Revolutionizing the Management of Large-Core Ischaemic Strokes: Decoding the Success of Endovascular Therapy in the Recent Stroke Trials

Endovascular therapy (EVT) has revolutionized the management of acute ischaemic strokes with large vessel occlusion, with emerging evidence suggesting its benefit also in large infarct core volume strokes. In the last two years, four randomised controlled trials have been published on this topic-RESCUE-Japan LIMIT, ANGEL-ASPECT, SELECT2 and TENSION, with overall results showing that EVT improves functional and neurological outcomes compared to medical management alone. This review aims to summarise the recent evidence presented by these four trials and highlight some of the limitations in our current understanding of this topic.

Comparison of short-term outcomes between patients with extracranial carotid and/or intracranial atherosclerotic disease

OBJECTIVE

To directly compare the 90-day outcomes of patients with symptomatic intracranial atherosclerotic disease (ICAD), extracranial carotid atherosclerotic disease (ECAD), and ICAD with concomitant ECAD.

METHODS

From 2017-2021, patients who had (1) a transient ischemic attack or ischemic stroke within 30 days of admission as evaluated by a stroke neurologist and (2) ipsilateral ICAD and/or ECAD were prospectively enrolled. The cohort was divided into three groups: ICAD, ECAD, and ICAD with concomitant ECAD. The primary outcome assessed was 90-day ischemic stroke recurrence. Secondary outcomes included 90-day myocardial infarction (MI), all-cause mortality, and major adverse cardiovascular events (MACE, including cardiovascular death, nonfatal MI, and/or nonfatal ischemic stroke).

RESULTS

Of 371 patients included in the analysis, 240 (64.7%) patients had ICAD only, 93 (25.0%) patients had ECAD only, and 38 (10.3%) patients had ICAD with concomitant ECAD. On multivariate time-to-event analysis adjusting for potential confounders and with ICAD as the reference comparator, the risk of 90-day clinical outcomes was highest among patients with ICAD and concomitant ECAD, with adjusted hazard ratios of 4.54 (95% CI=1.45, 14.2; p = 0.006), 9.32 (95% CI=1.58, 54.8; p = 0.014), and 8.52 (95% CI=3.54, 20.5; p < 0.001) for 90-day ischemic stroke, MI, and MACE, respectively.

CONCLUSIONS

Patients with ICAD and concomitant ECAD have a poorer prognosis and are at significantly higher risk for 90-day ischemic stroke, MI, and MACE. Further research should focus on the evaluation of coronary atherosclerotic disease and more intensive medical therapy in this population.

Bridging thrombolysis improves survival rates at 90 days compared with direct mechanical thrombectomy alone in acute ischemic stroke due to basilar artery occlusion: a systematic review and meta-analysis of 1096 patients

BACKGROUND

Mechanical thrombectomy (MT) is an effective treatment for patients with acute ischemic stroke (AIS) from basilar artery occlusion (BAO).

OBJECTIVE

To compare the clinical outcomes of MT, with and without bridging intravenous thrombolysis (IVT), in acute BAO through a systematic review and meta-analysis of the current literature.

METHODS

Systematic searches of Medline, EMBASE, and Cochrane Central were undertaken on August 1, 2022. Good functional outcome defined as 90-day modified Rankin Scale score 0-2 was the primary outcome measure. Secondary outcome measures were 90-day mortality, successful post-thrombectomy recanalization (modified Thrombolysis in Cerebral Infarction score ≥2b), symptomatic intracranial hemorrhage (sICH), and subarachnoid hemorrhage (SAH).

RESULTS

Three studies reporting 1096 patients with BAO AIS were included in the meta-analysis. No significant differences in good functional outcome were detected between the two groups (RR=1.28 (95% CI 0.86 to 1.92); p=0.117). However, specifically patients with large artery atherosclerosis (LAA) benefited from bridging IVT (OR=2.52 (95% CI 1.51 to 4.22); p<0.001) with better functional outcomes. There was a significantly lower 90-day mortality rate for patients who underwent bridging IVT compared with MT alone (RR=0.70 (95% CI 0.62 to 0.80); p=0.008). No significant differences were detected in rates of post-treatment recanalization (RR=1.01 (95% CI 0.35 to 2.91); p=0.954), sICH (RR=0.96 (95% CI 0.66 to 1.42); p=0.724), and SAH (RR=0.93 (95% CI 0.31 to 2.83); p=0.563).

CONCLUSIONS

In patients with AIS due to BAO, bridging IVT was associated with lower mortality rates at 90 days, compared with direct MT. There were no improved functional outcomes or increased sICH or SAH between both arms, However, patients with LAA benefited from bridging IVT, with better functional outcomes.

Non-alcoholic fatty liver disease increases risk of carotid atherosclerosis and ischemic stroke: An updated meta-analysis with 135,602 individuals

BACKGROUND/AIMS

Non-alcoholic fatty liver disease (NAFLD) is associated with the development of cardiovascular disease. While existing studies have examined cardiac remodeling in NAFLD, there has been less emphasis on the development of carotid atherosclerosis and stroke. We sought to conduct a meta-analysis to quantify the prevalence, risk factors, and degree of risk increment of carotid atherosclerosis and stroke in NAFLD.

METHODS

Embase and Medline were searched for articles relating to NAFLD, carotid atherosclerosis, and stroke. Proportional data was analysed using a generalized linear mixed model. Pairwise meta-analysis was conducted to obtain odds ratio or weighted mean difference for comparison between patients with and without NAFLD.

