Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Inhibition of the cGAS-STING pathway: contributing to the treatment of cerebral ischemia-reperfusion injury

The cGAS-STING pathway plays an important role in ischemia-reperfusion injury in the heart, liver, brain, and kidney, but its role and mechanisms in cerebral ischemia-reperfusion injury have not been systematically reviewed. Here, we outline the components of the cGAS-STING pathway and then analyze its role in autophagy, ferroptosis, cellular pyroptosis, disequilibrium of calcium homeostasis, inflammatory responses, disruption of the blood-brain barrier, microglia transformation, and complement system activation following cerebral ischemia-reperfusion injury. We further analyze the value of cGAS-STING pathway inhibitors in the treatment of cerebral ischemia-reperfusion injury and conclude that the pathway can regulate cerebral ischemia-reperfusion injury through multiple mechanisms. Inhibition of the cGAS-STING pathway may be helpful in the treatment of cerebral ischemia-reperfusion injury.

Exosomes: the next-generation therapeutic platform for ischemic stroke

Current therapeutic strategies for ischemic stroke fall short of the desired objective of neurological functional recovery. Therefore, there is an urgent need to develop new methods for the treatment of this condition. Exosomes are natural cell-derived vesicles that mediate signal transduction between cells under physiological and pathological conditions. They have low immunogenicity, good stability, high delivery efficiency, and the ability to cross the blood-brain barrier. These physiological properties of exosomes have the potential to lead to new breakthroughs in the treatment of ischemic stroke. The rapid development of nanotechnology has advanced the application of engineered exosomes, which can effectively improve targeting ability, enhance therapeutic efficacy, and minimize the dosages needed. Advances in technology have also driven clinical translational research on exosomes. In this review, we describe the therapeutic effects of exosomes and their positive roles in current treatment strategies for ischemic stroke, including their anti-inflammation, anti-apoptosis, autophagy-regulation, angiogenesis, neurogenesis, and glial scar formation reduction effects. However, it is worth noting that, despite their significant therapeutic potential, there remains a dearth of standardized characterization methods and efficient isolation techniques capable of producing highly purified exosomes. Future optimization strategies should prioritize the exploration of suitable isolation techniques and the establishment of unified workflows to effectively harness exosomes for diagnostic or therapeutic applications in ischemic stroke. Ultimately, our review aims to summarize our understanding of exosome-based treatment prospects in ischemic stroke and foster innovative ideas for the development of exosome-based therapies.

Non-coding RNAs in acute ischemic stroke: from brain to periphery

Acute ischemic stroke is a clinical emergency and a condition with high morbidity, mortality, and disability. Accurate predictive, diagnostic, and prognostic biomarkers and effective therapeutic targets for acute ischemic stroke remain undetermined. With innovations in high-throughput gene sequencing analysis, many aberrantly expressed non-coding RNAs (ncRNAs) in the brain and peripheral blood after acute ischemic stroke have been found in clinical samples and experimental models. Differentially expressed ncRNAs in the post-stroke brain were demonstrated to play vital roles in pathological processes, leading to neuroprotection or deterioration, thus ncRNAs can serve as therapeutic targets in acute ischemic stroke. Moreover, distinctly expressed ncRNAs in the peripheral blood can be used as biomarkers for acute ischemic stroke prediction, diagnosis, and prognosis. In particular, ncRNAs in peripheral immune cells were recently shown to be involved in the peripheral and brain immune response after acute ischemic stroke. In this review, we consolidate the latest progress of research into the roles of ncRNAs (microRNAs, long ncRNAs, and circular RNAs) in the pathological processes of acute ischemic stroke-induced brain damage, as well as the potential of these ncRNAs to act as biomarkers for acute ischemic stroke prediction, diagnosis, and prognosis. Findings from this review will provide novel ideas for the clinical application of ncRNAs in acute ischemic stroke.

Mesenchymal stem cell therapy in ischemic stroke trials. A systematic review

Cerebrovascular accidents, also known as strokes, are the leading cause of permanent disability in society, presenting significant socioeconomic and healthcare costs. They can be caused by ischemic factors or hemorrhages, with ischemic strokes being the most common among the population. Therapies for patients suffering from this condition are limited and primarily focus on acute-phase treatment. In recent years, there has been an increase in cellular therapies, employing Stem Cells to mitigate or eliminate the consequences arising from this disease. Mesenchymal Stem Cells (MSCs) hold substantial therapeutic potential in Nervous System pathologies due to their low antigenicity and capacity to differentiate into various human tissues, such as adipogenic, chondrogenic, and osteogenic tissues. This study conducts a literature review using the "clinical trials" and "Pubmed" database, summarizing all ongoing clinical trials for ischemic strokes that utilize MSCs as treatment.

Effects of intravenous rtPA in patients with minor stroke

BACKGROUND

Whether minor ischemic stroke (MIS) patients can benefit from intravenous thrombolysis (IVT) remains controversial. The association between the efficacy of IVT and baseline National Institute of Health Stroke Scale (NIHSS) score is unclear in MIS, while the association in moderate and severe stroke is known. This study aimed to explore the effect of IVT in patients with MIS and analyze its efficacy in patients with different baseline NIHSS scores.

METHODS

Patients with a NIHSS score ≤5 within 4.5 h of stroke onset were screened in 32 centers. Patients with and without IVT were matched to a ratio of 1:1 with propensity scores. An excellent outcome was defined as a modified Rankin Scale (mRS) score ≤1 at three months after stroke onset. Safety outcomes included mortality and symptomatic intracranial hemorrhage (sICH). Multivariate analysis was used to compute the adjusted odds ratio (OR) for excellent outcomes. The effect of IVT was further analyzed in subgroups according to the baseline NIHSS score.

RESULTS

Of the 23,853 screened, 3336 patients with MIS who arrived at the hospital within 4.5 h of onset were included. The 1163 patients treated with IVT were matched with 1163 patients without IVT. IVT in minor strokes generated an adjusted OR of 1.38 (95% CI: 1.09-1.75, p = 0.009) for excellent outcomes. There were no significant differences in mortality (0.17% vs. 0.09%, p = 1.000) and sICH (0.69% vs. 0.86%, p = 0.813) between patients with and without IVT. Subgroup analysis showed that there was no significant effect of IVT in the baseline NIHSS 0-1 or 2-3 subgroups, with adjusted OR of 0.816 (95% CI 0.437-1.53, p = 0.525) and1.22 (95% CI 0.845-1.77, p = 0.287), respectively. In patients with NIHSS score of 4-5, IVT was significantly effective, with an adjusted OR of 1.53 (95% CI 1.02-2.30, p = 0.038).

CONCLUSION

IVT can improve MIS outcomes. The risks of sICH and mortality did not increase, especially in patients with NIHSS scores 4 to 5, who could benefit from IVT significantly.

Delirium in the ICU: how much do we know? A narrative review

Delirium in critical ill patients is a complex and common neurological syndrome in the intensive care unit (ICU) that is caused by a range of structural or functional abnormalities. ICU Delirium is associated with reduced compliance, prolonged hospital stays, greater use or delayed withdrawal of sedatives, higher rates and durations of mechanical ventilation, and higher rates of mortality. The aetiology and pathogenesis of ICU delirium are unclear, and the lack of better prediction, prevention, and treatment measures leads to a non-standardized control of delirium. By searching the relevant literature, we aim in this narrative review to describe progress in the pathogenesis, predictive biomarkers, diagnosis, and treatment of ICU delirium.

Navigating the clinical landscape of artery of Percheron infarction: A systematic review

Introduction

Infarction of the artery of Percheron (AOP) is a rare vascular condition where a single arterial branch supplies blood to the thalamic and midbrain regions, leading to neurological deficits. The challenge lies in its often-delayed diagnosis due to its rarity and diverse clinical presentations, necessitating heightened awareness among clinicians for expedited diagnosis and appropriate therapeutic interventions.

Materials and methods

All relevant studies involving patients diagnosed with infarction of AOP were retrieved from PubMed, Google Scholar, Web of Science, and Scopus. Only human studies that were published in full English-language reports were included. Included in the search were the terms "Artery of Percheron," "infarction," "stroke," and "demarcation". Age, gender, presenting symptoms, treatment, recovery time, and outcome of patients with AOP infarction were all recorded.

Results

A systematic review was conducted on a total of 530 articles, out of which 130 articles met the specified requirements. The average age is 59, with men comprising 57.7% of the population. The symptoms reported were visual disturbance in 43.9% of cases and changed mental state in 77.2% of cases. Treatment options include conservative management (85.4%), thrombolysis (11.3%), and other approaches. The optimal age range for recovery is between 41 and 50 years old.

Conclusion

Our study on acute AOP infarction highlights male predominance, common comorbidities like hypertension and diabetes, and prevalent symptoms including visual disturbance and altered mental state. Early recognition is crucial, with thrombolytic therapy within the critical time window showing promising outcomes. These findings offer insights for enhanced clinical management of AOP infarction.

Tenecteplase vs Alteplase in Acute Ischemic Stroke Within 4.5 Hours: A Systematic Review and Meta-Analysis of Randomized Trials

BACKGROUND AND OBJECTIVES

The current European Stroke Organisation expedited recommendation on tenecteplase (TNK) for acute ischemic stroke (AIS) advocates that TNK 0.25 mg/kg can be used alternatively to alteplase (tissue plasminogen activator [TPA]) for AIS of <4.5 hours duration, based on a meta-analytical approach establishing noninferiority. Since the publication of these guidelines, 4 additional randomized controlled clinical trials (RCTs) have provided further insight.

