More expansive horizons: a review of endovascular therapy for patients with low NIHSS scores

Efficacy of Neuroendoscopy Surgery Combined With Postoperative Lokomat Rehabilitation Training in Patients With Hypertensive Intracerebral Hemorrhage

OBJECTIVE

To explore the effects of neuroendoscopy surgery combined with postoperative Lokomat rehabilitation training on patients with hypertensive cerebral hemorrhage.

METHODS

A total of 88 patients with hypertensive cerebral hemorrhage who underwent surgical treatment in our hospital were retrospectively analyzed. They were divided into a study group and a conventional group with 44 patients in each group. The patients in the 2 groups were compared regarding operation-related conditions, hospital stay, preoperative and postoperative functional status scores, and postoperative complications.

RESULTS

The operation time, intraoperative blood loss, hospital stays, and hematoma clearance rate of the study group were significantly better than those of the conventional group (P<0.001). Regarding scores of related functional status, there was no significant difference between the 2 groups before operation (P>0.05). The different scores of the study group were significantly better than those of the conventional group 1 month after the operation (P<0.05). Regarding complications, the study group also has significant advantages, with only one case of rebleeding.

CONCLUSION

Compared to the traditional approach of small bone window craniotomy followed by postoperative Lokomat rehabilitation training, the combination of neuroendoscopy surgery and Lokomat training proves to be more efficient. This approach can effectively reduce the operating time and hospital stay of patients with hypertensive intracerebral hemorrhage, minimize intraoperative blood loss, improve the hematoma clearance rate, and lower the incidence of postoperative complications.

Current and future trends in acute ischemic stroke treatment: direct-to-angiography suite, middle vessel occlusion, large core, and minor strokes

Since the publication of the landmark thrombectomy trials in 2015, the field of endovascular therapy for ischemic stroke has been rapidly growing. The very low number needed to treat to provide functional benefits shown by the initial randomized trials has led clinicians and investigators to seek to translate the benefits of endovascular therapy to other patient subgroups. Even if the treatment effect is diminished, currently available data has provided sufficient information to extend endovascular therapy to large infarct core patients. Recently, published data have also shown that sophisticated imaging is not necessary for late time- window patients. As a result, further research into patient selection and the stroke pathway now focuses on dramatically reducing door-to-groin times and improving outcomes by circumventing classical imaging paradigms altogether and employing a direct-to-angio suite approach for selected large vessel occlusion patients in the early time window. While the results of this approach mainly concern patients with severe deficits, there are further struggles to provide evidence of the efficacy and safety of endovascular treatment in minor stroke and large vessel occlusion, as well as in patients with middle vessel occlusions. The current lack of good quality data regarding these patients provides significant challenges for accurately selecting potential candidates for endovascular treatment. However, current and future randomized trials will probably elucidate the efficacy of endovascular treatment in these patient populations.

The Primary Prevention of Poststroke Epilepsy in Patients With Middle Cerebral Artery Infarct: Protocol for a Randomized Controlled Trial

BACKGROUND

Poststroke epilepsy poses a significant clinical challenge for individuals recovering from strokes, leading to a less favorable long-term outlook and increased mortality rates. Existing studies have primarily concentrated on administering antiseizure or anticonvulsant treatments only after the onset of late-onset seizures, without intervening during the epileptogenesis phase following a stroke.

OBJECTIVE

This research protocol is designed to conduct a randomized controlled trial to assess whether the early, preventive introduction of low-dose antiepileptic drug therapy (levetiracetam [LEV] or perampanel [PER]) in patients who have experienced middle cerebral artery (MCA) infarction can reduce the risk of developing poststroke epilepsy (primary prevention).

METHODS

Participants with MCA infarction, either with or without reperfusion treatments, will be recruited and promptly receive preventive intervention within 72 hours of the stroke occurrence. These participants will be randomly assigned to receive either PER (4 mg per day), LEV (1000 mg per day), or a placebo that matches the active drugs. This treatment will continue for 12 weeks after allocation. Brain magnetic resonance imaging will be used to confirm the presence of MCA territory infarction, and an electroencephalography will be used to ensure the absence of epileptiform discharges or electrographic seizures at the time of the stroke. All participants will undergo follow-up assessments for 72 weeks after allocation.

RESULTS

The primary outcome under evaluation will be the incidence of poststroke epilepsy in the 3 groups following the 18-month study period. Secondary outcomes will encompass the time to the occurrence of the first seizure, the severity of seizures, any treatment-related adverse events, and the modified Rankin scale score at 3 and 18 months. Exploratory outcomes will involve comparing the effectiveness and safety of PER and LEV.

