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.

Development and Internal Validation of Machine Learning Models to Predict Mortality and Disability After Mechanical Thrombectomy for Acute Anterior Circulation Large Vessel Occlusion

OBJECTIVE

Mechanical thrombectomy (MT) improves outcomes in patients with LVO but many still experience mortality or severe disability. We sought to develop machine learning (ML) models that predict 90-day outcomes after MT for LVO.

METHODS

Consecutive patients who underwent MT for LVO between 2015-2021 at a Comprehensive Stroke Center were reviewed. Outcomes included 90-day favorable functional status (mRS 0-2), severe disability (mRS 4-6), and mortality. ML models were trained for each outcome using prethrombectomy data (pre) and with thrombectomy data (post).

RESULTS

Three hundred and fifty seven patients met the inclusion criteria. After model screening and hyperparameter tuning the top performing ML model for each outcome and timepoint was random forest (RF). Using only prethrombectomy features, the AUCs for the RFpre models were 0.73 (95% CI 0.62-0.85) for favorable functional status, 0.77 (95% CI 0.65-0.86) for severe disability, and 0.78 (95% CI 0.64-0.88) for mortality. All of these were better than a standard statistical model except for favorable functional status. Each RF model outperformed Pre, SPAN-100, THRIVE, and HIAT scores (P < 0.0001 for all). The most predictive features were premorbid mRS, age, and NIHSS. Incorporating MT data, the AUCs for the RFpost models were 0.80 (95% CI 0.67-0.90) for favorable functional status, 0.82 (95% CI 0.69-0.91) for severe disability, and 0.71 (95% CI 0.55-0.84) for mortality.

CONCLUSIONS

RF models accurately predicted 90-day outcomes after MT and performed better than standard statistical and clinical prediction models.

Soluble PD-L1 reprograms blood monocytes to prevent cerebral edema and facilitate recovery after ischemic stroke

Acute cerebral ischemia triggers a profound inflammatory response. While macrophages polarized to an M2-like phenotype clear debris and facilitate tissue repair, aberrant or prolonged macrophage activation is counterproductive to recovery. The inhibitory immune checkpoint Programmed Cell Death Protein 1 (PD-1) is upregulated on macrophage precursors (monocytes) in the blood after acute cerebrovascular injury. To investigate the therapeutic potential of PD-1 activation, we immunophenotyped circulating monocytes from patients and found that PD-1 expression was upregulated in the acute period after stroke. Murine studies using a temporary middle cerebral artery (MCA) occlusion (MCAO) model showed that intraperitoneal administration of soluble Programmed Death Ligand-1 (sPD-L1) significantly decreased brain edema and improved overall survival. Mice receiving sPD-L1 also had higher performance scores short-term, and more closely resembled sham animals on assessments of long-term functional recovery. These clinical and radiographic benefits were abrogated in global and myeloid-specific PD-1 knockout animals, confirming PD-1+ monocytes as the therapeutic target of sPD-L1. Single-cell RNA sequencing revealed that treatment skewed monocyte maturation to a non-classical Ly6Clo, CD43hi, PD-L1+ phenotype. These data support peripheral activation of PD-1 on inflammatory monocytes as a therapeutic strategy to treat neuroinflammation after acute ischemic stroke.

Single-center outcomes of Onyx Frontier™ and Resolute Onyx™ drug-eluting balloon-mounted stents for rescue stenting for acute large vessel occlusion

BACKGROUND

In cases where mechanical thrombectomy (MT) fails, rescue stenting may be necessary to achieve reperfusion; however, the lack of standardized techniques or devices poses a challenge. This series aims to present our early experience with the Onyx Frontier™ and Resolute Onyx™ balloon-mounted drug-eluting stents for rescue stenting.

METHODS

A retrospective chart review was performed of all patients who underwent rescue stenting, in the setting of failed MT, using Onyx Frontier™ or Resolute Onyx™ stents at a single institution. Technical details, procedural complications, and patient outcomes were recorded for each case.

RESULTS

Twenty-two Onyx Frontier™ and Resolute Onyx™ stents were deployed in 18 patients undergoing rescue stenting. Stent locations included the middle cerebral artery (36.4%), internal carotid artery (18.2%), vertebral artery (22.7%), and basilar artery (22.7%). The average National Institutes of Health Stroke Scale score before MT was 13.8 (range 0-31). The median initial modified Rankin Scale (mRS) score was zero, while the median mRS score at follow-up was three. Successful reperfusion, as assessed by TICI scores, was achieved in 43.8% of patients for TICI 3, 43.8% for TICI 2C, and 12.5% for TICI 2B. Post-revascularization, 16.7% of patients experienced hemorrhage, of which one patient (5.6%) had symptomatic hemorrhage.

CONCLUSIONS

Onyx Frontier™ and Resolute Onyx™ stents are well suited for rescue stenting in cases of failed MT. These balloon-mounted drug-eluting stents exhibit excellent navigability, rendering them appropriate for rescue revascularization procedures. Our findings demonstrate that these stents confer a high degree of technical success.

