Endovascular Thrombectomy for Mild Strokes: How Low Should We Go?

A comparison of endovascular therapy and medical management in patients with large vessel occlusion mild stroke treated between 2015 and 2023: a systematic review and meta-analysis

OBJECTIVE

Endovascular therapy (EVT) is recommended for patients with acute large-vessel occlusion (LVO) However, its efficacy and safety compared to medical management (MM) in patients with a National Institutes of Health Stroke Scale (NIHSS) score of ≤6 remains unclear. This meta-analysis compared EVT with medical MM in patients with large vessel occlusion mild stroke treated between 2015 and 2023, following the publication of the first randomized controlled trial.

MATERIALS AND METHODS

Biomedical database searches (inception to March 21, 2023) retrieved articles reporting favorable functional outcome(modified Rankin Scale [mRS] 0-1) and functional independence (mRS 0-2), 90-day mortality and symptomatic intracranial hemorrhage (sICH). We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA) to maintain methodological rigor and transparency in our meta-analysis.

RESULTS

We conducted a meta-analysis of 22 studies (4,985 patients) to reveal no significant differences in favorable functional outcomes and independence across all groups. However, in patients treated between 2015 and 2023, EVT exhibited a higher risk of 90-day mortality (Odds Ratio [OR] = 1.84, 95% Confidence Interval [CI] [1.10, 3.07], p = 0.02) and sICH (OR = 3.36, 95% CI [1.96, 6.66], p < 0.01). EVT correlated with elevated sICH in the anterior circulation (OR=2.94, 95%CI [1.82, 4.74], p<0.01) regardless of the proximal (OR=2.20, 95%CI [1.04, 4.69], p=0.04) or distal (OR=3.44, 95%CI [1.43, 8.32], p<0.01) location of the occlusion. EVT correlated with elevated sICH rates in patients treated within 6 hours of symptom onset or those with NHISS≤5.

CONCLUSION

In patients treated between 2015 and 2023, EVT and MM did not differ in efficacy in acute LVO mild stroke; MM associated with better safety outcomes. Rigorous randomized controlled trials are warranted.

Follow-up infarct volume on fluid attenuated inversion recovery (FLAIR) imaging in distal medium vessel occlusions: the role of cerebral blood volume index

BACKGROUND

Distal medium vessel occlusions (DMVOs) contribute substantially to the incidence of acute ischemic strokes (AIS) and pose distinct challenges in clinical management and prognosis. Neuroimaging techniques, such as Fluid Attenuation Inversion Recovery (FLAIR) imaging and cerebral blood volume (CBV) index derived from perfusion imaging, have significantly improved our ability to assess the impact of strokes and predict their outcomes. The primary objective of this study was to investigate relationship between follow-up infarct volume (FIV) as assessed by FLAIR imaging in patients with DMVOs.

METHODS

This prospectively collected, retrospective reviewed cohort study included patients from two comprehensive stroke centers within the Johns Hopkins Medical Enterprise, spanning August 2018-October 2022. The cohort consisted of adults with AIS attributable to DMVO. Detailed imaging analyses were conducted, encompassing non-contrast CT, CT angiography (CTA), CT perfusion (CTP), and FLAIR imaging. Univariable and multivariable linear regression models were employed to assess the association between different factors and FIV.

RESULTS

The study included 79 patients with DMVO stroke with a median age of 69 years (IQR, 62-77 years), and 57% (n = 45) were female. There was a negative correlation between the CBV index and FIV in a univariable linear regression analysis (Beta =  - 16; 95% CI,  - 23 to  - 8.3; p < 0.001) and a multivariable linear regression model (Beta =  - 9.1 per 0.1 change; 95% CI,  - 15 to  - 2.7; p = 0.006). Diabetes was independently associated with larger FIV (Beta = 46; 95% CI, 16 to 75; p = 0.003). Additionally, a higher baseline ASPECTS was associated with lower FIV (Beta =  - 30; 95% CI,  - 41 to  - 20; p < 0.001).

CONCLUSION

Our findings underscore the CBV index as an independent association with FIV in DMVOs, which highlights the critical role of collateral circulation in determining stroke outcomes in this patient population. In addition, our study confirms a negative association of ASPECTS with FLAIR FIV and identifies diabetes as independent factor associated with larger FIV. These insights pave the way for further large-scale, prospective studies to corroborate these findings, thereby refining the strategies for stroke prognostication and management.

Ninety-Day Stroke Recurrence in Minor Stroke: Systematic Review and Meta-Analysis of Trials and Observational Studies

BACKGROUND

Risk of recurrence after minor ischemic stroke is usually reported with transient ischemic attack. No previous meta-analysis has focused on minor ischemic stroke alone. The objective was to evaluate the pooled proportion of 90-day stroke recurrence for minor ischemic stroke, defined as a National Institutes of Health Stroke Scale severity score of ≤5.

METHODS AND RESULTS

Published papers found on PubMed from 2000 to January 12, 2021, reference lists of relevant articles, and experts in the field were involved in identifying relevant studies. Randomized controlled trials and observational studies describing minor stroke cohort with reported 90-day stroke recurrence were selected by 2 independent reviewers. Altogether 14 of 432 (3.2%) studies met inclusion criteria. Multilevel random-effects meta-analysis was performed. A total of 6 randomized controlled trials and 8 observational studies totaling 45 462 patients were included. The pooled 90-day stroke recurrence was 8.6% (95% CI, 6.5-10.7), reducing by 0.60% (95% CI, 0.09-1.1; P=0.02) with each subsequent year of publication. Recurrence was lowest in dual antiplatelet trial arms (6.3%, 95% CI, 4.5-8.0) when compared with non-dual antiplatelet trial arms (7.2%, 95% CI, 4.7-9.6) and observational studies 10.6% (95% CI, 7.0-14.2). Age, hypertension, diabetes, ischemic heart disease, or known atrial fibrillation had no significant association with outcome. Defining minor stroke with a lower National Institutes of Health Stroke Scale threshold made no difference - score ≤3: 8.6% (95% CI, 6.0-11.1), score ≤4: 8.4% (95% CI, 6.1-10.6), as did excluding studies with n<500%-7.3% (95% CI, 5.5-9.0).

CONCLUSIONS

The risk of recurrence after minor ischemic stroke is declining over time but remains important.

Is thrombectomy indicated in all ischemic stroke with large vessel occlusion?

PURPOSE OF REVIEW

Purpose of this topical review is to examine the current randomized and nonrandomized evidence evaluating endovascular thrombectomy (EVT) in selected patient populations with acute ischemic stroke due to large vessel occlusions.

RECENT FINDINGS

After establishing EVT as the first-line treatment in patients with large vessel occlusions and limited ischemic changes on neuroimaging, recent trials successfully demonstrated efficacy and safety in patients with large core strokes and those with basilar occlusions up to 24 h of last known well. Nonrandomized evidence in patients with mild stroke severity, baseline disability, medium and distal vessel occlusions and time from last known well >24 h also suggested potential benefit of EVT in selected patients. Further randomized evidence will help establish EVT efficacy and safety in these populations.

SUMMARY

EVT is established as the de-facto treatment of choice in a significant proportion of patients presenting with acute ischemic stroke due to a large vessel occlusion and has shown potential benefits in additional patient subgroups. A rigorous risk-benefit assessment and discussions with patients and their families in the absence of randomized evidence should help facilitate an informed, individualized decision-making process for this revolutionary treatment in peripheral patient subgroups with limited evidence.

Endovascular therapy for acute ischemic stroke with distal medium vessel occlusion: a systematic review and meta-analysis

AIMS

Endovascular therapy (EVT) for distal medium vessel occlusions (DMVOs) is a potential frontier of acute ischemic stroke (AIS) treatment, but its efficacy against best medical therapy (BMT) remains unknown. We performed a systematic review and meta-analysis evaluating the efficacy and safety of EVT versus BMT in primary DMVO.

METHODS

We systematically searched PubMed, Cochrane Library and Embase, from inception to August 14, 2022, for studies comparing EVT with BMT in DMVO-AIS. We adopted the Distal Thrombectomy Summit Group's definition of DMVO. Efficacy outcomes were functional independence (90-day modified Rankin Scale (mRS) 0-2) and excellent functional outcomes (90-day mRS 0-1). Safety outcomes were symptomatic intracranial hemorrhage (sICH) and 90-day mortality.

