Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion

Endovascular management of acute stroke

Stroke related to large vessel occlusion is a leading cause of disability and death worldwide. Advances in endovascular therapy to reopen occluded arteries have been shown to reduce patient disability and mortality. Expanded indications to treat patients with large vessel occlusion in the late window (>6 h from symptom onset), with basilar artery occlusion, and with large ischaemic core at presentation have enabled treatment of more patients with simplified imaging methods. Ongoing knowledge gaps include an understanding of which patients with large ischaemic infarct are more likely to benefit from endovascular therapy, the role of endovascular therapy in patients who present with low National Institutes of Health Stroke Scale scores or medium or distal vessel occlusion, and optimal management of patients with underlying intracranial atherosclerotic disease. As reperfusion can now be facilitated by intravenous thrombolysis, mechanical thrombectomy, or both, the development of cytoprotective or adjunctive drugs to slow infarct growth, enhance reperfusion, or decrease haemorrhagic risk has gained renewed interest with the hope to improve patient outcomes.

Selective intra-arterial hypothermia combined with endovascular thrombectomy for large vessel occlusion: A systematic review and meta-analysis

BACKGROUND

Systemic therapeutic hypothermia may improve outcomes after acute ischemic stroke but increases complications. Selective intra-arterial hypothermia at the ischemic site during endovascular thrombectomy (EVT) theoretically offers benefits with fewer risks. However, there is little clinical evidence to support this approach.

METHODS

We searched Medline/PubMed, Embase and Cochrane electronic databases for studies evaluating the safety and feasibility of selective intra-arterial hypothermia as an adjunct to EVT for large vessel occlusion (LVO). Effect sizes with 95% confidence intervals (CIs) were pooled using the fixed-effect model. Odds ratios (ORs) were computed for binary variables, while the mean differences (MDs) were pooled for continuous data.

RESULTS

Of identified records, five clinical studies involving 463 LVO patients (62.9% male) were included. Of those, 224 (48.4%) patients received adjuvant selective intra-arterial hypothermia, while 239 (51.6%) received EVT alone. Selective intra-arterial hypothermia resulted in higher rates of good functional outcome (modified Rankin scale [mRS] 0-2 at 90-days) (OR 2.07, [95% CI, 1.36 to 3.16]), and lower final infarct volume (MD, -20.96 ml [95% CI, -26.17 to -15.75]) and lower rates of severe disability (mRS 3-5 at 90 days) (OR 0.44 [95% CI, 0.26 to 0.75]). Safety parameters including rates of symptomatic intracerebral hemorrhage, mortality, pneumonia, coagulation abnormalities, and arterial spasm were comparable between groups.

CONCLUSIONS

The initial evidence supports the safety and feasibility of selective intra-arterial hypothermia when combined with EVT for LVO. This approach shows promise for advancing research on neuroprotective strategies for ischemic stroke.

Analysis of relevant factors affecting the prognosis of mechanical thrombectomy in patients with acute posterior circulation large vessel occlusion cerebral infarction

OBJECTIVE

To explore the factors affecting the prognosis of patients with acute posterior circulation large vessel occlusion cerebral infarction (PCO) after mechanical thrombectomy.

METHOD

A retrospective study was conducted on a total of 58 patients who received thrombectomy and presented within 24 h of onset with PCO from 31 September 2020 to 31 December 2022. They were divided into two groups based on a 90-day mRS score(The mRS score of 0-3 was defined as a good prognosis, and 4-6 was defined as a poor prognosis).A univariate analysis was conducted on baseline data such as age and patient past medical history, as well as extended cerebral infarction thrombolysis grade (eTICI grade) and incidence of symptomatic intracranial hemorrhage (sICH) after surgery, for the groups with good prognosis and poor prognosis. Factors affecting the 90-day prognosis of patients were also analyzed in subgroups.

RESULTS

The preoperative National Institutes of Health Stroke Scale (NIHSS score)[21(12-35) vs 35(35-35)], postoperative 24-h NIHSS score[13(8-22) vs 35(35-35)], computed tomography (CT)[9(9-10) vs 6.5(6-7.75)] and computed tomography (CTP) brain blood volume (CBV)[9(8-10) vs 4(2-7.75)], cerebral blood flow (CBF)[7(4.5-9) vs 2(1-4)], time to peak (Tmax) [1(0.5-4) vs 0(0-1.75)] imaging of the posterior circulation Alberta stroke project early CT score (pc-ASPECTS score), Different locations of vascular occlusion, time from femoral artery puncture to vascular recanalization(64.96 ± 33.47 vs 92.68 ± 53.17). The differences in the conversion rate of postoperative intracranial hemorrhage(0 vs 16.1%) and the incidence of sICH(0 vs 12.9%) were statistically significant (P < 0.05). The subgroup analysis showed that vascular occlusion site, preoperative CBV pc-ASPECTS scores, and postoperative sICH occurrence were related to the 90-day prognosis of patients, and the differences were statistically significant (P < 0.05).

CONCLUSIONS

Some factors that can affect the prognosis of mechanical thrombectomy in patients with acute posterior circulation large vessel occlusion cerebral infarction. Preoperative clinical symptoms and imaging evaluation have certain evaluation values for prognosis.

Basilar artery occlusion location and clinical outcome: data from the ATTENTION multicenter registry

BACKGROUND

Acute basilar artery occlusion is a disabling and life-threatening condition. The purpose of this study was to evaluate the impact of occluded vessel location on the prognostic outcomes of patients who underwent endovascular treatment for acute basilar artery occlusion.

METHODS

Patient data for this study were obtained from the ATTENTION registry. Baseline data of the patients were described and compared across different occlusion locations. Univariable and multivariable regression analyses were performed to assess the effect of occluded vessel location on associated prognostic outcomes.

RESULTS

A total of 1672 patients were included in the analysis, with 583 having distal occlusion, 540 having middle occlusion, and 549 having proximal occlusion. Unlike distal occlusion, both proximal and middle occlusions were significantly and negatively associated with favorable clinical outcomes (for modified Rankin Scale score 0-3: adjusted odds ratio (aOR) 0.634, 95% confidence interval (95% CI) 0.493 to 0.816, P<0.001 in middle occlusion, and aOR 0.620, 95% CI 0.479 to 0.802, P<0.001 in proximal occlusion). Mortality was higher in patients with proximal and middle occlusions (aOR 1.461, 95% CI 1.123 to 1.902, P=0.005 in middle occlusion, and aOR 1.648, 95% CI 1.265 to 2.147, P<0.001 in proximal occlusion). The occluded vessel location was not associated with symptomatic intracranial hemorrhage.

CONCLUSIONS

Proximal and middle basilar artery occlusions were predominantly associated with poor clinical outcomes and increased risk of death following endovascular treatment.

Rescue intracranial stenting for failed posterior circulation thrombectomy: analysis from the Stenting and Angioplasty in NeuroThrombectomy (SAINT) study

BACKGROUNDS

Recent trials have shown improved outcomes after mechanical thrombectomy (MT) for vertebrobasilar occlusion (VBO) stroke. However, there is a paucity of data regarding safety and outcomes of rescue intracranial stenting (RS) after failed MT (FRRS+) for posterior circulation stroke. We sought to compare RS to failed reperfusion without RS (FRRS-).

METHODS

This is a retrospective analysis of the Stenting and Angioplasty in NeuroThrombectomy (SAINT) study, a multicenter collaboration involving prospectively collected databases. Patients were included if they had posterior circulation stroke and failed MT. The cohort was divided into two groups: FRRS+ and FRRS- (defined as modified Thrombolysis In Cerebral Infarction (mTICI) score 0-2a). The primary outcome was a shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included mRS 0-2 and mRS 0-3 at 90 days. Safety measures included rates of symptomatic intracranial hemorrhage (sICH), procedural complications, and 90-day mortality. Sensitivity and subgroup analyses were performed to identify outcomes in a matched cohort and in those with VBO, respectively.

RESULTS

A total of 152 failed thrombectomies were included in the analysis. FRRS+ (n=84) was associated with increased likelihood of lower disability (acOR 2.24, 95% CI 1.04 to 4.95, P=0.04), higher rates of mRS 0-2 (26.8% vs 12.5%, aOR 4.43, 95% CI 1.22 to 16.05, P=0.02) and mRS 0-3 (35.4% vs 18.8%, aOR 3.13, 95% CI 1.08 to 9.10, P=0.036), and lower mortality (42.7% vs 59.4%, aOR 0.40, 95% CI 0.17 to 0.97, P=0.04) at 90 days compared with FRRS- (n=68). The rates of sICH and procedural complications were comparable between the groups. Sensitivity and subgroup analyses showed similar results.

CONCLUSION

In patients with posterior circulation stroke who had failed MT, RS resulted in better functional outcomes with comparable safety profile to procedure termination.

Predictive value of white matter hyperintensity burden combined with collateral circulation in mechanical thrombectomy for acute anterior circulation large vessel occlusion

OBJECTIVE

To investigate the correlation and predictive value of white matter hyperintensity (WMH) burden in conjunction with collateral circulation during mechanical thrombectomy (MT) for acute anterior circulation occlusion.

METHODS

A database comprising consecutive registrations of patients who underwent mechanical thrombectomy for acute anterior circulation large vessel occlusive cerebral infarction at Nanjing Drum Tower Hospital from January 2018 to December 2021 was analyzed. Collateral circulation was assessed using the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) scoring criteria. The good collateral group included ASITN/SIR grades 3 and 4, while the poor collateral group included grades 1 and 2. Additionally, white matter hyperintensity burden was evaluated using white matter hyperintensity volume and the Fazekas scoring system. A favorable functional outcome was defined as a modified Rankin scale (mRS) of 0-2 at 90 days. Multivariable logistic regression analyses and Spearman correlation analysis were employed to assess the correlation between white matter hyperintensity burden and unfavorable outcomes in mechanical thrombectomy.

