Predictive Factors for Good Outcome and Mortality After Stent-Retriever Thrombectomy in Patients With Acute Anterior Circulation Stroke

Intracranial hemorrhage risk in patients with cerebral microbleeds after mechanical thrombectomy for acute ischemic stroke: a systematic review and meta-analysis

Background and purpose intracranial hemorrhage risk in patients with cerebral microbleeds (CMBs) after mechanical thrombectomy for acute ischemic stroke (AIS) was investigated. We searched PubMed and Embase from inception to 29 August 2023 for relevant studies, calculated pooled odds ratio (ORs) of intracerebral hemorrhage (ICH) subtypes in AIS patients with CMB presence, 1-4 or ≥ 5 CMBs versus CMB absence, and with different CMB locations after mechanical thrombectomy. ICH subtypes included any ICH, symptomatic and asymptomatic ICH, hemorrhage outside infarct (including subarachnoid hemorrhage), hemorrhagic infarction, and parenchymal hemorrhage after mechanical thrombectomy. Five eligible studies enrolling 2051 patients were included. No significant association was shown between CMB locations (lobar, deep, infratentorial or mixed) and ICH risk. CMB presence or 1-4 CMBs did not significantly increase the risk of any ICH, symptomatic or asymptomatic ICH, ICH outside infarct, subarachnoid hemorrhage, hemorrhagic infarction, or parenchymal hemorrhage. CMBs ≥ 5 increased the risk of any ICH (OR 2.58, 95% CI 1.16-5.72), parenchymal hemorrhage (OR 3.38, 95% CI 1.43-7.97) and parenchymal hemorrhage-2 (OR 5.33, 2.05-13.86), without increasing hemorrhagic infarction or parenchymal haemorrhage-1 risk. After adjusted for possible confounding factors, increases in CMB burden were associated with hemorrhagic complications but not with symptomatic ICH. In AIS patients who received mechanical thrombectomy, no association was shown between CMB location and ICH risk. ICH risk was not significantly increased by CMB presence or 1-4 CMBs. ICH risk in patients with ≥ 5 CMBs requires further study.

Kidney dysfunction predicts 90 days mortality after stroke thrombectomy independent of cardiovascular risk factors and chronic kidney disease

INTRODUCTION

Kidney dysfunction (KD) is a risk factor for cerebrovascular events and has been shown to have a detrimental effect on outcome after stroke. We evaluated the influence of KD at admission and pre-existing diagnosis of chronic kidney disease (CKD) before thrombectomy for anterior circulation stroke on functional independence and mortality 90 days after stroke in this cross-sectional study.

PATIENTS AND METHODS

We included patients with acute ischemic stroke in the anterior circulation treated with thrombectomy at our hospital between June 2015 and May 2022. We analyzed clinical characteristics, laboratory values and pre-existing diagnosis of CKD. KD at admission was defined as glomerular filtration rate (GFR) <60 ml/min/1.73 m2. Outcomes were defined as a modified Rankin Scale Score of 0-2 for functional independence and mortality at 90 days. We fitted multivariate regression analysis to examine the influence of pre-treatment KD and pre-diagnosed CKD on outcome.

RESULTS

Nine hundred fifty-three patients were included in this analysis (mean age 73.8 years, 54.2% female). KD was present in 31.8%, and patients with KD were older and more often female, presented more often with comorbidities such as arterial hypertension, diabetes, and atrial fibrillation, and were less often independent before the index stroke. In multivariate analysis adjusted for age, independence before the index stroke, diabetes, hypertension, atrial fibrillation, initial NIHSS, thrombolysis treatment, and recanalization outcome, KD on admission had no significant influence on functional independence 90 days after stroke, but predicted mortality with an odds ratio of 1.80 (95% CI 1.23-2.63, p = 0.003). This influence also persisted when controlling for pre-diagnosed CKD (OR 1.60, 95% CI 1.05-2.43, p = 0.027).

DISCUSSION

KD might function as a surrogate parameter for comorbidity burden and thus increased risk of mortality in this cohort.

CONCLUSIONS

KD on admission is associated with an 80% higher risk of mortality at 90 days after stroke thrombectomy independent of cardiovascular risk factors and CKD awareness. KD on admission should not exclude patients from thrombectomy but might support prognostic evaluation.

Functional long-term outcome following endovascular thrombectomy in patients with acute ischemic stroke

Endovascular thrombectomy (EVT) is the most effective treatment for acute ischemic stroke caused by large vessel occlusion (LVO). Yet, long-term outcome (LTO) and health-related quality of life (HRQoL) in these patients have rarely been addressed, as opposed to modified Rankin scale (mRS) recordings. We analysed demographic data, treatment and neuroimaging parameters in 694 consecutive stroke patients in a maximum care hospital. In 138 of these patients with respect on receipt of written informed consent, LTO and HRQoL were collected over a period of 48 months after EVT using a standardised telephone survey (median 2.1 years after EVT). Age < 70 years (OR 4.82), lower NIHSS on admission (OR 1.11), NIHSS ≤ 10 after 24 h (OR 11.23) and complete recanalisation (mTICI3) (OR 7.79) were identified as independent predictors of favourable LTO. Occurrence of an infection requiring treatment within the first 72 h was recognised as a negative predictor for good long-term outcome (OR 0.22). Patients with mRS > 2 according to the telephone survey more often had complaints regarding mobility, self-care, and usual activity domains of the HRQoL. Our results underline a sustainable positive effect of effective EVT on the quality of life in LVO stroke. Additionally, predictive parameters of outcome were identified, that may support clinical decision making in LVO stroke.

External validation of TICI-ASPECTS-glucose score as a predictive model for symptomatic intracranial hemorrhage following mechanical thrombectomy

INTRODUCTION

The indication for mechanical thrombectomy for acute ischemic stroke (AIS) secondary to large vessel occlusion has substantially increased in the past few years, but predictors of symptomatic intracranial hemorrhage (sICH) remain largely unstudied. A recent study assessing these predictors, led to the development of the TICI-ASPECTS-glucose (TAG) score, an internally validated model to predict sICH following thrombectomy.

METHODS

To externally validate this scoring system and identify other potential risk factors for hemorrhagic conversion following endovascular therapy for AIS, 420 consecutive patients treated with mechanical thrombectomy from 2014-2017 were retrospectively reviewed. Data were collected pertaining to admission factors, procedural metrics, and functional outcomes. The components comprising the TAG score consist of modified thrombolysis in cerebral infarction (mTICI) score (mTICI 0-2a=2 points; 2b-3=0 points), Alberta stroke program early CT (ASPECTS) score (<6=4 points, 6-7=2 points, ≥8=0 points), and glucose (≥150 mg/dL=1 point, <150 mg/dL=0 points). Statistical analyses including univariate analysis, logistic regression analysis, and area under the receiver-operating curve (AUROC) were performed to validate the predictive capability of the model.

RESULTS

The patients with sICH presented with lower ASPECTS (8.13±1.55 v 9.16±1.24, p < 0.001), but no significant correlation with mTICI scores and admission glucose was observed. Decreasing ASPECTS correlated with increased risk of sICH (OR 1.57, 95% CI 1.25-1.96, p < 0.001), and increasing TAG score was associated with increased sICH (OR 1.46, 95% CI 1.11-1.94, p < 0.01). AUROC of the model was 0.633. Stratifying patients into low (TAG 0-2), intermediate,^3,4 and high^5-7 risk groups identified similar results to the original study with sICH risks of 5.2%, 10.5%, and 33.3%, respectively.

CONCLUSION

The TICI-ASPECTS-glucose (TAG) score adequately predicts sICH following mechanical thrombectomy, and appropriately stratifies individual patient risk. Further inclusion of additional predictors of sICH would likely yield a more robust model.

Predictors of three months mortality after endovascular mechanical thrombectomy for acute ischemic stroke

Objective

This study aims to determine predictive factors of mortality within 3 months after mechanical thrombectomy (MT) for patients with acute ischemic stroke (AIS).

Methods

This prospective cohort study was carried out at Assiut University stroke center in collaboration with Ain Shams University Egypt. Forty-four patients with anterior circulation AIS underwent MT between the first of January 2020 to the end of December 2020. They were evaluated for detection of death rates and identification of risks of 3-month mortality after MT.

Results

This study comprised 44 patients (52.3% male) with a mean age of 64.3 years. The mean time from onset to femoral arterial puncture was 304.1 min. The mean Alberta Stroke Program Early CT Score (ASPECTS) and National Institutes of Health Stroke Scale (NIHSS) score were 9.3 and 19.2, respectively. The 3-month mortality rate was 13.6%. Univariate analyses found that higher baseline NIHSS score (mean 22.2 vs. 18.7, p = 0.021), absence of good collateral (16.7% vs. 68.4%, p = 0.02), longer duration of procedure ≥ 60 min (66.7% vs. 23.7%, p = 0.032), lower rates of successful recanalization (83.3% vs. 28.9%, p = 0.01) and developing symptomatic intracerebral hemorrhage (33.3% vs. 5.3%, p = 0.026) were associated with 3-month mortality. Multivariate analyses found that low rates of successful recanalization (OR 0.081; 95% CI 0.009–0.780, p = 0.030) remained significant independent predictive factor of 3-month mortality.

Conclusion

Successful recanalization was an independent predictor of 3-month mortality after MT.

Predictive Factors for Clinical Outcome After Direct Mechanical Thrombectomy for Anterior Circulation Large Vessel Occlusion Within 4.5 h

Background

Recent trials including DIRECT-MT, DEVT, and SKIP have found that direct mechanical thrombectomy (MT) is equally effective as the combination of MT and intravenous thrombolysis. However, the results of the other trials, namely MR-CLEAN NO-IV and the SWIFT-DIRECT trial have failed to confirm the non-inferiority of direct MT vs. the combination therapy.

