Ischemic Strokes Due to Large-Vessel Occlusions Contribute Disproportionately to Stroke-Related Dependence and Death: A Review

NLR and LMR could powerfully predict unfavorable outcomes in patients with acute anterior circulation large vessel occlusion stroke (ALVOS) who underwent mechanical thrombectomy

INTRODUCTION

To investigate the predictive value of Neutrophil to lymphocyte ratio (NLR) and Lymphocyte to monocyte ratio (LMR) on unfavorable outcomes of acute anterior circulation large vessel occlusion stroke (ALVOS) in patients who underwent mechanical thrombectomy (MT).

MATERIAL & METHOD

We retrospectively recruited 96 cases with ALVOS who underwent MT. These cases were divided into two groups including the favorable outcome group (3-month modified Rankin Scale scores (mRS) of 0-2) and the unfavorable outcome group (3-month mRS of 3-6). Logistic regression analysis was used to examine the independent risk factors of the 3-month unfavorable outcome of ALVOS. Moreover, we conducted a receiver operating characteristic curve (ROC) to estimate the valuable predictor of NLR, LMR, and the combination of NLR and LMR on unfavorable outcomes of ALVOS after MT.

RESULTS

46.9 % (45/96) cases had an unfavorable outcome and 53.1 % (51/96) cases had a favorable outcome. In the univariate regression analysis, baseline NIHSS score, symptomatic intracranial hemorrhage, and fasting glucose were included in the multi-factor binary logistic regression, and this revealed that NLR (OR 3.776, 95 %CI 1.067-13.363, p = 0.039) and LMR (OR 0.092, 95 %CI 0.017-0.0506, p = 0.006) were independent predictors of unfavorable outcomes (mRS score 3-6) at 3-month. Higher NLR (> 2.984) and lower LMR (< 3.775) were independently associated with unfavorable outcomes, and the combined predictive levels of both NLR and LMR (AUC = 0.941) were higher than single indicators (NLR, AUC = 0.876; LMR, AUC = 0.934).

CONCLUSIONS

The combination of NLR and LMR was a more powerful predictor of unfavorable outcomes of ALVOS after MT than NLR alone.

Cardiac Events After Mechanical Thrombectomy in Acute Ischemic Stroke: A Nation-Wide Cohort Study

INTRODUCTION

Mechanical thrombectomy (MT) markedly improves the outcome in patients with large vessel occlusion stroke. Given the cardiovascular risk profile of these patients, we wanted to investigate their post-MT risk of cardiac events compared to other patients with acute ischemic stroke (AIS).

METHODS

All hospitalizations for AIS in Denmark from 2014 to 2021 were included in this registry-based cohort study. Patients were categorized by reperfusion treatment: MT with or without intravenous thrombolysis (IVT), IVT alone, or no reperfusion treatment (NRT). Cardiac events included ischemic heart disease, heart failure, or cardiac death within 6 months of AIS. Pair-wise group comparisons were performed after inverse probability treatment weighting (IPTW).

RESULTS

Among 76,092 AIS patients, 4.4% received MT, 15.2% received IVT alone, and 80.4% received NRT. In the MT group, 9.6% of patients experienced cardiac events. After IPTW, MT patients had the highest risk of cardiac events compared to IVT (absolute risk difference [ARD] 4.6%, cause-specific hazard rate ratio [HRR] 1.42 [95% CI: 1.27-1.60]) and NRT (ARD 4.6%, HRR 1.35 [95% CI: 1.22-1.49]). Pre-existing cardiac disease was similar across groups (9.2%-11.8%) and after exclusion of patients with prior cardiac disease, the HRR of cardiac events remained consistent with the primary analysis (MT vs. IVT: HRR 1.48 [95% CI: 1.31-1.68]; MT vs. NRT: 1.39 [95% CI: 1.24-155]).

CONCLUSION

10% of patients with AIS undergoing MT experienced cardiac events within 6 months compared to 5% of other AIS patients. This study identified an unrecognized burden of cardiac disease in this group of AIS patients treated with MT.

Prehospital Large-Vessel Occlusion Stroke Detection Scales: A Pooled Individual Patient Data Analysis of 2 Prospective Cohorts

BACKGROUND AND OBJECTIVES

Various prehospital scales have been developed to detect patients with anterior-circulation large-vessel occlusion (aLVO) ischemic stroke to enable direct transportation to a thrombectomy-capable stroke center. To guide implementation, a head-to-head comparison of aLVO stroke detection scales is needed to determine which scale is most useful for prehospital triage in different regional contexts. We aimed to systematically identify and compare these scales.

METHODS

Published prehospital aLVO stroke scales were identified with a systematic literature search. Scales were reconstructed from individual patient data of 2 large prospective observational cohort studies conducted between 2018 and 2019, the Leiden Prehospital Stroke Study and PREhospital triage of patients with suspected STrOke symptoms study. Both studies included consecutive adult patients suspected by paramedics of having a stroke within 6 hours of symptom onset, from 4 Dutch ambulance regions, encompassing 15 stroke centers and serving 3.7 million people. All data used for the reconstruction of scales were acquired by paramedics in the field before hospital arrival. Scales' diagnostic performance to detect aLVO stroke was compared with the area under the receiver operating characteristic curve (AUROC) of the full scale and sensitivity and specificity at the scales' original cut-point. Decision curve analysis was used to evaluate harm-benefit trade-offs between delaying IV thrombolysis and expediting endovascular thrombectomy with direct transportation of patients to a thrombectomy-capable center.

RESULTS

We identified 63 aLVO scales, of which 14 could be reconstructed. Of 2,358 included patients (mean age 70 years; 47% female), 231 (9.8%) had aLVO stroke. The AUROC was highest for Rapid Arterial oCclusion Evaluation (RACE) (0.81, 95% CI 0.78-0.84), Los Angeles Motor Scale (LAMS) (0.80, 95% CI 0.77-0.83), Gaze-Face-Arm-Speech-Time (G-FAST) (0.80, 95% CI 0.77-0.83), and modified Gaze-Face-Arm-Speech-Time (mG-FAST) (0.79, 95% CI 0.76-0.82). The Emergency Medical Stroke Assessment had highest sensitivity (85%, 95% CI 80%-90%) but lowest specificity (58%, 95% CI 56%-61%) while Cincinnati Prehospital Stroke Scale with an adjusted cut-point of 3 + gaze had highest specificity (94%, 95% CI 93%-95%) but lowest sensitivity (35%, 95% CI 29%-41%). In decision curve analysis, RACE had the highest benefit across a clinically reasonable range of harm-benefit trade-offs.

DISCUSSION

RACE, LAMS, G-FAST, and mG-FAST are the best-performing scales, with RACE being preferred in most triage settings. Our findings may support policymakers with implementing a scale suitable for their region.

Automated Emergent Large Vessel Occlusion Detection Using Viz.ai Software and Its Impact on Stroke Workflow Metrics and Patient Outcomes in Stroke Centers: A Systematic Review and Meta-analysis

The implementation of artificial intelligence (AI), particularly Viz.ai software in stroke care, has emerged as a promising tool to enhance the detection of large vessel occlusion (LVO) and to improve stroke workflow metrics and patient outcomes. The aim of this systematic review and meta-analysis is to evaluate the impact of Viz.ai on stroke workflow efficiency in hospitals and on patients' outcomes. Following the PRISMA guidelines, we conducted a comprehensive search on electronic databases, including PubMed, Web of Science, and Scopus databases, to obtain relevant studies until 25 October 2024. Our primary outcomes were door-to-groin puncture (DTG) time, CT scan-to-start of endovascular treatment (EVT) time, CT scan-to-recanalization time, and door-in-door-out time. Secondary outcomes included symptomatic intracranial hemorrhage (ICH), any ICH, mortality, mRS score < 2 at 90 days, and length of hospital stay. A total of 12 studies involving 15,595 patients were included in our analysis. The pooled analysis demonstrated that the implementation of the Viz.ai algorithm was associated with lesser CT scan to EVT time (SMD -0.71, 95% CI [-0.98, -0.44], p < 0.001) and DTG time (SMD -0.50, 95% CI [-0.66, -0.35], p < 0.001) as well as CT to recanalization time (SMD -0.55, 95% CI [-0.76, -0.33], p < 0.001). Additionally, patients in the post-AI group had significantly lower door-in door-out time than the pre-AI group (SMD -0.49, 95% CI [-0.71, -0.28], p < 0.001). Despite the workflow metrics improvement, our analysis did not reveal statistically significant differences in patient clinical outcomes (p > 0.05). Our results suggest that the integration of the Viz.ai platform in stroke care holds significant potential for reducing EVT delays in patients with LVO and optimizing stroke flow metrics in comprehensive stroke centers. Further studies are required to validate its efficacy in improving clinical outcomes in patients with LVO.

The Role of Left Atrial Strain in Differentiating Embolic Stroke of Undetermined Source From Other Acute Ischemic Stroke Subtypes Related to Large-Vessel Occlusion

INTRODUCTION

To evaluate left atrial (LA) function in patients with embolic stroke of undetermined source (ESUS) and other subtypes of acute ischemic stroke (AIS) related to large-vessel occlusion (LVO).

METHODS

Consecutive patients with LVO-related AIS were prospectively enrolled from July 2019 to August 2022. To compare LA function with ESUS patients, a control group without prior stroke was sex- and age-matched with ESUS patients in a 1:1 ratio. LA strain was measured within 3 days after stroke. Multivariable logistic regression analysis was performed to assess associations between LA function and stroke subtypes.

RESULTS

This study included 126 patients (mean age 67.7 ± 12.3 year, 39.7% women). Of these, 28 patients met the diagnostic criteria for ESUS, while the remaining were classified as large artery atherosclerosis (n = 49) and non-valvular AF-related cardioembolic stroke (n = 49). Patients with ESUS had lower left atrial reservoir strain (LASr) and left atrial conduit strain (LAScd) compared to those with large artery atherosclerosis (27.8 ± 7.1% vs. 32.0 ± 5.3%, p = 0.004, and 14.3 ± 3.8% vs. 17.3 ± 4.6%, p = 0.005, respectively) and the control group (27.8 ± 7.1% vs. 37.6 ± 7.2%, p < 0.001 and 14.3 ± 3.8% vs. 21.5 ± 7.9%, p < 0.001, respectively). A 5% reduction in LASr and LAScd was associated with a 1.92- and 2.45-fold increase, respectively, in the likelihood of having ESUS compared to large artery atherosclerosis. Lower LASr and LAScd in ESUS patients were prone to be associated with a higher likelihood of cardiovascular events during follow-up.

CONCLUSIONS

LA strain is associated with ESUS in stroke patients with LVO. Further studies are needed to explore its utility in identifying specific stroke etiologies.

