Clinical frailty and outcome after mechanical thrombectomy for stroke in patients aged ≥ 80 years

Healthy ageing in older adults with cardiovascular disease

As life expectancy continues to increase due to advancements in medical technology, public health, nutrition, and socioeconomic progress, the population of older adults in the USA and Europe is rapidly growing. By 2050, individuals aged 65 and older are projected to constitute over 20% of the US population and 29% of the European population, leading to a higher prevalence of chronic diseases, including cardiovascular disease. Cardiovascular disease, the leading cause of death in the USA, poses significant challenges to healthy ageing by contributing to accelerated biological ageing and the development of geriatric syndromes. This state-of-the-art review aims to (i) define healthy ageing for older patients living with cardiovascular disease; (ii) compare chronological vs biological ageing as it pertains to cardiovascular disease; (iii) describe the impact of geriatric syndromes and provide an approach to management and prevention; and (iv) address the gaps in knowledge and future directions for potential interventions that could promote healthy ageing.

The impact of comorbidity burden on outcomes following endovascular thrombectomy for acute ischemic stroke: A nationwide prospective observational study

INTRODUCTION

Patients with substantial comorbidity burden are underrepresented in clinical trials on endovascular thrombectomy (EVT), despite being common in clinical routine care. Therefore, analysis of observational data is needed to evaluate how increasing comorbidity burden affects procedural success rate, complication rate, and clinical outcome following EVT.

PATIENTS AND METHODS

We conducted a register-based observational study involving pre-stroke functionally independent patients treated with EVT in Sweden 2015-2021. Comorbidity burden was assessed using the Charlson Comorbidity Index (CCI) and categorized as no (CCI 0), moderate (CCI 1), severe (CCI 2), and very severe (CCI ⩾3). The primary outcome was favorable 90-day outcome (modified Rankin Scale 0-2). Secondary outcomes included successful recanalization, and peri- and postoperative complications.

RESULTS

Of 4735 included patients, 40% had no comorbidity (CCI 0), 15% had moderate (CCI 1), 21% had severe (CCI 2), and 24% had very severe comorbidity burden (CCI ⩾3). The yearly proportion of patients with very severe comorbidity burden increased from 16% to 30% during the study period. Increasing comorbidity levels were associated with decreased odds ratio (OR) of favorable outcome compared to patients without comorbidity: CCI 1 adjusted OR (aOR) 0.64, 95% CI 0.57-0.85; CCI 2 aOR 0.59, 95% CI 0.47-0.74; and CCI ⩾3 aOR 0.38, 95% CI 0.30-0.47, but there were no significant differences in successful recanalization rates. Patients with CCI 2 had higher OR for perioperative and postoperative complications (OR 1.43, 95% CI 1.09-1.88, and OR 1.41, 95% CI 1.15-1.71), and patients in the CCI ⩾3 group had higher OR of postoperative complications (OR 1.34, 95% CI 1.14-1.67), compared to patients in the CCI 0 group. Successful recanalization was associated with favorable functional outcome in all CCI-groups.

DISCUSSION AND CONCLUSION

Severe and very severe comorbidity burden are increasingly common among EVT-treated patients in routine healthcare and are linked to poorer outcomes. However, our results suggest that successful EVT is associated with functional independency, also in patients with severe and very severe comorbidity burden.

Association of frailty with outcomes in patients with large vessel occlusion stroke undergoing mechanical thrombectomy

PURPOSE

Frailty is a clinical syndrome characterized by reduced physiological reserve and increased vulnerability to adverse health outcomes, potentially impacting patients undergoing mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion (LVO). This study aimed to evaluate the influence of frailty on in-hospital outcomes in these high-risk patients.

METHODS

We conducted a retrospective analysis of the National Inpatient Sample (2016-2021), identifying patients with large vessel occlusion stroke undergoing mechanical thrombectomy. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnoses. Propensity score matching (PSM) was applied to create balanced cohorts for primary analysis.