Microsurgical thrombectomy: where the ancient art meets the new era

Mechanical thrombectomy (MT) is the leading treatment for acute large vessel occlusion (LVO). However, surgical thrombectomy (ST) may have a role in well selected LVO patients where MT failed to re-establish flow, the endovascular route is inaccessible, or where MT is a financially prohibitive or absent option (developing and poor countries). We compared the efficacy and efficiency between ST and MT, and described our operative experience and its potential application in the developing world. Clinical outcomes, procedural times, and efficacy of treatment were compared between the MT and ST of acute LVO between 2012 and 2022. Propensity score-matched analysis was also conducted to compare MT and ST. One-hundred nine patients fulfilled the study criteria (77 MTs vs 32 STs). Factors driving outcome were age (aOR: 0.95, 95%CI, 0.91-0.98), hemisphere side (aOR: 0.38, 95%CI, 0.15-0.96), and DWI-ASPECT (aOR: 1.39, 95%CI, 1.09-1.77) at presentation by the multivariate analysis. Times from door-start of procedure (P = 0.45) and start of procedure-recanalization (P = 0.13) were similar between treatment options. Propensity score-matched analysis found no significant difference for 2 treatment methods about time of door to recanalization (P = 0.155) and outcome (P = 0.221). The prognosticators of thrombectomy for acute LVO in patients with successful recanalization were age, affected hemisphere side, and DWI-ASPECT score. Our evidence shows that the efficacy of ST is similar to that of MT. There should be a place of ST for cases of mechanical failure or tandem cervical ICA and MCA occlusion. ST may be a temporizing LVO treatment option in healthcare systems where MT is inexistent or financially prohibitive to patients.

The clinical outcome of emergency superficial temporal artery-to-middle cerebral artery bypass in acute ischemic stroke with large vessel occlusion

The role of superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass in acute ischemic stroke (AIS) is contentious, with no evidence in patients with AIS and large vessel occlusion (AIS-LVO). We conducted a cohort study to assess emergency STA-MCA outcomes in AIS-LVO and a meta-analysis to evaluate STA-MCA outcomes in early AIS treatment. From January 2018 to March 2021, we consecutively recruited newly diagnosed AIS-LVO patients, dividing them into STA-MCA and non-STA-MCA groups. To evaluate the neurological status and outcomes, we employed the National Institutes of Health Stroke Scale (NIHSS) during the acute phase and the modified Rankin Scale (mRS) during the follow-up period. Additionally, we conducted a meta-analysis encompassing all available clinical studies to assess the impact of STA-MCA on patients with AIS. In the cohort study (56 patients), we observed more significant neurological improvement in the STA-MCA group at two weeks (p = 0.030). However, there was no difference in the clinical outcomes between the two groups. Multivariable logistic regression identified the NIHSS at two weeks (OR: 0.840; 95% CI: 0.754-0.936, p = 0.002) as the most critical predictor of a good outcome. Our meta-analysis of seven studies indicated a 67% rate for achieving a good outcome (mRS < 3) at follow-up points (95% CI: 57%-77%, I2 = 44.1%). In summary, while the meta-analysis suggested the potential role of STA-MCA bypass in mild to moderate AIS, our single-center cohort study indicated that STA-MCA bypass does not seem to improve the prognosis of patients who suffer from AIS-LVO.

White matter hyperintensity burden and collateral circulation in acute ischemic stroke with large artery occlusion

OBJECTIVE

This study aimed to investigate the association between white matter hyperintensity (WMH) burden and pial collaterals in acute strokes caused by intracranial large artery occlusion treated with mechanical thrombectomy in the anterior circulation, focusing on stroke subtypes.

METHODS

Consecutive patients undergoing mechanical thrombectomy between December 2019 and June 2022 were retrospectively screened. The Fazekas scale assessed WMH burden. Pial collaterals were categorized as either poor (0-2) or good (3-4) based on the Higashida score. A multivariable analysis was used to determine the relationship between WMH burden and pial collaterals. Subgroup analyses delved into associations stratified by stroke subtypes, namely cardioembolism (CE), tandem lesions (TLs), and intracranial atherosclerosis (ICAS).

RESULTS

Of the 573 patients included, 274 (47.8%) demonstrated poor pial collaterals. Multivariable regression indicated a strong association between extensive WMH burden (Fazekas score of 3-6) and poor collaterals [adjusted OR 3.04, 95% CI 1.70-5.46, P < 0.001]. Additional independent predictors of poor collaterals encompassed ICAS-related occlusion (aOR 0.26, 95% CI 0.09-0.76, P = 0.014), female sex (aOR 0.63, 95% CI 0.41-0.96, P = 0.031), and baseline Alberta Stroke Program Early Computed Tomography scores (aOR 0.80, 95% CI 0.74-0.88, P < 0.001). Notably, an interaction between extensive WMH burden and stroke subtypes was observed in predicting poor collaterals (P = 0.001), being pronounced for CE (adjusted OR 2.30, 95% CI 1.21-4.37) and TLs (adjusted OR 5.09, 95% CI 2.32-11.16), but was absent in ICAS (adjusted OR 1.24, 95% CI 0.65-2.36).

CONCLUSIONS

Among patients treated with mechanical thrombectomy for anterior circulation large artery occlusion, extensive WMH burden correlates with poor pial collaterals in embolic occlusion cases (CE and TLs), but not in ICAS-related occlusion.