RESULTS

Fourteen observational and two randomized-controlled studies were included, with 1202 patients receiving EVT and 1267 receiving BMT. After trim-and-fill correction, EVT achieved significantly better odds of functional independence than BMT (adjusted OR 1.61, 95% CI 1.06 to 2.43). There were no significant differences in overall excellent functional outcomes (OR 1.23, 95% CI 0.88 to 1.71), sICH (OR 1.44, 95% CI 0.78 to 2.66), and mortality (OR 1.03, 95% CI 0.73 to 1.45). Stratified by EVT method, mechanical thrombectomy±intra-arterial thrombolysis achieved more excellent functional outcomes than BMT (OR 1.59, 95% CI 1.13 to 2.23). In mild strokes (National Institutes of Health Stroke Scale score <6), EVT caused significantly more sICH (OR 6.30, 95% CI 1.55 to 25.64).

CONCLUSIONS

EVT shows promising efficacy benefit over BMT for primary DMVO-AIS. Further randomized controlled trials are necessary to evaluate the efficacy and safety of EVT in DMVO-AIS.

Endovascular treatment versus medical management for mild stroke with acute anterior circulation large vessel occlusion: a meta-analysis

BACKGROUND

The effectiveness of endovascular treatment (EVT) in patients with mild stroke (National Institutes of Health Stroke Scale score ≤5) and acute anterior circulation large vessel occlusion (AACLVO) remains unknown.

OBJECTIVE

To conduct a meta-analysis to compare the efficacy and safety of EVT in patients with mild stroke and AACLVO.

METHODS

EMBASE, Cochrane Library, PubMed, and Clinicaltrials.gov databases were searched until October 2022. Both retrospective and prospective studies which compared the clinical outcomes between EVT and medical treatment were included. ORs and 95% confidence intervals (CIs) for excellent and favorable functional outcomes, symptomatic intracranial hemorrhage (ICH), and mortality were pooled using a random-effects model. A propensity score (PS)-based methods adjusted analysis was also performed.

RESULTS

4335 patients from 14 studies were included. In patients with mild stroke and AACLVO, EVT presented no marked differences in excellent and favorable functional outcomes and mortality compared with medical treatment. A higher risk of symptomatic ICH (OR=2.79; 95% CI 1.49 to 5.24; P=0.001) was observed with EVT. Subgroup analysis revealed that EVT had potential benefit for proximal occlusions with excellent functional outcomes (OR=1.68; 95% CI 1.01 to 2.82; P=0.05). Similar results were observed when PS-based methods adjusted analysis was used.

CONCLUSION

EVT did not significantly benefit clinical functional outcomes in comparison with medical treatment in patients with mild stroke and AACLVO. However, it may improve functional outcomes when treating patients with proximal occlusion, despite being associated with an increased risk of symptomatic ICH. Stronger evidence from ongoing randomized controlled trials is required.

Mechanical thrombectomy for AIS from large vessel occlusion - current trends and future perspectives

Stroke is found to be one of the global top causes of mortality and the major factor in years of life with a handicap (DALYs). Ischemic strokes contributed to nearly 70% of all strokes worldwide. For endovascular thrombectomy in acute ischemic stroke with large vessel obstruction (AIS-LVO), using stent retrievers and/or reperfusion catheters has become the gold standard of therapy. The methodology involved keyword-based search in databases like PubMed, Embase, and Google Scholar for recent publications on mechanical thrombectomy (MT), AIS, large vessel occlusion (Large Vessel Occlusion (LVO)), screening relevant articles, retrieving full texts, and synthesizing key findings on procedural advancements, patient selection, COVID-19 (coronavirus disease 2019) impact, delay effects, effectiveness, clinical outcomes, and future perspectives. Only people with substantial cerebral artery obstruction may do well from MT. This includes the distal carotid artery and the proximal middle cerebral artery (segment M1). The size of a blocked vessel and NIHSS (National Institute of Health Stroke Scale) score are directly connected. Both the 2018 and 2019 versions of the AHA/ASA (American Heart Association/American Stroke Association) Guidelines for the Early Management of Patients with Acute Ischemic Stroke contained the recommendations that cases with AIS-LVO get endovascular therapy when administered during the time frame of 0-6 h after onset (Grade IA evidence). It is questionable whether this group of patients can be managed without the need for intravenous tissue plasminogen activator at the onset. When functional independence [modified Rankin Scale (mRS) score 2] was present at long-term follow-up, the endovascular intervention was favored. Tenecteplase, which differs from alteplase in terms of genetic variation, has a greater half-life and a higher level of fibrin selectivity, enabling bolus infusion. Studies have also demonstrated its efficacy and safety, as well as its long-term cost-effectiveness.

Predictive Value of Acute Neurological Progression Using Bayesian CT Perfusion for Acute Ischemic Stroke with Large or Median Vessel Occlusion

Objective

Since the efficacy of mechanical thrombectomy (MT) for acute cerebral infarction due to large vessel occlusion has been proven, the time available for treatment has gradually increased. Currently, under certain conditions, treatment is indicated up to 24 h from onset. Based on neurological signs and imaging diagnosis, Stroke Treatment Guideline 2021 recommends initiation of MT within 6-24 h from onset. Herein, we retrospectively investigated the relationship between cerebral perfusion imaging evaluation and prognosis in patients with acute cerebral infarction due to large or median vessel occlusion.

Methods

Fifty-one patients diagnosed with acute cerebral infarction due to large or median vessel occlusions in anterior circulation between November 2019 and December 2021 were divided into medical care and reconstructive therapy (including tissue plasminogen activator [t-PA] therapy and MT) groups. The primary outcome was changes in the National Institutes of Health Stroke Scale (NIHSS) at admission and 1 week after onset. Patients in the medical care group were divided into those whose NIHSS did not worsen and those whose NIHSS worsened. Those in the reconstructive therapy group were divided into those whose NIHSS improved and those whose NIHSS did not improve. We evaluated the relationship between improvement factors in acute neurological symptoms and penumbral and core volumes from computed tomography perfusion performed at admission.

Results

Of 45 eligible patients, 10 received medical care without t-PA or MT and 35 underwent reconstructive therapy, including t-PA and MT. Among the 10 patients in the medical care group, 3 had worsening symptoms and 7 did not. The mean and median (interquartile range [IQR]) penumbra volumes were significantly higher in patients with worsening symptoms than in those without. The receiver operating characteristic (ROC) curve showed a threshold value of 28.6 mL with an area under the curve (AUC) of 0.952. Among the 35 patients in the reconstructive therapy group, symptoms improved for 29 but did not improve for 6. The mean and median (IQR) core volumes were significantly higher in patients whose symptoms did not improve than in those whose symptoms improved. The ROC curve showed a threshold value of 25 mL and an AUC of 0.632.

Conclusion

Evaluation of penumbra volumes could detect cases with worsening symptoms in cases where medical care was performed, and evaluation of core volumes may detect cases with non-improved symptoms in cases that received reconstructive therapy.

Endovascular treatment of acute tandem lesions in patients with mild anterior circulation stroke

BACKGROUND

In patients with mild strokes the risk-benefit ratio of endovascular treatment (EVT) for tandem lesions has yet to be evaluated outside of current guideline recommendations. This study investigates the frequency as well as procedural and safety outcomes in daily clinical practice.

METHODS

Using data from the German Stroke Registry-Endovascular Treatment (GSR-ET) we analyzed patients with anterior circulation stroke due to tandem-lesions and mild deficits. These patients were defined as ≤5 on the National Institutes of Health Stroke Scale (NIHSS). Recanalization was assessed with the modified Thrombolysis in Cerebral Infarction Scale (mTICI). Early neurological and long-term functional outcomes were assessed with the NIHSS change and modified Rankin scale (mRS), respectively. Safety assessment included periprocedural complications and the rate of symptomatic intracerebral hemorrhage (sICH).

RESULTS

A total of 61 patients met the inclusion criteria and were treated endovascularly for tandem lesions. The median age was 68 (IQR:59-76) and 32.9% (20) were female. Patients were admitted to the hospital with a median NIHSS score of 4 (IQR:2-5) and a median Alberta Stroke Programme Early CT Score (ASPECTS) of 9 (IQR:8-10). Successful recanalization (mTICI 2b-3) was observed in 86.9% (53). NIHSS decreased non-significantly (p=0.382) from baseline to two points (IQR:1-9) at discharge. Excellent (mRS≤1) and favorable (mRS≤2) long-term functional outcome at 90-days was 55.8% (29) and 69.2% (36), respectively. Mortality rates at 90-days were 9.6% (5) and sICH occurred in 8.2% (5).

