Successful Reperfusion With Mechanical Thrombectomy Is Associated With Reduced Disability and Mortality in Patients With Pretreatment Diffusion-Weighted Imaging–Alberta Stroke Program Early Computed Tomography Score ≤6

Outcomes of mechanical thrombectomy in stroke patients with extreme large infarction core

BACKGROUND

Recent clinical trials have demonstrated that patients with large vessel occlusion (LVO) and large infarction core may still benefit from mechanical thrombectomy (MT). In this study, we evaluate outcomes of MT in LVO patients presenting with extremely large infarction core Alberta Stroke Program Early CT Score (ASPECTS 0-2).

METHODS

Data from the Stroke Thrombectomy and Aneurysm Registry (STAR) was interrogated. We identified thrombectomy patients presenting with an occlusion in the intracranial internal carotid artery (ICA) or M1 segment of the middle cerebral artery and extremely large infarction core (ASPECTS 0-2). A favorable outcome was defined by achieving a modified Rankin scale of 0-3 at 90 days post-MT. Successful recanalization was defined by achieving a modified Thrombolysis In Cerebral Ischemia (mTICI) score ≥2B.

RESULTS

We identified 58 patients who presented with ASPECTS 0-2 and underwent MT. Median age was 74.0 (66.3-80.0) years, 30 (51.7%) were females, and 16 (27.6%) patients received intravenous tissue plasminogen activator. There was no difference regarding the location of the occlusion (p=0.57). Aspiration thrombectomy was performed in 34 (64.2%) patients and stent retriever was used in 8 (15.1%) patients. In patients presenting with ASPECTS 0-2 the mortality rate was 41.4%, 31% had mRS 0-3 at day 90, 66.67% ≥70 years of age had mRS of 5-6 at day 90. On multivariable analysis, age, National Institutes of Health Stroke Scale on admission, and successful recanalization (mTICI ≥2B) were independently associated with favorable outcomes.

CONCLUSIONS

This multicentered, retrospective cohort study suggests that MT may be beneficial in a select group of patients with ASPECTS 0-2.

Correlation between obstructive sleep apnea and hypoperfusion in patients with acute cerebral infarction

Purpose

To explore the relationship between obstructive sleep apnea (OSA) and hypoperfusion during ultra-early acute cerebral infarction.

Patients and methods

Data were retrospectively collected from patients admitted to our hospital with acute cerebral infarction between January 2020 and January 2022, who underwent comprehensive whole-brain computed tomography perfusion imaging and angiography examinations within 6 h of onset. The F-stroke software automatically assessed and obtained relevant data (Tmax). The patients underwent an initial screening for sleep apnea. Based on their Apnea-Hypopnea Index (AHI), patients were categorized into an AHI ≤15 (n = 22) or AHI >15 (n = 25) group. The pairwise difference of the time-to-maximum of the residue function (Tmax) > 6 s volume was compared, and the correlation between AHI, mean pulse oxygen saturation (SpO2), oxygen desaturation index (ODI), percentage of time with oxygen saturation < 90% (T90%), and the Tmax >6 s volume was analyzed.

Results

The Tmax >6 s volume in the AHI > 15 group was significantly larger than that in the AHI ≤ 15 group [109 (62-157) vs. 59 (21-106) mL, p = 0.013]. Spearman's correlation analysis revealed Tmax >6 s volume was significantly correlated with AHI, mean SpO2, ODI, and T90% in the AHI > 15 group, however, no significant correlations were observed in the AHI ≤ 15 group. Controlling for the site of occlusion and Multiphase CT angiography (mCTA) score, AHI (β = 0.919, p < 0.001), mean SpO2 (β = -0.460, p = 0.031), ODI (β = 0.467, p = 0.032), and T90% (β =0.478, p = 0.026) remained associated with early hypoperfusion in the AHI > 15 group.

Conclusion

In patients with acute cerebral infarction and AHI > 15, AHI, mean SpO2, ODI and T90% were associated with early hypoperfusion. However, no such relationship exists among patients with AHI ≤ 15.

Differences in outcome between left-sided and right-sided mechanical thrombectomy for acute ischemic stroke: A systematic review and meta-analysis

BACKGROUND

Mechanical thrombectomy (MT) is a safe and effective treatment option for acute ischemic stroke due to large vessel occlusion. To investigate differences in outcomes between patients receiving left-sided and right-sided MT, we performed a systematic review and meta-analysis.

METHODS

A systematic literature review was performed using Embase, PubMed, Scopus, and Web of Science databases. Additional literature was searched for manually. Studies reporting safety and efficacy metrics for MT were included. Data regarding the modified Rankin scale (mRS), thrombolysis in cerebral infarction (TICI), symptomatic intracranial hemorrhage (sICH), and 90-day mortality were included. A random-effects model was used to calculate pooled odds ratios (ORs), mean differences (MDs), and 95% confidence intervals (CIs).

RESULTS

The literature search yielded 13 reports consisting of 19 studies ranging from 98 to 5590 patients. Patients presenting with left-sided stroke had a National Institutes of health stroke scale score 2.89 greater than patients presenting with right-sided stroke (MD = 2.89; 95% CI = 2.09-3.68; P-value < 0.001). There were no differences between left-sided and right-sided MT patients for mRS 0-2 (OR = 0.94; 95% CI = 0.85-1.04; P-value = 0.224), TICI 2b-3 (OR = 1.05; 95% CI = 0.88-1.25; P-value = 0.598), sICH (OR = 0.83; 95% CI = 0.61-1.14; P-value = 0.255), or 90-day mortality (OR = 1.06; 95% CI = 0.84-1.33; P-value = 0.610).

CONCLUSIONS

There does not appear to be a difference in outcomes for patients undergoing left-sided or right-sided thrombectomy.

Direct to Angiosuite in Acute Stroke with Mobile Stroke Unit

BACKGROUND

Early reperfusion has the best likelihood for a favorable outcome in acute ischemic stroke (AIS) with large vessel occlusion (LVO). Our experience with mobile stroke unit (MSU) for direct to angiosuite (DTAS) transfer in AIS patients with suspected LVO is presented.

METHODS

Retrospective review of prospectively collected data from November 2019 to August 2022, of patients evaluated and transferred by the University of Alberta Hospital MSU and moved to angiosuite for endovascular thrombectomy (EVT).

RESULT

A total of 41 cases were included. Nine were chosen for DTAS and 32 were shifted to angiosuite after stopping for computed tomography (CT) angiography of the head and neck (no-DTAS). Stroke severity measured by NIHSS (median with interquartile range (IQR)) was higher in patients of DTAS, 22 (14-24) vs 14.5 (5-25) in no-DTAS (p = 0.001). The non-contrast CT head in MSU showed hyperdense vessels in 8 (88.88%) DTAS vs 11 (34.35%) no-DTAS patients (p = 0.003). The EVT timelines (median with IQR, 90th percentile) including "door to artery puncture time" were 31 (23-50, 49.2) vs 79 (39-264, 112.8) minutes, and "door to recanalization time" was 69 (49-110, 93.2) vs 105.5 (52-178, 159.5) minutes in DTAS vs no-DTAS group, respectively. The workflow times were significantly shorter in the DTAS group (p < 0.001). Eight (88.88%) out of 9 DTAS patients had LVO and underwent thrombectomy.

CONCLUSIONS

MSU for DTAS in patients with high NIHSS scores, cortical signs, and CT showing hyperdense vessel is an effective strategy to reduce the EVT workflow time.

Rescue intracranial permanent stenting for refractory occlusion following thrombectomy: a propensity matched analysis

BACKGROUND

Rescue intracranial stenting (RIS) can be used in refractory large vessel occlusion (LVO) after mechanical thrombectomy (MT). We aimed to assess the safety and efficacy of RIS versus a propensity matched sample of patients with persistent LVO.

METHODS

We retrospectively analysed a multicenter retrospective pooled cohort of patients with anterior LVO (2015-2021) treated with MT, and identified patients with at least three passes and a modified Thrombolysis In Cerebral Infarction (mTICI) score of 0 to 2a. Propensity score matching was used to account for determinants of outcome in patients with or without RIS. The study outcomes included 3 months modified Rankin Scale (mRS) and symptomatic hemorrhagic transformation (HT).

RESULTS

420 patients with a refractory anterior occlusion were included, of which 101 were treated with RIS (mean age 69 years). Favorable outcome (mRS 0-2) was more frequent in patients with a patent stent at day 1 (53% vs 6%, P<0.001), which was independently associated with an early dual antiplatelet regimen (P<0.05). In the propensity matched sample, patients treated with RIS versus without RIS had similar rates of favorable outcomes (36.8% vs 30.3%, P=0.606). Patients with RIS showed a favorable shift in the overall mRS distributions (common adjusted OR 0.74, 95% CI 0.60 to 0.91, P=0.006). Symptomatic HT was marginally more frequent in the RIS group (9% vs 3%, P=0.07), and there was no difference in 3-month mortality.

CONCLUSION

In selected patients with a refractory intracranial occlusion despite at least three thrombectomy passes, RIS may be associated with an overall shift towards more favorable clinical outcome, and no significant increase in the odds of symptomatic HT or death.