Development and validation of a blood biomarker-based model for differentiating stroke etiology in acute large vessel occlusion

Objective

Early differentiation of stroke etiology in acute large vessel occlusion stroke (LVOS) is crucial for optimizing endovascular treatment strategies. This study aimed to develop and validate a prediction model for pre-procedural etiological differentiation based on admission laboratory parameters.

Methods

We conducted a retrospective cohort study at a comprehensive stroke center, enrolling consecutive patients with acute LVOS who underwent endovascular treatment between January 2018 and October 2024. The study cohort (N = 415) was split into training (n = 291) and validation (n = 124) sets using a 7:3 ratio. We applied machine learning techniques-the Boruta algorithm followed by least absolute shrinkage and selection operator regression-for variable selection. The final predictive model was constructed using multivariable logistic regression. Model performance was evaluated through the area under the receiver operating characteristic curve (AUC), calibration plots, and decision curve analysis. We then developed a web-based calculator to facilitate clinical implementation.

Results

Of 415 enrolled patients, 199 (48.0%) had cardioembolism (CE). The final model incorporated six independent predictors: age [adjusted odds ratio (aOR) 1.03], male sex (aOR 0.35), white blood cell count (aOR 0.86), platelet-large cell ratio (aOR 1.06), aspartate aminotransferase (aOR 1.02), and non-high-density lipoprotein cholesterol (aOR 0.75). The model demonstrated good discriminatory ability in both the training set (AUC = 0.802) and the validation set (AUC = 0.784). Decision curve analysis demonstrated consistent clinical benefit across threshold probabilities of 20%-75%.

Conclusion

We developed and internally validated a practical model using routine admission laboratory parameters to differentiate between CE and large artery atherosclerosis in acute LVOS. This readily implementable tool could aid in preoperative decision-making for endovascular intervention.

Endovascular thrombectomy in young patients with large vessel occlusion stroke: a systematic review and meta-analysis

Data on endovascular thrombectomy (EVT) in young stroke patients due to large vessel occlusion (LVO) are limited. This systematic review and meta-analysis aim to compare the safety and efficacy of EVT in young patients (˂50 years) compared to older patients (≥ 50 years). A comprehensive literature search was conducted based on PubMed, EMBASE, and the Cochrane Library. We included studies that directly compared clinical outcomes of EVT in young patients and older patients. Random-effects meta-analyses were performed to measure functional independence (modified Rankin Scale [mRS] score 0-2 at 90 days), successful recanalization (expanded TICI [eTICI] score ≥ 2b) rates, symptomatic intracranial hemorrhage (sICH) rates, and mortality at 90 days. A total of three studies were included, encompassing 11,575 patients. The pooled analysis demonstrated that EVT significantly improved functional independence (OR = 2.47; 95% CI, 1.83-3.33; P < 0.00001) and reduced mortality (OR = 0.29; 95% CI, 0.09-0.90; P = 0.03) in young patients, compared to older patients. Recanalization rates were higher than older patients (OR = 1.22; 95% CI, 1.02-1.46; P = 0.03). Symptomatic intracranial hemorrhage occurred in 3.37% of young patients (30/889) and 4.50% of older patients (481/10686) (OR = 0.67; 95% CI, 0.45-0.98; P = 0.04). Endovascular thrombectomy is effective and safe in young patients with LVO stroke, leading to improved clinical outcomes, compared with older patients.

Association of liver fibrosis-4 index with functional outcomes in chinese patients with acute ischemic stroke undergoing mechanical thrombectomy

This study aimed to investigate the association between the Fibrosis-4 (FIB-4) index and functional outcomes and hemorrhagic complications in patients with large vessel occlusion acute ischemic stroke (LVO-AIS) treated with mechanical thrombectomy (MT). In this single-center retrospective cohort study, we consecutively enrolled patients with LVO-AIS who underwent MT between January 2018 and February 2024. The primary endpoint was poor functional outcome at 90 days (modified Rankin Scale score 3-6). Secondary endpoints included hemorrhagic transformation (HT) and symptomatic intracranial hemorrhage (sICH). Multivariable logistic regression models and restricted cubic spline analyses were used to evaluate the association between FIB-4 index and outcomes after adjusting for potential confounders. Among 421 patients, 254 (60.33%) had poor outcomes, 197 (46.79%) developed HT, and 76 (18.05%) experienced sICH. After adjustment for confounding factors, each unit increase in FIB-4 index was associated with a 38% higher risk of poor outcome (P = 0.013). This association showed significant nonlinearity (P-nonlinear = 0.010), with risk increasing exponentially beyond a FIB-4 threshold of 2.4. Advanced fibrosis (FIB-4 ≥ 2.67) was independently associated with poor outcomes (P = 0.024). FIB-4 index independently predicts poor functional outcomes in LVO-AIS patients. This readily available biomarker may help identify high-risk patients who could benefit from enhanced monitoring and individualized treatment strategies.

Cilostazole versus clopidogrel in acute large-vessel moderate and moderate-to-severe ischemic stroke: a randomized controlled trial

BACKGROUND

More than one-third of all ischemic strokes are induced by large vessel occlusion (LVO). All the wide-scale trials that assessed the impacts of cilostazol versus clopidogrel in stroke management have been conducted in Asia and involved patients with minor stroke or TIA. Our trial is the first-ever study to evaluate cilostazol versus clopidogrel in acute LVO with moderate to severe ischemic stroke in North Africa.

OBJECTIVES

We assessed the efficacy and safety of cilostazol versus clopidogrel in first-ever LVO moderate and moderate to severe ischemic stroke patients.

METHODS

580 moderate and moderate-to-severe LVO ischemic stroke participants were randomly enrolled to receive loading and maintenance doses of cilostazol or clopidogrel.

RESULTS

580 patients were included in the intention-to-treat analysis. 29 (10.0%) participants in the cilostazol arm and 43 (14.8%) participants in the clopidogrel arm experienced a new stroke (HR 0.37; 95% CI, 0.29-0.73; P-value = 0.03). Eight participants (2.8%) in the cilostazol arm and 17 patients (5.9%) in the clopidogrel arm had drug-related hemorrhagic complications (HR 0.29; 95% CI, 0.18-0.63; P-value = 0.008).

CONCLUSION

Patients who experienced acute LVO moderate and moderate-to-severe ischemic stroke and received loading and maintenance doses of cilostazol within the first 24 h after stroke onset had better clinical outcomes based on recurrent stroke rates and better safety outcomes regarding hemorrhagic transformation of brain infarction and drug-induced peripheral hemorrhagic side effects compared to those who received loading and maintenance doses of clopidogrel. There were no significant differences between the two groups regarding death due to vascular events and unfavorable mRS after three months of stroke onset.

REGISTRATION

Retrospectively registered on ClinicalTrials.gov, NCT06242145, 27-01-2024.

Outcomes of Blood Transfusions in Patients Undergoing Mechanical Thrombectomy for Acute Ischemic Stroke: A Population-Based Cross-Sectional Study of 47,835 Patients

Background/Objectives: Despite advances, large vessel occlusion strokes (LVO) remain associated with significant morbidity. Recent studies have suggested that blood transfusions may help manage critically ill LVO patients. We sought to evaluate the patient characteristics, complications, and clinical outcomes associated with blood transfusions in acute ischemic stroke (AIS) patients undergoing endovascular thrombectomy. Methods: A query of the 2016-2019 National Inpatient Sample was conducted to identify AIS patients who underwent endovascular thrombectomy, using International Classification of Disease 10th Revision diagnostic codes. Demographic, clinical characteristics, severity of presentation, complications, and outcomes were analyzed. Multivariate binary logistic regression was used to assess complications, length of stay (LOS), discharge disposition, and inpatient mortality. Results: A total of 47,835 AIS patients undergoing endovascular thrombectomy were identified. Of these patients, 1215 (2.5%) received blood transfusions. After controlling for age, gender, National Institutes of Health Stroke Scale scores, Elixhauser Comorbidity Index, and location of stroke, blood transfusions were significant positive predictors for higher rates of inpatient death (OR: 1.96; 95% CI: 1.681, 2.286; p < 0.001), lower rates of routine discharge (OR: 0.425; 95% CI: 0.342, 0.527; p < 0.001), and prolonged LOS (OR: 2.928; 95% CI: 2.572, 3.333; p < 0.001). Conclusions: Blood transfusions in AIS patients receiving endovascular thrombectomy are associated with elevated complication rates, extended hospital stays, and increased mortality, even after for controlling for predictors of poor outcome. Understanding the broader effects of blood transfusions in AIS patients is essential to ensure that the balance between potential benefits and risks upholds best care practice for all patients.

Clinical prediction model of invalid recanalization after complete reperfusion after thrombectomy in acute ischemic stroke patients: a large retrospective study

BACKGROUND

Studies have been conducted to explore the potential predictive indicators of unfavorable outcomes in patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). However, few studies have proposed a comprehensive predictive model combined with clinical baseline data and ancillary examination before surgery.

METHOD

In a retrospective study, we collected data on 823 patients with AIS-LVO who had undergone endovascular therapy (EVT); 562 patients who achieved successful revascularization with complete clinical and prognostic information were incorporated into the study. Those patients with a 90-day modified Rankin Scale (mRS) score of 0-2 were defined as having a favorable outcome, while a score of 3-6 represented an unfavorable outcome or futile reperfusion. To build up a predictive model, we applied multivariate logistic regression stepwise backward selection to decide which factors are supposed to be the components of the predictive model. Final model validity was testified by the variance inflation factor test and the Hosmer-Lemeshow (HL) goodness of fit test. The ultimate efficacy was supported by an area under the curve (AUC) value in both training groups and validation groups.

RESULTS

562 patients were enrolled in our study and divided into the training group and verification group in a ratio of 7:3. Factors of baseline data with P<0.1 in univariate logistic regression analysis were enrolled as the potential risk variables to conduct stepwise backward selection. The model was constructed by eight variables; higher mRS score (adjusted OR (aOR) 93.64, 95% CI 12.05 to 727.82, P<0.01), age >80 years (aOR 91.11, 95% CI 1.36 to 6116.36, P<0.05), National Institutes of Health Stroke Scale (NIHSS) >14 (aOR 0.15, 95% CI 0.02 to 0.99, P<0.05), operation history (aOR 8.13, 95% CI 1.32 to 50.20, P<0.05), creatinine (aOR 1.10, 95% CI 1.04 to 1.17, P<0.01), and neutrophil count (aOR 1.07, 95% CI 1.01 to 1.13, P<0.05) were associated with poor outcomes.

CONCLUSION

We established an estimation model for invalid reperfusion in AIS-LVO patients and constructed the nomogram for individualized predictions. The AUC of the training group and validation group were both 0.96, with excellent HL and decision curve analysis, presenting excellent clinical prediction efficiency and application potential.

