Endovascular Therapy for Stroke Due to Basilar-Artery Occlusion

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.

[Acute ischemic stroke treatment]

Intravenous thrombolysis (IVT) and endovascular therapy (EVT) are the cornerstones of acute ischemic stroke treatment. While IVT has been an integral part of acute therapy since the mid-1990s, EVT has evolved as one of the most effective treatments in medicine over the past decade. Traditionally, systemic thrombolysis has been performed with alteplase (rtPA). More recently, tenecteplase (TNK) has been shown to be non-inferior to rtPA. TNK has some pharmacological advantages over rtPA and may lead to earlier recanalization, particularly in large vessel occlusions. All recanalization therapies are highly time dependent. To ensure rapid treatment, standard operating procedures (SOPs) should be established and followed in clinical practice. The optimal time window for IVT is 4.5 h after symptom onset and can be extended up to 9 h using specialized imaging techniques. For EVT, studies suggest a time window up to 24 h after symptom onset. In some cases, EVT has been successfully performed beyond this time window. To select patients for EVT, advanced imaging identifying salvageable brain tissue might be necessary. Even in large ischemic stroke, EVT can still improve outcome. Compared to EVT, IVT requires fewer technical and human resources, so more stroke patients can potentially be treated. In contrast, EVT requires highly trained personnel with sophisticated equipment and can, therefore, only be performed in specialized centers. Both procedures should be combined within the 4.5 h time window for patients without contraindications.

Effectiveness of mechanical thrombectomy for acute unilateral vertebral artery occlusion with patent basilar artery: Case series and literature review

OBJECTIVE

Acute unilateral vertebral artery occlusion (VAO) with a patent basilar artery (BA) often results in neurological deterioration due to brainstem infarction from occluded VA perforators, despite comprehensive medical treatment. While recent studies show mechanical thrombectomy (MT) is effective for BA occlusion as well as anterior circulation occlusions, its role in acute unilateral VAO with patent BA remains unclear. This study aims to assess the effectiveness of MT for acute unilateral VAO with patent BA in patients presenting mild symptoms.

METHODS

We retrospectively reviewed cases of acute VAO with patent BA treated at our institution from April 2016 to March 2023. Patients were assigned to two groups: the MT Group (undergoing MT for unilateral VAO) and the Control Group (receiving medical treatment, including intravenous tissue-plasminogen activator). Clinical and radiological outcomes were compared between groups to evaluate procedural feasibility and safety.

RESULTS

Five cases (four males, one female) were included, with a median age of 71 years (IQR: 56-80) and a median NIHSS score of 6 at admission (IQR: 3-11). Three patients underwent MT, and two received conservative treatment. In the MT Group, two patients with successful recanalization experienced no complications or brainstem infarction. One patient with unsuccessful recanalization and both Control Group patients showed early neurological deterioration from brainstem infarction.

CONCLUSIONS

Acute unilateral VAO with patent BA frequently exacerbates symptoms due to brainstem perforator occlusion, worsening prognosis. Successful VA recanalization may prevent symptomatic brainstem infarction, potentially improving outcomes. Larger prospective studies are warranted.

Symptoms, Imaging Features, Treatment Decisions, and Outcomes of Patients with Top of the Basilar Artery Syndrome: Experiences from a Comprehensive Stroke Center

BACKGROUND

From visual, ocular, and pupillomotor abnormalities to qualitative and more importantly rapid quantitative disturbances of consciousness, top of the basilar artery syndrome (TOBS) represents a diagnostic challenge in neurocritical care. In this monocentric retrospective cross-sectional study, we will describe this particular patient group in detail and highlight its variability and the associated implications.

METHODS

Consecutive patients with radiologically confirmed TOBS presenting to our comprehensive stroke center were analyzed from 2010 to 2022. Baseline parameters at admission, including clinical symptoms, National Institutes of Health Stroke Scale (NIHSS) score, Glasgow Coma Scale (GCS) score, and imaging parameters (mode and success of recanalization measured by the Thrombolysis in Cerebral Infarction [TICI] score, extent of infarct, and infarct localization), were assessed. Functional dependence at discharge was analyzed with the modified Rankin scale (mRS) and Barthel Index.

RESULTS

We assessed 96 eligible patients with a mean age of 70 (SD ± 14) years, 41.67% of whom were female. The median NIHSS score at admission was 19 (interquartile range [IQR] 8-35), and the median GCS score was 7 (IQR 3-15). Dysphagia was identified in 51.72% of patients, with a significant number discharged with nasogastric tubes. Most patients received both intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) (47%), whereas 32% received MT only, and 10% received no acute recanalizing therapy. Patients receiving both IVT and MT had higher frequencies of successful vessel revascularization (higher TICI scores) and better clinical outcomes compared to those receiving only MT (median mRS score 4 [IQR 2-5] vs. 5 [IQR 2-6], p = 0.046). Multivariable regression analysis confirmed that successful recanalization (TICI) and GCS score at admission were key predictors of functional outcomes.

CONCLUSIONS

A large proportion of patients presenting with TOBS were severely affected by a significant reduction in vigilance, a condition that persists in the absence of recanalization and is then associated with a relevant dependency.

Predictors and outcomes of angioplasty and stenting in acute intracranial atherosclerosis-related vertebrobasilar artery occlusion

Objective

This study aimed to investigate clinical outcomes and predictors of favorable functional outcomes after endovascular treatment, including emergent angioplasty and stenting, in patients with intracranial atherosclerotic stenosis (ICAS)-related occlusions in vertebrobasilar arteries.

Materials and methods

This retrospective case series included 46 patients with acute occlusions of vertebrobasilar arteries, due to underlying ICAS. All patients underwent a thrombectomy, followed by angioplasty and/or stenting. We performed logistic regression analyses to identify independent predictors of favorable outcomes. A favorable outcome was defined as a score of 0-3 on the 90-day modified Rankin Scale.

Results

Overall, successful reperfusion was achieved in 44/46 (95.7%) patients and 90-day favorable outcomes were achieved in 21/46 patients (45.7%). The 90-day mortality rate was 23.9% (11/46). In a multivariate binary logistic analysis, independent predictors of favorable outcome were hyperlipidemia (OR = 7.866, 95% CI: 1.093-56.590, p = 0.040), admission hyperglycemia (OR = 0.144, 95% CI: 0.023-0.914, p = 0.040), basilar artery occlusion (OR = 0.086, 95% CI: 0.008-0.907, p = 0.041), and treatment with angioplasty alone (OR = 9.779, 95% CI: 1.022-93.525, p = 0.048).

Conclusion

Our findings suggested that emergent angioplasty and/or stenting could yield high rates of successful reperfusion and favorable outcomes in patients with ICAS-related occlusions in vertebrobasilar arteries. Our study also demonstrated that hyperlipidemia and treatment with angioplasty alone were associated with favorable outcomes, in contrast, admission hyperglycemia and basilar artery occlusion were associated with unfavorable outcomes in these patients.

Predicting symptomatic intracranial hemorrhage after endovascular treatment of vertebrobasilar artery occlusion: PEACE score

BACKGROUND

Current clinical decision tools for assessing the risk of symptomatic intracranial hemorrhage (sICH) in patients with vertebrobasilar artery occlusion (VBAO) who received endovascular treatment (EVT) have limited performance. This study develops and validates a clinical risk score to precisely estimate the risk of sICH in VBAO patients.

METHODS

The derivation cohort recruited patients with VBAO who received EVT from the Posterior Circulation IschemIc Stroke Registry in China. Based on the posterior circulation-Alberta Stroke Program Early CT Score (pc-ASPECTS) evaluation method, the cohort was further divided into non-contrast CT (NCCT) and diffusion weighted imaging (DWI) cohorts to construct predictive models. sICH was diagnosed according to the Heidelberg Bleeding Classification within 48 hours of EVT. Clinical signature was constructed in the derivation cohort using machine learning and was validated in two additional cohorts from Asia and Europe.

RESULTS

We enrolled 1843 patients who underwent EVT and had complete data. pc-ASPECTS of 1710 patients was evaluated on NCCT and 699 patients on DWI. In the NCCT cohort, 1364 individuals made up the training set, of whom 101 (7.4%) developed sICH. In the DWI cohort, the training set consisted of 560 individuals, with 44 (7.9%) experiencing sICH. Predictors of sICH were: glucose, pc-ASPECTS, time from estimated occlusion to groin puncture (EOT), poor collateral circulation, and modified Thrombolysis in Cerebral Infarction (mTICI) score. From these predictors, we derived the weighted poor collateral circulation-EOT-pc-ASPECTS-mTICI-glucose (PEACE) score. The PEACE score showed good discrimination in the training set (area under the curve (AUC)NCCT=0.85; AUCDWI=0.86), internal validation set (AUCNCCT=0.81; AUCDWI=0.82), and two additional external validation set (Asia: AUCNCCT=0.78, AUCDWI=0.80; Europe: AUCNCCT=0.74, AUCDWI=0.78).

CONCLUSION

The PEACE score reliably predicted the risk of sICH in VBAO patients who underwent EVT.

Endovascular Thrombectomy versus Medical Management for Acute Basilar Artery Occlusion Stroke in the Elderly

BACKGROUND AND PURPOSE

The efficacy and safety of endovascular thrombectomy (EVT) for elderly patients with basilar artery occlusion (BAO) stroke is unclear. The purpose of this study is to investigate the safety and efficacy of EVT for elderly BAO stroke patients.

MATERIALS AND METHODS

This was an explorative retrospective analysis of the 2016-21 National Inpatient Sample in the United States. Elderly patients with BAO stroke (80 years of age or older) with an NIHSS score of at least 5 were included. Primary outcome was discharge home. Secondary outcomes included in-hospital mortality and intracranial hemorrhage (ICH). Outcomes were compared between patients treated with EVT and those treated with medical management (MM) alone. Propensity score matching (PSM) was performed to control confounders. Subgroup analyses were conducted for patients who did and did not receive IV thrombolysis (IVT).

RESULTS

We identified 2520 elderly patients with BAO stroke; 830 received EVT and 1690 received MM alone. After PSM, 1115 patients and 715 patients remained in the MM and EVT groups, respectively. Compared with PSM controls, EVT was not significantly associated with different rates of home discharge (17.5% versus 12.2%; OR, 1.36 [95% CI, 0.76-2.44], P = .30) or in-hospital mortality (31.5% versus 32.9%; OR, 1.00 [95% CI, 0.63-1.60], P = .99), but it was significantly associated with higher rates of ICH (18.2% versus 7.3%; OR, 2.69 [95% CI, 1.41-5.15], P = .003). Among patients who did not receive IVT, EVT was significantly associated with higher rates of home discharge (21.5% versus 11.5%; OR, 1.93 [95% CI, 1.02-3.66], P = .044), whereas EVT was not significantly associated with a different rate of home discharge among those treated with IVT (5.6% versus 15.0%; OR, 0.28 [95% CI, 0.05-1.46], P = .13). Interaction analysis revealed that IVT was a negative modulator of the positive association of EVTs with home discharge (interaction P = .031).