CONCLUSIONS

We anticipate that the intervention groups will experience a lower incidence and reduced severity of poststroke epilepsy compared to the control group after 18 months. We aim to establish evidence supporting the potential preventive effects of LEV and PER on poststroke seizures and epilepsy in patients with MCA infarction, as well as to explore the antiepileptogenic potential of both LEV and PER in patients with major ischemic strokes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04858841; https://clinicaltrials.gov/study/NCT04858841.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49412.

Endovascular treatment of acute tandem lesions in patients with mild anterior circulation stroke

BACKGROUND

In patients with mild strokes the risk-benefit ratio of endovascular treatment (EVT) for tandem lesions has yet to be evaluated outside of current guideline recommendations. This study investigates the frequency as well as procedural and safety outcomes in daily clinical practice.

METHODS

Using data from the German Stroke Registry-Endovascular Treatment (GSR-ET) we analyzed patients with anterior circulation stroke due to tandem-lesions and mild deficits. These patients were defined as ≤5 on the National Institutes of Health Stroke Scale (NIHSS). Recanalization was assessed with the modified Thrombolysis in Cerebral Infarction Scale (mTICI). Early neurological and long-term functional outcomes were assessed with the NIHSS change and modified Rankin scale (mRS), respectively. Safety assessment included periprocedural complications and the rate of symptomatic intracerebral hemorrhage (sICH).

RESULTS

A total of 61 patients met the inclusion criteria and were treated endovascularly for tandem lesions. The median age was 68 (IQR:59-76) and 32.9% (20) were female. Patients were admitted to the hospital with a median NIHSS score of 4 (IQR:2-5) and a median Alberta Stroke Programme Early CT Score (ASPECTS) of 9 (IQR:8-10). Successful recanalization (mTICI 2b-3) was observed in 86.9% (53). NIHSS decreased non-significantly (p=0.382) from baseline to two points (IQR:1-9) at discharge. Excellent (mRS≤1) and favorable (mRS≤2) long-term functional outcome at 90-days was 55.8% (29) and 69.2% (36), respectively. Mortality rates at 90-days were 9.6% (5) and sICH occurred in 8.2% (5).

CONCLUSIONS

EVT for tandem lesions in patients with mild anterior circulation stroke appears to be feasible but may lead to increased rates of sICH. Further studies comparing endovascular with best medical treatment (BMT) especially investigating the risk of periprocedural hemorrhagic complications, are needed.

Preprocedural determination of an occlusion pathomechanism in endovascular treatment of acute stroke: a machine learning-based decision

OBJECTIVE

To evaluate whether an occlusion pathomechanism can be accurately determined by common preprocedural findings through a machine learning-based prediction model (ML-PM).

METHODS

A total of 476 patients with acute stroke who underwent endovascular treatment were retrospectively included to derive an ML-PM. For external validation, 152 patients from another tertiary stroke center were additionally included. An ML algorithm was trained to classify an occlusion pathomechanism into embolic or intracranial atherosclerosis. Various common preprocedural findings were entered into the model. Model performance was evaluated based on accuracy and area under the receiver operating characteristic curve (AUC). For practical utility, a decision flowchart was devised from an ML-PM with a few key preprocedural findings. Accuracy of the decision flowchart was validated internally and externally.

RESULTS

An ML-PM could determine an occlusion pathomechanism with an accuracy of 96.9% (AUC=0.95). In the model, CT angiography-determined occlusion type, atrial fibrillation, hyperdense artery sign, and occlusion location were top-ranked contributors. With these four findings only, an ML-PM had an accuracy of 93.8% (AUC=0.92). With a decision flowchart, an occlusion pathomechanism could be determined with an accuracy of 91.2% for the study cohort and 94.7% for the external validation cohort. The decision flowchart was more accurate than single preprocedural findings for determining an occlusion pathomechanism.

CONCLUSIONS

An ML-PM could accurately determine an occlusion pathomechanism with common preprocedural findings. A decision flowchart consisting of the four most influential findings was clinically applicable and superior to single common preprocedural findings for determining an occlusion pathomechanism.

Advances in mechanical thrombectomy for acute ischaemic stroke

Mechanical thrombectomy is a ground breaking treatment for acute ischaemic stroke caused by occlusion of a large vessel. Its efficacy over intravenous thrombolysis has been proven in multiple trials with a lower number needed to treat than percutaneous coronary intervention for acute myocardial infarction. However, access to this key treatment modality remains limited with a considerable postcode lottery across the UK and many parts of the world. The evidence base for mechanical thrombectomy dates back to 2015. Since then, there have been important advances in establishing and widening the criteria for treatment. This narrative review aims to summarise the current evidence base and latest advances for physicians and academics with an interest in recanalisation treatments for acute ischaemic stroke.

