Hyperdense middle cerebral artery sign predicts favorable outcome in patients undergoing mechanical thrombectomy

Predictors of futile recanalization in nonagenarians treated with mechanical thrombectomy: a multi-center observational study

BACKGROUND

There is a lack of data regarding patients aged 90 years or older undergoing mechanical thrombectomy and their predictors of futile recanalization.

AIMS

We sought to evaluate the predictors of futile recanalization in patients ≥ 90 years with large vessel occlusion undergoing mechanical thrombectomy.

METHODS

This multi-center observational retrospective study included patients ≥ 90 years consecutively treated with mechanical thrombectomy in four thrombectomy capable centers between January 1st, 2016 and 30th March 2023. Futile recanalization was defined as large vessel occlusion patients experiencing a 90-day poor outcome (mRS 3-6) despite successful recanalization (mTICI ≥ 2b) after mechanical thrombectomy.

RESULTS

Our cohort included 139 patients ≥ 90 years with acute ischemic stroke due to anterior circulation large vessel occlusion treated with mechanical thrombectomy. One hundred seventeen of one hundred thirty-nine patients ≥ 90 years who achieved successful recanalization were included in the analysis (seventy-six female (64.9%)), of whom thirty-one (26.49%) experienced effective recanalization and eighty-six (73.51%) experienced futile recanalization. Patients with futile recanalization had higher NIHSS on admission (p < 0.001); they were less frequently treated with intravenous thrombolysis (p = 0.048), had more often general anesthesia (p = 0.011), and longer door to groin puncture delay (p = 0.002). Univariable regression analysis showed that use of intravenous thrombolysis (0.29, 95% CI 0.02-0.79, p = 0.034) and site of occlusion distal vs proximal (0.34, 95% CI 0.11-0.97, p = 0.044) were associated with reduced probability of futile recanalization while NIHSS on admission (1.29, 95% CI 1.16-1.45, p < 0.001), NIHSS at 24 h (1.15, 95% CI 1.07-1.25, p = 0.002), type of anesthesia used (4.18, 95% CI 1.57-11.08, p = 0.004), and door to groin puncture time (1.02, 95% CI 1.00-1.05, p = 0.005) were associated with increased probability of futile recanalization. Multivariable regression analysis showed that use of intravenous thrombolysis (0.44, 95% CI 0.09-0.88, p = 0.039) was associated with reduced probability of futile recanalization.

CONCLUSION

Our study seems to suggest that mechanical thrombectomy with intravenous thrombolysis is associated with reduced probability of futile recanalization in a multi-center cohort of patients aged 90 years or older.

Outcomes of mechanical thrombectomy in M1 occlusion patients with or without hyperdense middle cerebral artery sign: A systematic review and meta-analysis

BACKGROUND

The comparison of mechanical thrombectomy (MT) outcomes between patients with the hyperdense middle cerebral artery sign (HMCAS) and non-HMCAS is important to evaluate the impact of this radiological finding on treatment efficacy. This meta-analysis aimed to assess the association between HMCAS and clinical outcomes in patients undergoing thrombectomy, comparing the outcomes over non-HMCAS.

METHODS

A systematic literature search was conducted in PubMed, Ovid Embase, Google Scholar, and Cochrane Library to identify studies on MT outcomes for M1 occlusions of HMCAS over non-HMCAS. Inclusion criteria encompassed modified Rankin Scale (mRS) score, mortality, symptomatic intracranial hemorrhage (sICH), and successful recanalization. Using R software version 4.1.2, we calculated pooled odds ratios (ORs) and their corresponding 95% confidence intervals (CI).

RESULTS

The meta-analysis was performed for 5 studies with 724 patients. There was no association found between presence of HMCAS and achieving mRS 0-2 (OR = 0.65, 95% CI: 0.29-1.47; p = .544). Mortality analysis also showed no significant association with presence of HMCAS (OR = 0.78, 95% CI: 0.37-1.65; p = .520). No significant difference in sICH risk (OR = 1.54, 95% CI: 0.24-9.66; p = .646) was found between groups. Recanalization analysis showed a non-significant positive association (OR = 1.23, 95% CI: 0.67-2.28; p = .501). Heterogeneity was observed in all analyses.

CONCLUSION

Our findings showed that there is no statistically significant difference in mRS scores, mortality, sICH, and recanalization success rates between the HMCAS and non-HMCAS groups.