CONCLUSIONS

EVT for tandem lesions in patients with mild anterior circulation stroke appears to be feasible but may lead to increased rates of sICH. Further studies comparing endovascular with best medical treatment (BMT) especially investigating the risk of periprocedural hemorrhagic complications, are needed.

Thrombectomy of Mild Stroke : An Analysis of the Nationwide Registry of the German Society for Neuroradiology

PURPOSE

Whether patients presenting with mild stroke (NIHSS at admission < 6) should be treated with mechanical thrombectomy (MT) is the subject of an ongoing debate. This retrospective study based on large-scale clinical data aims to identify factors associated with favorable outcome (FO) in patients with mild stroke.

METHODS

A total of 761 patients with mild stroke enrolled between 1 January 2020 and 31 December 2020 in the Quality Registry of the German Society for Neuroradiology were analyzed. The FO was defined as stable or improved NIHSS at discharge vs. admission. Descriptive statistics and multivariable logistic regression analyses were performed to identify factors associated with FO. Furthermore, a subgroup analysis of mild stroke based on distal vessel occlusion was conducted.

RESULTS

In this study 610 patients had FO with a median NIHSS at discharge of 1 (interquartile range, IQR, 0-2) and 151 had an unfavorable outcome (UO) with median NIHSS at discharge of 10 (IQR 13). Patients with FO had a slightly higher NIHSS at admission (4 vs. 3, p < 0.001), lower mTICI 0 (2.7% vs. 14.2%, p < 0.001), higher mTICI 3 (61.3% vs. 34.5%, p < 0.001) and a lower number of passes (1 vs. 2, p < 0.001). No statistically significant difference was observed for MT-related adverse events. Multivariable logistic regression suggested that NIHSS at admission (adjusted odds ratio (aOR) = 1.28, 95% confidence interval (CI) = 1.10-1.48), mTICI 2b (aOR = 5.44, CI = 2.06-15.03), mTICI 2c (aOR = 10.81, CI = 3.65-34.07) and mTICI 3 (aOR = 11.56, CI = 4.49-31.10) as well as number of passes (aOR 0.76, CI = 0.66-0.88) were significantly associated with FO. No MT-related adverse events were observed for distal vessel occlusions.

CONCLUSION

The FO in patients with mild stroke undergoing MT was associated with successful recanalization. No significant differences between patients with FO and UO were found for MT-related adverse events, suggesting that MT complications have no significant effects on the outcome of these patients. MT might improve the prognosis also in patients with mild stroke based on distal vessel occlusions without significantly increasing the risk of adverse events.

Thrombectomy vs. medical management for large vessel occlusion strokes with minimal symptoms

Patients with acute ischemic stroke (AIS) presenting mild symptoms with a low National Institutes of Health Stroke Scale (NIHSS) score ≤8 and also found to have an intracranial large vessel occlusion (LVO) undergo endovascular thrombolysis (ET) or medical management alone. The current study aimed to evaluate the safety and effectiveness of medical management vs. ET therapy among patients with mild AIS symptoms (NIHSS score ≤8) accompanied by LVO. The present meta-analysis included articles involving mild AIS, LVO, thrombectomy/ET and medical management alone published in full-text form (from 1980 to 2022). Collected variables included: First author name, covered study period, publication year, the total number of patients and age, number of males, presence of diabetes mellitus, hypertension, atrial fibrillation, prior ischemic stroke, location, NIHSS of admission, modified Rankin scale, bleeding, morbidity and mortality. After the initial search and applying all exclusion and inclusion criteria, eight articles were left in the final article pool. The total number of patients who underwent ET was 569, compared with 1097 with medical management for LVO strokes with minimal symptoms. The findings of the present meta-analysis study point out that ET management may be associated with a high risk of bleeding and mortality in patients with LVO presenting with mild symptoms (NIHSS score ≤8).

Intravenous Thrombolysis or Medical Management for Minor Strokes

OBJECTIVE

 To evaluate the outcomes of acute ischemic stroke patients with minor deficits treated with either intravenous thrombolysis (IVT) or routine medical management (MM).

METHODS

 The study included patients with acute ischemic stroke and National Institutes of Health Stroke Scale (NIHSS) scores of 5 or less who were treated with IVT within 4.5 hours from symptom onset and were classified as the IVT group. The MM group consisted of an equal number of patients with minor strokes, matched for sex, age, and severity, who did not receive thrombolysis. Data on patient information were collected for both groups.

RESULTS

 A total of 26,236 patients were included in this study (13,208 in IVT and 13,208 in MM). Of these patients, 67.9% were men, and the mean age was 67.1 years (standard deviation: 10.9). At 3 months, the IVT group had a higher rate of stroke-independent outcome (Rankin Scale score of 0-2) compared with the MM group (IVT vs. MM: 91.6 vs. 88.6%, absolute difference: 2.5%, 95% confidence interval [CI]: 1.6-3.4%, p = 0.008; adjusted hazard ratio [HR]: 1.2, 95% CI: 1.1-1.4, p = 0.003). Furthermore, there was no significant difference in 3-month mortality rates between the IVT and MM groups (IVT vs. MM: 2.1 vs. 2.5%, absolute difference: -0.6%, 95% CI: -1.1 to 0.3%, p = 0.11; adjusted HR: 0.9, 95% CI: 0.8-1.2, p = 0.09).

CONCLUSION

 Compared with MM, IVT does not reduce mortality in minor ischemic stroke but improves functional outcomes in minor stroke with an NIHSS score of 3 to 5.

Effects of endovascular therapy for mild stroke due to proximal or M2 occlusions: meta-analysis

OBJECTIVE

To conduct a meta-analysis to evaluate the effect of endovascular therapy (EVT) in mild acute ischemic stroke (AIS) due to proximal versus distal occlusions.

METHODS

We searched PubMed, Embase, the Cochrane Library, and clinicaltrials.gov from January 2000 to September 2021 to identify studies comparing EVT versus best medical management (BMM) in AIS with National Institutes of Health Stroke Scale (NIHSS) scores ≤5 due to proximal internal carotid artery (ICA) or M1 versus distal M2 occlusions. We included studies that reported the number of patients with proximal or distal occlusions separately and reported the number of patients with freedom of disability (modified Rankin Scale (mRS) score 0-1) or functional independence (mRS score 0-2) at 90 days in proximal or M2 occlusions, respectively. OR with 95% CI was used.

RESULTS

We identified six studies with 653 proximal ICA and M1 occlusion patients and 666 distal M2 occlusion patients. Pooled results showed EVT versus BMM was associated with a higher rate of being disability-free in patients with proximal occlusions (OR 1.58, 95% CI 1.09 to 2.30), but was associated with a lower rate of being disability-free in patients with M2 occlusions (OR 0.70, 95% CI 0.49 to 0.99). Effect of EVT in proximal versus distal occlusions was substantially different (P for interaction=0.002). A similar pattern was seen for functional independence (P for interaction=0.05).

CONCLUSIONS

For patients with mild AIS, observational data suggest that EVT may be beneficial for proximal ICA or M1 but not for distal M2 occlusions. Randomized trials are needed to confirm these findings.

PROSPERO REGISTRATION NUMBER

CRD42021281034.

Endovascular treatment achieves better outcomes than best medical management in patients with M2 occlusion and high stroke severity: a meta-analysis

BACKGROUND

The lack of randomized evidence makes it difficult to establish reliable treatment recommendations for patients with M2 occlusion. This study aims to compare the efficacy and safety of endovascular treatment (EVT) with best medical management (BMM) in patients with M2 occlusion, and to investigate whether the optimal treatment varies according to stroke severity.

METHODS

Comprehensive literature retrieval was conducted to identify studies that directly compared the outcomes of EVT and BMM. According to stroke severity, the study population were classified into those with moderate-severe stroke and those with mild stroke. National Institute of Health Stroke Scale (NIHSS) scores ≥ 6 was defined as moderate-severe stroke, and NIHSS scores 0-5 as mild stroke. Random-effects meta-analyses were performed to measure the symptomatic intracranial hemorrhage (sICH) within 72 h, and the modified Rankin Scale (mRS) scores 0-2 and the mortality at 90 days.