Case report: Flow changes in routes of collateral circulation in patients with LVO and low NIHSS: a point favor to treat

The effectiveness of endovascular thrombectomy in patients presenting low National Institutes of Health Stroke Scale (NIHSS) scores remains controversial, and the acquisition of additional evidence is required to refine the selection of candidates who may benefit the most from this therapeutic modality. In this study, we present the case of a 62-year-old individual, with left internal carotid occlusion stroke and low NIHSS, who had compensatory collateral flow from Willis polygon via the anterior communicating artery. The patient subsequently exhibited neurological deterioration and collateral flow failure from Willis polygon, indicating the need for urgent intervention. The study of collaterals in patients with large vessel occlusion stroke has garnered considerable attention, with research suggesting that individuals with low NIHSS scores and poor collateral profiles may be at a heightened risk of early neurological deterioration. We postulate that such patients may derive significant benefits from endovascular thrombectomy, and may posit that an intensive transcranial Doppler monitoring protocol could facilitate the identification of suitable candidates for such intervention.

Advanced Imaging for Acute Stroke Treatment Selection: CT, CTA, CT Perfusion, and MR Imaging

There is constant evolution in the diagnosis and treatment of acute ischemic stroke due to advances in treatments, imaging, and outreach. Two major revolutions were the advent of intravenous thrombolysis in the 1990s and endovascular thrombectomy in 2010s. Neuroimaging approaches have also evolved with key goals-detect hemorrhage, augment thrombolysis treatment selection, detect arterial occlusion, estimate infarct core, estimate viable penumbra, and augment thrombectomy treatment selection. The ideal approach to diagnosis and treatment may differ depending on the system of care and available resources. Future directions include expanding indications for these treatments, including a shift from time-based to tissue-based selection.

Effects of endovascular therapy for mild stroke due to proximal or M2 occlusions: meta-analysis

OBJECTIVE

To conduct a meta-analysis to evaluate the effect of endovascular therapy (EVT) in mild acute ischemic stroke (AIS) due to proximal versus distal occlusions.

METHODS

We searched PubMed, Embase, the Cochrane Library, and clinicaltrials.gov from January 2000 to September 2021 to identify studies comparing EVT versus best medical management (BMM) in AIS with National Institutes of Health Stroke Scale (NIHSS) scores ≤5 due to proximal internal carotid artery (ICA) or M1 versus distal M2 occlusions. We included studies that reported the number of patients with proximal or distal occlusions separately and reported the number of patients with freedom of disability (modified Rankin Scale (mRS) score 0-1) or functional independence (mRS score 0-2) at 90 days in proximal or M2 occlusions, respectively. OR with 95% CI was used.

RESULTS

We identified six studies with 653 proximal ICA and M1 occlusion patients and 666 distal M2 occlusion patients. Pooled results showed EVT versus BMM was associated with a higher rate of being disability-free in patients with proximal occlusions (OR 1.58, 95% CI 1.09 to 2.30), but was associated with a lower rate of being disability-free in patients with M2 occlusions (OR 0.70, 95% CI 0.49 to 0.99). Effect of EVT in proximal versus distal occlusions was substantially different (P for interaction=0.002). A similar pattern was seen for functional independence (P for interaction=0.05).

CONCLUSIONS

For patients with mild AIS, observational data suggest that EVT may be beneficial for proximal ICA or M1 but not for distal M2 occlusions. Randomized trials are needed to confirm these findings.

PROSPERO REGISTRATION NUMBER

CRD42021281034.

The role of extracranial carotid duplex in predicting functional outcome in first time lacunae strokes

BACKGROUND

Stroke is the third largest cause of death both worldwide and in Taiwan. Among the various stroke subtypes, lacunae strokes account for 20 to 30% of the total stroke population. Through vigorous risk control factors, the effective prevention and the long-term functional outcome remains are yet to be investigated. Carotid duplex is a non-invasive neuroimaging modality that is routinely applied to stroke patients. In the current research, we correlate baseline carotid duplex examination parameters with functional outcome assessment in an attempt to ascertain important variables for early outcome prediction.

