Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion

Association Between Collateral Status, Blood Pressure During Thrombectomy, and Clinical Outcomes in Patients With Basilar Artery Occlusion

BACKGROUND AND OBJECTIVES

We investigated the relationship between intraprocedural blood pressure (BP) and clinical outcomes in patients with basilar artery occlusion (BAO) undergoing endovascular treatment (EVT), exploring whether it is modifiable by collateral status.

METHODS

Patient data from the Endovascular Treatment for Acute Basilar Artery Occlusion (ATTENTION) randomized trial were analyzed for those with BAO who received EVT. Intraprocedural BP data were extracted, with collateral status assessed using the Basilar Artery on CT Angiography (BATMAN) score (BATMAN score ≥7 favorable collateral status, <7 unfavorable). Associations between BP parameters and outcomes were assessed using multivariable logistic regression and restricted cubic splines. The effect modification was assessed using an interaction term between BP parameters and collateral status. The primary outcome was a favorable outcome defined by a modified Rankin Scale (mRS) score of 0-3 at 90 days.

RESULTS

There were 212 patients included (median age 68 years, 32.1% female). Restricted cubic spline analysis showed that the SDs of systolic BP (SBP) and mean arterial pressure (MAP) had J-shaped relationships with favorable outcome (p for nonlinearity = 0.004 and <0.001, respectively), with inflection points at 12 and 8 mm Hg, respectively. Multivariable logistic regression showed that MAP of 80-110 mm Hg (adjusted odds ratio [aOR] 3.00, 95% CI 1.46-6.35) and MAP SD <8 mm Hg (aOR 2.28, 95% CI 1.24-4.25) were associated with favorable outcome. Significant interactions with collateral status were observed for MAP SD <8 mm Hg, SBP SD <12 mm Hg, MAP drop >20%, and minimum MAP and SBP (all pinteraction < 0.05). After Holm-Bonferroni correction, only the interaction between collateral status and MAP <80 mm Hg remained significant (corrected pinteraction = 0.036). In patients with unfavorable collateral status, MAP <80 mm Hg was associated with decreased probability of favorable outcome (aOR 0.04, 95% CI 0.00-0.21) while this association was not observed in patients with favorable collaterals.

DISCUSSION

For patients with BAO undergoing EVT, intraprocedural MAP between 80 and 110 mm Hg was associated with favorable outcome while MAP <80 mm Hg was associated with a lower probability of favorable outcome, especially in patients with unfavorable collateral status.

Feasibility of emergent single-step intracranial self-expanding stent deployment using over-the-wire coronary balloons in intracranial atherosclerosis-related large vessel occlusion thrombectomy

BACKGROUND

The currently US Food and Drug Administration approved intracranial stent delivery system involves a multistep deployment process that requires the use of an exchange length microwire (ELW). In this study, we describe a single-step approach to deploy the Neuroform Atlas stent without the need for ELW or lesion re-access, using the MINI TREK II over-the-wire (OTW) semi-compliant coronary balloon.

METHODS

We performed a retrospective review of prospectively maintained mechanical thrombectomy databases from two comprehensive stroke centers. The study included consecutive large vessel occlusion (LVO) stroke patients who underwent single-step angioplasty with the MINI TREK II OTW balloon followed by deployment of the Neuroform Atlas intracranial stent, without the use of an ELW.

RESULTS

A total of 12 patients met the inclusion criteria. Among them, the median age was 67 years (IQR: 58-73) and 50% were female. Most patients had middle cerebral artery (MCA) M1 occlusion (75%). One-third of the patients received intravenous thrombolysis. All patients achieved successful reperfusion (modified Treatment in Cerebral Ischemia (mTICI) 2b/3) with a median of two passes. The median National Institutes of Health Stroke Scale (NIHSS) score decreased from 14 (IQR: 10-19) at baseline to 4 (IQR: 1-9) at discharge, and the median modified Rankin Scale (mRS) score was 1 (IQR: 1-4) at discharge and 3 (IQR: 2-4) at 90 days. None of the patients in this series experienced symptomatic intracranial hemorrhage, though two patients (16.7%) were dead at 90 days but there was no procedural-related mortality.

CONCLUSIONS

This preliminary experience demonstrates the technical feasibility and success of single-step deployment of the Neuroform Atlas stent following angioplasty with the MINI TREK II OTW balloon, without the need for an ELW or lesion re-access. Larger prospective studies with extended clinical follow-up are needed to validate these findings.

Advances in treatments for acute ischemic stroke

Acute ischemic stroke is a leading global cause of death and disability. Intravenous thrombolysis was the first acute treatment developed for ischemic strokes. First with alteplase and now with tenecteplase, intravenous thrombolysis has remained a cornerstone of acute ischemic stroke management. In large vessel occlusions, endovascular thrombectomy has become the standard of care in acute stroke management for anterior and posterior circulation strokes. The boundaries for these treatments have expanded, which has improved outcomes in patients who were previously ineligible. This review summarizes the latest advances in interventions for acute ischemic stroke, extending beyond existing guidelines and review articles to explore emerging strategies and treatments currently under investigation.

Comparing Early National Institutes of Health Stroke Scale Versus 90-Day Modified Rankin Scale Outcomes in Acute Ischemic Stroke Trials: A Systematic Review and Analysis

BACKGROUND

Early National Institutes of Health Stroke Scale (NIHSS) assessment may provide practical benefits over 90-day modified Rankin Scale (mRS), but it is unclear how it compares in adjudicating randomized clinical trial (RCT) results in acute ischemic stroke.

METHODS AND RESULTS

We searched Ovid Medline (inception to April 1, 2023) and included RCTs of acute therapies for acute ischemic stroke with data for both 90-day mRS and NIHSS within 7 days. Primary outcome was agreement between trial results (classified as positive, negative, or neutral) based on 24-hour NIHSS and 90-day mRS scores. We additionally assessed agreement for 2-hour, 48-hour, 72- to 96-hour, and 5- to 7-day NIHSS scores. We aimed to validate our findings using individual patient data from the ESCAPE (Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke) and ESCAPE-NA1 (Safety and Efficacy of Nerinetide [NA-1] in Subjects Undergoing Endovascular Thrombectomy for Stroke) RCTs. We included 116 trials (44 387 patients), contributing 165 NIHSS assessments. The 24-hour NIHSS scores resulted in the same classification as 90-day mRS scores in 61/73 (83.6%) trials (Cohen's kappa, 0.64 [95% CI: 0.45-0.83] and Gwet's agreement coefficient 1, 0.79 [95% CI: 0.67-0.90]). Agreement was not statistically different by timing of NIHSS assessments (range 75%-100%, P=0.33). Individual patient data showed higher agreement for assessments between 48 hours and 7 days, varying by NIHSS dichotomization cutoffs (NIHSS score, 0-2; 2 hours, 56.6%; 24 hours, 66.6%; 48 hours, 71.8%; 5-7 days: 76.5%, P<0.01; NIHSS score, 0-7; 2 hours, 72.8%; 24 hours, 80.5%; 48 hours, 83.1%; 5-7 days: 84.7%, P<0.01).

CONCLUSIONS

The 24-hour NIHSS scores aligned with 90-day mRS scores in 84% of RCT results, indicating intermediate-to-good agreement. However, individual patient data showed that early NIHSS risks misclassifying around 1/4 patients. These data contribute to a better understanding of the nuances of early NIHSS score as an outcome in acute ischemic stroke RCTs.

Thrombectomy Selection in the Large Core Era: Implications for Regional Transfers

PURPOSE OF REVIEW

This review aims to evaluate recent advances in large core stroke management with a focus on diagnostic imaging protocols to select patients for endovascular therapy.

RECENT FINDINGS

Recent randomized controlled trials have shown that thrombectomy can lead to favorable outcomes in patients with large infarcts, contradicting previous assumptions that thrombectomy was not indicated in such patients due to higher risks and very low benefits. Although mechanical thrombectomy remains the gold standard of medical treatment for large vessel occlusions with demonstrated salvageable brain tissue, analysis of the results of recent randomized trials in patients with large ischemic stroke should help us expand patient selection, optimize timing, and explore different management modalities to improve the outcomes of therapy in these patients.

Rescue intracranial stenting for failed mechanical thrombectomy of vertebrobasilar occlusions: a pooled analysis from the French and German national stroke registries

BACKGROUND

Whether rescue intracranial stenting (RIS) should be performed in patients with vertebrobasilar occlusions (VBO) refractory to endovascular mechanical thrombectomy (MT) remains an open question.

METHODS

We conducted a pooled analysis using data from two national stroke registries, the Endovascular Treatment in Ischemic Stroke registry in France, and the German Stroke Registry-Endovascular Treatment. Patients with VBO who underwent RIS for failed MT, defined as a modified treatment in cerebral infarction (mTICI) score of 0 to 2a after MT, from January 2015 to December 2023 were included. The primary outcome was a modified Rankin Scale (mRS) score of 0-3 at 90 days. Secondary outcomes included mRS distribution and mortality at 90 days, any intracranial hemorrhage (ICH) and symptomatic intracranial hemorrhage (sICH). Propensity score matching and inverse propensity weighting were employed to balance baseline differences.

RESULTS

Among 2028 patients, 307 (15.1%) patients had MT-refractory VBO. Of these, 127 (41.4%) underwent RIS and 180 (58.6%) patients no RIS. After propensity score matching, two balanced groups were obtained: 106 patients with RIS and 99 without RIS. Patients who underwent RIS had higher odds of achieving an mRS 0-3 (adjusted odds ratio (aOR) 3.45, 95% confidence interval (CI) 1.27 to 9.34. P=0.014), a favorable shift across the mRS distribution (aOR 2.55 per 1-point mRS improvement, 95% CI 1.22 to 5.34; P=0.013) and lower odds of 90-day mortality (aOR 0.26, 95% CI 0.09 to 0.71; P=0.008). There were no significant differences in any ICH and sICH.

CONCLUSION

This registry-based study provides level 3 evidence supporting the use of RIS in patients with VBO refractory to MT. Prospective randomized trials are necessary to validate the potential benefits of RIS in this condition.