METHODS

We conducted an updated systematic review and meta-analysis including all available RCTs that investigated efficacy and safety of TNK 0.25 mg/kg compared with TPA for the treatment of AIS within 4.5 hours of onset. The primary outcome was defined as the excellent functional outcome at 3 months (modified Rankin Scale [mRS] score 0-1), whereas good functional outcome (mRS score 0-2), reduced disability at 3 months (≥1-point reduction across all mRS scores), symptomatic intracranial hemorrhage (sICH), and 3-month mortality were evaluated as secondary outcomes. Pooled estimates were calculated with random-effects model. A prespecified subgroup analysis was performed stratifying for TNK formulation, that is, original TNK vs biocopy: recombinant human TNK tissue-type plasminogen activator that is available in China and has a different production process.

RESULTS

Eleven RCTs were included comprising a total of 3,788 patients treated with TNK vs 3,757 patients treated with TPA. TNK was associated with higher likelihood of excellent functional outcome (risk ratio [RR] 1.05, 95% CI 1.01-1.10; p = 0.012; I2 = 0%; risk difference 2.95%; 95% CI 0.76%-5.14%; p = 0.008; I2 = 0%) and reduced disability at 3 months (common odds ratio 1.10, 95% CI 1.01-1.19; p = 0.034; I2 = 0%) compared with TPA while good functional outcome (RR 1.03, 95% CI 0.99-1.07; p = 0.142; I2 = 28%) was similar between the groups. Regarding safety outcomes, similar rates of sICH (RR 1.12, 95% CI 0.83-1.53; p = 0.456; I2 = 0%) and 3-month mortality (RR 0.97, 95% CI 0.82-1.15; p = 0.727; I2 = 12%) were observed. When stratified for TNK regimen (original vs biocopy), statistical significance in achieving an excellent functional outcome at 3 months was retained for the original TNK (RR 1.05, 95% CI 1.00-1.10; p = 0.044; I2 = 0%).

DISCUSSION

The updated meta-analysis confirms similar safety between TNK 0.25 mg/kg and TPA, while showing that TNK is superior to TPA regarding excellent functional outcome and reduced disability at 3 months. These findings support transitioning to TNK in clinical practice.

Reevaluating the role of heparin during mechanical thrombectomy for acute ischemic stroke: Increased risks without functional benefit

BACKGROUND

Heparin may be administered during mechanical thrombectomy (MT) for acute ischemic stroke due to large vessel occlusions (AIS-LVO), with the aim of enhancing reperfusion and improving patient outcomes. The uncertain balance between risks and benefits of administering heparin during MT prompted us to perform this systematic review and meta-analysis.

METHODS

A comprehensive search was conducted in PubMed, Embase, and Scopus to find studies that report the safety or efficacy of administering heparin during MT for AIS-LVO. Meta-analysis was performed using the random effects model. In case of significant heterogeneity a subgroup analysis was performed.

RESULTS

From 2398 screened records, we included 15 studies. Rate of favorable functional outcome (90 day modified Rankin Scale 0-2 (mRS 0-2)) was lower among patients who received heparin (OR, 0.88 [95 %CI 0.79-0.98]; p=.023). Risk of distal embolization was higher in patients who received heparin (OR, 1.25 [95 %CI 1.01-1.55]; p=.04). The subgroup analysis showed that patients who received intravenous thrombolysis (IVT) had higher risk of Symptomatic intracranial hemorrhage (sICH) (OR, 2.94 [95 %CI 1.30-6.63]; p=.009) and lower rate of mRS 0-2 (OR, 0.66 [95 %CI 0.50-0.87]; p=.004). Heparin use didn't affect successful reperfusion rate (Thrombolysis in cerebral infarction ≥2B), mortality or any ICH risk.

CONCLUSION

Overall, our analysis indicates that administering heparin during MT for AIS-LVO correlates with worse clinical outcomes and increased distal embolization rates. Moreover, it is linked to a higher risk of sICH in patients who receive IVT. Consequently, the routine utilization of heparin during MT should be reconsidered.

Factors associated with mortality and functional outcome after decompressive craniectomy in malignant middle cerebral artery infarction

OBJECTIVE

Identifying the predictive factors of mortality and functional outcomes following decompressive craniectomy (DC) surgery in patients with malignant middle cerebral artery infarction (MMCAI) is essential for decision-making regarding conservative versus surgical treatment. This study aimed to assess the mortality and functional outcomes of MMCAI patients after DC surgery and to identify the predictive factors associated with mortality and functional outcomes.

METHODS

A total of 76 patients with MMCAI who underwent surgical DC were included. The mortality rates and functional outcomes were assessed, and factors associated with mortality and functional outcomes were identified through univariate analysis followed by multivariate logistic regression analysis.

RESULTS

The mortality rate was 44.8%, while a favorable functional outcome was observed in 28.9% of the patients. modified Glasgow coma scale (GCS) before DC (OR = 0.416, 95% CI = 0.261-0.662, P < 0.001) and infarct volume before DC (OR = 1.000-1.012, 95% CI = 1.000-1.012, P = 0.037) were independent risk factors for death. Age (OR = 0.88, 95% CI = 0.812-0.952, P = 0.002), modified GCS before DC (OR = 2.477, 95% CI = 1.395-4.4, P = 0.002), and infarct volume before DC (OR = 0.987, 95% CI = 0.975-0.999, P = 0.035) were independent factors associated with favorable functional outcomes.

CONCLUSION

Preoperative modified GCS and preoperative infarct volume were independent factors associated with both mortality and functional outcomes. Age was only associated with functional outcomes.

Cutting-edge advances in nano/biomedicine: A review on transforming thrombolytic therapy

Thrombotic blockages within blood vessels give rise to critical cardiovascular disorders, including ischemic stroke, venous thromboembolism, and myocardial infarction. The current approach to the therapy of thrombolysis involves administering Plasminogen Activators (PA), but it is hindered by fast drug elimination, narrow treatment window, and the potential for bleeding complications. Leveraging nanomedicine to encapsulate and deliver PA offers a solution by improving the efficacy of therapy, safeguarding the medicine from proteinase biodegradation, and reducing unwanted effects in in vivo trials. In this review, we delve into the underlying venous as well as arterial thrombus pathophysiology and provide an overview of clinically approved PA used to address acute thrombotic conditions. We explore the existing challenges and potential directions within recent pivotal research on a variety of targeted nanocarriers, such as lipid, polymeric, inorganic, and biological carriers, designed for precise delivery of PA to specific sites. We also discuss the promising role of microbubbles and ultrasound-assisted Sono thrombolysis, which have exhibited enhanced thrombolysis in clinical studies. Furthermore, our review delves into approaches for the strategic development of nano-based carriers tailored for targeting thrombolytic action and efficient encapsulation of PA, considering the intricate interaction in biology systems as well as nanomaterials. In conclusion, the field of nanomedicine offers a valuable method for the exact and effective therapy of severe thrombus conditions, presenting a pathway toward improved patient outcomes and reduced complications.

Endovascular thrombectomy with or without intravenous alteplase in large-core ischemic stroke: a systematic review and meta-analysis

The role of bridging intravenous thrombolysis (IVT) with alteplase before endovascular thrombectomy (EVT) in treating large core ischemic stroke remains uncertain. We aimed to compare clinical outcomes and safety of EVT with or without bridging IVT in patients with anterior circulation large vessel occlusion (ACLVO) and baseline Alberta Stroke Program Early CT Score (ASPECTS) ≤ 5. We systematically searched PubMed, Web of Science, Cochrane Library, and Embase from inception until November 2023. The primary outcome was 90-day functional independence (modified Rankin Scale [mRS] 0-2). Secondary outcomes included 90-day independent ambulation (mRS 0-3), successful recanalization, any intracranial hemorrhage (ICH), symptomatic ICH (sICH) and 90-day mortality. A random-effects model was used for data pooling. Five high-quality studies, incorporating 2124 patients (41% treated with bridging IVT), were included. Across both unadjusted and adjusted analyses, no significant differences were found between the bridging IVT and EVT-alone groups in terms of functional independence (odds ratios [OR] = 1.36, 95% confidence interval [CI]: 0.90-2.07, P = 0.14; adjusted OR [aOR] = 1.19, 95% CI: 0.68-2.09, P = 0.53) or independent ambulation (OR = 1.14, 95% CI: 0.80-1.62, P = 0.47; aOR = 1.18, 95% CI: 1.00-1.39, P = 0.05) at 90 days. Furthermore, no differences were observed in successful recanalization, any ICH, sICH, and 90-day mortality between the two treatment groups. Bridging IVT exhibits similar functional and safety outcomes compared to EVT alone in ACLVO patients with baseline ASPECTS ≤ 5. Further research is warranted to confirm these findings.

Finding MeVO: Identifying Intracranial Medium-Vessel Occlusions at CT Angiography

The development of methods to detect and treat intracranial large-vessel occlusions (LVOs) has revolutionized the management of acute ischemic stroke. CT angiography (CTA) of the head and neck is effective in depicting LVOs and widely used in the evaluation of patients who have had a stroke. Ongoing efforts are now focused on the potential to detect and treat intracranial medium-vessel occlusions (MeVOs), which by definition are smaller than LVOs and thus more difficult to detect with CTA. The authors review common and variant anatomies of medium-sized cerebral arteries and the appearance of a variety of MeVOs on CT angiograms. Possible pitfalls in MeVO detection include rare anatomic variants, calcified thrombi, and stump occlusions. Current recommendations for performing CTA and ancillary methods that might aid in MeVO detection are discussed. Understanding the relevant anatomy and the variety of appearances of MeVOs aids radiologists in identifying these occlusions, particularly in the setting of urgent stroke. ©RSNA, 2024 See the invited commentary by Ospel and Nguyen in this issue.