A differential detailed diffusion-weighted imaging-ASPECTS for cerebral infarct volume measurement and outcome prediction

BACKGROUND

Diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) has been used to estimate infarct core volume in acute stroke. However, the same and indiscriminate score deduction for punctate or confluent DWI high-intensity lesion might lead to variation in performance.

AIMS

To develop and evaluate a differential detailed DWI-ASPECTS method in comparison with the conventional DWI-ASPECTS in core infarct volume measurement and clinical outcome prediction.

METHODS

We retrospectively recruited patients with acute ischemic stroke (AIS) treated with endovascular treatment between April 2013 and October 2019. In differential detailed DWI-ASPECTS, restricted diffusion lesion that was punctate or less than half of a cortical region (M1-M6) would not lead to subtraction of point. A favorable outcome was modified Rankin Scale score ⩽2 at 90 days after stroke onset.

RESULTS

Among 298 AIS patients, mean age was 75 years (interquartile range (IQR) 67-82), and 194 patients (65%) were males. Mean infarct core volume was 11 mL (IQR 3-37). Overall, the score by detailed DWI-ASPECTS was significantly higher than conventional DWI-ASPECTS (8 (7-9) vs. 7 (5-9); P < 0.01). The detailed DWI-ASPECTS resulted in a higher correlation coefficient (r) for core infarct volume estimation than the conventional DWI-ASPECTS (r = 0.832 vs. 0.773; P < 0.01). Upon re-classification of those scored ⩽6 in conventional DWI-ASPECTS (n = 134) by detailed DWI-ASPECTS, the rate of favorable outcome in patients with detailed DWI-ASPECTS >6 was significantly higher than those with ⩽6 (29 (48%) vs. 14 (19%); P < 0.01).

CONCLUSIONS

Detailed DWI-ASPECTS appeared to provide a more accurate infarct core volume measurement and clinical outcome correlation than conventional DWI-ASPECTS among AIS patients treated with endovascular therapy.

Endovascular therapy for acute stroke with a large infarct core: A systematic review and meta-analysis

OBJECTIVE

In this meta-analysis, we aimed to investigate the efficacy and safety of endovascular treatment (EVT) for acute ischemic stroke (AIS) patients with large core infarct.

METHODS

Three online databases of Web of Science, PubMed and Scopus were systematically searched. Original studies which evaluated AIS participants with large core infarction who underwent EVT were included. R statistical software was used for statistical analyses. Effect sizes were presented with odds ratios (ORs) with their 95% confidence intervals (CIs). The effect sizes were pooled using random effects modeling.

RESULTS

Including 47 studies and 15,173 patients, this meta-analysis showed that compared with medical management (MM), EVT was significantly associated with decreased odds of mortality (0.67, 95% CI: 0.51-0.87) and increased odds of favorable outcomes, including a modified Rankin Scale of 0-3 (2.36, 95% CI: 1.69-3.291) and of 0-2 (3.54, 95% CI: 1.96-6.4) in 90 days and remarkable improvement in National Institutes of Health Stroke Scale within 48 h after the procedure (3.6, 95% CI:1.32-9.79). Besides, there was a higher chance of intracranial hemorrhage (ICH) development (1.88, 95% CI: 1.32-2.68) but not symptomatic ICH (1.34, 95% CI: 0.78-2.31) in those who underwent EVT.

CONCLUSION

Our study suggests that EVT might be an effective and relatively safe treatment option for the treatment of AIS patients with large vessel occlusion who have large core infarcts, although more large-scale trials are needed to consolidate the results and to make inclusion criteria and the patient selection process clearer.

Usefulness of additional diffusion MRI acquisition prior to mechanical thrombectomy for acute large vessel occlusion in the early time period at a CT-based stroke center

OBJECTIVE

This study aimed to investigate whether evaluating the infarction core using additionally acquired diffusion magnetic resonance imaging (MRI) could help improve the assessment of prognosis including complication rates and modify the strategy for mechanical thrombectomy in endovascular procedures at a computed tomography (CT)-based stroke center.

METHODS

Single-center data from patients with acute large-vessel occlusion in the anterior circulation who underwent mechanical thrombectomy between May 2018 and January 2021 were analyzed. Diffusion MRI sequences were performed during the preparation period for mechanical thrombectomy after CT angiography. We set the infarction core reference volume on diffusion MRI to 60 cc and divided the patients into two groups: a small infarction core group (less than 60 cc) and a large infarction core group (more than 60 cc). The baseline characteristics, radiological and clinical outcomes of the patients were investigated and compared between the two groups.

RESULTS

The difference in numbers between the two groups was not significant in the Alberta Stroke Program Early Computed Tomography (ASPECT) score; however, the ASPECT score on diffusion MRI showed a remarkable difference between the two groups. The large infarction core volume group on diffusion MRI had a poor prognosis, with the modified Rankin score at 90 days showing a statistically significant difference (p = 0.011). Complications after the procedure, such as hemorrhagic transformation, that can occur after reperfusion, symptomatic intracerebral hemorrhage, decompressive craniectomy for increased intracranial pressure, and mortality, were significantly more frequent in the large infarction core volume group.

CONCLUSION

At a CT-based stroke center, additionally acquired diffusion MRI without a time delay for reperfusion would improve the assessment of prognosis including complication rate, and could help neurointerventionists determine the extent of recanalization of occluded vessels during mechanical thrombectomy.

Successful Thrombectomy Improves Functional Outcome in Tandem Occlusions with a Large Ischemic Core

BACKGROUND

Emergent stenting in tandem occlusions and mechanical thrombectomy (MT) of acute ischemic stroke related to large vessel occlusion (LVO-AIS) with a large core are tested independently. We aim to assess the impact of reperfusion with MT in patients with LVO-AIS with a large core and a tandem occlusion and to compare the safety of reperfusion between large core with tandem and nontandem occlusions in current practice.

METHODS

We analyzed data of all consecutive patients included in the prospective Endovascular Treatment in Ischemic Stroke Registry in France between January 2015 and March 2023 who presented with a pretreatment ASPECTS (Alberta Stroke Program Early CT Score) of 0-5 and angiographically proven tandem occlusion. The primary end point was a favorable outcome defined by a modified Rankin Scale (mRS) score of 0-3 at 90 days.

RESULTS

Among 262 included patients with a tandem occlusion and ASPECTS 0-5, 203 patients (77.5%) had a successful reperfusion (modified Thrombolysis in Cerebral Infarction grade 2b-3). Reperfused patients had a favorable shift in the overall mRS score distribution (adjusted odds ratio [aOR], 1.57 [1.22-2.03]; P < 0.001), higher rates of mRS score 0-3 (aOR, 7.03 [2.60-19.01]; P < 0.001) and mRS score 0-2 at 90 days (aOR, 3.85 [1.39-10.68]; P = 0.009) compared with nonreperfused. There was a trend between the occurrence of successful reperfusion and a decreased rate of symptomatic intracranial hemorrhage (aOR, 0.5 [0.22-1.13]; P = 0.096). Similar safety outcomes were observed after large core reperfusion in tandem and nontandem occlusions.

CONCLUSIONS

Successful reperfusion was associated with a higher rate of favorable outcome in large core LVO-AIS with a tandem occlusion, with a safety profile similar to nontandem occlusion.

Derivation and validation of a predictive scale to expedite endovascular intervention for acute stroke patients with an intervenable vessel occlusion

BACKGROUND

Early endovascular intervention team mobilization may reduce reperfusion times and improve clinical outcomes for patients with acute ischemic stroke (AIS) with a possible intervenable vessel occlusion (IVO). In an emergency department or mobile stroke unit, incorporating rapidly available non-contrast CT (NCCT) information with examination findings may improve the accuracy of arterial occlusion prediction scales. For this purpose, we developed a rapid and straightforward IVO predictive instrument-the T3AM2PA1 scale.

METHODS

The T3AM2PA1 scale was retrospectively derived from our 'Get with the Guidelines' database. We included all patients with acute stroke alert between January 2017 and August 2018 with a National Institutes of Health Stroke Scale (NIHSS) score between 5 and 25 inclusive. Different pre-intervention variables were collected, including itemized NIHSS and NCCT information. The T3AM2PA1 scale was also compared with other commonly used scales and was validated in a separate sequential retrospective cohort of patients with a full range of NIHSS scores.

RESULTS

574 eligible patients from 2115 acute stroke alerts were identified. The scale was established with five items (CT hyperdense sign, parenchymal hypodensity, lateralizing hemiparesis, gaze deviation, and language disturbance), with a total score of 9. To minimize unnecessary angiography, a cut-off of ≥5 for IVO detection yielded a sensitivity of 52%, a specificity of 90%, and a positive predictive value of 76%.

CONCLUSIONS

The T3AM2PA1 scale accurately predicts the presence of clinical IVO in patients with AIS. Adopting the T3AM2PA1 scale could reduce revascularization times, improve treatment outcomes, and potentially reduce disability.