Comparative effectiveness of intra-arterial thrombolysis vs. mechanical thrombectomy: a literature review

Background

Acute ischemic stroke (AIS) remains one of the leading causes of morbidity and mortality worldwide. Time is the single most critical factor in the management of patients presenting with AIS, where re-opening of occluded blood vessels is paramount. Intra-arterial thrombolysis (IAT) and mechanical thrombectomy (MT) are two such therapies employed to reestablish cerebrovascular blood flow in patients with AIS. This review compares both IAT and MT according to their efficacy, safety profiles, recanalization rates, clinical outcomes, and adverse procedural events.

Methods

Study abstraction from electronic search databases comprising PubMed/MEDLINE, ResearchGate, and the National Library of Medicine was used. Screening and selection of relevant articles were comprehensively conducted for this review. Direct comparisons between IAT and MT in terms of variables including recanalization rates, clinical outcomes, and adverse procedural events were warranted for study inclusion. Research determined to exhibit insufficient data or without comparable groups were subsequently excluded.

Results

MT was prompter when executing procedures than IAT, achieving greater rates of recanalization. Both interventions displayed similar results regarding rates of symptomatic intracranial hemorrhage (sICH) and mortality. Despite current available data indicating MT to demonstrate more efficiency as a procedure, further research is needed to examine IAT in light of specific patient demographics, clinical presentation, and circumstances.

Conclusion

This review elucidated that MT often takes less time peri-procedurally, achieving greater success in revascularization compared with that of IAT. Regarding mortality and sICH rates, IAT and MT comparison showed equivocal results. Thus, while making therapeutic decisions, it is important to consider the unique clinical features of each patient as well as the timing of interventions in order to maximize treatment outcomes.

Single-cell and spatial transcriptomics analysis reveals that Pros1+ oligodendrocytes are involved in endogenous neuroprotection after brainstem stroke

BACKGROUND

Brainstem stroke accounts only 7-10 % of all ischemic stroke while it had more morbidity and mortality. As the predominant cellular component of nerve tracts, oligodendrocytes might provide some neuroprotection against ischemic injury in the context of brainstem stroke, but the underlying mechanism remains unclear.

METHOD

A mouse model of brainstem stroke was established, and single-cell RNA sequencing and spatial transcriptomic sequencing analysis were performed to elucidate the phenotype of oligodendrocytes within this context.

RESULTS

Loss of oligodendrocytes led to neurological impairment following brainstem stroke, and subsequent proliferation of oligodendrocytes was observed. We identified a subcluster of Pros1+ oligodendrocytes, designated OLG8 cells. These cells increased in number after brainstem stroke and were enriched around the peri-infarct zone. OLG8 cells were derived from oligodendrocyte progenitor cells, and this process was found to be regulated by Myo1e. We found that OLG8 cells protected interneurons. Notably, the overexpression of Myo1e within OLG8 cells led to a marked reduction in infarct volume while simultaneously improving the recovery of neurological function.

CONCLUSION

In conclusion, we identified a novel cell subcluster, OLG8 cells, in the context of brainstem stroke, and found that overexpression of Myo1e alleviated ischemic injury by facilitating the differentiation of OLG8 cells. Our study provided insight into the mechanism of brainstem stroke.

Predicting clinical outcome in posterior circulation large-vessel occlusion patients with endovascular recanalisation: the GNC score

BACKGROUND AND PURPOSE

Acute ischaemic strokes caused by posterior circulation large-vessel occlusions (pc-LVOs) are associated with particularly poor prognoses, including significant disability and mortality rates. This study sought to develop and validate a novel scoring system for predicting functional outcomes in pc-LVO cases following successful endovascular recanalisation.

METHODS

We derived a predictive model from the DETECT-China cohort and externally validated it using the DETECT2-China dataset. Poor outcome was defined as a modified Rankin Scale score of 4-6 at 90 days. Cerebral circulation time (CCT), measured via digital subtraction angiography (DSA), served as a key predictor. Multivariable logistic regression was employed to construct the scoring system.

RESULTS

The training cohort comprised 92 patients, of whom 52 (56.5%) experienced poor outcomes. Multivariate analysis identified prolonged CCT (adjusted OR (aOR) 1.365; 95% CI 1.105 to 1.686; p=0.004), elevated admission National Institutes of Health Stroke Scale (NIHSS) (aOR 1.235; 95% CI 1.120 to 1.363; p<0.001) and higher blood glucose levels (aOR 1.345; 95% CI 1.023 to 1.769; p=0.034) as independent predictors. These variables were integrated into the GNC score (Glucose-NIHSS-CCT). The GNC score demonstrated excellent predictive performance for clinical outcome, good discrimination and calibration in this cohort, as well as the bootstrap validation. Importantly, the excellent performance of this score was further validated in DETECT2-China.

CONCLUSIONS

This is the first report that CCT based on DSA is an independent prognostic marker in pc-LVO patients with successful recanalisation post-endovascular treatment. The GNC score, incorporating readily available clinical and angiographic parameters, offers a reliable tool for outcome prediction in this high-risk population.

Magnitude of systolic blood pressure reduction following endovascular treatment and clinical outcomes in acute large artery occlusion stroke

BACKGROUND

The impact of lowering systolic blood pressure (SBP) following endovascular treatment (EVT) in acute large vessel occlusion stroke (LVOS) patients remains unclear. We aimed to explore the effect of the magnitude of SBP reduction (SBPr) after EVT on outcomes in LVOS patients.

METHODS

We consecutively registered patients at three comprehensive stroke centres who had experienced EVT as a result of acute anterior circulation LVOS. SBPr was calculated as follows: (baseline SBP-mean SBP/baseline SBP)×100%. The 90-day modified Rankin Scale score ranging from 0 to 2 was defined as a favourable functional outcome. Based on CT scans obtained within 24 hours after procedure, symptomatic intracranial haemorrhage (sICH) was assessed according to the criteria of the European Cooperative Acute Stroke Study III.

RESULTS

We enrolled 1080 patients, of which 908 (84.1%) had successful recanalisation. In the overall cohort, SBPr was correlated with lower odds of sICH (SBPr±10% as a reference, 20%-30%: OR 0.460; 95% CI: 0.245 to 0.864; p=0.016; >30%: OR 0.304; 95% CI 0.123 to 0.749; p=0.010). In patients who achieved successful reperfusion, SBPr>30% was correlated with higher odds of a poor outcome (SBPr±10% as a reference, OR 2.150; 95% CI 1.268 to 3.645; p=0.004) and SBPr has a similar tendency towards reducing the incidence of sICH. In the subgroup analyses, baseline Alberta Stroke Programme Early CT (ASPECT) score (pinteract=0.024) modified the effect of SBPr on the 90-day outcome.

CONCLUSION

Among patients with EVT, a significant drop in SBP may be related to a poor functional outcome and a reduced incidence of sICH. Baseline ASPECT score may be an important interacting factor in the association of SBPr with the 90-day outcome. This study provides new insights for individualised BP management in patients with EVT.

One-Year Outcome After Endovascular Thrombectomy for Basilar Artery Occlusion With Mild Deficits

BACKGROUND

The long-term benefits of endovascular thrombectomy (EVT) for basilar artery occlusion (BAO) in patients with low National Institutes of Health Stroke Scale scores upon admission remain unclear. This study aimed to compare the 1-year clinical follow-up outcomes of best medical management (BMM) alone versus BMM plus EVT.

METHODS

Patients with BAO and admission National Institutes of Health Stroke Scale score of ≤10 at 65 stroke centers in China from December 2015 to June 2022 were retrospectively enrolled. The primary outcome was favorable functional outcome (a modified Rankin Scale score of 0-3 at 1 year). Early (door-to-puncture time ≤120 minutes) and late EVT (door-to-puncture time >120 minutes) classifications were defined as surrogates for comparing initial treatment with EVT versus late (potentially rescue) EVT after initially being treated with BMM only. Multivariable logistic regression and propensity score matching analyses were used to assess the association between treatment and outcomes.

RESULTS

Among 1232 patients who had 1-year follow-up data, 856 (69.5%) were male, and the mean (SD) age was 65 (12) years. After adjustment for confounders, there were no significant differences between EVT and BMM in favorable functional outcome (odds ratio, 0.96 [95% CI, 0.71-1.29]; P=0.778). The cumulative 1-year mortality rate was 16.4% in the EVT group versus 13.7% in the BMM group (odds ratio, 1.23 [95% CI, 0.86-1.77]; P=0.262). Predefined subgroup analyses revealed that late EVT was inferior to early EVT (odds ratio, 0.47 [95% CI, 0.28-0.79]; P=0.005), while no significant difference was observed between BMM and early EVT in 1-year outcomes (odds ratio, 0.87 [95% CI, 0.63-1.21]; P=0.421).

CONCLUSIONS

In this long-term follow-up study among patients with BAO admitted with a National Institutes of Health Stroke Scale score of ≤10, there were no significant differences in functional outcomes and mortality at 1 year between BMM plus EVT and BMM alone.

Accuracy and usefulness of dual-energy computed tomography after mechanical thrombectomy: A retrospective study

PURPOSE

Hemorrhagic complications are serious concern following mechanical thrombectomy (MT), making early identification crucial. Dual Energy Computed Tomography (DECT)is considered a potentially effective tool for postoperative evaluation, as it minimizes the effects of contrast leakage. This study examined the accuracy and usefulness of the results.

METHODS

We retrospectively identified 118 patients who had DECT immediately after MT at our institution between April 2020 and March 2024. Follow-up imaging with either CT or Magnetic Resonance Imaging was conducted the day after MT to evaluate consistency with the immediate postoperative DECT findings.

RESULTS

Of the 118 cases, 39 were suspected to have bleeding based on immediate postoperative DECT, and 37 of these were confirmed to have actual bleeding on imaging evaluation the day after MT. Two cases were false positive on DECT. On the other hand, there was one case that bleeding was not initially suspected on immediate postoperative DECT, but was later identified on subsequent imaging. The overall sensitivity and specificity of DECT were 97.4 % and 97.5 %, respectively.

CONCLUSIONS

Immediate postoperative DECT demonstrated high reliability, with excellent sensitivity and specificity. DECT may serve as an effective indicator for secondary prevention management and blood pressure control during the immediate postoperative period following MT.