Streamlined workflow including nurse recognition of conjugate gaze deviation for reduced door-to-puncture time in endovascular thrombectomy: A retrospective study

BACKGROUND

Endovascular thrombectomy is recognized as a pivotal treatment for acute ischemic stroke due to large vessel occlusion. Prolonged door-to-puncture time correlates with decreased patient independence after acute ischemic stroke. This study aimed to assess whether a streamlined workflow, including nurse recognition of conjugate gaze deviation, could reduce door-to-puncture time in endovascular thrombectomy.

METHODS

This study retrospectively reviewed patients with acute ischemic stroke who underwent endovascular thrombectomy between March 2017 and March 2022 and compared a previous workflow with a streamlined workflow implemented in April 2019. In the streamlined workflow, nurses recognized conjugate gaze deviation to identify patients with large vessel occlusions and played a more active role in reducing the door-to-puncture time. We compared time metrics and outcomes, including recanalization status, parenchymal hemorrhage type 2, and favorable outcomes (modified Rankin Scale score 0-2) at three months between the previous and streamlined workflow groups.

RESULTS

After the application of the streamlined workflow, the door-to-puncture time was reduced from 76 min to 68 min (p = 0.014), and the number of patients with a door-to-puncture time of less than 60 min increased (15% vs. 36%, p = 0.002). Outcomes including modified thrombolysis in cerebral infarction ≥ 2b (73% vs. 71%, p = 1.000), parenchymal hemorrhage type 2 (7% vs. 2%, p = 0.281), and favorable outcome (33% vs. 34%, p = 1.000) were comparable between the two groups.

CONCLUSION

Nurse recognition of conjugate gaze deviation contributed to an 8-minute reduction in the door-to-puncture time, demonstrating the potential benefits of an organized workflow in acute ischemic stroke.

Immediate Carotid Artery Stenting or Deferred Treatment in Patients With Tandem Carotid Lesions Treated Endovascularly for Acute Ischaemic Stroke

Fifteen to 20% of patients with an acute ischaemic stroke have a tandem lesion defined by the combination of an intracranial large vessel thrombo-embolic occlusion and a high grade stenosis or occlusion of the ipsilateral internal carotid artery. These patients tend to have worse outcomes than patients with isolated intracranial occlusions, with higher rates of disability and death. The introduction of endovascular thrombectomy to treat the intracranial lesion clearly improved the outcome compared with treatment with intravenous thrombolysis alone. However, the best treatment strategy for managing the extracranial carotid artery lesion in patients with tandem lesions remains unknown. Current guidelines recommend carotid endarterectomy for patients with transient ischaemic attack or non-disabling stroke and moderate or severe stenosis of the internal carotid artery, within two weeks of the initial event, to prevent major stroke recurrence and death. Alternatively, the symptomatic carotid artery could be treated by endovascular placement of a stent during endovascular thrombectomy (EVT). This would negate the need for a second procedure, immediately reduce the risk of stroke recurrence, increase patient satisfaction, and could be cost effective. However, the administration of dual antiplatelet therapy could potentially increase the risk of symptomatic intracranial haemorrhage in patients with acute ischaemic stroke. Randomised controlled trials evaluating the efficacy and safety of immediate carotid artery stenting during EVT in acute stroke patients with tandem lesions are currently ongoing and will impact the current guidelines regarding the treatment of patients with acute ischaemic stroke due to these tandem lesions.

Clinical efficacy and safety of endovascular treatment for patients with wake-up stroke with large vessel occlusion guided by NCCT-ASPECTS

OBJECTIVE

To evaluate the clinical efficacy and safety of 6 to 24 h endovascular therapy (EVT) in patients with wake-up stroke (WUS) with acute large vessel occlusion (LVO) of the anterior circulation guided by noncontrast computed tomography-Alberta stroke program early CT score (NCCT-ASPECTS).

METHODS

Fifty-three patients with WUS with acute LVO of the anterior circulation who were treated at the Sir Run Run Shaw Hospital of Zhejiang Medical College from January 2018 to March 2021 were retrospectively analyzed. The patients were divided into NCCT-ASPECTS or CT perfusion groups. Baseline data, perioperative data, and 90-d prognostic information were compared between the two groups. Multivariable logistic regression analysis was used to determine the independent factors influencing outcomes.

RESULTS

There were no significant differences in the good prognosis, symptomatic intracranial hemorrhage, and mortality rates between the two groups (P > 0.05). Multivariate logistic regression analysis showed that the puncture-recanalization time was an independent factor for good prognosis.

CONCLUSION

Based on NCCT-ASPECTS guidance, EVT in patients with WUS for acute LVO of the anterior circulation within 6 to 24 h may be safe and effective.

Delayed microsurgical revascularization in an acute ischemic stroke based on perfusion study

A 58-year-old patient presented with a severe neurological deficit due to a stroke caused by an occlusion of the left internal carotid artery siphon. Standard treatment failed and neurosurgical consult was delayed. Because of a favorable perfusion imaging finding, microsurgical revascularization via an extra-intracranial bypass (left superficial temporal artery - left middle cerebral artery) was performed 36 hours after the onset of the symptoms. The outcome of the patient was favorable. The authors want to emphasize the need to actively seek patients with a severe neurological deficit and still viable brain tissue. The time window and treatment alternatives are discussed.