RESULTS

Totally, 20 studies were identified, including 4358 patients. In the moderate-severe stroke population, the EVT had 82% higher odds for mRS scores 0-2 (OR 1.82, 95% CI 1.34-2.49) and a 43% lower odds for mortality (OR 0.57, 95% CI 0.39-0.82) compared with the BMM. However, no difference was found in the sICH rate (OR 0.88, 95% CI 0.44-1.77). In the mild stroke population, no differences were observed in the mRS scores 0-2 (OR 0.81, 95% CI 0.59-1.10) or mortality (OR 1.23, 95% CI 0.72-2.10) between EVT and BMM, whereas EVT was associated with higher sICH rate (OR 4.21, 95% CI 1.86-9.49).

CONCLUSION

EVT may be only beneficial for patients with M2 occlusion and high stroke severity, but not for those with NIHSS scores 0-5.

Complete recanalization predicts favorable outcome in patients with distal M2-M3 middle cerebral artery occlusions following endovascular thrombectomy

BACKGROUND

- scanty articles illustrate the prognostic factors for favorable outcome after endovascular thrombectomy (EVT) in distal vessel occlusion (DMVO). Moreover, the current literature is diversified; conglomerating both primary, secondary, and anterior, posterior circulations embolic strokes in the same shell.

PURPOSE

to identify the association between complete reperfusion and favorable outcome following EVT for DMVO in the middle cerebral artery (MCA) territory.

METHODS

-we performed a retrospective analysis of prospectively maintained EVT registries at two comprehensive stroke centers between January 2015 and December 2019 for consecutive stroke patients with MCA-DMVO. DMVO was defined as an occlusion of distal M2 and M3 segments of the MCA. Only patients with primary isolated occlusions were included. A multivariate logistic regression was utilized to identify clinical and procedural-related factors associated with the 90-day favorable clinical outcome [defined as modified Rankin score (mRS) 0-2] after EVT.

RESULTS

-Out of 1823 within the registries; 66 patients (median age was 72 (60-78) and 59% were males) with primary isolated DMVO of the MCA were eligible for inclusion in the current study. Complete reperfusion was achieved in 56% (37/66) of the patients with no difference among the reperfusion strategies while the favorable outcome was observed in 68% (45/66). In the multivariate analysis, final complete reperfusion [modified Thrombolysis In Cerebral Infarction (mTICI) score 2c-3] was significantly associated with favorable outcome [aOR=7.69; (95% CI 1.73-34.17); p=.01], while higher baseline NIHSS score [aOR=0.82; (95% CI 0.69-0.98); p=.03] and increased imaging to puncture interval [aOR=0.99; (95% CI 0.98, 1.00); p=.01] decreased the probability of the favorable outcome.

CONCLUSION

according to our results, complete reperfusion was the most significant predictor of the favorable outcome, while higher baseline NIHSS and longer imaging to puncture interval decreased the probability of the favorable outcome.

Association of Perfusion Lesion Variables With Functional Outcome in Patients With Mild Stroke and Large Vessel Occlusion Managed Medically

BACKGROUND AND OBJECTIVES

The best management of patients with mild stroke and large vessel occlusion (LVO) remains unclear. This study aimed to identify perfusion imaging predictors of poor functional outcome in such patients.

METHODS

This cohort study retrospectively selected patients enrolled in the International Stroke Perfusion Imaging Registry between August 2011 and April 2022. The registry enrolled patients with acute ischemic stroke and with baseline CT perfusion scanned within 24 hours of stroke onset. This study identified patients with mild symptoms, defined by an NIH Stroke Scale score of ≤5. Patients with LVO of anterior circulation were selected. This study further selected patients who received medical management and excluded patients who received endovascular treatment. The primary outcome was poor functional outcome defined as a modified Rankin Scale of 3-6 at 3 months. Perfusion lesion was defined by delay time > 3 seconds on CTP. Regression analyses were used to identify clinical and imaging variables that predicted poor functional outcome.

RESULTS

A total of 139 patients with mild stroke were included, of whom 27 (19%) had poor functional outcome. Patients with poor outcome, compared with those with good outcome, had much larger perfusion lesion volume (median 80 mL vs 41 mL, p < 0.001). Perfusion lesion was a significant predictor of poor outcome in either univariable regression (crude OR = 1.02, 95% CI = [1.01-1.03]) or multivariable regression model (adjusted OR = 1.01, 95% CI = [1.01-1.02]), adjusting for occlusion site, good collaterals, baseline stroke severity, age, IV thrombolysis (IVT), and onset to scan time. A perfusion lesion of 65 mL was the optimal cutpoint to identify poor functional outcome (sensitivity = 59%, specificity = 77%). Patients with perfusion lesion ≥65 mL, compared with patients with perfusion lesion <65 mL, showed a much higher rate of poor functional outcome (38% vs 11%, p < 0.001). Of the 139 patients in this study, 95 received IVT. Patients treated with or without IVT did not influence their outcomes (crude OR = 0.74, 95% CI = [0.31-1.78]).

DISCUSSION

A perfusion lesion of ≥65 mL predicted poor functional outcome in mild stroke patients with LVO.

Outcomes after endovascular mechanical thrombectomy for low compared to high National Institutes of Health Stroke Scale (NIHSS): A multicenter study

OBJECTIVE

The role of endovascular mechanical thrombectomy (MT) in patients presenting with "minor" stroke is uncertain. We aimed to compare outcomes after MT for ischemic stroke patients presenting with National Institutes of Health Stroke Scale (NIHSS) 5 and - within the low NIHSS cohort - identify predictors of a favorable outcome, mortality, and symptomatic intracranial hemorrhage (ICH).

METHODS

We retrospectively analyzed a prospectively maintained, international, multicenter database.

RESULTS

The study cohort comprised a total of 7568 patients from 29 centers. NIHSS was low (<5) in 604 patients (8%), and > 5 in 6964 (92%). Patients with low NIHSS were younger (67 + 14.8 versus 69.6 + 14.7 years, p < 0.001), more likely to have diabetes (31.5% versus 26.9%, p = 0.016), and less likely to have atrial fibrillation (26.6% versus 37.6%, p < 0.001) compared to those with higher NIHSS. Radiographic outcomes (TICI > 2B 84.6% and 84.3%, p = 0.412) and complication rates (8.1% and 7.2%, p = 0.463) were similar between the low and high NIHSS groups, respectively. Clinical outcomes at every follow up interval, including NIHSS at 24 h and discharge, and mRS at discharge and 90 days, were better in the low NIHSS group, however patients in the low NIHSS group experienced a relative decline in NIHSS from admit to discharge. Mortality was lower in the low NIHSS group (10.4% versus 24.5%, p < 0.001).

CONCLUSIONS

Relative to patients with high NIHSS, MT is safe and effective for stroke patients with low NIHSS, and it is reasonable to offer it to appropriately selected patients presenting with minor stroke symptoms. Our findings justify efforts towards a randomized trial comparing MT versus medical management for patients with low NIHSS.

Assessing the Efficacy of Mechanical Thrombectomy in Patients with an NIHSS < 6 Presenting with Proximal Middle Cerebral Artery Vessel Occlusion as Compared to Best Medical Management

BACKGROUND AND PURPOSE

Minor acute ischemic stroke (AIS) patients-defined by an NIHSS score < 6-presenting with proximal middle cerebral artery large vessel occlusions (MCA-LVO) is a subgroup for which treatment is still debated. Although these patients present with minor symptoms initially, studies have shown that several patients afflicted with MCA-LVO in this subgroup experience cognitive and functional decline. Although mechanical thrombectomy (MT) is the standard of care for patients with an NIHSS score of 6 or higher, treatment in the minor stroke subgroup is still being explored. The purpose of this preliminary study is to report our center's experience in evaluating the potential benefit of mechanical thrombectomy (MT) in minor stroke patients when compared to medical management (MM).

METHODS

We performed a retrospective study with two comprehensive stroke centers within our hospital enterprise of consecutive patients presenting with minor AIS secondary to MCA-LVO (defined as M1 or proximal M2 segments of MCA). We subsequently evaluated patients who received MT versus those who received MM.

