Modified Thrombolysis in Cerebral Infarction 2C/Thrombolysis in Cerebral Infarction 3 Reperfusion Should Be the Aim of Mechanical Thrombectomy

Thrombectomy Alone or Alongside Intravenous Thrombolysis in Managing Acute Ischemic Stroke Caused by Basilar Artery Occlusion: A Multicenter Observational Study

BACKGROUND AND PURPOSE

It remains unclear whether the combination of endovascular treatment (EVT) with intravenous thrombolysis (IVT) results in a more favorable functional outcome than EVT alone in managing cases of acute ischemic stroke (AIS) caused by basilar artery occlusion (BAO). Thus, this study aimed to compare the outcomes of 2 approaches-direct endovascular treatment (DEVT) and bridging therapy (IVT plus EVT)-in patients with acute BAO presenting within 4.5 hours of stroke onset.

MATERIALS AND METHODS

This multicenter retrospective cohort study included 153 patients with acute BAO presenting within 4.5 hours of stroke onset. Of these patients, 65 (42.5%) and 88 (57.5%) underwent DEVT and bridging therapy, respectively. The primary outcome was defined as good functional outcome (mRS, 0-3) at 90 days. Additionally, preoperative clinical features, thrombectomy attempts, successful reperfusion rates, incidences of symptomatic intracranial hemorrhage (sICH), and mortality were compared between the 2 groups.

RESULTS

At 90 days, the rate of good functional outcome was comparable between the DEVT (44.6%) and bridging-therapy (39.8%) groups (adjusted odds ratio [aOR], 1.12; 95% CI, 0.55-2.31; P = .753). The bridging-therapy group exhibited a lower percentage of patients requiring ≥3 attempts of stent retrieval (aOR, 0.39; 95% CI, 0.16-0.93; P = .034). Preoperative clinical features, rate of successful reperfusion, sICH, and mortality were similar between the 2 groups.

CONCLUSIONS

In patients with BAO-induced AIS, DEVT demonstrates a comparable functional outcome to bridging therapy within 4.5 hours of symptom onset, but IVT reduces the number of thrombectomy attempts.

Mechanical Thrombectomy for Middle Cerebral Artery Medium Vessel Occlusions Using Single Plane Angiography

BACKGROUND AND PURPOSE

Endovascular thrombectomy is now the standard of care for large vessel occlusion acute ischemic stroke. However, acute stroke due to medium-vessel occlusions often result in unfavorable outcomes, and guidelines for thrombectomy are lacking. Moreover, nearly all clinical data and thrombectomy trials are based on biplane angiography systems. This study aims to compare the safety and efficacy of stroke thrombectomy procedures performed on single-plane versus biplane angiography systems in patients presenting with medium-vessel occlusions of the middle cerebral artery.

MATERIALS AND METHODS

This retrospective study included consecutive patients with acute ischemic stroke due to primary middle cerebral artery medium-vessel occlusions treated with thrombectomy between 7/1/2020 and 8/1/2022 at a single high-volume practice. Patients were dichotomized into those treated on single plane and biplane systems. Demographic, procedural, clinical and follow-up characteristics were compared.

RESULTS

Among the 149 patients included, 44 underwent thrombectomy on single-plane systems, and 93 on biplane systems. No significant differences were detected in rates of good functional outcomes (mRS < 2; SP 54% vs BP 42%, p = 0.19), successful recanalization (TICI ≥ 2B; SP 91% vs BP 86%, p = 0.77), intra-procedural vascular injury (SP 0% vs BP 3%; p = 0.56), or time from groin puncture to reperfusion (SP 25 min vs BP 27 min; p = 0.97). No significant differences were detected in peri-procedural complications, or symptomatic intracerebral hemorrhage.

CONCLUSION

Thrombectomy for middle cerebral artery medium-vessel occlusions performed on single-plane angiography systems is as safe and efficacious as biplane procedures. Our results may have implications for increasing access to care, especially in regions with limited resources.

Early technique switch following failed passes during mechanical thrombectomy for ischemic stroke: should the approach change and when?

BACKGROUND

Fast and complete reperfusion in endovascular therapy (EVT) for ischemic stroke leads to superior clinical outcomes. The effect of changing the technical approach following initially unsuccessful passes remains undetermined.

OBJECTIVE

To evaluate the association between early changes to the EVT approach and reperfusion.

METHODS

Multicenter retrospective analysis of prospectively collected data for patients who underwent EVT for intracranial internal carotid artery, middle cerebral artery (M1/M2), or basilar artery occlusions. Changes in EVT technique after one or two failed passes with stent retriever (SR), contact aspiration (CA), or a combined technique (CT) were compared with repeating the previous strategy. The primary outcome was complete/near-complete reperfusion, defined as an expanded Thrombolysis in Cerebral Infarction (eTICI) of 2c-3, following the second and third passes.

RESULTS

Among 2968 included patients, median age was 66 years and 52% were men. Changing from SR to CA on the second or third pass was not observed to influence the rates of eTICI 2c-3, whereas changing from SR to CT after two failed passes was associated with higher chances of eTICI 2c-3 (OR=5.3, 95% CI 1.9 to 14.6). Changing from CA to CT was associated with higher eTICI 2c-3 chances after one (OR=2.9, 95% CI 1.6 to 5.5) or two (OR=2.7, 95% CI 1.0 to 7.4) failed CA passes, while switching to SR was not significantly associated with reperfusion. Following one or two failed CT passes, switching to SR was not associated with different reperfusion rates, but changing to CA after two failed CT passes was associated with lower chances of eTICI 2c-3 (OR=0.3, 95% CI 0.1 to 0.9). Rates of functional independence were similar.

CONCLUSIONS

Early changes in EVT strategies were associated with higher reperfusion and should be contemplated following failed attempts with stand-alone CA or SR.

Efficacy and safety of mechanical thrombectomy in acute ischaemic stroke secondary to infective endocarditis

OBJECTIVES

Acute ischaemic strokes (stroke) are frequent and severe extracardiac complications in infective endocarditis (IE). Because intravenous thrombolysis (i.v.-thrombolysis) is contraindicated, mechanical thrombectomy (thrombectomy) offers potential benefits. We aimed to compare thrombectomy efficacy and safety between IE-related and general stroke cases.

METHODS

Multicentre study of consecutive IE cases treated with thrombectomy at nine stroke centres in Spain from 2011 to 2022. Using propensity score matching, 50 IE cases were 1:4 matched with patients without IE stroke (n = 200). Efficacy was defined by successful recanalization rates (modified treatment in cerebral ischaemia scale ≥2 b), neurological improvement at 24 hours (decrease of National Institutes of Health Stroke Scale compared with baseline), and good neurological outcome rates at 3 months (modified Rankin scale ≤2). Safety was assessed by intracranial haemorrhage (IC-haemorrhage), symptomatic IC-haemorrhage, crude mortality, and stroke-related mortality.

RESULTS

Among 54 IE cases, 50 were matched with 200 controls. Successful recanalization was similarly achieved in both groups (76% vs. 83%). Median National Institutes of Health Stroke Scale at 24 hours was comparable, with analogous rates of neurological improvement (78% vs. 78%), and early dramatic response (48% vs. 46.5%). No differences were seen regarding IC-haemorrhage rates, except for when prior i.v.-thrombolysis was given. Although crude mortality was higher in the IE cohort, no differences were seen in stroke-related mortality (12% vs. 15%). At 3 months, modified Rankin scale scores of the two groups were superimposable.

DISCUSSION

Thrombectomy in IE is as effective and safe as in patients without IE, and prior i.v.-thrombolysis could decrease the procedural safety. Clinical practice guidelines may consider including the recommendation to perform thrombectomy alone in IE-related stroke.

Three-dimensional rotational angiography improves mechanical thrombectomy recanalization rate for acute ischaemic stroke due to middle cerebral artery M2 segment occlusions

BACKGROUND

Occlusions of the middle cerebral artery (MCA) M2 segments can be difficult to address with mechanical thrombectomy (MTB) using standard projections and this can affect the final recanalization. Three-dimensional rotational angiography (3D-RA) allows to obtain a 3D model of cerebral vessels in a few seconds and to determine the best two-dimensional (2D) projections to be selected to evaluate and treat cerebrovascular diseases, such as aneurysms or vascular malformations. We aimed to determine if 3D-RA could be applied also in MTB.

METHODS

A retrospective review of two patient cohorts treated during two time periods of 12 months before and after the introduction of 3D-RA use at our institution for MTB in M2 occlusions. Analyses were conducted to compare the two groups for procedural characteristics, such as timing, recanalization rate and complications and clinical outcome.

RESULTS

One hundred acute ischaemic stroke (AIS) patients (3D-RA group = 57; controls = 43) underwent MTB for an M2 occlusion during the two study periods. Recanalization rates were significantly higher in cases treated with 3D-RA. The mean 3D technique thrombectomy time was compared to that of non-3D cases (47 vs. 49 min, respectively).

CONCLUSIONS

Our findings showed that 3D-RA is a useful tool to select specific working projections to AIS patients presenting an M2 occlusion by improving final recanalization compared to standard projections, without increasing the overall procedural time.

Comparison of combined intravenous and intra-arterial thrombolysis with intravenous thrombolysis alone in stroke patients undergoing mechanical thrombectomy: a propensity-matched analysis

BACKGROUND

A combination of intravenous (IVT) or intra-arterial (IAT) thrombolysis with mechanical thrombectomy (MT) for acute ischemic stroke due to large vessel occlusion (AIS-LVO) has been investigated. However, there is limited data on patients who receive both IVT and IAT compared with IVT alone before MT.

METHODS

STAR data from 2013 to 2023 was utilized. We performed propensity score matching between the two groups. The primary outcomes were symptomatic intracranial hemorrhage (sICH) and 90-day modified Rankin Scale (mRS) score 0-2. Secondary outcomes included successful recanalization (modified treatment in cerebral infarction (mTICI) ≥2B, ≥2C), early neurological improvement, any intracranial hemorrhage (ICH), and 90-day mortality.

RESULTS

A total of 2454 AIS-LVO patients were included. Propensity matching yielded 190 well-matched patients in each group. No significant differences were observed between the groups in either ICH or sICH (odds ratio (OR): 0.80, 95% confidence interval (CI) 0.51-1.24, P=0.37; OR: 0.60, 95% CI 0.29 to 1.24, P=0.21, respectively). Rates of successful recanalization and early neurological improvement (ENI) were significantly lower in MT+IVT + IAT. mRS 0-1 and mortality were not significantly different between the two groups. However, the MT+IVT + IAT group demonstrated superior rates of good functional outcomes (90-day mRS 0-1) compared with patients in the MT+IVT group who had mTICI ≤2B, (OR: 2.18, 95% CI 1.05 to 3.99, P=0.04).