CONCLUSIONS

EVT was not significantly associated with more favorable hospitalization outcomes for elderly patients with BAO stroke, and it was significantly associated with an increased risk of ICH. EVT may be an effective treatment for patients who did not receive IVT.

AI prediction model for endovascular treatment of vertebrobasilar occlusion with atrial fibrillation

Endovascular treatment (EVT) for vertebrobasilar artery occlusion (VBAO) with atrial fibrillation presents complex clinical challenges. This comprehensive multicenter study of 525 patients across 15 Chinese provinces investigated nuanced predictors beyond conventional metrics. While 45.1% achieved favorable outcomes at 90 days, our advanced machine learning approach unveiled subtle interaction effects among clinical variables not captured by traditional statistical methods. The predictive model distinguished high-risk subgroups by integrating multiple parameters, demonstrating superior prognostic precision compared to standard NIHSS-based assessments. Novel findings include nonlinear relationships between dyslipidemia, stroke severity, and functional recovery. The developed predictive algorithm (AUC 0.719 internally, 0.684 externally) offers a more sophisticated risk stratification tool, potentially guiding personalized treatment strategies in high-complexity VBAO patients with atrial fibrillation.

Advances in the Critical Care of Ischemic Brain Infarction

Acute care for ischemic stroke has dramatically evolved over the last years. Cerebral reperfusion is possible up to 24 h after symptoms onset. Advanced brain imaging allows identifying salvageable ischemic brain tissue, and the development of newer endovascular devices permits access to distal vessels. Monitoring for neurologic deterioration, diagnosis of stroke etiology, and secondary prevention treatments are important after initial treatment. This article reviews the recent advancements in the critical care of acute ischemic stroke.

Prospective evaluation of modified Cincinnati Prehospital Stroke Severity Scale for identifying large vessel occlusion

OBJECTIVE

To develop a novel, straightforward diagnostic scale for predicting large vessel occlusion (LVO) and anterior circulation LVO (ALVO) in the emergency setting, evaluating its validity against existing scales.

METHODS

We prospectively enrolled patients with suspected stroke presenting consecutively at the National Comprehensive Stroke Centre's emergency department between February 20, 2022, and November 11, 2022. Emergency physicians assessed each patient using the modified Cincinnati Prehospital Stroke Severity Scale (mCPSSS) and the National Institutes of Health Stroke Scale (NIHSS). The study analyzed the mCPSSS and other prevalent stroke scales to evaluate their efficacy in detecting LVO and ALVO, employing receiver operating characteristic curve (ROC) analysis and area under the curve (AUC) statistics to assess the scales' sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy.

RESULTS

A total of 383 patients with suspected stroke were included in this study. The performance in identifying LVO in the emergency setting was greatest for mCPSSS ≥ 2 with a sensitivity of 0.802 and specificity of 0.770, PPV of 0.644, NPV of 0.882, and accuracy of 0.781. mCPSSS ≥ 2 was 0.766 sensitive, 0.733 specific, PPV of 0.564, NPV of 0.886, and accuracy of 0.749 in predicting ALVO. The mCPSSS identified LVO and ALVO with an optimal cut-off value of 2, exhibiting AUC superior to those of other widely used stroke scales, with AUC values of 0.824 for LVO and 0.790 for ALVO.

CONCLUSION

The mCPSSS could serve as an effective and straightforward scale for identifying LVOs in emergency settings.

CLINICAL TRIAL REGISTRATION INFORMATION

https://www.chictr.org.cn/ (ChiCTR2200056776).

Efficacy and safety outcomes of endovascular versus best medical treatment in posterior cerebral artery occlusion stroke

BACKGROUND

The management of acute ischemic stroke due to isolated posterior cerebral artery occlusion (iPCAO) remains a topic of debate. This study investigates the efficacy and safety of endovascular treatment (EVT) versus best medical treatment (BMT) in patients with iPCAO.

METHODS

A systematic search was conducted across electronic databases including PubMed, Embase, and the Cochrane Library. Controlled studies comparing EVT and BMT in patients with iPCAO were selected. The primary efficacy outcome assessed was excellent outcome, defined as a modified Rankin Scale (mRS) score of 0-1. The primary safety outcome was symptomatic intracranial hemorrhage (sICH). Secondary outcomes included functional independence (mRS 0-2), early neurological improvement (ENI), and mortality rates. Statistical analyses were conducted using random effects models.

RESULTS

Eleven retrospective cohort studies involving 1811 patients with EVT and 2871 patients with BMT were analyzed. Compared with BMT, EVT was associated with a higher likelihood of an excellent outcome (adjusted OR (aOR) 1.33, 95% CI 1.14 to 1.54) and ENI (aOR 1.66, 95% CI 1.39 to 1.98), but no significant difference in functional independence (aOR 1.02, 95% CI 0.88 to 1.18). Compared with BMT, EVT may not be associated with an increased risk of sICH in patients with iPCAO (aOR 1.34, 95% CI 0.60 to 3.02) or mortality (aOR 1.31, 95% CI 0.83 to 2.08), although heterogeneity was high.

CONCLUSIONS

EVT may improve the likelihood of an excellent outcome and ENI in patients with iPCAO. However, the potential risks of sICH and mortality warrant consideration. Randomized trials are required to establish the definitive efficacy and safety of EVT in this patient population.

Whether mTICI 3 or mTICI 2b is better in patients with vertebrobasilar artery occlusion undergoing endovascular treatment depends on pc-ASPECTS

BACKGROUND

The clinical relevance of differentiating between mTICI (modified Thrombolysis In Cerebral Infarction) 2b and mTICI 3 in patients with vertebrobasilar artery occlusion (VBAO) remains unclear. This study aimed to investigate whether mTICI 3 improves functional outcomes compared with mTICI 2b in patients with VBAO and whether this improvement differs according to extent of ischemic damage.

METHODS

This retrospective study enrolled patients with VBAO within 24 hours of the estimated occlusion time at 65 stroke centers in a nationwide registration in China. The primary outcome was favorable functional outcome (modified Rankin scale score 0-3) at 90 days. Patients were matched by final mTICI grade using propensity score matching (PSM) and inverse probability of treatment weighting (IPTW). Logistic regression and ordinal regression models were used to assess the impact of mTICI 2b versus mTICI 3 grading on prognosis, based on different extent of ischemia damage (posterior circulation Alberta Stroke Program Early CT Score-pc-ASPECTS of 9-10, 7-8, and 3-6) and treatment strategies (bridging therapy and direct endovascular therapy (EVT)).

RESULTS

A total of 2075 patients with VBAO and successful reperfusion were included, 652 patients (31.4%) achieved mTICI 2b and 1423 patients (68.6%) achieved mTICI 3. After adjustment for confounders, achieving mTICI 3 following EVT in patients with VBAO and pc-ASPECTS 9-10 (OR 1.54, 95% CI 1.16 to 2.03) and pc-ASPECTS 7-8 (OR 1.80, 95% CI (1.26 to 2.56) were associated with favorable functional outcome compared with mTICI 2b, especially in those receiving direct EVT. However, in patients with pc-ASPECTS≤6, functional outcomes at 90 days did not differ between mTICI 3 and mTICI 2b (OR 1.12, 95% CI 0.67 to 1.88), irrespective of using bridging therapy or direct EVT.

CONCLUSION

In patients with VBAO undergoing EVT with pc-ASPECTS>6, achieving mTICI 3 favors better outcomes compared with mTICI 2b, especially in those receiving direct EVT. However, in patients with pc-ASPECTS≤6, mTICI 3 did not improve functional outcomes compared with mTICI 2b. Interventionalists should carefully assess the risk-benefit of additional maneuvers once mTICI 2b reperfusion is restored in EVT for patients with VBAO and pc-ASPECTS≤6. Further studies are needed to guide treatment decisions in these cases.

Developing a Coordinated Registry Network for devices used for acute ischemic stroke intervention: basilar artery occlusion quality assessment pilot

BACKGROUND

Real-world data can be helpful in evaluating endovascular therapy (EVT) in ischemic stroke care. We conducted a pilot study to aggregate data on basilar artery occlusion (BAO) EVT from existing registries in the USA. We evaluated the availability, completeness, quality, and consistency of common data elements (CDEs) across data sources.

METHODS

We harmonized patient-level data from five registry data sources and assessed the availability, completeness (defined by the presence in at least four data sources), and consistency of CDEs. We assessed data quality based on seven pre-defined critical domains for BAO EVT investigation: baseline patient and disease characteristics; time metrics; description of intervention; adjunctive devices, revascularization scores, complications; post-intervention National Institutes of Health Stroke Scale scores; discharge disposition; 30-day and 90-day mortality and modified Rankin Scale (mRS) scores.

RESULTS

The aggregated dataset of five registries included 493 BAO procedures between January 2013 and January 2020. In total, 88 CDEs were screened and 35 (40%) elements were considered prevalent. Of these 35 CDEs, the majority were collected for >80% of cases when aggregated. All seven pre-defined domains for BAO device investigation could be fulfilled with harmonized data elements. Most data elements were collected with consistent or compatible definitions across registries. The main challenge was the collection of 90-day outcomes.

CONCLUSIONS

This pilot shows the feasibility of aggregating and harmonizing critical CDEs across registries to create a Coordinated Registry Network (CRN). The CRN with partnerships between multiple registries and stakeholders could help improve the breadth and/or depth of real-world data to help answer relevant questions and support clinical and regulatory decisions.

Mechanical thrombectomy in basilar artery occlusions: impact of first-line strategy as a function of the occlusion level

BACKGROUND

Retrospective studies suggest the superiority of first-line contact aspiration (CA) thrombectomy over stent-retriever (SR) in basilar artery occlusions (BAO). We aimed to investigate the impact of first-line mechanical thrombectomy per the occlusion level, considering differences in stroke etiology prevalence between proximal and distal BAO.

METHODS

A retrospective, multicentric analysis of the Endovascular Treatment in Ischemic Stroke Registry (ETIS) included consecutive BAO patients treated from January 2016 to May 2022. Patients were categorized into SR (±aspiration) and CA alone groups. Occlusion levels were determined through digital subtraction angiography. Favorable clinical outcome was defined as 90-day modified Rankin Scale (mRS) 0-3.

RESULTS

A total of 380 patients were analyzed (251 CA alone, 129 SR±aspiration). Globally, first-line SR showed lower recanalization rates (89.1% vs 94.8%, OR=0.29, 95% CI 0.16 to 0.53; p<0.001) and worse clinical outcomes (mRS 0-3: 46.0% vs 52.2%, OR=0.62, 95% CI 0.44 to 0.87; p=0.006) compared with CA. In proximal occlusions, SR was significantly associated with poorer clinical outcomes (mRS 0-3: 20.9% vs 37.1%; OR=0.40, 95% CI 0.19 to 0.83; p=0.014) despite similar recanalization rates. Conversely, in distal occlusions there was no difference in clinical outcomes although recanalization rates were higher with CA (modified Thrombolysis in Cerebral Infarction score (mTICI 2b/3): 97.7% vs 91.7%; OR=0.17, 95% CI 0.05 to 0.66; p=0.01).