METHOD

We retrospectively recruited lacunae ischemic stroke patients from the Department of Neurology, Changhua Christian Hospital. Patient baseline demographics, biochemistry, neuroimaging, and outcome assessments were thoroughly evaluated via a modified Rankin Scale (mRS), NIHSS, and Barthel index scores, both prior and subsequent to patient discharge for a period of up to one year. Patients were divided into two groups based on their functional recovery status. This current study utilizes the Kaplan-Meier method to draw the survival curve and adopts the Cox proportional hazards model to estimate the hazard ratio between the two groups. The risk modeling method is also applied to formulate the best fit in seeking and identifying the variables, which has the most impact on determining theoutcome predictor. All statistical analyses were performed using R for Windows (version 3.6.3), with p < 0.05 meaning statistical significance and 0.05 < p < 0.1 denoting marginal statistical significance.

RESULTS

One hundred forty-one ischemic lacunae stroke patients are included in the study, of which the follow-ups of 69 patients showed no physical functionality improvement, whereas 72 patients demonstrated favorable functional outcomes. In terms of underlying diseases, more than 80% of the patients suffered from hyperlipidemia upon hospitalization and more than 40% of the patients suffered from diabetes mellitus and heart disease. There was a significant difference in pulmonary disease between improvement and non-improvement in disability (1.4% vs 10.1%, p = 0.034). The average age of the improved group was lower than that of the non-improved group (65.5 vs. 72, p = 0.014), and the WBC was higher (8 vs 6.95, p = 0.005); furthermore, higher NIHSS scores (6.5 vs 3, p = 0.001) and lower Barthel index scores (47.5 vs 80, p < 0.001) were also noted. The group with improved mRS required a longer hospital stay (with a median of 10 days), while their un-improved counterpart required 8 days (p < 0.05). The majority of patients were discharged within 30 days, and there was a slight difference between the two survival curves (marginal statistical significance, 0.05 < p < 0.1). The hazard ratio of the improved group was 0.7188. There was a difference in the end diastolic velocity (EDV) of common carotid artery (CCA) between the lesion and non-lesion sides of the patients (p < 0.05). Risk-stratifying models indicate that diabetes mellitus, peak systolic velocity (PSV) of the internal carotid artery (ICA) on the lesion side, the diameter of the ICA on the non-lesion side, and the pulsatility index (PI) of the ICA and external carotid artery (ECA) were selected as the most important factors affecting the end diastolic velocity (EDV) of the common carotid artery (CCA) in all four models.

CONCLUSION

In the current study, the most suitable length of stay in hospital for lacunae stroke patients to fully recuperate is ten days. Additionally, CCA EDV might be the key determinant, with baseline diabetes mellitus acting in a medium role, capable of altering long-term outcome functionality and recovery.

Mechanical Thrombectomy for Acute Ischemic Stroke

OBJECTIVE

Endovascular stroke therapy has greatly improved the ability to treat the deadliest and most disabling form of acute ischemic stroke. This article summarizes some of the recent innovations in this field and discusses likely future developments.

LATEST DEVELOPMENTS

At present, there is robust activity to improve all facets of care for patients with large vessel occlusion stroke, including better prehospital routing, more efficient in-hospital screening, expanding indications for thrombectomy eligibility, innovating novel thrombectomy devices, and improving the effects of recanalization on clinical outcomes. In addition, the integration of endovascular stroke therapy (EVT)-an emergent and frequently off-hours procedure that requires a specialized team of nurses, technologists, and physicians-into acute stroke care has transformed referral patterns, hospital accreditation pathways, and physician practices. The eligibility for the procedure will potentially continue to grow to include patients screened without advanced imaging, larger core infarcts, and more distal occlusions.

ESSENTIAL POINTS

In this review, we discuss the current state of EVT and its implications for practice, and present three cases that highlight some of the directions in which the field is moving.

Neuroimaging in Patient Selection for Thrombectomy, From the AJR Special Series on Emergency Radiology

Endovascular thrombectomy has become the standard-of-care treatment for carefully selected patients with acute ischemic stroke due to a large-vessel occlusion of the anterior circulation. Neuroimaging plays a vital role in determining patient eligibility for thrombectomy, both in the early (0-6 hours from symptom onset) and late (> 6 to 24 hours from symptom onset) time windows. Various neuroimaging algorithms are used to determine thrombectomy eligibility, and each algorithm must be optimized for institutional workflow. In this review, we describe common imaging modalities and recommended algorithms for the evaluation of patients for endovascular thrombectomy. We also discuss emerging patient populations who might qualify for thrombectomy in the coming years.