Aim

We aimed to identify prognostic factors of direct MT for anterior circulation large vessel occlusion within 4.5 h.

Materials and Methods

Data from January 2018 to January 2022 were retrospectively collected and analyzed. Adult patients with confirmed anterior circulation large vessel occlusion within 4.5 h of onset with baseline NIHSS of ≥6 and baseline ASPECTS of ≥6 treated using direct MT within 6 h were recruited.

Results

A total of 140 patients were enrolled in the study with a median age of 65.5 years [interquartile range (IQR), 59-76.5], median baseline NIHSS of 13.5 (IQR, 11-16), and median baseline ASPECTS of 8 (IQR, 7-8). Direct MT was feasible in all patients (100%). Successful reperfusion (mTICI 2b-3) was achieved in 124/140 patients (88.6%) with a low rate of complications (8/140, 5.7%). Any type of intracranial hemorrhage (ICH) and symptomatic ICH occurred in 44/140 (31.4%) and 5/140 (3.6%), respectively. Overall, a good outcome (mRS 0-2) was achieved in 93/140 (66.4%), and the mortality rate was 9.3% (13/140 patients). Using multivariate analysis, lower age [odds ratio (OR), 0.96; 95% CI, 0.92-1.00; P = 0.05], low baseline NIHSS (OR, 0.82; 95% CI, 0.74-0.92; P = 0.00), and absence of ICH (OR, 0.29; 95% CI, 0.10-0.81; P = 0.02) were independently associated with favorable outcome. Independent predictors of mortality were baseline NIHSS (OR, 1.21; 95% CI, 1.01-1.46; P = 0.04), successful reperfusion (OR, 0.02; 95% CI, 0.00-0.58; P = 0.02), and ICH (OR, 0.12; 95% CI, 0.02-0.75; P = 0.02). Further analysis showed that the median mRS at 90 days was significantly better in the MCA occlusion group compared to the ICA plus M1 occlusion group [1 (IQR 0-3) vs. 2 (IQR 1-4); P = 0.05].

Conclusions

Our findings suggest that direct thrombectomy may be an adequate clinical option for younger patients (≤70) experiencing proximal middle artery occlusion within 4.5 h and who have low baseline NIHSS (≤14).

Etiology-Related Outcome of Endovascular Therapy in Posterior Circulation Stroke Compared to Anterior Circulation Stroke

Background and Purpose

We investigated the impact of stroke etiology on the endovascular treatment (EVT) procedure and clinical outcome of posterior circulation stroke (PCS) patients with EVT compared to anterior circulation stroke (ACS) patients.

Methods

We retrospectively analyzed ischemic stroke patients who underwent EVT between January 2012 and December 2020. Enrolled ACS and PCS patients were compared according to etiologies (intracranial arterial steno-occlusion [ICAS-O], artery-to-artery embolic occlusion [AT-O], and cardioembolic occlusion [CA-O]). EVT procedure and favorable clinical outcomes at 3 months (modified Rankin Scale 0–2) were compared between the ACS and PCS groups for each etiology.

Results

We included 419 patients (ACS, 346; PCS, 73) including 88 ICAS-O (ACS, 67; PCS, 21), 66 AT-O (ACS, 50; PCS, 16), and 265 CA-O (ACS, 229; PCS, 36) patients in the study. The onset-to-recanalization time was longer in the PCS group than in the ACS group (median 628.0 minutes vs. 421.0 minutes, P=0.01). In CA-O patients, the door-to-puncture time was longer, whereas the puncture-to-recanalization time was shorter in the PCS group than in the ACS group. The proportions of successful recanalization and favorable clinical outcomes were similar between the ACS and PCS groups for all three etiologies. Low baseline National Institutes of Health Stroke Scale (NIHSS) scores and absence of intracerebral hemorrhage at follow-up imaging were associated with favorable clinical outcomes in both groups, whereas successful recanalization (odds ratio, 11.74; 95% confidence interval, 2.60 to 52.94; P=0.001) was only associated in the ACS group.

Conclusions

The proportions of successful recanalization and favorable clinical outcomes were similar among all three etiologies between PCS and ACS patients who underwent EVT. Initial baseline NIHSS score and absence of hemorrhagic transformation were related to favorable outcomes in the PCS and ACS groups, whereas successful recanalization was related to favorable outcomes only in the ACS group.

General Anesthesia-Related Drop in Diastolic Blood Pressure May Impact the Long-Term Outcome in Stroke Patients Undergoing Thrombectomy

Background: Several factors affect the efficacy of endovascular thrombectomy (EVT); however, the anesthesia-related factors have not been fully explored. We aimed to identify independent predictors of outcome by analyzing procedural factors based on a multicentric stroke registry. Methods: Data of consecutive patients with acute ischemic stroke (AIS) were extracted from the prospective STAY ALIVE stroke registry. Demographic, clinical, and periprocedural factors including hemodynamic values were analyzed in patients undergoing thrombectomy with either general anesthesia (GA) or conscious sedation (CS). Independent predictors of outcome both at 30 and 90 days based on the modified Rankin Scale (mRS: 0−2 as favorable outcome) were also explored. Results: A total of 199 patients (GA: 76 (38%) vs. CS: 117 (59%); in addition, six patients were converted from CS to GA) were included. The minimum value of systolic, diastolic, and mean arterial pressure was significantly lower in the GA compared to the CS group, and GA was associated with a longer onset to EVT time and a higher drop in all hemodynamic variables (all, p < 0.001). A higher drop in diastolic blood pressure (DBP) was even independently associated with a poor 90-day outcome (p = 0.024). Conclusion: A GA-related drop in DBP may independently predict a poor long-term outcome in stroke patients undergoing thrombectomy.

Reduced Severity of Tissue Injury Within the Infarct May Partially Mediate the Benefit of Reperfusion in Ischemic Stroke

BACKGROUND

Emerging data suggest tissue within the infarct lesion is not homogenously damaged following ischemic stroke but has a gradient of injury. Using blood-brain-barrier (BBB) disruption as a marker of tissue injury, we tested whether therapeutic reperfusion improves clinical outcome by reducing the severity of tissue injury within the infarct in patients with ischemic stroke.

METHODS

In a pooled analysis of patients treated for anterior circulation large vessel occlusion in the EXTEND-IA TNK (Tenecteplase Versus Alteplase Before Endovascular Therapy for Ischemic Stroke) and EXTEND-IA part-2 (Determining the Optimal Dose of Tenecteplase Before Endovascular Therapy for Ischaemic Stroke) trials, post-treatment BBB permeability at 24 hours was calculated based on the extent of T1-brightening by extravascular gadolinium on T2* perfusion-weighted imaging and measured within the diffusion-weighted-imaging lesion. First, to determine the clinical significance of BBB disruption as a marker of severity of tissue injury, we examined the association between post-treatment BBB permeability and functional outcome. Second, we performed an exploratory (reperfusion, BBB permeability, functional outcome) mediation analysis to estimate the proportion of the reperfusion-outcome relationship that is mediated by change in BBB permeability.

RESULTS

In the 238 patients analyzed, an increased BBB permeability measured within the infarct at 24 hours was associated with a reduced likelihood of favorable outcome (90-day modified Rankin Scale score of ≤2) after adjusting for age, baseline National Institutes of Health Stroke Scale, premorbid modified Rankin Scale, infarct topography, laterality, thrombolytic agent, sex, parenchymal hematoma, and follow-up infarct volume (adjusted odds ratio, 0.86 [95% CI, 0.75-0.98], P=0.023). Mediation analysis suggested reducing the severity of tissue injury (as estimated by BBB permeability) accounts for 18.2% of the association between reperfusion and favorable outcome, as indicated by a reduction in the regression coefficient of reperfusion after addition of BBB permeability as a covariate.

CONCLUSIONS

In patients with ischemic stroke, reduced severity of tissue injury within the infarct, as determined by assessing the integrity of the BBB, is independently associated with improved functional outcome. In addition to reducing diffusion-weighted imaging-defined infarct volume, reperfusion may also improve clinical outcome by reducing tissue injury severity within the infarct.

Characterization of Subarachnoid Hyperdensities After Thrombectomy for Acute Stroke Using Dual-Energy CT

BACKGROUND AND OBJECTIVES

The presence of post-interventional subarachnoid hyperdensities (SA-HD) is a relatively common finding after mechanical thrombectomy (MT). We aimed to assess the incidence, characteristics, clinical relevance and predictors of SA-HD after MT as categorized through the use of post-interventional Dual Energy-CT (DE-CT).

METHODS

A single-center consecutive series of acute stroke patients treated with MT were retrospectively reviewed. Post-treatment SA-HD were defined as incident extra-axial hyperdensities in a follow-up DE-CT performed within a median of 8 hours after MT. SA-HD were further classified according to their content (isolated contrast extravasation versus blood extravasation) and extension [diffuse (hyperdensities in more than one extraparenchymal compartments) versus non-diffuse]. Adjusted logistic regression models assessed the association of SA-HD with pretreatment and procedural variables and with bad clinical outcome (shift towards worse categories in the ordinal Rankin Scale at 90 days).

RESULTS

SA-HD were observed in 120 (28%) of the 424 included patients (isolated contrast extravasation n=22, blood extravasation n=98). In this group, SA-HD were diffuse in 72 (60%) patients (isolated contrast extravasation n=7, blood extravasation n=65) and non-diffuse in 48 (40%) patients (isolated contrast extravasation n=15, blood extravasation n=33). Diffuse SA-HD were significantly associated with worse clinical outcome in adjusted models (cOR=2.3, 95%CI=1.36-4.00, p=0.002), unlike the specific SA-HD content alone. In contrast with the absence of SA-HD, only the diffuse pattern with blood extravasation was significantly associated with worse clinical outcome (cOR=2.4, 95%CI=1.36-4.15, p=0.002). Diffuse SA-HD patterns were predicted by M2 occlusions, more thrombectomy passes and concurrent parenchymal hematomas.