CONCLUSION

The combined use of IAT and IVT thrombolysis in AIS-LVO patients undergoing MT is safe. Although the MT+IVT+ IAT group demonstrated lower rates of recanalization and early neurological improvement, long-term functional outcomes were favorable in this group suggesting a potential delayed benefit of IAT.

Safety and efficacy of adjunctive intra-arterial antithrombotic therapy during endovascular thrombectomy for acute ischemic stroke: a systematic review and meta-analysis

BACKGROUND

Half of patients who achieve successful recanalization following endovascular thrombectomy (EVT) for acute ischemic stroke experience poor functional outcome. We aim to investigate whether the use of adjunctive intra-arterial antithrombotic therapy (AAT) during EVT is safe and efficacious compared with standard therapy (ST) of EVT with or without prior intravenous thrombolysis.

METHODS

Electronic databases were searched (PubMed/MEDLINE, Embase, Cochrane Library) from 2010 until October 2023. Data were pooled using a random-effects model and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk of bias was assessed using ROBINS-I and ROB-2. The primary outcome was functional independence (modified Rankin Scale (mRS) 0-2) at 3 months. Secondary outcomes were successful recanalization (modified Thrombolysis In Cerebral Infarction (TICI) 2b-3), symptomatic intracranial hemorrhage (sICH), and 90-day mortality.

RESULTS

41 randomized and non-randomized studies met the eligibility criteria. Overall, 15 316 patients were included; 3296 patients were treated with AAT during EVT and 12 020 were treated with ST alone. Compared with ST, patients treated with AAT demonstrated higher odds of functional independence (46.5% AAT vs 42.6% ST; OR 1.22, 95% CI 1.07 to 1.40, P=0.004, I2=48%) and a lower likelihood of 90-day mortality (OR 0.71, 95% CI 0.61 to 0.83, P<0.0001, I2=20%). The rates of sICH (OR 1.00, 95% CI 0.82 to 1.22,P=0.97, I2=13%) and successful recanalization (OR 1.09, 95% CI 0.84 to 1.42, P=0.52, I2=76%) were not significantly different.

CONCLUSION

The use of AAT during EVT may improve functional outcomes and reduce mortality rates compared with ST alone, without an increased risk of sICH. These findings should be interpreted with caution pending the results from ongoing phase III trials to establish the efficacy and safety of AAT during EVT.

Impact of atherosclerotic etiology on technical and clinical outcomes of mechanical thrombectomy with a stent retriever: subanalysis of the Japan Trevo Registry

BACKGROUND

The safety and effectiveness of stent retriever use for patients with acute large vessel occlusion (LVO) due to intracranial atherosclerotic disease (ICAD) is not well established. We investigated the differences in clinical outcomes in patients with and without ICAD.

METHODS

We analyzed the Japan Trevo Registry, a nationwide registry which enrolled patients with acute LVO who underwent endovascular therapy (EVT) using the Trevo retriever alone or in combination with an aspiration catheter. We compared the technical and clinical outcomes of EVT between the ICAD and No-ICAD groups. The primary outcome was effective reperfusion and the secondary outcome was modified Rankin scale (mRS) score 0-2 at 90 days. Safety outcomes were worsening of neurologic symptoms within 24 hours, any intracranial hemorrhage within 24 hours, vessel dissection/vessel perforation related to using the Trevo retriever and mortality at 90 days.

RESULTS

A total of 835 patients (45 in the ICAD group and 790 in the No-ICAD group) were analyzed. In the ICAD group, more men (68.9% vs 50.8%, P=0.02) and a lower median National Institutes of Health Stroke Scale score at admission (11 vs 18, P<0.0001) were observed. The primary outcome was significantly more common in the No-ICAD group (92.5%) than in the ICAD group (80.0%) (adjusted odds ratio (aOR) 0.21, 95% CI 0.09 to 0.50). The proportion of patients with mRS score 0-2 at 90 days was significantly lower in the ICAD group (44.4% vs 42.4%, aOR 0.49, 95% CI 0.23 to 1.00, P=0.0496). Other secondary and safety outcomes were not significantly different between the two groups.

CONCLUSIONS

Patients with LVO with ICAD had a lower rate of effective reperfusion than those with No-ICAD.

Association of the Systemic Inflammation Response Index with Functional Outcome in Acute Large Vessel Occlusion Stroke Patients Receiving Mechanical Thrombectomy

Purpose

The systemic inflammation response index (SIRI) has recently emerged as a novel inflammatory and prognostic marker across various diseases. However, there is limited research examining the relationship between SIRI and 90-day functional outcome in patients with acute large vessel occlusion stroke (ALVOS) undergoing mechanical thrombectomy (MT). This study aimed to investigate the potential of SIRI as an innovative, inflammation-based predictor of 90-day functional outcome.

Methods

This retrospective cohort study consecutively recruited 604 Chinese patients with diagnosed ALVOS who underwent MT at the First College of Clinical Medical Science of China Three Gorges University between July 2017 and April 2023. Comprehensive data, including baseline demographic and clinical characteristics, were systematically extracted from electronic medical records. Poor functional outcome at 90 days was defined as modified Rankin Scale (mRS) score ≥3. We employed logistic regression models, curve fitting, sensitivity analyses, subgroup analyses, and receiver operating characteristic (ROC) curves to validate the association between SIRI and poor outcome, as well as to assess the predictive efficacy.

Results

Final analysis included 604 ALVOS subjects of whom 54.3% experienced poor functional outcome at 90 days. In the multivariate analysis, after adjusting for potential confounders, SIRI remained significantly associated with an elevated risk of poor outcomes (OR 1.18, 95% CI 1.08-1.28, P < 0.001). Nonlinear curve fitting revealed a reverse J-shaped association between SIRI and poor outcomes, with inflection points at 4.5. Subgroup analyses showed no significant interactions (all P for interaction > 0.05), However, atrial fibrillation demonstrated a significant interaction (all P for interaction = 0.001).

Conclusion

SIRI shows promise as a novel prognostic marker for 90-day functional outcome in patients with ALVOS undergoing MT. The identified nonlinear relationship and inflection point may provide valuable insights for risk stratification and clinical decision-making in this specific patient population.

Establishment of typical values in cerebral thrombectomy according to the stroke anatomical region and procedure clinical outcome

The aim of the study is to establish local diagnostic reference levels (DRLs) in cerebral thrombectomy, according to the anatomical region of ischemic stroke. This is a retrospective study from a single center involving 255 examinations. The proposed median values (P50) for thrombectomy are: 123 Gy.cm2 for air kerma-area product (PKA) and 915 mGy for air kerma (Ka,r). For middle cerebral artery (MCA) thrombectomies, the proposed DRLs are 118 Gy.cm2 for PKA and 112 Gy.cm2 for internal carotid artery (ICA). The Ka,r values for MCA and ICA are 849 and 775 mGy, respectively. It was observed that 94.9% of patients presented grade 0 on the initial modified treatment in cerebral infarction (mTICI) scale, and after thrombectomy, 63.1% of patients reached a final mTICI grade of 3. Stents were implanted in 37 patients (14.5% of cases). It was concluded that 16.1% of patients exceeded one trigger value of the Safety in Radiological Procedures' recommended parameters. Establishing DRLs is an important tool for optimizing practices and is considered a standard for quality control.

Association of Narrow Anterior Communicating Artery or Contralateral A1 Segment with Poor Outcomes After Mechanical Thrombectomy

Background and Objectives: Contralateral A1 and AComA aplasia/hypoplasia are critically important in distal ICA T occlusion as the protective collateral blood supply from the circle of Willis via the anterior communicating artery is compromised. Although the terms aplasia/hypoplasia are used broadly in the literature, the need for concrete measurements and data on their clinical significance is apparent. Features of the individual anatomy of the circle of Willis may determine patient outcomes. We aim to determine the cut-off values of contralateral A1 and AComA segments that determine worse outcomes for patients with acute ischemic stroke with T occlusion of the terminal internal carotid artery. Material and Methods: Retrospective patient data from 2015 to 2020 and prospective data from 2021 to 2022 of 482 patients with diagnosed acute ischemic stroke that underwent mechanical thrombectomy at the Republican Vilnius University Hospital (Vilnius, Lithuania) were obtained. Of these patients, 70 were selected with occlusion of internal carotid artery bifurcation and extension to M1 or A1 segments. For statistically significant interactions, patient data were analyzed using two statistical methods (logistic regression and Multivariate Adaptive Regression Splines (MARS)). Results: The narrowest segment of contralateral A1 and/or AComA was statistically significant for 7-day NIHSS, and the optimal cut-off points for this variable were 1.1 mm (MARS model) and 1.2 mm (logistic regression, p = 0.0079, sensitivity 66.7%, specificity 67.9%). The other considered variables (age, gender, time from last seen well to groin puncture, intravenous recombinant tissue plasminogen activator, admission NIHSS, and ASPECT score) and their interactions were not statistically significant. Conclusions: A negative correlation was found between the narrowest segment and seven days of NIHSS. A larger diameter of contralateral A1 and AComA appears to be essential for better patient outcomes at 7-day evaluation post mechanical thrombectomy.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

External validation of clinical risk prediction score for elderly treated with endovascular thrombectomy

BACKGROUND AND AIM

The thrombectomy in the elderly prediction score (TERPS) for functional outcome after anterior circulation endovascular therapy (EVT) in patients ≥ 80 years was recently developed. The aim of this study was to assess predictors of functional outcome in the elderly and validate the prediction model.

METHODS

Consecutive patients treated with EVT from the Oslo Acute Reperfusion Stroke Study were evaluated for inclusion. Clinical and radiological parameters were used to calculate the TERPS, and functional outcome were assessed at 3-month follow-up.

RESULTS

Out of 1028 patients who underwent EVT for acute ischemic stroke from January 2017 to July 2022, 218 (21.2%) patients ≥ 80 years with anterior ischemic stroke were included. Fair outcome, defined as modified Rankin scale ≤ 3 (mRS), was achieved in 117 (53.7%). In bivariate analyses, male sex (p 0.035), age (p 0.025), baseline National Institute of Health Stroke Scale (NIHSS, p < 0.001), pre-stroke mRS (p 0.002) and Alberta Stroke Program Early Computed Tomography score (ASPECTS, p 0.001) were associated with fair outcome. Significant predictors for fair outcome in regression analyses were lower pre-stroke mRS, adjusted odd ratio, (aOR) 0.67 (95% CI 0.50-0.91, p 0.01), NIHSS, aOR 0.92 (95% CI 0.87-0.97, p 0.002), and higher ASPECTS, aOR 1.22 (95% CI 1.03-1.44, p 0.023). The area under the curve (AUC) using TERPS was 0.74 (95% CI 0.67-0.80).