RESULTS

Between January 2017 and July 2021, we identified 46 AIS patients (11 treated with MT and 35 treated with MM) who presented with an NIHSS score < 6 secondary to MCA-LVO (47.8% 22/46 female, mean age 62.3 years, range 49-75 years). MT was associated with a significantly lower mRS at 90 days (median: 1.0 [IQR 0.0-2.0] versus 3.0 [IQR 1.0-4.0], p = <0.001), a favorable NIHSS shift (-4.0 [IQR -10.0--2.0] versus 0.0 [IQR -2.0-1.0], p = 0.002), favorable NIHSS shift dichotomization (5/11, 45.5% versus 3/35, 8.6%, p = 0.003) and favorable mRS dichotomization (7/11, 63.6% versus 14/35, 40.0%, p = 0.024).

CONCLUSIONS

In our center's preliminary experience, for AIS patients presenting with an NIHSS score < 6 secondary to MCA-LVO, MT may be associated with improved clinical outcomes when compared to MM only.

Sex differences in the utilization and outcomes of endovascular treatment after acute ischemic stroke: A systematic review and meta-analysis

Background

Studies of sex differences in the use and outcomes of endovascular treatment (EVT) for acute ischemic stroke report inconsistent results.

Methods

We systematically searched PubMed and Embase databases for studies examining sex-specific utilization of EVT for acute ischemic stroke published before 31 December 2021. Estimates were compared by study type: randomized clinical trials (RCTs) and non-RCTs (hospital-based, registry-based or administrative data). Random effects odds ratios (ORs) were generated to quantify sex differences in EVT use. To estimate sex differences in functional outcome on the modified Rankin scale after EVT, the female:male ratio of ORs and 95% confidence intervals (CIs) were obtained from ordinal or binary analysis.

Results

6,396 studies were identified through database searching, of which 594 qualified for a full review. A total of 51 studies (36 non-RCT and 15 RCTs) reporting on sex-specific utilization of EVT were included, and of those 10 estimated the sex differences of EVT on functional outcomes. EVT use was similar in women and men both in non-RCTs (OR: 1.03, 95% CI: 0.96-1.11) and RCTs (1.02, 95% CI: 0.89-1.16), with consistent results across years of publication and regions of study, except that in Europe EVT treatment was higher in women than men (1.15, 95% CI: 1.13-1.16). No sex differences were found in the functional outcome by either ordinal and binary analyses (ORs 0.95, 95% CI: 0.68-1.32] and 0.90, 95% CI: 0.65-1.25, respectively).

Conclusions

No sex differences in EVT utilization or on functional outcomes were evident after acute ischemic stroke from large-vessel occlusion. Further research may be required to examine sex differences in long-term outcomes, social domains, and quality of life.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=226100, identifier: CRD42021226100.

Quality metrics in the management of acute stroke in Greece during the first 5 years of Registry of Stroke Care Quality (RES-Q) implementation

Introduction

Establishment of a prospective stroke registry may promote the documentation and improvement of acute stroke care. We present the status of stroke management in Greece using the Registry of Stroke Care Quality (RES-Q) dataset.

Methods

Consecutive patients with acute stroke were prospectively registered in RES-Q registry by contributing sites in Greece during the years 2017-2021. Demographic and baseline characteristics, acute management, and clinical outcomes at discharge were recorded. Stroke quality metrics, with a specific interest in the association between acute reperfusion therapies and functional recovery in ischemic stroke patients are presented.

Results

A total of 3590 acute stroke patients were treated in 20 Greek sites (61% men, median age 64 years; median baseline NIHSS 4; 74% ischemic stroke). Acute reperfusion therapies were administered in almost 20% of acute ischemic stroke patients, with a door to needle and door to groin puncture times of 40 and 64 min, respectively. After adjustment for contributing sites, the rates of acute reperfusion therapies were higher during the time epoch 2020-2021 compared to 2017-2019 (adjusted OR 1.31; 95% CI 1.04-1.64; p < 0.022; Cochran-Mantel-Haenszel test). After propensity-score-matching, acute reperfusion therapies administration was independently associated with higher odds of reduced disability (one point reduction across all mRS scores) at hospital discharge (common OR 1.93; 95% CI 1.45-2.58; p < 0.001).

Conclusions

Implementation and maintenance of a nationwide stroke registry in Greece may guide the stroke management planning, so that prompt patient transportation, acute reperfusion therapies, and stroke unit hospitalization become more widely accessible, improving the functional outcomes of stroke patients.

Endovascular Treatment for Minor Acute Ischemic Strokes With Large Vessel Occlusion

Background It remains uncertain whether patients with minor acute ischemic stroke with large vessel occlusion benefit from endovascular treatment (EVT). We aim to evaluate the outcomes of EVT in minor acute ischemic stroke with anterior circulation large vessel occlusion. Methods and Results Based on a nationwide prospective stroke registry, patients with minor acute ischemic stroke with anterior circulation large vessel occlusion within 24 hours of onset were divided into groups receiving standard medical treatment plus EVT or standard medical treatment alone. Primary outcome was excellent functional outcome defined as modified Rankin Scale score 0 to 1 at 90 days. In addition, a multivariable logistic regression model was used to analyze the effect of EVT guided by perfusion imaging. A total of 572 patients with median age 68 years (interquartile range=60-77) and median National Institutes of Health Stroke score 3 (interquartile range =2-4) were identified and 123 patients were treated with standard medical treatment plus EVT. EVT was not associated with excellent functional outcome (unadjusted odds ratio [OR], 0.771 [95% CI, 0.516-1.151]; adjusted OR, 0.793 [95% CI, 0.515-1.219]; P=0.290). However, therapy selection guided by perfusion imaging was a modifier of EVT effect on outcomes, as EVT was significantly associated with excellent functional outcome (60.0% versus 50.8%, unadjusted OR, 1.451 [95% CI, 0.643-3.272]; adjusted OR, 2.849 [95% CI, 1.006-8.067]; P=0.049) but not with symptomatic intracerebral hemorrhage in the imaging-guided group. Conclusions Although functional outcomes in minor acute ischemic stroke caused by anterior circulation large vessel occlusion were not improved from the routine use of EVT, our results suggested that EVT guided by perfusion imaging could be beneficial for those patients. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04487340.

Acute ischaemic stroke: recent advances in reperfusion treatment

During the last 5–7 years, tremendous progress was achieved in the reperfusion treatment of acute ischaemic stroke during its first few hours from symptom onset. This review summarizes the latest evidence from randomized clinical trials and prospective registries with a focus on endovascular treatment using stent retrievers, aspiration catheters, thrombolytics, and (in selected patients) carotid stenting. Novel approaches in prehospital (mobile interventional stroke teams) and early hospital (direct transfer to angiography) management are described, and future perspectives (‘all-in-one’ laboratories with angiography and computed tomography integrated) are discussed. There is reasonable chance for patients with moderate-to-severe acute ischaemic stroke to survive without permanent sequelae when the large-vessel occlusion is removed by means of modern pharmaco-mechanic approach. Catheter thrombectomy is now the golden standard of acute stroke treatment. The role of cardiologists in stroke is expanding from diagnostic help (to reveal the cause of stroke) to acute therapy in those regions where such up-to-date Class I. A treatment is not yet available.

Thrombectomy versus Medical Management in Mild Strokes due to Large Vessel Occlusion: Exploratory Analysis from the EXTEND-IA Trials and a Pooled International Cohort

OBJECTIVE

This study was undertaken to evaluate functional and safety outcomes for endovascular thrombectomy (EVT) versus medical management (MM) in patients with large vessel occlusion (LVO) and mild neurological deficits, stratified by perfusion imaging mismatch.

METHODS

The pooled cohort consisted of patients with National Institutes of Health Stroke Scale (NIHSS) < 6 and internal carotid artery (ICA), M1, or M2 occlusions from the Extending the Time for Thrombolysis in Emergecy Neurological Deficits - Intra-Arterial (EXTEND-IA) Trial,  Tenecteplase vs Alteplase before Endovascular Thrombectomy in Ischemic Stroke (EXTEND-IA TNK) trials Part I/II and prospective data from 15 EVT centers from October 2010 to April 2020. RAPID software estimated ischemic core and mismatch. Patients receiving primary EVT (EVT_pri ) were compared to those who received primary MM (MM_pri ), including those who deteriorated and received rescue EVT, in overall and propensity score (PS)-matched cohorts. Patients were stratified by target mismatch (mismatch ratio ≥ 1.8 and mismatch volume ≥ 15ml). Primary outcome was functional independence (90-day modified Rankin Scale = 0-2). Secondary outcomes included safety (symptomatic intracerebral hemorrhage [sICH], neurological worsening, and mortality).