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

BACKGROUNDS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Thrombectomy in ischemic stroke patients with alberta stroke program early computed tomography score 4-5 and 0-3: Factors associated with favorable outcome

OBJECTIVES

Recently published results of the ANGEL-ASPECT and SELECT2 trials suggest that stroke patients presenting with low Alberta Stroke Program Early Computed Tomography Score (ASPECTS) benefit from mechanical thrombectomy. Purpose of this retrospective study was to identify factors that are associated with a favorable outcome in patients with low ASPECTS of 4-5 and 0-3 undergoing mechanical thrombectomy.

MATERIAL AND METHODS

All patients reported in the quality registry of the German Society for Neuroradiology that were treated between 2018 and 2020 were analyzed. Favorable outcome was defined as a National Institute of Health Stroke Scale (NIHSS) score of less than 9 at dismissal. Successful recanalization was defined as Thrombolysis in Cerebral Infarction (mTICI) ≥ 2b. Multivariable logistic regression analyses were performed to assess the association of baseline and treatment variables with favorable outcome.

RESULTS

621 patients were included in the analysis, thereof 495 with ASPECTS 4-5 and 126 with ASPECTS 0-3. In patients with ASPECTS 4-5patients with favorable outcome had less severe neurological symptoms at admission with median NIHSS of 15 vs. 18 (p<0.001), had less often wake-up strokes (44% vs. 81%, p<0.001), received more often iv-lysis (37% vs. 30%, p<0.001), had more often conscious sedation (29% vs. 16%, p<0.001), had a higher rate of successful recanalization (94% vs. 66% and lower times from groin puncture to recanalization. In multivariate regression analysis lower NIHSS at admission (aOR 0.87, CI 0.89-0.91) and successful recanalization (aOR 3.96, CI 2-8.56) were associated with favorable outcome. For ASPECTS 0-3, patients with favorable outcome had lower median NIHSS at admission (16 vs. 18 (p<0.001), lower number of passes (1 vs. 3, p=0.003) and a higher rate of successful recanalization (94% vs. 66%, p<0.001) and lower times from groin puncture to recanalization. In multivariate regression analysis lower NIHSS at admission (aOR 0.87, CI 0.81-0.94) and successful recanalization, (aOR 11.19, CI 3.19-55.53), were associated with favorable outcome.

CONCLUSION

Full recanalization with low groin punction to recanalization times and low number of passes were associated with favorable outcome in patients with low ASPECTS.

Imaging mismatch between Alberta Stroke Program Early CT Score and perfusion imaging may be a good variable for endovascular treatment

OBJECTIVE

Some patients with acute large vessel occlusion (LVO) presented imaging mismatch, low Alberta Stroke Program Early CT Score (ASPECTS) with small ischemic core, or high ASPECTS with large ischemic core. The study was designed to explore whether patients with imaging mismatch could benefit from endovascular treatment (EVT).

METHODS

We retrospectively reviewed patients with LVO treated with EVT in our center from March 2018 to Jul 2020. Patients were divided into three groups, imaging mismatch, small ischemic core, and large ischemic core groups. Pooled analyses based on stroke onset to treatment time were done. Multivariate regression analysis was performed to explore the factors for good outcomes.

RESULTS

Sixty-eight of 419 patients with LVO presented with imaging mismatch, and 35 of those (51%) achieved good outcomes after EVT at 90-day. No significant differences were noted in good outcomes and symptomatic intracranial hemorrhage (sICH) between patients with imaging mismatch and small ischemic core. Compared with large ischemic core, patients with imaging mismatch presented lower risk of sICH (95% confidence interval (CI) 0.04-0.75, p = 0.011) within 6 h and higher proportion of good outcomes (95% CI 0.37-0.82, p = 0.002) at 6 to 24 h. Baseline NIHSS (odds ratio (OR) = 0.91, 95% CI 0.88-0.95)), ASPECTS (OR = 1.14, 95% CI 1.01-1.29), ischemic core (OR = 0.99, 95% CI 0.98-1.00), and sICH (OR = 61.61, 95% CI 8.09-461.32) were associated with good outcomes.

CONCLUSIONS

Patients with imaging mismatch treated within 24 h could benefit from EVT and without increasing the risk of sICH.

KEY POINTS

• Patients with imaging mismatch between ASPECTS and ischemic core could achieve good outcomes after endovascular treatment. • Compared with large ischemic core, patients with imaging mismatch presented lower risk of symptomatic hemorrhage within 6 h and higher proportion of good outcomes within 6-24 h. • Baseline NIHSS score, ASPECTS, ischemic core, and symptomatic intracranial hemorrhage were associated with good outcomes.

Reversible CT Scan Hypodensity in Acute Ischemic Stroke Patient With Low Initial Alberta Stroke Program Early CT Score (ASPECTS) Following Endovascular Thrombectomy: A Case Report

According to current American and European guidelines, mechanical thrombectomy is recommended only for patients with an Alberta Stroke Program Early CT Score (ASPECTS) of 6 or higher. However, recent literature suggests that the potential benefits of reperfusion therapy should not be solely determined by baseline ASPECTS. In this case report, we present a young female patient with a low initial ASPECTS (4-5), who underwent mechanical thrombectomy and showed marked improvement in both CT imaging and clinical symptoms. Our findings potentially show that mechanical thrombectomy may be beneficial even for patients with an initial ASPECTS ≤ 5. These results may contribute to the growing evidence supporting the use of mechanical thrombectomy as a viable treatment option for acute ischemic stroke patients with low baseline ASPECTS.

Neurological Functional Independence After Endovascular Thrombectomy and Different Imaging Modalities for Large Infarct Core Assessment : A Systematic Review and Meta-analysis

PURPOSE

To investigate the rate of neurological functional independence (NFI) at 90 days in patients with large infarct core (LIC), which was evaluated by different imaging modalities before endovascular thrombectomy (EVT).

METHODS

PubMed and EMBASE were searched for original studies on clinical functional outcomes at 90 days in LIC patients who received EVT treatment from inception to 28 September 2021. The pooled NFI rates were calculated using random effects model according to different imaging modalities and criteria.

RESULTS

We included 34 studies enrolling 2997 LIC patients. The NFI rates were 23% (95% confidence interval, CI 15-32%) and 24% (95% CI 10-38%) when LIC was defined as core volume ≥50 ml and ≥ 70 ml separately on computed tomography perfusion, 36% (95% CI 23-48%) and 21% (95% CI 17-25%) when LIC was defined as core volume ≥ 50 ml and ≥ 70 ml separately on magnetic resonance diffusion-weighted imaging (DWI), 28% (95% CI 24-32%) and 37% (95% CI 21-53%) when LIC was defined as DWI-ASPECTS ≤ 5 and ≤ 6 separately, 23% (95% CI 19-27%) and 32% (95% CI 18-46%) when LIC was defined as NCCT-ASPECTS ≤ 5 and ≤ 6 separately.

CONCLUSION

Similar NFI rates could be obtained after EVT in LIC patients if proper LIC criteria were select according to the imaging modality.

Clinical Impact and Predictors of Diffusion Weighted Imaging (DWI) Reversal in Stroke Patients with Diffusion Weighted Imaging Alberta Stroke Program Early CT Score 0-5 Treated by Thrombectomy : Diffusion Weighted Imaging Reversal in Large Volume Stroke

PURPOSE

To determine whether reversal of DWI lesions (DWIr) on the DWI-ASPECTS (diffusion weighted imaging Alberta Stroke Program CT Score) template should serve as a predictor of 90-day clinical outcome in acute ischemic stroke (AIS) patients with pretreatment diffusion-weighted imaging (DWI)-ASPECTS 0-5 treated with thrombectomy, and to determine its predictors in current practice.

METHODS

We analyzed data of all consecutive patients included in the prospective multicenter national Endovascular Treatment in Ischemic Stroke Registry between 1 January 2015 and 31 December 2020 with a premorbid mRS ≤ 2, who presented with a pretreatment DWI-ASPECTS 0-5 score, underwent thrombectomy and had an available 24 h post-interventional MRI follow-up. Multivariable analyses were performed to evaluate the clinical impact of DWIr on early neurological improvement (ENI), 3‑month modified Rankin scale (mRS) score distribution (shift analysis) and to define independent predictors of DWIr.

RESULTS

Early neurological improvement was detected in 82/211 (41.7%) of patients while 3‑month functional independence was achieved by 75 (35.5%) patients. The DWI reversal (39/211, 18.9%) resulted an independent predictor of both ENI (aOR 3.6, 95% CI 1.2-7.7; p 0.018) and 3‑month clinical outcome (aOR for mRS shift: 2.2, 95% CI 1-4.6; p 0.030). Only successful recanalization (mTICI 2c-3) independently predicted DWIr in the studied population (aOR 3.3, 95% CI 1.3-7.9; p 0.009).

CONCLUSION

The DWI reversal occurs in a non-negligible proportion of DWI-ASPECTS 0-5 patients subjected to thrombectomy and significantly influences clinical outcome. The mTICI 2c-3 recanalization emerged as an independent DWIr predictor.