MR microscopy to assess clot composition following mechanical thrombectomy predicts recanalization and clinical outcome

BACKGROUND

Mechanical thrombectomy (MT) is the standard of care for patients with a stroke and large vessel occlusion. Clot composition is not routinely assessed in clinical practice as no specific diagnostic value is attributed to it, and MT is performed in a standardized 'non-personalized' approach. Whether different clot compositions are associated with intrinsic likelihoods of recanalization success or treatment outcome is unknown.

METHODS

We performed a prospective, non-randomized, single-center study and analyzed the clot composition in 60 consecutive patients with ischemic stroke undergoing MT. Clots were assessed by ex vivo multiparametric MRI at 9.4 T (MR microscopy), cone beam CT, and histopathology. Clot imaging was correlated with preinterventional CT and clinical data.

RESULTS

MR microscopy showed red blood cell (RBC)-rich (21.7%), platelet-rich (white,38.3%) or mixed clots (40.0%) as distinct morphological entities, and MR microscopy had high accuracy of 95.4% to differentiate clots. Clot composition could be further stratified on preinterventional non-contrast head CT by quantification of the hyperdense artery sign. During MT, white clots required more passes to achieve final recanalization and were not amenable to contact aspiration compared with mixed and RBC-rich clots (maneuvers: 4.7 vs 3.1 and 1.2 passes, P<0.05 and P<0.001, respectively), whereas RBC-rich clots showed higher probability of first pass recanalization (76.9%) compared with white clots (17.4%). White clots were associated with poorer clinical outcome at discharge and 90 days after MT.

CONCLUSION

Our study introduces MR microscopy to show that the hyperdense artery sign or MR relaxometry could guide interventional strategy. This could enable a personalized treatment approach to improve outcome of patients undergoing MT.

Comparison of radiological and clinical characteristics of COVID-19 positive and negative ischemic stroke patients undergoing revascularization: A single-centre Turkish study

OBJECTIVE

We aimed to compare the radiological and clinical characteristics of COVID-19-positive and -negative acute ischemic stroke (AIS) patients who underwent revascularization and to evaluate whether COVID-19 has an effect on revascularization and outcome in AIS patients with COVID-19 infection.

METHODS

Consecutive COVID-19 positive and negative AIS patients who underwent intravenous thrombolysis and/or endovascular therapy in our hospital between March 2020 and February 2022 were included in this study. Our study is retrospective and 23 COVID-19 positive patients and 108 COVID-19 negative patients were compared in terms of radiological and clinical characteristics.

RESULTS

Hypertension was lower in the COVID-19 positive ischemic stroke group (p=0.029). Admission NIHSS score was higher in COVID-19 positive patients (p=0.041). ASPECTS was found to be lower in COVID-19 positive ischemic stroke patients (p=0.019). The rate of hyperdense artery sign differed between groups (p=0.014) and was higher in the COVID-19 positive ischemic stroke group. The incidence of multi-vessel occlusion was found to be significantly higher in the COVID-19-positive ischemic stroke group (p=0.002). In terms of prognostic features, only the 3-month good outcome rate was statistically significantly lower in the COVID-19-positive ischemic stroke group (p=0.011).

CONCLUSION

This study found that radiologically, COVID-19 may be associated with lower ASPECTS in ischemic stroke patients receiving revascularization treatment and may predispose to multivessel occlusion and hyperdense artery sign. Clinically, COVID-19 may be associated with a more severe initial presentation and worse prognosis at 3 months in ischemic stroke patients undergoing revascularization, but may not affect long-term mortality.

The Role of Hyperdense Basilar Artery Sign in Predicting Outcome of Acute Basilar Artery Occlusion within Twelve Hours of Onset

BACKGROUND

The correlation between hyperdense basilar artery sign (HDBAS) and outcome after acute basilar artery occlusion (ABAO) is debated. Our objective was to determine the usefulness of HDBAS in predicting the outcomes of patients with ABAO after endovascular treatment (EVT), intravenous thrombolysis (IVT), and best medical treatment (BMT).

METHODS

The study participants were selected from the ATTENTION trial. The primary outcome of the study was a 90-day modified Rankin Scale (mRS) score, and the secondary outcome was the recanalization rate, any intracranial hemorrhage, and 90-day mortality.

