Leukoaraiosis and acute ischemic stroke: 90-day clinical outcome following endovascular recanalization, with proposed "L-ASPECTS"

The whole day matters after stroke: Study protocol for a randomized controlled trial investigating the effect of a 'sit less, move more, sleep better' program early after stroke

BACKGROUND

Movement-related behaviours, including prolonged sedentary behaviour, physical inactivity, and poor sleep, are associated with worse functional outcomes poststroke. Addressing these co-dependent behaviours early after stroke may help to optimize recovery and improve overall quality of life for individuals with stroke.

OBJECTIVE

This study aims to determine the feasibility and effect of a 'sit less, move more, sleep better' program early after stroke on functional mobility and global disability outcomes, while also exploring imaging and behavioural markers that may influence walking recovery.

METHODS

The study is an assessor-blinded, single-center, parallel-group, randomized controlled trial to be completed within 24 months from July 12, 2023 to June 30, 2025. We will enroll 50 patients with acute ischemic stroke within 7 days from symptom onset, aged 18 years or older, and with ongoing walking goals. Demographic and stroke characteristics, including stroke risk factors, neuroimaging, and acute stroke treatments, will be determined and documented. All participants will wear an accelerometer for one week at three different time-points (baseline, 6, and 12 weeks) to assess movement-related behaviours. Following randomization, participants in the intervention arm will receive a 'sit less, move more, sleep better' program for up to 1 hour/day, 5 days/week, for 6 weeks to enhance self-efficacy for change. Participants in the control arm will receive usual inpatient and early supported stroke discharge care. The feasibility outcomes will include reach (enrolled/eligible), retention (completed/enrolled), adverse events, and program adherence. Other outcomes at 6 and 12 weeks include the modified Rankin Scale, Timed-Up and Go, movement-related behaviours, walking endurance, gait speed, cognition, stroke severity and quality of life. Mixed-effects models will assess changes in outcomes over time. Compositional associations between movement-related behaviours and outcomes will consider covariates such as imaging markers.

DISCUSSION

Adopting a whole-day approach to poststroke rehabilitation will provide valuable insights into the relationship between optimizing movement-related behaviours early after stroke and their impact on functional outcomes. Through exploring person-specific behavioural and imaging markers, this study may inform precision rehabilitation strategies, and guide clinical decision making for more tailored interventions.

TRIAL REGISTRATION

Clinical Trial registration (ClinicalTrials.gov Identifier: NCT05753761, March 3, 2023).

White matter hyperintensity burden and functional outcomes in acute ischemic stroke patients after mechanical thrombectomy: A systematic review and meta-analysis

BACKGROUND

The influence of white matter hyperintensity (WMH) on clinical outcomes in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT) remains controversial. We performed a systematic review and meta-analysis to examine whether WMH burden is associated with clinical outcomes in AIS patients after MT.

METHODS

PubMed, Embase, and Web of Science were searched from inception to Sep 03, 2023. The registration number for PROSPERO is CRD42022340568. Studies reporting an association between the burden of WMH in AIS patients and clinical outcomes after MT were included in the meta-analysis. A random-effects model was used for meta-analysis. The quality of the included studies was assessed using the Newcastle-Ottawa Scale. Additionally, the presence of imprecise-study effects was evaluated using Egger's test and funnel plot.

RESULTS

Fifteen studies with 3,456 patients were enrolled in this meta-analysis. Among AIS patients who underwent MT, moderate/severe WMH had higher odds of 90-day unfavorable functional outcomes (odds ratio [OR] 2.72, 95% confidence interval [CI] 2.14-3.44; I2 = 0.0%; 95% CI 0.0%-42.7%), 90-day mortality (OR 1.94, 95% CI 1.45-2.60; I2 = 19.5%; 95% CI 0.0%-65.2%) and futile recanalization (OR 2.99, 95% CI 1.42-6.28; I2 = 69.7%; 95% CI 0.0%-91.0%) compared with none/mild WMH. However, the two groups had no significant difference in successful recanalization, symptomatic hemorrhagic transformation, and hemorrhagic transformation. A subset analysis of patients from 3 articles showed that WMH volume was not significantly associated with these outcomes. A notable limitation is that this meta-analysis lacks direct adjustment for imbalances in important baseline covariates.

CONCLUSIONS

Patients with moderate/severe WMH on baseline imaging are associated with substantially increased odds of 90-day unfavorable outcomes, futile recanalization, and 90-day mortality after MT. This association suggests that moderate/severe WMH may contribute to the prediction of clinical outcomes in AIS patients after MT.