RESULTS

A total of 123 patients who underwent mechanical thrombectomy for acute anterior circulation occlusion were included (56.9 % male). Favorable outcomes were observed in 45.5 % (56/123) of cases. Those with a low ASITN/SIR scale (r = -1.33, 95 % CI: 0.26 (0.09-0.78), P=0.01; cutoff value = 2.5), low low-density lipoprotein cholesterol (LDL-C) level (r = -1.00, 95 % CI: 0.37 (0.15-0.92), P=0.03; cutoff value = 2.26), and high white matter hyperintense volume (r = 0.28, 95 % CI: 1.33 (1.03-1.71), P=0.03; cutoff value = 10.03) were more likely to experience unfavorable outcomes. Moreover, when compared to ASITN/SIR scale (AUC=89.6, 95 % CI: 0.09-0.78) and LDL level (AUC=62.8, 95 % CI: 0.15-0.92), white matter hyperintense volume demonstrated greater accuracy in predicting poor outcomes (AUC=94.4, 95 % CI: 1.03-1.71). Importantly, white matter hyperintense volume showed a positive correlation with the modified Rankin Scale (mRS) Score (r = 0.8289, P<0.0001). In brief, the burden of white matter hyperintensity is negatively correlated with collateral circulation in mechanical thrombectomy for acute anterior circulation occlusion.

CONCLUSIONS

The higher the burden of white matter hyperintensity, the worse the collateral circulation in mechanical thrombectomy for acute anterior circulation occlusion. The combination of high white matter hyperintensity volume and poor collateral circulation enhances might predict a worse clinical outcome of mechanical thrombectomy with acute anterior circulation occlusion.

Mechanical thrombectomy treatment for cerebral infarction in circulation after 40 h

The treatment time window for acute cerebral infarction in global guidelines is within 24 h. We report a patient who was admitted to the hospital and underwent endovascular treatment reaching 40 h. During vascular examination, the thrombus moved to distant segment, and then the surgeon quickly performed endovascular treatment. The patient ultimately achieved a good outcome. This case indicates that thrombus is moveable at any time, we expected to provide advice to clinical doctors that vascular examination should also be arranged as soon as possible to clarify the etiology in stroke patients especially with low NIHSS scores.

Benefits of First Pass Recanalization in Basilar Strokes Based on Initial Clinical Severity

PURPOSE

Randomized trials demonstrating the benefits of thrombectomy for basilar artery occlusions have enrolled an insufficient number of patients with a National Institutes for Health Stroke Scale (NIHSS) score < 10 and shown discrepant results for patients with an NIHSS > 20. Achieving a first pass recanalization (FPR) improves clinical outcomes in stroke. We aimed to evaluate the effect of the FPR on outcomes among basilar artery occlusion patients, characterized by prethrombectomy initial NIHSS score.

METHODS

We retrospectively analyzed the Endovascular Treatment in Ischemic Stroke (ETIS) registry of 279 basilar artery occlusion patients treated with thrombectomy from 6 participating centers. We compared the 90-day clinical outcomes of achieving a FPR versus no FPR, categorized by initial clinical severity: mild (NIHSS < 10), moderate (NIHSS 10-20) and severe (NIHSS > 20). We used Poisson regression with robust error variance to determine the effect of the NIHSS score on the association between FPR and outcomes.

RESULTS

The FPR patients with NIHSS < 10 or NIHSS 10-20 were more likely to have a favorable clinical outcome (modified Rankin scale, mRS 0-3) than non-FPR patients (relative risk, RR = 1.32, 95% confidence interval, CI: 1.04, 1.66, p-value = 0.0213, and RR = 1.79, 95% CI: 1.26, 2.53, p-value = 0.0011, respectively). A similar benefit was not found in patients with severe symptoms. We found a significantly lower risk of poor clinical outcome (mRS 4-6) in FPR patients with NIHSS 10-20, but not among patients with an NIHSS > 20.

CONCLUSION

Achieving a FPR in basilar artery occlusion patients with mild (NIHSS < 10) or moderate (NIHSS 10-20) symptoms is associated with better clinical outcomes, but not in patients with severe symptoms. These results support the importance of further clinical trials on the benefits of thrombectomy in severe strokes.

Performance and clinical outcomes in telestroke remain robust during the COVID-pandemic: insight into the NEVAS network

BACKGROUND

The COVID-19 pandemic had significant impact on global healthcare, including stroke management. Telemedical stroke networks have emerged with positive results for patient outcome in rural areas without stroke expertise. However, telestroke faced enormous on-site challenges during the pandemic. So far, data on performance and clinical outcomes in telestroke settings during the COVID-pandemic are scarce.

METHODS

We retrospectively analyzed data from stroke patients treated in four spoke hospitals of the Bavarian telestroke network NEVAS in 2020-2021 and 2019 as reference year and compared the 3 years for various parameters. Primary outcome was functional outcome according to the modified Rankin scale (mRS). Secondary outcome parameters included time intervals, periprocedural intracranial hemorrhage rates, and mortality.

RESULTS

In 2019-2021, 2820 patients were treated for acute ischemic stroke with an admission decrease of 10% during the pandemic. Of those, 241 received only IVT and 204 were transferred to our center for MT. Door-to-imaging, door-to-needle, and symptom-onset-to-groin times remained comparable in the 3 years. Complication rates remained at a low level. Good clinical outcome rates (mRS 0-2) at discharge remained stable for all stroke patients (82-84%) and for those treated with IVT (64-77%). Good clinical outcome rates at 3 month follow-up for MT patients declined in 2020 (23% vs. 35% in 2019) but recovered again in 2021 (42%). Mortality rates did not increase for all patient groups analyzed.

CONCLUSIONS

Stroke care remained robust during the COVID-pandemic within our network, indicating that well-established telestroke networks can overcome unexpected critical challenges such as a pandemic, guaranteeing best practice stroke care in rural areas.

Predictors of outcome and symptomatic intracranial hemorrhage in acute basilar artery occlusions: Analysis of the PC-SEARCH thrombectomy registry

INTRODUCTION

Recent randomized controlled trials demonstrated superiority of mechanical thrombectomy compared to medical therapy in acute basilar artery occlusions, however, little data is available to guide clinicians in functional prognosis and risk stratification.

PATIENTS AND METHODS

Data from the retrospectively established PC-SEARCH Thrombectomy registry, which included patients with basilar artery occlusion from eight sites from January 2015 to December 2021, was interrogated. Outcomes were dichotomized into 90-day favorable (mRS ⩽ 3) and unfavorable (mRS > 3). Multivariate logistic regression analysis was performed with respect to the outcome groups and were adjusted for potential confounding baseline characteristics.

RESULTS

Four-hundred-forty-four patients were included in this analysis. Mean age was 66 [SD 15], with 56% male, and comprised of 76% Caucasian. Patients presented with an initial median NIHSS of 18 and 199 patients (44.8%) achieved favorable 90-day functional outcomes. Independent predictors of favorable outcomes included younger age, pc-ASPECTS > 8 (OR 2.30 p < 0.001), and TICI ⩾ 2b (OR 7.56 p < 0.001). Unfavorable outcomes were associated with increasing number of passes (OR 1.29 p = 0.004) and sICH (OR 4.19 p = 0.015). IA-tPA was an independent risk factor for sICH (OR 7.15 p = 0.002) without improving favorable functional outcomes.

CONCLUSION AND DISCUSSION

PC-ASPECTS > 8, successful recanalization (TICI ⩾ 2b), first-pass recanalization, and younger age are independent predictors of favorable 90-day functional outcome in thrombectomy treated patients with acute basilar artery occlusion. Conversely, sICH were independent predictors of unfavorable outcomes. IA-tPA and unsuccessful recanalization are independently associated with sICH.

Impact of prodromal symptoms on the prognosis of patients with basilar artery occlusion treated with mechanical thrombectomy

INTRODUCTION

Even with reperfusion therapies, the prognosis of patients with basilar artery occlusion (BAO) related stroke remains poor. We aimed to test the hypothesis that the presence of prodromal symptoms, an easily available anamnestic data, is a key determinant of poor functional outcome.

PATIENTS AND METHODS

Data from patients with BAO treated in Lille, France, with mechanical thrombectomy (MT) between 2015 and 2021 were prospectively collected. The presence of prodromal symptoms was defined by previous transient neurological deficit or gradual progressive clinical worsening preceding a secondary sudden clinical worsening. We compared the characteristics of patients with and without prodromal symptoms. We built multivariate logistic regression models to study the association between the presence of prodromal symptoms and functional (mRS 0-3 and mortality), and procedural (successful recanalization and early reocclusion) outcomes.

RESULTS

Among the 180 patients, 63 (35%) had prodromal symptoms, most frequently a vertigo. Large artery atherosclerosis was the predominant cause of stroke (41.3%). The presence of prodromal symptoms was an independent predictor of worse 90-day functional outcome (mRS 0-3: 25.4% vs 47.0%, odds ratio (OR) 0.39; 95% confidence interval (CI) 0.16-0.86) and 90-day mortality (OR 2.17; 95% CI 1.02-4.65). Despite similar successful recanalization rate, the proportion of early basilar artery reocclusion was higher in patients with prodromal symptoms (23.8% vs 5.6%, p = 0.002).

DISCUSSION AND CONCLUSION

More than one third of BAO patients treated with MT had prodromal symptoms, especially patients with large-artery atherosclerosis. Clinicians should systematically screen for prodromal symptoms given the poor related functional outcome and increased risk of early basilar artery reocclusion.

The impact of large core and late treatment trials: An update on the modelled annual thrombectomy eligibility of UK stroke patients

INTRODUCTION

To support decisions about thrombectomy provision, we have previously estimated the annual UK population eligible for treatment as ∼10% of stroke admissions. Since then, eight further randomised trials that could alter the eligibility rate have reported in 2021-23. We updated our estimates of the eligible population from these trials and other recent studies.

PATIENTS AND METHODS

An updated decision tree describing the EVT eligible population for UK stroke admissions was produced. Decision criteria were derived from the highest level of evidence available. For nodes where no specific RCT data existed, evidence was obtained from the latest systematic review(s) or the highest quality observational data.

RESULTS

We estimate that 15,420 (approximately 15%) of admitted UK stroke patients are now eligible for thrombectomy, or 14,930 if advanced brain imaging using MRI/CT perfusion or collateral assessment were used in all patients. This is a 54% increase in our previous estimate in 2021. Over 50% of LAO strokes are now potentially eligible for thrombectomy. The increase in eligibility is principally due to a much larger cohort of later presenting and/or larger ischaemic core patients.

CONCLUSION

Most previously independent LAO stroke patients presenting within 24 h, even in the presence of a large ischaemic core on initial non-contrast CT, should be considered for thrombectomy with use of advanced brain imaging in those presenting beyond 12 h to identify salvageable penumbral brain tissue. Treatment in most patients remains critically time-dependent and our estimates should be interpreted with this in mind.