Predictors of Futile Recanalization in Patients With Basilar Artery Occlusion With Large Versus Nonlarge Infarcts

BACKGROUND

Basilar artery occlusion is associated with high rates of disability and mortality, and despite advances in endovascular treatment, futile recanalization remains a challenge. This study aims to identify predictors of futile recanalization in patients with basilar artery occlusion, focusing on large and nonlarge infarcts.

METHODS AND RESULTS

This multicenter retrospective study included patients from 65 centers across China. Patients were categorized based on posterior circulation Alberta Stroke Program Early CT [Computed Tomography] Score (pc-ASPECTS) into 2 groups: large infarcts (pc-ASPECTS ≤6) and nonlarge infarcts (pc-ASPECTS >6). Predictors of futile recanalization-defined as a modified Rankin Scale score of 4 to 6 at 90 days despite successful recanalization-were analyzed using logistic regression models. Among the 2075 patients, 1113 (53.6%) experienced futile recanalization. In patients with pc-ASPECTS >6, predictors of futile recanalization included older age (odds ratio [OR], 1.18 [95% CI, 1.06-1.31]), higher National Institute of Health Stroke Scale scores (OR, 1.75 [95% CI, 1.58-1.94]), and prolonged time from puncture to reperfusion (OR, 1.24 [95% CI, [1.12-1.38]). Intravenous thrombolysis (OR, 0.85 [95% CI, [0.77-0.94]) and achieving modified Thrombolysis in Cerebral Infarction grade 3 (OR, 0.81 [95% CI, [0.74-0.90]) were associated with a lower likelihood of futile recanalization. In patients with pc-ASPECTS ≤6, being male (OR, 0.75 [95% CI, 0.58-0.96]) and having higher pc-ASPECTS scores (OR, 0.65 [95% CI, 0.48-0.85]) were protective against futile recanalization, whereas higher National Institute of Health Stroke Scale scores increased the risk (OR, 1.81 [95% CI, 1.42-2.32]).

CONCLUSIONS

This study identifies distinct predictors of futile recanalization in patients with basilar artery occlusion based on infarct size. The findings underscore the importance of individualized treatment strategies and timely intervention to optimize endovascular treatment outcomes in high-risk patients.

Intravenous thrombolysis before endovascular treatment in acute vertebrobasilar occlusions: Pooled analysis of the French and German Stroke Registries

INTRODUCTION

Whether intravenous thrombolysis (IVT) provides additional benefit in eligible patients with acute vertebrobasilar occlusion who undergo endovascular treatment (EVT) remains an open question.

PATIENTS AND METHODS

We conducted a pooled analysis using data from two national stroke registries, the ETIS registry in France and GSR-ET registry in Germany. Patients who underwent EVT for vertebral and/or basilar artery occlusions from January 2015 to December 2023 were included. The primary efficacy outcome was a favorable shift toward better functional outcomes on modified Rankin Scale (mRS) scores at 90 days. Safety outcomes included 90-days mortality and symptomatic haemorrhagic transformation (sICH). Comparisons between IVT + EVT and direct EVT groups were made combining inverse propensity score matching, probability of treatment weighting (IPTW) and regression models.

RESULTS

Among 2028 patients treated during the study period, 797 (39.2%) received IVT before EVT, while 1231 (60.7%) had EVT alone. After IPTW matching, we compared 211 patients treated with IVT + EVT to 260 direct EVT patients. Patients in the IVT + EVT group had a favorable shift across the 90-day mRS distribution (common aOR 1.43 per 1-point mRS improvement, 95% CI 1.01-2.04; p = 0.046), higher odds of 90-day favorable functional outcome (aOR 1.56, 95% CI 1.00-2.44; p = 0.049) and lower odds of 90-day mortality (aOR 0.62, 95% CI 0.39-0.99; p = 0.045). IVT was not associated with increased risk of sICH (aOR 1.65, 95% CI 0.62-4.35; p = 0.313).

DISCUSSION

This registry-based study suggests a potential benefit of IVT before EVT in eligible patients with vertebrobasilar occlusions. Conclusion: Randomized clinical trials are necessary to confirm these findings and to validate the benefits of IVT in this clinical context.

Advances in endovascular thrombectomy for the treatment of acute ischemic stroke

INTRODUCTION

Acute ischemic stroke (AIS) is the second leading cause of death and one of the leading causes of long-term disability globally. Endovascular thrombectomy (EVT) has revolutionized treatment for large vessel occlusion (LVO), providing 20% increase in post-stroke functional independence compared to intravenous thrombolysis (IVT) alone. Despite its proven efficacy, EVT is underutilized. While it is suitable for at least 15-20% of AIS patients, its mean adoption ranges from less than 1% to 7% in different areas.

AREAS COVERED

This review highlights key findings from pivotal randomized controlled trials and real-world data, focusing on patient selection criteria, advancements in thrombectomy devices, and procedural innovations. A comprehensive literature search was performed using PubMed, Scopus, EMBASE and the Cochrane Library for relevant randomized controlled trials and observational studies.

EXPERT OPINION

Disparity in access to EVT requires strategic investments in healthcare systems and international multidisciplinary collaboration. Enhancing geographic coverage with thrombectomy-capable centers and optimizing prehospital triage systems are essential. Bridging the gap between treatment capability and real-world implementation is critical to improving global AIS outcomes.

Clinical research progress on pathogenesis and treatment of Patent Foramen Ovale-associated stroke

Patent Foramen Ovale (PFO), a common cardiac abnormality, has been established as the most prevalent cause of Cryptogenic Stroke (CS). In 2022, the American Society of Cardiovascular Angiography and Interventions (SCAI) officially defined PFO-induced CS as PFO-Associated Stroke (PFO-AS), whose onset characteristics and treatment methods are currently the focus of pertinent clinical research. Previously, the pathogenesis of PFO-AS was commonly believed to be related to Paradoxical Embolism (PDE) or in situ thrombosis. Recently, atrial heart disease, which could lead to abnormal cardiac structure and circulating biomarker accumulation, potentially causing vascular endothelial injury and promoting thrombosis, has also been associated with the pathogenesis of PFO-AS. Therefore, PFO-AS could be the outcome of multiple pathogenesis mechanisms. Furthermore, significant research progress has been made in elucidating the pathogenic PFO gene. Nonetheless, additional in-depth research is still required to better elucidate the precise mechanisms underlying PFO-AS. Notably, the clinical and imaging characteristics of PFO-related Ischemic Stroke (IS) are slightly different from those of other IS causes. Furthermore, the assessment of the correlation between PFO and stroke mostly relies on The Risk of Paradoxical Embolism Score (RoPE) and PFO-Associated Stroke Causal Likelihood classification (PASCAL) system, which could be a limitation. Additionally, PFO examinations mainly relied on cardiac anatomy evaluation in the past, highlighting another potential gap. Moreover, recent research suggests that PFO closure may increase the risk of Heart Failure (HF) with preserved Ejection Fraction (HFpEF). Conversely, after 2017, four Randomized Controlled Trials (RCTs): CLOSE, RESPECT, REDUCE, and DEFENSE-PFO, demonstrated that transcatheter PFO closure is more effective in preventing various risk events than conventional pharmacotherapy. This review comprehensively summarizes the latest research progress on PFO-AS pathogenesis, treatment, prevention, and management decisions, providing a valuable clinical reference.

Endovascular Treatment for Stroke Due to Occlusion of Medium or Distal Vessels

BACKGROUND

Endovascular treatment (EVT) of stroke with large-vessel occlusion is known to be safe and effective. The effect of EVT for occlusion of medium or distal vessels is unclear.

METHODS

We randomly assigned participants with an isolated occlusion of medium or distal vessels (occlusion of the nondominant or codominant M2 segment of the middle cerebral artery [MCA]; the M3 or M4 segment of the MCA; the A1, A2, or A3 segment of the anterior cerebral artery; or the P1, P2, or P3 segment of the posterior cerebral artery) to receive EVT plus best medical treatment or best medical treatment alone within 24 hours after the participant was last seen to be well. The primary outcome was the level of disability at 90 days, as assessed with the modified Rankin scale score.

RESULTS

A total of 543 participants (women, 44%; median age, 77 years) were included in the analysis: 271 were assigned to receive EVT plus best medical treatment and 272 to receive best medical treatment alone. The median score on the National Institutes of Health Stroke Scale (range, 0 to 42, with higher scores indicating more severe symptoms) at admission was 6 (interquartile range, 5 to 9). Intravenous thrombolysis was given to 65.4% of the participants. The predominant occlusion locations were the M2 segment (in 44.0% of the participants), M3 segment (in 26.9%), P2 segment (in 13.4%), and P1 segment (in 5.5%). In the comparison between EVT plus best medical treatment and best medical treatment alone, no significant difference in the distribution of modified Rankin scale scores was observed at 90 days (common odds ratio for improvement in the score, 0.90; 95% confidence interval, 0.67 to 1.22; P = 0.50). All-cause mortality was similar in the two groups (15.5% with EVT plus best medical treatment and 14.0% with best medical treatment alone), as was the incidence of symptomatic intracranial hemorrhage (5.9% and 2.6%, respectively).

CONCLUSIONS

In persons with stroke with occlusion of medium or distal vessels, EVT did not result in a lower level of disability or a lower incidence of death than best medical treatment alone. (Funded by the Swiss National Science Foundation and others; DISTAL ClinicalTrials.gov number, NCT05029414.).

Predictors of successful recanalization following endovascular intervention in non-acute basilar artery occlusion

Objective

This study aims to identify factors influencing successful recanalization following endovascular intervention for non-acute basilar artery occlusion (NABAO).

Background

Endovascular treatment (EVT) is a feasible approach for treating non-acute basilar artery occlusion, but it presents significant technical challenges due to the lack of standardized treatment protocols. Therefore, identifying patients most likely to benefit is critical to minimizing procedural risks.

Methods

A retrospective analysis was conducted on 115 patients with NABAO treated via EVT. Factors associated with successful recanalization, including clinical symptoms, demographic characteristics, procedural outcomes, and imaging findings, were analyzed using multivariate analysis. A scoring system was developed based on independent predictors.