RESULTS

Of 540 patients, 286 (53%) received EVT_pri and demonstrated larger critically hypoperfused tissue (Tmax > 6 seconds) volumes (median [IQR]: 64 [26-96] ml vs MM_pri : 40 [14-76] ml, p < 0.001) and higher presentation NIHSS (median [IQR]: 4 [2-5] vs MM_pri : 3 [2-4], p < 0.001). Functional independence was similar (EVT_pri : 77.4% vs MM_pri : 75.6%, adjusted odds ratio [aOR] = 1.29, 95% confidence interval [CI] = 0.82-2.03, p = 0.27). EVT had worse safety regarding sICH (EVT_pri : 16.3% vs MM_pri : 1.3%, p < 0.001) and neurological worsening (EVT_pri : 19.6% vs MM_pri : 6.7%, p < 0.001). In 414 subjects (76.7%) with target mismatch, EVT was associated with improved functional independence (EVT_pri : 77.4% vs MM_pri : 72.7%, aOR = 1.68, 95% CI = 1.01-2.81, p = 0.048), whereas there was a trend toward less favorable outcomes with primary EVT (EVT_pri : 77.4% vs MM_pri : 83.3%, aOR = 0.39, 95% CI = 0.12-1.34, p = 0.13) without target mismatch (p_interaction  = 0.06). Similar findings were observed in a propensity score-matched subpopulation.

INTERPRETATION

Overall, EVT was not associated with improved clinical outcomes in mild strokes due to LVO, and sICH was increased. However, in patients with target mismatch profile, EVT was associated with increased functional independence. Perfusion imaging may be helpful to select mild stroke patients for EVT. ANN NEUROL 2022;92:364-378.

Effectiveness and safety of EVT in patients with acute LVO and low NIHSS

Background and purpose

There is much uncertainty in endovascular treatment (EVT) decisions in patients with acute large vessel occlusion (LVO) and mild neurological deficits.

Methods

From a prospective, nationwide stroke registry, all patients with LVO and baseline NIHSS &lt;6 presenting within 24 h from the time last known well (LKW) were included. Early neurological deterioration (END) developed before EVT was prospectively collected as an increasing total NIHSS score ≥2 or any worsening of the NIHSS consciousness or motor subscores during hospitalization not related to EVT. Significant hemorrhage was defined as PH2 hemorrhagic transformation or hemorrhage at a remote site. The modified Rankin Scale (mRS) was prospectively collected at 3 months.

Results

Among 1,083 patients, 149 (14%) patients received EVT after a median of 5.9 [3.6–12.3] h after LKW. In propensity score-matched analyses, EVT was not associated with mRS 0-1 (matched OR 0.99 [0.63–1.54]) but increased the risk of a significant hemorrhage (matched OR, 4.51 [1.59–12.80]). Extraneous END occurred in 207 (19%) patients after a median of 24.5 h [IQR, 13.5–41.9 h] after LKW (incidence rate, 1.41 [95% CI, 1.23–1.62] per 100 person-hours). END unrelated to EVT showed a tendency to modify the effectiveness of EVT (P-for-interaction, 0.08), which decreased the odds of having mRS 0–1 in mild LVO patients without END (adjusted OR, 0.63 [0.40–0.99]).

Conclusions

The use of EVT in patients with acute LVO and low NIHSS scores may require the assessment of individual risks of early deterioration, hemorrhagic complications and expected benefit.

Endovascular Treatment for Posterior Circulation Stroke: Ways to Maximize Therapeutic Efficacy

The efficacy of endovascular treatment (EVT) in patients with posterior circulation stroke has not been proven. Two recent randomized controlled trials failed to show improved functional outcomes after EVT for posterior circulation stroke (PC-EVT). However, promising results for two additional randomized controlled trials have also been presented at a recent conference. Studies have shown that patients undergoing PC-EVT had a higher rate of futile recanalization than those undergoing EVT for anterior circulation stroke. These findings call for further identification of prognostic factors beyond recanalization. The significance of baseline clinical severity, infarct volume, collaterals, time metrics, core-penumbra mismatch, and methods to accurately measure these parameters are discussed. Furthermore, their interplay on EVT outcomes and the potential to individualize patient selection for PC-EVT are reviewed. We also discuss technical considerations for improving the treatment efficacy of PC-EVT.

The End of Tissue-Type Plasminogen Activator's Reign?

Mechanical thrombectomy is a highly effective treatment for acute ischemic stroke caused by large-vessel occlusion in the anterior cerebral circulation, significantly increasing the likelihood of recovery to functional independence. Until recently, whether intravenous thrombolysis before mechanical thrombectomy provided additional benefits to patients with acute ischemic stroke-large-vessel occlusion remained unclear. Given that reperfusion is a key factor for clinical outcome in patients with acute ischemic stroke-large-vessel occlusion and the efficacy of both intravenous thrombolysis and mechanical thrombectomy is time-dependent, achieving complete reperfusion with a single pass should be the primary angiographic goal. However, it remains undetermined whether extending the procedure with additional endovascular attempts or local lytics administration safely leads to higher reperfusion grades and whether there are significant public health and cost implications. Here, we outline the current state of knowledge and research avenues that remain to be explored regarding the consistent therapeutic benefit of intravenous thrombolysis in anterior circulation strokes and the potential place of adjunctive intra-arterial lytics administration, including alternative thrombolytic agent place.

Decision-making strategies for reperfusion therapies: navigating through stroke trials gaps

Despite there being a robust amount of literature and numerous randomized clinical trials regarding acute ischemic stroke treatment, the trials have not included some frequent controversial situations for which decision-making strategies are an urgent and unmet need in clinical practice. This article tries to summarize the current evidence about some selected situations (mechanical thrombectomy in low ASPECTS, low NIHSS with proximal occlusion, acute basilar occlusion, distal and medium vessel occlusion, among others), make suggestions on how to approach them in clinical practice and show what to expect in acute stroke research in the near future.

Tenecteplase versus Alteplase for Stroke Thrombolysis Evaluation Trial in the Ambulance (Mobile Stroke Unit-TASTE-A): protocol for a prospective randomised, open-label, blinded endpoint, phase II superiority trial of tenecteplase versus alteplase for ischaemic stroke patients presenting within 4.5 hours of symptom onset to the mobile stroke unit

INTRODUCTION

Mobile stroke units (MSUs) equipped with a CT scanner are increasingly being used to assess and treat stroke patients' prehospital with thrombolysis and transfer them to the most appropriate hospital for ongoing stroke care and thrombectomy when indicated. The effect of MSUs in both reducing the time to reperfusion treatment and improving patient outcomes is now established. There is now an opportunity to improve the efficacy of treatment provided by the MSU. Tenecteplase is a potent plasminogen activator, which may have benefits over the standard of care stroke lytic alteplase. Specifically, in the MSU environment tenecteplase presents practical benefits since it is given as a single bolus and does not require an infusion over an hour like alteplase.

OBJECTIVE

In this trial, we seek to investigate if tenecteplase, given to patients with acute ischaemic stroke as diagnosed on the MSU, improves the rate of early reperfusion.

METHODS AND ANALYSIS

TASTE-A is a prospective, randomised, open-label, blinded endpoint (PROBE) phase II trial of patients who had an ischaemic stroke assessed in an MSU within 4.5 hours of symptom onset. The primary endpoint is early reperfusion measured by the post-lysis volume of the CT perfusion lesion performed immediately after hospital arrival.

ETHICS AND DISSEMINATION

The study was approved by the Royal Melbourne Hospital Human Ethics committee. The findings will be published in peer-reviewed journals, presented at academic conferences and disseminated among consumer and healthcare professional audiences.

TRIAL REGISTRATION NUMBER

NCT04071613.