DISCUSSION

In our cohort of patients imaged within a median of 8 hours after MT, post-interventional SA-HD showed a diffuse pattern in 17% of thrombectomies and were associated with more arduous procedures. Diffuse SA-HD but not local collections of blood or contrast extravasations were associated with an increased risk of poor outcome and death. These findings reinforce the need for improvement in reperfusion strategies.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that in individuals with proximal carotid artery territory occlusions treated with mechanical thrombectomy, diffuse post-interventional subarachnoid hyperdensities on imaging 8 hours post-procedure are associated with worse clinical outcomes at 90 days.

TAB-TICI Score: Successful Recanalization Score After Endovascular Thrombectomy in Acute Stroke

Background and Purpose: Successful reperfusion therapy is supposed to be comprehensive and validated beyond the grade of recanalization. This study aimed to develop a novel scoring system for defining the successful recanalization after endovascular thrombectomy.

Methods: We analyzed the data of consecutive acute stroke patients who were eligible to undergo reperfusion therapy within 24 h of onset and who underwent mechanical thrombectomy using a nationwide multicenter stroke registry. A new score was produced using the predictors which were directly linked to the procedure to evaluate the performance of the thrombectomy procedure.

Results: In total, 446 patients in the training population and 222 patients in the validation population were analyzed. From the potential components of the score, four items were selected: Emergency Room-to-puncture time (T), adjuvant devices used (A), procedural intracranial bleeding (B), and post-thrombectomy reperfusion status [Thrombolysis in Cerebral Infarction (TICI)]. Using these items, the TAB-TICI score was developed, which showed good performance in terms of discriminating early neurological aggravation [AUC 0.73, 95% confidence interval (CI) 0.67–0.78, P < 0.01] and favorable outcomes (AUC 0.69, 95% CI 0.64–0.75, P < 0.01) in the training population. The stability of the TAB-TICI score was confirmed by external validation and sensitivity analyses. The TAB-TICI score and its derived grade of successful recanalization were significantly associated with the volume of thrombectomy cases at each site and in each admission year.

Conclusion: The TAB-TICI score is a valid and easy-to-use tool to more comprehensively define successful recanalization after endovascular thrombectomy in acute stroke patients with large vessel occlusion.

Artery diameter ratio after recanalization in endovascular therapy for acute ischemic stroke: a new predictor of clinical outcomes

PURPOSE

This study aimed to investigate the relationship between the artery diameter ratio (ADR) after recanalization and clinical outcomes.

METHODS

Patients with middle cerebral artery occlusion confirmed by DSA from 1 January 2018, to 31 December 2019, were retrospectively analyzed. All patients confirmed TICI grade 2b or 3. The ADR was calculated as M2 segment diameter/M1 segment diameter. Multivariate regression analysis was used to describe clinical outcomes of two groups (ADR < 0.6 and ≥ 0.6). ROC curves were used to compare different models and find the best cutoff.

RESULTS

A total of 143 patients were included in the study, including 77 males and 66 females, with an average age of 67.79 ± 12 years. The NIHSS at discharge was significantly higher in the ADR < 0.6 group than another group (mean, 16.37 vs. 6.19, P < 0.001). At 90 days, the cases of functional independence was significantly less in the ADR < 0.6 group (20.97% vs. 83.95%, OR 0.05, 95% CI 0.02-0.12, P < 0.001). The ADR < 0.6 group had a higher incidence of cerebral edema (P = 0.027) and sICH (P = 0.038). The ADR had the strongest power to distinguish mRS > 2 (AUC = 0.851) and DC (AUC = 0.805), and the best cutoff value are 0.6 (specificity 85.19%, sensitivity 75.81%) and 0.58 (specificity 65.96%, sensitivity 100%), respectively.

CONCLUSION

The low ADR is associated with poor outcomes. The decrease in ADR may be an indirect manifestation of the loss of cerebrovascular autoregulation.

Added Value of Rescue Devices in Intra-Arterial Thrombectomy: When Should We Apply Them?

Introduction: Recent trials have demonstrated the superior efficacy of mechanical thrombectomy over other medical treatments for acute ischemic stroke; however, not every large vessel occlusion (LVO) can be recanalized using a single thrombectomy device. Rescue devices were proved to increase the reperfusion rate, but the efficacy is unclear.

Objective: In this retrospective study, we evaluated the efficacy of rescue therapy in different locations of LVO.

Methods: We analyzed the outcomes of mechanical thrombectomy from a prospective registry of consecutive 82 patients in Taipei Medical University Hospital. The reperfusion rate and the functional outcome were compared in patients who received first-line therapy only and patients who need rescue therapy.

Results: An 84.1% reperfusion rate was achieved in our cohort. We applied first-line stent retriever (SR) treatment in 6 patients, among which 4 (66.6%) achieved successful reperfusion. We applied a direct-aspiration first-pass technique (ADAPT) as the first-line treatment in 76 patients, among which 46 (60.5%) achieved successful reperfusion. Successful reperfusion could not be achieved in 30 cases (39.5%); therefore, we applied a second-line rescue SR for 28 patients, and reperfusion was established in 18 (64.3%) of them. These results revealed that the LVO in anterior circulation has a higher chance to respond to SR rescue therapy than posterior circulation lesions (68 vs. 33.3%, P < 0.001). Patients who received only first-line therapy exhibited significantly better functional outcomes than those who were also treated with rescue SR therapy (41.2 vs. 16.7%, P = 0.001). In addition, patients with LVO in the anterior circulation were found to have a higher probability of achieving functional independence than patients with posterior circulation lesions (10.7 vs. 0.0%, P < 0.001). The adjusted multivariate analysis revealed that successful reperfusion and treatment type (first-line or rescue therapy) were significantly related to a modified Rankin Scale (mRS) score at 90 days.

Conclusion: This study reveals that rescue SR therapy improves the reperfusion rate. Patients who require rescue SR therapy have a lower likelihood of functional independence. LVO in the anterior circulation responds better to rescue SR therapy and results in better functional outcomes than posterior circulation lesions.

Predicting 90-Day Outcome After Thrombectomy: Baseline-Adjusted 24-Hour NIHSS Is More Powerful Than NIHSS Score Change

BACKGROUND AND PURPOSE

The National Institutes of Health Stroke Scale (NIHSS) measured at an early time point is an appealing surrogate marker for long-term functional outcome of stroke patients treated with endovascular therapy. However, definitions and analytical methods for an early NIHSS-based outcome measure that optimize power and precision in clinical studies are not well-established.

METHODS

In this post-hoc analysis of our prospective observational study that enrolled endovascular therapy-treated patients at 12 comprehensive stroke centers across the US, we compared the ability of 24-hour NIHSS, ΔNIHSS (baseline minus 24-hour NIHSS), and percentage change (NIHSS×100/baseline NIHSS), analyzed as continuous and dichotomous measures, to predict 90-day modified Rankin Scale (mRS) using logistic regression (adjusted for age, baseline NIHSS, glucose, hypertension, Alberta Stroke Program Early CT Score, time to recanalization, recanalization status, and intravenous thrombolysis) and Spearman ρ.

RESULTS

Of 485 patients in the BEST (Blood Pressure After Endovascular Stroke Therapy) cohort, 446 (92%) with 90-day follow-up data were included. An absolute 24-hour NIHSS, adjusted for baseline in multivariable modeling, had the highest predictive power of all definitions evaluated (aR2 0.368 and adjusted odds ratio 0.79 [0.75-0.84], P<0.001 for mRS score 0-2; aR2 0.444 and adjusted odds ratio 0.84 [0.8-0.86] for ordinal mRS). For predicting mRS score of 0-2 with a cut point, the second most efficient approach, the optimal threshold for 24-hour NIHSS score was ≤7 (sensitivity 80.1%, specificity 80.4%; adjusted odds ratio 12.5 [7.14-20], P<0.001), followed by percent change in NIHSS (sensitivity 79%, specificity 58.5%; adjusted odds ratio 4.55 [2.85-7.69], P<0.001).

CONCLUSIONS

Twenty-four-hour NIHSS, adjusted for baseline, was the strongest predictor of both dichotomous and ordinal 90-day mRS outcomes for endovascular therapy-treated patients. A dichotomous 24-hour NIHSS score of ≤7 was the second-best predictor. Although ΔNIHSS, continuous and dichotomized at ≥4, predicted 90-day outcomes, absolute 24-hour NIHSS definitions performed better.

Clinical and Procedural Outcomes with or without Balloon Guide Catheters during Endovascular Thrombectomy in Acute Ischemic Stroke: A Systematic Review and Meta-analysis with First-line Technique Subgroup Analysis

BACKGROUND

Balloon guide catheters are increasingly used to improve clot retrieval by temporarily stopping proximal blood flow during endovascular thrombectomy.

PURPOSE

Our aim was to provide a summary of the literature comparing the procedural and clinical outcomes of endovascular thrombectomy with or without balloon guide catheters, depending on the first-line technique used.

DATA SOURCES

We used PubMed/MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews.

STUDY SELECTION

We chose studies that compared using balloon guide catheters with not using them.

DATA ANALYSIS

Random effects meta-analysis was performed to compare the procedural outcomes measured as the first-pass effect, successful reperfusion, number of passes, procedural duration, arterial puncture to reperfusion time, distal emboli, and clinical outcomes.