Thrombectomy improves functional independence in severe basilar artery occlusion with favorable collateral circulation

BACKGROUND AND PURPOSE

This study aimed to investigate the effect of collateral circulation on the outcomes of thrombectomy versus medical management alone in basilar artery occlusion (BAO) patients with varying stroke severities.

METHODS

Data from the ATTENTION cohort were used to perform a post-hoc analysis comparing the outcomes of thrombectomy with medical management in BAO patients with varying degrees of collateral circulation and stroke severity. Basilar Artery on Computed Tomography Angiography (BATMAN) scores were used to quantify the collateral circulation, and the effect was estimated through a primary outcome of 90-day functional independence (modified Rankin Scale score, mRS ≤2). Favorable versus unfavorable BATMAN scores were analyzed as both continuous and categorical variables, and an adjusted multivariate regression model was applied.

RESULTS

Among 221 BAO patients, thrombectomy significantly improved functional independence compared to medical management in patients with favorable BATMAN scores (aOR 7.75, 95% CI 2.78-26.1), but not in those with unfavorable BATMAN scores (aOR 1.33, 95% CI 0.28-6.92; pinteraction = 0.028). When treated as a continuous variable, increased BATMAN score was found to be associated with a higher likelihood of functional independence in the thrombectomy group (aOR 1.97, 95% CI 1.44-2.81; pinteraction = 0.053). In severe stroke patients with higher BATMAN scores (National Institutes of Health Stroke Scale (NIHSS) ≥21), we identified a significant interaction for treatment effect with thrombectomy compared to medical management (pinteraction = 0.042).

CONCLUSION

An increased BATMAN score was significantly associated with a higher probability of functional independence after thrombectomy than after medical management, particularly in patients with severe BAO.

Diagnostic accuracy of 3-item stroke scale for detection of cerebral large vessel occlusion: A systematic review and meta-analysis

BACKGROUND

Prompt identification of large vessel occlusion (LVO) in acute ischemic stroke (AIS) is crucial for expedited endovascular therapy (EVT) and improved patient outcomes. Prehospital stroke scales, such as the 3-Item Stroke Scale (3I-SS), could be beneficial in detecting LVO in suspected patients. This meta-analysis evaluates the diagnostic accuracy of 3I-SS for LVO detection in AIS.

METHODS

A systematic search was conducted in Medline, Embase, Scopus, and Web of Science databases until February 2024 with no time and language restrictions. Prehospital and in-hospital studies reporting diagnostic accuracy were included. Review articles, studies without reported 3I-SS cut-offs, and studies lacking the required data were excluded. Pooled effect sizes, including area under the curve (AUC), sensitivity, specificity, diagnostic odds ratio (DOR), positive and negative likelihood ratios (PLR and NLR) with 95% confidence intervals (CI) were calculated.

RESULTS

Twenty-two studies were included in the present meta-analysis. A 3I-SS score of 2 or higher demonstrated sensitivity of 76% (95% CI: 52%-90%) and specificity of 74% (95% CI: 57%-86%) as the optimal cut-off, with an AUC of 0.81 (95% CI: 0.78-0.84). DOR, PLR, and NLR, were 9 (95% CI: 5-15), 2.9 (95% CI: 2.0-4.3) and 0.32 (95% CI: 0.17-0.61), respectively. Sensitivity analysis confirmed the analyses' robustness in suspected to stroke patients, anterior circulation LVO, assessment by paramedics, and pre-hospital settings. Meta-regression analyses pinpointed LVO definition (anterior circulation, posterior circulation) and patient setting (suspected stroke, confirmed stroke) as potential sources of heterogeneity.

CONCLUSION

3I-SS demonstrates good diagnostic accuracy in identifying LVO stroke and may be valuable in the prompt identification of patients for direct transfer to comprehensive stroke centers.

A case of acute basilar artery occlusion due to atherosclerotic disease revascularized by drug-coated balloon dilation

Acute basilar artery occlusion (ABAO) accounts for 1% of all ischemic stroke cases, but has a high rate of severe complications and mortality (75-91%). Intracranial atherosclerosis is an significant cause of ischemic stroke. Revascularization using stents has shown good efficacy. However, intra-stent thrombosis and in-stent restenosis (ISR) are significant complications following stent placement. Drug-coated balloons (DCB), coated with the anti-proliferative drug paclitaxel (an inhibitor of endothelial proliferation), can prevent in-stent restenosis. Successful use of DCB dilation in the coronary and lower extremity vasculature has been reported. In our case, a 68-year-old Chinese male with ABAO was successfully revascularized by DCB dilation and showed dramatic improvement in stroke symptoms. This report may inform future treatment of patients with ABAO.

Influence of intracranial hemorrhage on clinical outcome in acute vertebrobasilar artery occlusion undergoing endovascular treatment

BACKGROUND AND PURPOSE

The effect of intracranial hemorrhage (ICH) on the outcome of patients with large-vessel occlusion undergoing endovascular treatment (EVT) has mainly focused on the anterior circulation. Knowledge of the relationship between ICH and outcomes in patients with acute vertebrobasilar artery occlusion (VBAO) receiving EVT is limited. We aimed to assess whether ICH is a prognostic marker for acute VBAO following EVT.

METHODS

Patients who underwent EVT for acute VBAO in the acute posterior circulation ischemic stroke (PERSIST) registry were included. All patients were classified as having no or any-ICH. Any-ICH was subdivided into asymptomatic and symptomatic ICH. A multivariate regression analysis was performed to evaluate the association between ICH and functional outcomes in patients with acute VBAO after receiving EVT.

RESULTS

Five hundred and forty-seven patients, including 107 patients with ICH (19.6%): 38 (7.0%) and 69 (12.6%) with symptomatic and asymptomatic ICH, respectively. After adjustment for potential confounders, any-ICH was independently associated with reduced chance of favorable outcome (OR 0.39, 95% CI 0.21-0.72, P=0.003), functional independence (OR 0.24, 95% CI 0.16-0.52, P<0.001), and excellent outcome (OR 0.34, 95% CI 0.15-0.75, P=0.008), and increased mortality risk (OR 2.14, 95% CI 1.30-3.51, P=0.003). Symptomatic ICH had a similar association. Moreover, asymptomatic ICH was a negative predictor of functional independence (OR 0.39, 95% CI 0.17-0.88, P=0.024).

CONCLUSION

Any- and symptomatic ICH were strongly associated with worse clinical outcomes and increased mortality in patients with acute VBAO who underwent EVT. Asymptomatic ICH was an inverse predictor of functional independence.

Should they stay or should they go? Stroke transfers across a hospital network pre- and post-implementation of an automated image interpretation and communication platform

BACKGROUND

A key decision facing nonthrombectomy capable (spoke) hospitals is whether to transfer a suspected large vessel occlusion (LVO) patient to a comprehensive stroke center (CSC). In a retrospective cohort study, we investigated the rate of transfers resulting in endovascular thrombectomy (EVT) and associated costs before and after implementation of an artificial intelligence (AI)-based software.

METHODS

All patients with a final diagnosis of acute ischemic stroke presenting across a five-spoke community hospital network in affiliation with a CSC were included. The Viz LVO (Viz.ai, Inc.) software was implemented across the spokes with image sharing and messaging between providers across sites. In a cohort of patients before (pre-AI, December 2018-October 2020) and after (post-AI, October 2020-August 2022) implementation, we compared the EVT rate among ischemic stroke patients transferred out of our health system to the CSC. Secondary outcomes included the EVT rate based on spoke computed tomography angiography (CTA) and estimated transfer costs.

RESULTS

A total of 3113 consecutive eligible patients (mean age 71 years, 50% female) presented to the spoke hospitals with 162 transfers pre-AI and 127 post-AI. The rate of transfers treated with EVT significantly increased (32.1% pre-AI vs. 45.7% post-AI, p = 0.02). There was a sharp increase in CTA use post-AI at the spoke hospitals for all patients and transfers that likely contributed to the increased EVT transfer rate, but prior spoke CTA use alone was not sufficient to account for all improvement in EVT transfer rate (37.2% pre-AI vs. 49.2% post-AI, p = 0.12). In a binary logistic regression model, the odds of an EVT transfer in the intervention period were 1.85 greater as compared to preintervention (adjusted odds ratio 1.85, 95% confidence interval 1.12-3.06). The decrease in non-EVT transfers resulted in an estimated annual benefit of $206,121 in spoke revenue and $119,921 in payor savings (all US dollars).

CONCLUSIONS

The implementation of an automated image interpretation and communication platform was associated with increased CTA use, more transfers treated with EVT, and potential economic benefits.

Basilar artery occlusion management: An international survey of gender influence on management

BACKGROUND

The superiority of endovascular thrombectomy (EVT) over medical management was not established in two early basilar artery occlusion (BAO) randomized controlled trials. Despite this, many clinicians recommended EVT for acute BAO under certain circumstances. This paper aims to compare physicians' diagnostic and management strategies of BAO according to gender.

METHODS

From January to March 2022 an international survey was conducted regarding management strategies in acute BAO. We compared responses between clinicians by identifying gender. Questions were designed to examine clinical and imaging parameters influencing management of patients with BAO.

RESULTS

Among the 1245 respondents from 73 countries, 311 (25.0%) identified as female. This figure was 13.6% amongst interventionists. Geographically, female respondents were lowest in Asia (14.5%) and North America (23.9%). The proportion of respondents identifying as female was consistent regardless of their years of experience. Female respondents were more likely to choose time of onset as time of first estimated stroke like symptom (48.0% vs. 38.5%, p < .01), were less likely to favor thrombectomy in the V4 segment of vertebrobasilar artery occlusions (31.5% vs. 43.3%, p < .01), and were less likely to find it acceptable to enroll all patients who met trial criteria in the standard medical treatment arm of a clinical trial (41.2% vs. 47.0%, p = .01). Male respondents were more likely to agree that thrombolysis would not alter their decision on proceeding with EVT (93.7% vs. 88.3%, p < .01).

CONCLUSIONS

Female clinicians appear to be significantly underrepresented in stroke medicine. This is most pronounced amongst interventionists and in Asia. Although male and female opinions were closely aligned on many aspects of BAO management, differences in opinion were observed in a number of significant areas which influence decision making.