RESULTS

In propensity-matched analysis, frail patients had higher in-hospital mortality (12.06% vs. 9.90%, P = 0.004), seizures (2.35% vs. 1.65%, P = 0.048), major adverse cardiac events (MACE) (15.29% vs. 13.51%, P = 0.044), pulmonary embolism (2.38% vs. 1.62%, P = 0.031), and hospital-acquired pneumonia (6.10% vs. 4.80%, P = 0.023). Sensitivity analysis using multivariable logistic regression confirmed similar trends, with frailty remaining an independent predictor of mortality (aOR 1.24, 95% CI: 1.04-2.23, P = 0.04).

CONCLUSION

Frailty is associated with significantly worse outcomes, including higher mortality, MACE, and pneumonia in patients undergoing mechanical thrombectomy for LVO. These findings emphasize the need for frailty screening as part of pre-procedural risk stratification and tailored management strategies to improve patient outcomes.

The Relationship Between Brain Frailty and Physical Function in Patients With Stroke Undergoing Rehabilitation

Background Brain frailty has gained attention as a predictor of poor functional outcomes. However, the relationship between brain frailty and physical function among patients with stroke undergoing rehabilitation remains unclear. This study aimed to investigate the relationship between brain frailty and activities of daily living (ADLs) at discharge among patients with stroke admitted to a convalescent rehabilitation ward. Methods This single-center retrospective cohort study included patients with stroke admitted to the convalescent rehabilitation ward. Brain frailty (i.e., white matter hyperintensity, old vascular lesions, and brain atrophy) was evaluated using cranial magnetic resonance imaging at stroke onset. The outcome measure was defined as ADLs at discharge, assessed using the motor item of the Functional Independence Measure (FIM-M). Multiple regression and mediation analyses were performed to assess the association between brain frailty scores and FIM-M scores at discharge. Results The final analysis included 160 patients (median age: 73.0 years; interquartile range: 64.0-80.0 years; male: n = 90, 56.2%). The multiple regression analysis revealed that severe brain frailty (score of 3) was significantly associated with FIM-M scores at discharge, even after adjusting for covariates (β = -0.18; p = 0.041). Furthermore, mediation analysis revealed that severe brain frailty was associated with FIM-M scores at discharge through the mediation of cognitive function (total effect = -16.20; p < 0.001). Conclusions Brain frailty may provide new insights for outcome prediction in stroke rehabilitation, highlighting the importance of incorporating its assessment into routine clinical practice.

Extended Length of Stay After Mechanical Thrombectomy for Stroke: A Single-Center Analysis of 703 Patients

BACKGROUND AND OBJECTIVES

Mechanical thrombectomy (MT) is crucial for improving functional outcomes for acute ischemic stroke. Length of stay (LOS) is a reimbursement metric implemented to incentivize value-based care. Our study aims to identify predictors of LOS in patients undergoing MT at a high-volume center in the United States.

METHODS

This was a retrospective study of patients who underwent MT at a single institution from 2017 to 2023. Patients who experienced mortality during their course of hospital stay were excluded from this study. Extended LOS (eLOS) was defined as the upper quartile (≥75th) of the median duration of hospital stay. Univariate and multivariate analyses were performed, with P values < .05 denoting statistical significance.

RESULTS

Seven hundred three patients met criteria for inclusion. The median age of the cohort was 72 years (IQR: 61-82), and 57.2% was female. The median LOS was 6, IQR: 4-10. A total of 28.9% of the cohort (n = 203) patients experienced eLOS. The multivariate regression model identified age (odds ratio [OR]: 0.98, 95% CI: 0.97-0.99), diabetes mellitus (OR: 1.68, 95% CI: 1.15-2.44), and hemorrhagic transformation of stroke (OR: 2.89, 95% CI: 0.39-0.90) as predictors of eLOS, whereas antiplatelet use before admission (OR: 0.55, 95% CI: 0.34-0.89) and higher baseline modified Rankin Scale before stroke were associated with lower odds (OR: 0.59 [0.39-0.90]; P < .05) of eLOS.