Results

Successful recanalization (defined as modified Thrombolysis in Cerebral Infarction [mTICI] ≥2b) was achieved in 81.7% (94/115) of cases. Multivariate analysis revealed that occlusion duration >3 months (odds ratio [OR]: 0.187, 95% confidence interval [CI]: 0.051-0.688, p = 0.012), blunt-shaped occlusion ends (OR: 0.236, 95% CI: 0.072-0.777, p = 0.018), occlusion length > 30 mm (OR: 0.144, 95% CI: 0.031-0.669, p = 0.013), and insufficient or absent distal compensation (OR: 0.25, 95% CI: 0.075-0.835, p = 0.024) were independent predictors of reduced technical success. The receiver operating characteristic (ROC) curve index for the scoring system, based on these independent predictors, was 0.817 (95% CI: 0.698-0.936, p < 0.001), with a sensitivity of 71.4% and a specificity of 85.4% at a cutoff of 2.5 points.

Conclusion

Longer occlusion duration (>3 months), blunt-shaped occlusion ends, occlusion length > 30 mm, and insufficient distal collateral compensation are independent negative predictors for successful recanalization in patients with NABAO treated via EVT. The proposed scoring system can help screen patients suitable for treatment and optimize treatment strategies, but further validation in prospective cohorts is needed.

Alteplase for Posterior Circulation Ischemic Stroke at 4.5 to 24 Hours

BACKGROUND

The effects and risks of the use of intravenous thrombolysis between 4.5 and 24 hours after the onset of a posterior circulation ischemic stroke are not well studied.

METHODS

In a trial conducted in China, we randomly assigned patients with posterior circulation stroke, without extensive early hypodensity on computed tomography and with no planned thrombectomy, to receive alteplase (0.9 mg per kilogram of body weight; maximum dose, 90 mg) or standard medical treatment 4.5 to 24 hours after the onset of symptoms. The primary outcome was functional independence (defined as a score of 0 to 2 on the modified Rankin scale; scores range from 0 to 6, with higher scores indicating greater disability) at 90 days. The key safety outcomes were symptomatic intracranial hemorrhage and death.

RESULTS

A total of 234 patients were enrolled; 117 were assigned to the alteplase group and 117 to the standard-treatment group. The median score on the National Institutes of Health Stroke Scale was 3 (interquartile range, 2 to 6) (scores range from 0 to 42, with higher scores indicating greater neurologic deficit). A higher percentage of patients in the alteplase group than in the standard-treatment group had functional independence at 90 days (89.6% vs. 72.6%; adjusted risk ratio, 1.16; 95% confidence interval [CI], 1.03 to 1.30; P = 0.01). The incidence of symptomatic intracranial hemorrhage within 36 hours was 1.7% in the alteplase group and 0.9% in the standard-treatment group. At 90 days, 5.2% of the patients in the alteplase group and 8.5% of those in the standard-treatment group had died.

CONCLUSIONS

Among Chinese patients with mainly mild posterior circulation stroke who did not receive thrombectomy, alteplase administered 4.5 to 24 hours after stroke onset resulted in a higher frequency of functional independence at 90 days than standard medical care. (Funded by the National Natural Science Foundation of China; EXPECTS ClinicalTrials.gov number, NCT05429476.).

Thrombectomy Alone or Alongside Intravenous Thrombolysis in Managing Acute Ischemic Stroke Caused by Basilar Artery Occlusion: A Multicenter Observational Study

BACKGROUND AND PURPOSE

It remains unclear whether the combination of endovascular treatment (EVT) with intravenous thrombolysis (IVT) results in a more favorable functional outcome than EVT alone in managing cases of acute ischemic stroke (AIS) caused by basilar artery occlusion (BAO). Thus, this study aimed to compare the outcomes of 2 approaches-direct endovascular treatment (DEVT) and bridging therapy (IVT plus EVT)-in patients with acute BAO presenting within 4.5 hours of stroke onset.

MATERIALS AND METHODS

This multicenter retrospective cohort study included 153 patients with acute BAO presenting within 4.5 hours of stroke onset. Of these patients, 65 (42.5%) and 88 (57.5%) underwent DEVT and bridging therapy, respectively. The primary outcome was defined as good functional outcome (mRS, 0-3) at 90 days. Additionally, preoperative clinical features, thrombectomy attempts, successful reperfusion rates, incidences of symptomatic intracranial hemorrhage (sICH), and mortality were compared between the 2 groups.

RESULTS

At 90 days, the rate of good functional outcome was comparable between the DEVT (44.6%) and bridging-therapy (39.8%) groups (adjusted odds ratio [aOR], 1.12; 95% CI, 0.55-2.31; P = .753). The bridging-therapy group exhibited a lower percentage of patients requiring ≥3 attempts of stent retrieval (aOR, 0.39; 95% CI, 0.16-0.93; P = .034). Preoperative clinical features, rate of successful reperfusion, sICH, and mortality were similar between the 2 groups.

CONCLUSIONS

In patients with BAO-induced AIS, DEVT demonstrates a comparable functional outcome to bridging therapy within 4.5 hours of symptom onset, but IVT reduces the number of thrombectomy attempts.

Impact of Intracranial Hemorrhage After Endovascular Treatment for Medium Vessel Occlusion

BACKGROUND AND OBJECTIVES

Endovascular treatment (EVT) for medium vessel occlusion (MeVO) raises concern about hemorrhagic complications; however, its clinical impact has not been elucidated. Therefore, we investigated the association between intracranial hemorrhage (ICH) after EVT for MeVO and functional outcomes.

METHODS

We conducted a post hoc analysis of the Japan Registry of NeuroEndovascular Therapy 4, a nationwide registry in Japan from 2015 to 2019 including 13 479 patients who underwent EVT for acute ischemic stroke. This study included 2465 patients with MeVO from 166 participating centers in Japan. We compared patients who underwent EVT for MeVO according to their hemorrhagic complication after EVT (no ICH, asymptomatic ICH, and symptomatic ICH). Outcomes included a modified Rankin scale (mRS) score at 30 days and all-cause mortality within 30 days. We estimated the odds ratios (ORs) and their CIs using a multivariable logistic regression model.

RESULTS

Among 2394 patients analyzed, 302 (12.6%) developed ICH, with 95 (31.5%) being symptomatic. Compared with the no-ICH group (n = 2092), the asymptomatic and symptomatic ICH groups had a lower proportion of patients with an mRS score of 0 to 2 at 30 days (41% vs 34%, vs 7.4%, P for trend <.001), with an adjusted ORs of 0.77 (95% CI, 0.53-1.12) and 0.12 (95% CI, 0.05-0.30) in the asymptomatic and symptomatic ICH groups, respectively. The adjusted common ORs of one-point shift of mRS score at 30 days in the asymptomatic ICH group was 0.76 (95% CI, 0.57-0.99) and that of the symptomatic ICH group was 0.13 (0.07-0.23), compared with the no-ICH group.

CONCLUSION

ICH after EVT for MeVO was associated with worse outcomes, whether they were symptomatic or not. The optimal treatment devices or techniques to reduce ICH after EVT for MeVO are crucial.

Clinical and subclinical acute brain injury caused by invasive cardiovascular procedures

Over the past 50 years, the number and invasiveness of percutaneous cardiovascular procedures globally have increased substantially. However, cardiovascular interventions are inherently associated with a risk of acute brain injury, both periprocedurally and postprocedurally, which impairs medical outcomes and increases health-care costs. Current international clinical guidelines generally do not cover the area of acute brain injury related to cardiovascular invasive procedures. In this international Consensus Statement, we compile the available knowledge (including data on prevalence, pathophysiology, risk factors, clinical presentation and management) to formulate consensus recommendations on the prevention, diagnosis and treatment of acute brain injury caused by cardiovascular interventions. We also identify knowledge gaps and possible future directions in clinical research into acute brain injury related to cardiovascular interventions.

Endovascular treatment of vertebrobasilar ischaemic stroke in Aragon: clinical and radiological characteristics, management times, and prognosis at 3 months

INTRODUCTION

Posterior circulation stroke accounts for 15% to 20% of ischaemic strokes, but is associated with poor functional and vital prognosis in over 60% of cases. Due to its clinical and radiological peculiarities, diagnosis and management are more complex than in anterior circulation stroke. This study analyses and characterises patients with vertebrobasilar strokes treated with mechanical thrombectomy in our region.

METHODS

We conducted a descriptive, retrospective analysis of patients with vertebrobasilar stroke and treated with mechanical thrombectomy at our centre, a reference centre for cerebrovascular emergencies for the region of Aragon. We recorded baseline characteristics, risk factors, signs and symptoms at onset, radiological assessment scale scores, procedure-related variables, management times, and functional prognosis at 3 months.

RESULTS

We selected 37 patients (39.5% women; mean age [standard deviation], 68.34 [14.1] years). Cardioembolic stroke (42.1%) was the most common aetiology, followed by atherothrombosis (28.9%). The top of the basilar artery was the most common site of obstruction (55.3%). The most frequent clinical features were somnolence (76.3%), motor deficits (71.1%), and nausea (55.3%). Successful reperfusion (mTICI ≥ 2b) was achieved in 81.1% of patients. Functional outcome at 90 days was poor (mRS < 3) in 59% of patients.

CONCLUSIONS

Posterior circulation stroke is associated with high rates of morbidity and mortality. Its subacute, nonspecific clinical course prolongs management times and hinders early detection. Mechanical thrombectomy is a safe and effective procedure, although further studies are needed to establish the optimal patient profile.

Prospective evaluation of modified Cincinnati Prehospital Stroke Severity Scale for identifying large vessel occlusion

OBJECTIVE

To develop a novel, straightforward diagnostic scale for predicting large vessel occlusion (LVO) and anterior circulation LVO (ALVO) in the emergency setting, evaluating its validity against existing scales.

METHODS

We prospectively enrolled patients with suspected stroke presenting consecutively at the National Comprehensive Stroke Centre's emergency department between February 20, 2022, and November 11, 2022. Emergency physicians assessed each patient using the modified Cincinnati Prehospital Stroke Severity Scale (mCPSSS) and the National Institutes of Health Stroke Scale (NIHSS). The study analyzed the mCPSSS and other prevalent stroke scales to evaluate their efficacy in detecting LVO and ALVO, employing receiver operating characteristic curve (ROC) analysis and area under the curve (AUC) statistics to assess the scales' sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy.