Impact of leukoaraiosis or blood pressure on clinical outcome, mortality and symptomatic intracerebral hemorrhage after mechanical thrombectomy in acute ischemic stroke

We aimed to study the impact of leukoaraiosis (LA) and blood pressure (BP) on clinical outcome, mortality and symptomatic intracerebral hemorrhage (sICH) in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT). We analyzed data retrospectively from 521 patients with anterior large vessel occlusion treated with MT. LA was dichotomized in 0-2 (absent-to-moderate) versus 3-4 (moderate-to-severe) according to the van Swieten scale. Various systolic (SBP) and diastolic (DBP) BP parameters during the first 24 h were collected. Multivariable logistic regressions were performed to identify predictors of a poor 90-day outcome, mortality and sICH. LA was significantly associated with poor outcome (OR 3.2; p < 0.001) and mortality (OR 3.19; p = 0.008), but not sICH (p = 0.19). Higher maximum SBP was significantly associated with poor outcome (OR per 10 mmHg increase = 1.21; p = 0.009) and lower mean DBP was a predictor of mortality (OR per 10 mmHg increase = 0.53; p < 0.001). In the univariate analysis high SBP variability was associated with poor outcome, mortality and sICH, but not in the multivariate model. There was no association between BP and sICH. Severity of LA, SBP variability, high maximum SBP and low DBP are associated with either poor outcome or mortality in AIS patients undergoing MT. However, neither LA nor BP were associated with sICH in our cohort. Thus, mechanisms of the negative impact on outcome remain unclear. Further studies on impact of BP course and its mechanisms and interventions are needed to improve outcome in patients undergoing MT.

The association between the severity and distribution of white matter lesions and hemorrhagic transformation after ischemic stroke: A systematic review and meta-analysis

Background and purpose

As a part of the natural course of ischemic stroke, hemorrhagic transformation (HT) is a serious complication after reperfusion treatment, which may affect the prognosis of patients with ischemic stroke. White matter lesions (WMLs) refer to focal lesions on neuroimaging and have been suggested to indicate a high risk of HT. This systematic review and meta-analysis aimed to summarize current evidence on the relation between WML and HT.

Methods

This systematic review was prepared with reference to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched PubMed, Embase, Web of Science, and Cochrane Library databases for publications on WML and HT in patients with ischemic stroke. Odds ratios (ORs) and 95% confidence intervals (CIs) from eligible studies were combined to quantify the association between the severity of WML and the risk of HT. In addition, the descriptive analysis was adopted to evaluate the influence of different WML distributions on predicting HT.

Results

A total of 2,303 articles were identified after removing duplicates through database searching, and 41 studies were included in our final analysis. The meta-analysis showed that the presence of WML was associated with HT (OR = 1.62, 95%CI 1.08-2.43, p = 0.019) and symptomatic intracerebral hemorrhage (sICH) (OR = 1.64, 95%CI 1.17-2.30, p = 0.004), and moderate-to-severe WML indicated a high risk of HT (OR = 2.03, 95%CI 1.33-3.12, p = 0.001) and sICH (OR = 1.92, 95%CI 1.31-2.81, p < 0.001). The dose-response meta-analysis revealed risk effects of increasing the severity of WML on both HT and ICH. In addition, both periventricular WML (PWML) (five of seven articles) and deep WML (DWML) (five of six articles) were shown to be associated with HT.

Conclusions

White matter lesions are associated with overall HT and sICH in patients with ischemic stroke, and more severe WMLs indicate a high risk of HT and sICH. In addition, both PWML and DWMLs could be risk factors for HT.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: PROSPERO CRD42022313467.

Elucidating the Role of Baseline Leukoaraiosis on Forecasting Clinical Outcome of Acute Ischemic Stroke Patients Undergoing Reperfusion Therapy

Stroke stands as a major cause of death and disability with increasing prevalence. The absence of clinical improvement after either intravenous thrombolysis (IVT) or mechanical thrombectomy (MT) represents a frequent concern in the setting of acute ischemic stroke (AIS). In an attempt to optimize overall stroke management, it is clinically valuable to provide important insight into functional outcomes after reperfusion therapy among patients presenting with AIS. The aim of the present review is to explore the predictive value of leukoaraiosis (LA) in terms of clinical response to revascularization poststroke. A literature research of two databases (MEDLINE and Scopus) was conducted in order to trace all relevant studies published between 1 January 2012 and 1 November 2022 that focused on the potential utility of LA severity regarding reperfusion status and clinical outcome after revascularization. A total of 37 articles have been traced and included in this review. LA burden assessment is indicative of functional outcome post-intervention and may be associated with hemorrhagic events' incidence among stroke individuals. Nevertheless, LA may not solely guide decision-making about treatment strategy poststroke. Overall, the evaluation of LA upon admission seems to have interesting prognostic potential and may substantially enhance individualized stroke care.