Outcomes after endovascular mechanical thrombectomy for low compared to high National Institutes of Health Stroke Scale (NIHSS): A multicenter study

OBJECTIVE

The role of endovascular mechanical thrombectomy (MT) in patients presenting with "minor" stroke is uncertain. We aimed to compare outcomes after MT for ischemic stroke patients presenting with National Institutes of Health Stroke Scale (NIHSS) 5 and - within the low NIHSS cohort - identify predictors of a favorable outcome, mortality, and symptomatic intracranial hemorrhage (ICH).

METHODS

We retrospectively analyzed a prospectively maintained, international, multicenter database.

RESULTS

The study cohort comprised a total of 7568 patients from 29 centers. NIHSS was low (<5) in 604 patients (8%), and > 5 in 6964 (92%). Patients with low NIHSS were younger (67 + 14.8 versus 69.6 + 14.7 years, p < 0.001), more likely to have diabetes (31.5% versus 26.9%, p = 0.016), and less likely to have atrial fibrillation (26.6% versus 37.6%, p < 0.001) compared to those with higher NIHSS. Radiographic outcomes (TICI > 2B 84.6% and 84.3%, p = 0.412) and complication rates (8.1% and 7.2%, p = 0.463) were similar between the low and high NIHSS groups, respectively. Clinical outcomes at every follow up interval, including NIHSS at 24 h and discharge, and mRS at discharge and 90 days, were better in the low NIHSS group, however patients in the low NIHSS group experienced a relative decline in NIHSS from admit to discharge. Mortality was lower in the low NIHSS group (10.4% versus 24.5%, p < 0.001).

CONCLUSIONS

Relative to patients with high NIHSS, MT is safe and effective for stroke patients with low NIHSS, and it is reasonable to offer it to appropriately selected patients presenting with minor stroke symptoms. Our findings justify efforts towards a randomized trial comparing MT versus medical management for patients with low NIHSS.

Assessing the Efficacy of Mechanical Thrombectomy in Patients with an NIHSS < 6 Presenting with Proximal Middle Cerebral Artery Vessel Occlusion as Compared to Best Medical Management

BACKGROUND AND PURPOSE

Minor acute ischemic stroke (AIS) patients-defined by an NIHSS score < 6-presenting with proximal middle cerebral artery large vessel occlusions (MCA-LVO) is a subgroup for which treatment is still debated. Although these patients present with minor symptoms initially, studies have shown that several patients afflicted with MCA-LVO in this subgroup experience cognitive and functional decline. Although mechanical thrombectomy (MT) is the standard of care for patients with an NIHSS score of 6 or higher, treatment in the minor stroke subgroup is still being explored. The purpose of this preliminary study is to report our center's experience in evaluating the potential benefit of mechanical thrombectomy (MT) in minor stroke patients when compared to medical management (MM).

METHODS

We performed a retrospective study with two comprehensive stroke centers within our hospital enterprise of consecutive patients presenting with minor AIS secondary to MCA-LVO (defined as M1 or proximal M2 segments of MCA). We subsequently evaluated patients who received MT versus those who received MM.

RESULTS

Between January 2017 and July 2021, we identified 46 AIS patients (11 treated with MT and 35 treated with MM) who presented with an NIHSS score < 6 secondary to MCA-LVO (47.8% 22/46 female, mean age 62.3 years, range 49-75 years). MT was associated with a significantly lower mRS at 90 days (median: 1.0 [IQR 0.0-2.0] versus 3.0 [IQR 1.0-4.0], p = <0.001), a favorable NIHSS shift (-4.0 [IQR -10.0--2.0] versus 0.0 [IQR -2.0-1.0], p = 0.002), favorable NIHSS shift dichotomization (5/11, 45.5% versus 3/35, 8.6%, p = 0.003) and favorable mRS dichotomization (7/11, 63.6% versus 14/35, 40.0%, p = 0.024).

CONCLUSIONS

In our center's preliminary experience, for AIS patients presenting with an NIHSS score < 6 secondary to MCA-LVO, MT may be associated with improved clinical outcomes when compared to MM only.

Cost-effectiveness of thrombectomy in patients with minor stroke and large vessel occlusion: effect of thrombus location on cost-effectiveness and outcomes

BACKGROUND

To evaluate the cost-effectiveness of endovascular thrombectomy (EVT) to treat large vessel occlusion (LVO) in patients with acute, minor stroke (National Institute of Health Stroke Scale (NIHSS) <6) and impact of occlusion site.

METHODS

A Markov decision-analytic model was constructed accounting for both costs and outcomes from a societal perspective. Two different management strategies were evaluated: EVT and medical management. Base case analysis was done for three different sites of occlusion: proximal M1, distal M1 and M2 occlusions. One-way, two-way and probabilistic sensitivity analyses were performed.