CONCLUSION

By identifying predictors of eLOS, we provide a foundation for targeted interventions aimed at optimizing post-thrombectomy care pathways and improving patient outcomes. The implications of our study extend beyond clinical practice, offering insights into healthcare resource utilization, reimbursement strategies, and value-based care initiatives.

Utility of A2L2 score in acute ischemic stroke patient triage: the "H.uni" experience

BACKGROUND AND AIMS

Two or more National Institutes of Health Stroke Scale (NIHSS) points on each motor items (A2L2 score) have shown good accuracy in predicting large vessel occlusion (LVO) in the prehospital setting of acute ischemic stroke (AIS) care. We aimed to study this score for LVO prediction in our stroke network and predictors of poor outcome (PO) after mechanical thrombectomy (MT).

METHODS

From our Safe Implementation of Thrombolysis in Stroke (SITS) registry including patients receiving reperfusion therapy for AIS, we retrospectively computed the A2L2 score from the admission NIHSS to test the diagnostic accuracy for LVO prediction. Multivariable analysis for independent predictors of LVO on the entire cohort and PO from patients with LVO were performed.

RESULTS

From the 853 patients with AIS (67% LVO), A2L2 was positive in 52%. A2L2 score (Odds ratio [OR] 4.6;95%CI 3.36-6.34), smoking (OR 2.1;95%CI 1.14-3.85), atrial fibrillation (OR 1.6;95%CI1.1-2.4) and younger age (OR 0.98;95%CI0.97-0.99) were independent predictors of LVO. A2L2 score showed 82%/49% positive/negative predictive values with 66% accuracy (64%/72% sensitivity/specificity) for LVO prediction. Age (OR 1.05;95%CI 1.03-1.07), atrial fibrillation (OR 4.85;95%CI 1.5-15.7), diabetes (OR 2.62;95% CI 1.14-6.05), dyslipidemia (OR 2;95% CI 1.04-3.87), A2L2 score (OR 2.68;95% CI 1.45-4.98), longer onset-to-groin time (OR 1.003;95% CI 1.001-1.01), MT procedure (OR 1.01;95%CI 1.003-1.02) general anaesthesia (OR 2.06;95% CI 1.1-3.83) and symptomatic intracranial hemorrhage (OR 12.10;95%CI 3.15-46.44) were independent predictors of PO.

CONCLUSIONS

A2L2 score independently predicted LVO and PO after MT. Patient characteristics and procedural factors determined PO of LVO patients after MT.

Low body mass index patients have worse outcomes after mechanical thrombectomy

BACKGROUND

There is evidence that frailty is an independent predictor of worse outcomes after stroke. Similarly, although obesity is associated with a higher risk for stroke, there are multiple reports describing improved mortality and functional outcomes in higher body mass index (BMI) patients in a phenomenon known as the obesity paradox. We investigated the effect of low BMI on outcomes after mechanical thrombectomy (MT).

METHODS

We conducted a retrospective analysis of 231 stroke patients who underwent MT at an academic medical center between 2020-2022. The patients' BMI data were collected from admission records and coded based on the Centers for Disease Control and Prevention (CDC) obesity guidelines. Recursive partitioning analysis (RPA) in R software was employed to automatically detect a BMI threshold associated with a significant survival benefit. Frailty was quantified using the Modified Frailty Index 5 and 11.

RESULTS

In our dataset, by CDC classification, 2.6% of patients were underweight, 27.3% were normal BMI, 30.7% were overweight, 19.9% were class I obese, 9.5% were class II obese, and 10% were class III obese. There were no significant differences between these groups. RPA identified a clinically significant BMI threshold of 23.62 kg/m2. Independent of frailty, patients with a BMI ≤23.62 kg/m2 had significantly worse overall survival (P<0.001) and 90-day modified Rankin Scale (P=0.027) than patients above the threshold.

CONCLUSIONS

Underweight patients had worse survival and functional outcomes after MT. Further research should focus on the pathophysiology underlying poor prognosis in underweight MT patients, and whether optimizing nutritional status confers any neuroprotective benefit.