Mortality Outcomes with Tenecteplase Versus Alteplase in the Treatment of Massive Pulmonary Embolism

BACKGROUND

Pulmonary embolism (PE) leads to many emergency department visits annually. Thrombolytic agents, such as alteplase, are currently recommended for massive PE, but genetically modified tenecteplase (TNK) presents advantages. Limited comparative studies exist between TNK and alteplase in PE treatment.

OBJECTIVE

The aim of this study was to assess the safety and mortality of TNK compared with alteplase in patients with PE using real-world evidence obtained from a large multicenter registry. Primary outcomes included mortality, intracranial hemorrhage, and blood transfusions.

METHODS

This retrospective cohort study used the TriNetX Global Health Research Network. Patients aged 18 years or older with a PE diagnosis (International Classification of Diseases, 10th Revision, Clinical Modification code I26) were included. The following two cohorts were defined: TNK-treated (29 organizations, 266 cases) and alteplase-treated (22,864 cases). Propensity matching controlled for demographic characteristics, anticoagulant use, pre-existing conditions, and vital sign abnormalities associated with PE severity. Patients received TNK or alteplase within 7 days of diagnosis and outcomes were measured at 30 days post thrombolysis.

RESULTS

Two hundred eighty-three patients in each cohort were comparable in demographic characteristics and pre-existing conditions. Mortality rates at 30 days post thrombolysis were similar between TNK and alteplase cohorts (19.4% vs 19.8%; risk ratio 0.982; 95% CI 0.704-1.371). Rates of intracerebral hemorrhages and transfusion were too infrequent to analyze.

CONCLUSIONS

This study found TNK to exhibit a similar mortality rate to alteplase in the treatment of PE with hemodynamic instability. The results necessitate prospective evaluation. Given the cost-effectiveness and ease of administration of TNK, these findings contribute to the ongoing discussion about its adoption as a primary thrombolytic agent for stroke and PE.

The impacts of venous outflow profiles on outcomes among large vessel occlusion patients receiving endovascular treatment in the late window

OBJECTIVES

To investigate the association between venous outflow (VO) profiles and outcomes among acute ischemic stroke caused by anterior circulation large vessel occlusion (AIS-LVO) patients who had undergone endovascular treatment (EVT) in the late window of 6-24 h from stroke onset.

METHODS

This was a post-hoc analysis of our preceding RESCUE-BT trial, with findings validated in an external cohort. Baseline computed tomographic angiography (CTA) was performed to assess VO using the Cortical Vein Opacification Score (COVES). The primary clinical outcome was functional independence at 90 days (modified Rankin Scale score of 0-2). The adjusted odd ratio (aOR) and confidence interval (CI) were obtained from multivariable logistic regressions.

RESULTS

A total of 440 patients were included in the present study. After identifying the cutoff of COVES by marginal effects approach, enrolled patients were divided into the favorable VO group (COVES 4-6) and the poor VO (COVES 0-3) group. Multivariable logistic regression analysis showed that favorable VO (aOR 2.25; 95% CI 1.31-3.86; p = 0.003) was associated with functional independence. Similar results were detected in the external validation cohort. Among those with poor arterial collateralization, favorable VO was still an independent predictor of functional independence (aOR 2.09; 95% CI 1.06-4.10; p = 0.032).

CONCLUSION

The robust VO profile indicated by COVES 4-6 could promote the frequency of functional independence among AIS-LVO patients receiving EVT in the late window, and the prognostic value of VO was independent of the arterial collateral status.

CLINICAL RELEVANCE STATEMENT

The robust venous outflow profile was a valid predictor for functional independence among AIS-LVO patients receiving EVT in the late window (6-24 h) and the predictive role of venous outflow did not rely on the status of arterial collateral circulation.

Dual Antiplatelet Versus Alteplase for Early Neurologic Deterioration in Minor Stroke With Versus Without Large Vessel Occlusion: Prespecified Post Hoc Analysis of the ARAMIS Trial

BACKGROUND

Dual antiplatelet therapy (DAPT) was noninferior to alteplase in minor nondisabling strokes in the ARAMIS trial (Antiplatelet Versus R-tPA for Acute Mild Ischemic Stroke); however, early neurological deterioration (END) associated with vessel stenosis may benefit from DAPT. We investigated whether the efficacy of DAPT was greater than alteplase in minor strokes with no large vessel occlusion (LVO).

METHODS

This study was a prespecified post hoc analysis of the ARAMIS trial and included patients with responsible vessel examination in the as-treated analysis set of the ARAMIS trial who were divided into LVO group and non-LVO group. In each group, patients were further classified into DAPT and intravenous alteplase treatments. Primary outcome was END at 24 hours defined as more than or equal to 4-point National Institutes of Health Stroke Scale score increase compared with baseline, and safety outcomes were symptomatic intracerebral hemorrhage and bleeding events during study. The primary analysis was estimated with a risk difference calculated by a generalized linear model including adjusted different baseline characteristics between treatments.

RESULTS

Of 723 patients from the ARAMIS trial, 480 patients were included: 36 were categorized into LVO group and 444 into non-LVO group, of whom 20 patients had END. Compared with intravenous alteplase, a lower proportion of END was found after DAPT treatment in the non-LVO group (adjusted risk difference, -4.8% [95% CI, -6.9% to -2.6%]; P<0.001), but not in the LVO group (adjusted risk difference, 2.3% [95% CI, -17.6% to 22.3%]; P=0.82). The interaction was marginally significant between groups (P=0.06). In the non-LVO group, a lower proportion of bleeding events was found after DAPT treatment than intravenous alteplase (adjusted risk difference, -6.4% [95% CI, -8.9% to -3.9%]; P<0.001). Other safety outcomes were similar between the 2 treatments.

CONCLUSIONS

Among minor nondisabling acute ischemic stroke without LVO, DAPT may be superior to intravenous alteplase regarding preventing END with a better safety profile.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03661411.

Efficacy of decompressive craniectomy: A retrospective case series study with 321 patients and an update on controversies

Decompressive craniectomy (DC) is considered a cornerstone in the management of refractory intracranial hypertension. For decades, DC was known as an occasionally lifesaving procedure; however, it was associated with numerous severe complications. The present study is a single-center retrospective case series study on with 321 patients who underwent DC between January, 2010 and December, 2020. All patients were divided into four groups as follows: Group A included patients who suffered from a space-occupying middle cerebral artery (MCA) ischemic event; group B included individuals who developed intracerebral hemorrhage; group C included patients admitted for traumatic brain injury; and group D included patients with other neurosurgical entities that underwent DC, such as subarachnoid hemorrhage, tumors, brain abscess and cerebral ventricular sinus thrombosis events. The present study enrolled a total of 321 patients who underwent DC. Group A included 52 out of the 321 (16.1%) patients, group B included 51 (15.8%) patients, group C included 164 (51.0%) patients, and group D included 54 (16.8%) patients. Of the 321 patients, 235 (73.2%) were males, and the median age was 53.7 years. Multivariate analysis revealed that only the group A parameter was an independent factor associated with a Glasgow outcome scale score >2 during follow-up (P<0.05). On the whole, the results of the present study suggest that among patients who underwent DC with different neurological entities, those who had experienced MCA events had more favorable outcomes.

Assessing mortality and safety of IV thrombolysis in ischemic stroke patients on direct oral anticoagulants (DOACs): A systematic review and meta-analysis

BACKGROUND

Intravenous thrombolysis (IVT) is considered a standard reperfusion therapy for acute ischemic stroke (AIS) patients presenting within 4.5 hours of the last known well (LKW). Current guidelines contraindicate the use of IVT in patients within the window who are on Direct Oral Anticoagulants (DOACs) and took their last dose within 48 hours of presentation, due to a risk of symptomatic intracranial hemorrhage (sICH).

OBJECTIVE

To assess the safety of IVT as management of AIS in patients who take DOACs.

METHODS

A thorough literature search of four databases (PubMed, Scopus, Medline, Google Scholar, Web of science and ScienceDirect) was done from inception until May 2023. Double-arm studies that reported outcomes of mortality, sICH, and mRS scores were selected. Results from these studies were presented as odds ratios (ORs) with 95 % confidence intervals (CIs) and were pooled using a random-effects model.

RESULTS

Four eligible studies were included with a total of 238,425 stroke patients who underwent IVT (3330 in the DOAC arm and 235,217 in the placebo arm). The group with prior DOAC intake showed a significant decrease in sICH development and an increase in functional independence at 90 days compared to the control group. No significant association was seen between prior DOAC use and any serious alteplase-related complication within 36 hours, serious systemic or life-threatening hemorrhage within 36 hours, mortality within 3 months, or mRS score at 3 months.

CONCLUSION

The pooled analysis suggests that IVT is a safe management option for acute ischemic stroke in patients with DOAC intake before symptom onset without an increased risk of serious adverse events.

Outcome of intravenous thrombolysis in acute ischemic stroke patients with small vessel disease

INTRODUCTION

Lacunar stroke (LS) subtype accounts for a quarter of ischemic strokes. Intravenous thrombolysis (IVT) is known to improve overall stroke outcomes. Very few studies have focused on the outcome of IVT in lacunar strokes.

AIM

To detect the outcome of IVT in LS patients compared to non-thrombolysed LS patients.

METHODS

Fifty patients presenting with LS received the standard protocol of IVT (Group I). They were compared to fifty matched LS patients who presented beyond the time window and were selected as the control group (Group II). Clinical outcome was measured using NIHSS within 24 h, NIHSS at discharge, and MRS after 3 months. Risk factors that could have affected clinical outcomes were compared in the thrombolysis group.

RESULTS

The short-term clinical outcome of Group I showed statistically significant improvement of NIHSS after 24 hrs compared to Group II (mean NIHSS = 5.52±3.89 and 7.44±1.82 respectively), as well as on discharge (mean NIHSS = 3.88±3.50 and 5.78±2.97) respectively. For long-term outcomes, 94 % of GroupⅠ reached MRS 0, 1, and 2 (n = 47/50) versus 74 % (n = 36/50) in Group II. Longer door-to-needle time, severe WMCs (Fazekas score), and pneumonia were shown to be significant predictor factors for the worst outcome.