European Stroke Organisation (ESO) and European Society for Minimally Invasive Neurological Therapy (ESMINT) guideline on acute management of basilar artery occlusion

The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology.Although BAO accounts for only 1-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five representing the European Society of Minimally Invasive Neurological Therapy (ESMINT)) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements.First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (although in small numbers) in IVT trials. Non-randomized studies of IVT-only cohorts showed a high proportion of favorable outcomes. Expert Consensus suggests using IVT up to 24 hours unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared with BMT alone within 6 and 6-24 hours from last seen well. In both time windows, we observed a different effect of treatment depending on a) the region where the patients were treated (Europe vs Asia), b) on the proportion of IVT in the BMT arm, and c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with a National Institutes of Health Stroke Scale (NIHSS) score below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT+BMT over BMT alone (this is based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS score below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT+BMT over BMT alone in proximal and middle locations of BAO compared with distal location. While recommendations for patients without extensive early ischemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 hours after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty).

Risk factors and clinical outcomes of basilar artery occlusion presenting with paroxysmal sympathetic hyperactivity as the initial manifestation: a prospective study

BACKGROUND

Paroxysmal sympathetic hyperactivity (PSH) has been linked to a worse clinical prognosis in patients with traumatic brain injury. We aimed to identify the risk factors and clinical features associated with basilar artery occlusion (BAO) presenting with PSH as the first clinical presentation.

METHODS

This study recruited patients with acute BAO who received endovascular therapy (EVT) at two stroke centers in China. PSH Assessment Measure ≥8 was included in the PSH+ group, while those with a score below 8 were classified as the PSH- group. Clinical data and radiological findings were compared between the two groups. A binary logistic regression model was employed to identify independent risk factors for PSH.

RESULTS

101 participants were enrolled, of whom 19 (18.8%) presented with PSH as the initial manifestation of BAO. Worse prognosis (modified Rankin Scale score of 4-6) at day 90 occurred in 14 (73.7%) of the PSH+ patients and 42 (51.2%) of the PSH- patients (P=0.076). The 90-day mortality rate was higher in the PSH+ group with 12 (63.2%) participants, compared with 31 (37.8%) participants in the PSH- group (P=0.044). A significantly increased risk of PSH was found in patients with midbrain involvement (OR 6.53, 95% CI 1.56 to 27.30, P=0.01) and a high baseline National Institutes of Health Stroke Scale (NIHSS) score (OR 1.15, 95% CI 1.01 to 1.31, P=0.037).

CONCLUSIONS

Patients with BAO presenting with PSH as the initial clinical manifestation experience a higher risk of 90-day mortality, despite undergoing EVT. Midbrain infarction and baseline NIHSS score may be significant risk factors for PSH following BAO.

Endovascular treatment effect in vertebrobasilar artery occlusion patients with posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) <6

BACKGROUND

Endovascular treatment (EVT) has revolutionized the standard treatment of vertebrobasilar artery occlusion (VBAO) with moderate infarct core, but its effectiveness in patients with a low posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) is unclear. This study aimed to assess EVT effects in VBAO patients with pc-ASPECTS <6.

METHODS

This retrospective study enrolled patients with VBAO within 24 hours of the estimated occlusion time at 65 stroke centers in a nationwide registration in China. The primary outcome was a favorable shift in the modified Rankin Scale (mRS) at 90 days. The secondary outcomes included a favorable outcome (mRS 0-3) and functional independence (mRS 0-2). Propensity score matching and inverse probability of treatment weighting were used to compare the outcomes of patients treated with EVT and those with best medical management.

RESULTS

A total of 431 patients with VBAO and pc-ASPECTS <6 were included. EVT was associated with a favorable shift in the mRS score at 90 days (OR 1.72, 95% CI 1.19 to 2.5), a higher probability of a favorable outcome (OR 1.66, 95% CI 1.02 to 2.74), and improved functional independence (OR 1.76, 95% CI 1.06 to 2.96). EVT also significantly reduced the risk of 90-day mortality (OR 0.62, 95% CI 0.40 to 0.96), but increased the risk of symptomatic intracranial hemorrhage (OR 2.76, 95% CI 1.06 to 8.58).

CONCLUSION

The results of this study suggest that EVT may be a safe and effective treatment option for patients with VBAO and pc-ASPECTS <6. Further studies are needed to investigate the effect of EVT in patients with pc-ASPECTS <6 and to identify patients who may benefit from EVT.

Acute myocardial infarction and ischaemic stroke: differences and similarities in reperfusion therapies-a review

Acute ST-elevation myocardial infarction (STEMI) and acute ischaemic stroke (AIS) share a number of similarities. However, important differences in pathophysiology demand a disease-tailored approach. In both conditions, fast treatment plays a crucial role as ischaemia and eventually infarction develop rapidly. Furthermore, in both fields, the introduction of fibrinolytic treatments historically preceded the implementation of endovascular techniques. However, in contrast to STEMI, only a minority of AIS patients will eventually be considered eligible for reperfusion treatment. Non-invasive cerebral imaging always precedes cerebral angiography and thrombectomy, whereas coronary angiography is not routinely preceded by non-invasive cardiac imaging in patients with STEMI. In the late or unknown time window, the presence of specific patterns on brain imaging may help identify AIS patients who benefit most from reperfusion treatment. For STEMI, a uniform time window for reperfusion up to 12 h after symptom onset, based on old placebo-controlled trials, is still recommended in guidelines and generally applied. Bridging fibrinolysis preceding endovascular treatment still remains the mainstay of reperfusion treatment in AIS, while primary percutaneous coronary intervention is the strategy of choice in STEMI. Shortening ischaemic times by fine-tuning collaboration networks between ambulances, community hospitals, and tertiary care hospitals, optimizing bridging fibrinolysis, and reducing ischaemia-reperfusion injury are important topics for further research. The aim of this review is to provide insights into the common as well as diverging pathophysiology behind current reperfusion strategies and to explore new ways to enhance their clinical benefit.

Transverse diameter of brainstem infarction is a strong predictor of miserable outcome after mechanical thrombectomy for acute basilar artery occlusion

Although the efficacy of mechanical thrombectomy (MT) for acute basilar artery occlusion (ABAO) has been established in two randomized controlled studies, many patients have miserable clinical outcomes after MT for ABAO. Predicting severe disability prior to the procedure might be useful in determining the appropriateness of treatment interventions. Among the ABAO cases treated at 10 hospitals between July 2014 and December 2021, 144 were included in the study, all of whom underwent MRI before treatment. A miserable outcome was defined as a modified Rankin Scale (mRS) of 5-6 at 3 months. The associations between clinical, imaging, and procedural factors and miserable outcomes were evaluated. A miserable outcome was observed in 54 cases (37.5%). Multivariate analysis identified the National Institutes of Health Stroke Scale (NIHSS), transverse diameter of brainstem infarction, and symptomatic intracerebral hemorrhage as independent factors associated with miserable outcomes, with cutoff values of NIHSS 22 and transverse diameter of brainstem infarction 15 mm. Cases with a higher preoperative severity may result in miserable postoperative outcomes. Particularly, the transverse diameter of a brainstem infarction can be easily measured and serves as a useful criterion for determining treatment indications.

Influence of Age on Outcomes of Endovascular Treatment in Posterior versus Anterior Circulation Stroke: A Comparative Analysis in a Nationwide Registry

INTRODUCTION

It is unknown whether the influence of age on clinical outcomes post endovascular treatment (EVT) is similar in posterior circulation stroke (PCS) compared to anterior circulation stroke (ACS).

METHODS

Data were extracted from the ETIS registry, a nationwide prospective, multicenter, observational registry for stroke EVT procedures in France. We included patients treated with EVT for PCS or ACS between January 2015 and August 2023. The relationship between patient age and clinical outcome variables was studied using regression analysis. Good clinical outcome was defined as modified Rankin scale score ≤2 at 90 days.

RESULTS

The study included 935 patients with PCS and 11,427 patients with ACS. There were no significant differences between PCS and ACS in the influence of age on the likelihood of good clinical outcome. The influence of age on the likelihood of mortality was significantly different. Mortality was higher for PCS between 30 and 85 years, without significant differences in younger or older patients. Elderly patients (≥80 years) with PCS had similar rates of good clinical outcome and mortality compared to patients with ACS from the same age group.

CONCLUSION

In this comparative analysis assessing the impact of age on EVT outcomes in posterior versus anterior circulation stroke, differences were observed in middle-aged patients, whereas outcomes tended to converge in young and elderly age groups. Elderly PCS patients had similar outcomes as ACS patients from the same age group.

Effect of Stroke Etiology on Endovascular Treatment for Acute Basilar-Artery Occlusion: A Post Hoc Analysis of the ATTENTION Randomized Trial

BACKGROUND

Stroke etiology could influence the outcomes in patients with basilar-artery occlusion (BAO). This study aimed to evaluate the differences in efficacy and safety of best medical treatment (BMT) plus endovascular treatment (EVT) versus BMT alone in acute BAO across different stroke etiologies.

METHODS

The study was a post hoc analysis of the ATTENTION trial (Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion), which was a multicenter, randomized trial at 36 centers in China from February 2021 to September 2022. Patients with acute BAO were classified into 3 groups according to stroke etiology (large-artery atherosclerosis [LAA], cardioembolism, and undetermined cause/other determined cause [UC/ODC]). The primary outcome was a favorable outcome (modified Rankin Scale score of 0-3) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage and 90-day mortality.

RESULTS

A total of 340 patients with BAO were included, 150 (44.1%) had LAA, 72 (21.2%) had cardioembolism, and 118 (34.7%) had UC/ODC. For patients treated with BMT plus EVT and BMT alone, respectively, the rate of favorable outcome at 90 days was 49.1% and 23.8% in the LAA group (odds ratio, 3.08 [95% CI, 1.38-6.89]); 52.2% and 30.8% in the cardioembolism group (odds ratio, 2.45 [95% CI, 0.89-6.77]); and 37.5% and 17.4% in the UC/ODC group (odds ratio, 2.85 [95% CI, 1.16-7.01]), with P=0.89 for the stroke etiology×treatment interaction. The rate of symptomatic intracranial hemorrhage in EVT-treated patients with LAA, cardioembolism, and UC/ODC was 8.3%, 2.2%, and 3.2%, respectively, and none of the BMT-treated patients. Lower 90-day mortality was observed in patients with EVT compared with BMT alone across 3 etiology groups.

CONCLUSIONS

Among patients with acute BAO, EVT compared with BMT alone might be associated with favorable outcomes and lower 90-day mortality, regardless of cardioembolism, LAA, or UC/ODC etiologies. The influence of stroke etiology on the benefit of EVT should be explored by further trials.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04751708.