Leukoaraiosis severity and post-reperfusion outcomes in acute ischaemic stroke: A meta-analysis

OBJECTIVES

Severity of leukoaraiosis may mediate outcomes after reperfusion therapy in acute ischaemic stroke (AIS) patients. However, the level of the association remains poorly understood. We performed a meta-analysis to investigate the impact of leukoaraiosis severity on functional outcome, survival, haemorrhagic complications, and procedural success in AIS patients treated with intravenous thrombolysis and/or endovascular thrombectomy.

MATERIALS AND METHODS

PubMed, EMBASE and the Cochrane library were searched for studies on leukoaraiosis in AIS receiving reperfusion therapy. A random-effects meta-analysis was conducted for post-reperfusion outcomes in AIS patients with absent-to-mild leukoaraiosis and moderate-to-severe leukoaraiosis. The strength of association between moderate-to-severe leukoaraiosis and poor outcomes was quantified using odds ratios (OR).

RESULTS

A total of 15 eligible studies involving 6460 patients (1451 with moderate-to-severe leukoaraiosis and 5009 with absent-to-mild leukoaraiosis) were included in the meta-analysis. Moderate-to-severe leukoaraiosis was significantly associated with poor 90-day functional outcome (OR 3.16; 95% confidence interval (CI) 2.69-3.72; p < .0001), 90-day mortality (OR 3.11; 95% CI 2.27-4.26; p < .0001) and increased risk of symptomatic intracerebral haemorrhage (OR 1.69; 95% CI 1.24-2.32; p = .001) after reperfusion therapy. Overall, no significant association of leukoaraiosis severity with haemorrhagic transformation (HT) and angiographic recanalization status were observed. However, subgroup analysis revealed a significant association of WML severity with HT in patients receiving EVT.

CONCLUSION

Leukoaraiosis is a useful prognostic biomarker in AIS. Patients with moderate-to-severe leukoaraiosis on baseline imaging are likely to have worse clinical and safety outcomes after reperfusion therapy.

Full Reperfusion Without Functional Independence After Mechanical Thrombectomy in the Anterior Circulation : Performance of Prediction Models Before Versus After Treatment Initiation

BACKGROUND AND PURPOSE

Prediction of futile recanalization (FR), i.e. failure of long-term functional independence despite full reperfusion in mechanical thrombectomy (MT), is instrumental in patients undergoing endovascular therapy.

METHODS

Retrospective single-center analysis of patients treated for anterior circulation LVO ensuing successful MT (mTICI 2c-3) between January 2014 and April 2019. FR was defined as modified Rankin Scale (mRS) 90 days after stroke onset > 2 or mRS > pre-stroke mRS. Multivariable analysis was performed with variables available before treatment initiation regarding their association with FR. Performance of the regression model was then compared with a model including parameters available after MT.

RESULTS

Successful MT was experienced by 549/1146 patients in total. FR occurred in 262/549 (47.7%) patients. Independent predictors of FR were male sex, odds ratio (OR) with 95% confidence interval (CI) 1.98 (1.31-3.05, p 0.001), age (OR 1.05, CI 1.03-1.07, p < 0.001), NIHSS on admission (OR 1.10, CI 1.06-1.13, p < 0.001), pre-stroke mRS (OR 1.22, CI 1.03-1.46, p 0.025), neutrophile-lymphocyte ratio (OR 1.03, CI 1.00-1.06, p 0.022), baseline ASPECTS (OR 0.77, CI 0.68-0.88, p < 0.001), and absence of bridging i.v. lysis (OR 1.62, 1.09-2.42, p 0.016). The prediction model's Area Under the Curve was 0.78 (CI 0.74-0.82) and increased with parameters available after MT to 0.86 (CI 0.83-0.89) with failure of early neurological improvement being the most important predictor of FR (OR 15.0, CI 7.2-33.8).

CONCLUSION

A variety of preinterventional factors may predict FR with substantial certainty, but the prediction model can still be improved by considering parameters only available after MT, in particular early neurological improvement.

Small Vessel Disease Burden and Outcomes of Mechanical Thrombectomy in Ischemic Stroke: A Systematic Review and Meta-Analysis

Background: Cerebral small vessel disease (SVD) is prevalent in the population, especially among elderly individuals. Substantial uncertainties remain about the clinical relevance of SVD with outcomes of mechanical thrombectomy (MT) in acute ischemic stroke (AIS).

Objectives: This systematic review and meta-analysis was performed to evaluate the association between SVD and clinical outcomes in patients with AIS undergoing MT.