Posterior cerebral artery embolism resulting in bilateral paramedian thalamic infarction: A case report

RATIONALE

Bilateral thalamic infarcts are not easily recognized, it have diverse clinical manifestations and relatively severe symptoms. It may leave long-term drowsiness, cognitive impairment, and speech impairment. We report a case of bilateral paramedian thalamic infarction with impaired consciousness as the main symptom. The digital subtraction angiography suggested that the left superior cerebellar artery and posterior cerebral artery (PCA) were occluded.

PATIENTS CONCERN

A previously 67-year-old man was taken to our hospital after 9.5 hours of acute dizziness and loss of consciousness.

DIAGNOSIS

The cranial DWI + MRA suggested acute cerebral infarction in bilateral thalamus and bilateral midbrain, and the left posterior cerebral artery was not clearly visualized. The patient was diagnosed with posterior cerebral artery embolism.

INTERVENTIONS

A mechanical thrombectomy was performed.

OUTCOME

The patient's symptoms did not completely improve after revascularization, followed by fluctuating consciousness.

LESSONS

Recurrent lethargy in patients after endovascular treatment may be a clinical manifestation of damage to thalamic structures or due to the presence of ineffective recanalization.

Short-term Montreal Cognitive Assessment predicts functional outcome after endovascular therapy

Background

The previous studies have shown that cognition in patients 4–8 weeks after stroke can predict early functional outcomes after stroke. The analyses of data from the REVASCAT trial proved that stent thrombectomy improves post-morbid wiring test outcomes in patients with AIS compared with drug therapy. However, few studies focus on the relationship between cognitive impairment and functional outcomes in patients undergoing endovascular treatment.

Methods

A total of 647 participants registered from stroke centers. Stroke severity was evaluated by National Institutes of Health stroke scale (NIHSS). The functional status was estimated by modified Rankin scale (mRS). The cognitive impairment was assessed by trained neurologists at 14 (±4) and 90 (±7) days after stroke onset using the Montreal Cognitive Assessment (MoCA). A MoCA score of less than 26 was considered post-stroke cognitive impairment (PSCI).

Results

A total of 120 Patients who underwent endovascular therapy were included. The PSCI group had higher levels of age, men, educational status, atrial fibrillation, smoking, alcoholism, Alberta Stroke Program Early CT (ASPECT) score of the anterior circulation, and OTP time than the non-PSCI group (p < 0.05). In contrast, the 14-day MoCA score, 14-day NIHSS score, 3-month MoCA score, 3-month NIHSS score, 3-month mRS score, and 3-month EQ5D score were lower in those PSCI patients. The risk predictors of PSCI were age, sex, educational level, atrial fibrillation, smoking, alcoholism, ASPECT Score (anterior circulation), 14-day MoCA score, and 14-day NIHSS score. There were strong relationships between 3-month NIHSS and MoCA (r = –0.483, p < 0.001). Receiver operating characteristic (ROC) curve indicated that 14-day MoCA score, memory, abstraction, visuospatial/executive functions, attention, and language, played a significant role to predict PSCI [area under the curve (AUC) > 0.7]. It had predictive value for the 14-day visuospatial/executive functions to predict 3-month functional outcomes.

Conclusion

Early application of the MoCA in different cognitive regions could predict the PSCI and future functional outcomes, which is necessary to screen high-risk patients with poor prognosis and conduct an early intervention.

Identifying 'fast progressors' likely to benefit from mechanical thrombectomy

OBJECTIVES

Although the effect of mechanical thrombectomy in large vessel occlusions has been clearly demonstrated, there are different opinions about the treatment of patients with low ASPECT scores. We conducted this research to explore the utility of mechanical thrombectomy for the fast progressor patients.

METHODS

We evaluated 394 patients with large vessel occlusion (LVO) who applied to our center between 2012 and 2020 retrospectively. Patients with posterior system stroke and who admitted 6 h after the onset of symptoms, were not included in the study. The remaining 256 patients were divided into two groups as computed tomography angiography source image Alberta stroke program early computer tomography score (CTA-SI ASPECT) ≤ 6 and > 6. Modified rankin scale (mRS) 0-2 defined as good clinical outcome. Thrombolysis in cerebral infarction (TICI) score 2c-3 was accepted as successful recanalization.

RESULTS

The mean age of the patients in the fast-progressive group (23.4%; n = 60) was 66.3 ± 11.6 years, whereas the mean age of the CTA-SI ASPECTS > 6 group (76.6%; n = 196) was 62.4 ± 12.8 years (p = 0.034) A statistically significant difference was found between the groups regarding 90-day mRS (p < 0.001). Whereas 61.7% of the patients with a CTA-SI ASPECTS > 6 had a 90-day mRS 0-2, this rate was 28.3% for patients with a CTA-SI ASPECTS ≤ 6.

CONCLUSION

According to our study, approximately 1/3 of patients with ASPECTS ≤ 6 benefit from mechanical thrombectomy. In this patient group, age emerged as a determinant of good clinical outcome.

Stenting and Angioplasty in Neurothrombectomy: Matched Analysis of Rescue Intracranial Stenting Versus Failed Thrombectomy

BACKGROUND:

Successful reperfusion is one of the strongest predictors of functional outcomes after mechanical thrombectomy (MT). Despite continuous advancements in MT technology and techniques, reperfusion failure still occurs in ≈15% to 30% of patients with large vessel occlusion strokes undergoing MT. We aim to evaluate the safety and efficacy of rescue intracranial stenting for large vessel occlusion stroke after failed MT.

METHODS:

The SAINT (Stenting and Angioplasty in Neurothrombectomy) Study is a retrospective analysis of prospectively collected data from 14 comprehensive stroke centers through January 2015 to December 2020. Patients were included if they had anterior circulation large vessel occlusion stroke due to intracranial internal carotid artery and middle cerebral artery-M1/M2 segments and failed MT. The cohort was divided into 2 groups: rescue intracranial stenting and failed recanalization (modified Thrombolysis in Cerebral Ischemia score 0–1). Propensity score matching was used to balance the 2 groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale at 90 days. Secondary outcomes included functional independence (90-day modified Rankin Scale score 0–2). Safety measures included symptomatic intracranial hemorrhage and 90-day mortality.

RESULTS:

A total of 499 patients were included in the analysis. Compared with the failed reperfusion group, rescue intracranial stenting had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 2.31 [95% CI, 1.61–3.32]; P <0.001), higher rates of functional independence (35.1% versus 7%; adjusted odds ratio [aOR], 6.33 [95% CI, 3.14–12.76]; P <0.001), and lower mortality (28% versus 46.5%; aOR, 0.55 [95% CI, 0.31–0.96]; P =0.04) at 90 days. Rates of symptomatic intracerebral hemorrhage were comparable across both groups (7.1% versus 10.2%; aOR, 0.99 [95% CI, 0.42–2.34]; P =0.98). The matched cohort analysis demonstrated similar results. Specifically, rescue intracranial stenting (n=107) had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 3.74 [95% CI, 2.16–6.57]; P <0.001), higher rates of functional independence (34.6% versus 6.5%; aOR, 10.91 [95% CI, 4.11–28.92]; P <0.001), and lower mortality (29.9% versus 43%; aOR, 0.49 [95% CI, 0.25–0.94]; P =0.03) at 90 days with similar rates of symptomatic intracerebral hemorrhage (7.5% versus 11.2%; aOR, 0.87 [95% CI, 0.31–2.42]; P =0.79) compared with patients who failed to reperfuse (n=107). There was no heterogeneity of treatment effect across the prespecified subgroups for improvement in functional outcomes.

CONCLUSIONS:

Acute intracranial stenting appears to be a safe and effective rescue strategy in patients with large vessel occlusion stroke who failed MT. Randomized multicenter trials are warranted.

Decision-making strategies for reperfusion therapies: navigating through stroke trials gaps

Despite there being a robust amount of literature and numerous randomized clinical trials regarding acute ischemic stroke treatment, the trials have not included some frequent controversial situations for which decision-making strategies are an urgent and unmet need in clinical practice. This article tries to summarize the current evidence about some selected situations (mechanical thrombectomy in low ASPECTS, low NIHSS with proximal occlusion, acute basilar occlusion, distal and medium vessel occlusion, among others), make suggestions on how to approach them in clinical practice and show what to expect in acute stroke research in the near future.

Endovascular treatment of ischemic stroke due to isolated internal carotid artery occlusion: ETIS registry data analysis

BACKGROUND

The best treatment for acute ischemic stroke (AIS) due to isolated cervical internal carotid artery occlusion (CICAO) (i.e., without associated occlusion of the circle of Willis) is still unknown. In this study, we aimed to describe EVT safety and clinical outcome in patients with CICAO.

METHODS

We analyzed data of all consecutive patients, included in the Endovascular Treatment in Ischemic Stroke (ETIS) Registry between 2013 and 2020, who presented AIS and proven CICAO on angiogram and underwent EVT. We assessed carotid recanalization, procedural complications, National Institutes of Health Stroke Scale (NIHSS) at 24 h post-EVT, and 3-month favorable outcome (modified Rankin Scale, mRS ≤ 2 or equal to the pre-stroke value).

