IQR: 1.0;1.6), while cumulative costs remained largely unchanged (median: -€15, IQR: -65;33) over a 5-year follow-up period. As costs over the follow-up period remained stable while QALYs decreased with longer time to treatment, which this results in a near-linear decrease of NMB. Since patients with faster EVT lived longer, they incurred more healthcare costs.

CONCLUSION

One-minute faster EVT increases QALYs while cumulative costs remain largely unaffected. Therefore, faster EVT provides better value of care at no extra healthcare costs.

Efficacy outcomes and safety measures of intravenous tirofiban or eptifibatide for patients with acute ischemic stroke: a systematic review and meta-analysis of prospective studies

To review the literature for randomized control trials (RCTs) and prospective cohort studies investigating the safety and efficacy of tirofiban and eptifibatide in patients with acute ischemic stroke (AIS). PubMed, Embase, and the Cochrane library were searched for available papers published up to September 2021. The efficacy was evaluated based on the 3-month favorable outcome [modified Rankin scale (mRS) = 0-1], functional outcome (mRS = 0-2), and the last available National Institutes of Health Stroke Scale (NIHSS) score measured in each study. Twelve studies (two RCTs and 10 prospective cohorts) and 2926 patients were included. Treatment with tirofiban or eptifibatide had no effects on the favorable outcome (RR = 1.09, 95% CI 0.89-1.35, P = 0.411), functional outcome (RR = 1.12, 95% CI 0.98-1.28, P = 0.010), and last available NIHSS (WMD = - 2.32, 95% CI - 5.14 to 0.50, P = 0.106), but might increase mortality (RR = 0.84, 95% CI 0.71-0.99, P = 0.121). The sensitivity analyses showed that the meta-analyses were robust. There was no significant publication bias. Tirofiban did not increase the risk of ICH (P = 0. 423) and sICH (P = 0. 990) but increased the risk of fatal ICH (RR = 3.59, 95% CI 1.62-7.96, P = 0.002). Thrombolysis/thrombectomy did not influence any of the outcomes. Adding tirofiban or eptifibatide to thrombolysis/thrombectomy was not significantly associated with a favorable outcome (mRS = 0-1) nor functional outcome (mRS = 0-2) in patients with AIS at 3 months, but might be associated with mortality, possibly due to fatal ICH. The NIHSS was also not significantly different between the intervention and control groups after treatments.

Economic Evaluation of Endovascular Treatment for Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Endovascular treatment for acute ischemic stroke has been proven clinically effective, but evidence of the cost-effectiveness based on real-world data is scarce. The aim of this study was to assess whether endovascular therapy plus usual care is cost-effective in comparison to usual care alone in acute ischemic stroke patients.

METHODS

An economic evaluation was performed from a societal perspective with a 2-year time horizon. Empirical data on health outcomes and the use of resources following endovascular treatment were gathered parallel to the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) and its 2-year follow-up study. Incremental cost-effectiveness ratios were calculated as the extra costs per additional patient with functional independence (modified Rankin Scale score 0-2) and the extra cost per quality-adjusted life year gained.

RESULTS

The mean costs per patient in the intervention group were $126 494 versus $143 331 in the control group (mean difference, -$16 839 [95% CI, -$38 113 to $5456]). Compared with patients in the control group, more patients in the intervention group achieved functional independence, 37.2% versus 23.9% (absolute difference, 13.3% [95% CI, 4.0%-22.0%]) and they generated more quality-adjusted life years, 0.99 versus 0.83 (mean difference of 0.16 [95% CI, 0.04-0.29]). Endovascular treatment dominated standard treatment with $18 233 saved per extra patient with a good outcome and $105 869 saved per additional quality-adjusted life year.

CONCLUSIONS

Endovascular treatment added to usual care is clinically effective, and cost saving in comparison to usual care alone in patients with acute ischemic stroke.

REGISTRATION

URL: https://www.trialregister.nl/trial/695; Unique identifier: NL695. https://www.isrctn.com/ISRCTN10888758; Unique identifier: ISRCTN10888758.

Variability of the Modified Rankin Scale Score Between Day 90 and 1 Year After Ischemic Stroke

Objective

Studies indicate that the functional outcome evolves in the year after ischemic stroke onset. However, the traditional outcome measure in stroke trials is the modified Rankin Scale (mRS) at 90 days from onset. To determine mRS fluctuations in the first year after stroke, we examined data from 3 major stroke trials.