Methods: We systematically searched the Medline, Embase, and Cochrane databases for relevant clinical studies. The exposure of SVD mainly included leukoaraiosis, cerebral microbleeds (CMBs), and lacunes. The pooled OR was used to calculate the association between each subtype of SVD and outcomes of MT. The primary outcome was poor functional outcome, which was defined as a modified Rankin Scale score (mRS) ≥3 at 90 days after MT. The secondary outcomes included mortality at 90 days, in-hospital mortality, intracranial hemorrhage (ICH) and symptomatic intracranial hemorrhage (sICH), successful recanalization and futile recanalization (FR), early neurological improvement, and early neurological deterioration (END) after MT.

Results: Overall, 20 studies with 5,189 patients with AIS undergoing MT were included. High leukoaraiosis burden (HLB) at baseline was associated with increased risks of poor functional outcome at 90 days (OR 2.70, 95% CI 2.01–3.63; p < 0.001; 10 studies; n = 2,004), in-hospital mortality (OR 4.06, 95% CI 1.48–11.13; p = 0.006; 2 studies; n = 314), FR (OR 5.00, 95% CI 2.86–8.73; p < 0.001; 3 studies; n = 493), and END (OR 2.65, 95% CI 1.09–6.45; 1 study; n = 273) after MT. HLB (VSS 3–4 or FS ≥ 2) at baseline was not associated with mortality at 90 days, ICH, or sICH after MT. CMBs at baseline were found to be associated with increased risks of poor functional outcome at 90 days (OR 1.84, 95% CI 1.17–2.90; p = 0.008; 2 studies; n = 1,924) after MT. We found no association between the presence of lacunes and poor functional outcome at 90 days after MT.

Conclusions: In patients with AIS undergoing MT, HLB and CMBs were associated with increased risks of unfavorable outcomes after MT.

Severe Cerebral Small Vessel Disease Burden Is Associated With Poor Outcomes After Endovascular Thrombectomy in Acute Ischemic Stroke With Large Vessel Occlusion

Background

Despite recent advancements in the treatment of acute ischemic stroke (AIS) with large vessel occlusion (LVO), infarct progression over time and functional outcomes remain variable. This variation in outcomes may be partially attributed to an underlying state of chronic cerebral hypoperfusion and ischemia affecting small cerebral perforating arterioles, venules, and capillaries of the brain; broadly termed cerebral small vessel disease (CSVD). We investigated the association between CSVD burden and the degree of disability following successful recanalization with endovascular thrombectomy (EVT) in patients with AIS presenting with LVO.

Methodology

We conducted a single center retrospective analysis of all patients presenting with AIS LVO between May 2016 and May 2019. Patients who were premorbidly independent and presented within six hours from the last known well (LKW) with a proximal anterior circulation occlusion confirmed on computed tomography (CT) angiography of the head or neck were treated with EVT. Patients presenting after six hours and up to 24 hours from LKW with a target ischemic core to perfusion mismatch profile on CT or magnetic resonance (MR) perfusion, or a clinical imaging mismatch on MR diffusion-weighted imaging, were also treated. Patients with successful revascularization, defined as a thrombolysis in cerebral infarction score 2b or 3, were included and evaluated for CSVD burden. The presence of CSVD was quantified using the Fazekas scale (0-3). All patients were further evaluated for disability at 90 days using the modified Rankin Scale (mRS, range 0-6). An mRS score of ≤2 was defined as a good functional outcome.

Results

Of the 190 patients evaluated, absent (Fazekas grade 0), mild (Fazekas grade 1), moderate (Fazekas grade 2), and severe (Fazekas grade 3) CSVD was present in 33 (17.4%), 84 (44.2%), 35 (18.4%), and 38 (20.0%) patients, respectively. Patients with severe CSVD (Fazekas grade 3) were found to be older, had a higher presenting National Institute of Health Stroke Scale (NIHSS), and had greater proportions of preexisting atrial fibrillation and dementia compared to patients with no CSVD (Fazekas grade 0). Using a multivariate ordinal logistic regression model to adjust for age, presenting NIHSS, thrombus location, LKW to groin puncture time, use of tissue plasminogen activator, ischemic infarct volume, development of a symptomatic intracerebral hemorrhage, and treatment with hemicraniectomy, patients with Fazekas grade 3 were significantly more likely to have poor 90-day functional outcomes compared to patients with Fazekas grade 0 (odds ratio 10.25, 95% confidence interval [3.3-31.84]).

Conclusions

Based on our analytical cohort of AIS LVO patients treated with EVT, we found that patients with severe CSVD burden had worse functional outcomes at 90 days and increased mortality. These results provide evidence that the burden of CSVD may be considered an independent risk factor of poor clinical outcome and a predictor of mortality in patients with AIS presenting with LVO, despite successful radiographic recanalization with EVT.