Large vessel occlusion identification network with vessel guidance and asymmetry learning on CT angiography of acute ischemic stroke patients

Identifying large vessel occlusion (LVO) is of significant importance for the treatment and prognosis of acute ischemic stroke (AIS) patients. CT Angiography (CTA) is commonly used in LVO identification due to its visibility of vessels and short acquisition time. It is challenging to make LVO identification methods focus on vascular regions without vessel segmentation while accurate vessel segmentation is difficult and takes more time. Meanwhile, most existing methods fail to effectively integrate clinical prior knowledge. In this work, we propose VANet, a novel LVO identification network which utilizes coarse-grained vessel feature for feature enhancement and learns asymmetry of two brain hemispheres on CTA of AIS patients. Firstly, we reconstruct 3D CTA scans into 2D based on maximum intensity projection (MIP) to reduce computational complexity and highlight vessel information. Secondly, we design a coarse-grained vessel aware module based on simple edge detection and morphological operations to acquire coarse-grained vessel feature without precise vessel segmentation. Thirdly, we design a vessel-guided feature enhancement that directs the model's attention to vessel areas in the images by utilizing coarse-grained vessel feature. Finally, inspired by the clinical knowledge that LVO can lead to asymmetry in brain, we design an asymmetry learning module utilizing deep asymmetry supervision to keep the patients' inherent asymmetry invariant and using asymmetry computing to acquire effective asymmetry features. We validate the proposed VANet on our private internal and external AIS-LVO datasets which contain 366 and 81 AIS patients, respectively. The results indicate that our proposed VANet achieves an accuracy of 94.54% and an AUC of 0.9685 on the internal dataset, outperforms 11 state-of-the-art methods (including general classification methods and LVO-specific methods). Besides, our method also achieves the best accuracy of 88.89% and AUC of 0.9111 when compared to 11 methods on the external test dataset, implying its good generalization ability. Interpretability analysis shows that the proposed VANet can effectively focus on vascular regions and learn asymmetry features.

Real world clinical experience of using Brainomix e-CTA software in a medium size acute National Health Service Trust

OBJECTIVES

Artificial intelligence (AI) software including Brainomix "e-CTA" which detect large vessel occlusions (LVO) have clinical potential. We hypothesized that in real world use where prevalence is low, its clinical utility may be overstated.

METHODS

In this single centre retrospective service evaluation project, data sent to Brainomix from a medium size acute National Health Service (NHS) Trust hospital between January 3, 2022 and January 3, 2023 was reviewed. 584 intracranial computed tomography angiogram (CTA) datasets were analysed for LVO by e-CTA. The e-CTA output and radiology report were compared to ground truth, defined by a consultant radiologist with fellowship neuroradiology training, with access to subsequent imaging and clinical notes. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated.

RESULTS

Of 584 cases (45% female, mean age 70 ± 16 years), 9% (n = 50) had LVO. e-CTA had a sensitivity of 0.78 (95% CI 0.64-0.88), specificity of 0.93 (0.9-0.95), PPV of 0.5 (0.42-0.58), and NPV of 0.98 (0.96-0.99). e-CTA had an error rate of 9% (52/584). Erroneous cases were categorized into causes for error. Common causes for false positives included incorrect anatomy (21%, 8/39) and other pathology (13%, 5/39), with several uncategorizable cases (39%, 15/39). Common causes for false negatives included LVO within the terminal internal carotid artery (ICA) (55%, 6/11) and uncategorizable (18%, 2/11).

CONCLUSIONS

We demonstrated that PPV of e-CTA is poor in consecutive cases in a real-world NHS setting. We advocate for local validation of AI software prior to clinical use.

ADVANCES IN KNOWLEDGE

Common AI errors were due to anatomical misidentification, presence of other pathology, and misidentifying LVO in the terminal ICA.

The Los Angeles Motor Scale is independently associated with cerebral blood flow < 30% volume in large vessel occlusions

Background and PurposeMechanical thrombectomy (MT) is the treatment standard for large vessel occlusion (LVO) stroke. Under current guidelines, only patients with smaller ischemic core volumes (ICV) are eligible for MT. Thus, it is of interest to quickly estimate ICV in stroke patients. The Los Angeles Motor Scale (LAMS) is a validated tool used to assess stroke severity directly in the field. This study aims to determine whether LAMS score is also associated with ICV, as defined by the CBF <30% volume on CT perfusion imaging.MethodsWe performed a retrospective, multicenter cohort study of consecutive patients presenting with LVO stroke from 9/1/2017 to 10/1/2023. The inclusion criteria were patients with (1) stroke caused by large vessel occlusion confirmed on CTA and (2) diagnostically adequate, multimodal pretreatment CT imaging. Demographic, clinical, and imaging data was collected through manual chart review. Both univariate and multivariate analyses were applied to assess associations. A p-value <.05 was considered significant.ResultsA total of 283 patients (median age: 69, IQR: 61-78) were included in the study. On multivariate logistic regression analysis, we found that lower admission LAMS score (adjusted OR: 0.511, 95% CI: 0.313-0.834, p = .007) was independently associated with a CBF <30% volume of less than 50cc.ConclusionsAdmission LAMS is an independent predictor of a CBF <30% volume of less than 50cc. This demonstrates that LAMS can be used to estimate ICV, which will aid in the early triaging of LVO patients to thrombectomy-capable centers.

Computational Modeling Of Immersed Non-spherical Bodies In Viscous Flows To Study Embolus Hemodynamics Interactions For Large Vessel Occlusion Stroke

Interactions of particles with unsteady non-linear viscous flows has widespread implications in physiological and biomedical systems. One key application where this plays a fundamental role is in the mechanism and etiology of embolic strokes. Specifically, there is a need to better understand how large occlusive emboli traverse complex vascular geometries, and block a vessel disrupting blood supply. Existing modeling approaches resort to key simplifications in terms of embolic particle shape, size, and their coupling to fluid flow. Here, we devise a novel computational model for resolving embolus-hemodynamics interactions for large non-spherical emboli approaching near occlusive regimes in anatomically real vascular segment. The formulation relies on extending an immersed finite element approach, coupled with a six degree-of-freedom particle dynamics model. The geometric complexities and their manifestation in embolus-flow and embolus-wall interactions are handles using a parametric shape representation, and projection of vessel signed distance fields on the particle boundaries. We illustrate our methodology and algorithmic details, as well as present examples of benchmark cases and convergence of our technique. Thereafter, we demonstrate a parametric study of large emboli for LVO strokes, showing that our methodology can capture the non-linear tumbling dynamics of emboli originating form their interactions with the flow and vessel walls; and resolve near-occlusive scenarios involving lubrication effects around the embolus and flow re-routing to non-occludes branches. This is a key methodological advancement in stroke modeling, as to the best of our knowledge this is the first modeling framework for LVO stroke and occlusion biofluid mechanics. Finally, even though we present our framework from the perspective of LVO strokes, the methodology as developed is broadly generalizable to two-way coupled fluid-particle interaction in unsteady viscous flows for a wide range of applications.

Transcutaneous Auricular Vagus Nerve Stimulation Reduces Inflammatory Biomarkers and May Improve Outcomes after Large Vessel Occlusion Strokes: Results of the Randomized Clinical Trial NUVISTA

Background

Inflammation plays a critical role in brain injury following acute ischemic stroke (AIS). Transcutaneous auricular vagus nerve stimulation (taVNS) has shown anti-inflammatory properties in various conditions, but its efficacy in AIS remains unexplored. We investigated if taVNS could mitigate post-AIS inflammation and its safety.

Methods

In this randomized, sham-controlled trial with blinded outcomes assessment, patients with anterior circulation large vessel occlusion (LVO) AIS were assigned to twice-daily taVNS or sham stimulation for five days or until discharge. Key inclusion criteria included age ≥18 years, National Institutes of Health Stroke Scale (NIHSS) ≥6, anterior circulation LVO, and enrollment within 36 hours of last known normal. Primary endpoints were changes in inflammatory biomarkers (white blood cells and cytokines including interleukins (IL)-1β, 6, 10, 17α, and tumor necrosis factor alpha (TNFα) measured at baseline and Days 1, 3, 5, and 7, and taVNS safety. Secondary exploratory endpoints included change in NIHSS, 90 day modified Rankin score (mRS), and safety (bradycardia, hypotension, infection, and death).

Results

Thirty-five patients (17 taVNS, 18 sham) were enrolled. The taVNS group showed a significant rate of change in normalized aggregate pro-inflammatory cytokines and interleukin-6 levels compared to sham (p=0.04 and p<0.001, respectively). Each 1 pg/mL reduction in interleukin-6 correlated with a 0.798-point improvement in NIHSS in the taVNS group (95% confidence interval [0.077, 1.518], p = 0.031]), with no significant correlation in the sham group. IL-1β, 10, 17α, and TNFα showed reduction in cytokine levels, but did not reach statistical significance. There were no statistically significant differences amongst mRS and safety outcomes between both groups.

Conclusions

taVNS safely reduced post-AIS inflammation in anterior circulation LVO stroke patients, demonstrating biological effects. Secondary analyses also found potential effects in NIHSS improvements. These promising findings warrant further investigation in larger trials.

Early statin use is associated with improved survival and cardiovascular outcomes in patients with atrial fibrillation and recent ischaemic stroke: A propensity-matched analysis of a global federated health database

INTRODUCTION

Statins reduce recurrent stroke and cardiovascular events in patients with non-cardioembolic stroke. The benefits of statins in patients with AF and recent IS remain unclear. We aimed to investigate the benefits of statins in patients with AF and recent IS.

PATIENTS AND METHODS

This retrospective, cohort study was conducted using deidentified electronic medical records within TriNetX platform. Patients with AF and recent IS, who received statins within 28 days of their index stroke were propensity score-matched with those who did not. Patients were followed up for up to 2 years. Primary outcomes were the 2-year risk of recurrent IS, all-cause mortality and the composite outcome of all-cause mortality, recurrent IS, transient ischaemic attack (TIA), and acute myocardial infarction (MI). Secondary outcomes were the 2-year risk of TIA, intracranial haemorrhage (ICH), acute MI, and hospital readmission. Cox regression analyses were used to calculate hazard ratios (HRs) with 95% confidence intervals (95%CI).

RESULTS

Of 20,902 patients with AF and recent IS, 7500 (35.9%) received statins within 28 days of their stroke and 13,402 (64.1%) did not. 11,182 patients (mean age 73.7 ± 11.5; 5277 (47.2%) female) remained after propensity score matching. Patients who received early statins had significantly lower risk of recurrent IS (HR: 0.45, 95%CI: 0.41-0.48, p < 0.001), mortality (HR: 0.75, 95%CI: 0.66-0.84, p < 0.001), the composite outcome (HR: 0.48, 95%CI: 0.45-0.52, p < 0.001), TIA (HR: 0.37, 95%CI: 0.30-0.44, p < 0.001), ICH (HR: 0.59, 95%CI: 0.47-0.72, p < 0.001 ), acute MI (HR: 0.35, 95%CI: 0.30-0.42, p < 0.001) and hospital readmission (HR: 0.46, 95%CI: 0.42-0.50, <0.001). Beneficial effects of early statins were evident in the elderly, different ethnic groups, statin dose intensity, and AF subtypes, large vessel occlusion and embolic strokes and within the context of statin lipophilicity, optimal LDL-cholesterol levels, various cardiovascular comorbidities, treatment with intravenous thrombolysis or endovascular thrombectomy, and NIHSS 0-5 and NIHSS > 5 subgroups.