Methods

In a secondary analysis, we evaluated intrapatient mRS between 90 days and 1 year from stroke onset, the mRS shift (∆mRS = 1 year-day 90), and the trials' primary outcome at day 90 and 1 year.

Results

We included 624 patients from the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study, 587 from Albumin Treatment for Acute Ischaemic Stroke, and 611 from Interventional Management of Stroke III, for which the proportion of patients with a ∆mRS change between day 90 and 1 year was 36.5%, 41.7%, and 36.0%. However, the trials' primary outcomes did not differ at 1 year vs 90 days. Similar findings were seen in a second cohort where we pooled the trials and excluded patients with recurrent stroke or death during the follow-up. In those 1,314 patients, 544 (41.4%) had a ∆mRS change, of which 379 (28.9%) had improvement and 165 (12.5%) had worsening, apart from death.

Conclusion

We describe the patient-level spectrum of mRS change from day 90 to 1 year after ischemic stroke in 3 high-quality randomized trials. The patient-level shifts consisted of a sufficiently counterbalanced number of mRS improvements and declines, which masked clinical evolution occurring in over one-third of patients. These results may have important implications, both for clinical trial design and outcome adjudication in stroke research and duration of rehabilitative therapy.

The Benefit of Endovascular Thrombectomy for Stroke on Functional Outcome Is Sustained at 12 Months

Background and Purpose

The short-term benefits of endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) have been widely documented, yet there is limited evidence to show that this is sustained in the long term. We aimed to determine whether the benefit of EVT on functional outcome at 3 months is maintained at 12 months and the factors correlating with functional independence and quality of life.

Methods

Data for analysis came from a prospective registry of consecutive patients undergoing EVT at a single Comprehensive Stroke Center (Oct 2018–Sep 2019). A phone interview was conducted for 12-month patient outcomes. Functional outcome was assessed by the modified Rankin Scale (mRS). Quality of life was determined by return to usual place of residence, work, or driving and calculation of a health utility index using the European Quality of Life-5 Dimensions questionnaire (EQ-5D-3L).

Results

Of the 151 patients who underwent EVT during the study period, 12-month follow-up was available for 145 (96%). At 12 months, 44% (n = 64) of patients were functionally independent (mRS 0–2) compared to 48% at 3 months. Mortality at 12 months was 26% compared to 17% at 3 months. Significant predictors of functional independence at 12 months were younger age and lower baseline National Institutes of Health Stroke Scale. Better quality of life significantly correlated with return to usual place of residence and driving.

Conclusion

Three-month functional independence was sustained at 12 months, indicating that EVT remains beneficial for patients with AIS in the longer term.

Endovascular Thrombectomy Treatment: Beyond Early Time Windows and Small Core

ABSTRACT

Tremendous advancements in the treatment of acute ischemic stroke in the last 25 years have been based on the principle of reperfusion in early time windows and identification of small core infarct for intravenous thrombolysis and mechanical thrombectomy. Advances in neuroimaging have made possible the safe treatment of patients with acute ischemic stroke in longer time windows and with more specific selection of patients with salvageable brain tissue. In this review, we discuss the history of endovascular stroke thrombectomy trials and highlight the neuroimaging-based trials that validated mechanical thrombectomy techniques in the extended time window with assessment of penumbral tissue. We conclude with a survey of currently open trials that seek to safely expand eligibility for this highly efficacious treatment.

From Three-Months to Five-Years: Sustaining Long-Term Benefits of Endovascular Therapy for Ischemic Stroke

Background and Purpose: During the months and years post-stroke, treatment benefits from endovascular therapy (EVT) may be magnified by disability-related differences in morbidity/mortality or may be eroded by recurrent strokes and non-stroke-related disability/mortality. Understanding the extent to which EVT benefits may be sustained at 5 years, and the factors influencing this outcome, may help us better promote the sustenance of EVT benefits until 5 years post-stroke and beyond.

Methods: In this review, undertaken 5 years after EVT became the standard of care, we searched PubMed and EMBASE to examine the current state of the literature on 5-year post-stroke outcomes, with particular attention to modifiable factors that influence outcomes between 3 months and 5 years post-EVT.