RESULTS

Base-case calculation showed EVT to be the dominant strategy in 65-year-old patients with proximal M1 occlusion and NIHSS <6, with lower cost (US$37 229 per patient) and higher effectiveness (1.47 quality-adjusted life years (QALYs)), equivalent to 537 days in perfect health or 603 days in modified Rankin score (mRS) 0-2 health state. EVT is the cost-effective strategy in 92.7% of iterations for patients with proximal M1 occlusion using a willingness-to-pay threshold of US$100 000/QALY. EVT was cost-effective if it had better outcomes in 2%-3% more patients than intravenous thrombolysis (IVT) in absolute numbers (base case difference -16%). EVT was cost-effective when the proportion of M2 occlusions was less than 37.1%.

CONCLUSIONS

EVT is cost-effective in patients with minor stroke and LVO in the long term (lifetime horizon), considering the poor outcomes and significant disability associated with non-reperfusion. Our study emphasizes the need for caution in interpreting previous observational studies which concluded similar results in EVT versus medical management in patients with minor stroke due to a high proportion of patients with M2 occlusions in the two strategies.

Characterizing reasons for stroke thrombectomy ineligibility among potential candidates transferred in a hub-and-spoke network

Background

Access to endovascular thrombectomy (EVT) is relatively limited. Hub-and-spoke networks seek to transfer appropriate large vessel occlusion (LVO) candidates to EVT-capable hubs. However, some patients are ineligible upon hub arrival, and factors that drive transfer inefficiencies are not well described. We sought to quantify EVT transfer efficiency and identify reasons for EVT ineligibility.

Methods

Consecutive EVT candidates presenting to 25 spokes from 2018-2020 with pre-transfer CTA-defined LVO and ASPECTS ≥6 were identified from a prospectively maintained database. Outcomes of interest included hub EVT, reasons for EVT ineligibility, and 90-day modified Rankin Scale (mRS) ≤2.

Results

Among 258 patients, the median age was 70 years (IQR 60-81); 50% were female. 56% were ineligible for EVT after hub arrival. Cited reasons were large established infarct (49%), mild symptoms (33%), recanalization (6%), distal occlusion (5%), sub-occlusive lesion (3%), and goals of care (3%). Late window patients [last known well (LKW) >6 hours] were more likely to be ineligible (67% vs 43%, P<0.0001). EVT ineligible patients were older (73 vs 68 years, p=0.04), had lower NIHSS (10 vs 16, p<0.0001), longer LKW-hub arrival time (8.4 vs 4.6 hours, p<0.0001), longer spoke Telestroke consult-hub arrival time (2.8 vs 2.2 hours, p<0.0001), and received less intravenous thrombolysis (32% vs 45%, p=0.04) compared to eligible patients. EVT ineligibility independently reduced the odds of 90-day mRS≤2 (aOR=0.26, 95%CI=0.12,0.56; p=0.001) when controlling for age, NIHSS, and LKW-hub arrival time.

Conclusions

Among patients transferred for EVT, there are multiple reasons for ineligibility upon hub arrival, with most excluded for infarct growth and mild symptoms. Understanding factors that drive transfer inefficiencies is important to improve EVT access and outcomes.

Effectiveness and safety of EVT in patients with acute LVO and low NIHSS

Background and purpose

There is much uncertainty in endovascular treatment (EVT) decisions in patients with acute large vessel occlusion (LVO) and mild neurological deficits.

Methods

From a prospective, nationwide stroke registry, all patients with LVO and baseline NIHSS &lt;6 presenting within 24 h from the time last known well (LKW) were included. Early neurological deterioration (END) developed before EVT was prospectively collected as an increasing total NIHSS score ≥2 or any worsening of the NIHSS consciousness or motor subscores during hospitalization not related to EVT. Significant hemorrhage was defined as PH2 hemorrhagic transformation or hemorrhage at a remote site. The modified Rankin Scale (mRS) was prospectively collected at 3 months.

Results

Among 1,083 patients, 149 (14%) patients received EVT after a median of 5.9 [3.6–12.3] h after LKW. In propensity score-matched analyses, EVT was not associated with mRS 0-1 (matched OR 0.99 [0.63–1.54]) but increased the risk of a significant hemorrhage (matched OR, 4.51 [1.59–12.80]). Extraneous END occurred in 207 (19%) patients after a median of 24.5 h [IQR, 13.5–41.9 h] after LKW (incidence rate, 1.41 [95% CI, 1.23–1.62] per 100 person-hours). END unrelated to EVT showed a tendency to modify the effectiveness of EVT (P-for-interaction, 0.08), which decreased the odds of having mRS 0–1 in mild LVO patients without END (adjusted OR, 0.63 [0.40–0.99]).