The impact of the COVID-19 pandemic on the provision of endovascular thrombectomy for stroke: an Irish perspective

BACKGROUND

The COVID-19 pandemic produced unprecedented challenges to healthcare systems. These challenges were amplified in the setting of endovascular thrombectomy (EVT) for large vessel occlusion strokes given the time-sensitive nature of the procedure.

AIMS

To assess the impact of the COVID-19 pandemic on service provision at the primary endovascular stroke centre in Ireland.

METHODS

A retrospective review of the National Thrombectomy Service database was performed. All patients undergoing EVT from 1 January to 31 December inclusive of 2019 to 2021 were included. Patient demographics, functional outcomes and endovascular treatment time metrics were recorded.

RESULTS

Data from 2019, 2020 and 2021 were extracted. Three hundred seven thrombectomies were performed in 2019 and 2020; this number increased to 327 in 2021. Median time from arrival to groin puncture for thrombectomy was 64 min in 2019, increasing to 65 min in 2020. In 2021, this decreased to 52 min. Median time taken from groin puncture to first perfusion remained stable from 2019 to 2021 years at 20 min. Total duration of emergency thrombectomies reduced from 32 min in 2019 to 27 min in 2020. This increased to 29 min in 2021.

CONCLUSIONS

Despite the myriad of challenges presented by the pandemic, service provision at the primary Irish ESC, and the referring hospitals, has proven to be robust. Procedural time metrics were maintained whilst the expected reduction in number of EVTs performed did not materialise, there actually being a significant increase in number of EVTs performed in the pandemic's second year.

Seizures at stroke onset: A case-control study

PURPOSE

Seizures occurring at the immediate onset of a stroke, abbreviated "seizures at onset" (SaO), pose a diagnostic and therapeutic challenge for physicians. In this study, we report on the current clinical practice in managing stroke patients with SaO from a large tertiary stroke center in Germany.

METHODS

We selected all patients with SaO and acute ischemic or hemorrhagic stroke admitted to the Department of Neurology at the University Hospital of Cologne between 2019 and 01-01 and 2020-12-31. SaO patients were then compared to patients with acute ischemic or hemorrhagic stroke without SaO from the local stroke registry. Further, we compared SaO patients who received intravenous recombinant tissue-type plasminogen activator (rt-PA) and/or mechanical thrombectomy with matched controls.

RESULTS

Overall, 54 out of 2312 stroke patients (2.3 %) in the examined period presented with SaO. The most prevalent SaO semiology was focal to bilateral tonic-clonic (42.6 %). SaO was associated with hemorrhagic strokes and higher in-hospital mortality in all stroke patients. The rate of acute stroke therapy was not influenced by the occurrence of SaO. In patients that received acute stroke therapy, patients with SaO had higher scores on the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS) at admission, and longer door-to-needle times for the administration of rt-PA, while none of the examined outcome parameters revealed a difference between patients with and without SaO after adjusting for potential confounders.

CONCLUSION

Data show that SaO is rare in stroke patients but associated with more extensive strokes.

Outcomes of mechanical thrombectomy in orally anticoagulated patients with anterior circulation large vessel occlusion: a propensity-matched analysis of the Imperial College Thrombectomy Registry

BACKGROUND

Mechanical thrombectomy (MT) remains an effective treatment for patients with acute ischemic stroke receiving oral anticoagulation (OAC) and large vessel occlusion (LVO). However, to date, it remains unclear whether MT is safe in patients on treatment with OAC.

AIMS

In our study, we performed a propensity-matched analysis to investigate the safety and efficacy of MT in patients with acute ischemic stroke receiving anticoagulants. A propensity score method was used to target the causal inference of the observational study design.

METHODS

This observational, prospective, single-centre study included consecutive patients with acute LVO ischemic stroke of the anterior circulation. Demographic, neuro-imaging and clinical data were collected and compared according to the anticoagulation status at baseline, patients on OAC vs those not on OAC. The primary study outcomes were the occurrence of any intracerebral haemorrhage (ICH) and symptomatic ICH. The secondary study outcomes were functional independence at 90 days after stroke (defined as modified Rankin Scale (mRS) scores of 0 through 2), mortality at 3 months and successful reperfusion rate according to the modified treatment in cerebral infarction (mTICI) score.

RESULTS

Overall, our cohort included 573 patients with acute ischemic stroke and LVO treated with MT. After propensity score matching, 495 patients were matched (99 OAC group vs 396 no OAC group). There were no differences in terms of clinical characteristics between the two groups, except for the rate of intravenous thrombolysis less frequently given in the OAC group. There was no significant difference in terms of the rate of any ICH and symptomatic ICH between the two groups. With regards to the secondary study outcome, there was no significant difference in terms of the rate of successful recanalization post-procedure and functional independence at 3 months between the two groups. Patients in the OAC group showed a reduced mortality rate at 90 days compared to the patients with no previous use of anticoagulation (20.2% vs 21.2%, p = 0.031). Logistic regression analysis did not reveal a statistically significant influence of the anticoagulation status on the likelihood of any ICH (OR = 0.95, 95% CI = 0.46-1.97, p = 0.900) and symptomatic ICH (OR = 4.87, 95% CI = 0.64-37.1, p = 0.127). Our analysis showed also that pre-admission anticoagulant use was not associated with functional independence at 90 days after stroke (OR = 0.76, 95% CI = 0.39-1.48, p = 0.422) and rate of successful reperfusion (OR = 0.81, 95% CI = 0.38-1.72, p = 0.582).