DATA SYNTHESIS

Overall, a meta-analysis of 16 studies (5507 patients, 50.8% treated with balloon guide catheters and 49.2% without them) shows that the use of balloon guide catheters increases the odds of achieving a first-pass effect (OR = 1.92; 95% CI, 1.34-2.76; P < .001), successful reperfusion (OR = 1.85; 95% CI, 1.42-2.40; P < .001), and good functional outcome (OR =1.48; 95% CI, 1.27-1.73; P < .001). Balloon guide catheters reduce the number of passes (mean difference = -0.35; 95% CI, -0.65 to -0.04; P = .02), procedural time (mean difference = -19.73; 95% CI, -34.63 to -4.83; P = .009), incidence of distal or new territory emboli (OR = 0.5; 95% CI, 0.26-0.98; P = .04), and mortality (OR = 0.72; 95% CI, 0.62-0.85; P < .001). Similar benefits of balloon guide catheters are observed when the first-line technique was a stent retriever or contact aspiration, but not for a combined approach.

LIMITATIONS

The analysis was based on nonrandomized trials with a moderate risk of bias.

CONCLUSIONS

Current literature suggests improved clinical and procedural outcomes associated with the use of balloon guide catheters during endovascular thrombectomy, especially when using the first-line stent retriever.

Mean Platelet Volume as a Potential Marker of Large Vessel Occlusion and Predictor of Outcome in Acute Ischemic Stroke Patients Treated with Reperfusion Therapy

(1) Background: An early diagnosis of a large vessel occlusion (LVO) is crucial in the management of the acute ischemic stroke (AIS). The laboratory predictors of LVO and a stroke outcome remain unknown. We have hypothesized that high MPV—a surrogate marker of the activated platelet—may be associated with LVO, and it may predict a worse AIS outcome. (2) Methods: This was a retrospective study of 361 patients with AIS who were treated with thrombolysis (tPA, 65.7%) and/or mechanical thrombectomy (MT, 34.3%) in a tertiary Stroke Center between 2011 and 2019. (3) Results: The mean MPV in the cohort was 9.86 ± 1.5 fL (1st–4th quartiles: <8.8, >10.80 fL). Patients in the 4th quartile compared to the 1st had a significantly (p < 0.01) more often incidence of an LVO related stroke (75% vs. 39%) and a severe stroke manifestation with a higher RACE score (5.2 ± 2.8 vs. 3.3 ± 2.4), NIHSS at baseline (mean ± SD, 14 ± 6.5 vs. 10.9 ± 5.2), and NIHSS at discharge (6.9 ± 7 vs. 3.9 ± 3.6). A multivariate analysis revealed that quartiles of MPV (OR 1.4; 95%CI 1.2–1.8) significantly predicted an LVO stroke, also after the adjustment for RACE < 5 (OR 1.4; 95%CI 1.08–1.89), but MPV quartiles did not predict a favorable stroke outcome (mRS ≤ 2) (OR 0.89; 95%CI 0.7–1.13). (4) Conclusion: Our data suggest that MPV is an independent predictor of LVO in patients with an acute ischemic stroke.

Predictors for affected stroke territory and outcome of acute stroke treatments are different for posterior versus anterior circulation stroke

Distinct patient characteristics have been proposed for ischaemic stroke in the anterior versus posterior circulation. However, data on functional outcome according to stroke territory in patients with acute stroke treatment are conflicting and information on outcome predictors is scarce. In this retrospective study, we analysed functional outcome in 517 patients with stroke and thrombolysis and/or thrombectomy treated at the University Hospital Zurich. We compared clinical factors and performed multivariate logistic regression analyses investigating the effect of outcome predictors according to stroke territory. Of the 517 patients included, 80 (15.5%) suffered a posterior circulation stroke (PCS). PCS patients were less often female (32.5% vs. 45.5%, p = 0.031), received thrombectomy less often (28.7% vs. 48.3%, p = 0.001), and had lower median admission NIHSS scores (5 vs. 10, p < 0.001) as well as a better median three months functional outcome (mRS 1 vs. 2, p = 0.010). Predictors for functional outcome were admission NIHSS (OR 0.864, 95% CI 0.790–0.944, p = 0.001) in PCS and age (OR 0.952, 95% CI 0.935–0.970, p < 0.001), known symptom onset (OR 1.869, 95% CI 1.111–3.144, p = 0.018) and admission NIHSS (OR 0.840, 95% CI 0.806–0.876, p < 0.001) in ACS. Acutely treated PCS and ACS patients differed in their baseline and treatment characteristics. We identified specific functional outcome predictors of thrombolysis and/or thrombectomy success for each stroke territory.

Intravenous abciximab as a rescue therapy for immediate reocclusion after successful mechanical thrombectomy in acute ischemic stroke patients

Background - Immediate reocclusion after mechanical thrombectomy (MT) for acute ischemic stroke (AIS) is a rare but devastating condition associated with poor functional outcome.Objective - The aim of this study was to gain insights into the mechanisms underlying immediate reocclusion, and to evaluate the efficacy and safety of the glycoprotein IIb/IIIa antagonist abciximab, for its treatment.Methods - Clinical data were collected from April 2015 to April 2019 in a monocentric prospective registry of AIS patients treated by MT. All patients with immediate reocclusion were retrospectively selected and subdivided into 2 groups according to abciximab treatment status. In vitro, the separate and combined effects of abciximab and alteplase on clot formation in whole blood under flow conditions were further investigated in microfluidic chambers.Results - From 929 MT-treated patients, 21 had post-MT immediate reocclusion. Abciximab treatment in reocclusion patients (n = 10) led to higher rate of final recanalization (p < .001) while it did not increase bleeding complications. Flow chamber experiments revealed that, in contrast to alteplase, abciximab efficiently limits thrombus accretion from flowing blood by blocking platelet aggregation.Conclusions - Our results underscore a key role for platelet aggregation and the potential of Glycoprotein IIb/IIIa antagonists as a rescue therapy in post-MT immediate reocclusion.

Pre-stroke cognitive impairment in acute ischemic stroke patients predicts poor functional outcome after mechanical thrombectomy

OBJECTIVE

Several studies have investigated the predictors of functional outcome in patients with ischemic stroke after mechanical thrombectomy (MT). However, it is not clear whether pre-stroke cognitive (PSC) impairment is associated with the functional outcome of patients treated with MT.

METHODS

We enrolled 113 patients treated with MT from December 2016 to November 2018. PSC was evaluated using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Poor outcome was defined as a modified Rankin Scale score of 3-6. We compared the clinical characteristics between the groups with poor outcome (n = 61) and good outcome (n = 52) to determine if PSC could be a predictor of poor outcome.

RESULTS

IQCODE was significantly higher in the group with poor outcome than good outcome (3.34 vs. 3.13, P = 0.017). Moreover, the following metrics differed between those two groups: age (75.9 vs. 71.6 years old, P = 0.010), the percentage of females (39.9% vs. 17.3%, P = 0.009), the percentage with hypertension (72.1% vs. 44.2%, P = 0.003), National Institutes of Health Stroke Scale (NIHSS) score on admission (20 vs. 11, P < 0.001), and no successful recanalization (24.5% vs. 7.7%; P = 0.025). Multivariable logistic regression analysis demonstrated that PSC (OR: 5.59; 95% CI: 1.55-23.47), history of hypertension (OR: 3.33; 95% CI: 1.29-9.11), no successful recanalization (OR: 5.51; 95% CI: 1.49-25.03), and NIHSS score on admission (OR: 1.14; 95% CI: 1.07-1.22) were associated with poor outcome 3 months after stroke onset.

CONCLUSIONS

PSC was significantly and independently associated with poor functional outcome in patients treated with MT.

Impact of Post-Stroke Recanalization on General and Upper Limb Functioning: A Prospective, Observational Study

The objective of this study is to assess the impact of recanalization (spontaneous and therapeutic) on upper limb functioning and general patient functioning after stroke. This is a prospective, observational study of patients hospitalized due to acute ischemic stroke in the territory of the middle cerebral artery (n = 98). Patients completed a comprehensive rehabilitation program and were followed-up for 24 weeks. The impact of recanalization on patient functioning was evaluated using the modified Rankin Scale (mRS) and Stroke Upper Limb Capacity Scale (SULCS). General and upper limb functioning improved markedly in the first three weeks after stroke. Age, gender, and National Institutes of Health Stroke Scale (NIHSS) score at admission were associated with general and upper limb functioning at 12 weeks. Successful recanalization was associated with better functioning. Among patients who underwent therapeutic recanalization, NIHSS scores ≥16.5 indicate lower general functioning at 12 weeks (sensibility = 72.4%; specificity = 78.6%) and NIHSS scores ≥13.5 indicate no hand functioning at 12 weeks (sensibility = 83.8%; specificity = 76.5%). Recanalization, either spontaneous or therapeutic, has a positive impact on patient functioning after acute ischemic stroke. Functional recovery occurs mostly within the first 12 weeks after stroke, with greater functional gains among patients with successful recanalization. Higher NIHSS scores at admission are associated with worse functional recovery.

Characteristics and prognosis of acute basilar artery occlusion in minor to moderate stroke and severe stroke after endovascular treatment: A multicenter retrospective study

OBJECTIVE

We aimed to investigate characteristics and outcomes of patients receiving mechanical thrombectomy (MT) between minor to moderate stroke and severe stroke caused by acute basilar artery occlusion (BAO).

METHODS

We retrospectively reviewed the data of all patients with BAO who underwent MT from three stroke centers between January 2016 and January 2020. The patients were dichotomized as minor to moderate or severe stroke group according to their admission National Institutes of Health Stroke Scale (NIHSS) score <21and ≥21. Patient characteristics, imaging findings, and outcomes were compared between the two groups.