DISCUSSION AND CONCLUSION

Patients with AF and recent IS, who received early statins, had a lower risk of recurrent stroke, death, and other cardiovascular outcomes including ICH, compared to those who did not.

The economic impact of stent retriever selection for acute ischemic stroke: a cost analysis of MASTRO I from the healthcare system perspective of the United States, Canada and eight European countries

Aim: According to the results of the MASTRO I living systematic review and meta-analysis, use of the EmboTrap Revascularization® Device in the treatment of acute ischemic stroke (AIS) results in higher rates of good functional outcomes (90-day modified Rankin Scale [mRS] 0-2) compared with use of the Trevo® Retriever or the Solitaire™ Revascularization Device. The aim of this analysis was to assess the potential economic impact of achieving improved functional outcomes for three commonly used stent retrievers (SRs) in the treatment of AIS. Methods: An economic model with short-term and long-term costs, representing a healthcare system perspective was developed using a decision tree to simulate a cohort of 1000 hypothetical patients treated for AIS with mechanical thrombectomy (MT) using EmboTrap, Trevo or Solitaire SRs. Based on the proportion of patients who achieved a 90-day mRS score of 0-2 or 3-5 for each device reported in MASTRO I (excluding patients not surviving after 90 days), this model estimated per-patient costs and the associated incremental cost savings. Results are reported from the healthcare system perspective in the US, Canada, the UK, Sweden, Germany, France, Italy, Spain, Belgium and The Netherlands. Results: Across all ten countries, the use of EmboTrap during MT was associated with the lowest short-term (ranging from €8412 in Italy to $66,525 in the US), long-term (ranging from €5249 in Italy to $25,757 in the US) and total (ranging from €13,661 in Italy to $92,282 in the US) per-patient costs. The total per-patient cost was higher with Trevo (ranging from €14,601 in Italy to $97,487 in the US) and Solitaire (ranging from €14,840 in Italy to $98,814 in the US). Cost savings were highest when comparing EmboTrap versus Solitaire, followed by EmboTrap versus Trevo, with Trevo versus Solitaire having the smallest cost savings. Results of sensitivity and scenario analyses supported the robustness of the base-case results. Conclusion: Across the ten countries, treating patients with AIS with EmboTrap resulted in lower short-term, long-term and total costs to the payer. With rising healthcare costs and limited hospital budgets, these results suggest EmboTrap proves to be an evidence-based economical choice of SR for hospitals and healthcare systems.

Brain Frailty on Neuroimaging Beyond Chronological Age Is Associated with Functional Outcome After Endovascular Thrombectomy in Patients with Anterior Large Vessel Occlusion

Background

Current guidelines have not recommended an upper age limit for endovascular thrombectomy (EVT) in patients with large vessel occlusion (LVO) stroke. However, elder age links to an increased risk of poor outcome. This study aimed to investigate the efficacy of EVT in elderly versus non-elderly patients and determine the respective factors of poor outcome.

Methods

Three hundred and two consecutive patients with LVO-stroke who underwent EVT were included, and we used sensitivity analysis with restricted cubic spline to define 75 years as the inflexion point. Participants were thus dichotomized into elderly (≥75 years) and non-elderly (<75 years) groups. Brain frailty on neuroimaging was evaluated using the global cortical atrophy (GCA) scale and the Fazekas scale for white matter lesions (WML). The primary outcome was 3-month functional outcome, and the secondary outcomes were EVT efficacy and safety.

Results

Elderly patients had significantly higher incidences of hypertension, diabetes mellitus, atrial fibrillation, and more severe GCA and WML. The rate of good outcome in elderly patients was 32%, significantly lower than non-elderly patients (54%, p<0.001). There was no difference in terms of reperfusion (89% vs 93%, p=0.363) and intracranial hemorrhage (38% vs 41%, p=0.826) between two groups. In elderly patients, high degree of GCA (OR 1.15, 95% CI 1.02-1.30, p=0.012) and moderate/severe WML (OR 5.88, 95% CI 1.47-23.50, p=0.015) independently predicted 3-month poor outcomes.

Conclusion

GCA and WML play pivotal roles for the functional outcomes in elderly patients undergoing EVT for LVO-stroke, providing valuable and practical information for early prediction of long-term prognosis.

Non-Contrast Computed Tomography-Based Triage and Notification for Large Vessel Occlusion Stroke: A Before and After Study Utilizing Artificial Intelligence on Treatment Times and Outcomes

Background/Objectives: The clinical impact of automated large vessel occlusion (LVO) detection tools using non-contrast CT (NCCT) is still unknown. We evaluated whether the implementation of Heuron ELVO, an artificial intelligence (AI)-driven software for triage and notification of LVO stroke using NCCT, can reduce treatment times and improve clinical outcomes in a real-world setting. Methods: We compared patients with LVO stroke before (pre-AI cohort, 84 patients) and after (post-AI cohort, 48 patients) the implementation of Heuron ELVO at a comprehensive stroke center. Primary outcomes included time-to-treatment initiation, including door-to-IV tPA and door-to-endovascular thrombectomy (EVT) times. Secondary outcomes measured changes in the National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) scores. Statistical analyses involved multiple linear regression to adjust for confounders. Results: The implementation of Heuron ELVO significantly reduced the door-to-EVT time (30.2 min, 95% CI, -56. to -4.3), CT-to-neurologist examination time (16.4 min, 95% CI, -27.6 to -5.3), and CT-to-EVT time (29.4 min, 95% CI, -53.6 to -5.0). There was no statistical difference in the door-to-IV tPA time (8.9 min). The post-AI cohort exhibited a greater improvement in the NIHSS score compared to the pre-AI cohort, with a reduction of 4.3 points. While the post-AI cohort demonstrated a higher proportion of good outcomes (mRS 0-1, 26% vs. 40%) at the 3-month follow-up, there was no statistical significance. Conclusions: The implementation of Heuron ELVO demonstrated substantial improvements in the timeliness of stroke interventions and patient outcomes. These findings underscore the potential of AI-driven NCCT analysis in enhancing acute stroke workflows and expediting treatments in real-world settings.

Cardiac CT in Large Vessel Occlusion Stroke for the Evaluation of Non-Thrombotic and Non-Atrial-Fibrillation-Related Embolic Causes

Background: The purpose of this study is the evaluation of imaging findings of acute-phase cardiac CT (cCT) in stroke patients with large vessel occlusion (LVO) to identify potential cardioembolic sources (CES) in patients without intracardiac thrombi and atrial fibrillation (AF). Material and Methods: This retrospective study included 315 patients with LVO who underwent cCT imaging in the acute stroke setting. The images were analysed for 15 imaging findings following the established minor and major cardioembolic risk factors. The final stroke aetiology was determined using the TOAST classification through interdisciplinary consensus following a thorough clinical evaluation. Multivariate regression analysis was performed to identify imaging findings associated with CES. Results: A cardioembolic aetiology was identified on cardiac CT in 211 cases (70%). After adjustment for AF and intracardiac thrombi, the multivariate regression analysis revealed significant associations with left ventricular dilation (adjusted odds-ratio (AOR) 32.4; 95% CI 3.0-349; p = 0.004), visible interatrial right-to-left shunt (AOR 30.8; 95% CI 2.7-341.3; p = 0.006), valve implants (AOR 24.5; 95% CI 2.2-270.9; p = 0.009), aortic arch atheroma grade > II (AOR 6.9; 95% CI 1.5-32.8; p = 0.015) and post-ischaemic myocardial scars (AOR 6.3, 95% CI 1.2-34.1; p = 0.032) as independent risk factors for a cardioembolic aetiology. The combined model achieved an area under the ROC curve of 0.83. Conclusions: In patients with LVO without AF and intracardiac thrombi as a cause, the presence of left ventricular dilatation, interatrial right-to-left shunts, valve implants, post-ischaemic myocardial scarring and advanced aortic arch atheroma (grade > 2) in particular is significantly associated with a cardioembolic cause of stroke and should be add-on evaluated in acute-phase cCT. Further investigations are warranted to confirm these associations.

A new taxonomy of neuroprotective agents for stroke appropriate for the reperfusion era

The advent of the era of highly effective reperfusion therapy for acute ischemic stroke has reawakened interest in neuroprotective treatments as they are far more likely to be efficacious as synergistic complements to reperfusion rather than standalone interventions. However, testing neuroprotective agents combined with reperfusion mandates not only renewed conduct of trials but also a fundamental reconceptualization of the subclasses of neuroprotection therapies. We propose a new taxonomy of neuroprotective treatment agents appropriate for the reperfusion era that recognizes six broad classes of agents, each targeting a distinct process and time epoch of injury: (1) Bridging neuroprotectives slow infarct expansion in the pre-reperfusion period, (2) Blood-brain barrier stabilizers restore the integrity of BBB before and early after reperfusion, (3) Microcirculation lumen preservers protect arteriolar and capillary endothelial cell integrity deterring the no-reflow phenomenon, (4) Reperfusion injury preventors block inflammatory, oxidative, and other processes that start immediately after reperfusion, (5) Edema reducers avert cerebral swelling and secondary injury due to brain tissue compression and herniation, and (6) Delayed neuroprotectives mitigate injury due to apoptosis and mitochondrial dysfunction in the late post-reperfusion period. This approach also broadly distinguishes neuroprotection from other major treatment strategies, including recanalization, collateral enhancement, and neurorepair. By focusing on broad physiologic targets of action rather than granular molecular mechanisms, this six-fold classification of neuroprotection can inform the design of preclinical studies and human clinical trials, including imaging biomarker endpoint selection and treatment timing. This updated taxonomy may accelerate the translation of cerebroprotective agents from bench to bedside.

The Role of Thrombo-inflammation in Ischemic Stroke: Focus on the Manipulation and Clinical Application

Stroke leaves a great economic burden due to its high morbidity and mortality. Rapid revascularization of targeted vessel(s) is the effective treatment for ischemic stroke, but subsequent ischemia-reperfusion (I/R) injury is a common complication following revascularization, leading to microcirculation dysfunction and infarct volume increase. Thrombo-inflammation, the interaction between thrombosis and inflammation, plays a critical role in the pathophysiology of ischemic stroke. In the context of I/R injury, thrombo-inflammation consists of platelet activation, endothelial injury, and inflammatory cell infiltration. Numerous studies are devoted to exploring methods of regulating thrombo-inflammation to mitigate I/R injury post-stroke, including blocking activations of platelets and neutrophils. Drugs such as antiplatelet medications, anticoagulants, and glucocorticoids have been confirmed to have the potential to regulate thrombo-inflammation. Furthermore, several recently developed drugs have also shown promises in relieving I/R injury by manipulating thrombo-inflammation. However, the majority of these studies are still in the preclinical stage. Herein, in this review, we will address the mechanisms of thrombo-inflammation in ischemic stroke, related research advances, and particularly the clinical feasibility of thrombo-inflammation as a therapeutic strategy against I/R injury.

