Symptomatic Intracranial Hemorrhage After Mechanical Thrombectomy in Chinese Ischemic Stroke Patients: The ASIAN Score

Protection of blood-brain barrier by endothelial DAPK1 deletion after stroke

Death-associated protein kinase (DAPK) 1 is a critical mediator for neuronal cell death in cerebral ischemia, but its role in blood-brain barrier (BBB) disruption is incompletely understood. Here, we found that endothelial-specific deletion of Dapk1 using Tie2 Cre protected the brain of Dapk1fl/fl mice against middle cerebral artery occlusion (MCAO), characterized by mitigated Evans blue dye (EBD) extravasation, reduced infarct size and improved behavior. In vitro experiments also indicated that DAPK1 deletion inhibited oxygen-glucose deprivation (OGD)-induced tight junction alteration between cerebral endothelial cells (CECs). Mechanistically, we revealed that DAPK1-DAPK3 interaction activated cytosolic phospholipase A2 (cPLA2) in OGD-stimulated CECs. Our results thus suggest that inhibition of endothelial DAPK1 specifically prevents BBB damage after stroke.

Endovascular therapy in patients with a large ischemic volume at presentation: An aggregate patient-level analysis

INTRODUCTION

Recently, four randomized controlled trials (RCTs) have demonstrated the benefits of mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) caused by anterior large vessel occlusion (LVO) and a large ischemic core at baseline (LIC). The purpose of this study was to investigate the features influencing the clinical outcome and the benefits of mechanical thrombectomy in this subgroup.

METHODS

We conducted a multicenter retrospective aggregate cohort study of patients with AIS-LVO and a LIC, assessed with quantitative core volume measures, treated with MT between 2012 and 2019. The data were queried through four registries, including patients with core volumes ≥50cc. Multivariable logistic regression models were employed to determine factors independently associated with clinical outcomes in patients with successful recanalization (modified-Thrombolysis-in-Cerebral-Infarction-score, mTICI=2b-3) and unsuccessful recanalization group (mTICI=0-2a). The primary endpoint was a favorable functional outcome at day-90, defined as a modified Rankin scale (mRS) of 0-3, accounting for the inherent severity of AIS with baseline LIC. Secondary outcomes included functional independence (mRS 0-2) at day-90, mortality, and symptomatic Intracranial Hemorrhage (sICH).

RESULTS

A total of 460 patients were included (mean age 66±14.2 years; 39.6 % females). The mean baseline NIHSS was 20±5.2, and the core volume was 103.2±54.6 ml. Overall, 39.8 % (183/460) of patients achieved a favorable outcome at day-90 (mRS 0-3). Successful recanalization was significantly associated with a more frequent favorable outcome (aOR, 4.79; 95 %CI, 2.73-8.38; P<0.01) and functional independence (P<0.01). This benefit remained significant in older patients and in patients with cores above 100cc. At 90 days, 147/460 patients (32 %) were deceased, with successful recanalization significantly associated with less frequent mortality (OR, 0.34; 95 %CI, 0.22-0.53; P<0.01). The rate of sICH was 17.4 % and did not differ significantly between groups.

CONCLUSIONS

In this large, pooled-cohort study of AIS-LVO patients with infarct cores over 50cc at baseline, we demonstrated that successful recanalization was associated with a better functional outcome, lower mortality, and similar rates of symptomatic intracranial hemorrhage for a wide spectrum of patients.

Effect of statin treatment on clinical outcomes in cardioembolic stroke with endovascular thrombectomy

BACKGROUND

While statins have been widely used in patients with large-artery atherosclerotic stroke, their effectiveness in patients with cardioembolic large vessel occlusion (CE-LVO) undergoing endovascular treatment (EVT) remains unclear. This study aimed to evaluate whether combining statin therapy with EVT could improve clinical outcomes in patients with acute ischemic stroke caused by CE-LVO in the anterior circulation.

METHODS

We performed a retrospective screening on patients with CE-LVO in the anterior circulation who underwent EVT in 27 hospitals across China between 2018 and 2021. The primary outcome measure was functional independence, defined as a 90-day modified Rankin Scale (mRS) score of 0 to 2. Safety outcomes included 90-day mortality and symptomatic intracranial hemorrhage (sICH).

RESULTS

A total of 510 patients with CE-LVO in the anterior circulation undergoing EVT were included in this study. Of these, 404 (79.2%) patients received statin treatment (statin group), while 106 (20.8%) did not (non-statin group). Statin treatment was significantly associated with improved functional independence (adjusted OR (aOR) 2.072, 95% CI 1.197 to 3.586, P=0.009). Moreover, statin use was associated with a lower rate of 90-day mortality (aOR 0.343, 95% CI 0.197 to 0.596, P<0.001) and a lower rate of sICH (aOR 0.153, 95% CI 0.072 to 0.325, P<0.001).