CONCLUSION

IVT has improved short- and long-term outcomes in LS patients. Longer door-to-needle time, severe WMCs, and pneumonia were shown to be significant predictor factors for the worst outcome.

Correlation and predictive value of platelet biological indicators and recurrence of large-artery atherosclerosis type of ischemic stroke

Large-artery atherosclerosis type of ischemic stroke happens when a blood clot forms in a major artery that carries blood to the brain. This causes a blockage and a decrease in blood flow to the brain tissue making up approximately 15-20% of all cases. This type of stroke is more prevalent in older adults and those with risk factors such as high blood pressure, high cholesterol, diabetes, smoking, and a family history of stroke. To investigate the correlation and predictive value of platelet-related biological indicators with recurrence of large-artery atherosclerosis type of ischemic stroke (LAA-IS)2. The patients were divided into a relapse group (R, n = 40) and non-relapse group (NR, n = 45). Platelet-related biological indicators were collected from both groups to analyze their correlation with neurological impairment score (NIHSS score). Risk factors were analyzed using binary logistic regression and a survival curve (ROC) was drawn to evaluate the predictive effect of clinical platelet-related biological indicators on LAA-IS recurrence. This study confirmed that PAg-ADP, PAg-COL, and FIB are closely related to the formation of LAA-IS due to carotid atherosclerosis, and the combined PAg-ADP, PAg-COL, and FIB index levels are the most promising for assessing the prognostic development of recurrence in patients with LAA-IS. Combined monitoring of platelet aggregation rate and FIB index is of important evaluation value in judging the recurrence prognosis of LAA-IS patients.

Arterial Ischemic Stroke in Children

Arterial ischemic stroke (AIS) in children has a high mortality and life-long disability rate in surviving patients. Diagnostic delays are longer and risk factors are different compared with AIS in the adult population. Congenital heart disease, cervical arterial dissection, and intracranial arteriopathies are the main causes of AIS in children. New revascularization time windows in children require the definition of diagnostic protocols for stroke in each referral center. In this article, we discuss the neuroimaging techniques and protocols, describe the main underlying causes, and review the current treatment options for pediatric and perinatal AIS.

Effects of world stroke campaign on stroke literacy and knowledge in Taiwan

OBJECTIVES

Stroke is a leading cause of death in Taiwan. Poor public knowledge of stroke may lead to delays in prehospital arrival, resulting in unfavorable prognoses. Studies have investigated public knowledge of stroke and highlighted the importance of stroke education, however, few such studies have been conducted in Taiwan. This study assessed the changes in public knowledge of stroke between 2012 and 2020 by conducting a survey during two World Stroke Day events. Furthermore, this study identified areas where educational efforts may have been insufficient.

MATERIALS & METHODS

Questionnaires were distributed to the participants of 2012 and 2020 World Stroke Day events in Taiwan. In total, 328 and 336 questionnaires were completed, respectively. Stroke literacy and knowledge were analyzed between 2012 and 2020. Data were analyzed using the chi-square test or independent t-test. p < 0.05 indicates statistical significance.

RESULTS

Hypertension was the most recognized risk factor for stroke in both years (p < 0.001), and recognition of most of the given risk factors significantly increased. In addition, recognition of more than half of the stroke warning signs significantly increased, awareness of the correct acute stroke response also increased (p < 0.001), and overall stroke literacy in Taiwan increased (p = 0.001).

CONCLUSION

Stroke literacy and knowledge in Taiwan have improved significantly between 2012 and 2020, but many people still lack adequate stroke knowledge and awareness. Government health department must take this sort of intervention continually (campaigns) and novel approaches (e.g. board game…) to improve stroke literacy and knowledge in public health.

REGISTRATION ID

N202109072, approved by the Joint Institutional Review Board of Taipei Medical University on 2021/11/02.

Success with incrementally faster times to endovascular therapy (SWIFT-EVT): A systematic review and meta-analysis

BACKGROUND

A major systematic review and meta-analysis assessing trial data through 2014 (the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials, HERMES) demonstrated that particularly over the initial six hours of acute ischemic stroke (AIS), rapid performance of endovascular therapy (EVT) markedly improves outcomes. The current analysis, Success with Incrementally Faster Times to EVT (SWIFT-EVT), aimed to provide an updated metric summarizing latest estimates for modified Rankin Scale (mRS) improvements accrued by streamlining time to EVT.

METHODS

A systematic review and meta-analysis was conducted using electronic databases. Eligible studies reported a time-benefit slope with times from AIS onset (or time last known normal) to EVT commencement; the predictor was onset-to-groin (OTG) time. Primary and secondary outcomes were 90-day functional independence (mRS 0-2) and 90-day excellent function (mRS 0-1), respectively.

RESULTS

Five studies were included. Results showed increased change of good outcome with each hour of pre-EVT time savings for mRS 0-2 for 0-270' (OR 1.25, 95 % CI 1.16-1.35, I2 40 %) and 271-360' time frame (1.22, 95 % CI 1.12-1.33, I2 58 %). For the studies assessing mRS 0-1, estimates were found appropriate for both the 0-270' time frame (OR 1.34, 95 % CI 1.19-1.51, I2 27 %) and the 271-360' time frame (OR 1.20, 95 % CI 1.03-1.38, I2 60 %).

CONCLUSIONS

Each hour saved from AIS onset to EVT start is associated with a 22-25 % increased odds of achieving functional independence, a useful metric to inform patient-specific and systems planning decisions.

Safety and efficacy of cangrelor in endovascular thrombectomy compared with glycoprotein IIb/IIIa Inhibitors

BACKGROUND

Cangrelor, an intravenous P2Y12-receptor inhibitor, is a reversible and short-acting antithrombotic medication non-inferior to irreversible glycoprotein IIb/IIIa inhibitors (GPIs) like eptifibatide. There are insufficient data to compare the medications in endovascular thrombectomies (EVTs) requiring emergent platelet inhibition.

OBJECTIVE

To review our institution's experience with cangrelor in EVT and compares its safety and efficacy against GPIs.

METHODS

A large healthcare system retrospective review identified all patients who had received cangrelor or eptifibatide intraoperatively during EVT between December 2018 and March 2023 for this cohort study. Clinical data were reviewed. Functional status was defined by the modified Rankin Scale (mRS) and National Institutes of Health Stroke Scale (NIHSS) at multiple time points. Multivariate regression was performed.

RESULTS

Of 1010 EVT patients, 36 cangrelor and 104 eptifibatide patients were selected. There were no differences in baseline function or presentations. Cangrelor was frequently administered for stenting tandem occlusions (n=16, 44.4%), and successful reperfusion occurred in 30 (83.3%) patients. On multivariate analysis, cangrelor was associated with decreased odds of hemorrhagic conversion (adjusted OR (aOR)=0.76, P=0.004) and symptomatic hemorrhage (aOR=0.86, P=0.021). There were no differences in thrombotic re-occlusion. Cangrelor was associated with a lower 24-hour NIHSS score (7.0 vs 12.0, P=0.013) and discharge NIHSS score (3.0 vs 9.0, P=0.004). There were no differences in in-hospital mortality or length of stay. Cangrelor was associated with improved odds of favorable outcome, defined as mRS score 0-2, at discharge (aOR=2.69, P=0.001) and on 90-day follow-up (aOR=2.23, P=0.031).

CONCLUSION

Cangrelor was associated with a decreased risk of hemorrhagic conversion and might lead to favorable functional outcomes for patients during hospitalization in comparison with GPIs. Prospective studies are warranted to investigate its use in EVT.

Risk of angioedema and thrombolytic therapy among stroke patients: An analysis of data from the FDA Adverse Event Reporting System database

The angioedema risk may vary among stroke patients receiving different thrombolytic agents. This study aimed to investigate the angioedema risk associated with different thrombolytic agents and to identify associated risk factors. We conducted a large-scale retrospective pharmacovigilance study using the FDA Adverse Event Reporting System (FAERS) database. Stroke patients receiving thrombolytic therapy (i.e., alteplase or tenecteplase) were identified, and the associations with angioedema were explored using disproportionality analysis and time-to-onset analysis. Additionally, we used adapted Bradford Hill criteria to confirm these associations. Risk factors for angioedema were explored using stepwise logistic regression. A total of 17,776 stroke patients were included, with 2973 receiving alteplase and 278 receiving tenecteplase. Disproportionality analysis revealed that angioedema might be associated with alteplase (adjusted ROR [aROR] 5.13 [95 ​% CI, 4.55-5.79]) or tenecteplase (aROR 2.72 [95 ​% CI, 1.98-3.67]). The adapted Bradford Hill criteria suggested a probable causal relationship between alteplase and angioedema, whereas there was insufficient evidence of a probable causal relationship with tenecteplase. Multivariate analysis revealed that ACE-inhibitors use (aROR 9.73 [95 ​% CI, 7.29-12.98]), female sex (aROR 1.38 [95 ​% CI, 1.13-1.67]) and hypertension (aROR 2.11 [95 ​% CI, 1.52-2.92]) were significant risk factors for angioedema among alteplase-treated stroke patients. Our study suggested that alteplase is associated with a greater risk of angioedema among stroke patients, but there is insufficient evidence to support an association between tenecteplase and angioedema. Clinicians should be vigilant for this potentially life-threatening complication, particularly in patients with identified risk factors. It is also prudent to consider tenecteplase as an alternative, if available.