RESULTS

A total of 383 patients with suspected stroke were included in this study. The performance in identifying LVO in the emergency setting was greatest for mCPSSS ≥ 2 with a sensitivity of 0.802 and specificity of 0.770, PPV of 0.644, NPV of 0.882, and accuracy of 0.781. mCPSSS ≥ 2 was 0.766 sensitive, 0.733 specific, PPV of 0.564, NPV of 0.886, and accuracy of 0.749 in predicting ALVO. The mCPSSS identified LVO and ALVO with an optimal cut-off value of 2, exhibiting AUC superior to those of other widely used stroke scales, with AUC values of 0.824 for LVO and 0.790 for ALVO.

CONCLUSION

The mCPSSS could serve as an effective and straightforward scale for identifying LVOs in emergency settings.

CLINICAL TRIAL REGISTRATION INFORMATION

https://www.chictr.org.cn/ (ChiCTR2200056776).

Predictors and outcomes of first pass efficacy in posterior circulation strokes: Insights from STAR collaboration

Background: First-pass efficacy (FPE) has been established as an important predictor of favorable functional outcomes after endovascular thrombectomy (ET) in anterior circulation strokes. In this retrospective cohort study, we investigate predictors and clinical outcomes of FPE in posterior circulation strokes (pcAIS). Methods: The Stroke Thrombectomy and Aneurysm Registry database was used to identify pcAIS patients who achieved FPE. Their baseline characteristics and outcomes were compared with the non-FPE group. The primary outcome was a 90-day modified Rankin Scale (mRS) of 0-3. Univariate (UVA) and multivariate (MVA) analyses were done to evaluate predictors of FPE. Safety outcomes included distal emboli, vessel rupture, symptomatic intracranial hemorrhage, and mortality. Results: Of 359 patients, 179 (50%) achieved FPE. Clot burden, occlusion site, and ET technique-related variables were similar between the two groups except for shorter procedure time with FPE. The primary outcome was significantly better with FPE (56.4% vs. 32.8%, p < 0.001). Complications were similar except for a higher rate of distal emboli in non-FPE group (11.1% vs. 3.2%, p = 0.032). Atrial fibrillation (Afib) had increased odds (aOR: 2.06, 95% CI; 1.24, 3.4, p = 0.005) and prior ischemic stroke had decreased odds (aOR: 0.524, 95% CI; 0.28, 0.97, p = 0.04) of FPE. Afib was the only independent predictor of FPE on MVA (1.94, 95% CI; 1.1, 3.43, p = 0.022). Conclusions: Higher rate of FPE in Afib-related pcAIS could possibly be explained by the differences in clot composition and degree of in-situ atherosclerotic disease burden. Future studies are warranted to explore the relationship of clot composition with ET outcomes.

Vertebrobasilar Artery Occlusion Treatment Outcomes Within 24 hours of Estimated Occlusion Time

BACKGROUND AND OBJECTIVES

The aim of this study was to investigate the efficacy and safety of endovascular treatment (EVT) in patients with acute vertebrobasilar artery occlusion (VBAO) within 24 hours of estimated occlusion time (EOT) and to evaluate the effect of early and late time window in a cohort of patients with VBAO treated with EVT.

METHODS

Retrospective analysis was conducted on patients within 24 hours of the EOT in 65 stroke centers in China. Favorable outcome was defined as modified Rankin Scale ≤3 at 90 days. Patients were divided into the medical management (MM) group and the EVT group. Times were dichotomized into early (EOT ≤6 hours) and late (>6 hours) time windows. Multivariate logical regression models were used to evaluate the efficacy and safety of EVT and the effect of time windows on outcomes in EVT patients.

RESULTS

Among 4124 patients, 2473 and 1651 patients were included in the early and late windows, respectively. 1702 patients received MM and 2422 were treated with EVT. EVT was associated with a higher rate of a favorable outcome at 90 days both in early (odds ratio [OR] 2.16, 95% CI 1.94-2.41) and late (OR 1.89, 95% CI 1.65-2.17) time windows. No differences were found regarding favorable outcome (OR 0.95, 95% CI 0.87-1.03) between VBAO patients treated with EVT within and beyond 6 hours.

CONCLUSION

Patients with acute VBAO who received EVT within 24 hours were associated with improved favorable outcome compared with patients who received MM. EVT beyond 6 hours is feasible and safe with no increase in symptomatic intracranial hemorrhage.

Endovascular Treatment in Patients with Large Vessel Occlusion Stroke of Different Mechanisms

INTRODUCTION

Acute ischemic stroke with large vessel occlusion (AIS-LVO) is mainly caused by in situ thrombosis (IST), artery-to-artery embolism (AAE), and cardioembolism (CE). The clinical characteristics and prognosis of each mechanism are unclear in a real-world scenario.

METHODS

We retrospectively analyzed patients with AIS-LVO who underwent endovascular treatment (EVT) between April 2023 and August 2024. Patients were classified according to three mechanisms. This study aimed to compare the clinical characteristics, lab results, EVT procedural factors, and prognosis of patients with AIS-LVO with three different mechanisms. The modified Rankin Scale (mRS) score at 3 months was the primary outcome, which was analyzed by ordinal logistic regression.

RESULTS

Among 162 patients included, IST (n = 81) was the most common mechanism, followed by CE (n = 41) and AAE (n = 40). Patients with CE showed more severe initial symptoms and the highest rate of intracranial hemorrhage. Patients with IST were associated with more rapid progression, more posterior circulation involvement, and higher inflammatory profile. Patients with AAE experienced a longer procedural time and had a higher rate of symptomatic intracranial hemorrhage (sICH). Although patients with IST and AAE more often required stenting, no significant difference in the rate of successful recanalization was found. The rates of mRS distribution (p = 0.24), and favorable outcomes at 3 months (p = 0.36) did not differ among the three groups. However, a trend towards better outcomes in the CE group was noted. On multivariable logistic regression, age (odds ratio, 0.97, 95% confidence interval, 0.95-1.00), pre-EVT National Institutes of Health Stroke Scale (NIHSS) (odds ratio, 0.94, 95% confidence interval, 0.89-0.98), and sICH (odds ratio, 0.33, 95% confidence interval, 0.12-0.95) could independently predict a favorable shift in mRS distribution. We failed to find that the mechanism was a predictor of the outcome.

CONCLUSIONS

The functional outcomes of patients with AIS-LVO were similar among different mechanisms, despite the sICH being much higher in patients with AAE. The optimal management for AIS-LVO with different mechanisms requires further research.

Endovascular treatment in acute intracranial distal medium vessel occlusion stroke: Study protocol and rationale

BACKGROUND

Distal medium vessel occlusions (MeVOs) account for an estimated 25% to 40% of all acute ischemic strokes. Emerging evidence from non-randomized trials suggest that endovascular thrombectomy (EVT) can achieve high rates of successful reperfusion in MeVO strokes, with a safety profile comparable to EVT for proximal arterial occlusions. These findings underscore the need for a prospective randomized clinical trial to evaluate the safety and efficacy of EVT for MeVO stroke.

OBJECTIVE

This trial aims to evaluate the safety and efficacy of EVT for MeVO stroke.

METHODS AND DESIGN

Endovascular treatment in acute intracranial distal medium vessel occlusion stroke (ORIENTAL-MeVO) is an investigator-initiated, multicenter, prospective, randomized clinical trial with open-label treatment and blinded endpoint assessment (PROBE). Up to 564 eligible patients will be consecutively randomized in a 1:1 ratio to receive either EVT or standard of care over a period of 2 years in over 50 comprehensive stroke centers in China.

OUTCOMES

The primary outcome is a shift in the distribution of the modified Rankin Scale (mRS) at day 90s with levels 5-6 combined (mRS = 0, 1, 2, 3, 4, 5-6). Primary safety endpoints include symptomatic intracerebral hemorrhage at 24 h and mortality at 90 days.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06146790.

The role of first pass effect in mechanical thrombectomy for vertebrobasilar artery occlusion: a comprehensive meta-analysis of prevalence, outcomes, and predictive factors

BACKGROUND

First-pass effect (FPE) is crucial for better outcomes in mechanical thrombectomy (MT) for acute large vessel occlusions. However, its frequency and predictors in vertebrobasilar artery occlusion (VBAO) remain unclear.

OBJECTIVE

To conduct a comprehensive systematic review and meta-analysis to assess the incidence of FPE in MT for VBAO and its impact on key clinical outcomes. Additionally, to explore potential predictors of achieving FPE, addressing critical knowledge gaps and providing evidence to optimize treatment strategies for patients with VBAO.

METHODS

A systematic literature search was performed in PubMed, EMBASE, Web of Science, and the Cochrane Library up to November 1, 2024. Studies evaluating FPE in patients with acute VBAO undergoing MT were included. The prevalence of FPE was estimated using a meta-analysis of proportions, and associations with clinical outcomes and predictive factors were assessed using pooled ORs with random-effects models.

RESULTS

Twenty studies involving 4315 patients met inclusion criteria. The overall prevalence of FPE in patients with VBAO was 41% (95% CI 33% to 50%). FPE was significantly associated with improved 90-day outcomes (modified Rankin Scale (mRS) score 0-2: OR=2.00, 95% CI 1.45 to 2.75; mRS score 0-3: OR=2.33, 95% CI 1.78 to 3.04), reduced risk of symptomatic intracranial hemorrhage (OR=0.49, 95% CI 0.27 to 0.87), and lower mortality (OR=0.43, 95% CI 0.32 to 0.57). The results showed that significant positive predictors of FPE included female sex, atrial fibrillation, cardioembolic or unknown stroke etiology, mid- or distal basilar artery occlusion, contact aspiration techniques, and the use of larger catheters. Conversely, negative predictors were identified as a history of hypertension, hyperlipidemia, prior stroke or transient ischemic attack, higher baseline NIHSS scores, prolonged procedure time, and the use of general anesthesia.

CONCLUSION

Achieving FPE in acute VBAO is strongly associated with improved clinical outcomes. Important clinical, procedural, and anatomical factors related to FPE were identified, aiding clinical decisions and thrombectomy techniques.