RESULTS

Forty-five patients were included (median age: 70 years; range: 62-82 years). The median NIHSS before EVT was 14 (9-21). Carotid stenting was performed in 23 (51%) patients. Carotid recanalization at procedure end and on control imaging was observed in 37 (82%) and 29 (70%) patients, respectively. At day 1 post-EVT, the NIHSS remained stable or decreased in 25 (60%) patients; 12 (29%) patients had early neurologic deterioration (NIHSS ≥ 4 points). The rate of procedural complications was 36%, including stent thrombosis (n = 7), intracranial embolism (n = 7), and symptomatic intracranial hemorrhage (n = 1). At 3 months, 18 (40%) patients had a favorable outcome, and 10 (22%) were dead.

CONCLUSION

Our study suggests that EVT in AIS patients with moderate/severe initial deficit due to CICAO led to high rate of recanalization at day 1, and a 40% rate of favorable outcome at 3 months. There was a high rate of procedural complication which is of concern. Randomized controlled trials assessing the superiority of EVT in patients with CICAO and severe deficits are needed.

Endovascular thrombectomy for acute ischemic stroke

This review describes the evolution of endovascular treatment for acute ischemic stroke, current state of the art, and the challenges for the next decade. The rapid development of endovascular thrombectomy (EVT), from the first attempts into standard of care on a global scale, is one of the major achievements in modern medicine. It was possible thanks to the establishment of a scientific framework for patient selection, assessment of stroke severity and outcome, technical development by dedicated physicians and the MedTech industry, including noninvasive imaging for patient selection, and radiological outcome evaluation. A series of randomized controlled trials on EVT in addition to intravenous thrombolytics, with overwhelmingly positive results for anterior circulation stroke within 6 h of onset regardless of patient characteristics with a number needed to treat of less than 3 for any positive shift in outcome, paved the way for a rapid introduction of EVT into clinical practice. Within the "extended" time window of 6-24 h, the effect has been even greater for patients with salvageable brain tissue according to perfusion imaging with a number needed to treat below 2. Even so, EVT is only available for a small portion of stroke patients, and successfully recanalized EVT patients do not always achieve excellent functional outcome. The major challenges in the years to come include rapid prehospital detection of stroke symptoms, adequate clinical and radiological diagnosis of severe ischemic stroke cases, enabling effective recanalization by EVT in dedicated angiosuites, followed by personalized post-EVT stroke care.

OUP accepted manuscript

Background: Time is brain! This paradigm is forcing the development of strategies with potential to shorten the time from symptom onset to recanalization. One of these strategies is to transport select patients with acute ischaemic stroke directly to an angio-suite equipped with flat-detector computed tomography (FD-CT) to exclude intracranial haemorrhage, followed directly by invasive angiography and mechanical thrombectomy if large-vessel occlusion (LVO) is confirmed. Aim: To present existing published data about the direct transfer (DT) of stroke patients to angio-suites and to describe our initial experience with this stroke pathway. Methods: We performed a systematic PubMed search of trials that described DT of stroke patients to angio-suites and summarized the results of these trials. In January 2020, we implemented a new algorithm for acute ischaemic stroke care in our stroke centre. Select patients suitable for DT (National Institute of Health Stroke Scale score ≥10, time from symptom onset to door <4.5 h) were referred by neurologists directly to an angio-suite equipped with FD-CT. Patients treated using this algorithm were analysed and compared with patients treated using the standard protocol including CT and CT angiography in our centre. Results: We identified seven trials comparing the DT protocol with the standard protocol in stroke patients. Among the 628 patients treated using the DT protocol, 104 (16.5%) did not have LVO and did not undergo endovascular treatment (EVT). All the trials demonstrated a significant reduction in door-to-groin time with DT, compared with the standard protocol. This reduction ranged from 22 min (DT protocol: 33 min; standard protocol: 55 min) to 59 min (DT protocol: 22 min; standard protocol: 81 min). In three of five trials comparing the 90-day modified Rankin scale scores between the DT and standard imaging groups, this reduction in ischaemic time translated into better clinical outcomes, whereas the two other trials reported no such difference in scores. Between January 2020 and October 2021, 116 patients underwent EVT for acute ischaemic stroke in our centre. Among these patients, 65 (56%) met the criteria for DT (National Institutes of Health Stroke Scale score >10, symptom onset-to-door time <4.5 h), but only 7 (10.8%) were transported directly to the angio-suite. The reasons that many patients who met the criteria were not transported directly to the angio-suite were lack of personnel trained in FD-CT acquisition outside of working hours, ongoing procedures in the angio-suite, contraindication to the DT protocol due to atypical clinical presentation, and neurologist’s decision for obtain complete neurological imaging. All seven patients who were transported directly to the angio-suite had LVOs. The median time from door-to-groin-puncture was significantly lower with the DT protocol compared with the standard protocol {29 min [interquartile range (IQR): 25–31 min] vs. 71 min [IQR: 55–94 min]; P < 0.001}. None of the patients had symptomatic intracranial haemorrhage in the DT protocol group, compared with 7 (6.4%) patients in the standard protocol group. Direct transfer of acute ischaemic stroke patients to the angio-suite equipped with FD-CT seems to reduce the time from patient arrival in the hospital to groin puncture. This reduction in the ischaemic time translates into better clinical outcomes. However, more data are needed to confirm these results.

Imaging Acute Stroke: From One-Size-Fit-All to Biomarkers

In acute stroke management, time window has been rigidly used as a guide for decades and the reperfusion treatment is only available in the first few limited hours. Recently, imaging-based selection of patients has successfully expanded the treatment window out to 16 and even 24 h in the DEFUSE 3 and DAWN trials, respectively. Recent guidelines recommend the use of imaging techniques to guide therapeutic decision-making and expanded eligibility in acute ischemic stroke. A tissue window is proposed to replace the time window and serve as the surrogate marker for potentially salvageable tissue. This article reviews the evolution of time window, addresses the advantage of a tissue window in precision medicine for ischemic stroke, and discusses both the established and emerging techniques of neuroimaging and their roles in defining a tissue window. We also emphasize the metabolic imaging and molecular imaging of brain pathophysiology, and highlight its potential in patient selection and treatment response prediction in ischemic stroke.

Endovascular Therapy of Anterior Circulation Tandem Occlusions: Pooled Analysis From the TITAN and ETIS Registries

BACKGROUND AND PURPOSE

Endovascular therapy for tandem occlusion strokes of the anterior circulation is an effective and safe treatment. The best treatment approach for the cervical internal carotid artery (ICA) lesion is still unknown. In this study, we aimed to compare the functional and safety outcomes between different treatment approaches for the cervical ICA lesion during endovascular therapy for acute ischemic strokes due to tandem occlusion in current clinical practice.

METHODS

Individual patients' data were pooled from the French prospective multicenter observational ETIS (Endovascular Treatment in Ischemic Stroke) and the international TITAN (Thrombectomy in Tandem Lesions) registries. TITAN enrolled patients from January 2012 to September 2016, and ETIS from January 2013 to July 2019. Patients with acute ischemic stroke due to anterior circulation tandem occlusion who were treated with endovascular therapy were included. Patients were divided based on the cervical ICA lesion treatment into stent and no-stent groups. Outcomes were compared between the two treatment groups using propensity score methods.

RESULTS

A total of 603 patients were included, of whom 341 were treated with acute cervical ICA stenting. In unadjusted analysis, the stent group had higher rate of favorable outcome (90-day modified Rankin Scale score, 0-2; 57% versus 45%) and excellent outcome (90-day modified Rankin Scale score, 0-1; 40% versus 27%) compared with the no-stent group. In inverse probability of treatment weighting propensity score-adjusted analyses, stent group had higher odds of favorable outcome (adjusted odds ratio, 1.09 [95% CI, 1.01-1.19]; P=0.036) and successful reperfusion (modified Thrombolysis in Cerebral Ischemia score, 2b-3; adjusted odds ratio, 1.19 [95% CI, 1.11-1.27]; P<0.001). However, stent group had higher odds of any intracerebral hemorrhage (adjusted odds ratio, 1.10 [95%, 1.02-1.19]; P=0.017) but not higher rate of symptomatic intracerebral hemorrhage or parenchymal hemorrhage type 2. Subgroup analysis demonstrated heterogeneity according to the lesion type (atherosclerosis versus dissection; P for heterogeneity, 0.01), and the benefit from acute carotid stenting was only observed for patients with atherosclerosis.

CONCLUSIONS

Patients treated with acute cervical ICA stenting for tandem occlusion strokes had higher odds of 90-day favorable outcome, despite higher odds of intracerebral hemorrhage; however, most of the intracerebral hemorrhages were asymptomatic.

Direct to Angiography Suite Without Stopping for Computed Tomography Imaging for Patients With Acute Stroke: A Randomized Clinical Trial

Importance

Direct transfer to angiography suite (DTAS) for patients with suspected large vessel occlusion (LVO) stroke has been described as an effective and safe measure to reduce workflow time in endovascular treatment (EVT). However, it is unknown whether DTAS improves long-term functional outcomes.

Objective

To explore the effect of DTAS on clinical outcomes among patients with LVO stroke in a randomized clinical trial.