Results: Prospective cohorts and follow-up data from EVT trials indicate that 3-month EVT benefits will likely translate into lower 5-year disability, mortality, institutionalization, and care costs and higher quality of life. However, these group-level data by no means guarantee maintenance of 3-month benefits for individual patients. We identify factors and associated “action items” for stroke teams/systems at three specific levels (medical care, individual psychosocioeconomic, and larger societal/environmental levels) that influence the long-term EVT outcome of a patient. Medical action items include optimizing stroke rehabilitation, clinical follow-up, secondary stroke prevention, infection prevention/control, and post-stroke depression care. Psychosocioeconomic aspects include addressing access to primary care, specialist clinics, and rehabilitation; affordability of healthy lifestyle choices and preventative therapies; and optimization of family/social support and return-to-work options. High-level societal efforts include improving accessibility of public/private spaces and transportation, empowering/engaging persons with disability in society, and investing in treatments/technologies to mitigate consequences of post-stroke disability.

Conclusions: In the longtime horizon from 3 months to 5 years, several factors in the medical and societal spheres could negate EVT benefits. However, many factors can be leveraged to preserve or magnify treatment benefits, with opportunities to share responsibility with widening circles of care around the patient.

Mitochondrial Quality Control in Cerebral Ischemia-Reperfusion Injury

Ischemic stroke is one of the leading causes of death and also a major cause of adult disability worldwide. Revascularization via reperfusion therapy is currently a standard clinical procedure for patients with ischemic stroke. Although the restoration of blood flow (reperfusion) is critical for the salvage of ischemic tissue, reperfusion can also, paradoxically, exacerbate neuronal damage through a series of cellular alterations. Among the various theories postulated for ischemia/reperfusion (I/R) injury, including the burst generation of reactive oxygen species (ROS), activation of autophagy, and release of apoptotic factors, mitochondrial dysfunction has been proposed to play an essential role in mediating these pathophysiological processes. Therefore, strict regulation of the quality and quantity of mitochondria via mitochondrial quality control is of great importance to avoid the pathological effects of impaired mitochondria on neurons. Furthermore, timely elimination of dysfunctional mitochondria via mitophagy is also crucial to maintain a healthy mitochondrial network, whereas intensive or excessive mitophagy could exacerbate cerebral I/R injury. This review will provide a comprehensive overview of the effect of mitochondrial quality control on cerebral I/R injury and introduce recent advances in the understanding of the possible signaling pathways of mitophagy and potential factors responsible for the double-edged roles of mitophagy in the pathological processes of cerebral I/R injury.

Identifying Cerebral Large Vessel Occlusion in Acute Ischemic Stroke by MRI Positioning Scanning

Various approaches have been tried for acute ischemic stroke (AIS) treatment to shorten the time from onset to recanalization. MRI positioning scanning (PS), which must be taken before any MRI sequences, was examined whether it can detect cerebral large vessel occlusion. A total of 68 consecutive patients with AIS who underwent MRI and were treated with intravenous recombinant tissue plasminogen activator or mechanical thrombectomy at our hospital were retrospectively included in this study. Occluded vessels were identified on the axial or coronal views of PS images, and these images were compared with 3D time-of-flight MRA and digital subtraction angiogram. The sensitivities, positive predictive values (PPVs), and negative predictive values (NPVs) for internal carotid artery (ICA), the proximal M1, distal M1, and M2 segment of the middle cerebral artery occlusion were assessed, and the number of PS slices was assessed. The sensitivities of the axial slices for ICA, proximal M1, distal M1, and M2 occlusion were 62%, 21%, 35%, and 86%, respectively. The PPVs of the axial slices for ICA, proximal M1, distal M1, and M2 occlusion were 81%, 88%, 100%, and 97%, respectively, and the NPVs of the axial slices for ICA, proximal M1, distal M1, and M2 occlusion were 94%, 90%, 86%, and 100%, respectively. The detection rate for the ICA was significantly higher with three axial slices (91%) than with two slices (47%) (p <0.01). MRI PS is warranted to be referred to detect large cerebral vessel occlusion.

An Older Thrombus Delays Reperfusion after Mechanical Thrombectomy for Ischemic Stroke

Background  Thrombosis is a dynamic process, and a thrombus undergoes physical and biochemical changes that may alter its response to reperfusion therapy. This study assessed whether thrombus age influenced reperfusion quality and outcomes after mechanical thrombectomy for cerebral embolism.