Association between pre-stroke frailty status and stroke risk and impact on outcomes: a systematic review and meta-analysis of 1,660,328 participants

The prevalence of frailty is increasing, and it is associated with increased risk of diseases and adverse outcomes. Although substantial research has focused on post-stroke frailty, understanding of pre-stroke frailty remains limited. Our aim was to synthesize literature on pre-stroke frailty and stroke risk to explore their relationship and impact on prognosis. A systematic search of multiple databases was conducted to identify cohort studies published until October 28, 2023. Meta-analysis was conducted using a random effects model. Heterogeneity was assessed with the I² statistic, and publication bias was evaluated using Begg's test. Finally, we included 11 studies (n = 1,660,328 participants). The pooled hazard ratios (HRs) for stroke risk associated with pre-stroke frailty compared to non-frail individuals was 1.72 (95% confidence interval, CI: 1.46-2.02, p = 0.002, I2 = 69.2%, Begg's test: p = 0.536). The pooled HRs for mortality and the pooled relative risk (RRs) modified Rankin Scale (mRs) associated with pre-stroke frailty were 1.68 (95% CI: 1.10-2.56, p = 0.136, I2 = 49.9%, Begg's test: p = 0.296) and 3.11 (95% CI: 1.77-5.46, p = 0.192, I2 = 39.4%, Begg's test: p = 1.000), respectively. In conclusion, pre-stroke frailty is strongly associated with stroke risk and impacts its prognosis, irrespective of the measurement method. Future research should focus on prospective studies to assess the effects of early intervention for frailty. This has significant implications for primary healthcare services and frailty management.

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.

Mechanical thrombectomy for treatment of acute ischemic stroke in frail patients: a systematic review of the literature

BACKGROUND

The overall safety and efficacy of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) in frail patients is not well delineated. This systematic review aims to summarize and compare outcomes in frail and non-frail patients who underwent MT for AIS.

METHODS

A systematic review of the literature was performed using PubMed, Ovid Medline, and Web of Science to identify studies with outcomes-related data for frail patients with MT-treated AIS. The recanalization rate, procedural complications, and clinical outcome at 90-day follow-up were collected.

RESULTS

In the four included studies there were 642 frail patients and 499 non-frail patients. Frail patients had reduced rates of good functional outcomes (29% vs 42%; χ2=22, p<0.01) and increased 90-day mortality (51% vs 25%; χ2=38, p<0.01) compared with non-frail patients.

CONCLUSION

MT for treatment of AIS in frail patients may be associated with worse rates of morbidity and mortality along with reduced efficacy. Given that no studies to date directly compare conservative measures with endovascular management for AIS in frail patients, more studies are required to further evaluate and identify characteristics that may improve outcomes in these patients.

Role of frailty in predicting outcomes after stroke: a systematic review and meta-analysis

Background

Stroke is considered the second most common cause of death and the third leading cause of disability worldwide. Frailty, characterized by increased vulnerability to stressors, is emerging as a key factor affecting outcomes in older adults and stroke patients. This study aimed to estimate the prevalence of frailty in acute stroke patients and assess its association with mortality and poor functional outcome.

Methods

Medline, Google Scholar, and Science Direct databases were systematically searched for English-language studies that included adult stroke patients (>16 years), have defined frailty, and reported mortality and functional outcomes. Meta-analysis was done using STATA 14.2, and the results were expressed as pooled odds ratios (OR) with 95% confidence intervals (CI). Heterogeneity was assessed using the I2 statistic and the Chi-square test. Study quality was evaluated using the Newcastle Ottawa Scale (NOS).

Results

Twenty-five studies were included in the analysis. Frailty prevalence in stroke patients was 23% (95% CI 22% - 23%). Unadjusted analysis showed an OR of 2.66 (95% CI: 1.93 - 3.67) for mortality and 2.04 (95% CI: 1.49 - 2.80) for poor functional outcome. Adjusted estimates indicated an OR of 1.22 (95% CI: 1.1 - 1.35) for mortality and 1.21 (95% CI: 1.04 - 1.41) for poor functional outcome, with substantial heterogeneity for both adjusted and unadjusted analyses. No publication bias was detected for the prevalence of frailty. However, there was a publication bias for the association between frailty and mortality.