Design, Setting, and Participants

The study was an investigator-initiated, single-center, evaluator-blinded randomized clinical trial. Of 466 consecutive patients with acute stroke screened, 174 with suspected LVO acute stroke within 6 hours of symptom onset were included. Enrollment took place from September 2018 to November 2020 and was stopped after a preplanned interim analysis. Final follow-up was in February 2021.

Interventions

Patients were randomly assigned (1:1) to follow either DTAS (89 patients) or conventional workflow (85 patients received direct transfer to computed tomographic imaging, with usual imaging performed and EVT indication decided) to assess the indication of EVT. Patients were stratified according to their having been transferred from a primary center vs having a direct admission.

Main Outcomes and Measures

The primary outcome was a shift analysis assessing the distribution of the 90-day 7-category (from 0 [no symptoms] to 6 [death]) modified Rankin Scale (mRS) score among patients with LVO whether or not they received EVT (modified intention-to-treat population) assessed by blinded external evaluators. Secondary outcomes included rate of EVT and door-to-arterial puncture time. Safety outcomes included 90-day mortality and rates of symptomatic intracranial hemorrhage.

Results

In total, 174 patients were included, with a mean (SD) age of 73.4 (12.6) years (range, 19-95 years), and 78 patients (44.8%) were women. Their mean (SD) onset-to-door time was 228.0 (117.9) minutes, and their median admission National Institutes of Health Stroke Scale score was 18 (interquartile range [IQR], 14-21). In the modified intention-to-treat population, EVT was performed for all 74 patients in the DTAS group and for 64 patients (87.7%) in the conventional workflow group (P = .002). The DTAS protocol decreased the median door-to-arterial puncture time (18 minutes [IQR, 15-24 minutes] vs 42 minutes [IQR, 35-51 minutes]; P < .001) and door-to-reperfusion time (57 minutes [IQR, 43-77 minutes] vs 84 minutes [IQR, 63-117 minutes]; P < .001). The DTAS protocol decreased the severity of disability across the range of the mRS (adjusted common odds ratio, 2.2; 95% CI, 1.2-4.1; P = .009). Safety variables were comparable between groups.

Conclusions and Relevance

For patients with LVO admitted within 6 hours after symptom onset, this randomized clinical trial found that, compared with conventional workflow, the use of DTAS increased the odds of patients undergoing EVT, decreased hospital workflow time, and improved clinical outcome.

Trial Registration

ClinicalTrials.gov Identifier: NCT04001738.

Effect of Operator's Experience on Proficiency in Mechanical Thrombectomy: A Multicenter Study

BACKGROUND AND PURPOSE

We aimed to evaluate among trained interventional neuroradiologist, whether increasing individual experience was associated with an improvement in mechanical thrombectomy (MT) procedural performance metrics.

METHODS

Individual MT procedural data from 5 centers of the Endovascular Treatment in Ischemic Stroke registry and 2 additional high-volume stroke centers were pooled. Operator experience was defined for each operator as a continuous variable, cumulating the number of MT procedures performed since January 2015, as MT became standard of care or, if later than this date, since the operator started performing mechanical thrombectomies in autonomy. We tested the associations between operator's experience and procedural metrics.

RESULTS

A total of 4516 procedures were included, performed by 36 operators at 7 distinct centers, with a median of 97.5 endovascular treatment procedures per operator (interquartile range, 57-170.2) over the study period. Higher operator's experience, analyzed as a continuous variable, was associated with a significantly shorter procedural duration (β estimate, -3.98 [95% CI, -5.1 to -2.8]; P<0.001), along with local anesthesia and M1 occlusion location in multivariable models. Increasing experience was associated with better Thrombolysis in Cerebral Infarction scores (estimate, 1.02 [1-1.04]; P=0.013).

CONCLUSIONS

In trained interventional neuroradiologists, increasing experience in MT is associated with significantly shorter procedural duration and better reperfusion rates, with a theoretical ceiling effect observed after around 100 procedures. These results may inform future training and practice guidelines to set minimal experience standards before autonomization, and to set-up operators' recertification processes tailored to individual case volume and prior experience.

Higher Baseline Cortical Score Predicts Good Outcome in Patients With Low Alberta Stroke Program Early Computed Tomography Score Treated with Endovascular Treatment

BACKGROUND

Patients with large vessel occlusion and noncontrast computed tomography (CT) Alberta Stroke Program Early CT Score (ASPECTS) <6 may benefit from endovascular treatment (EVT). There is uncertainty about who will benefit from it.

OBJECTIVE

To explore the predicting factors for good outcome in patients with ASPECTS <6 treated with EVT.

METHODS

We retrospectively reviewed 60 patients with ASPECTS <6 treated with EVT in our center between March 2018 and June 2019. Patients were divided into 2 groups because of the modified Rankin Score (mRS) at 90 d: good outcome group (mRS 0-2) and poor outcome group (mRS ≥3). Baseline and procedural characteristics were collected for unilateral variate and multivariate regression analyses to explore the influent variates for good outcome.

RESULTS

Good outcome (mRS 0-2) was achieved in 24 (40%) patients after EVT and mortality was 20% for 90 d. Compared with the poor outcome group, higher baseline cortical ASPECTS (c-ASPECTS), lower intracranial hemorrhage, and malignant brain edema after thrombectomy were noted in the good outcome group (all P < .01). Multivariate logistic regression showed that only baseline c-ASPECTS (≥3) was positive factor for good outcome (odds ratio = 4.29; 95% CI, 1.21-15.20; P = .024). The receiver operating characteristics curve indicated a moderate value of c-ASPECTS for predicting good outcome, with the area under receiver operating characteristics curve 0.70 (95% CI, 0.56-0.83; P = .011).

CONCLUSION

Higher baseline c-ASPECTS was a predictor for good clinical outcome in patients with ASPECTS <6 treated with EVT, which could be helpful to treatment decision.

Expanding indications for endovascular thrombectomy-how to leave no patient behind

Endovascular thrombectomy (EVT) has become standard of care for large vessel occlusion strokes but current guidelines exclude a large proportion of patients from this highly effective treatment. This review therefore focuses on expanding indications for EVT in several borderline indications such as patients in the extended time window, patients with extensive signs of infarction on admission imaging, elderly patients and patients with pre-existing deficits. It also discusses the current knowledge on intravenous thrombolysis as an adjunct to EVT and EVT as primary therapy for distal vessel occlusions, for tandem occlusions, for basilar artery occlusions and in pediatric patients. We provide clear recommendations based on current guidelines and further literature.

Endovascular reperfusion outcomes in patients with a stroke and low ASPECTS is highly dependent on baseline infarct volumes

BACKGROUND

Patients with large vessel occlusion stroke (LVOS) and a low Alberta Stroke Program Early CT Score (ASPECTS) are often not offered endovascular therapy (ET) as they are thought to have a poor prognosis.

OBJECTIVE

To compare the outcomes of patients with low and high ASPECTS undergoing ET based on baseline infarct volumes.

METHODS

Review of a prospectively collected endovascular database at a tertiary care center between September 2010 and March 2020. All patients with anterior circulation LVOS and interpretable baseline CT perfusion (CTP) were included. Subjects were divided into groups with low ASPECTS (0-5) and high ASPECTS (6-10) and subsequently into limited and large CTP-core volumes (cerebral blood flow 30% >70 cc). The primary outcome measure was the difference in rates of 90-day good outcome as defined by a modified Rankin Scale (mRS) score of 0 to 2 across groups.

RESULTS

1248 patients fit the inclusion criteria. 125 patients had low ASPECTS, of whom 16 (12.8%) had a large core (LC), whereas 1123 patients presented with high ASPECTS, including 29 (2.6%) patients with a LC. In the category with a low ASPECTS, there was a trend towards lower rates of functional independence (90-day modified Rankin Scale (mRS) score 0-2) in the LC group (18.8% vs 38.9%, p=0.12), which became significant after adjusting for potential confounders in multivariable analysis (aOR=0.12, 95% CI 0.016 to 0.912, p=0.04). Likewise, LC was associated with significantly lower rates of functional independence (31% vs 51.9%, p=0.03; aOR=0.293, 95% CI 0.095 to 0.909, p=0.04) among patients with high ASPECTS.

CONCLUSIONS

Outcomes may vary significantly in the same ASPECTS category depending on infarct volume. Patients with ASPECTS ≤5 but baseline infarct volumes ≤70 cc may achieve independence in nearly 40% of the cases and thus should not be excluded from treatment.

Treatment and Outcome in Stroke Patients With Acute M2 Occlusion and Minor Neurological Deficits

BACKGROUND AND PURPOSE

Treatment in stroke patients with M2 segment occlusion of the middle cerebral artery presenting with mild neurological deficits is a matter of debate. The main purpose was to compare the outcome in patients with a minor stroke and a M2 occlusion.

METHODS

Consecutive intravenous thrombolysis (IVT) eligible patients admitted to the Bernese stroke center between January 2005 and January 2020 with acute occlusion of the M2 segment and National Institutes of Health Stroke Scale score ≤5 were included. Outcome was compared between IVT only versus endovascular therapy (EVT) including intra-arterial thrombolysis and mechanical thrombectomy (MT; ±IVT) and between IVT only versus MT only.