RESULTS

A total of 72 patients were included in this study. The posterior circulation Alberta Stroke Program Early CT Score (PC-ASPECTS) in the minor to moderate stroke patients were significantly higher than that of patients with severe stroke (P = 0.013). The good posterior circulation collateral scores (PC-CS) (6-10) were more commonly found in patients with minor to moderate stroke than in patients with severe stroke (58.14 % vs 10.34 %,P < 0.001). There were similar rates of successful recanalization between the two groups. Patients with minor to moderate stroke had a higher rate of favorable outcomes (mRS score 0-2, 60.47 % vs 20.69 %, P = 0.002) and a lower rate of periprocedural complications (4.65 % vs 31.03 %, P = 0.005) and mortality (4.65 % vs 24.14 %, P = 0.026) at 3 months after MT compared with the patients with severe stroke.

CONCLUSIONS

Acute BAO patients with minor to moderate stroke had better posterior circulation collateral and had better outcomes after MT than those patients with severe stroke.

Post-stroke infection in acute ischemic stroke patients treated with mechanical thrombectomy does not affect long-term outcome

Introduction

The impact of an infection that requires antibiotic treatment (IRAT) after an acute ischemic stroke (AIS) treated with mechanical thrombectomy (MT) remains unclear.

Aim

Here, we studied the prevalence and the profile of IRAT in patients with AIS treated with MT, aiming to identify predictive factors and prognostic implications at 90 days after stroke.

Material and methods

We analyzed parameters available within 24 h after AIS including demographics, risk factors, National Institutes of Health Stroke Scale (NIHSS) upon admission and 24 h later, hemorrhagic transformation (HT) on computed tomography, and several clinical and biochemical markers. The outcome measures were the modified Rankin Scale (mRS) 0-2 and 90 days post-stroke mortality.

Results

We included 291 patients; in 184 (63.2%) patients MT was preceded by intravenous thrombolysis (IVT), and 83 (28.5%) patients developed IRAT. Multivariate analysis showed that male sex and hemorrhagic transformation on CT taken 24 h after stroke increased the risk of IRAT. We found that younger age, male sex, lower delta NIHSS, shorter time from stroke onset to groin puncture, better recanalization and a lack of hemorrhagic transformation on CT taken 24 h after stroke favorably affected outcome at day 90. Multivariate analysis showed that older age, higher delta NIHSS, unknown stroke etiology and lack of treatment with IVT were independent predictors of death up to day 90. Infection that required antibiotic treatment did not enter in the models for the studied outcome measures.

Conclusions

In AIS patients treated with MT, IRAT is not an independent factor that affects favorable outcome or mortality 90 days after stroke.

Functional Outcome After Mechanical Thrombectomy with or without Previous Thrombolysis

INTRODUCTION

Combined intravenous therapy (IVT) and mechanical thrombectomy (MT) is the standard treatment for acute ischemic stroke (AIS) with large vessel occlusion (LVO). However, the use of  IVT before MT is recently being questioned.

OBJECTIVES

To compare patients treated with IVT before MT with those treated with MT alone, in a real-world scenario.

METHODS

Retrospective analysis of AIS patients with LVO of the anterior circulation who underwent MT, with or without previous IVT, between 2016 and 2018.

RESULTS

A total of 524 patients were included (347 submitted to IVT+MT; 177 to MT alone). No differences between groups were found except for a higher time from stroke onset to CT and to groin puncture in the MT group (297.5 min vs 115.0 min and 394.0 min vs 250.0 min respectively, p < 0.001). Multivariable analysis showed that age<75 years (OR 2.65, 95% CI 1.71-4.07, p < 0.001), not using antiplatelet therapy (OR 1.93, 95% CI 1.21-3.08, p = 0.006), low prestroke mRS (OR 4.33, 95% CI 1.89-9.89, p < 0.001), initial NIHSS (OR 0.89, 95% CI 0.86-0.93, p < 0.001), absent cerebral edema (OR 7.83, 95% CI 3.31-18.51, p < 0.001), and mTICI 2b/3 (OR 4.56, 95% CI 2.17-9.59, p < 0.001) were independently associated with good outcome (mRS 0-2).

CONCLUSIONS

Our findings support the idea that IVT before MT does not influence prognosis, in a real-world setting.

Neighborhood Socioeconomic Status and Mechanical Thrombectomy Outcomes

BACKGROUND/PURPOSE

Our study aimed to assess the impacts of neighborhood socioeconomic status on mechanical thrombectomy (MT) outcomes for acute ischemic stroke (AIS).

METHODS

We conducted a prospective observational study of consecutive adult AIS patients treated with MT at one US comprehensive stroke center from 2012 to 2018. A composite neighborhood socioeconomic score (nSES) was created using patient home address, median household income, percentage of households with interest, dividend, or rental income, median value of housing units, percentage of persons 25 or older with high school degrees, college degrees or holding executive, managerial or professional specialty occupations. Using this score, patients were divided into low, middle and high nSES tertiles. Outcomes included 90-day functional independence, in-hospital mortality, length of hospital stay, discharge location, time to recanalization, successful recanalization, and symptomatic intracranial hemorrhage (sICH).

RESULTS

328 patients were included. Between the three nSES groups, proportion of White patients, time-to-recanalization and admission NIH stroke scale differed significantly (p<0.05). Patients in the high nSES tertile were more likely to be functionally dependent at 90 days (unadjusted OR, 95% CI, 1.91 [1.10, 3.36]) and were less likely to die in the hospital (unadjusted OR, 95% CI, 0.46, [0.20, 0.98]). Further, patients in the high nSES tertile had decreased times to recanalization (median time in minutes, low=335, mid=368, high=297, p=0.04). However, after adjusting for variance in race and severity of stroke, the differences in clinical outcomes were not significant.

CONCLUSION

This study highlights how unadjusted neighborhood socioeconomic status is significantly associated with functional outcome, mortality, and time-to-recanalization following MT for AIS. Since adjustment modifies the significant association, the socioeconomic differences may be influenced by differences in pre-hospital factors that drive severity of stroke and time to recanalization. Better understanding of the interplay of these factors may lead to timelier evaluation and improvement in patient outcomes.

Association between high-sensitivity C-reactive protein levels and clinical outcomes in acute ischemic stroke patients treated with endovascular therapy

Background

Increasing evidence demonstrates that high-sensitivity C-reactive protein (hs-CRP) is an independent prognostic predictor in acute ischemic stroke (AIS) patients. The purpose of this study is to investigate the association between hs-CRP levels and clinical outcomes in AIS patients receiving endovascular therapy (EVT).

Methods

This observational study was based on a prospective registry study. AIS patients receiving EVT from December 2012 to January 2019 were included. The modified Rankin Scale (mRS) scores at the 90-day and long-term follow-up were evaluated as clinical outcomes. Multivariable logistic regression analysis was conducted to adjust for confounders. Receiver operating characteristic (ROC) curve analysis was performed based on significant predictors of favorable outcomes in the logistic regression analysis. Patients were divided into two groups according to the cutoff value. Clinical outcomes were compared between groups. Survival probability was assessed using Kaplan-Meier survival analysis.

Results

Multivariable logistic regression analysis of the 362 enrolled AIS patients demonstrated that age (P=0.030), National Institutes of Health Stroke Scale (NIHSS) score (P=0.023), hs-CRP levels (P<0.001), and symptomatic intracranial hemorrhage (sICH) (P=0.006) were independently predictive of favorable outcomes. ROC curve analysis indicated that the hs-CRP level was predictive of favorable outcomes at the 90-day follow-up with a cutoff value of 8.255 mg/L. The mRS scores between patients with hs-CRP <8.255 mg/L and patients with hs-CRP ≥8.255 mg/L at the 90-day [2 (IQR, 1–2) vs. 4 (IQR, 3–6), P<0.001] and long-term follow-up [1 (IQR, 0–2) vs. 4 (IQR, 2–6), P<0.001] were significantly different. Patients with hs-CRP ≥8.255 mg/L had significantly increased risk of poor clinical outcomes at the 90-day and long-term follow-up compared with those with hs-CRP <8.255 mg/L (P<0.001 each).

Conclusions

Elevated hs-CRP levels were associated with poor clinical outcomes in AIS patients receiving EVT.

Predictors of Good Outcomes in Patients with Failed Endovascular Thrombectomy

OBJECTIVE

Endovascular thrombectomy (EVT) fails in approximately 20% of anterior circulation large vessel occlusion (AC-LVO). Nonetheless, the factors that affect clinical outcomes of non-recanalized AC-LVO despite EVT are less studied. The purpose of this study was to identify the factors affecting clinical outcomes in non-recanalized AC-LVO patients despite EVT.

MATERIALS AND METHODS

This was a retrospective analysis of clinical and imaging data from 136 consecutive patients who demonstrated recanalization failure (modified thrombolysis in cerebral ischemia [mTICI], 0-2a) despite EVT for AC-LVO. Data were collected in prospectively maintained registries at 16 stroke centers. Collateral status was categorized into good or poor based on the CT angiogram, and the mTICI was categorized as 0-1 or 2a on the final angiogram. Patients with good (modified Rankin Scale [mRS], 0-2) and poor outcomes (mRS, 3-6) were compared in multivariate analysis to evaluate the factors associated with a good outcome.

RESULTS

Thirty-five patients (25.7%) had good outcomes. The good outcome group was younger (odds ratio [OR], 0.962; 95% confidence interval [CI], 0.932-0.992; p = 0.015), had a lower incidence of hypertension (OR, 0.380; 95% CI, 0.173-0.839; p = 0.017) and distal internal carotid artery involvement (OR, 0.149; 95% CI, 0.043-0.520; p = 0.003), lower initial National Institute of Health Stroke Scale (NIHSS) (OR, 0.789; 95% CI, 0.713-0.873; p < 0.001) and good collateral status (OR, 13.818; 95% CI, 3.971-48.090; p < 0.001). In multivariate analysis, the initial NIHSS (OR, 0.760; 95% CI, 0.638-0.905; p = 0.002), good collateral status (OR, 14.130; 95% CI, 2.264-88.212; p = 0.005) and mTICI 2a recanalization (OR, 5.636; 95% CI, 1.216-26.119; p = 0.027) remained as independent factors with good outcome in non-recanalized patients.