CONCLUSION

According to our findings anticoagulation status at baseline did not raise any suggestion of safety and efficacy concerns when MT treatment is provided according to the standard guidelines. Confirmation of these results in larger controlled prospective cohorts is necessary.

IV thrombolysis plus thrombectomy versus IV thrombolysis alone for minor stroke with anterior circulation large vessel occlusion from the IRETAS and Italian SITS-ISTR cohorts

INTRODUCTION

The aim of this study was to compare the outcomes of patients treated with intravenous thrombolysis (IVT) <4.5 h after symptom onset plus mechanical thrombectomy (MT) <6 h with those treated with IVT alone <4.5 h for minor stroke (NIHSS ≤5) with large vessel occlusion (LVO) in the anterior circulation.

PATIENTS AND METHODS

Patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) and in the Italian centers included in the SITS-ISTR were analyzed.

RESULTS

Among the patients with complete data on 24-h ICH type, 236 received IVT plus MT and 382 received IVT alone. IVT plus MT was significantly associated with unfavorable shift on 24-h ICH types (from no ICH to PH-2) (OR, 2.130; 95% CI, 1.173-3.868; p=0.013) and higher rate of PH (OR, 4.363; 95% CI, 1.579-12.055; p=0.005), sICH per ECASS II definition (OR, 5.527; 95% CI, 1.378-22.167; p=0.016), and sICH per NINDS definition (OR, 3.805; 95% CI, 1.310-11.046; p=0.014). Among the patients with complete data on 3-month mRS score, 226 received IVT plus MT and 262 received IVT alone. No significant difference was reported between IVT plus MT and IVT alone on mRS score 0-1 (72.1% versus 69.1%), mRS score 0-2 (79.6% versus 79%), and death (6.2% versus 6.1%).

CONCLUSIONS

Compared with IVT alone, IVT plus MT was associated with unfavorable shift on 24-h ICH types and higher rate of 24-h PH and sICH in patients with minor stroke and LVO in the anterior circulation. However, no difference was reported between the groups on 3-month functional outcome measures.

Outcome of stroke patients eligible to mechanical thrombectomy managed by spoke center, primary stroke center or comprehensive stroke center in the East of France

BACKGROUND AND PURPOSE

Patients with suspected stroke are referred to the nearest hospital and are managed either in a spoke center (SC), a primary stroke center (PSC), or a comprehensive stroke center (CSC) in order to benefit from early intravenous thrombolysis (IVT). In case of large vessel occlusion (LVO), mechanical thrombectomy (MT) is only performed in the CSC, whereas the effectiveness of MT is highly time-dependent. There is a debate about the best management model of patients with suspected LVO. Therefore, we aimed to compare functional and safety outcomes of LVO patients eligible for MT managed through our regional telestroke system.

METHOD

We performed a retrospective analysis of our observational prospective clinical registry in all consecutive subjects with LVO within six hours of onset who were admitted to the SC, PSC, or CSC in the east of France between October 2017 and November 2022. The primary endpoint was the functional independence defined as modified Rankin scale (mRS) score 0 to 2 at 90 days. Secondary endpoints were functional outcome, early neurological improvement, symptomatic intracranial hemorrhage and 90-day mortality.

RESULTS

Among the 794 included patients with LVO who underwent MT, 122 (15.4%) were managed by a SC, 403 (50.8%) were first admitted to a PSC, and 269 (33.9%) were first admitted to the CSC. The overall median NIHSS and ASPECTS score were 16 and 8, respectively. Multivariate analysis did not find any significant difference for the primary endpoint between patients managed by PSC versus CSC (OR 1.06 [95% CI 0.64;1.76], P=0.82) and between patient managed by SC versus CSC (OR 0.69 [0.34;1.40], P=0.30). No difference between the three groups was found except for the parenchymal hematoma rate between PSC and CSC (15.7 versus 7.4%, OR 2.25 [1.07;4.74], P=0.032).

CONCLUSIONS

Compared with a first admission to a CSC, the clinical outcomes of stroke patients with LVO eligible for MT first admitted to a SC or a PSC are similar.

CTP-based estimated ischemic core: A comparative multicenter study between Olea and RAPID software

BACKGROUND AND PURPOSE

CTP is increasingly used to assess eligibility for endovascular therapy (EVT) in patients with large vessel occlusions (LVO). There remain variability and inconsistencies between software packages for estimation of ischemic core. We aimed to use heterogenous data from four stroke centers to perform a comparative analysis for CTP-estimated ischemic core between RAPID (iSchemaView) and Olea (Olea Medical).