Inflammation index in failure of delay functional independence after successful recanalization

BACKGROUND

Failure of delayed neurological improvement (fDNI) following successful recanalization is a prevalent clinical phenomenon in patients who have experienced acute ischemic stroke (AIS). An investigation into the potential link between markers of systemic inflammation such as platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), systemic immune-inflammation index known as SII, and the occurrence of fDNI in patients received successful reperfusion was conducted.

METHODS

The study included patients diagnosed with AIS who underwent thrombectomy and experienced fDNI, as observed in a prospective study conducted from January 2017 to April 2020. In order to identify predictors of fDNI, we performed multivariable logistic regression and receiver operating characteristic (ROC) curve.

RESULTS

Eighty-four patients (23.86%) without early neurological improvement (ENI) experienced DNI, and 268 (76.14%) patients did not show DNI. After adjustment for potential confounders, NLR (adjust OR, 2.131; 95%CI, 1.066-4.259; p = 0.032) and SII (adjust OR, 1.065; 95%CI, 1.001-1.132, p = 0.045) exhibited independent reationship with fDNI independently in multivariate analysis. The areas under AUC of multivariable NLR and SII mode were 0.862 and 0.861, respectively.

CONCLUSIONS

The immune-inflammatory biomarkers, including NLR and SII, exhibited associations with DNI in patients without ENI. Further investigations are warranted to elucidate the underlying mechanisms.

Delays in Cardiovascular Emergency Responses in Africa: Health System Failures or Cultural Challenges?

Delays in receiving care for debilitating cardiovascular emergencies, such as myocardial infarction and stroke, are multifaceted and include personal, systemic, and health facility-related factors, which must all be addressed to successfully improve cardiovascular emergency outcomes.

Association of albumin-corrected anion gap with severe consciousness disorders and outcomes in ischemic stroke: a retrospective MIMIC analysis

The relationship between albumin-corrected anion gap (ACAG) and severe disorder of consciousness (SDOC), in-hospital mortality, and long-term mortality in patients with ischemic stroke (IS) remains unclear. This study investigates the association of ACAG with SDOC and other outcomes in IS using data from the MIMIC-IV database. A total of 2,379 IS patients were included, with a demographic breakdown showing 51% were male and an SDOC incidence of 16.4%. Analysis through Cox proportional hazards models indicated that ACAG is significantly associated with the risks of both SDOC and mortality. Additionally, restricted cubic spline(RCS) analysis suggested a nearly linear relationship between increasing ACAG levels and the incidence of SDOC. Kaplan-Meier curves demonstrated significant differences in the incidence rates of SDOC, in-hospital mortality, and long-term mortality across varying ACAG levels. The findings suggest that ACAG serves as an independent predictor for SDOC, in-hospital mortality, and long-term mortality in IS patients. Nonetheless, further prospective studies are needed to confirm these causal relationships.

Tongue Pressure and Grip Strength as Indicators of Persistent Dysphagia After Acute Stroke

This study aimed to identify the independent predictors of postacute stroke dysphagia at discharge using sarcopenia-related parameters. This single-center prospective observational study assessed consecutive inpatients diagnosed with cerebral infarction or cerebral hemorrhage upon admission to the stroke unit. Tongue pressure, grip strength, and body composition were evaluated within 48 h. Dysphagia was defined by a functional oral intake scale of ≤ 5. Patient characteristics were compared between non-dysphagia and dysphagia groups using Mann-Whitney or chi-squared tests. Logistic regression analysis was performed using age, sex, tongue pressure, grip strength, skeletal muscle mass index (SMI), and National Institutes of Health Stroke Scale (NIHSS) scores as explanatory variables, with dysphagia at discharge as the objective variable. A total of 302 patients (mean age: 69.4 ± 13.8 years, 67.5% male) were analyzed, with 64 having dysphagia at discharge (21.2%). The dysphagia group was significantly older (p<0.001), had higher NIHSS scores on admission (p<0.001), lower SMI (p = 0.002), lower grip strength (p<0.001), and lower tongue pressure (p<0.001) than the non-dysphagia group. Logistic regression revealed that age (OR: 1.042, p = 0.018), tongue pressure (OR: 0.954, p = 0.010), and grip strength (OR: 0.943, p = 0.048) on admission were independent predictors of dysphagia at discharge, while NIHSS scores (OR: 1.403, p = 0.106), sex, and SMI (OR: 1.403, p = 0.150) were not. Older age, reduced tongue pressure, and reduced grip strength are strong predictors of persistent poststroke dysphagia at discharge. Thus, muscle strength is a more valuable parameter than muscle mass in predicting persistent poststroke dysphagia.

Amphetamine and methylphenidate potential on the recovery from stroke and traumatic brain injury: a review

The prevalence of stroke and traumatic brain injury is increasing worldwide. However, current treatments do not fully cure or stop their progression, acting mostly on symptoms. Amphetamine and methylphenidate are stimulants already approved for attention deficit hyperactivity disorder and narcolepsy treatment, with neuroprotective potential and benefits when used in appropriate doses. This review aimed to summarize pre-clinical and clinical trials testing either amphetamine or methylphenidate for the treatment of stroke and traumatic brain injury. We used PubMed as a database and included the following keywords ((methylphenidate) OR (Ritalin) OR (Concerta) OR (Biphentin) OR (amphetamine) OR (Adderall)) AND ((stroke) OR (brain injury) OR (neuroplasticity)). Overall, studies provided inconsistent results regarding cognitive and motor function. Neurite outgrowth, synaptic proteins, dendritic complexity, and synaptic plasticity increases were reported in pre-clinical studies along with function improvement. Clinical trials have demonstrated that, depending on the brain region, there is an increase in motor activity, attention, and memory due to the stimulation of the functionally depressed catecholamine system and the activation of neuronal remodeling proteins. Nevertheless, more clinical trials and pre-clinical studies are needed to understand the drugs' full potential for their use in these brain diseases namely, to ascertain the treatment time window, ideal dosage, long-term effects, and mechanisms, while avoiding their addictive potential.

Mobile Stroke Unit Management in Patients With Acute Ischemic Stroke Eligible for Intravenous Thrombolysis

Importance

Clinical trials have suggested that prehospital management in a mobile stroke unit (MSU) improves functional outcomes in patients with acute ischemic stroke who are potentially eligible for intravenous thrombolysis, but there is a paucity of real-world evidence from routine clinical practice on this topic.

Objective

To determine the association between prehospital management in an MSU vs standard emergency medical services (EMS) management and the level of global disability at hospital discharge.

Design, Setting, and Participants

This was a retrospective, observational, cohort study that included consecutive patients with a final diagnosis of ischemic stroke who received either prehospital management in an MSU or standard EMS management between August 1, 2018, and January 31, 2023. Follow-up ended at hospital discharge. The primary analytic cohort included those who were potentially eligible for IV thrombolysis. A separate, overlapping cohort including all patients regardless of diagnosis was also analyzed. Patient data were obtained from the American Heart Association's Get With The Guidelines-Stroke (GWTG-Stroke) Program, a nationwide, multicenter quality assurance registry. This analysis was completed in May 2024.

Exposure

Prehospital management in an MSU (vs standard EMS management).

Main Outcomes and Measures

The primary efficacy end point was the utility-weighted modified Rankin Scale (UW-mRS) score. The secondary efficacy end point was independent ambulation status. The coprimary safety end points were symptomatic intracranial hemorrhage (sICH) and in-hospital mortality.

Results

Of 19 433 patients (median [IQR] age, 73 [62-83] years; 9867 female [50.8%]) treated at 106 hospitals, 1237 (6.4%) received prehospital management in an MSU. Prehospital management in an MSU was associated with a better score on the UW-mRS at discharge (adjusted mean difference, 0.03; 95% CI, 0.01-0.05) and a higher likelihood of independent ambulation at discharge (53.3% [468 of 878 patients] vs 48.3% [5868 of 12 148 patients]; adjusted risk ratio [aRR], 1.08; 95% CI, 1.03-1.13). There was no statistically significant difference in sICH (5.2% [57 of 1094] vs 4.2% [545 of 13 014]; aRR, 1.30; 95% CI, 0.94-1.75]) or in-hospital mortality (5.7% [70 of 1237] vs 6.2% [1121 of 18 196]; aRR, 1.03; 95% CI, 0.78-1.27) between the 2 groups.

Conclusions and Relevance

Among patients with acute ischemic stroke potentially eligible for intravenous thrombolysis, prehospital management in an MSU compared with standard EMS management was associated with a significantly lower level of global disability at hospital discharge. These findings support policy efforts to expand access to prehospital MSU management.

Continuous transcranial ultrasound in large vessel stroke: Image guidance for high-intensity focused sonothrombolysis

BACKGROUND AND PURPOSE

Sonothrombolysis is a potential adjunctive therapy for large vessel occlusion (LVO) stroke. Bedside ultrasound image-guided high-intensity focused ultrasound (HIFU) therapy could deliver higher energy therapeutic ultrasound to the thrombus with higher precision than what was previously accomplished in human trials. The aim is to test the feasibility of diagnostic transcranial contrast-enhanced ultrasound (CEUS) to image the occlusion site and continuously maintain the guidance image on-target for a sufficient exposure time for HIFU to be effective during LVO stroke evaluation and treatment.

METHODS

This prospective, single center, observational cohort study included adult patients, presenting within 6 hours of stroke symptom onset, with LVO identified on computed tomography angiography (CTA). A hand-held CEUS imaging study was initiated following CTA and lasted up to 30 minutes. The primary outcome is the proportion of patients where a guidance CEUS image of the occlusion was achieved.

RESULTS

A CEUS image of the occluded artery was obtained in 32/35 of the included patients. The median total imaging time was 23 minutes (interquartile range 15-30). Patients undergoing thrombectomy had a lower total imaging time (17 vs. 29.5 minutes, p = .002). When imaging was successful, on-target image was maintained for only 58% (standard deviation 23.8%) of total imaging time. No complications related to CEUS were observed.