Mode of Onset Modifies the Effect of Time to Endovascular Reperfusion on Clinical Outcomes after Acute Ischemic Stroke: An Analysis of the DAWN Trial

OBJECTIVE

We aimed to assess the impact of time to endovascular thrombectomy (EVT) on clinical outcomes in the DAWN trial, while also exploring the potential effect modification of mode of stroke onset on this relationship.

METHODS

The association between every 1-h treatment delay with 90-day functional independence (modified Rankin Scale [mRS] score 0-2), symptomatic intracranial hemorrhage, and 90-day mortality was explored in the overall population and in three modes of onset subgroups (wake-up vs. witnessed vs. unwitnessed).

RESULTS

Out of the 205 patients, 98 (47.8%) and 107 (52.2%) presented in the 6 to 12 hours and 12 to 24 hours time window, respectively. Considering all three modes of onset together, there was no statistically significant association between time last seen well to randomization with either functional independence or mortality at 90 days in either the endovascular thrombectomy (mRS 0-2 1-hour delay OR 1.07; 95% CI 0.93-1.24; mRS 6 OR 0.84; 95% CI 0.65-1.03) or medical management (mRS 0-2 1-hour delay OR 0.98; 95% CI 0.80-1.14; mRS 6 1-hour delay OR 0.94; 95% CI 0.79-1.09) groups. Moreover, there was no significant interaction between treatment effect and time (p = 0.439 and p = 0.421 for mRS 0-2 and 6, respectively). However, within the thrombectomy group, the models that tested the association between time last seen well to successful reperfusion (modified Treatment in Cerebral Infarction ≥2b) and 90-day functional independence showed a significant interaction with mode of presentation (p = 0.013). This appeared to be driven by a nominally positive slope for both witnessed and unwitnessed strokes versus a significantly (p = 0.018) negative slope in wake-up patients. There was no association between treatment times and symptomatic intracranial hemorrhage.

INTERPRETATION

Mode of onset modifies the effect of time to reperfusion on thrombectomy outcomes, and should be considered when exploring different treatment paradigms in the extended window. ANN NEUROL 2024;96:356-364.

Learning Curve Effect of Combined Technique Thrombectomy as First-Line Attempt for Acute Ischemic Stroke: A Single-Center Retrospective Study

OBJECTIVES

We retrospectively examined the initial experience and learning curve after the introduction of thrombectomy with the combined technique using an aspiration catheter and a stent retriever as first-line attempt for acute ischemic stroke.

METHODS

Consecutive patients undergoing thrombectomy for acute ischemic stroke at our institution between January 2020 and December 2022 were divided into 3 groups according to the year of thrombectomy. Patient characteristics and procedural, safety, and clinical outcomes were compared between the three year periods to determine predictors of favorable clinical outcome.

RESULTS

In 2020, 2021, and 2022, the numbers of patients were 74, 70, and 90, respectively, with similar patient characteristics across the three years; successful recanalization rates were 79.7%, 97.1%, and 93.3%, respectively (P < 0.01 for the first 2 years); median procedure times were 67, 43, and 32 minutes, respectively (P < 0.01 for the first 2 years and P = 0.018 for the last 2 years); first pass effect rates were 20.3%, 41.4%, and 44.4%, respectively (P < 0.01 for the first 2 years); symptomatic intracranial hemorrhage rates were 14.9%, 2.9%, and 1.1%, respectively (P = 0.018 for the first 2 years); and percentages of modified Rankin Scale score 0-2 at 90 days were 24.3%, 42.9%, and 41.1%, respectively (P = 0.022 for the first 2 years). Procedure time (P = 0.038) and successful recanalization (P = 0.041) were independent predictors of favorable clinical outcome.

CONCLUSIONS

The learning curve effect of the combined technique may be associated with better clinical outcome due to increased successful recanalization rates, shortened procedure time, and reduced symptomatic intracranial hemorrhage.

Challenges to Widespread Implementation of Stroke Thrombectomy

Endovascular treatment (EVT) for acute ischemic stroke is one of the most efficacious and effective treatments in medicine, yet globally, its implementation remains limited. Patterns of EVT underutilization exist in virtually any health care system and range from a complete lack of access to selective undertreatment of certain patient subgroups. In this review, we outline different patterns of EVT underutilization and possible causes. We discuss common challenges and bottlenecks that are encountered by physicians, patients, and other stakeholders when trying to establish and expand EVT services in different scenarios and possible pathways to overcome these challenges. Lastly, we discuss the importance of implementation research studies, strategic partnerships, and advocacy efforts to mitigate EVT underutilization.

Bailout intracranial angioplasty or stenting following thrombectomy for acute large vessel occlusion in China (ANGEL-REBOOT): a multicentre, open-label, blinded-endpoint, randomised controlled trial

BACKGROUND

Unsuccessful recanalisation or reocclusion after thrombectomy is associated with poor outcomes in patients with large vessel occlusion (LVO) acute ischaemic stroke (LVO-AIS). Bailout angioplasty or stenting (BAOS) could represent a promising treatment for these patients. We conducted a randomised controlled trial with the aim to investigate the safety and efficacy of BAOS following thrombectomy in patients with LVO.

METHODS

ANGEL-REBOOT was an investigator-initiated, multicentre, prospective, randomised, controlled, open-label, blinded-endpoint clinical trial conducted at 36 tertiary hospitals in 19 provinces in China. Participants with LVO-AIS 24 h after symptom onset were eligible if they had unsuccessful recanalisation (expanded Thrombolysis In Cerebral Infarction score of 0-2a) or risk of reocclusion (residual stenosis >70%) after thrombectomy. Eligible patients were randomly assigned by the minimisation method in a 1:1 ratio to undergo BAOS as the intervention treatment, or to receive standard therapy (continue or terminate the thrombectomy procedure) as a control group, both open-label. In both treatment groups, tirofiban could be recommended for use during and after the procedure. The primary outcome was the change in modified Rankin Scale score at 90 days, assessed in the intention-to-treat population. Safety outcomes were compared between groups. This trial was completed and registered at ClinicalTrials.gov (NCT05122286).

FINDINGS

From Dec 19, 2021, to March 17, 2023, 706 patients were screened, and 348 were enrolled, with 176 assigned to the intervention group and 172 to the control group. No patients withdrew from the trial or were lost to follow-up for the primary outcome. The median age of patients was 63 years (IQR 55-69), 258 patients (74%) were male, and 90 patients (26%) were female; all participants were Chinese. After random allocation, tirofiban was administered either intra-arterially, intravenously, or both in 334 [96%] of 348 participants. No between-group differences were observed in the primary outcome (common odds ratio 0·86 [95% CI 0·59-1·24], p=0·41). Mortality was similar between the two groups (19 [11%] of 176 vs 17 [10%] of 172), but the intervention group showed a higher risk of symptomatic intracranial haemorrhage (eight [5%] of 175 vs one [1%] of 169), parenchymal haemorrhage type 2 (six [3%] of 175 vs none in the control group), and procedure-related arterial dissection (24 [14%] of 176 vs five [3%] of 172).

INTERPRETATION

Among Chinese patients with unsuccessful recanalisation or who are at risk of reocclusion after thrombectomy, BAOS did not improve clinical outcome at 90 days, and incurred more complications compared with standard therapy. The off-label use of tirofiban might have affected our results and their generalisability, but our findings do not support the addition of BAOS for such patients with LVO-AIS.

FUNDING

Beijing Natural Science Foundation, National Natural Science Foundation of China, National Key R&D Program Beijing Municipal Administration of Hospitals Incubating Program, Shanghai HeartCare Medical Technology, HeMo (China) Bioengineering, Sino Medical Sciences Technology.

Intravenous thrombolysis plus mechanical thrombectomy versus mechanical thrombectomy alone for acute ischemic stroke: A systematic review and updated meta-analysis of clinical trials

BACKGROUND

Mechanical thrombectomy (MT) is the gold standard treatment for large vessel occlusion (LVO). A vital factor that might influence MT outcomes is the use of intravenous thrombolysis (IVT). A few clinical trials in this domain thus far have not yielded consistent outcomes. We conducted this meta-analysis to synthesize collective evidence in this regard.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement guidelines were followed, and we performed a comprehensive literature search of four databases (PubMed, Scopus, Web of Science, Cochrane CENTRAL). For outcomes constituting continuous data, the mean difference (MD) and its standard deviation (SD) were pooled. For outcomes constituting dichotomous data, the frequency of events and the total number of patients were pooled as the risk ratio (RR).

RESULTS

Seven clinical trials with a total of 2317 patients are included in this meta-analysis. Six trials are randomized, and one trial was nonrandomized. No significant differences were found between MT plus IVT and MT alone in successful recanalization (RR 1.04, 95% Confidence Interval (CI) [0.92 to 1.17], P = 0.53), 90-day functional independence (RR 1.03, 95% CI [0.90 to 1.19], P = 0.65), symptomatic intracranial hemorrhage (sICH) (RR 1.22, 95% CI [0.84 to 1.75], P = 0.30), or mortality (RR 0.94, 95% CI [0.76 to 1.18], P = 0.61).

CONCLUSION

The current evidence does not favor either MT plus IVT or MT alone for LVO except for the procedural time. More trials are needed in this regard, and certain factors should be considered when comparing the two approaches.

Medium vessel occlusion thrombectomy: Single center experience using the 3 MAX catheter

INTRODUCTION

Thrombectomy for medium vessel occlusion is a topic of great interest. We describe a single-center experience with the Penumbra 3-MAX aspiration catheter in stroke thrombectomy of medium vessel occlusion(MeVO). We investigated the use of 3-MAX as a de-novo first pass catheter and as a rescue aspiration device following attempted thrombectomy with other devices. This is the first description of the first pass effect and successful recanalization rate of the 3-MAX catheter in de-novo vs. rescue use of this catheter.

METHODS

From January 2017 to January 2023, 84 patients underwent mechanical thrombectomy with use of a Penumbra 3MAX aspiration catheter at our comprehensive stroke center. Patient charts were retrospectively reviewed. Primary efficacy outcome was successful recanalization following mechanical thrombectomy. Primary safety outcome was intracerebral hemorrhage.