CONCLUSIONS

In our BAO population, CA demonstrated better angiographic outcomes in middle and distal occlusions and better clinical outcomes in proximal occlusions. This translated into better angiographic and clinical results in the global study population. Clinical results were particularly influenced by the negative impact of SR on 90-day mRS, independently of recanalization rates in proximal BAO.

Aspiration only versus stent retriever only thrombectomy in basilar artery occlusion: a propensity score-matched analysis of the German Stroke Registry

BACKGROUND

Endovascular treatment has become the standard care for acute basilar artery occlusion (BAO). Uncertainty persists about the optimal thrombectomy technique.

OBJECTIVE

To compare aspiration thrombectomy with stent retriever thrombectomy in patients with BAO in a multicenter real-world patient population.

METHODS

We analyzed data from the German Stroke Registry-Endovascular Treatment (GSR-ET). Patients with isolated BAO who underwent either aspiration or stent retriever thrombectomy were compared, including propensity score matching (PSM). The primary outcome measure was the modified Rankin Scale shift analysis at 90 days. Secondary outcomes included symptomatic intracranial hemorrhage (sICH), procedure complications, and metrics.

RESULTS

Of 13 082 patients in the GSR-ET, 387 patients (mean age 72.0±13.1 years; 45.0% female) fulfilled the inclusion criteria. The thrombectomy technique was aspiration only in 195 (50.4%) and stent retriever only in 192 (49.6%) patients. Functional outcome did not differ between the groups, either before (common OR (cOR) 0.94; 95% CI 0.64 to 1.38) or after PSM (cOR=1.37; 95% CI 0.90 to 2.09). There was no significant difference in sICH (2.6 vs 5.5%; P=0.231; OR=0.46; 95% CI 0.14 to 1.47), but aspiration thrombectomy demonstrated fewer procedure-related complications (4.6% vs 12.5%; P=0.017), a shorter procedure duration (24 vs 48 min; P<0.001), and higher first pass recanalization rates (75.1% vs 44.8%; P<0.001).

CONCLUSIONS

In this study both aspiration and stent retriever thrombectomy showed equal efficacy in terms of functional outcome in patients with BAO. However, procedure complications and metrics might favor aspiration over stent retriever thrombectomy.

Chinese stroke association guidelines on reperfusion therapy for acute ischaemic stroke 2024

BACKGROUND

Stroke remains a major global health challenge, with China experiencing a significant burden due to its high incidence and severe outcomes. Reperfusion therapies, such as intravenous thrombolysis and endovascular thrombectomy, have shown substantial benefits in improving early outcomes for ischaemic stroke. Recent clinical trials have validated the safety and efficacy of a broader range of thrombolytic agents and expanded the eligible patient populations for both intravenous thrombolysis and mechanical thrombectomy. This guideline aims to provide the latest evidence-based insights in the field of reperfusion therapy.

METHODS

The Chinese Stroke Association (CSA) established a writing group to develop updated guidelines on reperfusion therapy for acute ischaemic stroke. A comprehensive search of MEDLINE (via PubMed) was conducted up to 30 September 2024. Experts in the field of stroke engaged in extensive discussions, both online and offline, to evaluate the latest evidence. Each recommendation was graded using the CSA's class of recommendation and level of evidence in the Guideline Development Manual of the CSA.

RESULTS

This guideline, reviewed and approved by the CSA Guidelines Writing Group, outlines the criteria for patient selection for thrombolysis and thrombectomy and summarises the latest evidence on various thrombolytic drug options to support decision-making in reperfusion therapy. Additionally, the guideline includes green channel flow charts for intravenous thrombolysis and mechanical thrombectomy, designed to assist clinicians in optimising their clinical decisions.

CONCLUSION

This guideline updates the latest advancements in the field of reperfusion therapy for acute ischaemic stroke. It is anticipated that future clinical research will further advance areas such as innovative thrombolytic agents, expanded indications for thrombolysis and mechanical thrombectomy.

Intra-arterial tenecteplase after successful endovascular recanalisation in patients with acute posterior circulation arterial occlusion (ATTENTION-IA): multicentre randomised controlled trial

OBJECTIVE

To assess whether intra-arterial tenecteplase administered after successful endovascular recanalisation improves outcomes in patients with acute arterial occlusion of the posterior circulation.

DESIGN

Multicentre randomised controlled trial.

SETTING

31 hospitals in China, 24 January 2023 to 24 August 2023.

PARTICIPANTS

208 patients with successful recanalisation (grade 2b50-3 on the extended thrombolysis in cerebral infarction scale) of an occlusion in the V4 segment of the vertebral artery; proximal, middle, or distal segment of the basilar artery; or P1 segment of the posterior cerebral artery: 104 were randomly allocated to receive tenecteplase and 104 to receive standard care.

INTERVENTIONS

Intra-arterial tenecteplase (0.0625 mg/kg, maximum dose 6.25 mg) administered proximal to the residual thrombus (if still present) or distal to the origin of the main pontine perforator branches over 15 seconds, or endovascular treatment only (control group).

MAIN OUTCOME MEASURES

The primary outcome was freedom from disability (modified Rankin scale score 0 or 1) at 90 days after randomisation. Primary safety outcomes included symptomatic intracranial haemorrhage within 36 hours and all cause mortality at 90 days. All efficacy and safety analyses were conducted by intention to treat and adjusted for age, pre-stroke modified Rankin scale score, time from onset of moderate to severe stroke (National Institutes of Health stroke scale score ≥6) to randomisation, hypertension, and baseline stroke severity.

RESULTS

At 90 days, 36 patients (34.6%) in the tenecteplase group and 27 (26.0%) in the control group had a modified Rankin scale score of 0 or 1 (adjusted risk ratio 1.36, 95% confidence interval 0.92 to 2.02; P=0.12). Mortality at 90 days was similar between the tenecteplase and control groups: 29 (27.9%) v 28 (26.9%), adjusted risk ratio 1.13, 0.73 to 1.74. Symptomatic intracranial haemorrhage within 36 hours occurred in eight patients (8.3%) in the tenecteplase group and three (3.1%) in the control group (adjusted risk ratio 3.09, 0.78 to 12.20).

CONCLUSIONS

In patients with acute ischaemic stroke due to acute posterior large or proximal vessel occlusion, intra-arterial tenecteplase administered after successful recanalisation was not associated with a statistically significant reduction in combined disability and mortality at 90 days.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05684172.

Risk of Symptomatic Intracranial Hemorrhage After Mechanical Thrombectomy in Randomized Clinical Trials: A Systematic Review and Meta-Analysis

BACKGROUND

Symptomatic intracranial hemorrhage (sICH) is the most dreaded complication after reperfusion therapy for acute ischemic stroke. We performed a meta-analysis of randomized controlled trials to estimate and compare risks of sICH after mechanical thrombectomy (MT) depending on the location of the large vessel occlusion, concomitant use of intravenous thrombolysis, timing of treatment, and core size.

METHODS

Randomized controlled trials were included, following a comprehensive search of different databases from inception to 1 March 2024. Random-effect models in a meta-analysis were employed to obtain the pooled risk ratios (RRs) and their corresponding 95% confidence intervals (95% CI) for sICH with MT, and were then compared to other reperfusion treatment regimens, including best medical treatment and intravenous thrombolysis (IVT).

RESULTS

MT in the anterior circulation was associated with a significantly higher risk of sICH as compared with no-MT (RR: 1.46; 95%CI: 1.03-2.07; p = 0.037). The risk of sICH was comparable between the MT and MT+IVT groups (RR: 0.77; 95%CI: 0.57-1.03; p = 0.079). There was no difference in sICH risk with MT as compared with no-MT within 6 h of last known well (RR: 1.14; 95%CI: 0.78-1.66; p = 0.485) and beyond that time (RR: 1.29; 95%CI: 0.80-2.08; p = 0.252); the risk of sICH was also comparable between MT conducted within 6 h of last known well and MT conducted beyond that time (p = 0.512). The sICH risk for MT in the posterior circulation (RR: 7.48; 95%CI: 2.27-24.61) was significantly higher than for MT in the anterior circulation (RR: 1.18; 95%CI: 0.90-1.56) (p = 0.003). MT was also associated with a significantly higher sICH risk than no-MT among patients with large core strokes (RR: 1.71; 95%CI: 1.09-2.66, p = 0.018).

CONCLUSIONS

When evaluating cumulative evidence from randomized controlled trials, the risk of sICH is increased after MT compared with patients not treated with MT. Yet, the difference is largely driven by the greater risk of sICH in patients treated with MT for posterior circulation occlusions and, to a lesser degree, large core strokes. Concomitant use of intravenous thrombolysis and the use of MT in the extended therapeutic window do not raise the risk of sICH.

Long-term outcome of endovascular thrombectomy in patients with acute ischemic stroke: a systematic review and meta-analysis

BACKGROUND

Randomized controlled trials have demonstrated the efficacy and safety of endovascular thrombectomy (EVT) in patients with acute large vessel occlusion stroke. However, its long-term benefits remain uncertain. Therefore, this study aimed to investigate the long-term clinical outcomes of EVT.

METHODS

We searched PubMed, Embase, Cochrane Library, and Web of Science databases to identify relevant literature pertaining to patients with acute ischemic stroke who were treated with EVT plus medical management (MM) compared with MM alone, until August, 31, 2024. The primary outcome was functional independence (defined as a score of 0 to 2 on the modified Rankin scale [mRS]) at 12 months or beyond, while the safety outcome was mortality at 12 months or longer. Effect sizes were computed as risk ratio (RR) with random-effect or fixed-effect models. This study was registered on the International Prospective Register of Systematic Reviews on June 15, 2024 (PROSPERO, CRD42024554043).

RESULTS

A total of 4546 articles were obtained through the search. After excluding those that did not meet the inclusion criteria, 9 randomized controlled trials with 3358 patients (1821 and 1537 assigned to EVT + MM and MM alone group, respectively) were included in this analysis. The EVT + MM group had a higher proportion of functional independence (32.9% vs 18.2%, risk ratio 2.07, 95% confidence interval 1.50-2.87, P < 0.001) and lower mortality (34.1% vs 39.7%, risk ratio 0.86, 95% confidence interval 0.78-0.94, P = 0.001) compared to the MM group.

CONCLUSION

Endovascular thrombectomy was associated with improved functional outcomes and reduced mortality in acute large vessel occlusion stroke patients and presented a long-term favorable effect.

Endovascular therapy for acute vertebrobasilar occlusion (VERITAS): a systematic review and individual patient data meta-analysis

BACKGROUND

Trials of endovascular therapy for basilar artery occlusion, including vertebral occlusion extending into the basilar artery, have shown inconsistent results. We aimed to pool data to estimate safety and efficacy and to explore the benefit across pre-specified subgroups through individual patient data meta-analysis.