The Basilar Artery Collateral Simplified Score: a Novel Collateral Circulation Score Associated With Outcomes in Patients With Basilar Artery Occlusion: Results From the ATTENTION Study

BACKGROUND

The aim of the current study was to develop a simplified collateral score for basilar artery occlusion and assess its impact on the relationship between procedure time and outcomes.

METHODS AND RESULTS

The derivation cohort (n=221) from the ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion) study was used. Variables identified by logistic regression were used to develop the Basilar Artery Collateral Simplified Score (BACSS). Its performance was assessed through discrimination and calibration. BACSS was evaluated in an external cohort (n=191). The association between BACSS and outcomes was evaluated using adjusted logistic regression. In patients receiving endovascular treatment, associations of BACSS and time from puncture to recanalization with outcomes were evaluated, including an interaction term (BACSS×puncture to recanalization) to assess effect modification. The primary outcome was 90-day functional independence (modified Rankin Scale score ≤2). Posterior communicating artery, posterior cerebral artery, and superior cerebellar artery were identified through multivariable logistic regression to establish BACSS. The area under the curve of BACSS was 0.749 (95% CI, 0.679-0.819), comparable to the Basilar Artery on Computed Tomography Angiography score and Posterior Circulation Collateral Score, with substantial interobserver agreement. Both the calibration curves and the Hosmer-Lemeshow test showed good calibration. Similar findings were observed in the external cohort. BACSS was independently associated with functional independence (adjusted odds ratio, 2.11 [95% CI, 1.53-3.02]). The relationship between puncture to recanalization and outcomes (Pinteraction>0.05) was unchanged.

CONCLUSIONS

BACSS is a simple collateral score with improved interobserver reliability and shows a positive association with outcomes in basilar artery occlusion. In patients with basilar artery occlusion, shorter procedure time during endovascular treatment is associated with favorable outcome, regardless of collateral circulation.

REGISTRATION

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

Mechanical thrombectomy in basilar artery occlusions: impact of first-line strategy as a function of the occlusion level

BACKGROUND

Retrospective studies suggest the superiority of first-line contact aspiration (CA) thrombectomy over stent-retriever (SR) in basilar artery occlusions (BAO). We aimed to investigate the impact of first-line mechanical thrombectomy per the occlusion level, considering differences in stroke etiology prevalence between proximal and distal BAO.

METHODS

A retrospective, multicentric analysis of the Endovascular Treatment in Ischemic Stroke Registry (ETIS) included consecutive BAO patients treated from January 2016 to May 2022. Patients were categorized into SR (±aspiration) and CA alone groups. Occlusion levels were determined through digital subtraction angiography. Favorable clinical outcome was defined as 90-day modified Rankin Scale (mRS) 0-3.

RESULTS

A total of 380 patients were analyzed (251 CA alone, 129 SR±aspiration). Globally, first-line SR showed lower recanalization rates (89.1% vs 94.8%, OR=0.29, 95% CI 0.16 to 0.53; p<0.001) and worse clinical outcomes (mRS 0-3: 46.0% vs 52.2%, OR=0.62, 95% CI 0.44 to 0.87; p=0.006) compared with CA. In proximal occlusions, SR was significantly associated with poorer clinical outcomes (mRS 0-3: 20.9% vs 37.1%; OR=0.40, 95% CI 0.19 to 0.83; p=0.014) despite similar recanalization rates. Conversely, in distal occlusions there was no difference in clinical outcomes although recanalization rates were higher with CA (modified Thrombolysis in Cerebral Infarction score (mTICI 2b/3): 97.7% vs 91.7%; OR=0.17, 95% CI 0.05 to 0.66; p=0.01).

CONCLUSIONS

In our BAO population, CA demonstrated better angiographic outcomes in middle and distal occlusions and better clinical outcomes in proximal occlusions. This translated into better angiographic and clinical results in the global study population. Clinical results were particularly influenced by the negative impact of SR on 90-day mRS, independently of recanalization rates in proximal BAO.

Thrombectomy in Stroke Patients with Large Vessel Occlusion and Mild Symptoms: Insights from a Multicenter Observational Study

To evaluate whether endovascular thrombectomy (EVT) combined with best medical management (BMM) is more effective than BMM alone in treating mild stroke patients (National Institutes of Health Stroke Scale score < 6) with large vessel occlusion (LVO). A multicentric retrospective cohort of patients with LVO and mild stroke within 24 h from symptom onset was included. Patients were divided into the primary EVT (EVTpri) group and the primary BMM (BMMpri) group according to the treatment strategy. Functional outcomes were compared after propensity score matching. Additionally, adjusted logistic regression analysis was used to assess the association between treatment strategy and functional outcomes. Finally, 419 patients were included, with 137 receiving EVTpri and 282 receiving BMMpri. After propensity score matching (EVTpri, 126 vs. BMMpri, 126), baseline characteristics were balanced between the two groups. No significant difference was observed in 3-month functional independence (modified Rankin Scale [mRS] 0-2, 78.6% vs. 76.2%. In the overall cohort, EVTpri was not associated with functional independence (adjusted odds ratio [aOR], 0.87; 95% confidence interval [CI], 0.43-1.47). However, patients in the EVTpri group were more likely to experience symptomatic intracranial hemorrhage (aOR, 1.27; 95% CI, 1.05-1.89). Subgroup analysis revealed that EVTpri was significantly associated with functional independence in vertebrobasilar occlusion subgroup (aOR, 1.78; 95% CI, 1.20-3.90). Our findings did not support the systematic use of EVT for mild stroke with LVO, except in cases of vertebrobasilar occlusion, which may represent a subgroup where EVTpri could provide significant benefits.

[Acute ischemic stroke treatment]

Intravenous thrombolysis (IVT) and endovascular therapy (EVT) are the cornerstones of acute ischemic stroke treatment. While IVT has been an integral part of acute therapy since the mid-1990s, EVT has evolved as one of the most effective treatments in medicine over the past decade. Traditionally, systemic thrombolysis has been performed with alteplase (rtPA). More recently, tenecteplase (TNK) has been shown to be non-inferior to rtPA. TNK has some pharmacological advantages over rtPA and may lead to earlier recanalization, particularly in large vessel occlusions. All recanalization therapies are highly time dependent. To ensure rapid treatment, standard operating procedures (SOPs) should be established and followed in clinical practice. The optimal time window for IVT is 4.5 h after symptom onset and can be extended up to 9 h using specialized imaging techniques. For EVT, studies suggest a time window up to 24 h after symptom onset. In some cases, EVT has been successfully performed beyond this time window. To select patients for EVT, advanced imaging identifying salvageable brain tissue might be necessary. Even in large ischemic stroke, EVT can still improve outcome. Compared to EVT, IVT requires fewer technical and human resources, so more stroke patients can potentially be treated. In contrast, EVT requires highly trained personnel with sophisticated equipment and can, therefore, only be performed in specialized centers. Both procedures should be combined within the 4.5 h time window for patients without contraindications.

Recanalization is more important than procedure time on outcome of thrombectomy in acute vertebrobasilar artery occlusion

Longer procedure time (PT) predicts worse prognosis after endovascular treatment (EVT) in acute vertebrobasilar artery occlusion (VBAO), but it remains unknown whether it is worth pursuing recanalization when the PT is obviously extended. Patients with acute VBAO who received EVT were retrospectively enrolled from 21 stroke centers in China from December 2015 to December 2018. Multivariable logistic analysis was performed to analyze the associations of PT with favorable outcome (defined as modified Rankin Scale score of 0 to 3) and mortality at 90 days. A total of 541 patients with median age of 64 years (IQR, 55-73) were included. The median baseline National institutes of Health stroke scale score was 23 (IQR, 14-28) and PT was 110 min (IQR, 74-156). The rate of favorable outcome was 36.5% in patients with PT 111-155 min (adjusted OR 0.51 [95% CI 0.28-0.92]) and 33.3% in patients with PT > 155 min (adjusted OR 0.52 [95% CI 0.29-0.93]) compared with 42.9% in patients with PT ≤ 75 min. Compared with the PT ≤ 75 min, PT of 111-155 min (adjusted OR 1.96 [95% CI 1.11-3.46]) and PT > 155 min (adjusted OR 2.10 [95% CI 1.21-3.66]) were associated with increased risks of mortality. Recanalization within four PT intervals were consistently associated with better outcomes compared with failure of recanalization (all P < 0.05). For acute VBAO patients treated with EVT, recanalization regardless of PT was associated with improved prognosis than failure of recanalization, supporting the continued pursuit of recanalization despite the PT being obviously extended. The findings need validation in randomized controlled trials.

A New Fibrin-Heparine Coated Self-Expanding Stent for the Rescue Treatment of Intracranial Stenosis-a Multicentric Study

INTRODUCTION

Rescue intracranial stenting is necessary to provide sufficient recanalization after mechanical thrombectomy (MT) in patients with acute large vessel occlusions (LVO) due to an underlying intracranial atherosclerotic disease (ICAD). The CREDO heal is a novel stent that provides a potentially lower thrombogenicity due to surface modification. We present the first multicentric experience with the CREDO heal for acute rescue stenting.

METHODS

Data of 81 patients who underwent rescue stenting after MT at 12 centers in Germany and Spain were prospectively collected and retrospectively evaluated.

RESULTS

Final mTICI 2b‑3 was reached in 95.1% after median two MT maneuvers and stenting. Four periprocedural complications resulted in clinical deterioration (4.9%). Intraparenchymal hemorrhage occurred in one patient (1.2%) and functional independence at FU was reached by 42% of the patients. Most interventions were performed under Gp IIb/IIIa inhibitors.

CONCLUSION

CREDO heal was effective and safe in our case series. However, more data is needed to define the optimal antithrombotic regime. The use under single antiplatelet medication is not supported by our study.

Therapeutic Options for Disabling Acute Ischemic Stroke

Ischemic stroke affects up to 3% of the US population and is the leading cause of disability nationwide. This article outlines the evidence to support the use of intravenous thrombolytic, including tenecteplase, in the setting of acute ischemic stroke, along with thrombectomy for up to 24 hours, even in those patients with a large ischemic core and in those with an acute basilar artery occlusion. A clinical case of a patient with large ischemic core who received thrombectomy is included, along with images.