CONCLUSIONS

The risk prediction score TERPS showed moderate performance in this external validation. Other variables may still be included to improve the model and validation using other cohorts is recommended.

TRIAL REGISTRATION

NCT06220981.

Assessment of associations between neutrophil extracellular trap biomarkers in blood and thrombi in acute ischemic stroke patients

Inflammation including immunothrombosis by neutrophil extracellular traps (NETs) has important implications in acute ischemic stroke and can affect reperfusion status, susceptibility to stroke associated infections (SAI) as well as functional clinical outcome. NETs were shown to be prevalent in stroke thrombi and NET associated markers were found in stroke patients' blood. However, little is known whether blood derived NET markers reflect the amount of NETs in thrombi. Conclusions from blood derived markers to thrombus composition might open avenues for novel strategies in diagnostic and therapeutic approaches. We prospectively recruited 166 patients with acute ischemic stroke undergoing mechanical thrombectomy between March 2018 and May 2021. Available thrombi (n = 106) were stained for NET markers DNA-histone-1 complexes and myeloperoxidase (MPO). Cell free DNA (cfDNA), deoxyribonuclease (DNase) activity, MPO-histone complexes and a cytokine-panel were measured before thrombectomy and after seven days. Clinical data, including stroke etiology, reperfusion status, SAI and functional outcome after rehabilitation, were collected of all patients. NET markers were present in all thrombi. At onset the median concentration of cfDNA in blood was 0.19 µg/ml increasing to 0.30 µg/ml at 7 days. Median DNase activity at onset was 4.33 pmol/min/ml increasing to 4.96 pmol/min/ml at 7 days. Within thrombi DNA-histone-1 complexes and MPO correlated with each other (ρ = 0.792; p < 0.001). Moreover, our study provides evidence for an association between the amount of NETs and endogenous DNase activity in blood with amounts of NETs in cerebral thrombi. However, these associations need to be confirmed in larger cohorts, to investigate the potential clinical implications for individualized therapeutic and diagnostic approaches in acute ischemic stroke.

External Validation of a Model for Persistent Perfusion Deficit in Patients With Incomplete Reperfusion After Thrombectomy: EXTEND-PROCEED

BACKGROUND AND OBJECTIVES

We recently developed a model (PROCEED) that predicts the occurrence of persistent perfusion deficit (PPD) at 24 hours in patients with incomplete angiographic reperfusion after thrombectomy. This study aims to externally validate the PROCEED model using prospectively acquired multicenter data.

METHODS

Individual patient data for external validation were obtained from the Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection, Tenecteplase versus Alteplase Before Endovascular Therapy for Ischemic Stroke part 1 and 2 trials, and a prospective cohort of the Medical University of Graz. The model's primary outcome was the occurrence of PPD, defined as a focal, wedge-shaped perfusion delay on 24-hour follow-up perfusion imaging that corresponds to the capillary phase deficit on last angiographic series in patients with

RESULTS

We included 371 patients (38% with PPD). The externally validated model had good discrimination (C-statistic 0.81, 95% CI 0.77-0.86) and adequate calibration (intercept 0.25, 95% CI 0.21-0.29 and slope 0.98, 95% CI 0.90-1.12). Across a wide range of probability thresholds (i.e., depending on the physicians' preferences on how the model should be used), the model shows net benefit on clinical decision curves, informing physicians on the likelihood of PPD. If a physician's attitude toward false-positive and false-negative ratings is equal, the model would reduce 13 in 100 unnecessary interventions by correctly predicting complete delayed reperfusion, without missing a patient with PPD.

DISCUSSION

The externally validated model had adequate predictive accuracy and discrimination. Depending on the acceptable threshold probability, the model accurately predicts persistent incomplete reperfusion and may advise physicians whether additional reperfusion attempts should be performed.

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MESH Headings

• Humans
• Thrombectomy/methods
• Male
• Female
• Aged
• Middle Aged
• Reperfusion/methods
• Ischemic Stroke/surgery
• Ischemic Stroke/diagnostic imaging
• Ischemic Stroke/therapy
• Perfusion Imaging
• Prospective Studies
• Cerebrovascular Circulation/physiology
• Aged, 80 and over

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Affiliation(s)

Adnan Mujanovic From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
Felix C Ng From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
Mattia Branca From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
Hannes A Deutschmann From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
Thomas R Meinel From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
Leonid Churilov From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
Oliver Nistl From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
Peter J Mitchell From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
Nawaf Yassi From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
Mark W Parsons From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
Gagan J Sharma From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
Thomas Gattringer From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
Marcel Arnold From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
Fabiano Cavalcante From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
Eike I Piechowiak From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
Timothy J Kleinig From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
David J Seiffge From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
Tomas Dobrocky From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
Jan Gralla From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
Urs Fischer From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
Markus Kneihsl From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
Bruce C V Campbell From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland
Johannes Kaesmacher From the Departments of Diagnostic and Interventional Neuroradiology (A.M., E.I.P., T.D., J.G., J.K.), Neurology (T.R.M., M.A., D.J.S., U.F.), University Hospital Bern, Inselspital, Graduate School for Health Sciences (A.M.), and CTU Bern (M.B.), University of Bern, Switzerland; Department of Medicine and Neurology, Melbourne Brain Centre (F.C.N., N.Y., G.J.S., B.C.V.C.), Melbourne Medical School (L.C.), and Department of Radiology (P.J.M.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (F.C.N.), Austin Health, Heidelberg, Australia; Division of Neuroradiology, Vascular and Interventional Radiology Department of Radiology (H.A.D., O.N., T.G., M.K.), and Department of Neurology (T.G., M.K.), Medical University of Graz, Austria; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Department of Neurology (M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia; Department of Radiology and Nuclear Medicine (F.C.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, the Netherlands; Department of Neurology (T.J.K.), Royal Adelaide Hospital, Australia; and Department of Neurology (U.F.), University Hospital Basel, University of Basel, Switzerland

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Stent Retriever Deployment Tracing Susceptibility Vessel Sign in the M2 Branch Predicts the Effective First-Pass Reperfusion in Thrombectomy for M1 Occlusion

BACKGROUND AND PURPOSE

Successful first-pass reperfusion is associated with better functional outcomes after mechanical thrombectomy (MT) for acute ischemic stroke, but its treatment strategies remain unclear.

MATERIALS AND METHODS

We retrospectively recruited patients who underwent MT for M1 occlusion between December 2020 and May 2023 at our institution. The locations of susceptibility vessel sign (SVS) on magnetic resonance imaging were classified into M1 only, M1 to single M2 branch, or M1 to both M2 branches. Patients were included in the SVS tracing group when the stent retriever of the first pass covered the entire SVS length. Successful reperfusion was defined as a modified Thrombolysis in Cerebral Infarction scale 2b-3. Any intracranial hemorrhage detected at 24-hour postoperatively was included as a hemorrhagic complication.

RESULTS

The SVS was detected in M1 only, M1 to single M2 branch, and M1 to both M2 branches in 8, 22, and 4 patients, respectively. Among the 34 patients, 27 were included in the SVS-tracing group. Successful first-pass reperfusion was significantly more frequent in the SVS-tracing group compared with the non-SVS tracing group (odds ratio, 14.4; 95% confidence interval, 2.0 - 101; P = 0.007). The procedural time was significantly reduced in the SVS tracing group (median, 29 [interquartile range, 22 - 49] minute vs. 63 [43 - 106] minute; P = 0.043). There was a trend toward less frequent hemorrhagic complications in the SVS tracing group (odds ratio, 0.17; 95% confidence interval, 0.029 - 1.0; P = 0.052).

CONCLUSIONS

This study provides a thrombus imaging-based MT strategy to efficiently achieve first-pass reperfusion in M1 occlusion.

Dynamic Perviousness Has Predictive Value for Clot Fibrin Content in Acute Ischemic Stroke

Dynamic perviousness is a novel imaging biomarker, with clot density measurements at multiple timepoints to allow longer contrast to thrombus interaction. We investigated the correlations between dynamic perviousness and clot composition in the setting of acute ischemic stroke. Thirty-nine patients with large vessel occlusion (LVO) undergoing mechanical thrombectomy (MT) were analyzed. Patients received a three-phase CT imaging pre-thrombectomy and histopathological analysis of retrieved clots. Clot densities for every phase and change in densities between phases were calculated, leading to four patterns of dynamic perviousness: no contrast uptake, early contrast uptake with and without washout and late uptake. Clots were categorized into three groups based on dominant histologic composition: red blood cell (RBC)-rich, fibrin/platelet-rich and mixed. Clot composition was correlated with dynamic perviousness using the Kruskal-Wallis test and Pearson's correlation analysis. The dynamic perviousness categories showed a significant difference between fibrin-rich clots when compared to RBC-rich plus mixed groups. The uptake without washout category had significantly fewer fibrin clots compared to the uptake with washout (p = 0.036), and nearly significantly fewer fibrin clots when compared to the no uptake category (p = 0.057). Contrast uptake with different patterns of contrast washout showed significant differences of the likelihood for fibrin-rich clots.

Renal function affects the safety and efficacy of tirofiban in acute ischemic stroke thrombectomy patients

BACKGROUND

Acute ischemic stroke poses a significant health threat, and thrombectomy has become a routine treatment. Tirofiban has emerged as a promising adjunct therapy to minimize reocclusion after thrombectomy. We aimed to investigate whether renal function influences the safety and efficacy of tirofiban in patients undergoing endovascular therapy.

METHODS

Patients' clinical data collected from the stroke unit were analyzed. The modified Rankin scale score and symptomatic intracranial hemorrhage (sICH) were used as outcome measures.

RESULTS

A total of 409 patients (mean age: 66.5 years, 292 males [71.4%]) were included. Tirofiban significantly improved 3-month functional outcomes (adjusted odds ratio [aOR] = 2.408, 95% confidence interval [CI] 1.120-5.175), reduced 3-month mortality (aOR = 0.364, 95% CI 0.155-0.856), and decreased the incidence of sICH (aOR = 0.339, 95% CI 0.149-0.767) in patients with estimated glomerular filtration rate (eGFR) ≥ 90 mL/min/1.73 m². However, no significant improvement in prognosis was observed with tirofiban in patients with eGFR < 90 mL/min/1.73 m². Interaction analysis suggested a potential influence of renal function on tirofiban efficacy.

CONCLUSION

Renal function may impact the efficacy of tirofiban. Administration of tirofiban in direct thrombectomy patients with normal renal function is safe and improves prognosis. However, the prognostic benefits of tirofiban are limited in patients with impaired renal function.