RESULTS

The study comprised 276 participants, with cohorts for EVT (n = 188), IVT (n = 82), and BMT (n = 88). In the EVT cohort, HDBAS was not associated with 90-day mRS score (adjusted odds ratio [OR], 0.87; 95% confidence interval [CI], 0.51-1.48; P = 0.6029), the recanalization after 24 hours of onset (adjusted OR, 0.76; 95% CI, 0.30-3.61; P = 0.9422), and 90-day mortality (adjusted OR, 0.77; 95% CI, 0.41-1.46; P = 0.4238). In the IVT cohort, HDBAS was not associated with a 90-day mRS score (adjusted OR, 0.69; 95% CI, 0.31-1.56; P = 0.3742), the recanalization after 24 hours of onset (adjusted OR, 2.24; 95% CI, 0.47-10.78; P = 0.3132), and 90-day mortality (adjusted OR, 0.64; 95% CI, 0.26-1.57; P = 0.3264). Similarly, in the BMT cohort, HDBAS was not associated with 90-day mRS score (adjusted OR, 1.11; 95% CI, 0.47-2.63; P = 0.8152), the recanalization after 24 hours of onset (adjusted OR, 1.27; 95% CI, 0.40-4.02; P = 0.6874), and 90-day mortality (adjusted OR, 1.17; 95% CI, 0.46-2.96; P = 0.748).

CONCLUSIONS

HDBAS may not be a reliable predictor of outcomes for patients with ABAO, regardless of whether they received EVT, IVT, or BMT.

Hyperdense sign as a predictor for successful recanalization and clinical outcome in acute ischemic stroke: A systematic review and meta-analysis

OBJECTIVE

To assess the prognostic values of hyperdense sign on pretreatment non-contrast head CT scan for successful recanalization (mTICI ≥2b) and 90-day good functional outcome (mRs 0-2) in patients with acute ischemic stroke undergoing mechanical thrombectomy (MT).

METHODS

Literature search on PubMed, EMBASE, and Cochrane databases from inception up to 1 November 2023 was conducted. Twelve studies which reported hyperdense sign, recanalization and clinical outcomes were included in qualitative synthesis and meta-analysis.

RESULTS

Pooled analysis demonstrated a statistically significant association between successful recanalization and hyperdense sign-positive patients who underwent MT (odd ratios (OR) = 1.47, 95% confidence interval (CI) = 1.03-2.10, p = 0.04). No statistically significant association was demonstrated between presence of hyperdense sign and good functional outcome (OR = 1.04, 95% CI: 0.72-1.49, p = 0.85) or symptomatic intracranial hemorrhage sICH (OR: 1.80, 95% CI 0.72-4.47, p = 0.21).

CONCLUSIONS

This meta-analysis demonstrated that pre-intervention hyperdense sign on CT imaging might be useful in prediction of successful recanalization after MT.

Comparison of pharmacokinetic properties of alteplase and tenecteplase. The future of thrombolysis in acute ischemic stroke

INTRODUCTION

The drug most frequently used for thrombolysis in cases of acute ischemic stroke (AIS) is alteplase. However, there is moderate-to-high-quality evidence that tenecteplase has similar or higher efficacy and safety. With improved pharmacokinetic properties over alteplase, tenecteplase could be a significant advantage in treating AIS.

AREAS COVERED

After conducting an extensive search on Scopus and PubMed, this manuscript reviews and compares the pharmacokinetic properties of alteplase and tenecteplase. Additionally, it provides information on pharmacodynamics, clinical efficacy, safety, tolerability, and drug-drug interactions.

EXPERT OPINION

The pharmacokinetic profile of alteplase and tenecteplase is derived from studies in patients with acute myocardial infarction. Thanks to its pharmacokinetic properties, tenecteplase is the drug closest to being the ideal fibrinolytic for AIS. Its longer half-life enables a single-bolus administration, which is particularly useful in emergencies. Tenecteplase has proven to have a good efficacy and safety profile in randomized clinical trials. Although we are awaiting the results of the ongoing phase 3 randomized clinical trials, we believe that tenecteplase has the potential to revolutionize the treatment of AIS through thrombolysis.

Minimal Imaging Requirements

The minimal requirements for imaging studies prior to endovascular treatment (EVT) of acute ischemic stroke are those that can provide the information necessary to determine the indication for treatment (treatment triage) and procedural strategies without being time-consuming. An important notion is to determine whether the patient can benefit from EVT. We should recognize that the perfect diagnostic imaging technique does not yet exist, and each has advantages and disadvantages. Generally, stroke imaging protocols to triage for EVT include the following three options: 1) non-contrast CT and CTA, 2) CT perfusion and CTA, and 3) MRI and MRA. It is not known if perfusion imaging or MRI is mandatory for patients with stroke presenting within 6 hours of onset, although non-contrast CT alone has less power to obtain the necessary information. Dual-energy CT can distinguish between post-EVT hemorrhage and contrast agent leakage immediately after EVT.