RESULTS

A total of 84 patients underwent MT with the 3MAX device. It was used as a de novo catheter in 27(32.1%) and as a rescue catheter in 57(67.9%) patients. 35(41.6%) patients achieved angiographic TICI grade ≥ 2c. De novo 3MAX use led to 68.18% successful recanalization and rescue use led to 72.22% recanalization (p = 0.67) as measured by TICI score of 2c or better. Parenchymal intracerebral hemorrhages (PH) were present in 8 patients (9.5%).

CONCLUSION

The Penumbra 3MAX catheter is safe and effective when used as a first pass or a rescue device in mechanical thrombectomy. We found similar rates of successful recanalization and minimal hemorrhagic risk when comparing the 3MAX as a rescue or de novo aspiration catheter.

The Utilization of Systematic Reviews and Meta-Analyses in Stroke Guidelines

BACKGROUND

Stroke guideline statements are important references for clinicians due to the rapidly evolving nature of treatments. Guideline statements should be informed by up-to-date systematic reviews (SRs) and meta-analyses (MAs) because they provide the highest level of evidence. To investigate the utilization of SRs/MAs in stroke management guidelines, we conducted a literature review of guidelines and extracted relevant information regarding SRs/MAs.

METHODS

A literature review was conducted in PubMed with supplementation using the Trip medical database with the term "stroke" as the target population, followed by using the filter "guidelines". We extracted the number of included SRs/MAs, the years of publication, the country of origin, and other characteristics of interest. Descriptive statistics were generated using the R software version 4.2.1.

RESULTS

We included 27 guideline statements. The median number of overall SRs or MAs within the guidelines was 4.0 (interquartile range [IQR] = 2-9). For MAs only, the median number included in the guidelines was 3.0 (IQR = 2.0-5.5). Canadian guidelines had the oldest citations, with a median gap of 12.0 (IQR = 5.2-18.0) years for the oldest citation, followed by European (median = 12; IQR = 9.5-13.5) and US (median = 10.0; IQR = 5.2-16) guidelines.

CONCLUSIONS

Stroke guideline writing groups and issuing bodies should devote greater effort to the inclusion of up-to-date SRs/MAs in their guideline statements so that clinicians can reference recent data with the highest level of evidence.

Focused update to guidelines for endovascular therapy for emergent large vessel occlusion: basilar artery occlusion patients

BACKGROUND

Endovascular therapy (EVT) dramatically improves clinical outcomes for patients with anterior circulation emergent large vessel occlusion (ELVO) strokes. With recent publication of two randomized controlled trials in favor of EVT for basilar artery occlusions, the Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee provides this focused update for the existing SNIS guideline, 'Current endovascular strategies for posterior circulation large vessel occlusion stroke.'

METHODS

A structured literature review and analysis of studies related to posterior circulation large vessel occlusion (basilar or vertebral artery) strokes treated by EVT was performed. Based on the strength and quality of the evidence, recommendations were made by consensus of the writing committee, with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors.

RESULTS

Based on the results of the most recent randomized, controlled trials on EVT for basilar or vertebral artery occlusion, the expert panel agreed on the following recommendations. For patients presenting with an acute ischemic stroke due to an acute basilar or vertebral artery occlusion confirmed on CT angiography, National Institutes of Health Stroke Scale (NIHSS) score of ≥6, posterior circulation Alberta Stroke Program Early CT Score (PC-ASPECTS) ≥6, and age 18-89 years: (1) thrombectomy is indicated within 12 hours since last known well (class I, level B-R); (2) thrombectomy is reasonable within 12-24 hours from the last known well (class IIa, level B-R); (3) thrombectomy may be considered on a case by case basis for patients presenting beyond 24 hours since last known well (class IIb, level C-EO). In addition, thrombectomy may be considered on a case by case basis for patients aged <18 years or >89 years on a case by case basis (class IIb, level C-EO).

CONCLUSIONS

The indications for EVT of ELVO strokes continue to expand and now include patients with basilar artery occlusion. Further prospective, randomized controlled trials are warranted to elucidate the efficacy and safety of EVT in populations not included in this set of recommendations, and to confirm long term outcomes.

Endovascular Treatment for Basilar Artery Occlusion

Basilar artery occlusion (BAO) is a neurological emergency associated with a high risk for adverse outcomes. This review provides evidence on the therapeutic efficacy of intravenous thrombolysis (IVT) and endovascular therapy (EVT) in the treatment of BAO. Historically considered the primary intervention for acute ischemic stroke, IVT has been progressively combined with EVT, which has emerged from recent studies demonstrating clinical benefits, notably in patients presenting with severe stroke. Several randomised controlled trials have shown that EVT improves patient outcomes in select clinical contexts. Future research directions could address therapeutic treatment thresholds, combination strategies, and long-term outcomes.

Thrombectomy alone versus intravenous thrombolysis before thrombectomy for acute basilar artery occlusion

BACKGROUND

Endovascular treatment (EVT) is a well-established approach for acute ischemic stroke. Whether bridging intravenous thrombolysis (IVT) before EVT confers any benefits remains uncertain. The objective of the study was to compare the efficacy and safety of direct EVT with or without bridging IVT in patients with acute basilar artery occlusion (BAO).

METHODS

This multicenter cohort study enrolled 647 patients with acute BAO who underwent either bridging IVT before EVT or direct EVT from the BASILAR registry. The primary outcome was an independent functional outcome measured by the modified Rankin Scale (mRS) score of 0-2. Secondary outcomes included excellent functional outcome (mRS 0-1), favorable functional outcome (mRS 0-3), and mortality rate at 90 days, as well as symptomatic intracranial hemorrhage (sICH), and successful reperfusion between the two treatment groups.

RESULTS

Direct EVT and bridging IVT before EVT exhibited similar primary outcomes (27.3% vs 27.7%, respectively) and distributions of mRS scores at 90 days. Moreover, rates of sICH and 90-day mortality were not significantly different between the two groups (7.3% vs 6.0%, adjusted OR (aOR) 0.79, 95% CI 0.34 to 1.86, P=0.84 for sICH; 46.8% vs 43.7%, aOR 0.86, 95% CI 0.54 to 1.38, P=0.53 for mortality).

CONCLUSIONS

Among patients with acute BAO, functional outcomes were similar between those treated with bridging IVT before EVT and those treated with direct EVT, and there was no difference between the two groups in terms of sICH and mortality rates.

Hasty generalizations and generics in medical research: A systematic review

It is unknown to what extent medical researchers generalize study findings beyond their samples when their sample size, sample diversity, or knowledge of conditions that support external validity do not warrant it. It is also unknown to what extent medical researchers describe their results with precise quantifications or unquantified generalizations, i.e., generics, that can obscure variations between individuals. We therefore systematically reviewed all prospective studies (n = 533) published in the top four highest ranking medical journals, Lancet, New England Journal of Medicine (NEJM), Journal of the American Medical Association (JAMA), and the British Medical Journal (BMJ), from January 2022 to May 2023. We additionally reviewed all NEJM Journal Watch clinical research summaries (n = 143) published during the same time. Of all research articles reporting prospective studies, 52.5% included generalizations beyond specific national study populations, with the numbers of articles with generics varying significantly between journals (JAMA = 12%; Lancet = 77%) (p < 0.001, V = 0.48). There was no evidence that articles containing broader generalizations or generics were correlated with larger or more nationally diverse samples. Moreover, only 10.2% of articles with generalizations beyond specific national populations reported external validity strengthening factors that could potentially support such extrapolations. There was no evidence that original research articles and NEJM Journal Watch summaries intended for practitioners differed in their use of broad generalizations, including generics. Finally, from the journal with the highest citation impact, articles containing broader conclusions were correlated with more citations. Since there was no evidence that studies with generalizations beyond specific national study populations or with generics were associated with larger, more nationally diverse samples, or with reports of population similarity that may permit extensions of conclusions, our findings suggest that the generalizations in many articles were insufficiently supported. Caution against overly broad generalizations in medical research is warranted.

After early mTICI 2b, stop or continue? Insights from the PERSIST Registry

OBJECTIVES

A higher reperfusion grade after endovascular thrombectomy (EVT) is associated with a good prognosis. However, the effect of the number of retrievals has not yet been investigated in vertebrobasilar occlusion (VBAO). Therefore, the aim of this study was to investigate whether to continue retrieval after early modified thrombolysis in cerebral infarction (mTICI) 2b to achieve a better reperfusion grade.

METHODS

We retrospectively analyzed the data of patients who underwent EVT caused by VBAO in a multicenter registry dataset. Patients who underwent successful reperfusion were included (mTICI 2b/3). Regression models were used to analyze the correlation of different reperfusion grades stratified by the number of retrieval attempts with clinical prognosis and hemorrhage transition.

RESULTS

We included 432 patients: 34.5% (n = 149) had a final mTICI score of 2b and 65.5% (n = 283) had a final mTICI score of 3. Patients who obtained a mTICI of 3 after the first pass had significantly increased odds of having a good prognosis. As the number of passes increases, the chances of obtaining a good prognosis decreases. After three or more passes, the odds of achieving functional independence and favorable outcomes were comparable to those of the first mTICI 2b, regardless of the 90-day (OR 1.132 95% CI 0.367-3.487 p = 0.829; OR 1.070 95% CI 0.375-3.047 p = 0.900) or 1-year follow-up (OR 1.217 95% CI 0.407-3.637 p = 0.725; OR 1.068 95% CI 0.359-3.173 p = 0.906).

INTERPRETATION

Within two retrieval attempts, mTICI 3 was better than the first retrieval to mTICI 2b. After early mTICI 2b, each retrieval should be undertaken with caution to pursue a higher reperfusion grade.

Endovascular Versus Medical Therapy in Posterior Cerebral Artery Stroke: Role of Baseline NIHSS Score and Occlusion Site

BACKGROUND

Acute ischemic stroke with isolated posterior cerebral artery occlusion (iPCAO) lacks management evidence from randomized trials. We aimed to evaluate whether the association between endovascular treatment (EVT) and outcomes in iPCAO acute ischemic stroke is modified by initial stroke severity (baseline National Institutes of Health Stroke Scale [NIHSS]) and arterial occlusion site.

METHODS

Based on the multicenter, retrospective, case-control study of consecutive iPCAO acute ischemic stroke patients (PLATO study [Posterior Cerebral Artery Occlusion Stroke]), we assessed the heterogeneity of EVT outcomes compared with medical management (MM) for iPCAO, according to baseline NIHSS score (≤6 versus >6) and occlusion site (P1 versus P2), using multivariable regression modeling with interaction terms. The primary outcome was the favorable shift of 3-month modified Rankin Scale (mRS). Secondary outcomes included excellent outcome (mRS score 0-1), functional independence (mRS score 0-2), symptomatic intracranial hemorrhage, and mortality.