METHODS

In this retrospective multicenter study, patients with anterior circulation LVO who underwent pretreatment CTP, successful EVT (defined TICI ≥ 2b), and follow-up MRI included. Automated CTP analysis was performed using Olea platform [rCBF < 25% and differential time-to-peak (dTTP)>5s] and RAPID (rCBF < 30%). The CTP estimated core volumes were compared against the final infarct volume (FIV) on post treatment MRI-DWI.

RESULTS

A total of 151 patients included. The CTP-estimated ischemic core volumes (mean ± SD) were 18.7 ± 18.9 mL on Olea and 10.5 ± 17.9 mL on RAPID significantly different (p < 0.01). The correlation between CTP estimated core and MRI final infarct volume was r = 0.38, p < 0.01 for RAPID and r = 0.39, p < 0.01 for Olea. Both software platforms demonstrated a strong correlation with each other (r = 0.864, p < 0.001). Both software overestimated the ischemic core volume above 70 mL in 4 patients (2.6%).

CONCLUSIONS

Substantial variation between Olea and RAPID CTP-estimated core volumes exists, though rates of overcalling of large core were low and identical. Both showed comparable core volume correlation to MRI infarct volume.

Effect of mechanical thrombectomy with and without intravenous thrombolysis on the functional outcome of patients with different degrees of thrombus perviousness

PURPOSE

This study aimed to investigate the long-term functional outcome of patients with different degrees of thrombus perviousness (TP) undergoing mechanical thrombectomy alone and those undergoing combined intravenous thrombolysis (IVT) plus mechanical thrombectomy.

METHODS

We conducted a retrospective analysis of consecutive patients with acute ischemic stroke due to large vessel occlusion who underwent mechanical thrombectomy alone or bridging therapy between January 2016 and October 2020. TP was quantified by thrombus attenuation increase (TAI) on admission computed tomography angiography compared with non-contrast computed tomography. After dichotomization of TAI as higher or lower perviousness, Fisher exact tests were performed to estimate the associations of different therapies with favorable functional outcomes [Modified Ranking Scale score at 90 days (90-day mRS) of 0 to 2].

RESULTS

A total of 73 patients were included in our study. 35 (47.9%) thrombi were classified as higher-perviousness clots with TAI of ≥ 24 HU, and the other 38 thrombi were lower-perviousness clots. A favorable outcome with a 90-day mRS of 0 to 2 was observed in 32 patients. In patients with thrombi of lower perviousness, favorable outcome was more common in the bridging therapy group than in the thrombectomy-alone group (p = 0.013), whereas in patients with thrombi of higher perviousness, the long-term neurological outcome did not significantly differ between two therapy groups (p = 0.094).

CONCLUSION

Patients with thrombi of lower perviousness were recommended to undergo intravenous alteplase followed by endovascular thrombectomy, and those with thrombi of higher perviousness could undergo thrombectomy alone.

Association between left atrial enlargement and poor cerebral collaterals in large vessel occlusion

OBJECTIVES

Left atrial enlargement (LAE) is a known risk factor for atrial fibrillation, a common cause of large vessel occlusion (LVO) leading to ischemic stroke. While robust cerebral collaterals protect penumbral tissue from infarction, the effect of structural heart disease on cerebral collaterals remains uncertain. This study aims to investigate the association between LAE and cerebral collaterals in patients with acute LVO stroke.

MATERIALS AND METHODS

We conducted a retrospective study of consecutive patients with middle cerebral and/or internal carotid LVO who underwent endovascular thrombectomy (EVT) between 2012 to 2020. Consecutive patients with echocardiography and computed tomography angiography (CTA) of the head were included. Multivariate logistic regression analysis was performed to evaluate the relationship between LAE and poor cerebral collaterals, adjusting for demographics (age, sex, race) and vascular risk factors (hypertension, diabetes and smoking).

RESULTS

The study included 235 patients with mean age of 69±15 years and an initial mean National Institutes of Health Stroke Scale score of 18. Of these, 89 (37.9 %) had LAE, and 105 (44.7 %) had poor collaterals. Patients with LAE were more likely to have poor collaterals compared to those without LAE (58.4 % vs 36.3 %, P = 0.001). LAE was independently associated with higher odds of poor collaterals (odds ratio, 2.47; P = 0.001), even after adjusting for covariables (odds ratio 1.84, P = 0.048).

CONCLUSIONS

Our study demonstrated a significant association between LAE and poor cerebral collaterals in patients with LVO stroke undergoing EVT. Further research is warranted to explore potential shared mechanisms, such as endothelial dysfunction, underlying this heart-brain association.

The risk and outcome of malignant brain edema in post-mechanical thrombectomy: acute ischemic stroke by anterior circulation occlusion

BACKGROUND AND PURPOSE

Malignant brain edema (MBE) occurring after mechanical thrombectomy (MT) in acute ischemic stroke (AIS) could lead to severe disability and mortality. We aimed to investigate the incidence, predictors, and clinical outcomes of MBE in patients with AIS after MT.

METHODS

The clinical and imaging data of 155 patients with AIS of anterior circulation after MT were studied. Standard non-contrast CT was used to evaluate baseline imaging characteristics at admission. Clinical outcomes were measured using the 90-day modified Rankin Scale (mRS) score. Based on the follow-up CT scans performed within 72 h after MT, the patients were classified into MBE and non-MBE group. MBE was defined as a midline shift of ≥ 5 mm with signs of local brain swelling. Univariate and multivariate regression analyses were used to analyze the relationship between MBE and clinical outcomes and identify the predictors that correlate with MBE.