RESULTS

From pooled analysis of 30 studies involving 7,951 patients with NAFLD, 35.02% (95% confidence interval [CI], 27.36-43.53%) had carotid atherosclerosis with an odds ratio of 3.20 (95% CI, 2.37-4.32; P<0.0001). Pooled analysis of 25,839 patients with NAFLD found the prevalence of stroke to be 5.04% (95% CI, 2.74-9.09%) with an odds ratio of 1.88 (95% CI, 1.23-2.88; P=0.02) compared to non-NAFLD. The degree of steatosis assessed by ultrasonography in NAFLD was closely associated with risk of carotid atherosclerosis and stroke. Older age significantly increased the risk of developing carotid atherosclerosis, but not stroke in NAFLD.

CONCLUSION

This meta-analysis shows that a stepwise increment of steatosis of NAFLD can significantly increase the risk of carotid atherosclerosis and stroke development in NAFLD. Patients more than a third sufferred from carotid atherosclerosis and routine assessment of carotid atherosclerosis is quintessential in NAFLD.

Internal cerebral vein asymmetry is an independent predictor of poor functional outcome in endovascular thrombectomy

BACKGROUND

Endovascular thrombectomy (EVT) in large vessel occlusion (LVO) in anterior circulation acute ischaemic stroke (AIS) results in good functional outcomes in only approximately 60% of the patients. Internal cerebral veins (ICVs) are easily visible, with a consistent midline location, and are linked to stroke outcomes. We hypothesize that ICV asymmetry on multiphasic CT angiogram (mCTA) can be an adjunctive predictor for poor functional outcomes.

METHODS

We studied consecutive AIS patients from 2017 to 2019 with anterior circulation LVO treated with EVT regardless of intravenous thrombolysis. Asymmetrical ICV was defined as the presence of hypodensity (less opacification) on the ipsilateral occlusion side as compared with the contralateral side. The primary outcome was modified Rankin Score (mRS) score at 3 months. Secondary outcomes were good recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) 2b-3), symptomatic hemorrhage, and mortality.

RESULTS

A total of 185 patients were included with a median age of 70 years (IQR 59-77); 87 patients (47%) were female. 82 patients (44.3%) achieved good functional outcomes (mRS 0-2) at 3 months. On multivariate analysis, National Institutes of Health Stroke Scale (NIHSS) (OR 1.076, 95% CI 1.015 to 1.140; p<0.013), poor collateral score (OR 0.285, 95% CI 0.162 to 0.501; p<0.001), asymmetrical ICV on the peak venous phase (OR 2.47, 95% CI 1.115 to 5.471; p<0.026), and late venous phase of the mCTA (OR 2.642, 95% CI 1.161 to 6.016; p<0.021) were independent risks factors of poor outcomes.

CONCLUSION

ICV asymmetry is a novel radiological sign which is independently associated with poor functional outcomes in EVT, even after correction for collateral circulation. Further studies are needed to validate this finding.

Abstract P471: Ipsilateral Asymmetrical Internal Cerebral Vein on Multiphasic Computed Tomography for Acute Anterior Circulation Ischemic Stroke Thrombectomy is an Independent Predictor of Poor Functional Outcome

Background: National Institute of health stroke scale(NIHSS) and collateral circulation are well-established predictors for functional outcomes of endovascular thrombectomy (EVT) patients in acute ischemic stroke (AIS), nonetheless additional prognostic markers can improve the prediction of stroke outcomes. The inflow and drainage into the internal cerebral veins (ICV) can be seen consistently on multiphasic computed tomography angiography (mCTA). Thus, we hypothesize that asymmetry of ICV in the mCTA in large vessel occlusion AIS can be used as an adjunctive predictor of functional outcomes and complications.

Method: We enrolled 185 consecutive anterior circulation AIS patients who underwent EVT that presented to our hospital between 2017 and 2019. The collateral circulation was defined by the university of Calgary mCTA collateral flow assessment in stroke. The ICV on the ipsilateral occlusion side was compared with the contralateral side according to a binary scale: 1 (less than contralateral or absent) or 2(equal or greater than contralateral). The primary outcome was modified Rankin scale at 3 months (mRS), and secondary outcomes included symptomatic intracranial hemorrhage and mortality.

Result: Among 185 patients, 53% were men, the median age 70 years (range 29-91) and the median NIHSS score on arrival (NIHSS OA) was 19 (range 4-34). 82 patients (44.3%) had good functional outcomes at 3 months. Ipsilateral asymmetry in all three stages of mCTA were statistically significantly associated with good functional outcomes. The 1 st delay phase of mCTA showed the strongest association. On multivariate analysis, high NIHSS OA (OR 1.09, 95% CI 1.02-1.15, P = 0.007), good mCTA collateral score (OR 0.30, 95% CI .16- .53, P < .001), ipsilateral asymmetrical ICV on the 1 st delay phase of mCTA (OR 2.64, 95% CI 1.17-5.96, P = 0.01) were independent predictors of poor functional outcome. Ipsilateral asymmetry was not associated with mortality or symptomatic intracranial hemorrhage on multivariate analysis.

Conclusion: Ipsilateral assymetrical ICV is a novel radiological marker associated with functional outcomes after thrombectomy even after correction for the collateral circulation. Further studies should be done to validate this finding in different datasets.

Problem based review: the patient with recent onset polyarthritis

A wide variety of conditions can present as acute polyarthritis, ranging from those that are potentially life threatening, to those that are self-limiting, and those that represent the early stages of a persistent and potentially destructive form of arthritis. In this article, we describe the diagnostic approach and initial management of patients with recent onset polyarthritis, with the aid of an illustrative case vignette.