RESULTS

From 1344 patients assessed for eligibility, 1059 were included (median age, 74 years; 43.7% women; 41.3% had intravenous thrombolysis): 364 receiving EVT and 695 receiving MM. Baseline stroke severity did not modify the association of EVT with 3-month mRS distribution (Pinteraction=0.312) but did with functional independence (Pinteraction=0.010), with a similar trend on excellent outcome (Pinteraction=0.069). EVT was associated with more favorable outcomes than MM in patients with baseline NIHSS score >6 (mRS score 0-1, 30.6% versus 17.7%; adjusted odds ratio [aOR], 2.01 [95% CI, 1.22-3.31]; mRS score 0 to 2, 46.1% versus 31.9%; aOR, 1.64 [95% CI, 1.08-2.51]) but not in those with NIHSS score ≤6 (mRS score 0-1, 43.8% versus 46.3%; aOR, 0.90 [95% CI, 0.49-1.64]; mRS score 0-2, 65.3% versus 74.3%; aOR, 0.55 [95% CI, 0.30-1.0]). EVT was associated with more symptomatic intracranial hemorrhage regardless of baseline NIHSS score (Pinteraction=0.467), while the mortality increase was more pronounced in patients with NIHSS score ≤6 (Pinteraction=0.044; NIHSS score ≤6: aOR, 7.95 [95% CI, 3.11-20.28]; NIHSS score >6: aOR, 1.98 [95% CI, 1.08-3.65]). Arterial occlusion site did not modify the association of EVT with outcomes compared with MM.

CONCLUSIONS

Baseline clinical stroke severity, rather than the occlusion site, may be an important modifier of the association between EVT and outcomes in iPCAO. Only severely affected patients with iPCAO (NIHSS score >6) had more favorable disability outcomes with EVT than MM, despite increased mortality and symptomatic intracranial hemorrhage.

Contact aspiration for basilar artery occlusion safely reduces the puncture-to-recanalization time

OBJECTIVE

Effective thrombectomies in the posterior circulation remain controversial. Previous reports have demonstrated the superiority of contact aspiration in anterior circulation. Aspiration catheters and stent retrievers are often used alone on a global scale, while combined techniques are commonly used in Japan. This study evaluated the effect of first-line contact aspiration with other strategies for the treatment of basilar artery occlusion.

METHODS

The primary outcome was the frequency of the first-pass effect, and the secondary outcome was the time from puncture to the first-pass effect. A multicenter observational registry including 16 Japanese stroke centers was used. Between December 2013 and February 2021, enrolled patients underwent endovascular thrombectomy for basilar artery occlusion. The efficacy of contact aspiration compared to other methods (including stent retrievers and combined techniques) was evaluated.

RESULTS

Eighty-four patients were included, all of whom had achieved effective recanalization. Twenty-six patients were treated with contact aspiration, 13 with combined technique, and 45 with stent retrievers. The two groups: contact aspiration and non-contact aspiration, had different backgrounds. Both had similar frequencies of effective recanalization and first-pass effects. The contact aspiration group experienced better functional outcomes without statistical significance, while this strategy was significantly associated with a shorter puncture-to-recanalization time (38 vs. 55 minutes, P=0.036). In particular, in the 55 patients with the first-pass effect, multivariate Cox proportional hazard analysis showed that contact aspiration was significantly associated with a shorter time from puncture to first-pass effect, independent of age and etiology of large-artery atherosclerosis (hazard ratio 2.02, 95% confidence intervals 1.10-3.69, P=0.023).

CONCLUSION

This study suggested that contact aspiration for basilar artery occlusion may shorten the puncture-to-first-pass effect, compared to stent retrievers and combined techniques.

Chronic basilar artery occlusion: a retrospective monocentric study

BACKGROUND

Acute basilar artery occlusion is a life-threatening medical emergency with a highly elevated mortality rate when left untreated. Little is known about symptoms and clinical progression of chronic occlusions. The aim of this study was to systematically analyze the clinical presentation of patients with chronic basilar artery occlusion (CBAO).

METHODS

Monocentric retrospective analysis of adult patients with CBAO was treated between 2015 and 2023 in the Department of Neurology, Klinikum Kassel. Inclusion criteria were basilar artery occlusion without brainstem infarction as well as patients with a basilar artery occlusion in whom revascularization could not be achieved and a follow-up period of at least 3 months.

RESULTS

A total of 15 patients were found. In five patients basilar artery occlusion was diagnosed as an incidental finding, four patients had neurological symptoms but no proven brainstem infarction (3 × transient ischemic attack, 1 × isolated posterior artery infarct) and six patients presented with acute basilar artery occlusion and a follow-up > 3 months. The most common site of occlusion was midbasilar (80%, n = 12), isolated (n = 7) or in combination with other locations (n = 5). In all cases collateralization could be demonstrated by the posterior communicating arteries. The most common vascular risk factors (VRF) were hypertension (100%) and hypercholesterolemia (67%).

CONCLUSIONS

Patients with CBAO may present with only mild symptoms or may even be asymptomatic. This condition may be survived for a long time. The high percentage of vascular risk factors and further cerebral vessel occlusions suggest arteriosclerosis as the major causing factor of CBAO.

Mechanical Thrombectomy Workshops Improve Procedural Knowledge and Skills Among Neurointerventional Teams in Low- to Middle-Income Countries

BACKGROUND

While mechanical thrombectomy (MT) is proven to be lifesaving and disability sparing, there remains a disparity in its access in low- to middle-income countries. We hypothesized that team-based MT workshops would improve MT knowledge and skills.

METHODS

We designed a 22-hour MT workshop, conducted as 2 identical events: in English (Jamaica, January 2022) and in Spanish (Dominican Republic, May 2022). The workshops included participating neurointerventional teams (practicing neurointerventionalists, neurointerventional nurses, and technicians) focused on acute stroke due to large vessel occlusion. The course faculty led didactic and hands-on components, covering topics from case selection and postoperative management to device technology and MT surgical techniques. Attendees were evaluated on stroke knowledge and MT skills before and after the course using a multiple choice exam and simulated procedures utilizing flow models under fluoroscopy, respectively. Press conferences for public education with invited government officials were included to raise stroke awareness.

RESULTS

Twenty-two physicians and their teams from 8 countries across the Caribbean completed the didactic and hands-on training. Overall test scores (n=18) improved from 67% to 85% (P<0.002). Precourse and postcourse hands-on assessments demonstrated reduced time to completion from 36.5 to 21.1 minutes (P<0.001). All teams showed an improvement in measures of good MT techniques, with 39% improvement in complete reperfusion. Eight teams achieved a Thrombolysis in Cerebral Infarction score of 3 on pre-course versus 15 of 18 teams on post-course. There was a significant reduction in total potentially dangerous maneuvers (70% pre versus 20% post; P<0.002). Universally, the workshop was rated as satisfactory and likely to change practice in 93% Dominican Republic and 75% Jamaica.

CONCLUSIONS

A team-based hands-on simulation approach to MT training is novel, feasible, and effective in improving procedural skills. Participants viewed these workshops as practice-changing and instrumental in creating a pathway for increasing access to MT in low- to middle-income countries.

Basilar artery stenting in hyperacute stroke: A systematic review of published cases

BACKGROUND AND PURPOSE

Basilar artery stenting is a rescue therapy in the management of hyperacute stroke. Published data on efficacy and safety are limited.

METHODS

A systematic review of published studies was performed in accordance with PRISMA guidelines. Inclusion criteria were adult patients with ischemic stroke with permanent basilar artery stent placement within 48 h of onset. Data were extracted by two independent reviewers. Additional cases from our institution were identified via a local stroke registry.

RESULTS

Of 212 screened articles, patient-level data was reported in 35 studies (87 individuals) and six additional patients were included from our registry. Patients (n = 93, 63 % male; median age 64) most often presented with mid-basilar occlusion (52 %) and 76 % received treatment within 12 hours of onset. Favorable angiographic results occurred in 67 %. The final modified Rankin Scale score (mRS) was 0-3 for 56 % of patients; mortality was 29 %. Those with complete flow post-procedure were more likely to have a final mRS of 0-3 (p = 0.05).

CONCLUSIONS

In 93 cases of basilar stenting in hyperacute stroke, favourable angiographic and functional outcomes were reported in 67 % and 56 % of patients, respectively. International multicenter registries are required to establish benefit and identify patient and technical factors that predict favorable outcomes.

Stroke

Stroke affects up to one in five people during their lifetime in some high-income countries, and up to almost one in two in low-income countries. Globally, it is the second leading cause of death. Clinically, the disease is characterised by sudden neurological deficits. Vascular aetiologies contribute to the most common causes of ischaemic stroke, including large artery disease, cardioembolism, and small vessel disease. Small vessel disease is also the most frequent cause of intracerebral haemorrhage, followed by macrovascular causes. For acute ischaemic stroke, multimodal CT or MRI reveal infarct core, ischaemic penumbra, and site of vascular occlusion. For intracerebral haemorrhage, neuroimaging identifies early radiological markers of haematoma expansion and probable underlying cause. For intravenous thrombolysis in ischaemic stroke, tenecteplase is now a safe and effective alternative to alteplase. In patients with strokes caused by large vessel occlusion, the indications for endovascular thrombectomy have been extended to include larger core infarcts and basilar artery occlusion, and the treatment time window has increased to up to 24 h from stroke onset. Regarding intracerebral haemorrhage, prompt delivery of bundled care consisting of immediate anticoagulation reversal, simultaneous blood pressure lowering, and prespecified stroke unit protocols can improve clinical outcomes. Guided by underlying stroke mechanisms, secondary prevention encompasses pharmacological, vascular, or endovascular interventions and lifestyle modifications.

Endovascular treatment for basilar artery occlusion: whether the "weekend effect" affects time metrics and clinical outcomes at a comprehensive stroke center

Objectives

This study aimed to evaluate whether the "weekend effect" would affect the time metrics and the prognosis of acute ischemic stroke (AIS) patients who underwent endovascular treatment (EVT) due to basilar artery occlusion (BAO).