Conclusions

The use of EVT in patients with acute LVO and low NIHSS scores may require the assessment of individual risks of early deterioration, hemorrhagic complications and expected benefit.

NR-2 antikor peptid düzeyinin akut iskemik inmede tanı, prognoz ve koma skorları ile ilişkisi var mıdır?

Aim: This study aimed to demonstrate the diagnostic and prognostic value of NR-2 peptides as a biomarker in acute ischemic stroke and to evaluate their correlation with the Glasgow Coma Scale (GCS) and the National Institutes of Health Stroke Scale (NIHSS). Materials and Methods: This is a prospective study evaluating the value of NR-2 peptide levels in the diagnosis and prognosis of acute stroke. The study included 101 patients, who presented to a tertiary healthcare facility and were diagnosed with acute stroke, and 57 healthy controls. In the whole study population, serum NR-2 peptide levels were measured using the ELISA method. Results: The NR-2 peptide level was 6.32 ± 8.30 in the patient group and 3.91 ± 1.64 in the study group. The NR-2 peptide level was significantly higher in the patient group (p = 0.006). No correlation was detected between NR-2 peptide levels and scores in the GCS or NIHSS. The results indicated that NR-2 was a potential biomarker elevated in the early phase of acute stroke, but had no correlation with the prognosis of acute stroke. Conclusion: Although our data shed light on the use of the NR-2 peptide level as a biomarker in the acute phase in patients with stroke, data are insufficient to predict prognosis. We think that larger, multicentre studies with longer follow-up periods are needed.

Primer reporte de inmaduros de Cryptocephalus Geoffroy, 1762 (Coleoptera: Chrysomelidae) de Brasil con notas de su bioecología sobre Wedelia goyazensis Gardner (Asteraceae) y síntesis de los registros de presencia del género en territorio brasileño

Cryptocephalus Geoffroy, 1762 es reconocido por su distribución cosmopolita y gran riqueza, con al menos 1700 especies descritas. Sin embargo, falta información para Brasil: (1) no hay registro de inmaduros; y (2) no se conoce casi nada sobre la biología de este género. En este trabajo se documentan por primera vez las etapas inmaduras de Cryptocephalus de Brasil y se presentan algunas notas sobre su bioecología en la planta huésped. Además, se recopilan sus registros en territorio brasileño a partir de la bibliografía.

Efficacy, Influencing Factors, and Safety of Alteplase Intravenous Thrombolysis in Patients with Acute Ischemic Stroke Combined with Atrial Fibrillation

Ischemic stroke is the most common type of stroke. Intravenous thrombolytic therapy with alteplase is currently the most effective method to improve the prognosis of patients with acute cerebral infarction. The purpose of this study was to investigate the efficacy and safety of intravenous thrombolysis with alteplase in patients with acute ischemic stroke combined with atrial fibrillation and to analyze the related influencing factors. It turns out, alteplase intravenous thrombolysis is effective for patients with ICS combined with atrial fibrillation, and the incidence of sICH are lower than those without alteplase intravenous thrombolysis, but the efficacy is worse than that of patients without atrial fibrillation. At the same time, the baseline NHISS score and systolic pressure before the thrombolytic were independent risk factors affecting the efficacy of intravenous thrombolysis with alteplase in ICS patients with atrial fibrillation. This study has provided a scientific basis for making an active decision to perform ultraearly intravenous thrombolysis in our hospital to reduce the mortality and disability rate of stroke in the region.

Persistent challenges in endovascular treatment decision-making for acute ischaemic stroke

PURPOSE OF REVIEW

Although endovascular treatment (EVT) is the gold standard for treating acute stroke patients with large vessel occlusion (LVO), multiple challenges in decision-making for specific conditions persist. Recent evidence on a selection of patient subgroups will be discussed in this narrative review.

RECENT FINDINGS

Two randomized controlled trials (RCTs) have been published in EVT of basilar artery occlusion (BAO). Large single arm studies showed promising results in Patients with low Alberta stroke program early CT score (ASPECTS) and more distal vessel occlusions. Recent data confirm patients with low National Institutes of Health Stroke Scale (NIHSS) despite LVO to represent a heterogeneous and challenging patient group.

SUMMARY

The current evidence does not justify withholding EVT from BAO patients as none of the RCTs showed any signal of superiority of BMT alone vs. EVT. Patients with low ASPECTS, more distal vessel occlusions and patients with low NIHSS scores should be included into RCTs if possible. Without participation in a RCT, patients should be selected for EVT based on age, severity and type of neurological impairment, time since symptom onset, location of the ischaemic lesion and perhaps also results of advanced imaging.