CONCLUSION

Baseline NIHSS score, good collateral status, and mTICI 2a recanalization remained independently associated with clinical outcome in non-recanalized patients. mTICI 2a recanalization would benefit patients with good collaterals in non-recanalized AC-LVO patients despite EVT.

Prediction of mTICI 3 recanalization and clinical outcomes in endovascular thrombectomy for acute ischemic stroke: a retrospective study in the Taiwan registry

PURPOSE

Early recanalization for acute ischemic stroke (AIS) due to large vessel occlusion (LVO) by endovascular thrombectomy (EVT) is strongly related to improved functional outcomes. With data obtained from the Taiwan registry, the factors associated with mTICI 3 recanalization and clinical outcomes in EVT are investigated.

METHODS

From January 2014 to September 2016, 108 patients who underwent EVT for AIS due to LVO in 11 medical centers throughout Taiwan were included. Complete recanalization is defined as achieving modified thrombolysis in cerebral infarction (mTICI) grade 3. Good clinical outcomes are defined by the modified Rankin scale (mRS) 0-2 at 3 months after EVT. Clinical and imaging parameters for predicting mTICI 3 recanalization and good clinical outcomes are analyzed.

RESULTS

Of the 108 patients who received EVT, 54 (50%) patients had mTICI 3 recanalization. Having received aspiration only and the use of IV-tPA are shown to be significant predictors for mTICI 3 recanalization with odds ratios of 2.61 and 2.53 respectively. Forty-six (42.6%) patients experienced good 3-month clinical outcomes (mRS 0-2). Pretreatment collateral statuses, NIHSS scores, time lapses between symptoms to needle, and the occurrence of hemorrhage at 24 h are all significant predictors for good outcomes with odds ratios of 2.88, 0.91, 0.99, and 0.31 respectively.

CONCLUSIONS

Prediction of mTICI 3 recanalization and clinical outcomes offer valuable clinical information for treatment planning in EVT.

Predictors of Catastrophic Outcome after Endovascular Thrombectomy in Elderly Patients with Acute Anterior Circulation Stroke

Objective

Avoiding a catastrophic outcome may be a more realistic goal than achieving functional independence in the treatment of acute stroke in octogenarians. This study aimed to investigate predictors of catastrophic outcome in elderly patients after an endovascular thrombectomy with an acute anterior circulation large vessel occlusion (LVO).

Materials and Methods

Data from 82 patients aged ≥ 80 years, who were treated with thrombectomy for acute anterior circulation LVO, were analyzed. The association between clinical/imaging variables and catastrophic outcomes was assessed. A catastrophic outcome was defined as a modified Rankin Scale score of 4–6 at 90 days.

Results

Successful reperfusion was achieved in 61 patients (74.4%), while 47 patients (57.3%) had a catastrophic outcome. The 90-day mortality rate of the treated patients was 15.9% (13/82). The catastrophic outcome group had a significantly lower baseline diffusion-weighted imaging-Alberta stroke program early CT score (DWI-ASPECTS) (7 vs. 8, p = 0.014) and a longer procedure time (42 minutes vs. 29 minutes, p = 0.031) compared to the non-catastrophic outcome group. Successful reperfusion was significantly less frequent in the catastrophic outcome group (63.8% vs. 88.6%, p = 0.011) compared to the non-catastrophic outcome group. In a binary logistic regression analysis, DWI-ASPECTS (odds ratio [OR], 0.709; 95% confidence interval [CI], 0.524–0.960; p = 0.026) and successful reperfusion (OR, 0.242; 95% CI, 0.071–0.822; p = 0.023) were independent predictors of a catastrophic outcome.

Conclusion

Baseline infarct size and reperfusion status were independently associated with a catastrophic outcome after endovascular thrombectomy in elderly patients aged ≥ 80 years with acute anterior circulation LVO.

A novel toolkit for the prediction of clinical outcomes following mechanical thrombectomy

AIM

To develop a robust toolkit to aid decision-making for mechanical thrombectomy (MT) based on readily available patient variables that could accurately predict functional outcome following MT.

MATERIALS AND METHODS

Data from patients with anterior circulation stroke who underwent MT between October 2009 and January 2018 (n=239) were identified from our MT database. Patient explanatory variables were age, sex, National Institutes of Health Stroke Scale (NIHSS), Alberta Stroke Program Early CT Score (ASPECTS), collateral score, and Glasgow Coma Scale. Five models were developed from the data to predict five outcomes of interest: model 1: prediction of survival: modified Rankin Scale (mRS) of 0-5 (alive) or 6 (dead); model 2: prediction of good/poor outcome: mRS of 0-3 (good), or 4-6 (poor); model 3: prediction of good/poor outcome: mRS of 0-2 (good), or 3-6 (poor); model 4: prediction of mRS category: mRS of 0-2 (no disability), 3 (minor disability), 4-5 (severe disability) or 6 (dead); model 5: prediction of the exact mRs score (mRs as a continuous variable). The accuracy and discriminative power of each predictive model were tested.

RESULTS

Prediction of survival was 87% accurate (area under the curve [AUC] 0.89). Prediction of good/poor outcome was 91% accurate (AUC 0.94) for Model 2 and 95% accurate (AUC 0.98) for Model 3. Prediction of mRS category was 76% accurate, and increased to 98% using the "one-score-out rule". Prediction of the exact mRS value was accurate to an error of 0.89.

CONCLUSIONS

This novel toolkit provided accurate estimations of outcome for MT.

Perfusion recovery on TTP maps after endovascular stroke treatment might predict favorable neurological outcomes

OBJECTIVES

Early recanalization and adequate collateral blood flow are surrogates for functional recovery in endovascular stroke treatment (EVT). We evaluated the prognostic value of pre- and immediate post-thrombectomy perfusion-weighted magnetic resonance imaging (PWI) parameters.

METHODS

Consecutive patients with acute ischemic stroke who underwent EVT were enrolled. Lesion volumes and their corresponding changes on diffusion-weighted (DWI) and PWI were assessed. Outcome was measured with modified Rankin Scale (mRS) at 90 days, and early neurological improvement (> 8 points improvement on National Institutes of Health Stroke Scale [NIHSS] or 0 to 1) at 7 days.

RESULTS

Fifty-two patients were enrolled. After control of initial NIHSS and recanalization status, post-thrombectomy time-to-peak (TTP) hypoperfused volume and TTP hypoperfused volume change remained independent predictors of favorable functional outcome (odds ratio [OR] = 0.13, 95% confidence interval [CI] = 0.03-0.54, p = 0.005; OR = 1.018, 95% CI = 1.00-1.03, p = 0.017), and early neurological improvement (OR = 0.20, 95% CI 0.07-0.58, p = 0.003; OR = 1.02, 95% CI = 1.00-1.03, p = 0.010). The areas under the curve of post-thrombectomy TTP hypoperfused volume and TTP hypoperfused volume change were 0.90 and 0.82 (cutoff 68 mL and 56 mL) for favorable outcome and 0.86 and 0.82 (cutoff 76 mL and 58 mL) for early neurological improvement, which had better prognostic values than other MR parameters and recanalization grades.

CONCLUSIONS

These results suggest a large amount of perfusion recovery on TTP is associated with favorable outcome as well as early neurological improvement after EVT, and may be a useful prognostic marker.

KEY POINTS

• A large amount of perfusion recovery on TTP map is associated with favorable outcome and early neurological improvement after EVT. • The best cutoff value for favorable functional outcome was 68 mL for post-EVT TTP hypoperfused volume and 56 mL decrease for TTP hypoperfused volume. • Amount of perfusion recovery on TTP map has better performance on the prediction of favorable functional recovery and early neurological improvement than other diffusion- and perfusion-weighted MRI parameters and recanalization grades.

Baseline ASPECTS and hypoperfusion intensity ratio influence the impact of first pass reperfusion on functional outcomes

BACKGROUND

First pass reperfusion (FPR) has been established as a key performance metric in mechanical thrombectomy (MT). The impact of FPR may be more relevant in fast progressors. We aim to study the impact of baseline Alberta Stroke Program Early CT Score (ASPECTS) on non-contrast CT and hypoperfusion intensity ratio (HIR) on CT perfusion on clinical outcomes after FPR.

METHODS

A prospective MT database was reviewed for patients with isolated occlusion of the intracranial internal carotid artery and/or middle cerebral artery M1 segment who underwent MT with complete reperfusion (modified Thrombolyis in Cerebral Infarction score 2c-3) from January 2012 to May 2019. The overall population was divided into ASPECTS >7 versus ≤7 and the subgroup of patients with baseline CT perfusion was divided into HIR <0.3 versus ≥0.3. Univariable and multivariable analyses were performed to establish the predictors of 90-day functional independence (modified Rankin Scale (mRS) ≤2) in each subgroup.

RESULTS

A total of 436 patients were included in the analyses. FPR was achieved in 254 (58.3%) patients. ASPECTS modified the effect of FPR on clinical outcomes, with FPR predicting good outcomes in patients with ASPECTS ≤7 (46% vs 29%, adjusted OR 3.748; 95% CI 1.590 to 8.838, p=0.003) while no significant effect was detected in those with ASPECTS >7 (62.3% vs 53.1%, adjusted OR 1.372; 95% CI 0.798 to 2.358, p=0.25). Similarly, FPR predicted good outcomes in patients with HIR ≥0.3 (54.8% vs 41.9%, adjusted OR 2.204; 95% CI 1.148 to 4.233, p=0.01) but not in those with HIR <0.3 (62.9% vs 52.8%, adjusted OR 1.524; 95% CI 0.592 to 3.920, p=0.38).