CONCLUSION

Statin treatment was associated with improved clinical outcomes and reduced risks of mortality and sICH in patients with CE-LVO in the anterior circulation undergoing EVT.

Low caveolin-1 levels and symptomatic intracranial haemorrhage risk in large-vessel occlusive stroke patients after endovascular thrombectomy

BACKGROUND AND PURPOSE

Caveolin-1 (Cav-1) is reported to mediate blood-brain barrier integrity after ischaemic stroke. Our purpose was to assess the role of circulating Cav-1 levels in predicting symptomatic intracranial haemorrhage (sICH) amongst ischaemic stroke patients after endovascular thrombectomy (EVT).

METHODS

Patients with large-vessel occlusive stroke after EVT from two stroke centres were prospectively included. Serum Cav-1 level was tested after admission. sICH was diagnosed according to the Heidelberg Bleeding Classification.

RESULTS

Of 325 patients (mean age 68.6 years; 207 men) included, 47 (14.5%) were diagnosed with sICH. Compared with patients without sICH, those with sICH had a lower concentration of Cav-1. After adjusting for potential confounders, multivariate regression analysis demonstrated that the increased Cav-1 level was associated with a lower sICH risk (odds ratio 0.055; 95% confidence interval 0.005-0.669; p = 0.038). Similar results were obtained when Cav-1 levels were analysed as a categorical variable. Using a logistic regression model with restricted cubic splines, a linear and negative association of Cav-1 concentration was found with sICH risk (p = 0.001 for linearity). Furthermore, the performance of the conventional risk factors model in predicting sICH was substantially improved after addition of the Cav-1 levels (integrated discrimination index 2.7%, p = 0.002; net reclassification improvement 39.7%, p = 0.007).

CONCLUSIONS

Our data demonstrate that decreased Cav-1 levels are related to sICH after EVT. Incorporation of Cav-1 into clinical decision-making may help to identify patients at a high risk of sICH and warrants further consideration.

Nomogram established on account of Lasso-logistic regression for predicting hemorrhagic transformation in patients with acute ischemic stroke after endovascular thrombectomy

BACKGROUND

Hemorrhagic transformation (HT) is a common and serious complication in patients with acute ischemic stroke (AIS) after endovascular thrombectomy (EVT). This study was performed to determine the predictive factors associated with HT in stroke patients with EVT and to establish and validate a nomogram that combines with independent predictors to predict the probability of HT after EVT in patients with AIS.

METHODS

All patients were randomly divided into development and validation cohorts at a ratio of 7:3. The least absolute shrinkage and selection operator (LASSO) regression was used to select the optimal factors, and multivariate logistic regression analysis was used to build a clinical prediction model. Calibration plots, decision curve analysis (DCA) and receiver operating characteristic curve (ROC) were generated to assess predictive performance.

RESULTS

LASSO regression analysis showed that Alberta Stroke Program Early CT Scores (ASPECTS), international normalized ratio (INR), uric acid (UA), neutrophils (NEU) were the influencing factors for AIS with HT after EVT. A novel prognostic nomogram model was established to predict the possibility of HT with AIS after EVT. The calibration curve showed that the model had good consistency. The results of ROC analysis showed that the AUC of the prediction model established in this study for predicting HT was 0.797 in the development cohort and 0.786 in the validation cohort.

CONCLUSION

This study proposes a novel and practical nomogram based on ASPECTS, INR, UA, NEU, which can well predict the probability of HT after EVT in patients with AIS.

Impact of carotid stenosis on the outcome of stroke patients submitted to reperfusion treatments: a narrative review

Intravenous thrombolysis (IT) and mechanical thrombectomy (MD) are the two interventional approaches that have changed the outcome of patients with acute ischemic stroke (AIS). Ipsilateral and contralateral carotid stenosis (ICS, CCS) play an important role in regulating cerebral hemodynamics, both in chronic and acute situations such as AIS. Several studies have explored their role in the incidence and severity of stroke, but very few have investigated the possible impact of ICS and CCS on the efficacy of interventional procedures. The purpose of this review was to I) highlight the incidence and prevalence of carotid stenosis (CS); II) assess the impact of ICS and CCS on cerebral hemodynamics; III) evaluate the effect of carotid stenosis on the efficacy of interventional therapies (IT and MT) for AIS; and IV) report therapeutic complications related to CS. We searched PubMed/Medline for case reports, reviews, and original research articles on English-language review topics during the period from January 1, 2000 to October 1, 2023. CS is associated with 15-20 % of the total number of AIS. ICS and CCS had a negative influence on both cerebral hemodynamics before AIS and outcome after interventional procedures (IT, MT alone or in bridging). Available data on cerebral hemodynamics and efficacy of interventional therapies for AIS suggest a negative role of CS. Therefore, early diagnosis of CS may be considered relevant to preventive and post-stroke treatment strategies.