METHODS

VERITAS was a systematic review and meta-analysis that pooled patient-level data from trials that recruited patients with vertebrobasilar ischaemic stroke who were randomly assigned to treatment with either endovascular therapy or standard medical treatment alone. We included studies done between Jan 1, 2010, and Sept 1, 2023. The primary outcome was 90-day favourable functional status (modified Rankin Scale [mRS] score 0-3, with a score of 3 indicating moderate disability). Safety outcomes were symptomatic intracranial haemorrhage and 90-day mortality.

FINDINGS

We screened 934 titles and abstracts. Of these, seven (<1%) full texts were screened. We included four trials (ATTENTION, BAOCHE, BASICS, and BEST). The pooled data included 988 patients (556 [56%] in the intervention groups and 432 [44%] in the control groups; median age 67 years [IQR 58-74]; 686 (69%) were male and 302 (31%) were female). 904 (91%) patients were randomly assigned within 12 h of estimated stroke onset. Three RCTs were done in a Chinese population and one included European and Brazilian patients. The proportion of patients achieving favourable functional status was higher in the endovascular therapy than control group (90-day mRS score 0-3 in 251 [45%] participants vs 128 [30%]; adjusted common odds ratio 2·41 [95% CI 1·78-3·26]; p<0·0001). Endovascular therapy led to an increase in functional independence (mRS score 0-2 in 194 [35%] participants vs 89 [21%]; 2·52 [1·82-3·48]; p<0·0001) as well as a reduction in both the degree of overall disability (2·09 [1·61-2·71]; p<0·0001) and mortality (198 [36%] of 556 patients vs 196 [45%] of 432; 0·60 [0·45-0·80]; p<0·0001) at 90 days, despite higher rates of symptomatic intracranial haemorrhage (30 [5%] of 548 vs two [<1%] of 413; 11·98 [2·82-50·81]; p<0·0001). Heterogeneity of treatment effect was noted for baseline stroke severity (uncertain effect in baseline National Institutes of Health Stroke Scale <10) and occlusion site (greater benefit with more proximal occlusions) but not across subgroups defined by age, sex, baseline posterior circulation Alberta Stroke Program Early CT Score, presence of atrial fibrillation or intracranial atherosclerotic disease, and time from onset to imaging.

INTERPRETATION

VERITAS supports the robust benefit of endovascular therapy in patients with vertebrobasilar artery occlusion with moderate to severe symptoms, with approximately 2·5-times increased likelihood of achieving a favourable functional outcome. Despite a significant increase in symptomatic intracranial haemorrhage risk, endovascular therapy for vertebrobasilar artery occlusion was associated with a significant reduction in both overall disability and mortality. Although the benefit of endovascular therapy remains uncertain for patients vertebrobasilar artery occlusion presenting with mild stroke severity and extensive infarcts on neuroimaging, we found a significant clinical benefit across a range of patients with vertebrobasilar artery occlusion.

FUNDING

None.

Impact of number of passes and futile reperfusion in basilar artery occlusion acute ischaemic stroke

INTRODUCTION

Mechanical thrombectomy (MT) is the standard of care in anterior circulation large vessel occlusion. A vital modifiable factor is successful reperfusion. While multiple passes improve the rates of successful reperfusion, previous studies have reported progressively diminishing returns. This study aimed to investigate the relationship between number of passes and outcomes in basilar artery occlusion (BAO).

METHODS

This multicentre retrospective cohort study included patients who were treated with MT for acute BAO from eight comprehensive stroke centres between 2015 and 2020. The primary outcome was favourable functional outcome (FFO) defined as modified Rankin Scale (mRS) 0-3 measured at 90 days. Secondary outcomes included spontaneous intracranial haemorrhage and mortality. Patients were stratified according to reperfusion status and the number of passes for further analysis.

RESULTS

The adjusted odds ratio (OR) for FFO 90 days for each additional pass of a thrombectomy device was 0.56 (P = 0.003). When ≤3 passes of the thrombectomy device were made, achieving reperfusion led to higher rates of FFOs. However, when >3 passes of the thrombectomy device were made, achieving reperfusion no longer led to higher rates of FFOs (FFO = 0% in patients who did not achieve reperfusion vs. FFO = 14.5 in patients who achieved reperfusion; P = 0.200). Notably, increasing number of passes was associated with a non-significant trend towards higher rate of parenchymal haemorrhage (OR 1.55, P = 0.055).

CONCLUSION

Acute BAO patients treated with up to three passes of a thrombectomy device derived improved functional outcomes from reperfusion compared to those with more than three passes. Further prospective cohort studies are necessary to validate these findings.

Endovascular Thrombectomy for Acute Vertebrobasilar Artery Occlusion with Mild Deficits: A Multicenter Registry Study

Background Endovascular thrombectomy (EVT) is an effective method for vertebrobasilar artery occlusion (VBAO) in patients with moderate to severe deficits but has unclear benefits in patients with low National Institutes of Health Stroke Scale (NIHSS) scores at hospital admission. Purpose To compare the clinical outcomes of best medical management (BMM) alone versus BMM and early EVT (door-to-puncture time [DPT] ≤ 120 minutes) versus BMM and late EVT (DPT > 120 minutes) in patients with VBAO who have NIHSS scores of 10 or less at admission. Materials and Methods This retrospective study evaluated patients with VBAO and admission NIHSS score of 10 or less who were seen at 65 stroke centers in China from December 2015 to June 2022. The primary outcome was whether the patient achieved a favorable functional outcome (a modified Rankin scale [mRS] score of 0-3 at 90 days). Adjusted multivariable logistic regression analyses were used to assess the association between treatment (BMM alone vs early EVT and BMM vs late EVT and BMM) and outcomes. Results Among 1365 patients (mean age ± SD, 65 years ± 12; 951 male) with VBAO and an NIHSS score of 10 or less at admission, 489 patients (35.8%) received EVT. Of these, 382 (78.1%) received early EVT, and 107 (21.9%) received late EVT. After adjustment for confounders, compared with BMM alone, early EVT plus BMM was associated with increased rates of favorable functional outcome (odds ratio [OR], 1.41 [95% CI: 1.05, 1.87]; P = .02), whereas late EVT plus BMM did not outperform BMM alone (OR, 0.83 [95% CI: 0.54, 1.28]; P = .39). Conclusion In patients with VBAO admitted with an NIHSS score of 10 or less, early EVT (DPT ≤ 120 minutes) combined with BMM outperformed BMM alone, whereas late EVT (DPT > 120 minutes) combined with BMM did not outperform BMM alone. © RSNA, 2025 Supplemental material is available for this article.

Presentation, treatment and outcomes of acute basilar artery occlusion: A retrospective analysis

INTRODUCTION

We aim to assess the clinical presentation, treatment, and outcomes in patients with acute basilar artery occlusion (BAO) after receiving medical management (MM) (including IV thrombolysis, antiplatelet, anticoagulation) and endovascular therapy (EVT) (including intra-arterial thrombolysis, stent placement, mechanical thrombectomy).

METHODS

This is a retrospective cohort study including all adult patients treated at three Mayo Clinic stroke centers with acute BAO from 2008 to 2021. Chart review was conducted to extract details of presentation, treatment, and outcome. Comparisons of treatment outcomes between patients treated with MM and EVT were analyzed and include changes of modified Rankin Scale (mRS) and NIHSS score change from admission to discharge.

RESULTS

A total of 182 patients were included in our final analysis: 95 in the MM group and 87 in the EVT group. There was a statistically significant difference in favorable functional outcome at discharge (mRS 0-3) favoring the MM group compared to EVT group (56.0 % vs 34.9 %; OR 0.42, p = 0.005) and the difference remained significant in multivariate analysis (OR 0.38, p = 0.048). There were significantly increased odds of having NIHSS improvement of >5 points (OR 3.94 p < 0.001), and 10 points (OR 3.92 p < 0.001) in patients treated with EVT compared to MM.

CONCLUSION

Our data demonstrates that although in general patients who received EVT had lower odds of having favorable outcomes at discharge, they were also more likely to have NIHSS score improvement of >5 and 10 points from presentation to discharge compared to MM, suggesting EVT could be beneficial in some patients.

Neutrophil-to-Lymphocyte Ratio is Associated with Clinical Outcomes in Patients Treated with Mechanical Thrombectomy for Posterior Circulation Large Vessel Occlusion

OBJECTIVE

To investigate the potential of composite inflammatory markers, including the neutrophil-to-lymphocyte ratio (NLR), in predicting outcomes in patients with posterior circulation large vessel occlusion who underwent mechanical thrombectomy (MT).

METHODS

We included patients who underwent MT for posterior circulation large vessel occlusion between February 2016 and December 2021. We then assessed composite inflammatory markers on day 1 post-MT. The primary outcome was the modified Rankin Scale score at 3 months (favorable score: 0-3). The primary safety measure was 3-month mortality. Receiver operating characteristic (ROC) curve analysis determined each marker's predictive values and optimal cutoff values. Multivariable regression analysis assessed the relationship between markers and outcomes.

RESULTS

We included a total of 137 patients (median age: 71 years, 26% female, median National Institutes of Health Stroke Scale score: 23). NLR demonstrated the best predictive value for the prognosis of patients with posterior circulation large vessel occlusion who underwent MT. ROC analysis identified an optimal NLR cutoff of 12.5 (area under curve [AUC]: 0.741, 95% CI: 0.652-0.830) for favorable outcomes and 14.1 (AUC: 0.764, 95% CI: 0.662-0.865) for predicting death. Multivariate analysis determined an NLR <12.5 as an independent predictor of favorable post-MT outcomes (odds ratio [OR]: 10.43, 95% CI: 3.85-28.29, P < 0.001), and NLR <14.1 as an independent predictor of post-MT survival (OR: 0.09, 95% CI: 0.03-0.25, P < 0.001).

CONCLUSIONS

Among the assessed markers, NLR emerged as the strongest predictor of clinical outcomes following MT for posterior circulation large vessel occlusion.

Intra-arterial tenecteplase following endovascular therapy in patients with acute posterior circulation arterial occlusion: study protocol and rationale

BACKGROUND

Recently, a randomized controlled trial showed a beneficial effect of intra-arterial thrombolysis following successful endovascular thrombectomy (EVT) in patients with acute ischemic stroke due to large vessel occlusion in the anterior circulation. Due to differences in response to thrombolytics in occlusion of the posterior circulation, the purpose of ATTENTION IA is to explore the adjunct benefit of intra-arterial thrombolysis after successful recanalization in patients presenting with large and medium vessel occlusion of the posterior circulation.

METHODS

ATTENTION-IA is an investigator-initiated, multicenter, prospective, randomized clinical trial with open-label treatment and blinded endpoint assessment (PROBE). After achieving successful recanalization (expanded Thrombolysis In Cerebral Infarction (eTICI) 2b-3) of an occlusion of the vertebral, basilar, or posterior cerebral artery, patients will be randomized 1:1 to receive intra-arterial tenecteplase or standard of care. The primary effect parameter is a modified Rankin Score of 0-1 at day 90.