Personalized Neurophysiological and Neuropsychological Assessment of Patients with Left and Right Hemispheric Damage in Acute Ischemic Stroke

The leading factors of post-stroke disability are motor disorders and cognitive dysfunctions. The aim of the study was to identify and provide a rationale for the variable early cognitive dysfunction in right and left hemispheric damage in patients with acute stroke. The study included 80 patients diagnosed with ischemic stroke. All patients were assessed for cognitive status, depression, fatigue and anxiety. For objectification, the method of evoked potentials (P300) and neuroimaging were used. Our findings revealed distinguishing features of cognitive dysfunction and identified a combination of the most informative markers characteristic of right and left hemispheric damage in patients with acute ischemic stroke. In patients with damage to the left hemisphere, a predominance of dysregulation syndrome (decrease in executive function and attention) was revealed, accompanied by various disorders such as severe anxiety and fatigue. The causes of this cognitive dysfunction may be directly related to stroke (damage to subcortical structures), as well as to a preexisting reduction in higher mental functions associated with age and vascular conditions. Cognitive impairments in patients with lesions of the right hemisphere were characterized by polymorphism and observed in the mental praxis, speech (with predominant semantic component) and abstract thinking domains. They are closely linked to each other and are more related to the lateralization of the lesion and preexisting neurodegeneration than to the localization of the ischemic lesion. The study of P300-evoked potentials is a good tool for confirming cognitive dysfunction. The latent period of the P300 wave is more sensitive to neurodegeneration, while the amplitude factor characterizes vascular pathology to a greater extent. The results of the study provide a rationale for a comprehensive assessment of lateralization, stroke localization, underlying diseases, neurophysiological parameters and identified cognitive impairments when developing a plan of rehabilitation and neuropsychological measures aimed at cognitive and emotional recovery of patients both in the acute phase of ischemic stroke and when selecting further personalized rehabilitation programs.

Mechanical Thrombectomy for Mild Acute Ischemic Stroke with Large-Vessel Occlusion: A Systematic Review and Meta-Analysis

BACKGROUND

The functional prognosis of mechanical thrombectomy (MT) for mild acute ischemic stroke (AIS) with large-vessel occlusion (LVO) is controversial. To explore a more precise estimation, a meta-analysis was conducted.

METHODS

The relevant studies were identified by searching PubMed, Embase, Web of Science, and Cochrane Collaboration Database until October 2021. The pooled analysis, subgroup analysis, sensitivity analysis, and publication bias examination were all conducted. The meta-analysis was performed by using Stata 12.0.

RESULTS

Eleven studies were included with a total of 1,929 subjects, including 794 patients receiving MT and 1,135 patients receiving medical management. The pooled analysis showed that MT might be not associated with functional prognosis among mild AIS with LVO (excellent functional prognosis: risk ratio (RR) = 1.07, 95% confidence interval (CI) = 0.94-1.21, p = 0.294; favorable functional prognosis: RR = 1.01, 95% CI = 0.96-1.06, p = 0.823). The statistical stability and reliability were demonstrated by the sensitivity analysis and publication bias outcomes.

CONCLUSION

Our meta-analysis suggests that MT may be not associated with functional prognosis of mild AIS with LVO.

Mechanical Thrombectomy in Patients Presenting with NIHSS Score <6: A Safety and Efficacy Analysis

BACKGROUND AND OBJECTIVES

Groundbreaking trials have shown the tremendous efficacy of mechanical thrombectomy for large vessel occlusions. Currently, mechanical thrombectomy is limited to patients with NIHSS scores ≥6. We investigated the feasibility and safety of MT in patients presenting with NIHSS scores <6.

MATERIALS AND METHODS

A retrospective review of patient who presented with acute ischemic stroke due to large vessel occlusion with an NIHSS score <6 between 2015 - 2021. The patients were then divided into two groups: those who received mechanical thrombectomy and those who did not.

RESULTS

Among 83 patients, 41 received a mechanical thrombectomy while 42 received medical treatment only. The mean age in the mechanical thrombectomy group was 66 years versus 60 years in the medical group (p = 0.06). Risk factors for stroke did not differ significantly between both groups. 14 patients (34.1%) in the mechanical thrombectomy group and 20 (47.6%) in the medical group received tissue plasminogen activator. No significant difference in clinical improvement (NIHSS) at discharge (p=0.85) or the mRS score at 90 days (p = 0.15) was noted. Mechanical thrombectomy was associated with smaller infarct size (p=0.04) and decreased mortality (p=0.03).

CONCLUSIONS

Mechanical thrombectomy is safe and effective for patients who present with large vessel occlusions and low initial NIHSS scores. Therefore, the decision to offer the patient mechanical thrombectomy or not should not be decided by NIHSS score alone. Rather, the decision should be multifactorial with the aim of maximizing the patients' outcomes.

Mechanical Thrombectomy for Acute Stroke Due to Large-Vessel Occlusion Presenting With Mild Symptoms

Purpose: To evaluate the safety and efficacy of mechanical thrombectomy (MT) for acute stroke due to large vessel occlusion (LVO), presenting with mild symptoms.

Methods: A prospective cohort study of patients with mild ischemic stroke and LVO was conducted. Patients were divided into two groups: MT group or best medical management (MM) group. Propensity score matching (PSM) was conducted to reduce the confounding bias between the groups. The primary outcome was functional independence at 90 days. The safety outcome was symptomatic intracranial hemorrhage (sICH). Univariate and multivariate logistic regression analyses were used to identify the independent factors associated with outcomes.

Results: Among the 105 included patients, 43 were in the MT group and 62 in the MM group. Forty-three pairs of patients were generated after PSM. There were no significant differences in sICH rates between two groups (p = 1.000). The MT group had a higher proportion of independent outcomes (83.7% MT vs. 67.4% MM; OR 2.483; 95% CI 0.886–6.959; p = 0.079) and excellent outcomes (76.7% MT vs. 51.2% MM; OR 3.150; 95% CI 1.247–7.954; p = 0.013) compared to the MM group, especially in patients with stroke of the anterior circulation (p < 0.05). Multivariate logistic regression analysis showed that small infarct core volume (p = 0.015) and MT treatment (p = 0.013) were independently associated with excellent outcomes.

Conclusions: Our results suggest that MT in stroke patients, presenting with mild symptoms, due to acute LVO in the anterior circulation may be associated with satisfactory clinical outcomes.

Clinical Trial Registration:ClinicalTrials.gov, identifier: NCT04526756.

Effectiveness of Thrombectomy in Stroke According to Baseline Prognostic Factors: Inverse Probability of Treatment Weighting Analysis of a Population-Based Registry

Background and Purpose

 In real-world practice, the benefit of mechanical thrombectomy (MT) is uncertain in stroke patients with very favorable or poor prognostic profiles at baseline. We studied the effectiveness of MT versus medical treatment stratifying by different baseline prognostic factors.

Methods

 Retrospective analysis of 2,588 patients with an ischemic stroke due to large vessel occlusion nested in the population-based registry of stroke code activations in Catalonia from January 2017 to June 2019. The effect of MT on good functional outcome (modified Rankin Score ≤2) and survival at 3 months was studied using inverse probability of treatment weighting (IPTW) analysis in three pre-defined baseline prognostic groups: poor (if pre-stroke disability, age >85 years, National Institutes of Health Stroke Scale [NIHSS] >25, time from onset >6 hours, Alberta Stroke Program Early CT Score <6, proximal vertebrobasilar occlusion, supratherapeutic international normalized ratio >3), good (if NIHSS <6 or distal occlusion, in the absence of poor prognostic factors), or reference (not meeting other groups’ criteria).

Results

 Patients receiving MT (n=1,996, 77%) were younger, had less pre-stroke disability, and received systemic thrombolysis less frequently. These differences were balanced after the IPTW stratified by prognosis. MT was associated with good functional outcome in the reference (odds ratio [OR], 2.9; 95% confidence interval [CI], 2.0 to 4.4), and especially in the poor baseline prognostic stratum (OR, 3.9; 95% CI, 2.6 to 5.9), but not in the good prognostic stratum. MT was associated with survival only in the poor prognostic stratum (OR, 2.6; 95% CI, 2.0 to 3.3).

Conclusions

 Despite their worse overall outcomes, the impact of thrombectomy over medical management was more substantial in patients with poorer baseline prognostic factors than patients with good prognostic factors.