Initial clinical experience with a novel mechanical thrombectomy device-the ThrombX retriever

BACKGROUND AND PURPOSE

The ThrombX Retriever is a novel mechanical thrombectomy device that adjusts the distance between two mesh segments to axially hold thrombus. A post-market study assessed safety and performance in acute ischemic stroke patients with large artery occlusion.

METHODS

A single-arm prospective multi-center study enrolled patients at 5 European Centers. Patients had a symptomatic large-artery occlusion of the intracranial Internal Carotid or the Middle Cerebral Artery, M1 segment. The primary outcome measure was the modified treatment in cerebral infarction (mTICI) score, on the immediate post-procedure angiogram after up to three device passes. Key secondary outcome measures were the mTICI score after a single pass and functional independence, defined as an mRS score ≤ 2 at 90 days.

RESULTS

Thirty patients (16 Females, mean age 72 years), with NIHSS 4-25 (mean 15.5) were treated. Twenty-eight (93%) achieved mTICI 2b-3 within 3 passes, and 24 (80%) were with the first pass (FP). FP mTICI 2c-3 reperfusion was achieved in 19 (63%) cases. Seventeen of 24 (71%) patients treated with a balloon guide and the ThrombX Retriever had a FP mTICI 2c-3 reperfusion. After all interventions, mTICI 2b-3 was seen in 30 (100%) patients. Twenty-one of the 29 (73%) patients with 90-day follow-up were functionally independent (mRS≤2). No device-related serious adverse events were observed.

CONCLUSION

This preliminary study suggests the ThrombX Retriever is safe and has a high rate of substantial reperfusion. A larger prospective trial to assess the device effectiveness is planned.

Evolution pattern estimated by computed tomography perfusion post-thrombectomy predicts outcome in acute ischemic stroke

OBJECTIVES

Computed tomography perfusion (CTP) and computed tomography angiography (CTA) have been recommended to select acute ischemic stroke (AIS) patients for endovascular thrombectomy (EVT) but are not widely used for post-treatment evaluation. We aimed to observe abnormalities in CTP and CTA before and after EVT and evaluate post-EVT CTP and CTA as potential tools for improving clinical outcome prediction.

METHODS

Patients with AIS who underwent EVT and received CTP and CTA before and after EVT were retrospectively evaluated. The ischemic core was defined as the volume of relative cerebral blood flow <30% and hypoperfusion as the volume of Tmax >6 s. A reduction in hypoperfusion volume >90% between baseline and post-EVT CTP was defined as tissue optimal reperfusion (TOR). The 90-day modified Rankin scale was used to evaluate the clinical outcome.

RESULTS

Eighty-three patients were included. Patients with an absent ischemic core or with TOR after EVT had a higher rate of modified Thrombolysis in Cerebral Ischemia score 2c-3 and recanalization of post-treatment vessel condition based on follow-up CTA. Multivariable logistic regression revealed that the baseline ischemic core volume (OR:0.934, p=0.009), TOR (OR:8.322, p=0.029) and immediate NIHSS score after EVT (OR:0.761, p=0.012) were factors significantly associated with good clinical outcome. Combining baseline ischemic core volume and TOR with immediate NIHSS score after EVT showed greatest performance for good outcome prediction after EVT(AUC=0.921).

CONCLUSIONS

The addition of pretreatment and post-treatment CTP information to purely clinical NIHSS scores might help to improve the efficacy for good outcome prediction after EVT.

Extended treatment in cerebral ischemia score 2c or 3 as goal of successful endovascular treatment is associated with clinical benefit

BACKGROUND AND PURPOSE

Successful reperfusion, defined as a modified treatment in cerebral ischemia (mTICI) score 2b or 3, is an important goal for endovascular treatment (EVT) of stroke. Recently, an extension of the mTICI score with an additional grade 2c indicating near-complete reperfusion (expanded TICI, eTICI) and a revised definition of success as eTICI 2c or 3 were proposed. We evaluate whether eTICI 2c translates into improved clinical outcome compared to eTICI 2b.

MATERIAL AND METHODS

Consecutive patients with large vessel occlusion in the anterior circulation who underwent EVT between December 2013 and December 2020 were included. Clinical outcome measures were favorable functional outcome at 90 days (modified Rankin Scale [mRS] scores 0 to 2 or return to pre-stroke mRS) and early neurological improvement (National Institutes of Health Stroke Scale [NIHSS] improvement ≥4 points or a score of 0-1 at 24 h).

RESULTS

Of 1282 included patients (median age 76, median NIHSS 16), reperfusion was classified as eTICI 2b in 410 (32%), eTICI 2c in 242 (19%) and eTICI 3 in 464 (36%). eTICI 2c differed significally from 2b with respect to early neurological improvement (aOR = 1.49, 95% CI = 1.01-2.19). No statistically significant difference in favorable functional outcome at 90 days was found (eTICI 2c vs 2b, aOR = 1.31, 95% CI = 0.88-2.00).

CONCLUSION

Our study indicates early clinical benefit at 24 h of achieving eTICI 2c compared to eTICI 2b, but no significant difference was seen in favorable functional outcome at 90 days. Our results support eTICI 2c and 3 as the goal of a successful thrombectomy but do not exclude eTICI 2b as an acceptable result.

Impact of Early Mobilization on Patients With Acute Ischemic Stroke Treated With Thrombolysis or Thrombectomy: A Randomized Controlled Trial

BACKGROUND

Early mobilization (EM) within 24 to 72 hours post-stroke may improve patients' performance and ability. However, after intravenous thrombolysis (IVT) or mechanical thrombectomy (MT), the increased risk of hemorrhagic complications impacts the implementation of early out-of-bed mobilization. Few studies have investigated EM after IVT or MT for acute ischemic stroke (AIS), and its impact in these patients is unknown.

OBJECTIVE

To investigate the effect of EM on AIS treated with IVT or MT.|.

METHODS

We recruited 122 patients with first AIS; 60 patients were treated with IVT, and 62 patients were treated with MT. For each IVT and MT cohort, the control groups received standard early rehabilitation, and the intervention groups received an EM protocol. The training lasted 30 minutes/day, 5 days/week until discharge.

MAIN OUTCOMES MEASURES

The effectiveness of the interventions was evaluated using the motor domain of the Functional Independence Measure (FIM-motor) and the Postural Assessment Scale for Stroke Patients (PASS) at baseline, 2-week, 4-week, and 3-month post-stroke, the Functional Ambulation Category 2-week post-stroke, and the total length of stay at the stroke center.

RESULTS

Both IVT and MT treatment groups showed improved FIM-motor and PASS scores over time; however, only the IVT EM group had significantly improved FIM-motor performance within 1 month after stroke than the control group. Conclusion. An EM protocol with the same intervention time and session frequency per day as in the standard care protocol was effective in improving the functional ability of stroke patients after IVT.

The Management of Persistent Distal Occlusions after Mechanical Thrombectomy and Thrombolysis: An Inter- and Intrarater Agreement Study

BACKGROUND AND PURPOSE

The best management of patients with persistent distal occlusion after mechanical thrombectomy with or without IV thrombolysis remains unknown. We sought to evaluate the variability and agreement in decision-making for persistent distal occlusions.

MATERIALS AND METHODS

A portfolio of 60 cases was sent to clinicians with varying backgrounds and experience. Responders were asked whether they considered conservative management or rescue therapy (stent retriever, aspiration, or intra-arterial thrombolytics) a treatment option as well as their willingness to enroll patients in a randomized trial. Agreement was assessed using κ statistics.

RESULTS

The electronic survey was answered by 31 physicians (8 vascular neurologists and 23 interventional neuroradiologists). Decisions for rescue therapies were more frequent (n = 1116/1860, 60%) than for conservative management (n = 744/1860, 40%; P < .001). Interrater agreement regarding the final management decision was "slight" (κ = 0.12; 95% CI, 0.09-0.14) and did not improve when subgroups of clinicians were studied according to background, experience, and specialty or when cases were grouped according to the level of occlusion. On delayed re-questioning, 23 of 29 respondents (79.3%) disagreed with themselves on at least 20% of cases. Respondents were willing to offer trial participation in 1295 of 1860 (69.6%) cases.

CONCLUSIONS

Individuals did not agree regarding the best management of patients with persistent distal occlusion after mechanical thrombectomy and IV thrombolysis. There is sufficient uncertainty to justify a dedicated randomized trial.

Safety and efficacy of platelet glycoprotein VI inhibition in acute ischaemic stroke (ACTIMIS): a randomised, double-blind, placebo-controlled, phase 1b/2a trial

BACKGROUND

Antagonists of glycoprotein VI-triggered platelet activation used in combination with recanalisation therapies are a promising therapeutic approach in acute ischaemic stroke. Glenzocimab is an antibody fragment that inhibits the action of platelet glycoprotein VI. We aimed to determine and assess the safety and efficacy of the optimal dose of glenzocimab in patients with acute ischaemic stroke eligible to receive alteplase with or without mechanical thrombectomy.

METHODS

This randomised, double-blind, placebo-controlled study with dose-escalation (1b) and dose-confirmation (2a) phases (ACTIMIS) was done in 26 stroke centres in six European countries. Participants were adults (≥18 years) with disabling acute ischaemic stroke with a National Institutes of Health Stroke Scale score of 6 or higher before alteplase administration. Patients were randomly assigned treatment using a central electronic procedure. Total administered dose at the end of the intravenous administration was 125 mg, 250 mg, 500 mg, and 1000 mg of glenzocimab or placebo in phase 1b and 1000 mg of glenzocimab or placebo in phase 2a. Treatment was initiated 4·5 h or earlier from stroke symptom onset in patients treated with alteplase with or without mechanical thrombectomy. The sponsor, study investigator and study staff, patients, and central laboratories were all masked to study treatment until database lock. Primary endpoints across both phases were safety, mortality, and intracranial haemorrhage (symptomatic, total, and fatal), assessed in all patients who received at least a partial dose of study medication (safety set). The trial is registered on ClinicalTrials.gov, NCT03803007, and is complete.

FINDINGS

Between March 6, 2019, and June 27, 2021, 60 recruited patients were randomly assigned to 125 mg, 250 mg, 500 mg, or 1000 mg glenzocimab, or to placebo in phase 1b (n=12 per group) and were included in the safety analysis. Glenzocimab 1000 mg was well tolerated and selected as the phase 2a recommended dose; from Oct 2, 2020, to June 27, 2021, 106 patients were randomly assigned to glenzocimab 1000 mg (n=53) or placebo (n=53). One patient in the placebo group received glenzocimab in error and therefore 54 and 52, respectively, were included in the safety set. In phase 2a, the most frequent treatment-emergent adverse event was non-symptomatic haemorrhagic transformation, which occurred in 17 (31%) of 54 patients treated with glenzocimab and 26 (50%) of 52 patients treated with placebo. Symptomatic intracranial haemorrhage occurred in no patients treated with glenzocimab compared with five (10%) patients in the placebo group. All-cause deaths were lower with glenzocimab 1000 mg (four [7%] patients) than with placebo (11 [21%] patients).