Methods  We retrospectively evaluated 185 stroke patients and thrombi that were collected during mechanical thrombectomy at three stroke centers. Thrombi were pathologically classified as fresh or older based on their granulocytes' nuclear morphology and organization. Thrombus components were quantified, and the extent of NETosis (the process of neutrophil extracellular trap formation) was assessed using the density of citrullinated histone H3-positive cells. Baseline patient characteristics, thrombus features, endovascular procedures, and functional outcomes were compared according to thrombus age.

Results  Fresh thrombi were acquired from 43 patients, and older thrombi were acquired from 142 patients. Older thrombi had a lower erythrocyte content ( p  < 0.001) and higher extent of NETosis ( p  = 0.006). Restricted mean survival time analysis revealed that older thrombi were associated with longer puncture-to-reperfusion times (difference: 15.6 minutes longer for older thrombi, p  = 0.002). This association remained significant even after adjustment for erythrocyte content and the extent of NETosis (adjusted difference: 10.8 minutes, 95% confidence interval [CI]: 0.6–21.1 minutes, p  = 0.039). Compared with fresh thrombi, older thrombi required more device passes before reperfusion ( p  < 0.001) and were associated with poorer functional outcomes (adjusted common odds ratio: 0.49; 95% CI: 0.24–0.99).

Conclusion  An older thrombus delays reperfusion after mechanical thrombectomy for ischemic stroke. Adding therapies targeting thrombus maturation may improve the efficacy of mechanical thrombectomy.

Health-Related Quality of Life Among Patients With Acute Ischemic Stroke and Large Vessel Occlusion in the ESCAPE Trial

[Figure: see text].

Quality of Life in Physical, Social, and Cognitive Domains Improves With Endovascular Therapy in the DEFUSE 3 Trial

BACKGROUND AND PURPOSE

The DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3) randomized clinical trial demonstrated the efficacy of endovascular therapy in treating ischemic stroke 6 to 16 hours after onset, resulting in better functional outcomes than standard medical therapy alone. The objective of this secondary analysis is to analyze the effect of late-window endovascular treatment of ischemic stroke on quality of life (QoL) outcomes.

METHODS

Patients (n=182) who presented between 6 and 16 hours after they were last known to be well with acute anterior circulation ischemic stroke were randomized to endovascular thrombectomy plus standard medical therapy or standard medical therapy alone and followed-up through 90 days poststroke. QoL at day 90 was assessed with the QoL in Neurological Disorders measurement tool.

RESULTS

Of the 146 subjects alive at day 90, 136 (95%) filled out QoL in Neurological Disorders short forms. Patients treated with endovascular therapy had better QoL scores in each domain: mobility, social participation, cognitive function, and depression (P<0.01 for all). Variables other than endovascular therapy that were independently associated with better QoL included lower baseline National Institutes of Health Stroke Scale, younger age, and male sex. The degree to which the modified Rankin Scale captures differences in QoL between patients varied by domain; the modified Rankin Scale score accounted for a high proportion of the variability in mobility (Rs²=0.82), a moderate proportion in social participation (Rs²=0.62), and a low proportion in cognition (Rs²=0.31) and depression (Rs²=0.19).

CONCLUSIONS

Patients treated with endovascular therapy 6 to 16 hours after stroke have better QoL than patients treated with medical therapy alone, including better mobility, more social participation, superior cognition, and less depression. The modified Rankin Scale fails to capture patients' outcomes in cognition and depression, which should therefore be assessed with dedicated QoL tools. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02586415.

MR CLEAN-NO IV: intravenous treatment followed by endovascular treatment versus direct endovascular treatment for acute ischemic stroke caused by a proximal intracranial occlusion-study protocol for a randomized clinical trial

Background

Endovascular treatment (EVT) has greatly improved the prognosis of acute ischemic stroke (AIS) patients with a proximal intracranial large vessel occlusion (LVO) of the anterior circulation. Currently, there is clinical equipoise concerning the added benefit of intravenous alteplase administration (IVT) prior to EVT. The aim of this study is to assess the efficacy and safety of omitting IVT before EVT in patients with AIS caused by an anterior circulation LVO.