Overview of Acute Ischemic Stroke Evaluation and Management

Stroke is a major contributor to death and disability worldwide. Prior to modern therapy, post-stroke mortality was approximately 10% in the acute period, with nearly one-half of the patients developing moderate-to-severe disability. The most fundamental aspect of acute stroke management is "time is brain". In acute ischemic stroke, the primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction. Several landmark endovascular thrombectomy trials were found to be of benefit in select patients with acute stroke caused by occlusion of the proximal anterior circulation, which has led to a paradigm shift in the management of acute ischemic strokes. In this modern era of acute stroke care, more patients will survive with varying degrees of disability post-stroke. A comprehensive stroke rehabilitation program is critical to optimize post-stroke outcomes. Understanding the natural history of stroke recovery, and adapting a multidisciplinary approach, will lead to improved chances for successful rehabilitation. In this article, we provide an overview on the evaluation and the current advances in the management of acute ischemic stroke, starting in the prehospital setting and in the emergency department, followed by post-acute stroke hospital management and rehabilitation.

Similar admission NIHSS may represent larger tissue-at-risk in patients with right-sided versus left-sided large vessel occlusion

BACKGROUND

We investigated the effects of the side of large vessel occlusion (LVO) on post-thrombectomy infarct volume and clinical outcome with regard to admission National Institutes of Health Stroke Scale (NIHSS) score.

METHODS

We retrospectively identified patients with anterior LVO who received endovascular thrombectomy and follow-up MRI. Applying voxel-wise general linear models and multivariate analysis, we assessed the effects of occlusion side, admission NIHSS, and post-thrombectomy reperfusion (modified Thrombolysis in Cerebral Infarction, mTICI) on final infarct distribution and volume as well as discharge modified Rankin Scale (mRS) score.

RESULTS

We included 469 patients, 254 with left-sided and 215 with right-sided LVO. Admission NIHSS was higher in those with left-sided LVO (median (IQR) 16 (10-22)) than in those with right-sided LVO (14 (8-16), p>0.001). In voxel-wise analysis, worse post-thrombectomy reperfusion, lower admission NIHSS score, and poor discharge outcome were associated with right-hemispheric infarct lesions. In multivariate analysis, right-sided LVO was an independent predictor of larger final infarct volume (p=0.003). There was a significant three-way interaction between admission stroke severity (based on NIHSS), LVO side, and mTICI with regard to final infarct volume (p=0.041). Specifically, in patients with moderate stroke (NIHSS 6-15), incomplete reperfusion (mTICI 0-2b) was associated with larger final infarct volume (p<0.001) and worse discharge outcome (p=0.02) in right-sided compared with left-sided LVO.

CONCLUSIONS

When adjusted for admission NIHSS, worse post-thrombectomy reperfusion is associated with larger infarct volume and worse discharge outcome in right-sided versus left-sided LVO. This may represent larger tissue-at-risk in patients with right-sided LVO when applying admission NIHSS as a clinical biomarker for penumbra.

Reperfusion Therapies for Children With Arterial Ischemic Stroke

ABSTRACT

Modern hyperacute reperfusion therapies including intravenous thrombolysis and mechanical thrombectomy have transformed the management of arterial ischemic stroke (AIS) in adults. Multiple randomized clinical trials have demonstrated that these therapies enable remarkable improvements in clinical outcome for properly selected patients with AIS. Because pediatric patients were excluded from predicate clinical trials, there is a conspicuous lack of data to guide selection of therapies and inform age-adjusted and pathology-oriented treatment modifications for children. Specifically, technical guidance concerning treatment eligibility, drug dosing, and device implementation is lacking. This review aims to outline important features that differentiate pediatric AIS from adult AIS and provide practical strategies that will assist the stroke specialist with therapeutic decision making.

Reasons for Not Performing Mechanical Thrombectomy: A Population-Based Study of Stroke Codes

[Figure: see text].

Advances in mechanical thrombectomy for acute ischaemic stroke from large vessel occlusions

Advances in endovascular treatment of acute ischaemic stroke from intracranial large vessel occlusions have continued in the past decade. Here, we performed a detailed review of all the new trials and studies that had the highest evidence, the guidelines for mechanical thrombectomy, the selection of the particular population outside the guidelines and endovascular therapeutic strategies for acute ischemic stroke from occluded intracranial arteries.

[Cerebrovascular imaging to facilitate stroke reperfusion therapy in Japan]

Imaging diagnosis is essential to perform appropriate reperfusion therapy for acute ischemic stroke. To equally perform reperfusion therapy all over in Japan, it is important to properly facilitate acute imaging evaluation for stroke suspected patients by medical staff not only in stroke-specialized hospitals but also in non-stroke-specialized hospitals. It is unique that CT and MRI are available in most of Japanese hospitals. Even in non-stroke-specialized hospitals, inpatients may suffer from in-hospital stroke. We review statements and recommendation items for a diagnostic imaging to appropriately perform reperfusion therapy based on major clinical trials, stroke guidelines and the current status of acute stroke imaging in Japan.

Mechanical thrombectomy versus intravenous thrombolysis for distal large-vessel occlusion: a systematic review and meta-analysis of observational studies

OBJECTIVE

While several studies have compared the feasibility and safety of mechanical thrombectomy (MT) for distal large-vessel occlusion (LVO) strokes in patients, few studies have compared MT with intravenous thrombolysis (IVT) alone. The purpose of this systematic review was to compare the effectiveness and safety between MT and standard medical management with IVT alone for patients with distal LVOs.

METHODS

PubMed, Google Scholar, Embase, Scopus, Web of Science, Ovid Medline, and Cochrane Library were searched in order to identify studies that directly compared MT with IVT for distal LVOs (anterior cerebral artery A2, middle cerebral artery M3-4, and posterior cerebral artery P2-4). Primary outcomes of interest included a modified Rankin Scale (mRS) score of 0 to 2 at 90 days posttreatment, occurrence of symptomatic intracerebral hemorrhage (sICH), and all-cause mortality at 90 days posttreatment.

RESULTS

Four studies representing a total of 381 patients were included in this meta-analysis. The pooled results indicated that the proportion of patients with an mRS score of 0 to 2 at 90 days (OR 1.16, 95% CI 0.23-5.93; p = 0.861), the occurrence of sICH (OR 2.45, 95% CI 0.75-8.03; p = 0.140), and the mortality rate at 90 days (OR 1.73, 95% CI 0.66-4.55; p = 0.263) did not differ between patients who underwent MT and those who received IVT alone.

CONCLUSIONS

The meta-analysis did not demonstrate a significant difference between MT and standard medical management with regard to favorable outcome, occurrence of sICH, or 90-day mortality. Prospective clinical trials are needed to further compare the efficacy of MT with IVT alone for distal vessel occlusion.

Influence of intravenous alteplase on endovascular treatment decision-making in acute ischemic stroke due to primary medium-vessel occlusion: a case-based survey study

Background

Intravenous alteplase is currently the only evidence-based treatment for medium-vessel occlusion stroke (MeVO; M2/3, A2/3, and P2/3 vessel segment occlusions), but due to its limited efficacy, endovascular treatment (EVT) is increasingly performed in these patients. In this case-based survey study, we examined the influence of intravenous alteplase treatment on physicians’ decision-making for EVT in primary MeVO stroke.

Methods

In an international web-based survey among physicians involved in acute stroke care, participants provided their EVT decision for six quasi-identical fictional MeVO case scenarios (three with and without intravenous alteplase administered). Each scenario showed radiological images and clinical information in the form of a short case vignette. We compared EVT decisions (“immediate EVT”, “no EVT”, or “wait for alteplase effect” [in case scenarios with alteplase treatment only]) for case scenarios with and without alteplase treatment. Clustered multivariable logistic regression was performed to assess the effect of alteplase on treatment decision.

Results

The survey was completed by 366 physicians from 44 countries, resulting in 2196 responses included in this study. In alteplase-treated cases, 641/1098 (58.4%) responses favored immediate EVT, (279/1098 [25.4%]) favored no EVT and 178/1098 (16.2%) opted to wait for alteplase effect. In non-alteplase-treated case scenarios, 846/1098 (78.7%) were in favor of and 252/1098 (21.3%) against EVT. Intravenous alteplase was associated with a lower chance of a decision in favor of immediate EVT (adjusted OR 0.38 [95%CI 0.31 to 0.46]).

Conclusions

Intravenous alteplase is an important factor in EVT decision-making for MeVO stroke. However, even in alteplase-treated patients, more than half of the physicians decided to proceed with EVT without waiting for alteplase effect.