Symptomatic intracerebral hemorrhage in proximal and distal medium middle cerebral artery occlusion patients treated with mechanical thrombectomy

BACKGROUND

Acute ischemic stroke (AIS) caused by distal medium vessel occlusions (DMVOs) represents a significant proportion of overall stroke cases. While intravenous thrombolysis (IVT) has been a primary treatment, advancements in endovascular procedures have led to increased use of mechanical thrombectomy (MT) in DMVO stroke patients. However, symptomatic intracerebral hemorrhage (sICH) remains a critical complication of AIS, particularly after undergoing intervention. This study aims to identify factors associated with sICH in DMVO stroke patients undergoing MT.

METHODS

This retrospective analysis utilized data from the Multicenter Analysis of Distal Medium Vessel Occlusions: Effect of Mechanical Thrombectomy (MAD-MT) registry, involving 37 centers across North America, Asia, and Europe. Middle cerebral artery (MCA) DMVO stroke patients were included. The primary outcome measured was sICH, as defined per the Heidelberg Bleeding Classification. Univariable and multivariable logistic regression were used to identify factors independently associated with sICH.

RESULTS

Among 1708 DMVO stroke patients, 148 (8.7%) developed sICH. Factors associated with sICH in DMVO patients treated with MT included older age (adjusted odds ratio (aOR) 1.01, 95% confidence interval (95% CI) 1.00 to 1.03, P=0.048), distal occlusion site (M3, M4) compared with medium occlusions (M2) (aOR 1.71, 95% CI 1.07 to 2.74, P=0.026), prior use of antiplatelet drugs (aOR 2.06, 95% CI 1.41 to 2.99, P<0.001), lower Alberta Stroke Program Early CT Scores (ASPECTS) (aOR 0.75, 95% CI 0.66 to 0.84, P<0.001), higher preoperative blood glucose level (aOR 1.00, 95% CI 1.00 to 1.01, P=0.012), number of passes (aOR 1.27, 95% CI 1.15 to 1.39, P<0.001), and successful recanalization (Thrombolysis In Cerebral Infarction (TICI) 2b-3) (aOR 0.43, 95% CI 0.28 to 0.66, P<0.001).

CONCLUSION

This study provides novel insight into factors associated with sICH in patients undergoing MT for DMVO, emphasizing the importance of age, distal occlusion site, prior use of antiplatelet drugs, lower ASPECTS, higher preoperative blood glucose level, and procedural factors such as the number of passes and successful recanalization. Pending confirmation, consideration of these factors may improve personalized treatment strategies.

Development and validation of an interpretable model for predicting sepsis mortality across care settings

There are numerous prognostic predictive models for evaluating mortality risk, but current scoring models might not fully cater to sepsis patients' needs. This study developed and validated a new model for sepsis patients that is suitable for any care setting and accurately forecasts 28-day mortality. The derivation dataset, gathered from 20 hospitals between September 2019 and December 2021, contrasted with the validation dataset, collected from 15 hospitals from January 2022 to December 2022. In this study, 7436 patients were classified as members of the derivation dataset, and 2284 patients were classified as members of the validation dataset. The point system model emerged as the optimal model among the tested predictive models for foreseeing sepsis mortality. For community-acquired sepsis, the model's performance was satisfactory (derivation dataset AUC: 0.779, 95% CI 0.765-0.792; validation dataset AUC: 0.787, 95% CI 0.765-0.810). Similarly, for hospital-acquired sepsis, it performed well (derivation dataset AUC: 0.768, 95% CI 0.748-0.788; validation dataset AUC: 0.729, 95% CI 0.687-0.770). The calculator, accessible at https://avonlea76.shinyapps.io/shiny_app_up/ , is user-friendly and compatible. The new predictive model of sepsis mortality is user-friendly and satisfactorily forecasts 28-day mortality. Its versatility lies in its applicability to all patients, encompassing both community-acquired and hospital-acquired sepsis.