Methods

MR CLEAN-NO IV is a multicenter randomized open-label clinical trial with blinded outcome assessment (PROBE design). Patients ≥ 18 years of age with a pre-stroke mRS < 3 with an LVO confirmed on CT angiography/MR angiography eligible for both IVT and EVT are randomized to receive either IVT (0.9 mg/kg) followed by EVT, or direct EVT in a 1:1 ratio. The primary objective is to assess superiority of direct EVT. Secondarily, non-inferiority of direct EVT compared to IVT before EVT will be explored. The primary outcome is the score on the modified Rankin Scale at 90 days. Ordinal regression with adjustment for prognostic variables will be used to estimate treatment effect. Secondary outcomes include reperfusion graded with the eTICI scale after EVT and stroke severity (National Institutes of Health Stroke Scale) at 24 h. Safety outcomes include intracranial hemorrhages scored according to the Heidelberg criteria. A total of 540 patients will be included.

Discussion

IVT prior to EVT might facilitate early reperfusion before EVT or improved reperfusion rates during EVT. Conversely, among other potential adverse effects, the increased risk of bleeding could nullify the beneficial effects of IVT. MR CLEAN-NO IV will provide insight into whether IVT is still of added value in patients eligible for EVT.

Trial registration

www.isrctn.com: ISRCTN80619088. Registered on 31 October 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05063-5.

Distal Vessel Imaging via Intra-arterial Flat Panel Detector CTA during Mechanical Thrombectomy

BACKGROUND AND PURPOSE

Obtaining information on invisible vasculature distal to the occlusion site helps to deploy a stent retriever safely during mechanical thrombectomy for large-vessel occlusion. It is essential to reduce the amount of contrast used for detecting the vessels distal to the occlusion site because acute ischemic stroke patients tend to have chronic kidney disease and patients with severe chronic kidney disease are at an increased risk of contrast-associated acute kidney injury. We assessed whether vessels distal to the occlusion site during acute ischemic stroke with large-vessel occlusion could be visualized on angiographic images using flat panel detector CT acquired following intra-arterial diluted contrast injection, compared with MRA findings.

MATERIALS AND METHODS

Between May 2019 and January 2020, we enrolled 28 consecutive patients with large-vessel occlusions of the anterior circulation eligible for mechanical thrombectomy following MR imaging. The patients underwent CBV imaging using flat panel detector CT with an intra-arterial diluted contrast injection instead of intravenous injection. Flat panel detector CT angiographic images reconstructed from the same dataset were evaluated for image quality, collateral status of the MCA territory, and visualization of the vessels distal to the occlusion site. These findings were compared with MRA findings.

RESULTS

Twenty-two patients were retrospectively examined. Flat panel detector CT angiographic image quality in 20 patients (91%) was excellent or good. The distal portion of the occluded vessel segment was visualized in 14 patients (70%), while the proximal portion of the segment adjacent to the occluded vessel in 3 (15%) was visualized. No visualization was observed in only 1 patient (5%) with no collateral supply. Flat panel detector CT angiographic images were shown to evaluate vessels distal to the occlusion site more accurately than MRA.

CONCLUSIONS

In acute ischemic stroke with large-vessel occlusion, flat panel detector CT angiographic images could successfully visualize vessels distal to the occlusion site with a small amount of contrast material.

Adiposity and Outcome After Ischemic Stroke: Obesity Paradox for Mortality and Obesity Parabola for Favorable Functional Outcomes

BACKGROUND AND PURPOSE

A survival advantage among individuals with higher body mass index (BMI) has been observed for diverse acute illnesses, including stroke, and termed the obesity paradox. However, prior ischemic stroke studies have generally tested only for linear rather than nonlinear relations between body mass and outcome, and few studies have investigated poststroke functional outcomes in addition to mortality.

METHODS

We analyzed consecutive patients with acute ischemic stroke enrolled in a 60-center acute treatment trial, the NIH FAST-MAG acute stroke trial. Outcomes at 3 months analyzed were (1) death; (2) disability or death (modified Rankin Scale score, 2-6); and (3) low stroke-related quality of life (Stroke Impact Scale<median). Relations with BMI were analyzed univariately and in multivariate models adjusting for 14 additional prognostic variables.

RESULTS

Among 1033 patients with acute ischemic stroke, average age was 71 years (±13), 45.1% female, National Institutes of Health Stroke Scale 10.6 (±8.3), and BMI 27.5 (±5.6). In both unadjusted and adjusted analysis, increasing BMI was linearly associated with improved 3-month survival (P=0.01) odds ratios in adjusted analysis for mortality declined across the BMI categories of underweight (odds ratio, 1.7 [CI, 0.6-4.9]), normal (odds ratio, 1), overweight (0.9 [CI, 0.5-1.4]), obese (0.5, [CI, 0.3-1.0]), and severely obese (0.4 [CI, 0.2-0.9]). In unadjusted analysis, increasing BMI showed a U-shaped relation to poststroke disability or death (modified Rankin Scale score, 2-6), with odds ratios of modified Rankin Scale score, 2 to 6 for underweight, overweight, and obese declined initially when compared with normal weight patients, but then increased again in severely obese patients, suggesting a U-shaped or J-shaped relation. After adjustment, including for baseline National Institutes of Health Stroke Scale, modified Rankin Scale score 2 to 6 was no longer related to adiposity.