CONCLUSIONS

This feasibility study explored the use of diagnostic transcranial CEUS for continuous imaging of occlusion sites in LVO strokes. Challenges in maintaining target image during HIFU were identified, highlighting the need for technical advances for clinical application.

Successfully intravenous thrombolytic therapy in systemic lupus erythematosus-related ischemic stroke: A case report

RATIONALE

Stroke is a relatively frequent complication occurring in patients with systemic lupus erythematosus (SLE). The increasing number of patients with Ischemic Stroke secondary to SLE aroused the clinician's concern. SLE thrombosis markers, diagnostic high-resolution magnetic resonance image (HR-MRI), and therapeutic interventions for acute ischemic stroke were recently coming into focus perspectives from the field.

PATIENT CONCERNS

A 42-year-old female with slurred speech and numbness in her left limb was admitted to our hospital.

DIAGNOSES

Magnetic resonance imaging (MRI) revealed right thalamic infarction with diffusion-weighted lesions. Prior to admission, the patient had a National Institute of Health Stroke Scale (NIHSS) score of 3.

INTERVENTIONS

In light of the clinical manifestation, the American Heart Association/American Stroke Association (AHA/ASA) Guidelines for Intravenous Thrombolysis in Acute Ischemic Stroke (2019) should be referred to. The patient was treated with thrombolytic alteplase (rt-PA).

OUTCOMES

The patient was hospitalized for 2 weeks and discharged after his symptoms improved.

LESSONS

After thrombolysis, the NIHSS score of the patient decreased to zero. The computed tomography scan was reexamined 24 hours later, and no acute changes or hemorrhage were identified in the infarcted area. Subsequent imaging and serological analyses indicated that HR-MRI of the responsible vessel was negative, but the infarction in this patient was still regarded as being caused by vasculitis of the right posterior cerebral artery in the region supplying the thalamus. This is the first case of successful intravenous thrombolytic therapy with rt-PA in a patient with SLE secondary to stroke with an NIHSS score of 3. This provides further evidence for expanding the reference of indications with rt-PA intravenous thrombolysis.

Optimal Endovascular Therapy Technique for Isolated Intracranial Atherothrombotic Stroke-Related Large-Vessel Occlusion in the Acute-to-Subacute Stage

BACKGROUND AND PURPOSE

Reocclusion after treatment is a concern in endovascular therapy for isolated intracranial atherothrombotic stroke-related large-vessel occlusion (AT-LVO). However, the optimal endovascular therapy technique for AT-LVO has not yet been investigated. This study evaluated the optimal endovascular therapy technique for AT-LVO in a real-world setting.

MATERIALS AND METHODS

We conducted a historical, multicenter registry study at 51 centers that enrolled patients with AT-LVO. We divided the patients into 3 groups based on the endovascular therapy technique: mechanical thrombectomy alone, percutaneous transluminal angioplasty (PTA), and stent deployment. Mechanical thrombectomy alone was classified into the mechanical thrombectomy-only group; PTA and mechanical thrombectomy-PTA, into the PTA group; and mechanical thrombectomy-stent deployment, mechanical thrombectomy-PTA-stent deployment, PTA-stent deployment, and stent deployment-only into the stent group. The primary outcome was incidence of reocclusion of the treated vessels within 90 days of endovascular therapy completion.

RESULTS

We enrolled 770 patients and analyzed 509 patients. The rates in the mechanical thrombectomy-only, PTA, and stent deployment groups were 40.7%, 44.4%, and 14.9%, respectively. Incidence rate of residual stenosis >70% of final angiography was significantly higher in the mechanical thrombectomy-only group than in the PTA and stent deployment groups (mechanical thrombectomy-only versus PTA versus stent deployment: 34.5% versus 26.3% versus 13.2%, P = .002). Reocclusion rate was significantly lower in the PTA group than in the mechanical thrombectomy-only group (adjusted hazard ratio, 0.48; 95% CI, 0.29-0.80). Of the patients, 83.5% experienced reocclusion within 10 days after endovascular therapy. Alarmingly, a substantial subset (approximately 62.0%) of patients experienced reocclusion within 2 days of endovascular therapy. Incidence of mRS scores of 0-2 ninety days after endovascular therapy was not significantly different among the 3 groups. Incidences of symptomatic intracranial hemorrhage, any other intracranial hemorrhage, and death were not significantly different.

CONCLUSIONS

Incidence rate of reocclusion was significantly lower in the PTA group than in the mechanical thrombectomy-only group. We found no meaningful difference in reocclusion rates between the stent deployment and mechanical thrombectomy-only groups. In Japan, glycoprotein IIb/IIIa inhibitors are not reimbursed. Therefore, PTA might be the preferred choice for AT-LVOs due to the higher reocclusion risk with mechanical thrombectomy-only. Reocclusion was likely to occur within 10 days, particularly within 2 days post-endovascular therapy.

Diagnostic value of routine CT perfusion imaging for radiology residents

To evaluate whether incorporating CT perfusion imaging can significantly enhance diagnostic CT accuracy in stroke detection. Two 3rd-year residents (3rd of 5 years of residency) reviewed CT scans of 200 patients with suspected stroke, consisting of 104 patients with a proven stroke and a control group with 96 patients. They analyzed each patient in a blinded and randomized manner in two runs. In one session, they had only non-contrast CT and CT angiography available for diagnosis; in the other session at a later time point, an additional CT perfusion imaging was available. The performance achieved by the two readers was determined in terms of AUC (area under the curve), accuracy, sensitivity, specificity, positive and negative predictive value and Cohen's Kappa. Reader 1 achieved an AUC of 87.64% with the basic stroke-protocol vs. an AUC of 97.4% with an additional CT-perfusion given. Based on the DeLong test, these values differ significantly (p-value: 0.00017). Reader 2 achieved an AUC of 91.23% in basic stroke-protocol vs. an AUC of 96.42% with an additional CT-perfusion. These values also differ significantly (p-value: 0.02612).. The performance gain achieved with CT-perfusion is most evident in the decrease in the number of false classified cases (Reader 1: 24 to 5; Reader 2: 18 or 14 to 7) and the significant increase in Cohen's kappa. Our study shows that additional CT-perfusion imaging in stroke diagnosis significantly improves the diagnostic reliability of residents. Therefore, it should be further investigated whether perfusion imaging should be a general standard of initial stroke diagnosis no matter of the onset.

The characteristics of T-cell receptor repertoire in relation to systemic immune response of patients with ischemic stroke

T lymphocytes play a vital role in the immune-inflammatory response following a stroke. However, the specific mechanisms behind the contrasting functions of T cells in the brain and peripheral tissues after a stroke remain unclear and require further investigation. T-cell receptors (TCRs) are essential in controlling how T lymphocytes develop and become active. This study aims to gain a deeper understanding of the biological function of T lymphocytes by analyzing the TCR repertoire in patients who have experienced an acute ischemic stroke (AIS). High-throughput TCR sequencing was conducted on peripheral blood samples from 25 AIS patients and 10 healthy controls. We compared the percentage of T cells and the characteristics of the TCR repertoire, specifically focusing on the recombination of V(D)J gene fragments and the diversity of the complementarity determining region 3 (CDR3) of the Vβ gene. Additionally, this study analyzed the potential biological significance of the skewed TCR repertoire in AIS patients. In patients with AIS, the proportion of circulating lymphocytes (LY%) decreased while the systemic immune-inflammatory index (SII) increased compared to healthy controls. The average number of TCR read pairs decreased, corresponding with the presence of lymphopenia. However, the recombination of V(D)J gene fragments, the number of CDR3 clonotypes, and the diversity of CDR3 was elevated in the peripheral blood of AIS patients. Furthermore, the increased number of CDR3 amino acid or nucleotide clonotypes was negatively correlated with neurologic deficits but positively correlated with AIS patients' systemic immune condition and functional outcomes. Our findings suggest that both immunosuppression and enhanced antigen-specific T-cell response may exist in the periphery of the AIS patients. Further investigation into the mechanisms underlying these opposing changes may lead to the discovery of novel targets to reverse immunosuppression or mitigate the detrimental effects of T cells in the lesioned brain of AIS patients.

Efficacy and Safety of Intravenous Tenecteplase Before Endovascular Thrombectomy for Acute Ischemic Stroke: The Multicenter, Randomized, BRIDGE-TNK Trial Protocol

BACKGROUND

Six randomized trials have not detected a difference between intravenous alteplase plus endovascular thrombectomy and endovascular thrombectomy alone in stroke. Tenecteplase, a recombinant human tenecteplase tissue-type plasminogen activator, is a genetically modified variant of alteplase. It is unclear whether the outcomes are different if alteplase is replaced with tenecteplase. This trial aims to determine whether intravenous tenecteplase within 4.5 hours of time last known well confers benefit in patients with acute ischemic stroke with large-vessel occlusion who undergo endovascular thrombectomy.

METHODS

BRIDGE-TNK (Thrombectomy With Versus Without rhTNK-tPA in Stroke) is an investigator-initiated, multicenter, prospective, randomized, open-label trial with blinded end point evaluation conducted at 40 thrombectomy-capable centers in China. This trial will randomize 544 patients with intravenous thrombolysis-eligible stroke (272 in each arm) with large-vessel occlusion within 4.5 hours of last known well to receive bridging intravenous tenecteplase with endovascular thrombectomy (tenecteplase-plus-thrombectomy group) or endovascular thrombectomy alone (thrombectomy-alone group). The primary outcome is the proportion of patients achieving functional independence, defined as a score of 0 to 2 on the modified Rankin Scale, at 90 days. Safety will be assessed via symptomatic intracranial hemorrhage at 48 hours and death at 90 days.