RESULTS

The trial recently completed enrollment, and data collection/verification is ongoing. The final results will be made available on completion of enrollment and follow-up.

CONCLUSIONS

ATTENTION-IA will provide definitive evidence for the efficacy and safety of adjunct intra-arterial tenecteplase after successful EVT in patients with an acute posterior circulation arterial occlusion stroke presenting within 24 hours of symptom onset.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05684172.

Predictors of good outcomes and mortality after thrombectomy for basilar artery occlusion within 12 hours of onset

BACKGROUND

Patients with acute basilar artery occlusion (ABAO) who undergo combined standard medical treatment (SMT) and endovascular thrombectomy (EVT) may still have unsatisfactory outcomes. This study was conducted to identify the factors that may impact their outcomes.

METHODS

We retrospectively reviewed the data of all patients with ABAO combined with SMT and EVT in the endovascular treatment for acute basilar artery occlusion (ATTENTION) trial. A good outcome is defined as a modified Rankin Scale (mRS) score of 0-3, a poor outcome as mRS score of 4-6, and mortality as death at 90-day follow-up. The study analyzed various factors influencing the patients' good outcomes and mortality.

RESULTS

The study included 221 patients (148 men and 73 women). Among these patients, 45.7% achieved an mRS score of 0-3, while the overall mortality rate was 37.1% (82/221). A good outcome was significantly associated with younger age (adjusted OR 0.96; 95% CI 0.93 to 0.99; P=0.019), a baseline posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) of 8-10 (adjusted OR 2.34; 95% CI 1.07 to 5.12; P=0.034), and post-procedure pc-ASPECTS of 8-10 (adjusted OR 1.40; 95% CI 1.07 to 1.84; P=0.013). Additionally, time from puncture to reperfusion (adjusted OR 2.02; 95% CI 1.2 to 3.41; P=0.008) and intracranial hemorrhage (adjusted OR 3.59; 95% CI 1.09 to 11.8; P=0.035) were associated with 90-day mortality.

CONCLUSIONS

Younger age, baseline pc-ASPECTS of 8-10, and higher post-procedure pc-ASPECTS could effectively predict good outcomes for patients with ABAO undergoing EVT. Additionally, a prolonged time from puncture to reperfusion and intracranial hemorrhage can independently predict mortality.

TRIAL REGISTRATION NUMBER

NCT04751708.

Sex differences in outcomes after endovascular treatment in posterior circulation stroke: results from the MR CLEAN Registry

BACKGROUND

Women with anterior circulation large vessel occlusion (LVO) have been reported to have worse outcomes after endovascular treatment (EVT) than men. Whether these disparities also exist in LVO of the posterior circulation is yet uncertain. We assessed sex differences in clinical, technical, and safety outcomes of EVT in posterior circulation LVO.

METHODS

We used data of patients with posterior circulation LVO included in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry (2014-2018). Primary outcome was the modified Rankin Scale (mRS) score at 90 days assessed with multivariable ordinal regression analysis. Secondary outcomes included favorable functional outcome (mRS ≤3), functional independence (mRS ≤2), death within 90 days, National Institutes of Health Stroke Scale (NIHSS) score 24-48 hours postintervention, complications, successful reperfusion (extended Thrombolysis in Cerebral Ischemia 2B-3), and procedure duration analyzed with multivariable logistic and linear regression analyses.

RESULTS

We included 264 patients (42% women). Compared with men, women were older (median age 68 vs 63 years), more often had prestroke disability (mRS ≥1: 37% vs 30%), and received intravenous thrombolytics less often (45% vs 56%). Clinical outcomes were similar between sexes (adjusted (common) OR (aOR) 0.82, 95% CI 0.51 to 1.34; favorable functional outcome 50% vs 43%, aOR 1.31, 95% CI 0.77 to 2.25; death 32% vs 29%, aOR 0.98, 95% CI 0.52 to 1.84). In addition, NIHSS score after 24-48 hours (median 7 vs 9), successful reperfusion (77% vs 73%), and complications did not differ between men and women.

CONCLUSIONS

Outcomes in women treated with EVT for posterior circulation LVO were similar compared with men despite less favorable baseline characteristics in women. Therefore men and women may benefit equally from EVT.

Impact of tortuosity of the V1-segment vertebral artery on mechanical thrombectomy

Tortuosity of the vasculature poses challenges to mechanical thrombectomy (MT); however, only a few studies have reported the impact of vertebral artery (VA) tortuosity on MT. The present study aimed to investigate the impact of tortuosity of the V1-segment VA on MT in patients with acute vertebrobasilar artery occlusion (AVBAO). The patients diagnosed with AVBAO and treated with MT in the Stroke Center of Xijing Hospital from November 2019 to March 2022 were analyzed retrospectively. According to the tortuosity of V1-segment VA, patients were divided into tortuous (coiling and kinking) and non-tortuous groups (straight, single-arc, and multi-arc). A binary logistic regression model was established to analyze the association between the tortuosity of V1-segment VA and successful reperfusion (mTICI ≥ 2b), neurological improvement at 7 days, favorable and poor outcome at 90 days, and symptomatic intracranial hemorrhage (ICH) within 24 h. After adjustment for age, baseline National Institute of health stroke scale (NIHSS) score and puncture-to-recanalization time, the impact of tortuosity of the V1-segment VA on outcomes was analyzed. After screening, 35 patients were enrolled in this study. The overall rate of successful reperfusion was 74.3% (26/35), and 40% (14/34) patients achieved favorable outcomes at 90 days. Subsequently, 15/35 (42.9%) patients were included in the tortuous group, and the remaining 20 patients comprised the non-tortuous group. After adjustment for age, baseline NIHSS score, and puncture-to-recanalization time, the rate of 90-day favorable outcome in the tortuous group was significantly lower than that of the non-tortuous group (20% vs. 57.9%, P = 0.034), while the rates of reperfusion (80% vs. 73.7%) and 7-day neurological improvement (33.3% vs. 36.8%) were similar between the two groups. The incidence of 24-h symptomatic ICH in the tortuous group was higher than that in the non-tortuous group (26.7% vs. 15.8%), albeit not significantly. In patients with AVBAO, tortuosity of the V1-segment VA was negatively associated with favorable outcomes 90 days after MT.

Influence of TyG Index on Large Vascular Occlusive Stroke Following Endovascular Treatment

AIMS

This study aimed to investigate the impact of the triglyceride-glucose index (TyG index) on clinical consequences in individuals with large vascular occlusion (LVO)-induced acute ischemic stroke (AIS) following endovascular treatment (EVT).

METHODS

We conducted a single-center retrospective cohort study, including AIS with LVO who underwent EVT. Patients were categorized into TyG index groups, calculated as "(fasting triglyceride [mg/dL] × fasting blood glucose [mg/dL]/2)." Clinical outcomes were assessed, including poor outcome (modified Rankin Scale [mRS] > 2 [3-6]) at 90 days, early neurological deterioration (END), symptomatic intracranial hemorrhage (sICH), and 90-day mortality after EVT. Logistic regression and restricted cubic splines (RCS) were used to examine the relationship between the TyG index and clinical outcomes. Receiver operating characteristic (ROC) curve was constructed to evaluate the prognostic capacity of the TyG index.

RESULTS

A total of 424 patients were included. Higher TyG levels were associated with worse functional outcome at 90 days (per unit: p = 0.006), sICH (per unit: p = 0.002, T3 versus T1: p = 0.004), and 90-day mortality (T2 versus T1: p = 0.011, T3 versus T1: p = 0.029) in logistic regression. A RCS model revealed a linear association between the TyG index and poor outcome at 90 days, sICH, and 90-day mortality (p for nonlinearity > 0.05). In ROC curve analysis, the traditional risk factors model (area under the curve [AUC]: 0.824, 95% CI: 0.784-0.859) was outperformed by the conventional risk factors + TyG index model (AUC: 0.845, 95% CI: 0.807-0.878) in predicting poor outcome (p = 0.021).

CONCLUSION

A higher TyG index is associated with worse clinical outcomes in LVO-induced AIS patients after EVT. Additionally, the TyG index enhances risk prediction of traditional risk factors for poor outcome.

Congenital and acquired anomalies of the basilar artery: A pictorial essay

INTRODUCTION

The basilar artery is one of the two cases in our body where an arterial vessel is formed by the union of two others - the vertebral arteries. It provides vascular supply to essential structures for the main vital functions; the posterior cerebral arteries originate from it as terminal branches, and form part of the anastomotic circle of Willis.

IMAGING FINDINGS

Congenital and acquired anomalies of the basilar trunk are described. We provide a schematic and detailed representation of normal anatomical variants - mainly represented by the fenestrated basilar artery or the persistence of carotid-basilar anastomosis; course anomalies are also illustrated, with reference to neuro-vascular conflicts and dolichoectasia. Among congenital anomalies, this pictorial review also shows the variants of the basilar origin, such as in the case of basilar trunk arising from only one of the two vertebral arteries, and the calibre changes - which are represented by aneurysm and hypoplasia. The latter appears to be a risk factor for posterior circulation stroke, when associated with a bilateral posterior foetal variant.Among the acquired forms, this pictorial essay describes some clinical cases of dissections, non-congenital aneurysms, thrombosis and tumour with vascular encasing or compression of basilar artery.

CONCLUSION

CT angiography and MRI allow us to study the posterior intracranial circulation in detail, providing useful pre-treatment information. Therefore, knowledge of congenital or acquired anomalies of the basilar artery is essential for radiologists, neuroradiologists and neurosurgeons.

EnDovascular therapy plus best medical treatment (BMT) versus BMT alone for medIum distal veSsel occlusion sTroke (DISTAL): An international, multicentre, randomized-controlled, two-arm, assessor-blinded trial

RATIONALE

Whether endovascular therapy (EVT) in addition to best medical treatment (BMT) in people with acute ischemic stroke (AIS) due to a medium distal vessel occlusion (MDVO) is beneficial remains unclear.

AIM

To determine if people experiencing an AIS due to an isolated MDVO (defined as the co- or non-dominant M2 segment, the M3 or M4 segment of the middle cerebral artery, the A1, A2, or A3 segment of the anterior cerebral artery or the P1, P2 or P3 segment of the posterior cerebral artery) will have superior outcome if treated with EVT in addition to BMT compared to BMT alone.

SAMPLE SIZE

To randomize 526 participants 1:1 to EVT plus BMT or BMT alone.

METHODS AND DESIGN

A multicentre, international, prospective, randomized, open-label, blinded-endpoint (PROBE) superiority trial.

OUTCOMES

The primary efficacy endpoint is the distribution of disability levels on the modified Rankin Scale at 90 days. Secondary clinical efficacy outcomes include normalized change in National Institutes of Health Stroke Scale score from baseline to day 1, cognitive outcome at 90 days, and health-related quality of life at 90 days. Safety outcomes include all serious adverse events, symptomatic intracranial hemorrhage within 24 h, and all-cause mortality up to 90 days. Secondary imaging outcomes include successful reperfusion at end of EVT procedure and recanalization of target artery at 24 h.