Association Between Serum Uric Acid to High-Density Lipoprotein Cholesterol Ratio and Pneumonia After Endovascular Treatment of Vertebrobasilar Artery Occlusion

Background

The uric acid to high-density lipoprotein cholesterol ratio (UHR) is a novel marker of inflammation and metabolism. We aimed to explore the association of UHR with pneumonia after endovascular thrombectomy (EVT) in patients with vertebrobasilar artery occlusion (VBAO).

Methods

We retrospectively enrolled participants diagnosed with acute VBAO treated with EVT within 24 hours of estimated occlusion time from the multicenter PERSIST study. The primary outcome was pneumonia within 7 days after EVT according to the Pneumonia in Stroke Consensus Group recommendations. We utilized the restricted cubic spline curve to explore the dose-response relationship between UHR and pneumonia. We used multivariable logistic regression models to assess the association between UHR and the risk of pneumonia after EVT and verified the findings in subgroup analysis.

Results

Three hundred and seventy-eight patients were enrolled in this study, and 236 (62.4%) were diagnosed with pneumonia. In multivariable models, a higher UHR was associated with an increased risk of pneumonia after EVT (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.10; P = 0.020; tertile 3 versus tertile 1: OR, 2.09; 95% CI, 1.15-3.82; P = 0.016). The dose-response relationship indicated that UHR was linearly associated with the risk of pneumonia (P = 0.888). The association between UHR and pneumonia remained significant in different subgroups.

Conclusion

This study demonstrated that a higher UHR was associated with an increased risk of pneumonia in VABO patients treated with EVT. Further studies were warranted to verify the prognostic values of UHR in pneumonia after EVT.

Llama 3.1 405B Is Comparable to GPT-4 for Extraction of Data from Thrombectomy Reports-A Step Towards Secure Data Extraction

PURPOSE

GPT‑4 has been shown to correctly extract procedural details from free-text reports on mechanical thrombectomy. However, GPT may not be suitable for analyzing reports containing personal data. The purpose of this study was to evaluate the ability of the large language models (LLM) Llama3.1 405B, Llama3 70B, Llama3 8B, and Mixtral 8X7B, that can be operated offline, to extract procedural details from free-text reports on mechanical thrombectomies.

METHODS

Free-text reports on mechanical thrombectomy from two institutions were included. A detailed prompt was used in German and English languages. The ability of the LLMs to extract procedural data was compared to GPT‑4 using McNemar's test. The manual data entries made by an interventional neuroradiologist served as the reference standard.

RESULTS

100 reports from institution 1 (mean age 74.7 ± 13.2 years; 53 females) and 30 reports from institution 2 (mean age 72.7 ± 13.5 years; 18 males) were included. Llama 3.1 405B extracted 2619 of 2800 data points correctly (93.5% [95%CI: 92.6%, 94.4%], p = 0.39 vs. GPT-4). Llama3 70B with the English prompt extracted 2537 data points correctly (90.6% [95%CI: 89.5%, 91.7%], p < 0.001 vs. GPT-4), and 2471 (88.2% [95%CI: 87.0%, 89.4%], p < 0.001 vs. GPT-4) with the German prompt. Llama 3 8B extracted 2314 data points correctly (86.1% [95%CI: 84.8%, 87.4%], p < 0.001 vs. GPT-4), and Mixtral 8X7B extracted 2411 (86.1% [95%CI: 84.8%, 87.4%], p < 0.001 vs. GPT-4) correctly.

CONCLUSION

Llama 3.1 405B was equal to GPT‑4 for data extraction from free-text reports on mechanical thrombectomies and may represent a data secure alternative, when operated locally.

Symptoms, Imaging Features, Treatment Decisions, and Outcomes of Patients with Top of the Basilar Artery Syndrome: Experiences from a Comprehensive Stroke Center

BACKGROUND

From visual, ocular, and pupillomotor abnormalities to qualitative and more importantly rapid quantitative disturbances of consciousness, top of the basilar artery syndrome (TOBS) represents a diagnostic challenge in neurocritical care. In this monocentric retrospective cross-sectional study, we will describe this particular patient group in detail and highlight its variability and the associated implications.

METHODS

Consecutive patients with radiologically confirmed TOBS presenting to our comprehensive stroke center were analyzed from 2010 to 2022. Baseline parameters at admission, including clinical symptoms, National Institutes of Health Stroke Scale (NIHSS) score, Glasgow Coma Scale (GCS) score, and imaging parameters (mode and success of recanalization measured by the Thrombolysis in Cerebral Infarction [TICI] score, extent of infarct, and infarct localization), were assessed. Functional dependence at discharge was analyzed with the modified Rankin scale (mRS) and Barthel Index.

RESULTS

We assessed 96 eligible patients with a mean age of 70 (SD ± 14) years, 41.67% of whom were female. The median NIHSS score at admission was 19 (interquartile range [IQR] 8-35), and the median GCS score was 7 (IQR 3-15). Dysphagia was identified in 51.72% of patients, with a significant number discharged with nasogastric tubes. Most patients received both intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) (47%), whereas 32% received MT only, and 10% received no acute recanalizing therapy. Patients receiving both IVT and MT had higher frequencies of successful vessel revascularization (higher TICI scores) and better clinical outcomes compared to those receiving only MT (median mRS score 4 [IQR 2-5] vs. 5 [IQR 2-6], p = 0.046). Multivariable regression analysis confirmed that successful recanalization (TICI) and GCS score at admission were key predictors of functional outcomes.

CONCLUSIONS

A large proportion of patients presenting with TOBS were severely affected by a significant reduction in vigilance, a condition that persists in the absence of recanalization and is then associated with a relevant dependency.

Predictors and outcomes of angioplasty and stenting in acute intracranial atherosclerosis-related vertebrobasilar artery occlusion

Objective

This study aimed to investigate clinical outcomes and predictors of favorable functional outcomes after endovascular treatment, including emergent angioplasty and stenting, in patients with intracranial atherosclerotic stenosis (ICAS)-related occlusions in vertebrobasilar arteries.

Materials and methods

This retrospective case series included 46 patients with acute occlusions of vertebrobasilar arteries, due to underlying ICAS. All patients underwent a thrombectomy, followed by angioplasty and/or stenting. We performed logistic regression analyses to identify independent predictors of favorable outcomes. A favorable outcome was defined as a score of 0-3 on the 90-day modified Rankin Scale.

Results

Overall, successful reperfusion was achieved in 44/46 (95.7%) patients and 90-day favorable outcomes were achieved in 21/46 patients (45.7%). The 90-day mortality rate was 23.9% (11/46). In a multivariate binary logistic analysis, independent predictors of favorable outcome were hyperlipidemia (OR = 7.866, 95% CI: 1.093-56.590, p = 0.040), admission hyperglycemia (OR = 0.144, 95% CI: 0.023-0.914, p = 0.040), basilar artery occlusion (OR = 0.086, 95% CI: 0.008-0.907, p = 0.041), and treatment with angioplasty alone (OR = 9.779, 95% CI: 1.022-93.525, p = 0.048).

Conclusion

Our findings suggested that emergent angioplasty and/or stenting could yield high rates of successful reperfusion and favorable outcomes in patients with ICAS-related occlusions in vertebrobasilar arteries. Our study also demonstrated that hyperlipidemia and treatment with angioplasty alone were associated with favorable outcomes, in contrast, admission hyperglycemia and basilar artery occlusion were associated with unfavorable outcomes in these patients.

Predicting symptomatic intracranial hemorrhage after endovascular treatment of vertebrobasilar artery occlusion: PEACE score

BACKGROUND

Current clinical decision tools for assessing the risk of symptomatic intracranial hemorrhage (sICH) in patients with vertebrobasilar artery occlusion (VBAO) who received endovascular treatment (EVT) have limited performance. This study develops and validates a clinical risk score to precisely estimate the risk of sICH in VBAO patients.

METHODS

The derivation cohort recruited patients with VBAO who received EVT from the Posterior Circulation IschemIc Stroke Registry in China. Based on the posterior circulation-Alberta Stroke Program Early CT Score (pc-ASPECTS) evaluation method, the cohort was further divided into non-contrast CT (NCCT) and diffusion weighted imaging (DWI) cohorts to construct predictive models. sICH was diagnosed according to the Heidelberg Bleeding Classification within 48 hours of EVT. Clinical signature was constructed in the derivation cohort using machine learning and was validated in two additional cohorts from Asia and Europe.

RESULTS

We enrolled 1843 patients who underwent EVT and had complete data. pc-ASPECTS of 1710 patients was evaluated on NCCT and 699 patients on DWI. In the NCCT cohort, 1364 individuals made up the training set, of whom 101 (7.4%) developed sICH. In the DWI cohort, the training set consisted of 560 individuals, with 44 (7.9%) experiencing sICH. Predictors of sICH were: glucose, pc-ASPECTS, time from estimated occlusion to groin puncture (EOT), poor collateral circulation, and modified Thrombolysis in Cerebral Infarction (mTICI) score. From these predictors, we derived the weighted poor collateral circulation-EOT-pc-ASPECTS-mTICI-glucose (PEACE) score. The PEACE score showed good discrimination in the training set (area under the curve (AUC)NCCT=0.85; AUCDWI=0.86), internal validation set (AUCNCCT=0.81; AUCDWI=0.82), and two additional external validation set (Asia: AUCNCCT=0.78, AUCDWI=0.80; Europe: AUCNCCT=0.74, AUCDWI=0.78).

CONCLUSION

The PEACE score reliably predicted the risk of sICH in VBAO patients who underwent EVT.

Endovascular Thrombectomy versus Medical Management for Acute Basilar Artery Occlusion Stroke in the Elderly

BACKGROUND AND PURPOSE

The efficacy and safety of endovascular thrombectomy (EVT) for elderly patients with basilar artery occlusion (BAO) stroke is unclear. The purpose of this study is to investigate the safety and efficacy of EVT for elderly BAO stroke patients.

MATERIALS AND METHODS

This was an explorative retrospective analysis of the 2016-21 National Inpatient Sample in the United States. Elderly patients with BAO stroke (80 years of age or older) with an NIHSS score of at least 5 were included. Primary outcome was discharge home. Secondary outcomes included in-hospital mortality and intracranial hemorrhage (ICH). Outcomes were compared between patients treated with EVT and those treated with medical management (MM) alone. Propensity score matching (PSM) was performed to control confounders. Subgroup analyses were conducted for patients who did and did not receive IV thrombolysis (IVT).