CONCLUSIONS

Mortality and functional outcomes after acute ischemic stroke have disparate relations with patients' adiposity. Higher BMI is linearly associated with increased survival; and BMI has a U-shaped or J-shaped relation to disability and stroke-related quality of life. Potential mechanisms including nutritional reserve aiding survival during recovery and greater frequency of atherosclerotic than thromboembolic infarcts in individuals with higher BMI.

Outcomes and long-term mortality after basilar artery occlusion-A cohort with up to 20 years' follow-up

BACKGROUND

The data on long-term outcome after basilar artery occlusion (BAO) are scarce. Little is known about BAO survivors´ outcome over decades.

AIM

We set out to investigate long-term survival and causes of death in BAO patients with up to two decades of follow-up. We also evaluated differences in outcome trends.

METHODS

Two hundred and seven BAO patients treated with intravenous thrombolysis (IVT) at the Department of Neurology, Helsinki University Hospital, between 1995 and 2016, were analyzed. Short-term outcome was assessed by modified Rankin Scale (mRS) at 3 months. Long-term cumulative survival rate was analyzed using Kaplan-Meier analysis. Factors associated with mortality were analyzed with Cox regression.

RESULTS

Moderate outcome (mRS 0-3) was achieved in 41.1% and good outcome (mRS 0-2) in 30.4% of patients at 3 months. Three-month mortality was 39.6%, of which 89% died within the first month. The median follow-up time in 3-month survivors was 8.9 years (maximum 21.8 years). Total mortality during follow-up was 52.2%. Cumulative mortality rate was 25.7%. Older age, coronary artery disease and more extensive ischemic changes on admission brain imaging were independently associated with long-term mortality. After the acute phase, the rate of other vascular causes of death increased in relation to stroke.

CONCLUSIONS

The described evolution of a large, single-center BAO cohort shows a trend towards a higher rate of good and/or moderate outcome during later years in IVT-treated patients. Survivors showed relative longevity, and the rate of cardiac and other vascular causes of death increased in relation to stroke sequelae over the long term.

Diagnostic performance of single-phase CT angiography in detecting large vessel occlusion in ischemic stroke: A systematic review

PURPOSE

To systematically review the diagnostic performance of single-phase CT angiography (CTA) in detecting intracranial large vessel occlusion (LVO).

METHOD

MEDLINE and Embase were searched for studies investigating the diagnostic performance of single-phase CTA in detecting LVO. Study quality was assessed. Sensitivity and specificity were calculated and meta-analyzed with a bivariate random-effects model. Heterogeneity was assessed with a chi-squared test.

RESULTS

Eleven studies were included. High risk of bias with regard to "patient selection", "reference standard", and "flow and timing" was present in 4, 1, and 2 studies, respectively. In 7 studies, it was unclear whether reference tests were interpreted blinded to CTA readings. There was variability in types of vessel segments analyzed, resulting in heterogeneous sensitivity and specificity (P < 0.05). Two studies provided data for the proximal anterior circulation (distal intracranial carotid artery, A1-, A2-, M1- and M2-segments), with pooled sensitivity of 88.4 % (95 % CI: 62.2-97.2 %) and pooled specificity of 98.5 % (95 % CI: 33.2-100 %). One study suggested that multiphase CTA improved agreement between nonexperts and an expert in detecting A1-, A2-, M1-, M2-, and M3-segment occlusions compared to single-phase CTA (ĸ = 0.72-0.76 vs. ĸ = 0.32-0.45). No other included study reported added value of advanced CTA (CT perfusion, 4D-CTA, or multiphase CTA) compared to single-phase CTA in detecting proximal anterior circulation LVO.

CONCLUSION

There is lack of high-quality studies on the diagnostic performance of single-phase CTA for LVO detection in the proximal anterior circulation. The added value of advanced CTA techniques in detecting proximal anterior circulation LVO is not completely clear yet.