Effect of prior use of statins on endovascular thrombectomy outcomes in acute ischemic stroke

INTRODUCTION

Acute large vessel occlusions (LVOs) account for up to one-third of acute ischemic strokes (AIS) and are associated with high mortality and severe functional deficits. Animal model research suggests that statins may have a protective effect on vessel wall injury during endovascular thrombectomy (EVT). We conducted a retrospective observational study to assess the impact of statin use on clinical outcomes post-EVT in AIS patients with LVOs.

METHODS

Using the Global Collaborative Network consisting of about 143 million patients in TriNetX database, we identified adult AIS patients who underwent EVT between 2018 and 2023. Patients were categorized based on any statin use (atorvastatin, simvastatin, rosuvastatin, pravastatin, lovastatin, or pitavastatin) in the 3 months before AIS admission. The primary outcome was all-cause mortality at one-week post-EVT. Secondary outcomes included intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), decompressive hemicraniectomy procedure (DHC), and aspiration pneumonia at one-week post-EVT. Propensity score matching balanced relevant medical history, stroke severity, medications, and demographics. Cox proportional hazard regression analysis compared outcomes between statin and non-statin cohorts.

RESULTS

We identified 17,774 patients who received EVT for LVO ischemic stroke. A total of 10,678 patients were on statins during 3 months prior to EVT and 7096 patients were not on statins. After 1:1 propensity matching, 2148 patients were included in each group. AIS patients treated with EVT and on statins had lower risk of all-cause mortality [7 % vs. 17 %; HR 0.43, 95 % CI 0.35-0.51], ICH [10 % vs. 15 %; HR 0.64, 95 % CI 0.51-0.74], SAH [3 % vs. 6 %; HR 0.48, 95 % CI 0.35-0.64], and aspiration pneumonia [4 % vs 8 %; HR 0.53, 95 % CI 0.41-0.70] compared to AIS patients treated with EVT but not on statins. Rates of DHC were similar between groups [2 % vs 2 %; HR 0.81; 95 % CI (0.52,1.25)].

CONCLUSION

Statin use within 3 months prior to AIS was associated with better survival and lesser intracranial bleeding risks and complications following EVT. Future studies may help examine how the duration or dosages of statins or LDL levels on admission affect outcomes in LVO strokes treated with EVT.

Emergency Admission Plasma D-Dimer and Prothrombin Activity: Novel Predictors for Clinical Outcomes After Thrombectomy in Acute Ischemic Stroke With Large Artery Occlusion

BACKGROUND

The coagulation system is intrinsically linked to pathological mechanisms and progression of ischemic stroke. However, the role of preoperative coagulation function in determining the functional outcomes of acute ischemic stroke patients following large artery occlusion (AIS-LVO) has not been extensively evaluated in peer-reviewed literature.

METHODS

We utilized logistic regression analyses, complemented by the construction of receiver operating characteristic (ROC) curves, to identify significant predictive factors for poor prognosis following endovascular thrombectomy (EVT). Additionally, subgroup analyses were conducted to further assess the prognostic efficacy of coagulation function across different subgroups.

RESULTS

A total of 607 patients were enrolled, with 335 (55.19%) experiencing an unfavorable outcome. Multivariate regression analysis identified preoperative D-dimer and PTA as independent predictors of 3-month prognosis. After adjusting for confounders, elevated preoperative D-dimer levels (≥ 715 mg/L), identified by cut-off value, were a significant predictor of poor prognosis, with 2.51-fold higher risk compared to the normal range. Conversely, elevated PTA levels (≥ 85.5%) were significantly and inversely associated with poor prognosis, indicating a reduced risk of 0.39 times. Furthermore, the combination of elevated D-dimer and reduced PTA demonstrated a synergistic effect, markedly increasing the risk of poor outcomes in AIS-LVO patients. Subgroup analyses revealed that failed recanalization, comorbid diabetes, and non-middle cerebral artery (MCA) occlusion significantly influence the predictive value of D-dimer and PTA for clinical outcomes.

CONCLUSION

Elevated admission D-dimer and reduced PTA levels are independent predictors of poor prognosis in patients with AIS-LVO, and there is a synergistic interaction between the two variables.

Poor venous outflow is associated with hyperintense acute reperfusion marker on follow-up MRI in patients with acute ischemic stroke with a large vessel occlusion

BACKGROUND

Hyperintense acute reperfusion marker (HARM) refers to delayed enhancement in the subarachnoid or subpial space on post-contrast fluid attenuated inversion recovery (FLAIR) images. HARM is a measure of blood-brain barrier breakdown, which has been correlated with poor outcomes in patients with acute ischemic stroke with large vessel occlusion (AIS-LVO). We hypothesized that unfavorable venous outflow (VO) would be correlated with HARM after thrombectomy treatment of AIS-LVO.

OBJECTIVE

To determine whether poor VO is associated with HARM on follow-up MRI after stroke in patients with AIS-LVO.

METHODS

Patients with AIS-LVO from the prospective CRISP2 and DEFUSE2 studies with a baseline CT angiography (CTA) scan and a follow-up MRI with FLAIR sequence were screened for enrollment. VO was measured on the baseline CTA scan using the cortical venous opacification score (COVES). HARM was determined on FLAIR sequences at the follow-up MRI. The primary outcome was the occurrence of HARM between those with good VO (VO+; COVES 3-6) and bad VO (VO-; COVES 0-2).

RESULTS

121 patients were included; 60.3% (n=73) had VO+ and 39.7% (n=48) had VO-. Patients with VO- had higher presentation National Institutes of Health Stroke Scale scores (18 (IQR 12-20) vs 12 (IQR 8-16) in VO+; P<0.001). Middle cerebral artery M1 segment occlusions were more common in VO- patients (65% vs 43% VO+; P=0.028). VO- patients also had a larger pre-treatment ischemic core (23 (4-44) mL vs 12 (3-22) mL in VO+; P=0.049) and Tmax >6 s volumes (105 (72-142) mL vs 66 (35-95) mL in VO+; P<0.001). VO- patients were more likely to develop HARM after thrombectomy (31% vs 10% in VO+; P=0.003). On multivariable regression analysis, VO- (OR=3.6 (95% CI 1.2 to 10.6); P=0.02) and the presence of any ICH (OR=3.6 (95% CI 1.2 to 10.5); P=0.02) were independently associated with the occurrence of HARM.

CONCLUSIONS

In patients with AIS-LVO, VO- correlated with HARM on post-thrombectomy MRI.

Higher intracranial positioning of an 8 Fr guide catheter improves efficacy of aspiration thrombectomy in large vessel occlusion stroke

BACKGROUND

Higher positioning of a large bore guide catheter during endovascular thrombectomy (EVT) is hypothesized to potentially improve thrombectomy success.

OBJECTIVE

To evaluate the safety and efficacy of intracranial guide catheter placement during EVT using a multicenter database.

METHODS

We reviewed data on consecutive patients undergoing EVT for anterior circulation large vessel occlusion (LVO) at three comprehensive stroke centers between October 2019 and December 2022. Participants were allocated to one of two cohorts: intracranial (n=141)-guide catheter tip positioned in the petrous carotid or further distal; and control (n=285)-guide catheter tip below the petrous carotid. Primary outcome was excellent reperfusion (Thrombolysis in Cerebral Ischemia (TICI) 2c or better), first pass effect (TICI 2c or better after one pass), and arterial access to final reperfusion time. The unpaired t-test, Mann-Whitney U test, and Fisher's exact test were used to compare themeans, medians and proportions of the two groups, respectively. P values & lt;0.05 were considered statistically significant two cohorts.

RESULTS

A total of 426 patients were included in the analysis. Patients with guide catheter location in the petrous segment or further distal had a significantly higher first-pass effect (111/284, 39.1% vs 37/141, 26.2%, P=0.009). There was no significant difference in final excellent recanalization rates between groups (202/285, 70.9% vs 92/141, 65.2%, P=0.266). Furthermore, intracranial positioning of the guide catheter was associated with significantly shorter time to final recanalization (median 21.0 (13.0-38.0) min vs 30.0 (17.0-48.0) min, P<0.001).

CONCLUSION

Positioning a large bore guide catheter in the petrous segment or further distal resulted in a significantly higher rate of first pass effect, faster procedural times, and equivalent final excellent reperfusion rates compared with more proximal guide catheter placement for patients with anterior circulation LVO.

Lean body mass and stroke volume, a sex issue

Introduction

Large vessel occlusions (LVO) account for over 60% of stroke-related mortality and disability. Lean body mass (LBM) represents metabolically active body tissue and has been associated with reduced mortality. This study aimed to investigate whether body composition influences LVO stroke perfusion volumes and whether this effect is sex-specific.

Methods

Data were retrospectively collected from all patients admitted between January 2017 and January 2022 with LVO ischemic stroke at the Erasmus Hospital (Brussels), for whom anthropometric and perfusion data were available. Body mass index (BMI) and LBM were calculated using, respectively, the Quetelet's and the James' formula. Correlations between body composition and stroke volumes were investigated using Spearman correlations.

Results

A total of 152 patients were included in this study. Mean age 72 ± 14y, female ratio 62.5%, core volume 26 ± 38 mL, penumbra volume 104 ± 61 mL. LBM correlated significantly with stroke volumes (penumbra and core) in the entire group (core: p = 0.001; penumbra: p = 0.001). There was a significant sex-effect, with a significant correlation observed only in women (core: p = 0.008; penumbra: p = 0.007). BMI did not correlate with perfusion volumes at the group level nor at the sex-level.

Conclusion

LBM significantly impacts LVO stroke volumes, but this effect is observed only in women. LBM may serve as a superior indicator of body composition compared to BMI.

Trends in utilization and impact of hospital procedural volume on mortality after endovascular thrombectomy for acute ischemic stroke

OBJECTIVES

Endovascular thrombectomy (EVT) has become an established treatment for eligible acute ischemic stroke (AIS) patients, but data on mortality trends and the association between procedural volume and outcomes in the United States is limited.

MATERIALS AND METHODS

This retrospective study analyzed data from the Nationwide Readmissions Database (NRD) to investigate trends in EVT utilization, outcomes, and the relationship between hospital procedural volume and inpatient mortality for AIS admissions between 2016-2020. Patients undergoing EVT were identified using ICD-10 procedure codes. Hospitals were categorized into quintiles based on EVT volumes, and mortality rates compared across quintiles. Multivariable regression identified predictors of mortality.