INTERPRETATION

Glenzocimab 1000 mg in addition to alteplase, with or without mechanical thrombectomy, was well tolerated, and might reduce serious adverse events, intracranial haemorrhage, and mortality. These findings support the need for future research into the potential therapeutic inhibition of glycoprotein VI with glenzocimab plus alteplase in patients with acute ischaemic stroke.

FUNDING

Acticor Biotech.

A nomogram predicting the relationship between recanalization time and successful endovascular recanalization of non-acute internal carotid artery occlusion in a Chinese population

Different recanalization times for endovascular interventions may affect the success of non-acute internal carotid artery occlusion procedures. Nomograms can provide personalized and more accurate risk estimates based on predictive values. Therefore, we developed a nomogram to predict the probability of success of endovascular recanalization procedures for non-acute internal carotid artery occlusion. We performed a single-center retrospective analysis of data collected from patients who underwent endovascular treatment for non-acute internal carotid artery occlusion between January 2015 and December 2022. Multifactorial logistic regression analyses were performed to identify independent predictors affecting the success rate of non-acute internal carotid artery occlusion procedures and to create nomograms. The model was differentiated and calibrated using the area under the ROC curve (AUC-ROC) and calibration plots. Internal validation of the model was performed by using resampling (1000 replications). In total, 46 patients were identified and a total of 39 patients met the study criteria. Predictors in the nomogram included vascular occlusion proximal morphology, reversed flow of the ophthalmic artery, and recanalization time. The model showed good resolution with an ROC area of 0.917 (95% CI: 0.814-0.967). The nomogram can be used to personalize, visualize, and accurately predict the surgical success of endovascular treatment of non-acute internal carotid artery occlusion.

Periodontitis in ischemic stroke: impact of Porphyromonas gingivalis on thrombus composition and ischemic stroke outcomes

Background

Periodontitis is associated with an increased risk of ischemic stroke, but the mechanisms underlying this association remain unclear.

Objectives

Our objective was to determine whether Porphyromonas gingivalis (Pg), a periodontal bacterium, could be detected within thrombus aspirates, modify thrombus composition, and endovascular therapy responses.

Methods

The presence of Pg gingipain in 175 consecutive thrombi from patients with large vessel occlusion stroke enrolled in the multicenter research cohort compoCLOT was investigated by immunostaining. Thrombus blood cell composition according to gingipain status was analyzed in a subset of 63 patients.

Results

Pg gingipain immunostaining was positive in 33.7% of thrombi (95% CI, 26.7%-40.8%). The percentage of near to complete reperfusion (modified Thrombolysis in Cerebral Infarction Score 2c/3) at the end of the procedure was lower in the Pgpos group than the Pgneg group (39.0% vs 57.8% respectively; adjusted odds ratio, 0.38; 95% CI, 0.19-0.77). At 3 months, 35.7% of patients in the Pgpos group had a favorable neurological outcome vs 49.5% in the Pgneg group (odds ratio, 0.65; 95% CI, 0.30-1.40). Quantitative analysis of a subset of 63 thrombi showed that neutrophil elastase content was significantly (P < .05) higher in Pgpos thrombi than in Pgneg thrombi.

Conclusion

Our results indicate that intrathrombus Pg gingipain is associated with increased neutrophil content and resistance to endovascular therapy.

Predictors of mTICI 2c/3 over 2b in patients successfully recanalized with mechanical thrombectomy

OBJECTIVE

For patients presenting with acute ischemic stroke (AIS) caused by large vessel occlusions (LVO), mechanical thrombectomy (MT) is the treatment standard of care in eligible patients. Modified Thrombolysis in Cerebral Infarction (mTICI) grades of 2b, 2c, and 3 are all considered successful reperfusion; however, recent studies have shown achieving mTICI 2c/3 leads to better outcomes than mTICI 2b. This study aims to investigate whether any baseline preprocedural or periprocedural parameters are predictive of achieving mTICI 2c/3 in successfully recanalized LVO patients.

METHODS

We conducted a retrospective multicenter cohort study of consecutive patients presenting with AIS caused by a LVO from 1 January 2017 to 1 January 2023. Baseline and procedural data were collected through chart review. Univariate and multivariate analysis were applied to determine significant predictors of mTICI 2c/3.

RESULTS

A total of 216 patients were included in the study, with 159 (73.6%) achieving mTICI 2c/3 recanalization and 57 (26.4%) achieving mTICI 2b recanalization. We found that a higher groin puncture to first pass time (OR = 0.976, 95%CI: 0.960-0.992, p = 0.004), a higher first pass to recanalization time (OR = 0.985, 95%CI: 0.972-0.998, p = 0.029), a higher admission NIHSS (OR = 0.949, 95%CI: 0.904-0.995, p = 0.031), and a lower age (OR = 1.032, 95%CI: 1.01-1.055, p = 0.005) were associated with a decreased probability of achieving mTICI 2c/3.

INTERPRETATION

A lower groin puncture to first pass time, a lower first pass to recanalization time, a lower admission NIHSS, and a higher age were independent predictors of mTICI 2c/3 recanalization.

Association of Ferroptosis with Severity and Outcomes in Acute Ischemic Stroke Patients Undergoing Endovascular Thrombectomy: A Case-control Study

Ferroptosis, an iron-dependent form of cell death, is characterized by intracellular accumulation of iron and reactive oxygen species-induced lipid peroxidation. Animal experiments have shown the important roles of ferroptosis in ischemic stroke, but the evidence in human stroke is insufficient. This prospective study evaluated the associations between plasma ferroptosis biomarkers at hyperacute stage and long-term outcomes in patients with acute ischemic stroke undergoing endovascular thrombectomy (EVT). The plasma samples were collected immediately before and after EVT (T1 and T2) and at 24 h (T3) for the 126 stroke patients and once for the 50 stroke-free control subjects. Compared with controls, stroke patients had higher 4-hydroxynonenal (4-HNE) levels at T1 and T2 while lower homocysteine and soluble transferrin receptor (sTfR) levels at T3. In stroke patients, higher National Institutes of Health Stroke Scale scores at admission were correlated with higher 4-HNE and lower sTfR levels. Lower Alberta Stroke Program Early CT (ASPECT) scores and larger infarct core volumes on CT perfusion before EVT were correlated with higher 4-HNE and homocysteine levels. After adjusting for significant parameters, homocysteine levels at T2 were significantly associated with poor functional outcome and mortality at 3 months. In the receiver operating characteristic (ROC) models, adding homocysteine levels at T2 and hemoglobin levels to the reference model for predicting poor functional outcome significantly increased the area under the ROC curve. In summary, this study provides evidence that ferroptosis is associated with stroke severity and outcomes in patients with acute ischemic stroke undergoing EVT.

Temporal trends in results of endovascular treatment of anterior intracranial large cerebral vessel occlusion: A 7-year study

BACKGROUND

Technical improvements in devices, changes in angiographic grading scales and various confounding factors have made difficult the detection of the temporal evolution of angiographic and clinical results after endovascular treatment (EVT) for acute ischemic Stroke (AIS). We analyzed this evolution in time using the Endovascular Treatment in Ischemic Stroke (ETIS) registry.

MATERIALS AND METHODS

We analyzed the efficacy outcomes of EVT performed from January 2015 to January 2022, and modelized the temporal trends using mixed logistic regression models, further adjusted for age, intravenous thrombolysis prior to EVT, general anesthesia, occlusion site, balloon catheter use and the type of first-line EVT strategy. We assessed heterogeneity in temporal trends according to occlusion site, balloon catheter use, cardio embolic etiology, age (<80 years vs ⩾80 years) and first-line EVT strategy.

RESULTS

Among 6104 patients treated from 2015 to 2021, the rates of successful reperfusion (71.1%-89.6%) and of complete first pass effect (FPE) (4.6%-28.9%) increase, whereas the rates of patients with >3 EVT device passes (43.1%-17.5%) and favorable outcome (35.8%-28.9%) decrease significantly over time. A significant heterogeneity in temporal trends in successful reperfusion according to the first-line EVT strategy was found (p-het = 0.018). The temporal trend of increasing successful reperfusion rate was only significant in patients treated with contact aspiration in first-line (adjusted overall effect p = 0.010).

CONCLUSION

In this 7-year-old large registry of ischemic stroke cases treated with EVT, we observed a significant increase with time in the rate of recanalization whereas there was a tendency toward a decrease in the rate of favorable outcome over the same period.

The effect of butylphthalide on improving the neurological function of patients with acute anterior circulation cerebral infarction after mechanical thrombectomy

Butylphthalide can improve blood circulation in patients with acute cerebral infarction. Complement 3a receptor 1 (C3aR1) is involved in the regulation of innate immune response and pathogen monitoring, which is closely related to the pathophysiological processes of breast cancer, neurogenesis and lipid catabolism. Our study explored the therapeutic effect of butylphthalide on improving the neurological function of patients with acute anterior circulation cerebral infarction after mechanical thrombectomy, and evaluated the correlation between serum C3aR1 and butylphthalide on improving the neurological function after mechanical thrombectomy. 288 patients with acute anterior circulation cerebral infarction who were admitted to our hospital from January 2019 to November 2022 and were treated with mechanical thrombectomy for the first time were included in this retrospective study and divided into the butylphthalide group and control group that they received treatment methods. The National Institutes of Health Stroke Scale (NIHSS) scale was used to evaluate the patient neurological function treatment efficacy, and the modified Rankin Scale (mRS) scale was used to measure the patient neurological function status 3 months after surgery. Enzyme-linked immunosorbent assay method was used to determine the content of C3aR1 in serum. Two weeks after thrombus removal, the NIHSS efficacy of the butylphthalide group and the control group were 94.44% and 72.22%, respectively. The butylphthalide group was significantly higher than the control group (P < .001). Three months after the operation, the mRS score of the butylphthalide group was significantly lower than that of the control group (P = .001), and the excellent and good rate was significantly higher than that of the control group (P < .001). The serum C3aR1 level of the butylphthalide group was significantly lower than that of the control group 2 weeks after operation and 3 months after operation (P < .001). The serum C3aR1 was positively correlated with the efficacy of NIHSS (R = 0.815, P = .004), which was positively correlated with mRS score (R = 0.774, P = .007). Butylphthalide can improve the therapeutic effect of neurological function in patients with acute anterior circulation cerebral infarction after mechanical thrombus removal. The patient serum C3aR1 is related to the patient neurotherapy efficacy and neurological function status, and its level can reflect the patient neurological function recovery to a certain extent.

