[Incidence and predictors of 90-day poor clinical outcome after successful endovascular treatment for acute basilar artery occlusion]

Objective: To investigate the incidence and predictors of 90-day poor clinical outcome after successful endovascular treatment for acute basilar artery occlusion. Methods: Patients were selected from the Acute Ischemic Stroke Cooperation Group of Endovascular Treatment (ANGEL) registry, which was a prospective, multicenter registry study between June 2015 and December 2017. The demographic characteristics, past history, personal history, vital signs, National Institutes of Health Stroke Scale (NIHSS) score, imaging examination, onset/admission/puncture/end of operation, operation-related variables, medication during operation, patency of occluded blood vessels after operation, etiology classification, and 90-day modified Rankin scale (mRS) score were collected. Successful endovascular treatment was defined as modified thrombolysis in cerebral infarction (mTICI) 2b-3. Poor outcome was defined as 90-day mRS 4-6. Multivariate logistic regression analysis was performed to analyze the predictors of poor clinical outcome after successful endovascular treatment. Results: A total of 170 (128 males and 42 females) acute basilar artery occlusion patients undergoing successful endovascular treatment were included in the analysis, with the median age of [M (Q1, Q3)] of 64 (55, 70) years. Poor clinical outcome occurred in 72 patients (42.4%). Multivariate logistic regression analysis revealed that high baseline NIHSS score (OR=1.166, 95%CI: 1.109-1.225, P<0.001) and high baseline systolic blood pressure (OR=1.032, 95%CI: 1.010-1.053, P=0.003) were the independent predictors of poor clinical outcome. Conclusions: The incidence of 90-day poor clinical outcome after successful endovascular treatment for acute basilar artery occlusion is 42.4%. High baseline NIHSS score and systolic blood pressure are associated with the poor clinical outcome.

Endovascular thrombectomy versus standard bridging thrombolytic with endovascular thrombectomy within 4·5 h of stroke onset: an open-label, blinded-endpoint, randomised non-inferiority trial

BACKGROUND

The benefit of combined treatment with intravenous thrombolysis before endovascular thrombectomy in patients with acute ischaemic stroke caused by large vessel occlusion remains unclear. We hypothesised that the clinical outcomes of patients with stroke with large vessel occlusion treated with direct endovascular thrombectomy within 4·5 h would be non-inferior compared with the outcomes of those treated with standard bridging therapy (intravenous thrombolysis before endovascular thrombectomy).

METHODS

DIRECT-SAFE was an international, multicentre, prospective, randomised, open-label, blinded-endpoint trial. Adult patients with stroke and large vessel occlusion in the intracranial internal carotid artery, middle cerebral artery (M1 or M2), or basilar artery, confirmed by non-contrast CT and vascular imaging, and who presented within 4·5 h of stroke onset were recruited from 25 acute-care hospitals in Australia, New Zealand, China, and Vietnam. Eligible patients were randomly assigned (1:1) via a web-based, computer-generated randomisation procedure stratified by site of baseline arterial occlusion and by geographic region to direct endovascular thrombectomy or bridging therapy. Patients assigned to bridging therapy received intravenous thrombolytic (alteplase or tenecteplase) as per standard care at each site; endovascular thrombectomy was also per standard of care, using the Trevo device (Stryker Neurovascular, Fremont, CA, USA) as first-line intervention. Personnel assessing outcomes were masked to group allocation; patients and treating physicians were not. The primary efficacy endpoint was functional independence defined as modified Rankin Scale score 0-2 or return to baseline at 90 days, with a non-inferiority margin of -0·1, analysed by intention to treat (including all randomly assigned and consenting patients) and per protocol. The intention-to-treat population was included in the safety analyses. The trial is registered with ClinicalTrials.gov, NCT03494920, and is closed to new participants.

FINDINGS

Between June 2, 2018, and July 8, 2021, 295 patients were randomly assigned to direct endovascular thrombectomy (n=148) or bridging therapy (n=147). Functional independence occurred in 80 (55%) of 146 patients in the direct thrombectomy group and 89 (61%) of 147 patients in the bridging therapy group (intention-to-treat risk difference -0·051, two-sided 95% CI -0·160 to 0·059; per-protocol risk difference -0·062, two-sided 95% CI -0·173 to 0·049). Safety outcomes were similar between groups, with symptomatic intracerebral haemorrhage occurring in two (1%) of 146 patients in the direct group and one (1%) of 147 patients in the bridging group (adjusted odds ratio 1·70, 95% CI 0·22-13·04) and death in 22 (15%) of 146 patients in the direct group and 24 (16%) of 147 patients in the bridging group (adjusted odds ratio 0·92, 95% CI 0·46-1·84).