RESULTS

Of 2,535,777 AIS admissions, 90,110 (3.6 %) underwent EVT (median age of 70 and 50 % female in both groups). EVT utilization increased from 2.8 % in 2016 to 3.9 % in 2020 (p < 0.001). Patients receiving EVT had higher prevalence of atrial fibrillation and coronary artery disease but lower rates of hyperlipidemia and tobacco use. Inpatient mortality was higher with EVT (13 % vs 4 %, p < 0.001) but declined from 16 % in 2016-2017 to 12 % in 2020 (p < 0.001). Hemiparalysis and atrial fibrillation were associated with higher EVT likelihood. Mortality decreased with higher hospital EVT volume. After adjustment, higher procedural centers were associated with lower mortality.

CONCLUSION

EVT utilization for AIS increased nationally from 2016-2020 while associated mortality declined. Higher hospital procedural volumes were associated with lower mortality.

Thrombectomy Failure and Associated Factors for Large-Vessel Occlusion Stroke

BACKGROUND

Ischemic stroke due to Large Vessel Occlusion (LVO) represents a critical and time-sensitive neurological emergency. Advancements in imaging technology and endovascular therapies have transformed the management of LVO. Nonetheless, thrombectomy failure diminishes the chances of patients achieving a favorable clinical outcome.

OBJECTIVE

We aimed to determine the factors influencing recanalization failure in order to optimize thrombectomy therapy along with enhancing patient outcomes.

METHODS

A retrospective analysis was performed employing consecutive LVO patients who underwent Endovascular Thrombectomy (EVT) in a tertiary comprehensive stroke center between January 2020 and June 2024. Recanalization failure (mTICI 0-2a) following thrombectomy was assessed using the Kolmogorov-Smirnov test, χ2 test, Fisher's exact test, and multivariable logistic regression to identify the related factors.

RESULTS

A total of 82 EVT patients were analyzed. The mean age was 58.20 years and 70.73% of the patients were male. The rate of recanalization failure was 61%. Multivariable logistic regression analysis with age-sex adjusted factors has revealed hypertension [aOR: 5.31 (95% CI: 1.23-22.77); p =0.025] and no IVT [aOR: 2.75 (95% CI: 1.06-7.14); p =0.037] to be independent predictors of recanalization failure in this study.

CONCLUSION

Hypertension and the absence of prior intravenous thrombolysis have been found to be significant contributing factors to the high rate of thrombectomy failure in large-vessel occlusion.

Mechanical Thrombectomy Access Score: A Systematic Review and Modified Delphi of Global Barriers to Endovascular Therapy

BACKGROUND

The availability of mechanical thrombectomy (MT) for acute ischemic stroke is limited, and vast disparities exist between countries. We aim to create a MT access score to measure the drivers of access to help quantify and accelerate treatment worldwide.

METHODS

We used a systematic review complemented by a modified Delphi method. In the first of 3 rounds, 4 independent investigators performed a systematic literature review using key search terms that drive MT access, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In the second round, a panel of 6 anonymous international experts selected key attributes needed for scoring. In the final round, a total of 12 attributes were selected on consensus, each given a score on a 0 to 3 scale. An ultimate MT access score (range, 0-36) was proposed as a new tool to use in identifying barriers to MT access and assist in providing an initial framework for public health interventions.

RESULTS

Of 2864 abstracts screened, 121 studies were included in the final systematic review. A total of 34 attributes that potentially drive MT access were initially identified. In the final round, 12 attributes were selected by the expert panel: public awareness, emergency medical services transportation, prehospital large vessel occlusion screening, interhospital transfer policy, emergency department protocols, stroke imaging protocols, emergency department stroke expertise or telestroke availability, interventionalists, MT-capable centers, device availability, and insurance coverage. These attributes were weighted as part of the final score of 0 to 36.

CONCLUSIONS

The MT access score represents the first tool to quantify barriers to global MT access. Its implementation stands not just as an academic achievement but as a beacon of hope for improving stroke care and outcomes worldwide, bringing us a step closer to bridging the gap in stroke treatment disparities.

Safety and Effectiveness Analysis of Endovascular Treatment versus Standard Medication Treatment in Patients with Progressive Acute Ischemic Stroke with Large Vessel Occlusion Stroke in the Ultra-Late Time Window: A Propensity Score Matched Cohort Study

BACKGROUND

The time from onset to symptom deterioration in ischemic stroke often exceeds 24 hours, and this ultra-late time window is excluded from the endovascular treatment (EVT) guideline. This study aimed to explore the safety and efficacy of EVT in progressive acute ischemic stroke with large vessel occlusion stroke patients with onset to symptom deterioration times of 24 hours-7 days.

METHODS

Progressive stroke patients with time window of 24 hours-7 days treated at our hospital over the past 6 years were retrospectively collected. Patients were categorized into EVT and standard medication treatment (SMT) groups based on the treatment approach. Patients were matched using propensity score matching. Safety outcomes primarily included 3-month mortality and symptomatic intracranial hemorrhage; efficacy outcome primarily included functional independence (3-month modified Rankin scale ≤ 2).

RESULTS

A total of 396 patients were included in the study, with 86 (21.7%) in EVT and 310 (78.3%) in SMT group. There were 140 remaining after propensity score matching, with 70 in each group (50%). Compared to SMT group, EVT group had higher functional independence (52.9% vs. 15.7%, odds ratio [OR] = 7.504, 95% confidence interval [CI] 2.141-14.093, P < 0.001) and lower 3-month mortality (14.3% vs. 40.0%, OR = 0.412, 95% CI 0.099-0.856, P < 0.001). EVT was also associated with higher symptomatic intracranial hemorrhage (25.7% vs. 5.7%, OR = 9.926, 95% CI 1.874-36.547, P < 0.001).

CONCLUSIONS

For patients with progressive acute ischemic stroke with large vessel occlusion in the ultra-late time window, EVT remains a viable treatment approach.

Impact of COVID-19 pandemic on acute stroke care in a tertiary stroke centre

The aim of this study was to evaluate how COVID-19 affected acute stroke care and outcome in patients with acute ischemic or hemorrhagic stroke. We performed a retrospective analysis on patients who were admitted with acute ischemic (AIS) or hemorrhagic (ICH) stroke from September 2020 to May 2021 with and without COVID-19. We recorded demographic and clinical data, imaging parameters, functional outcome and mortality at one year. Beside descriptive statistics we performed χ2-probe, Mann-Witney U-test, Student t-probe and multivariate testing. We found a 29%-reduction in the number of AIS cases during the pandemic. The number of the large vessel occlusions /LVOs/ (N = 83, 41.7%), from them 37 (17.7%) had mechanical thrombectomy (MT), was higher than before the COVID-19 period (p = 0.02 and p = 0.001, respectively). From all patients needing acute revascularization therapy (N = 137) 118 patients received it, among them 20 (16.9%) had COVID-19. Those positive for COVID-19 were more likely to have a higher median NIHSS score at baseline and at 24 h (p = 0.02 and p = 0.03, respectively). They also had a lower rate of favourable outcome at discharge (15% vs. 41.8%; p = 0.024) and at three months (25% vs. 52%, p = 0.02), longer median hospitalization (p < 0.0001), and a higher mortality rate (52% vs. 25%; p = 0.03). The incidence of symptomatic intracerebral hemorrhage (sICH) did not differ between the groups. Regarding the ICH patients, NIHSS score at 24 h (p = 0.036), mortality at 3 months (p = 0.004) and at one year (p = 0.00) were higher in the COVID-19 group. We concluded that the pandemic resulted fewer admission due to AIS with an increased number of LVOs and MTs. AIS patients with concomitant SARS-CoV-2 infection have more severe strokes and unfavorable long term outcome. The risk of sICH was not increased in COVID-19 positive patients therefore reperfusion therapies appear to be safe and beneficial for some individuals. Patients with ICH and comorbid COVID-19 have a very poor prognosis.

A brief history of the development of transcranial tissue Doppler ultrasound

This article documents the early development of the first transcranial Doppler (TCD)-based ultrasound system for continuous monitoring of brain tissue pulsations (BTPs). Transcranial tissue Doppler (TCTD) uses a lightweight, wearable single-element ultrasound probe to track tissue motion perpendicular to the skin's surface, providing tissue displacement estimates along a single beam line. Feasibility tests using an adapted TCD system confirmed that brain tissue motion data can be obtained from existing TCD hardware. Brain Tissue Velocimetry (Brain TV), a TCTD data acquisition system, was then developed to provide a lightweight and portable means of continuously recording TCTD data in real-time. Brain TV measurements are synchronized to a 3-lead electrocardiogram and can be recorded alongside other physiological measurements, such as blood pressure, heart rate and end-tidal carbon dioxide. We have shown that Brain TV is able to record BTPs from sample depths ranging from 22 to 80 mm below the probe's surface and from multiple positions on the head. Studies in healthy volunteers, stroke patients and ultrasound phantom brain models demonstrate how TCTD might provide insights into the relationships between physiological measurements and brain tissue motion and show promise for rapid clinical assessment and continuous monitoring of BTPs.

The foam cell-derived exosomal miRNA Novel-3 drives neuroinflammation and ferroptosis during ischemic stroke

Large artery atherosclerosis (LAA) is a prevalent cause of acute ischemic stroke (AIS). Understanding the mechanisms linking atherosclerosis to stroke is essential for developing appropriate intervention strategies. Here, we found that the exosomal miRNA Novel-3 is selectively upregulated in the plasma of patients with LAA-AIS. Notably, Novel-3 was predominantly expressed in macrophage-derived foam cells, and its expression correlated with atherosclerotic plaque vulnerability in patients undergoing carotid endarterectomy. Exploring the function of Novel-3 in a mouse model of cerebral ischemia, we found that Novel-3 exacerbated ischemic injury and targeted microglia and macrophages expressing ionized calcium-binding adapter molecule 1 in peri-infarct regions. Mechanistically, Novel-3 increased ferroptosis and neuroinflammation by interacting with striatin (STRN) and downregulating the phosphoinositide 3-kinase-AKT-mechanistic target of rapamycin signaling pathway. Blocking Novel-3 activity or overexpressing STRN provided neuroprotection under ischemic conditions. Our findings suggest that exosomal Novel-3, which is primarily derived from macrophage-derived foam cells, targets microglia and macrophages in the brain to induce neuroinflammation and could serve as a potential therapeutic target for patients with stroke who have atherosclerosis.

Utility of A2L2 score in acute ischemic stroke patient triage: the "H.uni" experience

BACKGROUND AND AIMS

Two or more National Institutes of Health Stroke Scale (NIHSS) points on each motor items (A2L2 score) have shown good accuracy in predicting large vessel occlusion (LVO) in the prehospital setting of acute ischemic stroke (AIS) care. We aimed to study this score for LVO prediction in our stroke network and predictors of poor outcome (PO) after mechanical thrombectomy (MT).