Methods

Clinical data of AIS patients who underwent EVT due to BAO between December 2019 and July 2023 were retrospectively analyzed. At the time when the patients were admitted, the study population was divided into the weekdays daytime group and weekends nighttime group. In the subgroup analysis, the study cohort was divided into four groups: the weekdays daytime group, weekdays nighttime group, weekend daytime group, and weekend nighttime group. A good outcome was defined as a modified Rankin Scale score of ≤3 at 90 days after EVT. Time metrics [e.g. onset-to-door time (ODT) and door-to-puncture time (DPT)] and clinical outcomes were compared using appropriate statistical methods.

Results

A total of 111 patients (88 male patients, mean age, 67.7 ± 11.7 years) were included. Of these, 37 patients were treated during weekdays daytime, while 74 patients were treated during nights or weekends. There were no statistically significant differences in ODT (P = 0.136), DPT (P = 0.931), and also clinical outcomes (P = 0.826) between the two groups. Similarly, we found no significant differences in the time metrics and clinical outcomes among the four sub-groups (all P > 0.05).

Conclusion

This study did not reveal any influence of the "weekend effect" on the time metrics and clinical outcomes in AIS patients who underwent EVT due to BAO at a comprehensive stroke center.

Incidence and predictors of futile recanalisation after endovascular therapy in acute vertebrobasilar artery occlusion patients: insight from the ANGEL-ACT registry

OBJECTIVES

To identify the occurrence rate and predictors of futile recanalisation after endovascular therapy (EVT) for acute vertebrobasilar artery occlusion (VBAO).

METHODS

Participants of the Endovascular Treatment Key Technique and Emergency Workflow Improvement of Acute Ischaemic Stroke (ANGEL-ACT) registry were selected for the analysis. Futile recanalisation was defined as patients did not achieve a 90-day good outcome (modified Rankin Scale ≤3) despite successful recanalisation (modified Treatment in Cerebral Ischaemia Scale ≥2b) after the procedure. Multivariable logistic regression analysis was conducted to find independent predictors of futile recanalisation in VBAO patients undergoing EVT.

RESULTS

Three hundred and fifteen patients with VBAO who achieved successful recanalisation after EVT were included in current analysis, of whom, 155 (49.2%) suffered futile recanalisation, and 160 achieved effective recanalisation. After the multivariable analysis, we found admission National Institutes of Health Stroke Scale (NIHSS) ≥19 (OR 4.81, 95% CI 2.76 to 8.39, p<0.001), platelet-lymphocyte ratio (PLR) ≥162.2 (OR 1.93, 95% CI 1.14 to 3.27, p=0.001), onset-to-puncture time (OTP) ≥334 min (OR 2.15, 95% CI 1.25 to 3.68, p=0.005) and use of general anesthesia (GA) (OR 1.87, 95% CI 1.09 to 3.22, p=0.024) were associated with futile recanalisation.

CONCLUSIONS

Futile recanalisation after EVT occurred 49.2% of VBAO patients in the ANGEL-ACT registry. NIHSS≥19, PLR≥162.2, OTP≥334 min and use of GA were independent predictors of futile recanalisation.

CT perfusion for predicting intracranial atherosclerotic middle cerebral artery occlusion

Backgrounds and purpose

Identifying the underlying cause of acute middle cerebral artery occlusion (MCAO) as intracranial atherosclerotic stenosis (ICAS) or embolism is essential for determining the optimal treatment strategy before endovascular thrombectomy. We aimed to evaluate whether baseline computed tomography perfusion (CTP) characteristics could differentiate ICAS-related MCAO from embolic MCAO.

Methods

We conducted a retrospective analysis of the clinical and baseline CTP data from patients who underwent endovascular thrombectomy for acute MCAO between January 2018 and December 2022. Core volume growth rate was defined as core volume on CTP divided by onset to CTP time. Multivariate logistic analysis was utilized to identify independent predictors for ICAS-related acute MCAO, and the diagnostic performance of these predictors was evaluated using receiver operating characteristic curve analysis.

Results

Among the 97 patients included (median age, 71 years; 60% male), 31 (32%) were diagnosed with ICAS-related MCAO, and 66 (68%) had embolism-related MCAO. The ICAS group was younger (p = 0.002), had a higher proportion of males (p = 0.04) and smokers (p = 0.001), a lower prevalence of atrial fibrillation (AF) (p < 0.001), lower NIHSS score at admission (p = 0.04), smaller core volume (p < 0.001), slower core volume growth rate (p < 0.001), and more frequent core located deep in the brain (p < 0.001) compared to the embolism group. Multivariate logistic analysis identified core volume growth rate (aOR 0.46, 95% CI 0.26-0.83, p = 0.01) as an independent predictor of ICAS-related MCAO. A cutoff value of 2.5 mL/h for core volume growth rate in predicting ICAS-related MCAO was determined from the receiver operating characteristic curve analysis, with a sensitivity of 81%, specificity of 80%, positive predictive value of 66%, and negative predictive value of 90%.

Conclusion

Slow core volume growth rate identified on baseline CTP can predict ICAS-related MCAO. Further prospective studies are warranted to confirm and validate these findings.

Atrial fibrillation is associated with higher first pass effect following thrombectomy for large vessel occlusion

BACKGROUND

First pass effect (FPE), defined as single-pass complete or near complete reperfusion during endovascular thrombectomy (EVT) for large vessel occlusion (LVO) strokes, is a critical performance metric. Atrial fibrillation (AF)-related strokes have different clot composition compared with non-AF strokes, which may impact thrombectomy reperfusion results. We compared FPE rates in AF and non-AF stroke patients to evaluate if AF-related strokes had higher FPE rates.

METHODS

We conducted a post-hoc analysis of the DIRECT-SAFE trial data, including patients with retrievable clots on the initial angiographic run. Patients were categorized into AF and non-AF groups. The primary outcome was the presence or absence of FPE (single-pass, single-device resulting in complete/near complete reperfusion) in AF and non-AF groups. We used multivariable logistic regression to examine the association between FPE and AF, adjusting for thrombolysis pre-thrombectomy and clot location.

RESULTS

We included 253 patients (67 with AF, 186 without AF). AF patients were older (mean age: 74 years vs 67.5 years, p=0.001), had a higher proportion of females (55% vs 40%, p=0.044), and experienced more severe strokes (median National Institutes of Health Stroke Scale (NIHSS) score: 17 vs 14, p=0.009) than non-AF patients. No differences were observed in thrombolytic agent usage, time metrics, or clot location. AF patients achieved a higher proportion of FPE compared with non-AF patients (55.22% vs 37.3%, adjusted odds ratio 2.00 (95% CI 1.13 to 3.55), p=0.017).

CONCLUSIONS

AF-related strokes in LVO patients treated with EVT were associated with FPE. This highlights the need for preparedness for multiple passes and potential adjuvant/rescue therapy in non-AF-related strokes.

Endovascular thrombectomy beyond 24 hours from last known well: a systematic review with meta-analysis

BACKGROUND

Different studies have demonstrated the benefit of endovascular treatment (EVT) up to 24 hours after acute ischemic stroke (AIS) onset. Recent cohort observational studies suggest that patients with large vessel occlusion AIS may benefit from EVT beyond 24 hours from the last known well (LKW) when adequately selected. We aimed to examine the safety and efficacy of EVT beyond 24 hours from LKW using a meta-analysis of all the literature available.

METHODS

A systematic search from inception to April 2023 was conducted for studies including AIS patients with EVT beyond 24 hours from LKW in Medline, Embase, Scopus, and Web of Science. Outcomes of interest included favorable functional outcome (90-day modified Rankin scale (mRS) 0-2), successful reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2b-3), symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. Data were pooled using a random-effects model.

RESULTS

Twelve studies with 894 patients were included. The rate of favorable functional outcome was 40% (95% CI 31% to 49%; I2=76%). The rate of successful reperfusion was 83% (95% CI 80% to 85%; I2=0%). The sICH rate was 7% (95% CI 5% to 9%; I2=0%) and the 90-day mortality rate was 28% (95% CI 24% to 33%; I2=0%). There was no significant difference in favorable outcomes (OR=0.69; 95% CI 0.41 to 1.14) and 90-day mortality (OR=1.35; 95% CI 0.90 to 2.00) among patients who underwent EVT <24 hours versus >24 hours.

CONCLUSIONS

EVT beyond 24 hours from LKW may achieve favorable clinical outcomes and high reperfusion rates, with acceptable intracranial hemorrhage rates in selected patients. Considering the current certainty of the evidence and heterogenous individual study results, larger prospective trials are warranted.

Chronic Kidney Disease Increases Mortality and Reduces the Chance of a Favorable Outcome in Stroke Patients Treated with Mechanical Thrombectomy-Single-Center Study

Background/Objectives: Chronic kidney disease (CKD) is identified as a risk factor for the occurrence of ischemic stroke. There is substantial evidence that CKD is linked to a worse prognosis and higher mortality rates in stroke patients. This study aimed to evaluate the characteristics and factors affecting favorable outcomes and mortality in patients treated using mechanical thrombectomy (MT) for ischemic stroke, with particular emphasis on patients suffering from CKD. Methods: The retrospective study included an analysis of data from 723 patients (139; 19.4% had CKD) with ischemic stroke treated with MT between March 2019 and July 2022. Results: Patients with CKD were significantly older (median age 76.5 vs. 65.65, p < 0.001) and more often female (59.7% vs. 42.6%, p < 0.001). CKD decreased the likelihood of achieving a favorable outcome (0-2 points in modified Rankin scale; OR: 0.56, CI95%: 0.38-0.81) and increased mortality (OR: 2.59, CI95%: 1.74-3.84) on the 90th day after stroke. In addition, CKD was associated with intracranial hemorrhage (ICH) in patients who underwent posterior circulation MT (13.85% vs. 50%, p = 0.022). In patients with CKD, inter alia, higher levels of C-reactive protein (OR: 0.94, CI95%: 0.92-0.99) reduced the chance of a favorable outcome. In addition, the occurrence of ICH in patients with CKD increased mortality on the 90th day after stroke (OR: 4.18, CI95%: 1.56-11.21), which was almost twice as high as in patients without CKD (OR: 2.29, CI95%: 1.54-3.40). Conclusions: Patients suffering from CKD had a lower probability of achieving a favorable outcome and had increased mortality following MT for ischemic stroke. It is crucial to understand the variations between patients with unimpaired and impaired renal function, as this could aid in predicting the outcomes of this method.