DISCUSSION

DISTAL will inform physicians whether EVT in addition to BMT in people with AIS due to a MDVO is more efficacious than BMT alone.

European Stroke Organisation and European Society for Minimally Invasive Neurological Therapy guideline on acute management of basilar artery occlusion

The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology. Although BAO accounts for only 1%-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five ESMINT) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements. First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (albeit in small numbers) in IVT trials. Non-randomised studies of IVT-only cohorts showed high proportion of favourable outcomes. Expert Consensus suggests using IVT up to 24 h unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared to BMT alone within 6 and 6-24 h from last seen well. In both time windows, we observed a different effect of treatment depending on (a) the region where the patients were treated (Europe vs. Asia), (b) on the proportion of IVT in the BMT arm, and (c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with NIHSS below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT + BMT over BMT alone (i.e. based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT + BMT over BMT alone in proximal and middle locations of BAO compared to distal location. While recommendations for patients without extensive early ischaemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischaemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 h after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty).

The safety and efficacy of NeVa mechanical thrombectomy device in acute ischemic stroke: A systematic review and meta-analysis

BACKGROUND

Recent favorable cohort studies on endovascular therapy for ischemic stroke have predominantly utilized NeVa thrombectomy (NeVaTM) stent retrievers. We carried out a systematic review and meta-analysis to investigate the efficacy and safety of this second-generation stent retriever in acute ischemic stroke patients.

METHOD

We conducted the study according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The electronic databases of PubMed, Embase, and Scopus were searched until 26 November 2023 and was updated on August 1, 2024.

RESULTS

This meta-analysis systematically investigated 11 studies with a total of 805 patients suffering from ischemic stroke. The mean age of participants across the studies ranged from 65 to 77 years with a male preponderance of 50.16 %. While ten studies reported on the etiology of strokes, some studies reported the risk factors such as hypertension, dyslipidemia, diabetes, history of coronary artery disease, and previous stroke. The results of our study indicate that the all-hemorrhagic complications rate was 0.32 (95 %CI: 0.18-0.45), while the complete arterial recanalization rate was 0.76 [95 %CI: 0.49-1.04]. The overall recanalization rate was found to be 0.97 [95 %CI: 0.94-1.00]. Moreover, the postoperative hemorrhage rate was 0.28 [95 %CI: 0.14-0.41], while the repeated re-thrombosis rate was 0.01 [95 %CI: -0.01-0.03]. Lastly, the vasospasm rate was calculated to be 0.09 [95 %CI: -0.03-0.21].

CONCLUSION

NeVa™ is a safe option capable of achieving a high rate of recanalization and functional independence.

ABBREVIATIONS

PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PROSPERO, International Prospective Register of Systematic Reviews; NeVa™, NeVa Thrombectomy; ICH, Intracranial Hemorrhage; mTICI, modified Thrombolysis in Cerebral Infarction; mRS, modified Rankin Scale; ACA, Anterior Cerebral Artery; MCA, Middle Cerebral Artery; PCA, Posterior Cerebral Artery; ICA, Internal Carotid Artery; NIHSS, National Institutes of Health Stroke Scale.

Thrombectomy Outcomes in Acute Basilar Artery Occlusions Due to Intracranial Atherosclerotic Disease

BACKGROUND AND OBJECTIVES

Intracranial atherosclerotic disease (ICAD) large vessel occlusion (LVO) is responsible for up to 30% of LVO. In this study, we aimed to determine the likelihood of favorable functional outcomes (modified Rankin Scale 0-3) in acute ICAD-LVO basilar occlusion compared with embolic basilar occlusion.

METHODS

This is an analysis of the Posterior Circulation Ischemic Stroke Evaluation: Analyzing Radiographic and Intraprocedural Predictors for Mechanical Thrombectomy Registry in which patients with acute basilar artery occlusions from 8 comprehensive stroke centers were included from 2015 to 2021. Patients were dichotomized into with (ICAD-LVO) or without underlying ICAD (embolic). Descriptive statistics for each group and multivariate logistic analysis were performed on the primary outcome.

RESULTS

Three hundred forty-six patients were included. There were 215 patients with embolic (62%) and 131 patients with ICAD-LVO (38%). Baseline demographics were equivalent between the 2 groups except for sex (male 47% vs 67%; P < .001), history of stroke (12% vs 25%; P = .002), and atrial fibrillation (31% vs 17%; P = .003). At 90 days, patients in the ICAD-LVO cohort were less likely to achieve favorable functional outcomes (odds ratio [OR] 0.41, 95% CI 0.22-0.72; P = .003) after adjusting for potentially confounding factors. In addition, ICAD-LVO strokes were less likely to achieve thrombolysis in cerebral infarction ≥2b (OR 0.29, 95% CI 0.14-0.57; P < .001). ICAD-LVO lesions were more likely to require stent placement (OR 14.94, 95% CI 4.91-45.49; P < .001). Subgroup analysis demonstrated favorable functional outcomes in patients who underwent stenting and angioplasty compared with failed recanalization cohort (OR 4.96, 95% CI 1.68-14.64; P < .004).

CONCLUSION

Patients with acute basilar ICAD-LVO have higher morbidity and mortality compared with patients with embolic source. Lower rates of successful recanalization in the ICAD-LVO cohort support this finding. Our subgroup analysis demonstrates that stenting should be considered in patients with recanalization failure. Rates of symptomatic intracranial hemorrhage were similar between the ICAD-LVO and embolic cohorts.

Trial selection criteria should not be used for clinical decisions and recommendations: the thrombectomy trials example

BACKGROUND

Despite multiple calls for more inclusive studies, most clinical trial eligibility criteria remain too restrictive. Thrombectomy trials have been no exception.

METHODS

We review the landmark trials that have shown the benefits of thrombectomy, their eligibility criteria, and consequences on clinical practice. We discuss the rationale behind various reasons for exclusions. We also examine the logical problem involved in using eligibility criteria as indications for treatment.

RESULTS

Most thrombectomy trials have been too restrictive. This has been shown by a plethora of follow-up studies that have refuted most of the previously recommended trial eligibility restrictions. Meanwhile, the effect of clinical recommendations based on restrictive eligibility criteria is that treatment has been denied to the majority of patients who could have benefitted. Trial eligibility criteria cannot be used to make clinical decisions or recommendations unless, like any other medical diagnosis, they have been shown capable of reliably differentiating patients into those that will, and those that will not benefit from treatment. This goal can only be achieved with all-inclusive pragmatic trials.

CONCLUSION

Restrictive eligibility criteria render clinical trials incapable of guiding medical decisions or recommendations.

Association between blood pressure variability and clinical outcomes after successful thrombectomy in acute basilar artery occlusion stroke patients: A multicenter cohort study

BACKGROUND

Limited data are available on the appropriate choice of blood pressure management strategy for patients with acute basilar artery occlusion (BAO) treated with mechanical thrombectomy (MT). We evaluated the impact of blood pressure variability on clinical outcomes after MT in patients with acute BAO.

METHODS

This multicenter cohort study included 108 patients with acute BAO who underwent successful emergency thrombectomy at two comprehensive stroke centers from 2016 to 2021. Blood pressure was measured hourly during the first 24 h after successful reperfusion. Blood pressure variability was calculated as mean arterial pressure (MAP) assessed by the standard deviation (SD). Multivariate logistic models were used to investigate the association between BPV, the primary outcome (futile recanalization, 90-day modified Rankin Scale score 3-6), and the secondary outcome (30-day mortality). Subgroup analysis was performed as a sensitivity test.

RESULTS

Futile recanalization occurred in 60 (56 %) patients, while 26 (24 %) patients died within 30 days. In the fully adjusted model, MAP SD was associated with a higher risk of futile recanalization (OR adj=1.36, per 1 mmHg increase, 95 % CI: 1.09-1.69, P=0.006) and 30-day mortality (OR adj=1.56, per 1 mmHg increase, 95 % CI: 1.20-2.04, P=0.001). A significant interaction between MAP SD and the lack of hypertension history on futile recanalization (P<0.05) was observed.

CONCLUSIONS

Among recanalized acute BAO ischemic patients, higher blood pressure variability during the first 24 h after MT was associated with worse outcomes. This association was stronger in patients without a history of hypertension.

Efficacy and safety of thrombectomy with or without intravenous thrombolysis in the treatment of acute basilar artery occlusion ischemic stroke: an updated systematic review and meta-analysis

Background

Mechanical thrombectomy (MT) is a well-established treatment for acute basilar artery occlusion (BAO)-induced posterior circulation ischemic stroke.

Objective

The objective of the study was to compare the outcomes of endovascular therapy (EVT) with and without bridging intravenous thrombolysis (IVT) in patients with acute BAO, using an updated meta-analysis.

Methods

A systematic literature search was conducted to identify studies that compared the efficacy and safety of EVT with and without IVT in the treatment of acute BAO ischemic stroke. The extracted data included sample size, patient age, National Institutes of Health Stroke Scale (NIHSS) scores, 90-day modified Rankin Scale (mRS) scores of 0-2 and 0-3, mortality rates, symptomatic intracranial hemorrhage (sICH), and occurrence of subarachnoid hemorrhage (SAH).

Results

Five studies that included a total of 1,578 patients (594 IVT + EVT vs. 984 EVT), met the inclusion criteria and were analyzed. The meta-analysis demonstrated that bridging IVT was associated with a higher likelihood of achieving a 90-day mRS score of 0-2 (41% vs. 34%; OR = 1.35, 95% CI 1.09-1.68, p = 0.006). Furthermore, the mortality rate was significantly lower in the IVT + EVT group than in the direct EVT group (25% vs. 30%; OR = 0.70, 95% CI 0.55-0.89, p = 0.003), with low heterogeneity observed (I 2 = 0.0%, p = 0.78). However, there were no significant differences between the groups regarding the rates of sICH (5% vs. 6%; OR = 0.85, 95% CI: 0.52-1.39, p = 0.53), SAH (3% vs. 3%; OR = 0.93, 95% CI: 0.39-2.22, p = 0.87), perforation (2% vs. 3%; OR = 0.71, 95% CI 0.26-1.95, p = 0.51), and dissection (3% vs. 2%; OR = 0.97, 95% CI: 0.13-7.14, p = 0.98).

Conclusion

Bridging IVT in conjunction with EVT was associated with better functional outcomes and reduced mortality rates in patients with acute ischemic stroke (AIS) due to BAO compared to EVT alone, without an increased risk of sICH, SAH, perforation, and dissection. In addition, the benefit of bridging IVT to EVT appeared to be more pronounced in European patients than in Asian patients compared to EVT alone. However, the conclusions of this study are not definitive and require validation through large-scale randomized controlled trials (RCTs) to draw more robust conclusions.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42024531363.