METHODS

From our Safe Implementation of Thrombolysis in Stroke (SITS) registry including patients receiving reperfusion therapy for AIS, we retrospectively computed the A2L2 score from the admission NIHSS to test the diagnostic accuracy for LVO prediction. Multivariable analysis for independent predictors of LVO on the entire cohort and PO from patients with LVO were performed.

RESULTS

From the 853 patients with AIS (67% LVO), A2L2 was positive in 52%. A2L2 score (Odds ratio [OR] 4.6;95%CI 3.36-6.34), smoking (OR 2.1;95%CI 1.14-3.85), atrial fibrillation (OR 1.6;95%CI1.1-2.4) and younger age (OR 0.98;95%CI0.97-0.99) were independent predictors of LVO. A2L2 score showed 82%/49% positive/negative predictive values with 66% accuracy (64%/72% sensitivity/specificity) for LVO prediction. Age (OR 1.05;95%CI 1.03-1.07), atrial fibrillation (OR 4.85;95%CI 1.5-15.7), diabetes (OR 2.62;95% CI 1.14-6.05), dyslipidemia (OR 2;95% CI 1.04-3.87), A2L2 score (OR 2.68;95% CI 1.45-4.98), longer onset-to-groin time (OR 1.003;95% CI 1.001-1.01), MT procedure (OR 1.01;95%CI 1.003-1.02) general anaesthesia (OR 2.06;95% CI 1.1-3.83) and symptomatic intracranial hemorrhage (OR 12.10;95%CI 3.15-46.44) were independent predictors of PO.

CONCLUSIONS

A2L2 score independently predicted LVO and PO after MT. Patient characteristics and procedural factors determined PO of LVO patients after MT.

Navigating stroke care: Geospatial assessment of regional stroke center accessibility: Geospatial Assessment of Stroke Centers

INTRODUCTION

Reducing time between stroke onset and hospital intervention is crucial for positive outcomes in stroke patients. While EMS utilization decreases time to intervention, many US regions are not within timely proximity to an advanced-care-capable stroke center (ASC), defined as a comprehensive or thrombectomy-capable center. This study aims to utilize geographic methodology to identify regions in Wisconsin with both high stroke mortality and low physical accessibility to certified stroke centers (SCs), particularly ASCs.

METHODS

Geocoded mortality records for stroke death between 2015 and 2020 were accessed from the Wisconsin Department of Health Services. Indirectly age-standardized mortality ratios (SMRs) were estimated continuously across Wisconsin using adaptive spatial filtering and mortality records at the census block group level; the surface was then averaged by census tract for tract level SMRs. Addresses for SC locations within Wisconsin and bordering states were collected, and drive times from Wisconsin census tract centroids to the nearest SC subtypes were estimated. Drive times and mortality ratios were evaluated at the tract level alongside Rural-Urban Commuting Area (RUCA) codes. Spatial error regression modeling was used to determine RUCA classifications with the highest stroke risk independent of accessibility to stroke centers.

RESULTS

Approximately 50%, 68%, and 78% of Wisconsin residents resided within 30, 45, and 60 minutes of an ASC, respectively. Median drive time from census tract centroids to the nearest ASC were highest for rural tracts (M=90 minutes, IQR=68-115) compared to small-town (M=82 minutes, IQR=49-113), micropolitan (M=53 minutes, IQR=43-77), and metropolitan tracts (M=19 minutes, IQR=11-35; p<0.001). Clusters of high stroke SMRs were found in urban centers as well as rural areas irrespective of county declinations. Spatial regression modeling suggested small-town census tracts had the highest SMR irrespective of physical accessibility to care and spatial correlation. In small-town census tracts >45 minutes from the nearest ASC, the median stroke SMR was 1.12 (IQR=0.94-1.40) with 226,000 residents and 150 stroke deaths per year.

CONCLUSION

Small-town areas are associated with both long drive distance to ASC locations and high stroke mortality. Geographical analyses reveal apparent stroke care deserts and may inform strategic allocation of emergency medicine resources and coverage.

Safety and Efficacy of Thrombectomy in Vietnamese Stroke Patients Selected through Perfusion Imaging with an Onset Time between 6 and 24 Hours

INTRODUCTION

Recent trials have demonstrated the remarkable benefit of endovascular treatment (EVT) up to 24 h in patients with large vessel occlusion (LVO) and target mismatch profiles; however, benefits of late-window EVT in Vietnamese population remain poorly understood. This study aims to evaluate the real-world outcomes of EVT in acute ischemic stroke (AIS) patients selected using perfusion imaging within the 6-24-h window.

METHODS

This is a prospective study of consecutive patients with anterior circulation LVO stroke who underwent EVT within 6-24 h after last known well between August 2022 and March 2024. Patients were selected based on the DAWN/DEFUSE-3 criteria (Perfusion-RAPID, iSchemaView). The primary outcome was the proportion of patients with functional independence at 90 days (modified Rankin Scale score of 0-2). The secondary outcomes were successful reperfusion defined by thrombolysis in cerebral infarction (TICI) ≥2b on the final procedure and subgroup analysis between good (hypoperfusion intensity ratio [HIR] <0.4) and poor collaterals (HIR ≥0.4) groups. Safety outcomes were mortality rate and symptomatic intracranial hemorrhage (sICH).

RESULTS

Of 122 enrolled patients, 68% met inclusion criteria of DEFUSE-3 trial, 61% met DAWN trial criteria. Mean age was 66 years, median baseline NIHSS was 13, median time from stroke onset to hospital arrival was 12.55 h (9.50-16.48), and median infarct volume was 11.5 mL. The rate of functional independence at 90 days was 45.9%. Successful reperfusion (TICI score of ≥2b) was achieved by 83.6% of cases. The 90-day mortality rate was 10.7%; sICH was reported in 8 patients (6.6%). Patients with good collaterals had better functional outcome.

CONCLUSIONS

This real-world observational study suggests that late-window EVT may be safe and effective in eligible Vietnamese patients selected based on perfusion imaging, thus supporting its practical use in this patient population. HIR is a robust indicator of collateral status and could made it a valuable addition to stroke imaging workup in clinical setting.

Platelet-Function-Monitoring-Guided Therapy After Emergent Carotid Artery Stenting

Background/Objectives: Antiplatelet therapy after emergent carotid stenting (eCAS) represents a challenge in balancing the risk of intracerebral hemorrhages (ICHs) and in-stent thrombosis (IST). Post-procedural platelet function monitoring may guide antiplatelet therapy and could potentially improve outcomes due to fewer post-procedural complications. Methods: Consecutive eCAS patients (2019-2021) were included in a single-center retrospective observational study. Patients treated with eCAS received peri-procedural eptifibatide followed by dual antiplatelet treatment with aspirin and clopidogrel. The effect of platelet ADP inhibition by clopidogrel was monitored using the Multiplate® Analyzer (Roche). Clopidogrel non-responders were changed to ticagrelor treatment. The primary outcome was defined as a favorable outcome at 90 days using the modified Rankin Scale (mRS) of 0-2 versus 3-6. Safety outcomes included ICH, IST, and mortality. Data were analyzed and compared in clopidogrel- and ticagrelor-treated patients using Fischer's exact test and multivariate logistic regression. Results: A total of 105 patients had eCAS, and 28 patients (27%) were clopidogrel non-responders and were changed to treatment with ticagrelor. The favorable outcome was more frequent in ticagrelor-treated patients, 23 (82%), than in clopidogrel-treated patients, 44 (57%), p = 0.036. Numerically, ICH, IST, and mortality were more frequent in clopidogrel-treated patients, but none of the differences were statistically significant. In multivariate analyses, ticagrelor treatment was significantly associated with the favorable outcome, OR = 3.89 (95% CI: 1.09-13.86), p = 0.036. Conclusions: One in four eCAS patients were clopidogrel non-responders. This study suggests that personalized antiplatelet treatment therapy was safe, and that changing treatment to ticagrelor in clopidogrel non-responders was associated with better outcomes in eCAS patients.

Early recanalization after tenecteplase versus alteplase: Experience in a large stroke network

INTRODUCTION

Previously published data are conflicting regarding the ability of tenecteplase versus alteplase to produce early recanalization of an intracranial large vessel occlusion. We compared the performance of each thrombolytic in a stroke network.

METHODS

We queried our prospectively collected code stroke registry for basilar, internal carotid, or proximal middle cerebral artery occlusion patients treated with intravenous thrombolysis from 11/17/2021-9/16/2023. The primary outcome was early recanalization, defined using angiographic or clinical criteria. Secondary and safety outcomes included 90-day functional independence and symptomatic intracranial hemorrhage. A multivariable regression analysis was performed to determine independent associations with the primary outcome.

RESULTS

233 patients, with mean age 66.9 (16.6) years and median National Institutes of Health Stroke Scale score 15 (10-21), were included. One-hundred twenty-four of 233 (53.2 %) patients were treated with alteplase while 109/233 (46.8 %) were treated with tenecteplase. Endovascular thrombectomy was performed in 82 % of subjects. Early recanalization rates were similar between the groups (alteplase 22.6 %, tenecteplase 14.7 %; p = 0.14), as were rates of 90-day independent neurological function, symptomatic intracranial hemorrhage, and mortality. Patients with an internal carotid artery occlusion or with higher presenting stroke severity were less likely to achieve early recanalization.

CONCLUSIONS

Tenecteplase and alteplase have similar rates of early recanalization, 90-day functional independence, and safety outcomes in large vessel occlusion patients. Occlusion site and stroke severity predict response to thrombolysis. Future studies may investigate other factors associated with a positive response to thrombolytics as expanded treatment indications are explored.

A 9-Fr Endovascular Therapy Transducer With an Acoustic Metamaterial Lens for Rapid Stroke Thrombectomy

Large vessel occlusion (LVO) stroke, in which major cerebral arteries such as the internal carotid and middle cerebral arteries supplying the brain are occluded, is the most debilitating form of acute ischemic stroke (AIS). The current gold standard treatment for LVO stroke is mechanical thrombectomy; however, initial attempts to recanalize these large, proximal arteries supplying the brain fail in up to 75% of cases, leading to repeated passes that decrease the likelihood of success and affect patient outcomes. We report the design, fabrication, and testing of a mm forward-treating ultrasound (US) transducer with an acoustic metamaterial lens to dissolve blood clots recalcitrant to first-pass mechanical thrombectomy in LVO stroke. Due to the lens with microscale features, the device was able to produce a increase in peak negative pressure (PNP) (4.3 versus 1.8 MPa) and increase in blood clot dissolution rate ( versus mg/min) with 90% mass reduction after 30 min of treatment. In this small endovascular form factor, the acoustic metamaterial lens increased the acoustic output from the transducer while minimizing the US energy delivered to the surrounding areas outside of the treatment volume.

Caregiver burden, hopelessness, and anxiety: Association between sociodemographic and clinical profiles of patients with stroke

OBJECTIVES

This study aimed to evaluate the association between the sociodemographic characteristics of caregivers and patients with stroke, clinical data on stroke, and disability with caregiver burden, hopelessness, and anxiety.