RESULTS

We identified 2520 elderly patients with BAO stroke; 830 received EVT and 1690 received MM alone. After PSM, 1115 patients and 715 patients remained in the MM and EVT groups, respectively. Compared with PSM controls, EVT was not significantly associated with different rates of home discharge (17.5% versus 12.2%; OR, 1.36 [95% CI, 0.76-2.44], P = .30) or in-hospital mortality (31.5% versus 32.9%; OR, 1.00 [95% CI, 0.63-1.60], P = .99), but it was significantly associated with higher rates of ICH (18.2% versus 7.3%; OR, 2.69 [95% CI, 1.41-5.15], P = .003). Among patients who did not receive IVT, EVT was significantly associated with higher rates of home discharge (21.5% versus 11.5%; OR, 1.93 [95% CI, 1.02-3.66], P = .044), whereas EVT was not significantly associated with a different rate of home discharge among those treated with IVT (5.6% versus 15.0%; OR, 0.28 [95% CI, 0.05-1.46], P = .13). Interaction analysis revealed that IVT was a negative modulator of the positive association of EVTs with home discharge (interaction P = .031).

CONCLUSIONS

EVT was not significantly associated with more favorable hospitalization outcomes for elderly patients with BAO stroke, and it was significantly associated with an increased risk of ICH. EVT may be an effective treatment for patients who did not receive IVT.

AI prediction model for endovascular treatment of vertebrobasilar occlusion with atrial fibrillation

Endovascular treatment (EVT) for vertebrobasilar artery occlusion (VBAO) with atrial fibrillation presents complex clinical challenges. This comprehensive multicenter study of 525 patients across 15 Chinese provinces investigated nuanced predictors beyond conventional metrics. While 45.1% achieved favorable outcomes at 90 days, our advanced machine learning approach unveiled subtle interaction effects among clinical variables not captured by traditional statistical methods. The predictive model distinguished high-risk subgroups by integrating multiple parameters, demonstrating superior prognostic precision compared to standard NIHSS-based assessments. Novel findings include nonlinear relationships between dyslipidemia, stroke severity, and functional recovery. The developed predictive algorithm (AUC 0.719 internally, 0.684 externally) offers a more sophisticated risk stratification tool, potentially guiding personalized treatment strategies in high-complexity VBAO patients with atrial fibrillation.

Mechanical thrombectomy failure in anterior and posterior circulation stroke: current results from a high-volume comprehensive center

BACKGROUND

Mechanical thrombectomy (MT) is an established therapy for acute ischemic stroke (AIS), but recanalization is not always achieved. Common reasons are inadequate removal at the thrombus site and difficulties with the access route. In order to identify risk factors for MT failure we conducted a retrospective study on a high-volume comprehensive stroke center.

METHODS

Evaluation of 552 thrombectomies (2019-23; anterior and posterior circulation, direct aspiration +/- stent retriever [SR]). MT failures (= modified Thrombolysis in Cerebral Infarction score 0 or 1) were analyzed for age, sex, pre- and post-MT modified Rankin Scale, bridging intravenous thrombolysis (IVT), occlusion site (anterior / posterior circulation, proximal / distal), the Kaesmacher classification and time trend results.

RESULTS

MT failure occurred in 56 patients (10.1%; median age 76; 53.6% female). Nineteen (33.9%) patients received IVT (p = 0.326). Logistic regression analysis did not show a significant association of age, sex or occlusion site with MT failure (p = 0.165, p = 0.738, p = 0.838). Distal MT generally demonstrated lower success rates (p < 0.01). According to the Kaesmacher classification SR failure was the most frequent cause of MT failure (category 2B: 48%, p < 0.001). Time trend analysis suggests improving recanalization rates in the further course (4 times in year-on-year comparison; p < 0.01).

CONCLUSION

MT failure occurs in AIS treatment, even in high-volume centers and occurs more frequently in distal occlusions. Improvements in device technology, particularly SR, and ongoing refinements in access route selection offer the prospect of better outcomes in the future.

Global Trends of Mechanical Thrombectomy in Acute Ischemic Stroke Over the Past Decade: A Scientometric Analysis Based on WOSCC and GBD Database

OBJECTIVE

To present a global overview of the current research landscape and emerging trends in mechanical thrombectomy for acute ischemic stroke (AIS) over the past decade.

METHODS

A thorough search was conducted on the Web of Science on May 20, 2024, focusing on original articles and reviews in English. Bibliometric tools were employed to make a network analysis and visual representation. Additionally, data on disability-adjusted life years, prevalence, and incidence of ischemic strokes were extracted from the Global Burden of Disease database.

RESULTS

A total of 7776 papers were included, indicating a steady increase from 169 to 1311 between 2014 and 2023. The United States led in core publications with 2887 papers. The incidence and disability-adjusted life years of ischemic stroke have continued to rise in Asia but have recently declined in North America and European countries. The University of Calgary emerged as the leading institution and Mayank Goyal was the most prolific author. Neurointerventional Surgery was the top contributing journal with 790 articles. The analysis identified 6332 keywords forming 5 clusters, with "mechanical thrombectomy" serving as the largest cluster, focusing mainly on interventional thrombectomy techniques for AIS. The term "tissue plasminogen activator" exhibited strong burst strength of 46.58. Keywords such as "injury", "diagnosis", "posterior circulation", and "severity" burst in 2020 and lasted until 2024.

CONCLUSIONS

Interest in mechanical thrombectomy for AIS was progressively increasing. Future research directions may include minimizing intraoperative injuries, refining diagnostic techniques, investigating interventions for posterior circulation, and tailoring thrombectomy strategies based on stroke severity and large vessel occlusion etiology.

Infarct Growth in Patients with Emergent Large Vessel Occlusion Stroke Transferred for Endovascular Thrombectomy

INTRODUCTION

Patients with a large vessel occlusion (LVO) stroke who are transferred to a comprehensive stroke center (CSC) for endovascular thrombectomy (EVT) often experience infarct growth. We aimed to investigate the clinical predictors of fast infarct growth and its effect on clinical outcomes.

METHODS

We retrospectively collected EVT data of patients with LVO transferred to our center between March 14, 2019, and June 28, 2022. The absolute rate of Alberta Stroke Program Early Computed Tomography Score (ASPECTS) decay was defined as (ASPECTS primary CT - ASPECTS repeat CT)/elapsed hours. The ratio of relative ASPECTS deterioration was defined as (ASPECTS primary CT - ASPECTS repeat CT)/ASPECTS primary CT. In the primary analysis, the study population was dichotomized into absolute slow progressors and absolute fast progressors using the median absolute rate of ASPECTS decay. Secondary analysis was also conducted using the median relative ASPECTS deterioration ratio, and the study population was categorized into relative fast progressors and relative slow progressors. Favorable outcome was defined as a 90-day modified Rankin Scale (mRS) score ≤ 2.

RESULTS

We included 309 patients: median age 72 years (IQR 65-77); median National Institutes of Health Stroke Scale (NIHSS) 14 (IQR 11-18). The median absolute rate of ASPECTS decay was 0.42 points/hour and the median relative ASPECTS deterioration ratio was 11.1%. Overall, fast infarct growth was independently associated with worse 90-day outcome (absolute rate of ASPECTS decay: OR = 3.395; 95% CI 1.844-6.250; P < 0.001; relative ASPECTS deterioration ratio: OR = 3.754; 95% CI 2.050-6.873; P < 0.001). In multivariable analysis, fast infarct growth was independently associated with high admission NIHSS, proximal occlusions, and poor collateral status, while intravenous thrombolysis before transfer was negative with fast inter-hospital infarct growth.

CONCLUSIONS

For patients with LVO stroke who are transferred from a PSC to CSC for EVT, the infarct growth rate is highly variable and is strongly associated with 90-day outcomes. Initiation of intravenous bridging therapy before transfer may limit the infarct growth during inter-hospital transfer.

Rescue Stenting for Failed Mechanical Thrombectomy in Acute Basilar Artery Occlusions: Analysis of the PC-SEARCH Registry

BACKGROUND

We aimed to investigate whether rescue stenting (RS) following failed mechanical thrombectomy (MT) for acute basilar artery occlusion results in superior functional outcomes and enhanced safety compared with the natural history of failed MT.

METHODS

This retrospective cohort study utilized data from the Posterior Circulation Ischemic Stroke Evaluation: Analyzing Radiographic and Intra-Procedural Predictors for Mechanical Thrombectomy registry, encompassing 8 high-volume centers in the United States and covering the period from 2015 to 2021. Patients with basilar artery occlusion who experienced failed MT (modified Thrombolysis in Cerebral Infarction score of 0-2a after at least 1 attempt of clot retrieval) were categorized based on whether they received additional intervention with RS. The primary outcome was a shift analysis of the 90-day modified Rankin Scale. Multivariable logistic regression was used to assess both efficacy and safety outcomes.

RESULTS

Of a total of 444 patients, 119 presented failed MT and were included in the analysis. The RS group comprised 65 (14.6%) patients, while the control group consisted of 54 (12.2%) patients. After adjusting, the RS group showed a favorable shift in the overall 90-day modified Rankin Scale distribution (adjusted common odds ratio, 4.56 [95% CI, 1.67-12.45]; P=0.003) and higher rates of 90-day 0 to 3 modified Rankin Scale score (RS: 44.6% versus control: 18.5%; adjusted odds ratio, 7.57 [95% CI, 1.91-30.12]; P=0.004) compared with the control group. RS also showed lower rates of 90-day mortality (RS: 43.1% versus control: 64.8%; adjusted odds ratio, 0.27 [95% CI, 0.09-0.80]; P=0.018) and comparable rates of symptomatic intracranial hemorrhage (RS: 3.1% versus control: 13%; adjusted odds ratio, 0.31 [95% CI, 0.05-1.95]; P=0.214).

CONCLUSIONS

Our study demonstrated that RS is associated with improved functional outcomes and reduced mortality in basilar artery occlusion patients presenting MT failure. Further randomized trials are needed to validate these findings.