Contact aspiration and stent retriever versus stent retriever alone following mechanical thrombectomy for patients of acute ischemic stroke: A recanalization success analysis

OBJECTIVE

Second-generation catheters used in mechanical thrombectomy have different advantages and disadvantages. The objective of this study was to evaluate the effectiveness and safety of the combination of contact aspiration and stent retriever technique on the rate of reperfusion after mechanical thrombectomy for large vessel occlusion.

METHODS

Patients who underwent contact aspiration alone (CAA cohort, n = 150), stent retriever alone (SRA cohort, n = 129), or combined contact aspiration and stent retriever (CSR cohort, n = 122) techniques following mechanical thrombectomy were included in the analysis. A balloon guide catheter was used for all thrombectomies. Digital subtraction angiography was used to identify thrombolysis in cerebral infarction.

RESULTS

The number of patients with thrombolysis in cerebral infarction score of ≥ 2c (near complete or complete antegrade reperfusion) was significantly higher in the CSR cohort than those in the CAA cohort (101 [83%] vs. 90 [60%], p < 0.0001) and those of SRA cohort (101 [83%] vs. 77 [59%], p = 0.0001). Arterial perforation was higher in patients in the CSR cohort than in those in the CAA (p < 0.0001) and SRA (p = 0.015) cohorts. Intracerebral hemorrhage was lower in patients in the CSR cohort than in those in the CAA (p = 0.0001) and SRA (p = 0.0353) cohorts. All-cause mortality at 1 year was fewer in the CSR cohort than in the CAA cohort (p = 0.018).

CONCLUSIONS

The combination of thrombo aspiration by large bore aspiration catheter and stent retriever is the most effective technique but has some related risks.

LEVEL OF EVIDENCE

IV.

TECHNICAL EFFICACY STAGE

1.

Clinical Significance and Influencing Factors of Microvascular Tissue Reperfusion After Macrovascular Recanalization

The relevance of impaired microvascular tissue reperfusion despite successful macrovascular angiographic reperfusion (no-reflow) in acute ischemic stroke (AIS) remains controversial. In this study, we aimed to investigate the impact of tissue optimal reperfusion (TOR) and its influencing factors. From December 1, 2020 to December 1, 2021, AIS patients with successful recanalization (modified Thrombolysis in Cerebral Infarction score [mTICI] ≥ 2b) after mechanical thrombectomy (MT) were retrospectively reviewed. Computed tomography perfusion was performed before and after MT. Successful reperfusion was assessed by TOR, defined as > 90% reduction of the Tmax > 6 s lesion volumes between baseline and early follow-up perfusion profiles. The impact of TOR on functional outcomes after successful recanalization and influencing factors for TOR were both investigated. Sixty-three patients were included, including 44 cases in the TOR group and 19 cases in the non-TOR group. The TOR group had a higher rate of favorable outcome (aOR 4.366, 95%CI 1.159-16.445, p = 0.030) and NIHSS improvement (aOR 5.089, 95%CI 1.340-19.322, p = 0.017) than the non-TOR group. Multivariable logistic regression showed baseline glucose (OR 0.648, 95%CI 0.492-0.854, p = 0.002) and mTICI 2c/3 (OR 10.984, 95%CI 2.220-54.343, p = 0.003) predicted TOR in model 1; in model 2, postoperative glucose (OR 0.468, 95%CI 0.278-0.787, p = 0.004) and mTICI 2c/3 (OR 9.436, 95%CI 1.889-47.144, p = 0.006) were predictive. TOR was strongly associated with good functional outcomes after successful recanalization of MT. Higher mTICI grade and lower perioperative glucose level may predict microvascular tissue reperfusion.

Factors influencing the prognosis of acute basilar artery occlusion patients treated endovascularly: the impact of treatment time window and preoperative symptoms

Objective

The aim of this study was to examine the factors influencing the prognosis of patients diagnosed with acute basilar artery occlusion (BAO) who receive endovascular treatment. Our particular emphasis was on the predictive implications of the time window for treatment (from symptom onset to femoral artery puncture) and preoperative symptoms for prognosis.

Methods

A retrospective analysis of data collected from 51 BAO patients who received endovascular treatment at the Neurosurgery Department of Jinhua Central Hospital from April 2018 to October 2021 was undertaken. The data included immediate post-interventional recanalization rates and the 90-day clinical prognoses of the patients. We used the Modified Rankin Scale (mRs) to categorize patients into two prognosis groups: a favorable prognosis group (mRs score ≤2) and an unfavorable prognosis group (mRs score >2). Preoperative symptoms were gauged using the Glasgow Coma Scale (GCS) and National Institutes of Health Stroke Scale (NIHSS) scores. A logistic regression analysis was conducted to identify risk factors affecting the prognosis of BAO patients following endovascular treatment.

Results

The procedure resulted in complete recanalization in all patients (100%). However, four patients (7.8%) passed away during the postoperative hospitalization period. The remaining 47 patients were followed up for 3 months. It was found that 15 patients (31.91%) had a favorable prognosis, while 32 (68.09%) had an unfavorable prognosis. It was generally observed that patients with an unfavorable prognosis had notably higher preoperative GCS and NIHSS scores (p < 0.05). Logistic regression analysis revealed that preoperative symptom severity, as indicated by NIHSS score, and treatment time window were significant prognostic risk factors for patients undergoing endovascular treatment for BAO (p < 0.05).

Conclusion

Endovascular intervention for BAO appears to be safe and effective, with greater likelihood of a favorable prognosis in patients treated within ≤6 h. The chances of favorable prognosis could potentially be linked to the severity of the patient's preoperative symptoms.

Subcortical infarcts on admission CTP predict poor outcome despite excellent reperfusion in delayed time windows

PURPOSE

The effect of pretreatment infarct location on clinical outcome after successful mechanical thrombectomy is not understood. Our aim was to evaluate the association between computed tomography perfusion (CTP)-based ischemic core location and clinical outcome following excellent reperfusion in late time windows.

METHODS

We retrospectively reviewed patients who underwent thrombectomy for acute anterior circulation large vessel occlusion in late time windows from October 2019 to June 2021 and enrolled 65 patients with visible ischemic core on admission CTP who had received excellent reperfusion (modified thrombolysis in cerebral infarction grade 2c/3). Poor outcome was defined as a modified Rankin scale score of 3-6 at 90 days. The ischemic core infarct territories were classified into the cortical and subcortical areas. Multivariate logistic regression and receiver operating characteristic (ROC) curve analyses were used in this study.

RESULTS

Of the 65 patients analyzed, 38 (58.5%) had a poor outcome. Multivariable logistic analysis showed that the subcortical infarcts (OR 11.75; 95% CI 1.79-77.32; P = 0.010) and their volume (OR 1.17; 95% CI 1.04-1.32; P = 0.011) were independently associated with poor outcome. The ROC curve indicated the capacity of the subcortical infarct involvement (areas under the curve (AUC) = 0.65; 95% CI, 0.53-0.77, P < 0.001) and subcortical infarct volume (AUC = 0.72; 95% CI, 0.60-0.83, P < 0.001) in predicting poor outcome accurately.

CONCLUSION

Subcortical infarcts and their volume on admission CTP are associated with poor outcome after excellent reperfusion in late time windows, rather than cortical infarcts.

Negative susceptibility vessel sign might be predictive of complete reperfusion in patients with acute basilar artery occlusion managed with thrombectomy

OBJECTIVES

Negative susceptibility vessel sign (SVS) on pre-thrombectomy MRI has been linked to fibrin-rich thrombus and difficult retrieval in anterior ischemic stroke. However, its impact in posterior circulation-large vessel occlusion stroke (PC-LVOS) has not yet been elucidated. We aim to investigate the relationship of SVS parameters with stroke subtypes and their influence on angiographic and functional outcomes.

METHODS

Prospective thrombectomy registries at two-comprehensive stroke centers were retrospectively reviewed between January 2015 and December 2019 for consecutive MRI-selected patients with PC-LVOS. Two groups were assigned by two independent readers, based on the presence or absence of the SVS (SVS +, SVS -) on MRI-GRE sequence. Multivariate logistic regression analysis was utilized to study primarily the impact of the SVS on the rate of complete recanalization (defined as mTICI 2c/3) at the final series following endovascular thrombectomy (EVT) and whether or not it might influence the efficacy of the frontline EVT strategy. Secondarily, we studied whether the absence of the SVS was predictive of the rate of 90-day functional independence (defined as mRS score < 2). Lastly, both qualitative (SVS +, SVS-) and quantitative (SVS length and diameter) parameters of the SVS were analyzed in association with the puncture to recanalization interval and various stroke etiological subtypes based on TOAST criteria.

RESULTS

Among 1823 patients, 116 were qualified for final analysis (median age, 68 (59-75) years; male, 65%); SVS was detected in 62.9% (73/116) of cases. SVS length was an independent predictor of procedural duration (p = .01) whilst two-layered SVS was inversely associated with the atherosclerosis etiological subtype (aOR = 0.27, 95% CI 0.08-0.89; p = .03). Successful recanalization was achieved in 82% (60/73) vs. 86% (37/43), p = .80 of patients with SVS (+, -) respectively. Only in SVS (+), stentriever (RR 0.59 (0.4-0.88), p = .009), and contact-aspiration (RR 0.82 (0.7-0.96), p = .01) achieved a lower rate of successful recanalization compared to combined technique. SVS (-) was significantly associated with a higher rate of mTICI 2c/3 (aOR = 4.444; 95% CI 1.466-13.473; p = .008) and showed an indirect effect of 9% towards functional independence mediated by mTICI 2c/3.

CONCLUSION

SVS parameters in PC-LVOS might predict stroke subtype and indirectly influence the functional outcome by virtue of complete recanalization.

KEY POINTS

• Negative susceptibility vessel sign (SVS) in patients with basilar occlusion independently predict complete recanalization that indirectly instigated a 3-month favorable outcome following thrombectomy. • The longer the SVS, the higher likelihood of large artery atherosclerosis and the longer the thrombectomy procedure. • Two-layered SVS might be negatively associated with the presence of atherosclerosis, yet already-known limitations of TOAST classification and the absence of pathological analysis should be taken into consideration.

Association of Intravenous Thrombolysis with Delayed Reperfusion After Incomplete Mechanical Thrombectomy

PURPOSE

Treatment of distal vessel occlusions causing incomplete reperfusion after mechanical thrombectomy (MT) is debated. We hypothesized that pretreatment with intravenous thrombolysis (IVT) may facilitate delayed reperfusion (DR) of residual vessel occlusions causing incomplete reperfusion after MT.