RESULTS

MBE was observed in 19.4% of the patients who underwent MT and was associated with a lower rate of favorable 90-day clinical outcomes. Significant differences were observed in both MBE and non-MBE groups: baseline Alberta Stroke Program Early CT (ASPECT) score, hyperdense middle cerebral artery sign (HMCAS), baseline signs of early infarct, angiographic favorable collaterals, number of retrieval attempts, and revascularization rate. Multivariate analysis indicated that low baseline ASPECT score, absent HMCAS, angiographic poor collaterals, more retrieval attempt count, and poor revascularization independently influenced the occurrence of MBE in AIS patients with anterior circulation after MT.

CONCLUSION

MBE was associated with a lower rate of favorable 90-day clinical outcomes. Low baseline ASPECT score, absent HMCAS, angiographic poor collaterals, more retrieval attempt count and poor revascularization were independently associated with MBE after MT.

Stroke with large vessel occlusion in the posterior circulation: IV thrombolysis plus thrombectomy versus IV thrombolysis alone

Efficacy and safety of mechanical thrombectomy (MT) for stroke with posterior circulation large vessel occlusion (LVO) is still under debate. We aimed to compare the outcomes of stroke patients with posterior circulation LVO treated with intravenous thrombolysis (IVT) (< 4.5 h after symptom onset) plus MT < 6 h after symptom onset with those treated with IVT alone (< 4.5 h after symptom onset). Patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) and in the Italian centers included in the SITS-ISTR were analysed. We identified 409 IRETAS patients treated with IVT plus MT and 384 SITS-ISTR patients treated with IVT alone. IVT plus MT was significantly associated with higher rate of sICH (ECASS II) compared with IVT alone (3.1 vs 1.9%; OR 3.984, 95% CI 1.014-15.815), while the two treatments did not differ significantly in 3-month mRS score ≤ 3 (64.3 vs 74.1%; OR 0.829, 95% CI 0.524-1.311). In 389 patients with isolated basilar artery (BA) occlusion, IVT plus MT was significantly associated with higher rate of any ICH compared with IVT alone (9.4 vs 7.4%; OR 4.131, 95% CI 1.215-14.040), while two treatments did not differ significantly in 3-month mRS score ≤ 3 and sICH per ECASS II definition. IVT plus MT was significantly associated with higher rate mRS score ≤ 2 (69.1 vs 52.1%; OR 2.692, 95% CI 1.064-6.811) and lower rate of death (13.8 vs 27.1%; OR 0.299, 95% CI 0.095-0.942) in patients with distal-segment BA occlusion, while two treatments did not differ significantly in 3-month mRS score ≤ 3 and sICH per ECASS II definition. IVT plus MT was significantly associated with lower rate of mRS score ≤ 3 (37.1 vs 53.3%; OR 0.137, 0.009-0.987), mRS score ≤ 1 (22.9 vs 53.3%; OR 0.066, 95% CI 0.006-0.764), mRS score ≤ 2 (34.3 vs 53.3%; OR 0.102, 95% CI 0.011-0.935), and higher rate of death (51.4 vs 40%; OR 16.244, 1.395-89.209) in patients with proximal-segment BA occlusion. Compared with IVT alone, IVT plus MT was significantly associated with higher rate of sICH per ECASS II definition in patients with stroke and posterior circulation LVO, while two treatment groups did not differ significantly in 3-month mRS score ≤ 3. IVT plus MT was associated with lower rate of mRS score ≤ 3 compared with IVT alone in patients with proximal-segment BA occlusion, whereas no significant difference was found between the two treatments in primary endpoints in patients isolated BA occlusion and in the other subgroups based on site occlusion.

Arterial Glyceryl Trinitrate in Acute Ischemic Stroke After Thrombectomy for Neuroprotection (AGAIN): A Pilot Randomized Controlled Trial

Although endovascular therapy demonstrates robust clinical efficacy in acute ischemic stroke (AIS), not all stroke patients benefit from successful reperfusion. This study aimed to evaluate the safety, feasibility, and preliminary efficacy of intra-arterial administration of glyceryl trinitrate (GTN) after endovascular recanalization for neuroprotection. This is a prospective randomized controlled study. Eligible patients were randomized to receive 800 μg GTN or the same volume of normal saline through the catheter after recanalization. The primary outcome was symptomatic intracranial hemorrhage (ICH), while secondary outcomes included mortality, functional outcome, infarction volume, complications, and blood nitrate index (NOx). A total of 40 patients were enrolled and randomized with no participants being lost to follow-up. There was no significant difference in the proportion of sICH between GTN and control groups. Additionally, no significant difference was observed in mortality or rates of neurological deterioration and other complications. Favorable trends, while non-significant, were noted in both outcome and imaging for functional independence at 90 days and reduction in final infarct volume (75.0% vs 65.0%; 33.2 vs 38.9 ml) for the GTN group. Moreover, the concentration of blood NOx in the GTN group was significantly higher than in the control group at 2 h after GTN administration (26.2 vs 18.0 μmol/l, p < 0.05). The AGAIN study suggests intra-arterial administration of GTN post-endovascular therapy is safe and feasible and GTN successfully raised NOx levels over controls at 2 h. A multi-center randomized controlled trial with a larger sample size is warranted to determine GTN neoadjuvant efficacy.