INTERPRETATION

We did not show non-inferiority of direct endovascular thrombectomy compared with bridging therapy. The additional information from our study should inform guidelines to recommend bridging therapy as standard treatment.

FUNDING

Australian National Health and Medical Research Council and Stryker USA.

[Endovascular thrombectomy in patients with intracranial large artery occlusion and atrial fibrillation]

Objective: To investigate the safety and efficacy of mechanical thrombectomy in patients with atrial fibrillation complicated with acute intracranial arterial occlusion. Methods: Fifty-eight patients with atrial fibrillation complicated with acute intracranial arterial occlusion in the intervention group of East (Endovascular Therapy for Acute ischemic Stroke Trial) were analyzed. According to the TOAST (Trial of Org 10 172 in Acute Stroke Treatment) classification, patients were divided into ICAS (Intracranial Atherosclerotic Stenosis) group and cardiogenic embolism group. Clinical characteristics, treatment methods and clinical prognosis were compared between ICAS group and cardiogenic embolism group. Results: A total of 58 patients with atrial fibrillation complicated with acute intracranial arterial occlusion were included in this study, including 46 patients in the cardiogenic embolism group (79%) and 12 patients in the ICAS group (21%). The pre-hospital transport time in ICAS group was longer than that in cardiogenic embolism group (P<0.05).Patency rate in patients with atrial fibrillation complicated with acute intracranial arterial occlusion was 98.3% (57/58), The rate of patients with the 90-day function independent (mRS 0-2) was 51.7% (30/58). There were no statistically significant differences in functional independence, mortality rate, ICH and sICH at 90 days between the cardiogenic embolism group and the ICAS group. Conclusions: Mechanical thrombectomy is an effective method to treat patients with atrial fibrillation complicated with acute intracranial arterial occlusion.

[Clinical characteristics of 57 patients with polyarteritis nodosa and renal involvement]

Objective: To investigate the clinical characteristics of polyarteritis nodosa (PAN) patients with renal involvement. Methods: PAN patients admitted to the department of rheumatology, department of pediatrics, department of nephrology, general internal medicine department and department of vascular surgery at Peking Union Medical College Hospital from June 2012 to August 2018 were enrolled in this study and were divided into two groups according to renal involvement or not. The clinical characteristics were analyzed. Results: A total of 94 PAN patients were finally enrolled and 57 (60.64%) presented kidney manifestation. The mean age of onset was (37.76±17.40) years old and the interval from onset to diagnosis was 10 (0 to 240) months. Forty patients were misdiagnosed once or more times. In patients with renal involvement, 9 cases suffered from renal ischemia or infarction, 31 with microscopic haematuria, 26 with proteinuria, renal artery or its branch involved in 17 cases, renal vein thrombosis in 1 case, 4 cases with pyeloureterectasis, one case with renal fascia thickening, 33 cases with impaired renal function (serum creatinine>84 μmol/L) including creatinine>140 μmol/L in 10 patients. Renal artery branch stenosis was the most common presentation [9 cases (52.94%)] of renal vascular involvement, other abnormalities including nodular dilatation [4 cases (23.53%)], occlusion [3 cases (17.65%)]. There were significant differences (P<0.05) in the PAN patients with and without renal involvement in the following: age of onset [(33.72±16.13) years vs. (43.97±17.66) years, t(2)=2.901, P=0.005], weight loss(≥4kg since PAN onset) [25(43.86%) vs. 7(18.92%), χ(2)=6.216, P=0.013], elevation of diastolic blood pressure [22(38.60%) vs. 7(18.92%), χ(2)=4.072, P=0.044], acromegaly gangrene [18(31.58%) vs. 21(56.76%), χ(2)=5.859, P=0.015], and gastrointestinal artery involvement [20(35.09%) vs. 6(1.22%), χ(2)=3.993, P=0.046]. Laboratory parameters and the application of glucocorticoid and cyclophosphamide therapies were similar in two groups (all P>0.05). Conclusion: Young PAN patients are more likely to be associated with renal involvement, especially gastrointestinal arteries.