Conclusions

Frailty was significantly associated with increased mortality and poorer functional outcomes in stroke patients. Our study highlights the need to focus on frailty in stroke patients to improve outcomes and quality of life. Further research should aim to standardize assessment of frailty and reduce heterogeneity in study outcomes.

Systematic review registration

https://www.crd.york.ac.uk/prospero/#searchadvanced, CRD42023470325.

Safety and outcomes of different endovascular treatment techniques for anterior circulation ischaemic stroke in the elderly: data from the Imperial College Thrombectomy Registry

BACKGROUND

Although previous studies investigated the main predictors of outcomes after endovascular thrombectomy (EVT) in patients aged 80 years and older, less is known about the impact of the procedural features on outcomes in elderly patients. The aim of this study was to investigate the influence of EVT technical procedures on the main 3-month outcomes in a population of patients aged 80 years and older.

METHODS

This observational, prospective, single-centre study included consecutive patients with acute LVO ischaemic stroke of the anterior circulation. The study outcomes were functional independence at 3 months after EVT (defined as a mRS score of 0-2), successful reperfusion (mTICI ≥ 2b), incidence of haeamorrhagic transformation, and 90-day all cause of mortality.

RESULTS

Our cohort included 497 patients with acute ischaemic stroke due to LVO treated with EVT. Among them, 105 (21.1%) patients were aged ≥ 80 years. In the elderly group, multivariable regression analysis showed that thromboaspiration technique vs stent-retriever was the single independent predictor of favourable post-procedural TICI score (OR = 7.65, 95%CI = 2.22-26.32, p = 0.001).

CONCLUSIONS

Our study suggests that EVT for LVO stroke in the elderly could be safe. The use of thromboaspiration was associated with positive reperfusion outcome in this population. Further studies in larger series are warranted to confirm the present results and to evaluate the safety and efficacy of EVT in the elderly and oldest adults.

Clinical outcome after thrombectomy in patients with MeVO stroke: importance of clinical and technical factors

BACKGROUND AND AIMS

Whereas high-level evidence has been proven for safety and efficacy of endovascular treatment (EVT) in large vessel occlusion (LVO) stroke, the evidence for EVT in medium vessel occlusion (MeVO) in both sexes and different age groupremains to be answered. The aim of this study was to evaluate the importance of clinical and technical parameters, focusing on sex, age and EVT procedural factors, on functional outcome in primary MeVO (pMeVO) strokes.

METHODS

144 patients with pMeVO in the MCA territory from the Oslo Acute Reperfusion Stroke Study (OSCAR) were included. Clinical and radiological data were collected including 90-day mRS follow-up.

RESULTS

Successful reperfusion with modified thrombolysis in cerebral infarction (mTICI) ≥ 2b was achieved in 123 patients (84%). Good functional outcome (mRS ≤ 2) at 90-day follow-up was achieved in 84 patients (61.8%). Two or more passes with stent retriever was associated with increased risk of SAH, poor mTICI and poor functional outcome. In average, women had 62 min longer ictus to recanalization time compared to men. Age over 80 years was significantly associated with poor outcome and death.

CONCLUSION

In pMeVO patients, TICI score and number of passes with stent retriever were the main technical factors predicting mRS ≤ 2. Good clinical outcome occurred almost twice as often in patients under 80 years of age compared to patients over 80 years. Women with MeVO strokes had significant longer time from ictus to recanalization; however, this did not affect the clinical outcome.

To what extent does frailty mediate the association between age and the outcomes of brain reperfusion following acute ischemic stroke?

OBJECTIVE

We evaluated the extent to which frailty mediated the association between age, poor functional outcomes, and mortality after acute ischemic stroke when patients were treated with brain reperfusion (thrombolytic therapy and/or thrombectomy).

MATERIALS AND METHODS

This retrospective cohort study included patients diagnosed with ischemic stroke who had undergone intravenous cerebral reperfusion therapy and/or mechanical thrombectomy. We created a mediation model by analyzing the direct natural effect of an mRS score > 2 and death on age-mediated frailty according to the Frailty Index.