RESULTS

Among 169 patients (38.5% women, median age 70.2 years), 84 (49.7%) received IVT only and 85 (50.3%) EVT (±IVT), the latter including 39 (45.9%) treated with MT only. Groups were similar in sex, age, vascular risk factors, event cause, or preevent independency. Compared with IVT only, there was no difference in favorable outcome (modified Rankin Scale score, 0-2) for EVT (adjusted odds ratio, 0.96; adjusted P=0.935) or for MT only (adjusted odds ratio, 1.12; adjusted P=0.547) groups. Considering only patients treated after 2015, there was a significantly better 3-month modified Rankin Scale shift (adjusted P=0.032) in the EVT compared with the IVT only group.

CONCLUSIONS

Our study demonstrates similar effectiveness of IVT only versus EVT (±IVT), and of IVT only versus MT only in patients with peripheral middle cerebral artery occlusions and minor neurological deficits and indicates a possible benefit of EVT considering only patients treated after 2015. There is an unmet need for randomized controlled trials in this stroke field, including imaging parameters, and more sophisticated evaluation of National Institutes of Health Stroke Scale score subitems, neurocognition, and quality of life neglected by the standard outcome scales such as modified Rankin Scale and National Institutes of Health Stroke Scale score.

Factors associated with DWI-ASPECTS score in patients with acute ischemic stroke due to cerebral large vessel occlusion

BACKGROUND

The Alberta Stroke Program Early CT score (ASPECTS) of patients with acute ischemic stroke at the time of admission varies. It is crucial to select appropriate methods of treatment, such as recombinant tissue-plasminogen activator, and/or endovascular thrombectomy. According to the recent guidelines, endovascular thrombectomy for patients with large vessel occlusion (LVO) and lesion of ischemic tissue that was not yet infarcted is effective. This result demonstrates the importance of patient selection based on neuroradiological imaging. However, there are many patients who are judged as ineligibility for recanalization therapy because of presence of large ischemic core, indicating unfavorable ASPECTS, at the time of admission. We investigated the factors associated with favorable diffusion-weighted image (DWI)-ASPECTS score at the time of admission.

METHODS

We studies patients with LVO within 24 h from onset who were admitted into our hospital. We divided them into two groups, with favorable DWI-ASPECTS (≥6), and unfavorable DWI-ASPECTS (<6) at the time of admission. We investigated factors associated with favorable DWI-ASPECTS by evaluation of our patients' severity of clinical symptom, etiology, and radiological findings.

RESULTS

This study showed that mild white matter lesion (Fazekas scale ≤1), absence of internal carotid artery (ICA) occlusion and cardioembolic stroke were independent factor of favorable DWI-ASPECTS at the time of admission. (odds ratio 12.92, p <  0.001, odds ratio 0.31, p =  0.001, odds ratio 0.16, p = 0.001, respectively) CONCLUSIONS: Absence of severe white matter lesion, cardioembolic stroke, and ICA occlusion might be associated with favorable DWI-ASPECTS at the time of admission.

Prognosis and risk factors associated with asymptomatic intracranial hemorrhage after endovascular treatment of large vessel occlusion stroke: a prospective multicenter cohort study

BACKGROUND AND PURPOSE

Asymptomatic intracranial hemorrhage (aICH) is a common occurrence after endovascular treatment (EVT) for acute ischemic stroke (AIS). The aims of this study were to address its impact on 3-month functional outcome and to identify risk factors for aICH after EVT.

METHODS

Patients with AIS attributable to anterior circulation large vessel occlusion who underwent EVT were enrolled in a multicenter prospective registry. Based on imaging performed 22-36 h post-EVT, we included patients with no intracranial hemorrhage (ICH) or aICH. Poor outcome defined as a 3-month modified Rankin Scale (mRS) score 4-6 and overall 3-month mRS score distribution were compared according to presence/absence of aICH, and aICH subtype using logistic regression. We assessed the risk factors of aICH using a multivariate logistic regression model.

RESULTS

Of the 1526 patients included in the study, 653 (42.7%) had aICH. Patients with aICH had a higher rate of poor outcome: odds ratio (OR) 1.88 (95% confidence interval [CI] 1.44-2.44). Shift analysis of mRS score found a fully adjusted OR of 1.79 (95% CI 1.47-2.18). Hemorrhagic infarction (OR 1.63 [95% CI 1.22-2.18]) and parenchymal hematoma (OR 2.99 [95% CI 1.77-5.02]) were associated with higher risk of poor outcome. Male sex, diabetes, coronary artery disease, baseline National Institutes of Health Stroke Scale score and Alberta Stroke Program Early Computed Tomography Score, number of passes and onset to groin puncture time were independently associated with aICH.

CONCLUSIONS

Patients with aICH, irrespective of the radiological pattern, have a worse functional outcome at 3 months compared with those without ICH after EVT for AIS. The number of EVT passes and the time from onset to groin puncture are factors that could be modified to reduce deleterious ICH.

The role of infarct location in patients with DWI-ASPECTS 0-5 acute stroke treated with thrombectomy

OBJECTIVE

To determine whether hemisphere involvement and infarct location on the Alberta Stroke Program CT Score (ASPECTS) template should serve as predictors of 90-day clinical outcome in patients with acute ischemic stroke with pretreatment diffusion-weighted imaging (DWI)-ASPECTS 0-5 treated with mechanical thrombectomy (MT).

METHODS

We analyzed data of all consecutive patients included in the Endovascular Treatment in Ischemic Stroke registry between January 1, 2012, and August 31, 2018, who presented with a pretreatment DWI-ASPECTS 0-5 and underwent MT. Multivariable analyses were performed in order to identify the role of infarct location and hemisphere involvement on good outcome defined by a modified Rankin Scale (mRS) score 0-2 at 90 days and on the whole distribution of mRS (shift analysis).

RESULTS

A total of 344 patients with a DWI-ASPECTS 0-5 (median 4, IQR 3-5) were included. Neither infarct location nor hemisphere involvement was found to be an independent predictor of good outcome. Involvement of the M6 region in right-sided strokes (adjusted odds ratio [aOR] 2.6, 99% confidence interval [CI] 1.14-5.8; p = 0.003) and the internal capsule in left-sided strokes (aOR 2.6, 99% CI 0.8-7.9; p < 0.020) independently predicted increased disability on the mRS distribution in the affected subpopulations.

CONCLUSION

Our study suggests that neither hemisphere nor infarct location should be considered as an exclusion criterion for MT in patients with stroke with pretreatment DWI-ASPECTS 0-5. The involvement of specific regions of interest was associated with increased disability. These may provide valuable information regarding stroke management options and neurologic recovery for use of caregivers in the postacute phase.

The Safety and Efficacy of Endovascular Treatment for Patients With ASPECTS<6 in Anterior Circulation Stroke: A Meta-Analysis and Subgroup Analysis by Imaging Techniques

BACKGROUND

Endovascular treatment (EVT) is merely recommended as class of recommendation IIb for patients with ASPECTS <6 according to the American Heart Association guideline 2019. In addition, the best determined imaging technique for EVT in patient with ASPECTS<6 remains unknown. The objective of this study was to define the safety and efficacy of EVT for patients with ASPECTS<6 and investigate the superiority between MRI and CT for patient selection.

METHODS

A systematic search of PubMed, EMBASE, The Cochrane Library and other additional sources was performed for studies published with no publication period. Our study was conducted corresponding to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRIMA) guidelines. The analysis was performed using the Comprehensive Meta-Analysis (CMA) 2.0.

RESULTS

Five studies reporting data from 844 participants were included in our analysis according to the inclusion criteria. Consequently, EVT was associated with statistically significant higher functional independence compared with MT (OR 5.401, 95% CI 3.227-9.041). Whereas EVT was found to be related to lower mortality compared with MT based on eligible data (OR 0.461, 95% CI 0.329-0.647). No significant difference was identified in sICH between EVT and MT (OR 1.075, 95% CI 0.452-2.558).

CONCLUSION

According to the results of our study, we suggested that EVT is a preferred therapy in ACS patients with ASPECTS<6 in consideration of efficacy and safety. Furthermore, MRI did not show superiority over CT as no statistical difference was detected in all subgroups.

Predictors of malignant middle cerebral artery infarction after mechanical thrombectomy

INTRODUCTION

Several predictors have been described to early diagnose malignant middle cerebral artery infarction (MMI) and select patient for hemicraniectomy. Nevertheless, few studies have assessed them among patients with acute ischemic stroke undergoing mechanical endovascular thrombectomy (MET). The overall objective in this study was to evaluate these predictors in patients undergoing MET in the purpose to guide the medical care in the acute phase.

METHODS

We selected patients from a prospective local database which reference all patients eligible for treatment with Alteplase thrombolysis and/or mechanical endovascular thrombectomy in acute stroke. We investigated demographic, clinical, and radiological data. Multivariate regression analysis was used to identify clinical and imaging predictors of MMI.