CONCLUSIONS

BRIDGE-TNK will provide important data on the role of intravenous tenecteplase before endovascular thrombectomy in patients with acute ischemic stroke with large-vessel occlusion who can be treated within 4.5 hours of last known well.

REGISTRATION

URL: https://clinicaltrials.gov. Unique identifier: NCT04733742.

Bridging the Gap: Improving Acute Ischemic Stroke Outcomes with Intravenous Thrombolysis Prior to Mechanical Thrombectomy

BACKGROUND/OBJECTIVES

Current guidelines recommend intravenous thrombolysis (IVT) followed by mechanical thrombectomy (MT) for patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). This combined approach, known as bridging therapy (BT), is believed to increase the likelihood of a favorable functional outcome when administered within 4.5 h of symptom onset. However, the benefits of BT over direct mechanical thrombectomy (d-MT) remain debated. This study aimed to compare the outcomes of AIS-LVO patients undergoing MT within 6 h of symptom onset, with and without prior IVT.

METHODS

Within the prospective Transzlációs Idegtudományi Nemzeti Laboratórium (TINL) STROKE-registry, AIS-LVO patients admitted to the Department of Neurology, University of Pécs between February 2023 and June 2024 were investigated. The primary endpoint was the proportion of patients reaching functional independence at 90 days, defined as a modified Rankin Scale (mRS) score of 0-2. Secondary endpoints included clinical improvement at 72 h (National Institute of Health Stroke Scale [NIHSS] score of ≤1 or a change from baseline [ΔNIHSS] of ≥4) and successful recanalization (modified Thrombolysis in Cerebral Infarction [mTICI] score ≥ 2). Safety outcomes were evaluated based on thrombus migration and intracranial hemorrhage (ICH). Results were compared using linear and logistic regression analyses adjusted for baseline variables.

RESULTS

Of 82 patients, 51 (62.2%) received BT, while 31 (37.8%) underwent d-MT. The BT group showed a significantly higher rate of functional independence (45.7% vs. 17.2%, p = 0.014) and a lower 90-day mortality rate (13.7% vs. 35.5%, p = 0.029). Multivariate analysis revealed that IVT was independently associated with favorable functional outcomes (p = 0.011) and reduced mortality (p = 0.021). No significant differences were observed in terms of clinical improvement at 72 h, successful recanalization, thrombus migration, or hemorrhagic transformation between the groups.

CONCLUSIONS

This study supports current guidelines recommending BT for thrombectomy-eligible AIS-LVO patients, offering new insights into the ongoing clinical debate.

RVG-peptide-camouflaged iron-coordinated engineered polydopamine nanoenzyme with ROS scavenging and inhibiting inflammatory response for ischemic stroke therapy

Stroke is one of the most common causes of death and disability. In addition, most neuroprotective agents fail to rescue neurons from cerebral ischemic insults due to their poor ability to penetrate the blood-brain barrier (BBB). Here, the tailored engineered nanoenzyme has been successfully synthesized by coordination-driven co-assembly of dopamine (DA) and iron ion (Fe3+), which is subsequently camouflaged by neuron-specific rabies viral glycoprotein (RVG) peptide to scavenge reactive oxygen species (ROS) and inhibit inflammatory response in damaged neuron for the efficient therapy of ischemic stroke. The resulting nanoenzyme with good biocompatibility, core-shell structure, and suitable diameter can nondestructively cross the BBB and then internalize into the damaged neuron through the camouflaging and homologous targeted strategy of neuron-specific RVG peptide. After intravenous injection into transient middle cerebral artery occlusion (tMCAO) mouse models, nanoenzyme exerted a significant neuroprotective effect, resulting in a 50 % reduction in neurological scores and an approximate 33 % decrease in cerebral infarction volume. Interestingly, such nanoenzyme can eliminate free radicals, reduce neuroinflammation, enhance BBB integrity, improve mitochondrial function, and inhibit neuronal ferroptosis. Taken together, this well-designed nanoenzyme with its excellent biocompatibility and well-understood mechanisms holds promise a robust therapy for ischemic stroke.

Association between blood glucose level trajectories and 30-day mortality risk in patients with acute ischemic stroke: analysis of the MIMIC database 2001-2019

BACKGROUND

Hyperglycemia is one of the most common comorbidities in patients with acute ischemic stroke (AIS). This study aimed to assess the impact of short-term longitudinal blood glucose level change trajectories on the 30-day mortality risk in patients with AIS.

METHODS

Data for AIS patients were obtained from the 2001-2019 Medical Information Mart for Intensive Care (MIMIC) database. The latent growth mixture modeling (LGMM) was utilized to classify a patient's blood glucose level trajectory within 24 h of admission. Cox regression analyses were applied to examine the relationship between blood glucose levels at admission and blood glucose level trajectories and the risk of 30-day mortality in patients with AIS.

RESULTS

A total of 2,432 patients with AIS were included in this retrospective cohort study, with 30-day mortality occurring in 574 (23.60%) patients. The median glucose levels of all patients were 136.00 (110.00, 178.00) mg/dL. Four blood glucose level trajectories were identified: low level-stable trend (type 1), moderate level-stable trend (type 2), high level-decreasing-increasing trend (type 3), and moderate level-increasing-decreasing trend (type 4). Type 2 blood glucose level trajectory was associated with an increased risk of 30-day mortality compared with type 1 blood glucose level trajectory [hazard ratio (HR) = 1.28, 95% confidence interval (CI): 1.03-1.59), but there were no significant associations between type 3 (HR = 1.16, 95%CI: 0.77-1.74) and type 4 (HR = 1.44, 95%CI: 0.84-2.45) trajectories and 30-day mortality risk. Subgroup analysis demonstrated that the association between type 2 trajectory and 30-day mortality risk was observed in patients aged ≥ 65 years (HR = 1.37, 95%CI: 1.05-1.79), female (HR = 1.42, 95%CI: 1.05-1.94), with (HR = 1.44, 95%CI: 1.02-2.02) or without (HR = 1.42, 95%CI: 1.01-1.99) diabetes, and not using insulin (HR = 2.80, 95%CI: 1.43-5.49).

CONCLUSION

AIS patients with consistently high blood glucose levels within 24 h of admission increased the risk of 30-day mortality.

Quality in Acute Stroke Care (QASC) Germany: improving efficiency in stroke care with nurse-initiated FeSS-protocols

BACKGROUND

Nurse-initiated supported implementation of protocols to manage fever, hyperglycaemia (sugar) and swallowing (FeSS) following acute stroke reduced 90-day death and disability in the landmark Australian Quality in Acute Stroke Care (QASC)-Trial. An international interprofessional collaboration sought to evaluate the effects of nurse-led FeSS implementation on FeSS Protocol adherence in German stroke units.

METHODS

This pre-test/post-test study was conducted in eight German stroke units between 2020 and 2022. Stroke nurses as clinical champions, supported by the project team, conducted multidisciplinary workshops discussing pre-implementation medical record audit results, barriers and facilitators to FeSS Protocol implementation, developed action plans and provided education, with ongoing support from Australia. Medical record audit data were collected by nurses, pre-implementation and three months post-implementation.

RESULTS

In 771 (pre-implementation) and 679 (post-implementation) patients there were improvements in overall FeSS adherence (pre 20%, post 28%; adjusted difference in proportions (95% CI) 11%, (5.1%, 16%); p < 0.001), adherence to hyperglycaemia (pre 43%, post 55%; adjusted difference 23%, (17%, 29%); p < 0.001) and swallowing (pre 52%, post 61%; adjusted difference 11%, (5.2%, 17%); p < 0.001) but not fever protocol (pre 76%, post 78%; adjusted difference 1.5%, (-2.6%, 5.7%); p = 0.474). Improvements also were noted in administration of anti-pyretics (pre 29%, post 59%; adjusted difference 32%, (20%, 44%); p < 0.001); and insulin (pre 41%, post 60%; adjusted difference 14%, (1.1%, 28%); p < 0.034) both within one hour, as well as in performing a swallow screen within 24 h of admission (pre 65%, post 74%; adjusted difference 18% (8.8%, 26%); p < 0.001).

CONCLUSIONS

Supported implementation of the FeSS Protocols significantly improved acute care for post stroke complications of fever, hyperglycaemia and dysphagia in terms of higher adherence and shorter time to treatment.

TRIAL REGISTRATION

As this is a pre-test/post-test study and does not meet the WHO/ICMJE definition of a clinical trial, registration was not required.

HouShiHeiSan attenuates sarcopenia in middle cerebral artery occlusion (MCAO) rats

ETHNOPHARMACOLOGICAL RELEVANCE

Physical therapy is the main clinical treatment for limb symptoms after ischemic stroke, and there is a lack of reliable drug intervention programs. HouShiHeiSan (HS)comes from "Synopsis of the Golden Chamber", where it is recorded: "seauelae of wind stroke and heaviness of limbs", indicating this formulae is a promising opion for clinical practice.

AIM OF THE STUDY

The aim of this study is to explore the therapeutic effect of HS on sarcopenia after ischemic stroke (ISS) by using the middle cerebral artery occlusion (MCAO) rats.

MATERIALS AND METHODS

After 7 days of adaptive feeding Sprague-Dawley (SD) rats were randomly divided into sham and MCAO surgery groups. After MCAO operation, the agreement of the models was evaluated with a laser speckle instrument, and then, treatment groups were administered HS and related solvent. During the 7 days treatment period, the Zea-Longa score was used to assess the neural function, the treadmill for exercise capacity and traction instrument for grip strength. Besides, the physiological electrical signal system was used to record muscular electrical signals, while the muscle thickness was measured by ultrasound. After data acquisition on the 7th day after MCAO operation, the soleus muscle was dissected, and the indexes of length, weight of whole muscle tissue and cross-sectional area of muscular cells by H&E were recorded. Subsequently, mechanistic indicators were examined. MuRF1 and MAFbx expression was detected by immunohistochemistry (IHC). Furthermore, the expression level of more related indicators of muscular differentiation and cellular proterin balance, including mTOR, p-mTOR, AKT, p-AKT, p70s6k, p-p70s6, FOXO1, p-FOXO1, MyoD1, Myostatin, MuRF1 and MAFbx, were tested via Western blot.