METHODS

Retrospective analysis of patients with incomplete reperfusion after MT, defined as extended thrombolysis in cerebral infarction (eTICI) 2a-2c, and available perfusion follow-up imaging at 24 ± 12 h after MT. DR was defined as absence of any perfusion deficit on time-sensitive perfusion maps, indicating the absence of any residual occlusion. The association of IVT with the occurrence of DR was evaluated using a logistic regression analysis adjusted for confounders. Sensitivity analyses based on IVT timing (time between IVT start and the occurrence incomplete reperfusion following MT) were performed.

RESULTS

In 368 included patients (median age 73.7 years, 51.1% female), DR occurred in 225 (61.1%). Atrial fibrillation, higher eTICI grade, better collateral status and longer intervention-to-follow-up time were all associated with DR. IVT did not show an association with the occurrence of DR (aOR 0.80, 95% CI 0.44-1.46, even in time-sensitive strata, aOR 2.28 [95% CI 0.65-9.23] and aOR 1.53 [95% CI 0.52-4.73] for IVT to incomplete reperfusion following MT timing <80 and <100 min, respectively).

CONCLUSION

A DR occurred in 60% of patients with incomplete MT at ~24 h and did not seem to occur more often in patients receiving pretreatment IVT. Further research on potential associations of IVT and DR after MT is required.

Predictors of outcome after endovascular treatment for tandem occlusions: a single center retrospective analysis

BACKGROUND

The endovascular treatment procedure in tandem occlusions (TO) is complex compared to single occlusion (SO) and optimal management remains uncertain. The aim of this study was to identify clinical and procedural factors that may be associated to efficacy and safety in the management of TO and compare functional outcome in TO and SO stroke patients.

METHODS

This is a retrospective single center study of medium (MeVO) and large vessel occlusion (LVO) of the anterior circulation. Clinical, imaging, and interventional data were analyzed to identify predictive factors for symptomatic intracranial hemorrhage (sICH) and functional outcome after endovascular treatment (EVT) in TO. Functional outcome in TO and SO patients was compared.

RESULTS

Of 662 anterior circulation stroke patients with MeVO and LVO stroke, 90 (14%) had TO. Stenting was performed in 73 (81%) of TO patients. Stent thromboses occurred in 8 (11%) patients. Successful reperfusion with modified thrombolysis in cerebral infarction (mTICI) ≥ 2b was achieved in 82 (91%). SICH occurred in seven (8%). The strongest predictors for sICH were diabetes mellitus and number of stent retriever passes. Good functional clinical outcome (mRS ≤ 2) at 90-day follow up was similar in TO and SO patients (58% vs 59% respectively). General anesthesia (GA) was associated with good functional outcome whereas hemorrhage in the infarcted tissue, lower mTICI score and history of smoking were associated with poor outcome.

CONCLUSIONS

The risk of sICH was increased in patients with diabetes mellitus and those with extra stent-retriever attempts. Functional clinical outcomes in patients with TO were comparable to patients with SO.

Association of Perfusion Lesion Variables With Functional Outcome in Patients With Mild Stroke and Large Vessel Occlusion Managed Medically

BACKGROUND AND OBJECTIVES

The best management of patients with mild stroke and large vessel occlusion (LVO) remains unclear. This study aimed to identify perfusion imaging predictors of poor functional outcome in such patients.

METHODS

This cohort study retrospectively selected patients enrolled in the International Stroke Perfusion Imaging Registry between August 2011 and April 2022. The registry enrolled patients with acute ischemic stroke and with baseline CT perfusion scanned within 24 hours of stroke onset. This study identified patients with mild symptoms, defined by an NIH Stroke Scale score of ≤5. Patients with LVO of anterior circulation were selected. This study further selected patients who received medical management and excluded patients who received endovascular treatment. The primary outcome was poor functional outcome defined as a modified Rankin Scale of 3-6 at 3 months. Perfusion lesion was defined by delay time > 3 seconds on CTP. Regression analyses were used to identify clinical and imaging variables that predicted poor functional outcome.

RESULTS

A total of 139 patients with mild stroke were included, of whom 27 (19%) had poor functional outcome. Patients with poor outcome, compared with those with good outcome, had much larger perfusion lesion volume (median 80 mL vs 41 mL, p < 0.001). Perfusion lesion was a significant predictor of poor outcome in either univariable regression (crude OR = 1.02, 95% CI = [1.01-1.03]) or multivariable regression model (adjusted OR = 1.01, 95% CI = [1.01-1.02]), adjusting for occlusion site, good collaterals, baseline stroke severity, age, IV thrombolysis (IVT), and onset to scan time. A perfusion lesion of 65 mL was the optimal cutpoint to identify poor functional outcome (sensitivity = 59%, specificity = 77%). Patients with perfusion lesion ≥65 mL, compared with patients with perfusion lesion <65 mL, showed a much higher rate of poor functional outcome (38% vs 11%, p < 0.001). Of the 139 patients in this study, 95 received IVT. Patients treated with or without IVT did not influence their outcomes (crude OR = 0.74, 95% CI = [0.31-1.78]).

DISCUSSION

A perfusion lesion of ≥65 mL predicted poor functional outcome in mild stroke patients with LVO.

Thrombus enhancement sign on CT angiography is associated with the first pass effect of stent retrievers

BACKGROUND

The thrombus enhancement sign (TES) is thought to be associated with the source of the stroke and thrombus composition. We investigated whether this imaging sign along with other thrombus characteristics could be used to predict the successful first pass effect (FPE) of mechanical thrombectomy.

METHODS

246 consecutive patients with acute ischemic stroke in the anterior circulation with large vessel occlusion who underwent thrombectomy with a stent retriever and clot collection were included. Patients were divided into FPE (modified Thrombolysis in Cerebral Infarction (mTICI) grade 2c or 3)/non-FPE (mTICI 0-2b) and modified FPE (mFPE) (mTICI 2b-3)/non-mFPE (mTICI 0-2a) groups based on flow restoration after the first pass. TES presence, thrombus density, thrombus length, clot burden score, and thrombus composition were compared. The association between FPE and imaging biomarkers, along with clinical and interventional parameters, was investigated by univariate and multivariate analysis.

RESULTS

FPE was achieved in 85 (34.6%) patients. TES presence was significantly lower in the FPE group (64.7% vs 80.7% in the non-FPE group, p=0.008) and mFPE group (69.1% vs 81.0% in the non-mFPE group, p=0.039). Histopathological examination revealed that TES (+) thrombi contained a higher fibrin/platelet proportion (50.9% vs 46.9% in TES (-) thrombi, p=0.029) and fewer erythrocytes (43.3% vs 47.3% in TES (-) thrombi, p=0.030). Thrombus characteristics, namely shorter thrombus length (p=0.032), higher erythrocyte proportions (p=0.026), and less fibrin/platelets (p=0.014), were confirmed in patients with FPE. In multivariable analysis, TES was the only independent predictor of FPE failure (OR 0.51, 95% CI 0.28 to 0.94; p=0.031).

CONCLUSIONS

TES was independently associated with first pass angiographic failure in patients treated with a stent retriever.

Survival and functional outcome following endovascular thrombectomy for anterior circulation acute ischemic stroke caused by large vessel occlusion in Sweden 2017-2019-a nationwide, prospective, observational study

BACKGROUND

Endovascular thrombectomy (EVT) is standard of care for anterior circulation acute ischemic stroke (AIS) caused by large vessel occlusion (LVO), but data on nationwide performance in routine healthcare are sparse. The study aims were to describe EVT patients with LVO AIS, analyze mortality and functional outcome, and compare results with randomized controlled trials (RCTs).

METHODS

Data from the Riksstroke and the Swedish Endovascular Treatment of Acute Stroke Registry (RSEVAS) on pre-stroke independent patients, with LVO AIS in 2017-2019, defined as occlusion of the intracranial internal carotid artery, or the M1 or M2 segments of the middle cerebral artery, and groin puncture <6 h of onset, were compared to aggregated HERMES collaboration RCT data. We assessed 90-day survival and function, defined by the modified Rankin Scale. Specific analyzes were stratified by occlusion location.

RESULTS

In all, 1011/2560 of RSEVAS patients matched RCT inclusion criteria. Compared with RCT data, patients were older (73 vs. 68), fewer received intravenous thrombolysis (63.1% vs. 83%), and M2 occlusions were more common (24.5% vs. 8%). 90-day survival in RSEVAS was 85.3%, 42.8% achieved good outcome and 5% had symptomatic intracerebral hemorrhage (sICH). Corresponding outcomes in RCT data were 84.7% survival, 46% good outcome, and 4.4% sICH. Functional outcome was most favorable following M2 occlusions.

CONCLUSIONS

EVT patients from our large real-world national dataset differed from RCT patients in several baseline factors including distribution of vascular occlusion site. However, the overall outcome of EVT in our Swedish cohort appeared to well match the pivotal trial findings.

The Benefit of a Complete over a Successful Reperfusion Decreases with Time

OBJECTIVE

Time from stroke onset to reperfusion (TSOR) is strongly associated with outcomes after endovascular treatment. A near-to-complete or complete reperfusion (modified Treatment in Cerebral Ischemia [mTICI] 2c-3) is associated with improved outcomes compared with a successful reperfusion (mTICI 2b). However, it is unknown whether this association remains stable as TSOR increases. Therefore, we sought to investigate the association between TSOR and outcomes according to the reperfusion status.

METHODS

We analyzed data from the Endovascular Treatment in Ischemic Stroke registry, a prospective, observational, multicentric study of acute ischemic stroke patients treated with endovascular treatment in 21 centers in France. We included patients with anterior occlusions (M1, internal carotid artery, tandem), with a known time of symptom onset. Outcomes were early neurological improvement at 24 hours and favorable outcome (modified Rankin Scale between 0 and 2) at 90 days.

RESULTS

Overall, 4,444 patients were analyzed. Compared with a mTICI 2b, a mTICI 2c-3 at 1 hour was associated with higher mean marginal probabilities of early neurological improvement (25.6%, 95% CI 11.7-39.5, p = 0.0003) and favorable outcome (15.2%, 95% CI 3.0-27.4, p = 0.0143), and progressively declined with TSOR. The benefit of a mTICI 2c-3 over a mTICI 2b was no longer significant regarding the rates of early neurological improvement and favorable outcome after a TSOR of 414 and 344 minutes, respectively.

INTERPRETATION

The prognostic value of a complete over a successful reperfusion progressively declined with time, and no difference regarding the rates of favorable outcome was observed between a complete and successful reperfusion beyond 5.7 hours. ANN NEUROL 2023.

Effect of intravenous thrombolysis on core growth rate in patients with acute cerebral infarction

Objective

This study aimed to investigate the effects of recombinant tissue plasminogen activator intravenous thrombolysis (IVT) on the core growth rate of acute ischemic stroke.