RESULTS

In 32 months, 66 patients were included. Eighteen (27.3%) developed MMI. Malignant evolution was associated with: severity of neurological deficit and level of consciousness at admission, infarct size in DWI sequence and involvement of other vascular territories. Study groups didn't differ in terms of successful reperfusion. Two variables were identified as independent predictors of MMI: DWI infarct volume (p<0.001) and time to thrombectomy (p=0.018). A decision tree based on these two factors was able to predict malignant evolution with high specificity (100%) and sensibility (73%).

CONCLUSION

Our study proposes a practical decision tree including DWI lesion volume and delay before thrombectomy to early and accurately predict MMI in a subgroup of patients with MCA infarction undergoing MET regardless to the status of reperfusion.

Physiologic predictors of collateral circulation and infarct growth during anesthesia - Detailed analyses of the GOLIATH trial

Collateral circulation plays a pivotal role in acute ischemic stroke due to large vessel occlusion (LVO) and may be affected by multiple variables during sedation for endovascular therapy (EVT). We conducted detailed analyses of the GOLIATH trial to identify predictors of collateral circulation grade and infarct growth. We also modified the ASITN collateral grading scale and sought to determine its impact on clinical outcome and infarct growth. Multivariable analysis was used to identify predictors of collaterals and infarct growth. Ordinal analysis demonstrated nominal, but non-significant association between modified ASITN scale and infarct growth. Among all analyzed baseline clinical and procedural variables, the most significant predictors of infarct growth at 24 h were phenylephrine dose (estimate 6.78; p = 0.014) and baseline infarct volume (estimate 0.93; p = 0.03). The most significant predictors of worse collateral grade were mean arterial pressure (MAP) <70 mmHg (OR 0.35; p = 0.048) and baseline infarct volume (OR 0.96; p = 0.003). Hypotension during sedation for EVT for LVO negatively impacts collateral circulation, while higher pressor dose is a strong predictor of infarct growth. Avoidance of anesthesia-induced hypotension and consequent need for pressor therapy may prevent collateral failure and minimize infarct growth.

Identifying the predictors of first-pass effect and its influence on clinical outcome in the setting of endovascular thrombectomy for acute ischemic stroke: Results from a multicentric prospective registry

BACKGROUND

The first-pass effect, defined as a complete or near-complete recanalization after one pass (first-pass effect) of a mechanical thrombectomy device, has been related to better clinical outcome than good recanalization after more than one pass in acute ischemic stroke. We searched for predictors of first-pass effect by analyzing the results within a large prospective multicentric registry.

METHODS

We included patients treated by mechanical thrombectomy for isolated anterior intracranial occlusions. A multi-variate logistic regression analysis was carried out to search for predictors of first-pass effect. We also analyzed the percentage of patients with 90-day modified Rankin Scale score 0 to 2, excellent outcome (90-day modified Rankin Scale 0 to 1), 24-h NIHSS change, and 90-day all-cause mortality.

RESULTS

Among the 1832 patients included, clinical outcome at 90 days was significantly better in first-pass effect patients (50.6% vs. 38.9% in patients without first-pass effect), with a center-adjusted OR associated with first-pass effect of 1.74 (95%CI, 1.24 to 1.77). Older age, a lower systolic blood pressure, an MCA-M1 occlusion, higher DWI-ASPECTS at admission, mechanical thrombectomy under local anesthesia, and combined first-line device strategy were independent predictors of first-pass effect.

CONCLUSIONS

In this study, a strategy combining thrombectomy and thrombo-aspiration was more effective than other strategies in achieving first-pass effect. In addition, we confirm that clinical outcome was better in patients with first-pass effect compared to non-first-pass effect patients.

Perfusion Imaging to Select Patients with Large Ischemic Core for Mechanical Thrombectomy

BACKGROUND AND PURPOSE

Patients with acute ischemic stroke, proximal vessel occlusion and a large ischemic core at presentation are commonly not considered for mechanical thrombectomy (MT). We tested the hypothesis that in patients with baseline large infarct cores, identification of remaining penumbral tissue using perfusion imaging would translate to better outcomes after MT.

METHODS

This was a multicenter, retrospective, core lab adjudicated, cohort study of adult patients with proximal vessel occlusion, a large ischemic core volume (diffusion weighted imaging volume ≥70 mL), with pre-treatment magnetic resonance imaging perfusion, treated with MT (2015 to 2018) or medical care alone (controls; before 2015). Primary outcome measure was 3-month favorable outcome (defined as a modified Rankin Scale of 0-3). Core perfusion mismatch ratio (CPMR) was defined as the volume of critically hypo-perfused tissue (Tmax >6 seconds) divided by the core volume. Multivariable logistic regression models were used to determine factors that were independently associated with clinical outcomes. Outputs are displayed as adjusted odds ratio (aOR) and 95% confidence interval (CI).

RESULTS

A total of 172 patients were included (MT n=130; Control n=42; mean age 69.0±15.4 years; 36% females). Mean core-volume and CPMR were 102.3±36.7 and 1.8±0.7 mL, respectively. As hypothesized, receiving MT was associated with increased probability of favorable outcome and functional independence, as CPMR increased, a difference becoming statistically significant above a mismatch-ratio of 1.72. Similarly, receiving MT was also associated with favorable outcome in the subgroup of 74 patients with CPMR >1.7 (aOR, 8.12; 95% CI, 1.24 to 53.11; P=0.028). Overall (prior to stratification by CPMR) 73 (42.4%) patients had a favorable outcome at 3 months, with no difference amongst groups.

CONCLUSION

s In patients currently deemed ineligible for MT due to large infarct ischemic cores at baseline, CPMR identifies a subgroup strongly benefiting from MT. Prospective studies are warranted.

Endovascular Thrombectomy for Low ASPECTS Large Vessel Occlusion Ischemic Stroke: A Systematic Review and Meta-Analysis

Background:

The current American Heart Association guidelines for acute ischemic stroke reserve Grade 1A recommendation for the use of endovascular thrombectomy (EVT) for patients with an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of ≥6.

Objective:

We aim to determine the safety and efficacy of EVT for large vessel occlusion ischemic stroke patients with low ASPECTS (5 or less).

Methods:

Medline, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched for studies appraising the outcomes of EVT for low ASPECTS ischemic stroke. A meta-analysis of proportions compared the clinical outcomes of patients undergoing EVT and those receiving best medical therapy only.

Results:

Nine studies (1,196 patients) were included. There was a trend (p = 0.11) toward a higher rate of symptomatic intracranial hemorrhage (sICH) in the EVT group (9.2%; 95% CI 6.1–13.6; I2 53.37%) compared to the medical group (5.5%; 95% CI 3.7–8.1; I2 0%). There was no difference (p = 0.41) in the pooled 90-day mortality of EVT patients (30.7%; 95% CI 21.7–41.5; I2 84.23%) and medical patients (36.6%; 95% CI 26.4–48.1; I2 76.2%). EVT patients had better (p = 0.001) 90-day outcomes, with 27.7% (95% CI 21.8–34.5; I2 62.08%) of patients attaining a modified Rankin Scale of 0–2 compared to only 3.7% (95% CI 2.3–5.9; I2 87.21%) in the medical group.

Conclusions:

This meta-analysis demonstrates a trend in higher sICH among low ASPECTS patients undergoing EVT. Despite this, a significant proportion of this subset of patients still achieved good functional outcomes at 90 days. Randomized trials are necessary to substantiate this result as significant bias is inherent in the observational studies included in this review.

Subarachnoid Contrast Accumulation and Alberta Stroke Program Early Computed Tomography Score Applied to Contrast Accumulation After Thrombectomy as Predictors of Symptomatic Hemorrhage

BACKGROUND

Areas of contrast accumulation (CA) are commonly found on routine computed tomography (CT) performed immediately after thrombectomy. In the present study, we investigated the types of CA associated with the different outcomes, including symptomatic intracranial hemorrhage (sICH).

METHODS

The present study analyzed the data from 145 patients with anterior circulation stroke who had undergone non-contrast-enhanced conventional CT immediately after thrombectomy. The following variables were investigated: collateral status, failure of recanalization, Alberta stroke program early CT score (ASPECTS) applied to CA lesions and diffusion-weighted imaging infarct lesions, and sICH.

RESULTS

Of the 145 patients, 102 (70.3%) had CA lesions. All types of CA (any CA, cortical CA, subarachnoid CA, and CA ASPECTS) were significantly associated with poor outcomes (modified Rankin scale score >2). In particular, subarachnoid CA (odds ratio, 23.994; 95% confidence interval, 4.696-122.589) and CA ASPECTS (odds ratio, 0.550; 95% confidence interval, 0.404-0.750) were independently associated with sICH. Patients with subarachnoid CA had poorer collateral status and a larger final infarct size than those without subarachnoid CA, although the initial National Institutes of Health stroke scale score and recanalization rate were comparable between the 2 groups. A CA ASPECTS of ≤5 predicted sICH with a sensitivity of 66.7% and a specificity of 92.6% (area under the curve, 0.854).

CONCLUSIONS

Our data suggest that a subarachnoid CA location and CA ASPECTS are predictors of sICH. In particular, a subarachnoid location of CA might signify damage of the subarachnoid collateral arteries, leading to a larger infarct.