Mechanical Thrombectomy in Patients Presenting with NIHSS Score <6: A Safety and Efficacy Analysis

BACKGROUND AND OBJECTIVES

Groundbreaking trials have shown the tremendous efficacy of mechanical thrombectomy for large vessel occlusions. Currently, mechanical thrombectomy is limited to patients with NIHSS scores ≥6. We investigated the feasibility and safety of MT in patients presenting with NIHSS scores <6.

MATERIALS AND METHODS

A retrospective review of patient who presented with acute ischemic stroke due to large vessel occlusion with an NIHSS score <6 between 2015 - 2021. The patients were then divided into two groups: those who received mechanical thrombectomy and those who did not.

RESULTS

Among 83 patients, 41 received a mechanical thrombectomy while 42 received medical treatment only. The mean age in the mechanical thrombectomy group was 66 years versus 60 years in the medical group (p = 0.06). Risk factors for stroke did not differ significantly between both groups. 14 patients (34.1%) in the mechanical thrombectomy group and 20 (47.6%) in the medical group received tissue plasminogen activator. No significant difference in clinical improvement (NIHSS) at discharge (p=0.85) or the mRS score at 90 days (p = 0.15) was noted. Mechanical thrombectomy was associated with smaller infarct size (p=0.04) and decreased mortality (p=0.03).

CONCLUSIONS

Mechanical thrombectomy is safe and effective for patients who present with large vessel occlusions and low initial NIHSS scores. Therefore, the decision to offer the patient mechanical thrombectomy or not should not be decided by NIHSS score alone. Rather, the decision should be multifactorial with the aim of maximizing the patients' outcomes.

National implementation of reperfusion for acute ischaemic stroke in England: How should services be configured? A modelling study

Objectives

To guide policy when planning thrombolysis (IVT) and thrombectomy (MT) services for acute stroke in England, focussing on the choice between ‘mothership’ (direct conveyance to an MT centre) and ‘drip-and-ship’ (secondary transfer) provision and the impact of bypassing local acute stroke centres.

Design

Outcome-based modelling study.

Setting

107 acute stroke centres in England, 24 of which provide IVT and MT (IVT/MT centres) and 83 provide only IVT (IVT-only units).

Participants

242,874 emergency admissions with acute stroke over 3 years (2015–2017).

Intervention

Reperfusion delivered by drip-and-ship, mothership or ‘hybrid’ models; impact of additional travel time to directly access an IVT/MT centre by bypassing a more local IVT-only unit; effect of pre-hospital selection for large artery occlusion (LAO).

Main outcome measures

Population benefit from reperfusion, time to IVT and MT, admission numbers to IVT-only units and IVT/MT centres.

Results

Without pre-hospital selection for LAO, 94% of the population of England live in areas where the greatest clinical benefit, assuming unknown patient status, accrues from direct conveyance to an IVT/MT centre. However, this policy produces unsustainable admission numbers at these centres, with 78 out of 83 IVT-only units receiving fewer than 300 admissions per year (compared to 3 with drip-and-ship). Implementing a maximum permitted additional travel time to bypass an IVT-only unit, using a pre-hospital test for LAO, and selecting patients based on stroke onset time, all help to mitigate the destabilising effect but there is still some significant disruption to admission numbers, and improved selection of patients suitable for MT selectively reduces the number of patients who would receive IVT at IVT-only centres, challenging the sustainability of IVT expertise in IVT-only centres.

Conclusions

Implementation of reperfusion for acute stroke based solely on achieving the maximum population benefit potentially leads to destabilisation of the emergency stroke care system. Careful planning is required to create a sustainable system, and modelling may be used to help planners maximise benefit from reperfusion while creating a sustainable emergency stroke care system.

Treatment Challenges in Acute Minor Ischemic Stroke

Patients with acute ischemic stroke may present with minor neurologic deficits. Acute treatment decisions depend on the disability imposed by the symptoms along with radiographic features. The presence of disabling neurologic deficits warrants intravenous thrombolysis, but the indications for endovascular therapy are less defined. The degree of disability, presence of a large vessel occlusion with perfusion mismatch, and collateral circulation status may all be factors in selecting patients for endovascular treatment. Identification of patients who are at risk for neurologic deterioration is critical to preventing poor outcomes in this patient population.

Endovascular Thrombectomy Treatment: Beyond Early Time Windows and Small Core

ABSTRACT

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