RESULTS

HS improved motor performance and promoted muscle regeneration in MCAO rats. In terms of motor ability, HS mixed with alcohol significantly improved the neurological function damage, reduce the weight loss, increase the running distance per unit time and increase the grip strength. The postoperative muscle electrical signal intensity increased, and muscle thickness, weight, and length were maintained. The HS with alcohol group significantly maintained the cross-sectional size of muscle cells and reduced the number of MyoD1 and myostatin-positive cells in the muscle tissue. It simultaneously promoted the expression of p-mTOR, p-AKT, p-p70s6k, and MyoD1 to promote the synthesis of muscle proteins and inhibited the expression of p-FOXO1, myostatin, MAFbx, and MuRF1 to reduce muscle protein degradation.

CONCLUSION

HS can enhance muscle protein synthesis and decrease protein breakdown by activating the AKT/mTOR/FOXO1 pathway, thereby preserving muscle health and enhancing motor performance following stroke in rats.

The Hidden Heart: Exploring Cardiac Damage Post-Stroke: A Narrative Review

Stroke-heart syndrome (SHS), a critical yet underrecognized condition, encompasses a range of cardiac complications that arise following an ischemic stroke. This narrative review explores the pathophysiology, clinical manifestations, and implications of SHS, focusing on the complex interplay between the brain and the heart. Acute ischemic stroke (AIS) triggers autonomic dysfunction, leading to a surge in catecholamines and subsequent myocardial injury. Our review highlights the five cardinal manifestations of SHS: elevated cardiac troponin (cTn) levels, acute myocardial infarction, left ventricular dysfunction, arrhythmias, and sudden cardiac death. Despite the significant impact of these complications on patient outcomes, there is a notable absence of specific guidelines for their management. Through a comprehensive literature search, we synthesized findings from recent studies to elucidate the mechanisms underlying SHS and identified gaps in the current understanding. Our findings underscore the importance of early detection and multidisciplinary management of cardiac complications post-stroke. Future research should focus on establishing evidence-based protocols to improve clinical outcomes for stroke patients with SHS. Addressing this unmet need will enhance the care of stroke survivors and reduce mortality rates associated with cardiac complications.

Age-specific ASPECTS atlas of Chinese subjects across different age groups for assessing acute ischemic stroke

The Alberta Stroke Program Early Computed Tomography Score (ASPECTS) is a valuable and easy-to-use method for assessing acute ischemic stroke. It aids in identifying suitable candidates for thrombolytic therapies and evaluating treatment effectiveness. However, ASPECTS evaluation primarily relies on visual observation in current clinical practice, lacking a common standardized space. Additionally, different doctors may have varying clinical experiences, leading to a poor inter-reader agreement and potential errors in the final ASPECTS scoring. To address these issues and fill in the absence of a publicly available ASPECTS atlas, this work constructs age-specific Chinese ASPECTS atlases based on non-contrast computed tomography images of 281 healthy subjects across different age groups. Images of different age groups are warped into respective common averaged spaces, where the average intensity atlases are computed. More importantly, 10 ASPECTS regions can be obtained during this process. We develop an automated ASPECTS region mapping pipeline and collect an independent dataset to validate our atlas. The results prove that the age-specific ASPECTS atlas is of great promise in clinical availability.

Left Ventricular Diastolic Dysfunction with Elevated Filling Pressures Is Associated with Embolic Stroke of Undetermined Source and Atrial Fibrillation

Background/Objectives: Left ventricular diastolic dysfunction (LVDD) and elevated left ventricular filling pressure (LVFP) are strong predictors of clinical outcomes across various populations. However, their diagnostic utility in embolic stroke of undetermined source (ESUS) remains unclear. We hypothesized that LVDD with elevated LVFP (based on echocardiography) was more likely to be prevalent in ESUS compared to non-cardioembolic stroke (NCE) and to be associated with atrial fibrillation (AF) on follow-up monitoring. Methods: This is a single-center retrospective study that included adult patients with a diagnosis of acute ischemic stroke between January 2016 and June 2017. LV function was assessed by inpatient transthoracic echocardiogram (TTE), and stroke etiology was adjudicated by the neurologist per the consensus criteria. Patients with cardioembolic stroke and those with indeterminate diastolic function on TTE were excluded. Baseline patient characteristics and clinical variables were compared among patients with and without LVDD and elevated LVFP. Multivariable regression models were used to assess the associations between diastolic dysfunction, ESUS, and AF detection in ESUS patients. Results: We identified 509 patients with ESUS and NCE stroke who had reported diastolic function. The mean age was 64.19 years, 45.19% were female, and 146 had LVDD with available LVFP data. LVDD was not associated with ESUS (adjusted OR: 1.43, 95% CI: 0.90-2.27, p = 0.130) or atrial fibrillation (AF) detection on cardiac monitoring (adjusted OR: 1.88, 95% CI: 0.75-4.72, p = 0.179). However, LVDD with elevated LVFP was borderline associated with ESUS (adjusted OR: 2.17, 95% CI: 0.99-4.77, p = 0.054) and significantly associated with AF detection (adjusted OR: 3.59, 95% CI: 1.07-12.06, p = 0.038). Conclusions: Our data suggest that LVDD with elevated LVFP is borderline associated with ESUS and significantly associated with AF detection on follow-up cardiac monitoring. Therefore, the presence of LVDD with an increased probability of elevated LVFP may help identify a subset of stroke patients more likely to have ESUS, potentially due to atrial cardiopathy with underlying occult AF. Further studies are needed to confirm our findings and to evaluate the safety and efficacy of anticoagulation in patients with ESUS and LVDD with elevated LVFP.

Microvascular reperfusion during endovascular therapy: the balance of supply and demand

BACKGROUND

Endovascular therapy (EVT) has revolutionized the treatment of acute stroke, but large vessel recanalization does not always result in tissue-level reperfusion. Cerebral blood flow (CBF) is not routinely monitored during EVT. We aimed to leverage diffuse correlation spectroscopy (DCS), a novel transcranial optical imaging technique, to assess the relationship between microvascular CBF and post-EVT outcomes.

METHODS

Frontal lobe CBF was monitored by DCS in 40 patients undergoing EVT. Baseline CBF deficit was calculated as the percentage of CBF impairment on pre-EVT CT perfusion. Microvascular reperfusion was calculated as the percentage increase in DCS-derived CBF that occurred with recanalization. The adequacy of reperfusion was defined by persistent CBF deficit, calculated as: baseline CBF deficit - microvascular reperfusion. A good functional outcome was defined as 90-day modified Rankin Scale score ≤2.

RESULTS

Thirty-six of 40 patients achieved successful recanalization, in whom microvascular reperfusion in itself was not associated with infarct volume or functional outcome. However, patients with good functional outcomes had a smaller persistent CBF deficit (median 1% (IQR -11%-16%)) than patients with poor outcomes (median 28% (IQR 2-50%)) (p=0.02). Smaller persistent CBF deficit was also associated with smaller infarct volume (p=0.004). Multivariate models confirmed that persistent CBF deficit was independently associated with infarct volume and functional outcome.

CONCLUSIONS

CBF augmentation alone does not predict post-EVT outcomes, but when microvascular reperfusion closely matches the baseline CBF deficit, patients experience favorable clinical and radiographic outcomes. By recognizing inadequate reperfusion, bedside CBF monitoring may provide opportunities to personalize post-EVT care aimed at CBF optimization.

Intravenous alteplase before endovascular therapy for acute large vessel occlusion with large ischemic core: subanalysis of a randomized clinical trial

BACKGROUND

The efficacy of endovascular therapy (EVT) in patients with large ischemic core has been reported, but it remains unclear whether IV alteplase (IVT) has beneficial effects in addition to EVT in such patients. We evaluated the efficacy and safety of EVT with or without IVT.

METHODS

The RESCUE-Japan LIMIT was an open-label, prospective, multicenter, randomized clinical trial to evaluate the efficacy and safety of EVT in stroke patients with large ischemic core, defined as Alberta Stroke Program Early CT Score (ASPECTS) 3-5. This subanalysis evaluated the differences in the effects of EVT with medical care (EVT group) compared with medical care alone (No-EVT group) between those who received IVT (IVT stratum) and those who did not (No-IVT stratum) before EVT.

RESULTS

Among 202 enrolled patients, 147 (73%) did not receive IVT. In the No-IVT stratum, the modified Rankin Scale (mRS) score of 0-3 at 90 days was significantly higher in the EVT group than in the No-EVT group (31.1% vs 12.3%, OR 3.21 (95% CI 1.37 to 7.53)). In the IVT stratum, the mRS score of 0-3 was 30.8% in the EVT group and 13.8% in the No-EVT group (OR 2.78 (95% CI 0.72 to 10.7)) (interaction p=0.77). The incidence of symptomatic intracranial hemorrhage was not different between the two groups in the No-IVT stratum (OR 1.20 (95% CI 0.35 to 4.12)), but it was significantly higher in the EVT group than in the No-EVT group in the IVT stratum (11.5% vs 0%, p=0.03).

CONCLUSIONS

There was no difference in efficacy of EVT with or without IVT, while IVT before EVT might increase symptomatic intracranial hemorrhage in patients with large ischemic core.

TRIAL REGISTRATION INFORMATION

NCT03702413.