CONCLUSIONS

The impact of FPR on functional outcomes is highly dependent on baseline imaging characteristics, with a more prominent influence in patients presenting with lower ASPECTS and/or higher HIR.

Effects of hypertension in patients receiving mechanical thrombectomy: A meta-analysis

BACKGROUND

Available evidence shows conflicting results with regard to a potential detrimental effect of hypertension on clinical outcomes in patients who undergo mechanical thrombectomy (MT). We performed a meta-analysis to evaluate the impact of hypertension on the prognosis of patients with acute ischaemic stroke (AIS) treated by MT.

METHODS

We systematically reviewed previous studies in the PubMed, EMBASE, and Cochrane library databases that reported MT outcomes in AIS patients and their relationships with hypertension or blood pressure. We used a poor outcome (modified Rankin score >2 at 3 months) as the primary end point. Mortality and symptomatic intracranial hemorrhage were the secondary end points. We incorporated a random effect for trials in all models.

RESULTS

Data from 6650 patients in 31 articles that evaluated the effect of hypertension or blood pressure on outcomes after MT were included. Compared with patients without hypertension, patients with hypertension had significantly higher odds of a poor outcome (odds ratio 0.70; 95% confidence interval 0.57-0.85; I = 43%) and higher mortality (odds ratio 1.70; 95% confidence interval 1.26-2.29; I = 33%). Symptomatic intracranial hemorrhage did not differ by patient hypertension status.

CONCLUSIONS

The present study confirms that hypertension and high blood pressure are associated with a poor outcome at 3 months after MT in AIS patients. However, the causal relationship between hypertension and a poor outcome remains undetermined, and further investigations are required to ascertain whether AIS patients receiving MT could benefit from intensive blood pressure control.

Current Opinion on Endovascular Therapy for Emergent Large Vessel Occlusion Due to Underlying Intracranial Atherosclerotic Stenosis

For recanalization of emergent large vessel occlusions (ELVOs), endovascular therapy (EVT) using newer devices, such as a stent retriever and large-bore catheter, has shown better patient outcomes compared with intravenous recombinant tissue plasminogen activator only. Intracranial atherosclerotic stenosis (ICAS) is a major cause of acute ischemic stroke, the incidence of which is rising worldwide. Thus, it is not rare to encounter underlying ICAS during EVT procedures, particularly in Asian countries. ELVO due to underlying ICAS is often related to EVT procedure failure or complications, which can lead to poor functional recovery. However, information regarding EVT for this type of stroke is lacking because large clinical trials have been largely based on Western populations. In this review, we discuss the unique pathologic basis of ELVO with underlying ICAS, which may complicate EVT procedures. Moreover, we review EVT data for patients with ELVO due to underlying ICAS and suggest an optimal endovascular recanalization strategy based on the existing literature. Finally, we present future perspectives on this subject.

Pretreatment Anterior Choroidal Artery Infarction Predicts Poor Outcome after Thrombectomy in Intracranial ICA Occlusion

BACKGROUND AND PURPOSE

Predictors of outcome after endovascular thrombectomy have not been investigated adequately in patients with intracranial ICA occlusions. This study aimed to assess the impact of anterior choroidal artery infarction in pretreatment DWI on the outcome of patients with acute intracranial ICA occlusion who underwent thrombectomy.

MATERIALS AND METHODS

This study included 113 patients with acute intracranial ICA occlusion who underwent DWI followed by thrombectomy between January 2011 and July 2016. Characteristics and outcomes were compared between the groups positive and negative for anterior choroidal artery infarction and patients with good outcomes (90-day mRS 0-2) and poor outcomes (mRS 3-6). Binary logistic regression analyses were performed to identify independent predictors of a good outcome.

RESULTS

On pretreatment DWI, anterior choroidal artery infarction was observed in 60 patients (53.1%). Good outcomes were significantly less frequent in the group positive for anterior choroidal artery infarction than in the group negative for it (25% versus 49.1%, P = .008). Parenchymal hemorrhage occurred only in the group positive for anterior choroidal artery infarction (13.3% versus 0%, P = .007). In the multivariate logistic regression analysis, independent predictors of good outcome were an absence of anterior choroidal artery infarction (OR, 0.333; 95% CI, 0.135-0.824; P = .017) and successful reperfusion (OR, 5.598; 95% CI, 1.135-27.604; P = .034).

CONCLUSIONS

Pretreatment anterior choroidal artery infarction is associated with parenchymal hemorrhage and poor outcome after thrombectomy in patients with acute intracranial ICA occlusion. In addition, the absence of anterior choroidal artery infarction and successful reperfusion were independent predictors of good outcome after thrombectomy in acute intracranial ICA occlusion.

Predictors of Acute Neurological Worsening after Endovascular Thrombectomy

Background

Successful reperfusion after endovascular thrombectomy (EVT) correlates with good outcome. However, radiographic reperfusion does not always translate into good clinical outcomes even if the reperfusion occurs early after the stroke onset. Reasons for neurological worsening (NW) are thought to be many, such as progression of the stroke, hemorrhagic conversion post tissue plasminogen activator and/or EVT, and procedural complications such as vessel dissection or perforation, distal emboli, and re-occlusion. Data on patients worsening in the acute phase after EVT are limited.

Objective

We studied the factors associated with acute NW and also identified the predictors of NW after EVT and its association with poor outcome at discharge.

Methods

A retrospective cohort from a single comprehensive stroke center includes patients with acute ischemic stroke and large vessel occlusion in anterior and posterior circulation who presented between December 2014 and May 2017 and received EVT were reviewed. Primary outcome was defined as acute NW defined as change in NIHSS ≥4 from baseline in the first 24 h after EVT. Secondary outcome were modified Rankin scale (mRS) 0-2 at discharge and final infarct volume. Univariate and multivariate analyses were performed to evaluate clinical and radiographic variables independently correlating with NW after EVT. Receiver operating curve analysis was also performed to identify predictors.

Results

178 patients were included in the analysis, 26 (14.7%) met the criteria for acute NW. For these 178 patients, the median age was 63 (IQR 53-74, range 26-89), baseline median NIHSS was 19 (IQR 14-24, range 5-37), ASPECTS was 8 (IQR 7-9, range 4-10), admission median systolic blood pressure (SBP) was 150 (IQR 131-170, range 94-287), and initial median blood glucose (BG) was 123 (IQR 106-157, range 69-433). The most common reasons for worsening were progression of the stroke (42.3%) and reperfusion injury PH-2 (26.9%) (p < 0.0001). Univariate logistic analysis showed that race, ASPECTS, collateral score, diabetes mellitus, admission SBP, and admission BG were associated with acute NW. In multivariate analysis, only admission BG (OR 1.00, CI 1.00-1.01, p = 0.04) was found to have a significant association with acute NW. We ran a prediction analysis for variables and found the area under the curve to be 0.75. Finally, there was strong association between NW and poor outcome at discharge (MRS 3-6, p < 0.01) by Fisher's exact test. About 46.1% in the NW group died during hospitalization compared to 10% in the non-NW group (p < 0.0001).

Conclusion

Our single-center retrospective cohort result is limited by small sample size. It showed that high admission BG is an independent predictor of NW after EVT and ultimately leads to poor outcome.

Endovascular treatment for emergent large vessel occlusion due to severe intracranial atherosclerotic stenosis

OBJECTIVE

The optimal treatment strategy for patients with emergent large vessel occlusion (ELVO) due to underlying severe intracranial atherosclerotic stenosis (ICAS) is unclear. The purpose of this study was to compare treatment outcomes from intracranial angioplasty with or without stenting and intraarterial infusion of a glycoprotein IIb/IIIa inhibitor in patients with ELVO due to severe ICAS, and to investigate predictors of outcome after endovascular therapy in such patients.

METHODS

A total of 140 consecutive patients with ELVO attributable to severe ICAS underwent endovascular therapy at two stroke centers (A and B). Intracranial angioplasty/stenting was primarily performed at center A and intraarterial infusion of glycoprotein IIb/IIIa inhibitor (tirofiban) at center B. Data from both centers were prospectively collected into a database and retrospectively analyzed.

RESULTS

Overall, successful reperfusion was achieved in 95% (133/140) of patients and a good outcome in 60% (84/140). The mortality rate was 7.9%. Symptomatic hemorrhage occurred in 1 patient. There were no significant differences in the rates of successful reperfusion, symptomatic hemorrhage, 3-month modified Rankin scale score 0-2, and mortality between the two centers. Multivariate logistic regression analysis revealed the only independent predictor of good outcome was a history of previous stroke or transient ischemic attack (TIA) (odds ratio 0.254, 95% confidence interval 0.094-0.689, p = 0.007).

CONCLUSIONS

Both intracranial angioplasty/stenting and intraarterial infusion of a glycoprotein IIb/IIIa inhibitor are effective and safe in the treatment of underlying severe ICAS in acute stroke patients with ELVO. In addition, a lack of a history of stroke/TIA was the only independent predictor of good outcome after endovascular therapy in such patients.

Impact of isolated basal ganglia infarction at pretreatment DWI on outcomes after endovascular thrombectomy in acute anterior circulation stroke

PURPOSE

Acute infarction confined to the basal ganglia (BG) is occasionally observed on baseline imaging before endovascular thrombectomy. This study aimed to investigate the impact of isolated BG infarction revealed on pretreatment DWI in a large cohort of patients with acute anterior circulation stroke who underwent thrombectomy.

METHODS

We retrospectively analyzed clinical and DWI data from 328 patients who underwent thrombectomy for emergent occlusions of the intracranial internal carotid artery or the middle cerebral artery. Characteristics and treatment outcomes were compared between patients with isolated BG infarction and those with non-isolated BG infarction. Binary logistic regression analyses were performed to identify independent predictors of good outcome (90-day mRS 0-2).