MATERIALS AND METHODS

This cross-sectional study included patients with stroke of either sex, aged >18 years. Data were collected between January 2020 and July 2021. Patient demographic included age, sex, stroke type, severity, etiology, topography, treatment, and stroke recurrence. Stroke disability was assessed using the modified Rankin Scale and Barthel Index at 90 days post-discharge. Additionally, caregiver burden, hopelessness, and anxiety were evaluated during patient consultations using the Zarit Burden Interview (ZBI), Beck Hopelessness Scale (BHS), and Beck Anxiety Inventory (BAI).

RESULTS

We included 104 patients with stroke and their caregivers. Overall caregiver burden was moderate (ZBI: 24 [25]), with mild hopelessness (BHS: 4 [4]) and minimal to mild anxiety (BAI: 8 [13]). The linear regression model presented in Table 3 showed that female caregivers scored up to 11 points higher on the Zarit Burden Interview (p = 0.011). Additionally, increased patient age was associated with a higher caregiver burden (p = 0.002) on the Zarit Burden Interview. Posterior circulation stroke and total anterior circulation stroke were also associated with higher Zarit Burden Interview scores compared to lacunar stroke (p = 0.017). Age was not associated with caregiver burden in the entire sample. However, an association between age and caregiver burden was found only in the female group. Furthermore, women aged 65 years and older experienced a more severe burden than women aged 18 to 64 years (p<0.001). Stroke disability was not associated with caregiver burden.

CONCLUSIONS

Older female caregivers were significantly affected when caring for stroke patients. Total anterior circulation stroke and Posterior circulation stroke increased Zarit Burden Interview scores. However, no association was observed between stroke disability and the caregiver burden.

A systematic review of the socioeconomic impact of mechanical thrombectomy for acute ischemic stroke

BACKGROUND

Mechanical Thrombectomy (MT) is an efficacious treatment for severe acute ischemic stroke patients. However, access to MT is limited in many parts of the world, partly due to economic barriers. The purpose of this systematic review is to provide an updated frame about the socioeconomic impact of MT.

METHODS

To carry out this systematic review we used the PRISMA guidelines. We included scientific articles analyzing the socioeconomic impact of MT for acute ischemic stroke, in which MT was compared to best medical therapy (BMT). The online databases of Pubmed, Scopus and Web of Science were used as main sources of information. To carry out the comparative analysis, the incremental cost-effectiveness ratio (ICER) was used, relating the cost to quality-adjusted life-year (QALY). Risk of bias was assessed with the Consensus Health Economic Criteria (CHEC) and the Consolidated Health Economic Evaluation Reporting Standards (CHEERS).

RESULTS

Eight hundred thirty-two studies were identified in this systematic review. As a result, studies that used cost-effectiveness analysis show that MT saves costs in the long term and cost-utility analysis show that the cost per QALY is reasonable with a mean ICER value of $14242.36/QALY.

CONCLUSIONS

MT has a favorable socioeconomic impact, as derived from cost-effectiveness and cost-utility analyses. Therefore, public policies should encourage the implementation of MT for stroke patients around the world.

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

BACKGROUND/OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Combined Selective Endovascular Brain Hypothermia with Edaravone Dexborneol versus Edaravone Dexborneol Alone for Endovascular Treatment in Acute Ischemic Stroke (SHE): Protocol for a Multicenter, Single-Blind, Randomized Controlled Study

INTRODUCTION

Selective endovascular brain hypothermia has been proposed as a potential neuroprotective strategy; however, its effectiveness is still not well established. The primary objective of this trial is to investigate the efficacy and safety of selective endovascular brain hypothermia with edaravone dexborneol for endovascular treatment in acute ischemic stroke (AIS).

METHODS

The SHE study is a multicenter, single-blind, randomized controlled clinical trial. Patients with acute anterior circulation ischemic stroke who received endovascular treatment within 24 h after stroke onset and achieved successful recanalization will be enrolled and centrally randomized into combined selective endovascular brain hypothermia with edaravone dexborneol or edaravone dexborneol alone groups in a 1:1 ratio (n = 564). Patients allocated to the hypothermia group will receive 300 mL cool saline at 4°C through guiding catheter (30 mL/min) into target vessel within 3 min after recanalization and then receive edaravone dexborneol (edaravone dexborneol 15 mL + NS 100 mL ivgtt bid for 10-14 days) within 24 h after admission. The control group will receive 300 mL 37°C saline (30 mL/min) infused into target vessel through guiding catheter and then receive edaravone dexborneol. All patients enrolled will receive standard care according to current guidelines for stroke management. The primary outcome is the proportion of functional independence, defined as a mRS score of 0-2 at 90 days after randomization.

CONCLUSION

This is a randomized clinical trial with a large sample size to compare combined selective endovascular brain hypothermia and edaravone dexborneol with edaravone dexborneol alone in patients with acute anterior ischemic stroke. The SHE trial aims to provide further evidence of the benefit of selective endovascular brain hypothermia in AIS patients who received endovascular treatment.

Race, Ethnicity, and Gender Disparities in the Management and Outcomes of Critically Ill Adults with Acute Stroke

Racial, ethnicity and sex disparities are pervasive in the evaluation and acute care of ischemic stroke patients. Administration of intravenous thrombolysis and mechanical thrombectomy are the most critical steps in ischemic stroke treatment but compared to White patients, ischemic stroke patients from minority racial and ethnic groups are less likely to receive these potentially life-saving interventions. Sex and racial disparities in intracerebral hemorrhage or subarachnoid hemorrhage treatment have not been well studied.

The Los Angeles motor scale (LAMS) and ASPECTS score are independently associated with DSA ASITN collateral score

BACKGROUND

Mechanical thrombectomy (MT) is the treatment standard in eligible patients with acute ischemic stroke (AIS) secondary to large vessel occlusions (LVO). Studies have shown that good collateral status is a strong predictor of MT efficacy, thus making collateral status important to quickly assess. The Los Angeles Motor Scale is a clinically validated tool for identifying LVO in the field. The aim of this study is to investigate whether admission LAMS score is also associated with the American Society of Interventional and Therapeutic Neuroradiology (ASITN) collateral score on digital subtraction angiography (DSA).

METHODS

We conducted a retrospective multicenter cohort study of consecutive patients presenting with AIS caused by LVO from 9/1/2017 to 10/1/2023 with diagnostically adequate DSA imaging. Demographic, clinical, and imaging data was collected through manual chart review. Both univariate and multivariate analysis were applied to assess associations. A p-value <0.05 was considered significant.

RESULTS

A total of 308 patients (median age: 68, IQR: 57.5-77) were included in the study. On multivariate logistic regression analysis, we found that lower admission LAMS score (adjusted OR: 0.82, 95% CI: 0.68-0.98, p < 0.05) and higher ASPECTS score (adjusted OR: 1.21, 95% CI: 1.02-1.42, p < 0.05) were independently associated with good DSA ASITN collateral score of 3-4.

CONCLUSIONS

Admission LAMS and ASPECTS score are both independently associated with DSA ASITN collateral score. This demonstrates the capability of LAMS to act as a surrogate marker of CS in the field.

Repeated mechanical thrombectomy for recurrent large vessel occlusion: A systematic review and meta-analysis

BACKGROUND

Mechanical thrombectomy (MT) is the standard treatment for acute large vessel occlusion (LVO). Recurrent LVO can still occur in patients who already underwent MT for the first LVO. This study aimed to evaluate the efficacy of repeating MT for recurrent LVO.

METHODS

This meta-analysis of the available literature was conducted to summarize the current evidence regarding repeated MT outcomes in patients with recurrent LVO. All studies with ≥ 1 outcomes of interest were included. The Newcastle-Ottawa Scale (NOS) was used for risk of bias assessment.

RESULTS

Twenty studies, 10 observational (n = 21,251 patients) and 10 case reports (n = 10 patients), were included. 266 patients (62.78% females) with recurrent LVO were identified, with an overall prevalence of 1.6% and a mean age of 65.67 ± 16.23 years. Cardio-embolism was the most common mechanism in both times, with a median of 15 days between the first and second LVOs. Compared with pre-intervention, the first and second MTs significantly reduced the National Institute of Health Stroke Scale (NIHSS) score, (mean difference (MD) = -8.91) and (MD = -5.97) respectively, with a significant difference (p = 0.001). The rate of favorable outcome (modified Rankin scale (mRS) score 0-3) was 82.6% and 59.2% after the first and second MTs respectively, with a significant difference (p < 0.001).

CONCLUSION

In properly selected recurrent LVO patients, repeated MT is efficacious and safe. A prior MT procedure should not discourage aggressive treatment as many patients may achieve favorable outcomes.

A prospective, randomized, controlled, interventional clinical trial to evaluate the safety and efficacy of the medical monopoint reperfusion system for aspiration thrombectomy in acute ischemic stroke patients (SUMMIT MAX): Trial rationale and design

BACKGROUND

Treatment of large vessel occlusion (LVO) using mechanical thrombectomy with or without intravenous thrombolysis has demonstrated better outcomes compared to medical treatment alone. Large-bore aspiration catheters have been recently introduced. Their effectiveness and safety have not been demonstrated in a randomized trial. The SUMMIT MAX study is designed to address this question.

METHODS

SUMMIT MAX is a randomized controlled trial where the effectiveness and safety of the large-bore Monopoint Reperfusion system (Route 92 Medical, San Mateo, CA), will be compared to the currently largest available FDA-cleared aspiration thrombectomy device the AXS Vecta Aspiration system (Stryker Neurovascular, Fremont, CA). The study is a multi-center, prospective, randomized, controlled, interventional, open label clinical trial. The hypothesis is that the effectiveness measured by the recanalization rate (modified thrombolysis in cerebrovascular infarction - mTICI) and safety measured by symptomatic intracranial hemorrhage rate (sICH) of the medical monopoint reperfusion system is non-inferior to the AXS Vecta Aspiration system.

RESULTS

Up to 250 subjects are enrolled with at least 50% of subjects enrolled by US sites. The primary effectiveness endpoint is successful arterial revascularization defined as an mTICI score ≥ 2b after use of the assigned device adjudicated by an independent core lab. The primary safety endpoint is defined as sICH within 24 h (-8/+24) post-procedure. Secondary endpoints include successful arterial revascularization defined as a mTICI score ≥ 2b after use of the assigned device with or without adjunctive therapy; device-related serious adverse events; all asymptomatic hemorrhages; time from groin puncture to final angiogram; and rate of first pass effect defined as mTICI 2b after first pass with the assigned device stratified by age (≤85, ≥ 86).

CONCLUSION

SUMMIT MAX is a randomized controlled trial comparing the effectiveness and safety of a new large bore class of aspiration devices to the currently largest FDA-cleared aspiration device available.