Methods

Stroke patients with large vessel occlusion and non-recanalization from IVT treatment were retrospectively included in this study and divided into two groups: IVT and non-IVT. The core growth rate was estimated by the acute core volume on perfusion CT divided by the last known well time from stroke to CT perfusion. The primary endpoint was the core growth rate, the tissue outcome was 24 h-ASPECTS, and the clinical outcome was a 3-month modified Rankin score.

Results

A total of 94 patients were included with 53 in the IVT group and 41 in the non-IVT group. There was no significant difference in age, gender, hypertension, diabetes, atrial fibrillation, acute NIHSS, and last known well time from stroke to CT perfusion acquisition between the two groups. The core growth rate in the IVT group was lower than that in the non-IVT group, which was statistically significant after multivariate adjustment (coefficient: -5.20, 95% CI= [-9.85, -0.56], p = 0.028). There was a significant interaction between the IVT and the collateral index in predicting the core growth rate. The analysis was then stratified according to the collateral index, and the results suggested that IVT reduced the core growth rate more significantly after the worsening of collateral circulation (coefficient: 15.38, 95% CI= [-26.25, -4.40], p = 0.007). The 3-month modified Rankin score and 24 h-ASPECTS were not statistically significant between the two groups.

Conclusion

Intravenous thrombolysis reduces the core growth rate in patients with AIS, especially those with poor collateral status.

Frontline thrombectomy strategy and outcome in acute basilar artery occlusion

BACKGROUND

Novel thrombectomy strategies emanate expeditiously day-by-day counting on access system, clot retriever device, proximity to and integration with the thrombus, and microcatheter disengagement. Nonetheless, the relationship between native thrombectomy strategies and revascularization success remains to be evaluated in basilar artery occlusion (BAO).

PURPOSE

To compare the safety and efficacy profile of key frontline thrombectomy strategies in BAO.

METHODS

Retrospective analyses of prospectively maintained stroke registries at two comprehensive stroke centers were performed between January 2015 and December 2019. Patients with BAO selected after MR imaging were categorized into three groups based on the frontline thrombectomy strategy (contact aspiration (CA), stent retriever (SR), or combined (SR+CA)). Patients who experienced failure of clot retrieval followed by an interchanging strategy were categorized as a fourth (switch) group. Clinicoradiological features and procedural variables were compared. The primary outcome measure was the rate of complete revascularization (modified Thrombolysis in Cerebral Infarction (mTICI) grade 2c-3). Favorable outcome was defined as a 90 day modified Rankin Scale score of 0-2.

RESULTS

Of 1823 patients, we included 128 (33 underwent CA, 35 SR, 35 SR +CA, and 25 switch techniques). Complete revascularization was achieved in 83/140 (59%) primarily analyzed patients. SR +CA was associated with higher odds of complete revascularization (adjusted OR 3.04, 95% CI 1.077 to 8.593, p=0.04) which was an independent predictor of favorable outcome (adjusted OR 2.73. 95% CI 1.152 to 6.458, p=0.02). No significant differences were observed for symptomatic intracranial hemorrhage, functional outcome, or mortality rate.

CONCLUSION

Among BAO patients, the combined technique effectively contributed to complete revascularization that showed a 90 day favorable outcome with an equivalent complication rate after thrombectomy.

Updates in mechanical thrombectomy

Stroke is a leading cause of morbidity and mortality. The advent of mechanical thrombectomy has largely improved patient outcomes. This article reviews the features and outcomes associated with aspiration, stent retrievers, and combination catheters used in current practice. There is also a discussion on clinical considerations based on anatomical features and clot composition. The reperfusion grading scale and outcome metrics commonly used following thrombectomy when a patient is still in the hospital are reviewed. Lastly, there are proposed discharge and outpatient follow-up goals in caring for patients hospitalized for a stroke.

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.

Thrombectomy Using the EmboTrap Clot-Retrieving Device for the Treatment of Acute Ischemic Stroke: A Glimpse of Clinical Evidence

BACKGROUND

The EmboTrap Recanalization Device is a novel stent retriever for thrombectomy in the setting of acute ischemic stroke due to large-vessel occlusion.

PURPOSE

Our aim was to summarize the safety and efficacy of the EmboTrap Recanalization Device in acute ischemic stroke-large-vessel occlusion through a systematic review and meta-analysis.

DATA SOURCES

Medline, EMBASE, the Cochrane Library, Web of Science, and Google Scholar were searched up to April 2022.

STUDY SELECTION

Nine observational studies using the EmboTrap Recanalization Device were selected.

DATA ANALYSIS

We adapted effect size with 95% CIs for dichotomous data. P value <.05 was statistically significant.

DATA SYNTHESIS

The estimated rate of successful recanalization (modified TICI 2b-3) was 90% (95% CI, 86%-95%; I ² = 82.4%); 90-day favorable outcome (mRS 0-2), 53% (95% CI, 42%-63%; I ² = 88.6%); modified first-pass effect, 43% (95% CI, 35%-51%; I ² = 63.7%); and first-pass effect, 36% (95% CI, 29%-46%; I ² = 10.7%). The rate of any intracerebral hemorrhage was 19% (95% CI, 16%-22%; I ² = 0.0%); symptomatic intracerebral hemorrhage, 5% (95% CI, 1%-8%; I ² = 84.6%); and 90-day mortality, 14% (95% CI, 9%-19%; I ² = 79.3%). Subgroup analysis showed higher rates of complete recanalization for EmboTrap II than for the EmboTrap System.

LIMITATIONS

The included studies are single-arm without direct comparison with other stent retrievers. Some of the studies recruited had a small sample size and were limited by the retrospective study design. In addition, the uncertain heterogeneity among studies was high.

CONCLUSIONS

The EmboTrap Recanalization Device is safe and efficient in treating acute ischemic stroke due to large-vessel occlusion.

Complete Recanalization in Mechanical Thrombectomy Is Associated with Favorable Functional Outcome for M2 Occlusions

Objective

There are insufficient coherent reports on mechanical thrombectomy (MT) for occlusion of the second segment of the middle cerebral artery (M2 occlusion) in a real-world clinical setting. We evaluated the efficacy and safety of MT for M2 occlusions and compared the primary thrombectomy strategies (stent retriever, aspiration catheter, and combined technique) to analyze factors predicting good functional outcomes.

Methods

We evaluated background factors, preprocedural factors, procedural factors, and procedural time for patients who underwent MT for M2 occlusions from our retrospective cohort. According to the modified Rankin Scale (mRS) score three months after MT, patients were divided into good (mRS ≤2) and poor (mRS ≥3) prognosis groups.

Results

A total of 29 patients (median age, 78 years; 11 [37.9%] females) were included in the study. In this cohort, rates of successful reperfusion, thrombolysis in cerebral infarction (TICI) 3, postprocedural hemorrhage (PPH), and symptomatic PPH were 82.8, 34.5, 31.0, and 0%, respectively. Good prognoses were achieved in 13 (45%) cases. A prognostic factor of MT for M2 occlusions is TICI 3 from multivariate analysis (OR, 11.7; 95% CI, 1.003-136; p = 0.0497). There was no statistically significant difference in the functional outcome three months after MT based on the choice of the primary thrombectomy strategy.

Conclusion

MT for M2 occlusions is a reliable and relatively safe procedure. The presence of TICI 3 was a prognostic factor in this cohort. Future studies are warranted to investigate the optimal thrombectomy strategy for medium vessel occlusion.

A Simple Grading Scale for Predicting Symptomatic Intracranial Hemorrhage after Mechanical Thrombectomy

INTRODUCTION

Hemorrhagic transformation, especially symptomatic intracranial hemorrhage (sICH), is a common complication after mechanical embolectomy. This study explored a grading scale based on clinical and radiological parameters to predict sICH after mechanical embolectomy.

METHODS

Demographic and clinical data were retrospectively collected from patients with acute ischemic stroke treated with mechanical embolectomy at West China Hospital. Clinical and radiological factors associated with sICH were identified and used to develop the "STBA" grading scale. This score was then validated using data from an independent sample at the First Affiliated Hospital of Kunming Medical University.

RESULTS

We analyzed 268 patients with acute ischemic stroke who were treated with mechanical embolectomy at West China Hospital, of whom 30 (11.2%) had sICH. Patients were rated on an "STBA" score ranging from 0 to 6 based on whether systolic blood pressure was ≥145 mm Hg at admission (yes = 2 points; no = 0 points), time from acute ischemic stroke until groin puncture was ≥300 min (yes = 1; no = 0), blood glucose was ≥8.8 mmol/L (yes = 1; no = 0), and the Alberta Stroke Program Early Computed Tomography score at admission was 0-5 (2 points), 6-7 (1 point), or 8-10 (0 points). The STBA score showed good discrimination in the derivation sample (area under the receiver operating characteristic curve = 0.858) and in the validation sample (area = 0.814).

CONCLUSIONS

The STBA score may be a reliable clinical scoring system to predict sICH in acute ischemic stroke patients treated with mechanical embolectomy.

Successful Reperfusion is Associated with Favorable Functional Outcome despite Vessel Perforation during Thrombectomy: A Case Series and Systematic Review

BACKGROUND

Arterial perforation is a potentially serious complication during endovascular thrombectomy.

PURPOSE

Our aim was to describe interventional approaches after arterial perforation during endovascular thrombectomy and to determine whether reperfusion remains associated with favorable outcome despite this complication.

DATA SOURCES

Data from consecutive patients with acute stroke undergoing endovascular thrombectomy were retrospectively collected between 2015 to 2020 from a single-center cohort, and a systematic review was performed using PubMed, EMBASE, and Ovid MEDLINE up to June 2020.

STUDY SELECTION

Articles reporting functional outcome after arterial perforation during endovascular thrombectomy were selected.

DATA ANALYSIS

Functional outcomes of patients achieving successful reperfusion (TICI 2b/3) were compared with outcomes of those with unsuccessful reperfusion in our single-center cohort. We then summarized the literature review to describe interventional approaches and outcomes after arterial perforation during endovascular thrombectomy.

DATA SYNTHESIS

In our single-center cohort, 1419 patients underwent endovascular thrombectomy, among whom 32 (2.3%) had vessel perforation and were included in the analysis. The most common hemostatic strategy was watchful waiting (71% of cases). Patients with successful reperfusion had a higher proportion of favorable 90-day mRS scores (60% versus 12.5%; P = .006) and a lower mortality rate (13.3% versus 56.3%, P = .01) than patients without successful reperfusion. Thirteen articles were included in the systematic review. Successful reperfusion also appeared to be associated with better outcomes.

LIMITATIONS

Given the low number of published reports, we performed only a descriptive analysis.

CONCLUSIONS

Arterial perforation during endovascular thrombectomy is rare but is associated with high mortality rates and poor outcome. However, successful reperfusion remains correlated with favorable outcome in these patients.