RESULTS

We enrolled 292 patients with acute ischemic stroke who underwent brain reperfusion. Their mean age was 67.7 ± 13.1 years. Ninety days after the stroke ictus, 54 (18.5%) participants died, and 83 (28.4%) lived with moderate to severe disability (2 < mRS < 6). In the mediation analysis of the composite outcome of disability (mRS score > 2) or death, frailty accounted for 28% of the total effect of age. The models used to test for the interaction between age and frailty did not show statistically significant interactions for either outcome, and the addition of the interaction did not significantly change the direct or indirect effects, nor did it improve model fit.

CONCLUSION

Frailty mediated almost one-third of the effect of age on the composite outcome of disability or death after acute ischemic stroke.

Predictors of mTICI 2c/3 over 2b in patients successfully recanalized with mechanical thrombectomy

OBJECTIVE

For patients presenting with acute ischemic stroke (AIS) caused by large vessel occlusions (LVO), mechanical thrombectomy (MT) is the treatment standard of care in eligible patients. Modified Thrombolysis in Cerebral Infarction (mTICI) grades of 2b, 2c, and 3 are all considered successful reperfusion; however, recent studies have shown achieving mTICI 2c/3 leads to better outcomes than mTICI 2b. This study aims to investigate whether any baseline preprocedural or periprocedural parameters are predictive of achieving mTICI 2c/3 in successfully recanalized LVO patients.

METHODS

We conducted a retrospective multicenter cohort study of consecutive patients presenting with AIS caused by a LVO from 1 January 2017 to 1 January 2023. Baseline and procedural data were collected through chart review. Univariate and multivariate analysis were applied to determine significant predictors of mTICI 2c/3.

RESULTS

A total of 216 patients were included in the study, with 159 (73.6%) achieving mTICI 2c/3 recanalization and 57 (26.4%) achieving mTICI 2b recanalization. We found that a higher groin puncture to first pass time (OR = 0.976, 95%CI: 0.960-0.992, p = 0.004), a higher first pass to recanalization time (OR = 0.985, 95%CI: 0.972-0.998, p = 0.029), a higher admission NIHSS (OR = 0.949, 95%CI: 0.904-0.995, p = 0.031), and a lower age (OR = 1.032, 95%CI: 1.01-1.055, p = 0.005) were associated with a decreased probability of achieving mTICI 2c/3.

INTERPRETATION

A lower groin puncture to first pass time, a lower first pass to recanalization time, a lower admission NIHSS, and a higher age were independent predictors of mTICI 2c/3 recanalization.

Posterior Circulation Stroke Patients Receive Less Reperfusion Therapy Because of Late Arrival and Relative Contraindications: A Retrospective Study

BACKGROUND

Reperfusion treatment (RT) is administered to individuals with posterior circulation strokes (PCS) later and less frequently. We aimed to study the impact of demographic and clinical factors on the decision for RT in PCS.

METHODS

We conducted a retrospective analysis of the data from 500 subjects admitted to the tertiary stroke centre's emergency department between 2018 and 2020 due to PCS. Demographic and clinical factors were analysed among three groups: the RT group, the group with no RT because of absolute contraindications (ACI), and the group with no RT because of relative contraindications (RCI).

RESULTS

Of the patients, 202 (40.3%) were female. The median NIHSS was four (4), and the subjects' median age was 69 (18). RT was performed on 120 (24%) subjects. FAST symptoms (OR-5.62, 95% CI [2.90-12.28]) and higher NIHSS (OR-1.13, 95% CI [1.09-1.18]) at presentation, atrial fibrillation (OR-1.56, 95% CI [1.02-2.38]), hypertension (OR-2.19, 95% CI [1.17-4.53]) and diabetes (OR-1.70, 95% CI [1.06-2.71]) increased the chance of RT. Late arrival was the most prevalent ACI for 291 (58.2%) patients. FAST-negative subjects (OR-2.92, 95% CI [1.84-4.77]) and males (OR-1.58, 95% CI [1.11-2.28]) had a higher risk of arriving late. Because of RCI, 50 (10%) subjects did not receive RT; the majority were above 80 and had NIHSS ≤ 5. Subjects with RCI who received the RT had a higher NIHSS (4 vs. 3, p < 0.001), higher hypertension (59 (92.2%) vs. 35 (77.8%), p = 0.032) and heart failure (23 (35.9%) vs. 7 (15.6%), p = 0.018) prevalence. There was a trend for less RT in females with RCI.