Temporal progression of functional independence after mechanical thrombectomy in acute vertebrobasilar artery occlusions

BACKGROUND

Neurological recovery after endovascular treatment (EVT) for large vessel occlusion stroke often has diverse timelines. Understanding the temporal progression of functional independence after EVT, especially delayed functional independence (DFI) and highly delayed functional independence (HDFI), in patients who do not improve early is essential for prognostication and rehabilitation. We aimed to analyze the prevalence and predictors of DFI and HDFI after EVT in acute vertebrobasilar artery occlusions (VBAO).

METHODS

Patients with VBAO who received EVT in China were retrospectively enrolled. Early functional independence (EFI) was defined as a modified Rankin Scale (mRS) score of 0-2 at discharge. The incidence and predictors of DFI (mRS score 0-2 at 90 days in non-EFI patients) and HDFI (mRS score 0-2 at 1 year in non-DFI patients) were analyzed.

RESULTS

2422 patients met the study criteria. EFI was observed in 20% (483) of patients. Among non-EFI patients, DFI was observed in 21% (395/1880). HDFI was observed in 13% (191/1439) of non-DFI patients. Younger age (P=0.006), lower pre-EVT National Institutes of Health Stroke Scale (NIHSS) score (P<0.001), higher posterior circulation-Alberta Stroke Program Early CT Score (PC-ASPECTS) (P=0.012), and absence of symptomatic intracranial hemorrhage (sICH) (P<0.001) were predictors of DFI. Predictors of HDFI were younger age (P<0.001) and lower pre-EVT NIHSS score (P<0.001).

CONCLUSION

A considerable proportion of patients have DFI and HDFI. The independent predictors of DFI were younger age, lower pre-EVT NIHSS score, higher PC-ASPECTS, and absence of sICH. Predictors of HDFI included younger age and lower pre-EVT NIHSS score.

Endovascular treatment versus medical management for basilar artery occlusion with low-to-moderate symptoms (National Institutes of Health Stroke Scale < 10)

BACKGROUND

Patients with acute basilar artery occlusion (BAO) and low-to-moderate symptoms (National Institutes of Health Stroke Scale [NIHSS] < 10) are poorly represented in thrombectomy trials. Our objective is to compare thrombectomy and best medical management (BMT) in this population.

METHODS

We compared data of all consecutive patients presenting with an initial NIHSS < 10 and acute symptomatic BAO included in two registries. The main outcome was the proportion of patients achieving a 3-months favorable outcome (mRS 0-2 or equal to the pre-stroke value). Secondary outcomes included the proportion of patients with an excellent outcome (mRS 0-1 or equal to pre-stroke value), overall mRs distribution (shift analysis) and mortality. Effect sizes for thrombectomy versus BMT alone were calculated using binary or ordinal logistic regression model before after considering confounders using the inverse probability of treatment weighting (IPTW) propensity score method.

RESULTS

One hundred twenty-seven patients were included: sixty-four patients treated with thrombectomy (mean ± SD age: 63.4 ± 16.1) and sixty-three with BMT (mean ± SD age: 69.0 ± 14.3). There was no significant difference between groups for the rate of 3 month-favorable outcome or mortality. After propensity-score adjustment, thrombectomy was associated with a significantly higher chance of excellent outcome at 3 months (mRS 0-1 or equal to pre-stroke value; adjusted OR, 2.68; 95%CI, 1.04-6.90; p = 0.041).

CONCLUSION

Our study suggests that thrombectomy in patients with low-to-moderate symptoms (NIHSS < 10) due to BAO does not improve the rate of favorable outcome but could lead to a higher chance of excellent outcome at 3 months.Trial Registration: ETIS Registry. http://www.clinicaltrials.govNCT03776877.

Effect of INR on Outcomes of Endovascular Treatment for Acute Vertebrobasilar Artery Occlusion

Endovascular treatment (EVT) has been proven to be the standard treatment for acute vertebrobasilar artery occlusion (VBAO). This study aimed to analyze the effects of international normalized ratio (INR) indicators on outcomes in patients with acute VBAO treated with EVT. Dynamic data on INR in patients with VBAO who received endovascular treatment (EVT) at 65 stroke centers in China were retrospectively enrolled. Outcome measures included the modified Rankin Scale (mRS) score at 90 days and 1 year and symptomatic intracranial hemorrhage (sICH). The associations between elevated INR (INR > 1.1), INR variability (time-weighted variance of INR changes), and various clinical outcomes were analyzed in all patients and subgroups stratified by oral anticoagulation (OAC) by mixed logistic regression analysis. A total of 1825 patients met the study criteria, of which 1384 had normal INR and 441 had elevated INR. Multivariate analysis showed that elevated INR was significantly associated with poor functional outcomes (mRS 4-6) at 90 days (odds ratio [OR] 1.36, 95% confidence interval [CI] 1.08-1.72) and 1 year (OR 1.32, 95% CI 1.05-1.66), but was not associated with an increased risk of sICH (OR 1.00, 95% CI 0.83-1.20). Similar associations exist between INR variability and poor functional outcomes at 90 days (OR 2.17, 95% CI 1.09-4.30), 1 year (OR 2.28, 95% CI 1.16-4.46), and sICH (OR 1.11, 95% CI 0.93-1.33). Subgroup analyses further revealed that elevated INR and INR variability remained associated with poor functional outcomes in patients not receiving oral anticoagulation (OAC) therapy, while no significant associations were observed in OAC-treated patients, regardless of whether they were on warfarin or direct oral anticoagulants. Elevated INR and INR variability in VBAO patients treated with EVT were associated with poor functional outcomes. The mechanism underlying the association between elevated INR and poor functional outcomes might be attributed to the fact that elevated INR indirectly reflects the burden of comorbidities, which could independently worsen outcomes. These findings underscore the importance of a comprehensive and dynamic evaluation of INR levels in the management of VBAO patients receiving EVT, providing valuable insights for optimizing patient outcomes.

Endovascular vs Medical Management of Acute Basilar Artery Occlusion: A Secondary Analysis of a Randomized Clinical Trial

Importance

In several randomized clinical trials, endovascular thrombectomy led to better functional outcomes than conventional treatment at 90 days poststroke in patients with acute basilar artery occlusion. However, the long-term clinical outcomes of these patients have not been well delineated.

Objective

To evaluate 1-year clinical outcomes in patients with acute basilar artery occlusion following endovascular thrombectomy vs control.

Design, Setting, and Participants

This study is an extension of the ATTENTION trial, a multicenter, randomized clinical trial. Patients were included between February 2021 and January 2022, with 1-year follow-up through April 2023. This multicenter, population-based study was conducted at 36 comprehensive stroke sites. Patients with acute basilar artery occlusion within 12 hours of estimated symptom onset were included. Of the 342 patients randomized in the ATTENTION trial, 330 (96.5%) had 1-year follow-up information available.

Exposures

Endovascular thrombectomy (thrombectomy group) vs best medical treatment (control group).

Main Outcomes and Measures

The primary outcome was defined as a score of 0 to 3 on the modified Rankin Scale (mRS) at 1 year. Secondary outcomes were functional independence (mRS score 0-2), excellent outcome (mRS score 0-1), level of disability (distribution of all 7 mRS scores), mortality, and health-related quality of life at 1 year.

Results

Among 330 patients who had 1-year follow-up data, 227 (68.8%) were male, and the mean (SD) age was 67.0 (10.7) years. An mRS score 0 to 3 at 1 year was achieved by 99 of 222 patients (44.6%) in the thrombectomy group and 21 of 108 (19.4%) in the control group (adjusted rate ratio, 2.23; 95% CI, 1.51-3.29). Mortality at 1 year compared with 90 days was more frequent in both the thrombectomy group (101 of 222 [45.5%] vs 83 of 226 [36.7%]) and the control group (69 of 108 [63.9%] vs 63 of 114 [55.3%]). Excellent outcome (mRS score 0-1) at 1 year compared with 90 days increased in the thrombectomy group (62 of 222 [27.9%] vs 45 of 226 [19.9%]) but not in the control group (9 of 108 [8.3%] vs 9 of 114 [7.9%]) resulting in a magnified treatment benefit.

Conclusions and Relevance

Among patients with basilar artery occlusion within 12 hours of onset, the benefits of endovascular thrombectomy at 1 year compared with 90 days were sustained for favorable (mRS score 0-3) outcome and enhanced for excellent (mRS score 0-1) outcome.

Big data analysis of endovascular treatment for acute ischemic stroke: a study based on bibliometric analysis

BACKGROUND

 While bibliometric analyses are prevalent in the medical field, few have focused on ther endovascular treatment for acute ischemic stroke (AIS).

OBJECTIVE

 To employ big data analysis to examine the research status, trends, and hotspots in endovascular treatment for AIS.

METHODS

 We conducted a comprehensive search using the Web of Science (WOS) database to identify relevant articles on the endovascular treatment for AIS from 1980 to the present. We used various tools for data analysis, including an online platform (https://bibliometric.com/app), the Citespace software, the Vosviewer software, and the ArcMap software, version 10.8. A number of bibliometric indicators were collected and analyzed, such as publication date, country where the studies were conducted, institutions to which the authors were affiliated, authors, high-frequency keywords, cooperative relationship etc. RESULTS:  A total of 5,576 articles were retrieved. A substantial increase in the number of articles occurred after 2010. High-frequency keywords included terms such as large vessel occlusion, reperfusion, outcome, and basilar artery occlusion. Among the top 10 most productive authors, Raul G. Nogueira ranked first, with 136 published articles. Among the journals, The New England Journal of Medicine ranked first, with 5,631 citations. The United States has the closest collaborative ties with other nations.

CONCLUSION

 In the present study, we found that the reports of endovascular treatment for AIS gradually increased after 2010. Among them, Raul G. Nogueira was the most productive author in this field. The New England Journal of Medicine was the most cited, and it had the greatest impact. The Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands (MR CLEAN) trial study was the most cited, and it was a landmark study. There are many interesting studies on endovascular treatment for AIS, such as ischemic penumbra, collateral circulation, bridging therapy etc.

Basilar artery occlusion management: An international survey of middle versus high-income countries

BACKGROUND AND PURPOSE

Two early basilar artery occlusion (BAO) randomized controlled trials (RCTs) did not establish the superiority of endovascular thrombectomy (EVT) over medical management. Yet many providers continued to recommend EVT. The goal of the present article is to compare physicians' diagnostic and management strategies of BAO among middle-income and high-income countries (MICs and HICs, respectively).

METHODS

We conducted an international survey from January to March 2022 regarding management strategies in acute BAO, to examine clinical and imaging parameters influencing clinician management of patients with BAO. We compared responses between physicians from HIC and MIC.