Effect of using G-FAST to recognize emergent large vessel occlusion: A city-wide community experience

BACKGROUND/PURPOSE

A prehospital bypass strategy was suggested for large vessel occlusion. This study aimed to evaluate the effect of a bypass strategy using the gaze-face-arm-speech-time test (G-FAST) implemented in a metropolitan community.

METHODS

Pre-notified patients with positive Cincinnati Prehospital Stroke Scale and symptom onset <3 h from July 2016 to December 2017 (pre-intervention period) and those with positive G-FAST and symptom onset <6 h from July 2019 to December 2020 (intervention period) were included. Patients aged <20 years and those with missing in-hospital data were excluded. The primary outcomes were the rates of receiving endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT). The secondary outcomes were total prehospital time, door-to-computed tomography (CT) time, door-to-needle (DTN) time, and door-to-puncture (DTP) time.

RESULTS

We included 802 and 695 pre-notified patients from the pre-intervention and intervention periods, respectively. The characteristics of the patients in the two periods were similar. In the primary outcomes, pre-notified patients during the intervention period showed higher rates of receiving EVT (4.49% vs. 15.25%, p < 0.001) and IVT (15.34% vs. 21.58%, p = 0.002). In the secondary outcomes, pre-notified patients during intervention period had longer total prehospital time (mean 23.38 vs 25.23 min, p < 0.001), longer door-to-CT time (median 10 vs 11 min, p < 0.001), longer DTN time (median 53 vs 54.5 min, p < 0.001) but shorter DTP time (median 141 vs 139.5 min, p < 0.001).

CONCLUSION

The prehospital bypass strategy with G-FAST showed benefits for stroke patients.

Efficacy, safety, and predictors for functional outcomes of mechanical thrombectomy in patients aged over 90 years with acute ischemic stroke and literature review

BACKGROUND

No evidence supports the efficacy and safety of mechanical thrombectomy (MT) in patients aged ≥ 90 years with acute ischemic stroke (AIS). This study clarifies the efficacy, safety, and predictors of MTs in patients aged ≥ 90 years by investigating our results and reviewing previous studies.

METHODS

We retrospectively investigated data from 80 consecutive patients who underwent MT at our hospital between 2018 and 2021. We analyzed outcomes using the modified Thrombolysis in the Cerebral Infarction (mTICI) scale and modified Rankin Scale (mRS). Functional outcomes were investigated at 90 days or discharge.

RESULTS

We obtained functional outcomes mRS ≤ 3 patients in 41.6%. The mortality rate was 16.6%. The rate of successful recanalization was 75%. Comparison mRS ≤ 3 and mRS ≥ 4 at 90 days or discharge showed statistical significance in the National Institute of Health Stroke Scale, the location of occluded vessels, and mTICI ≥ 2b at the first pass. Univariable logistic regression analysis indicated that the Alberta Stroke Program Early Computed Tomography Score was a predictor of mRS ≤ 3.

CONCLUSIONS

The efficacy is lower than that of patients aged < 90; however, MT is effective even in patients aged ≥ 90 years. The safety of MT in patients aged ≥ 90 years was similar to that in those aged < 90 years. Neuro-interventionalists should consider predictors and take the best strategies to achieve successful recanalization in patients aged ≥ 90 years with AIS.

Impact of age on mechanical thrombectomy and clinical outcome in patients with acute ischemic stroke

BACKGROUND AND PURPOSE

Mechanical thrombectomy is less effective in patients aged 80 years or older. Our goal was to better understand the impact of age in general on recanalization rates and clinical outcome.

METHODS

We performed a retrospective analysis of our prospective database of adult patients with acute ischemic stroke due to large vessel occlusions, who had undergone mechanical thrombectomy between 2019 and mid-2021. The cohort was categorized into five age groups: 18 - 49, 50 - 59, 60 - 69, 70 - 79 and ≥ 80 years. Our primary outcome measure was clinical outcome at three months after mechanical thrombectomy, measured by the mRS score. Secondary outcomes were procedure times and rates of successful recanalization, defined by mTICI ≥ 2b.

RESULTS

Data of 264 patients were analyzed. There were no significant differences in procedure times (p = 0.46) or in rates of successful recanalization (p = 0.49) between age groups. There was a significant association of age and mRS score at three months (p < 0.0001): From youngest to oldest group, odds of functional independence (mRS ≤ 2) decreased (80.0% vs. 21.3%) and odds of death (mRS 6) increased (13.3% vs. 57.3%). Increasing age was significantly associated with lower rates of functional independence (OR 0.93; [95% CI 0.90 - 0.95]), higher rates of care dependency (OR 1.04; [95% CI 1.01 - 1.07]) and higher mortality rates (OR 1.06; [95% CI 1.04 - 1.09]).

CONCLUSION

Higher age had no significant impact on recanalization times or recanalization rates but was strongly associated with worse clinical outcome after mechanical thrombectomy.