CONCLUSIONS

Late arrival was the most common barrier to RT, and the male gender increased this risk. because of relative contraindications, 10% of subjects were not considered for RT. The presence of FAST symptoms, vascular risk factors, and a higher NIHSS increased the chance of RT.

Predicting Mechanical Thrombectomy Outcome and Time Limit through ADC Value Analysis: A Comprehensive Clinical and Simulation Study Using Machine Learning

Predicting outcomes after mechanical thrombectomy (MT) remains challenging for patients with acute ischemic stroke (AIS). This study aimed to explore the usefulness of machine learning (ML) methods using detailed apparent diffusion coefficient (ADC) analysis to predict patient outcomes and simulate the time limit for MT in AIS. A total of 75 consecutive patients with AIS with complete reperfusion in MT were included; 20% were separated to test data. The threshold ranged from 620 × 10^-6 mm²/s to 480 × 10^-6 mm²/s with a 20 × 10^-6 mm²/s step. The mean, standard deviation, and pixel number of the region of interest were obtained according to the threshold. Simulation data were created by mean measurement value of patients with a modified Rankin score of 3-4. The time limit was simulated from the cross point of the prediction score according to the time to perform reperfusion from imaging. The extra tree classifier accurately predicted the outcome (AUC: 0.833. Accuracy: 0.933). In simulation data, the prediction score to obtain a good outcome decreased according to increasing time to reperfusion, and the time limit was longer among younger patients. ML methods using detailed ADC analysis accurately predicted patient outcomes in AIS and simulated tolerance time for MT.

Implications of frailty in acute ischemic stroke receiving endovascular treatment: systematic review and meta-analysis

BACKGROUND

Frailty is a state of cumulative degeneration of bodily functions that is consistently associated with poor outcomes in older people following illness. Combined stroke intervention and frailty may yield additive and synergistic effects adults with stroke.

OBJECTIVE

To evaluate the safety and efficacy of endovascular therapy (EVT) in frail patients.

METHODS

We conducted a systematic review of the relationship between debilitation and acute ischemic stroke (AIS) after EVT. Until August 2022, researchers have searched three databases (Pubmed, EMBASE and Cochrane). Random-effects meta-analysis, combined ratio (OR) and 95% confidence interval (95%CI) were used to assess efficacy values. The I² statistic was used to assess heterogeneity. Comprehensive meta-analysis software was used for meta-analysis.

RESULTS

We ultimately included eight studies including 3662 non-overlapping participants. Four studies used the Clinical Frailty Scale (CFS), two studies used the Hospital Frailty Risk Score (HFRS), a study used frailty index and a study used the comprehensive geriatric assessment (CGA). Frailty prevalence: 35%; 95% CI, 0.27-0.43; low quality evidence, downgraded due to heterogeneity, bias. Random effects showed that poor functional outcome (5 studies, OR 1.956, 95% CI 1.256-3.048) and mortality (9 studies, OR 2.320, 95% CI 1.680-3.205) was significantly associated with frailty. In adjusted analyses, poor functional outcome (4 studies, OR_adj 1.189, 95% CI 1.043-1.357), and mortality (3 studies, OR_adj 1.036, 95% CI 1.008-1.065) were significantly associated with frailty.

CONCLUSION

Pre-stroke frailty is an important predictor of poor prognosis assessed by EVT and can be added to the classical predictors of stroke outcome. Routine assessment of pre-stroke frailty can help patients to make decisions about the efficacy of their choice of EVT.