RESULTS

Among the 1245 respondents from 73 countries, 799 (64.2%) were from HIC, with the remaining 393 (31.6%) from MIC. Most respondents perceived that EVT was superior to medical management for acute BAO, but more so in respondents from HIC (98.0% vs. 94.2%, p < 0.01). MIC respondents were more likely to believe further RCTs were warranted (91.6% vs. 74.0%, p < 0.01) and were more likely to find it acceptable to enroll any patient who met a trial's criteria in the standard medical treatment arm (58.8% vs. 38.5%, p < 0.01).

CONCLUSIONS

In an area where clinical equipoise was called into question despite the lack of RCT evidence, we found that respondents from MIC were more likely to express willingness to enroll patients with BAO in an RCT than their HIC counterparts.

Endovascular management of acute stroke

Stroke related to large vessel occlusion is a leading cause of disability and death worldwide. Advances in endovascular therapy to reopen occluded arteries have been shown to reduce patient disability and mortality. Expanded indications to treat patients with large vessel occlusion in the late window (>6 h from symptom onset), with basilar artery occlusion, and with large ischaemic core at presentation have enabled treatment of more patients with simplified imaging methods. Ongoing knowledge gaps include an understanding of which patients with large ischaemic infarct are more likely to benefit from endovascular therapy, the role of endovascular therapy in patients who present with low National Institutes of Health Stroke Scale scores or medium or distal vessel occlusion, and optimal management of patients with underlying intracranial atherosclerotic disease. As reperfusion can now be facilitated by intravenous thrombolysis, mechanical thrombectomy, or both, the development of cytoprotective or adjunctive drugs to slow infarct growth, enhance reperfusion, or decrease haemorrhagic risk has gained renewed interest with the hope to improve patient outcomes.

Radiographic predictors of neurologic outcomes in patients with basilar artery occlusion: A single-center experience

BACKGROUND

Randomized controlled trials indicate functional and mortality benefits in endovascular therapy for basilar artery occlusion (BAO). However, these studies only include patients who meet specific prognostic scores. This study investigates radiographic predictors of posterior circulation territory infarcts that may predict neurologic outcome at 90-day post-intervention.

METHODS

This is a retrospective cohort study of a prospectively maintained thrombectomy database of all patients who underwent mechanical thrombectomy for BAO. Baseline demographics, comorbidities, baseline functional status (mRS), and severity of presenting neurologic deficits (NIHSS) were collected. Pc-ASPECTS, posterior circulation collateral score (PCCS), and basilar artery on computed tomography angiography (BATMAN) measured radiographic characteristics. Core infarct territory was identified. Primary outcomes were good neurologic outcome (mRS 0-3) and poor neurologic outcome (mRS 4-6) at 90-day post-thrombectomy. 90-day mortality was a secondary outcome.

RESULTS

About 21.5% of patients achieved a good neurologic outcome. About 32.3% of patients were deceased at 90 days. Receiver operating characteristic analysis shows PCCS collateral scores (AUC = 0.74, SE = 0.03, CI = 0.62-0.74) and BATMAN (AUC = 0.72, SE = 0.04, CI = 0.35-0.49) have potential to differentiate between those with good neurologic outcome from those with poor neurologic outcome. Although there was no statistically significant difference in AUC between the three curves, pc-ASPECTS score trended toward being weaker predictor of neurologic outcome (AUC = 0.49, SE = 0.04, CI = 0.35-0.49). There were significant associations between 90-day poor neurologic outcome and established infarcts within the pons (p = 0.01), left cerebellum (p = 0.01), and left occipital lobe (p = 0.03) on pre-thrombectomy CT.

CONCLUSION

Low BATMAN and PCCS collateral scores can be predictors of poor neurologic outcomes at 90-day post-thrombectomy for BAO while pc-ASPECTS score may be a weaker predictor of outcome.

Selective intra-arterial hypothermia combined with endovascular thrombectomy for large vessel occlusion: A systematic review and meta-analysis

BACKGROUND

Systemic therapeutic hypothermia may improve outcomes after acute ischemic stroke but increases complications. Selective intra-arterial hypothermia at the ischemic site during endovascular thrombectomy (EVT) theoretically offers benefits with fewer risks. However, there is little clinical evidence to support this approach.

METHODS

We searched Medline/PubMed, Embase and Cochrane electronic databases for studies evaluating the safety and feasibility of selective intra-arterial hypothermia as an adjunct to EVT for large vessel occlusion (LVO). Effect sizes with 95% confidence intervals (CIs) were pooled using the fixed-effect model. Odds ratios (ORs) were computed for binary variables, while the mean differences (MDs) were pooled for continuous data.

RESULTS

Of identified records, five clinical studies involving 463 LVO patients (62.9% male) were included. Of those, 224 (48.4%) patients received adjuvant selective intra-arterial hypothermia, while 239 (51.6%) received EVT alone. Selective intra-arterial hypothermia resulted in higher rates of good functional outcome (modified Rankin scale [mRS] 0-2 at 90-days) (OR 2.07, [95% CI, 1.36 to 3.16]), and lower final infarct volume (MD, -20.96 ml [95% CI, -26.17 to -15.75]) and lower rates of severe disability (mRS 3-5 at 90 days) (OR 0.44 [95% CI, 0.26 to 0.75]). Safety parameters including rates of symptomatic intracerebral hemorrhage, mortality, pneumonia, coagulation abnormalities, and arterial spasm were comparable between groups.

CONCLUSIONS

The initial evidence supports the safety and feasibility of selective intra-arterial hypothermia when combined with EVT for LVO. This approach shows promise for advancing research on neuroprotective strategies for ischemic stroke.

Rescue intracranial stenting for failed posterior circulation thrombectomy: analysis from the Stenting and Angioplasty in NeuroThrombectomy (SAINT) study

BACKGROUNDS

Recent trials have shown improved outcomes after mechanical thrombectomy (MT) for vertebrobasilar occlusion (VBO) stroke. However, there is a paucity of data regarding safety and outcomes of rescue intracranial stenting (RS) after failed MT (FRRS+) for posterior circulation stroke. We sought to compare RS to failed reperfusion without RS (FRRS-).

METHODS

This is a retrospective analysis of the Stenting and Angioplasty in NeuroThrombectomy (SAINT) study, a multicenter collaboration involving prospectively collected databases. Patients were included if they had posterior circulation stroke and failed MT. The cohort was divided into two groups: FRRS+ and FRRS- (defined as modified Thrombolysis In Cerebral Infarction (mTICI) score 0-2a). The primary outcome was a shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included mRS 0-2 and mRS 0-3 at 90 days. Safety measures included rates of symptomatic intracranial hemorrhage (sICH), procedural complications, and 90-day mortality. Sensitivity and subgroup analyses were performed to identify outcomes in a matched cohort and in those with VBO, respectively.

RESULTS

A total of 152 failed thrombectomies were included in the analysis. FRRS+ (n=84) was associated with increased likelihood of lower disability (acOR 2.24, 95% CI 1.04 to 4.95, P=0.04), higher rates of mRS 0-2 (26.8% vs 12.5%, aOR 4.43, 95% CI 1.22 to 16.05, P=0.02) and mRS 0-3 (35.4% vs 18.8%, aOR 3.13, 95% CI 1.08 to 9.10, P=0.036), and lower mortality (42.7% vs 59.4%, aOR 0.40, 95% CI 0.17 to 0.97, P=0.04) at 90 days compared with FRRS- (n=68). The rates of sICH and procedural complications were comparable between the groups. Sensitivity and subgroup analyses showed similar results.

CONCLUSION

In patients with posterior circulation stroke who had failed MT, RS resulted in better functional outcomes with comparable safety profile to procedure termination.

Vertebrobasilar Artery Occlusion Treatment Outcomes Within 24 hours of Estimated Occlusion Time

BACKGROUND AND OBJECTIVES

The aim of this study was to investigate the efficacy and safety of endovascular treatment (EVT) in patients with acute vertebrobasilar artery occlusion (VBAO) within 24 hours of estimated occlusion time (EOT) and to evaluate the effect of early and late time window in a cohort of patients with VBAO treated with EVT.

METHODS

Retrospective analysis was conducted on patients within 24 hours of the EOT in 65 stroke centers in China. Favorable outcome was defined as modified Rankin Scale ≤3 at 90 days. Patients were divided into the medical management (MM) group and the EVT group. Times were dichotomized into early (EOT ≤6 hours) and late (>6 hours) time windows. Multivariate logical regression models were used to evaluate the efficacy and safety of EVT and the effect of time windows on outcomes in EVT patients.

RESULTS

Among 4124 patients, 2473 and 1651 patients were included in the early and late windows, respectively. 1702 patients received MM and 2422 were treated with EVT. EVT was associated with a higher rate of a favorable outcome at 90 days both in early (odds ratio [OR] 2.16, 95% CI 1.94-2.41) and late (OR 1.89, 95% CI 1.65-2.17) time windows. No differences were found regarding favorable outcome (OR 0.95, 95% CI 0.87-1.03) between VBAO patients treated with EVT within and beyond 6 hours.

CONCLUSION

Patients with acute VBAO who received EVT within 24 hours were associated with improved favorable outcome compared with patients who received MM. EVT beyond 6 hours is feasible and safe with no increase in symptomatic intracranial hemorrhage.

Benefits of First Pass Recanalization in Basilar Strokes Based on Initial Clinical Severity

PURPOSE

Randomized trials demonstrating the benefits of thrombectomy for basilar artery occlusions have enrolled an insufficient number of patients with a National Institutes for Health Stroke Scale (NIHSS) score < 10 and shown discrepant results for patients with an NIHSS > 20. Achieving a first pass recanalization (FPR) improves clinical outcomes in stroke. We aimed to evaluate the effect of the FPR on outcomes among basilar artery occlusion patients, characterized by prethrombectomy initial NIHSS score.

METHODS

We retrospectively analyzed the Endovascular Treatment in Ischemic Stroke (ETIS) registry of 279 basilar artery occlusion patients treated with thrombectomy from 6 participating centers. We compared the 90-day clinical outcomes of achieving a FPR versus no FPR, categorized by initial clinical severity: mild (NIHSS < 10), moderate (NIHSS 10-20) and severe (NIHSS > 20). We used Poisson regression with robust error variance to determine the effect of the NIHSS score on the association between FPR and outcomes.

RESULTS

The FPR patients with NIHSS < 10 or NIHSS 10-20 were more likely to have a favorable clinical outcome (modified Rankin scale, mRS 0-3) than non-FPR patients (relative risk, RR = 1.32, 95% confidence interval, CI: 1.04, 1.66, p-value = 0.0213, and RR = 1.79, 95% CI: 1.26, 2.53, p-value = 0.0011, respectively). A similar benefit was not found in patients with severe symptoms. We found a significantly lower risk of poor clinical outcome (mRS 4-6) in FPR patients with NIHSS 10-20, but not among patients with an NIHSS > 20.

CONCLUSION

Achieving a FPR in basilar artery occlusion patients with mild (NIHSS < 10) or moderate (NIHSS 10-20) symptoms is associated with better clinical outcomes, but not in patients with severe symptoms. These results support the importance of further clinical trials on the benefits of thrombectomy in severe strokes.