RESULTS

Isolated BG infarction was found in 57 patients (17.4%). Patients with isolated BG infarction had a higher incidence of underlying severe intracranial atherosclerotic stenosis (21.1% vs. 10.7%, P = 0.032) than those with non-isolated BG infarction. Successful reperfusion occurred more frequently in patients with isolated BG infarction than those with non-isolated BG infarction (93% vs. 79%, odds ratio 3.529, 95% confidence interval 1.226-10.161, P = 0.014). On multivariate logistic regression analysis, independent predictors of good outcome were age, DWI-ASPECTS, and admission NIHSS score. There was no significant difference in the rate of good outcome between the two groups (54.4% vs. 42.8%, P = 0.110).

CONCLUSION

Isolated BG infarction on pretreatment DWI may predict successful reperfusion after endovascular thrombectomy in patients with acute anterior circulation stroke. In addition, our study suggested a novel finding that isolated BG infarction was more frequently associated with underlying severe ICAS than non-isolated BG infarction.

Predictors of 30-day mortality after endovascular mechanical thrombectomy for acute ischemic stroke

OBJECTIVE

The aims of this single-center, retrospective cohort study are to assess the outcomes of endovascular mechanical thrombectomy (EMT) for acute ischemic stroke (AIS) and determine predictors of 30-day mortality at an academic comprehensive stroke center (CSC).

METHODS

We retrospectively collected data from consecutive patients who underwent EMT for AIS at our institution between April 2016 and January 2018. Primary outcome was defined as mortality within 30 days from EMT. Successful revascularization was defined as a modified Thrombolysis in Cerebral Infarction (mTICI) grade 2b-3. Statistical analyses were performed to identify predictors of 30-day mortality.

RESULTS

The study cohort was comprised 57 patients (51% male) with mean age of 72 years. Intravenous tissue plasminogen activator was administered in 51%. The median Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and National Institutes of Health Stroke Scale (NIHSS) score were 8 and 20, respectively. The 30-day mortality rate was 39%. Univariate analyses found that older age (mean 77 vs. 68 years, p = 0.022), higher baseline NIHSS score (median 23 vs. 19, p = 0.032), NIHSS score at 24 h after EMT (median 14.5 vs. 7.5, p < 0.001), and lower rates of successful revascularization (59% vs. 89%, p = 0.021) were associated with 30-day mortality.

CONCLUSION

We observed a moderate rate of 30-day mortality after EMT at an academic CSC. Older age, higher baseline NIHSS score, higher NIHSS score at 24 h after thrombectomy, and lower rates of successful revascularization were predictive of 30-day mortality in univariate analysis. Further efforts to identify modifiable risk factors of mortality are warranted.

Is the Efficacy of Endovascular Treatment for Acute Ischemic Stroke Sex-Related

BACKGROUND

Several reports refer to differences in stroke between females and males, namely in incidence and clinical outcome, but also in response to treatments. Driven by a recent analysis of the MR CLEAN trial, which showed a higher benefit from acute stroke endovascular treatment (EVT) in males, we intended to determine if clinical outcomes after EVT differ between sexes, in a real-world setting.

METHODS

We analyzed 145 consecutive patients submitted to EVT for anterior circulation large-vessel occlusion, between January 2015 and September 2016, and compared the outcomes between sexes.

RESULTS

Our population was represented by 81 (55.9%) females, with similar baseline characteristics (pre-stroke disability, baseline NIHSS, and ASPECTS), rate of previous intravenous thrombolysis, time from onset to recanalization, and rate of revascularization; with the exception that women were on average 4 years older and had more hypertension, and men in turn had more tandem occlusions and atherosclerotic etiology (all p < 0.05). Even after adjusting for these statistically significant variables and for intravenous thrombolysis (as some studies advocate a different response to this treatment between sexes), there were no differences in intracranial hemorrhage, functional independence (mRS ≤2 in 60.9% males vs. 66.7% in females, p = 0.48; adjusted p = 0.36), or mortality at 3 months.

CONCLUSION

In a real-world setting, we found no sex differences in clinical and safety outcomes after acute stroke EVT. Our results support the idea that women are equally likely to achieve good outcomes as men after acute stroke EVT.

Erythrocyte Fraction Within Retrieved Thrombi Contributes to Thrombolytic Response in Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Recent advent of endovascular thrombectomy (EVT) enables us to provide a new perspective on the use of tPA (tissue-type plasminogen activator) through histological analysis of retrieved thrombus. We investigated the responsiveness of intravenous thrombolysis (IVT) according to the thrombus composition in EVT-attempted patients with acute ischemic stroke.

METHODS

We reviewed 92 consecutive patients with anterior circulation stroke who received combined IVT and EVT for 2 years. IVT responsiveness is defined as any decrease in the clot burden from baseline computed tomographic angiography to digital subtraction angiography during EVT. We histologically analyzed the relative fractions of red blood cells (RBCs), congregated fibrin and platelets, and white blood cells in the retrieved thrombi using semiautomated color-based segmentation method. Clinical characteristics according to the RBC fraction were investigated, and associated factors with IVT responsiveness were explored.

RESULTS

Fifty-two patients with histological analyses were stratified into lowest, middle, and highest tertiles of RBC fraction. Toward higher RBC fraction, there was more common susceptibility vessel signs on magnetic resonance imaging (50.0% versus 66.7% versus 91.7%; P=0.022) and prevalent IVT responsiveness (25.0% versus 41.7% versus 75.0%; P=0.010). IVT-responsive group (n=23) had higher RBC fraction (45.7±15.5% versus 35.9±12.2%; P=0.010), lower fibrin and platelet (50.4±14.0% versus 58.5±11.1%; P=0.027), and lower white blood cells fraction (3.9±2.1% versus 5.5±3.0%; P=0.027) than IVT-unresponsive group (n=29). After adjusting for potential variables, RBC fraction (odds ratio, 1.05; 95% confidence interval, 1.01-1.10) remained only independent determinant of IVT responsiveness.

CONCLUSIONS

In EVT-attempted patients with acute ischemic stroke, IVT responsiveness would be closely associated with RBC fraction.

Importance of Reperfusion Status after Intra-Arterial Thrombectomy for Prediction of Outcome in Anterior Circulation Large Vessel Stroke

Background

Reperfusion status after intra-arterial thrombectomy (IAT) is a critical predictor of functional outcome after acute ischemic stroke. However, most prognostic models have not included a detailed assessment of reperfusion status after IAT.

Objective

The aim of this work was to assess the association between successful reperfusion and clinical outcome.

Methods

Clinical, radiological, and procedural variables of patients treated with IAT were extracted from our prospective stroke registry. The association with functional outcome using the modified Rankin Scale (mRS) after 3 months was assessed using multivariable logistic regression. An extension of the modified TICI score, eTICI, was used to classify reperfusion status. The prognostic value of reperfusion status after IAT in addition to age, stroke severity, imaging characteristics, treatment with intravenous thrombolysis, and time from symptom onset to the end of IAT was assessed with logistic regression and summarized with receiver operating characteristic curves.

Results

In total, 119 patients were included (mean age 66 years). In multivariable analysis, age >80 years (OR 6.8, 95% CI 1.2-39.8), NIHSS at presentation >15 (OR 7.3, 95% CI 2.3-23.5), and incomplete reperfusion status (eTICI score <2C; OR 10.3, 95% CI 3.5-30.6) were the strongest predictors of a poor outcome (mRS 3-6). Adding reperfusion status to the model improved the prognostic accuracy (AUC 0.88, 95% CI 0.91-0.94). Our results indicate a large difference between using an eTICI cutoff of ≥2C versus ≥2B: a cutoff ≥2C improved the predictive value for a good clinical outcome (2C: positive predictive value, PPV, 0.78; 2B: PPV 0.32).

Conclusion

Our results promote using reperfusion status for assessing prognosis in ischemic stroke patients treated with IAT. A model using eTICI ≥2C had greater PPV than eTICI ≥2B and could improve prognostic accuracy.

Clinical implications of CT hyperdense artery sign in patients with acute middle cerebral artery occlusion in the era of modern mechanical thrombectomy

The clinical implications of the CT hyperdense artery sign have yet to be established in the new era of modern mechanical thrombectomy. This study aimed to investigate prognostic implications of the CT hyperdense middle cerebral artery sign (HMCAS) on treatment outcomes after mechanical thrombectomy for acute MCA occlusions. A retrospective analysis of CT and clinical data from 212 patients with acute MCA occlusions who underwent mechanical thrombectomy was conducted. HMCAS was determined with visual assessment by consensus of two readers. Interobserver agreement was measured. HMCAS was classified into two groups: M1 and M2 HMCAS. Associations between HMCAS and vascular risk factors, stroke etiology, and treatment outcomes were analyzed. Of 212 patients, HMCAS was identified in 118 patients (55.7%). Overall, successful reperfusion was achieved in 82.5% (175/212) and a good outcome in 45.8% (97/212). There was no significant association between HMCAS and treatment outcomes after mechanical thrombectomy, regardless of HMCAS location. Cardioembolism was more frequent in patients with a positive HMCAS (67.8 vs 48.9%, P = 0.005). Large-artery atherosclerosis was more frequent in patients with a negative HMCAS (31.9 vs 12.7%, P = 0.001). Underlying severe MCA stenosis was more frequently observed in patients with a negative HMCAS (25.5 vs 3.4%, P < 0.001). Our study suggests that the prognostic implication of a HMCAS in predicting outcomes after endovascular therapy in patients with acute MCA occlusion may be low in the era of modern mechanical thrombectomy. Negative HMCAS is predictive of in situ thrombotic occlusion due to underlying severe atherosclerotic stenosis in such patients.