Sex Differences in Outcomes after Endovascular Thrombectomy for Patients with Acute Ischemic Stroke

INTRODUCTION

Endovascular thrombectomy (EVT) is the standard of care for patients with large-vessel occlusion acute ischemic stroke (AIS). There may be differing recanalization effectiveness based on patients' sex, and understanding such variations can improve patient outcomes by adjusting for differences. We aimed to assess the sex differences in outcome after EVT for patients with AIS.

METHODS

We retrospectively analyzed 250 consecutive AIS patients who underwent EVT from July 2019 to February 2022 across two large comprehensive tertiary care stroke centers in China. Outcomes of male patients were compared to females, where poor outcome was defined as a modified Rankin score (mRS) of 3-6 at 90 days.

RESULTS

Male patients had higher rates of symptomatic intracranial hemorrhage (sICH) (12.50% vs. 4.05%, p = 0.042) and higher hospitalization costs (114,541.08 vs. 105,790.27 RMB, p = 0.024). Male patients also had a longer median onset-to-needle time (ONT) (146.00 [104.00, 202.00] versus 120.00 [99.25, 144.75], p = 0.026). However, there were no differences in hospitalization length (p = 0.251), 90-day favorable outcome (p = 0.952), and 90-day mortality (p = 0.931) between the sexes.

CONCLUSION

Female patients had lower hospitalization costs and sICH rates than males after EVT for AIS. Identifying such differences and implementing measures, including adaptations to workflow optimization, would help to reduce the ONT and last known normal-to-puncture time seen in males to improve patient outcomes. Despite such variations, favorable outcomes and mortality are similar in female and male AIS patients.

Correlation of LP-PLA2 and MMP-9 with the occurrence of early neurological deterioration in patients with acute ischemic stroke

Early neurological deterioration is a common complication of acute ischemic stroke (AIS), which aggravates symptoms, worsens the condition, and counteracts the benefits of clinical treatment. The aim of this paper was to analyze the correlation between lipoprotein-associated phospholipase A2 (Lp-PLA2), matrix metalloproteinase-9 (MMP-9), and the occurrence of early neurological deterioration (END) in patients with AIS and to explore the clinical prediction of END by the combination of the 2 assays for the clinical prediction of END. A total of 500 AIS patients admitted to our hospital from October 2022 to October 2023 were included as study subjects, and the clinical data of all AIS patients were collected and organized to detect the levels of Lp-PLA2 and MMP-9. Categorized into END and non-END groups according to whether END occurred within 7 days of the onset of AIS, and comparing the clinical baseline data and laboratory index levels of the 2 groups. Logistic regression analysis was performed to determine the independent predictors of END, and the predictive effects of Lp-PLA2 and MMP-9 levels on END were assessed by subject work characteristics (ROC) curves. END occurred in 111 (22.2%) of 500 AIS patients. Multivariate logistic regression analysis showed that diabetes (OR 2.717, 95% CI:1.53-4.81, P < .001), baseline NIHSS score (OR 1.65, 95% CI:1.41-1.94, P < .001), Lp-PLA2 (OR 1.07, 95% CI:1.05-1.09, P < .001) and MMP-9 (OR 1.12, 95% CI:1.09-1.16, P < .001) levels were independent influences on the occurrence of END in patients with AIS after correcting for confounders. ROC curve analysis showed that Lp-PLA2, MMP-9, and a combination of both predicted END with an area under the curve was 0.730, 0.763, and 0.831, respectively, and the area under the curve for the combination of both predicting END was significantly higher than that for any of the inflammatory markers alone (P < .05). Both inflammatory markers, Lp-PLA2 and MMP-9, were independent predictors of the development of END in patients with AIS, and the combination of the two had a higher predictive value.

Cerebral microbleeds and risk of symptomatic hemorrhagic transformation following mechanical thrombectomy for large vessel ischemic stroke

BACKGROUND AND PURPOSE

In patients with acute ischemic stroke (AIS) treated with endovascular therapy (EVT), the association of pre-existing cerebral small vessel disease (cSVD) with symptomatic intracerebral hemorrhage (sICH) remains controversial. We tested the hypothesis that the presence of cerebral microbleeds (CMBs) and their burden would be associated with sICH after EVT of AIS.

METHODS

We conducted a retrospective study combining cohorts of patients that underwent EVT between January 1st 2015 and January 1st 2020. CMB presence, burden, and other cSVD markers were assessed on a pre-treatment MRI, evaluated independently by two observers. Primary outcome was the occurrence of sICH.

RESULTS

445 patients with pretreatment MRI were included, of which 70 (15.7%) demonstrated CMBs on baseline MRI. sICH occurred in 36 (7.6%) of all patients. Univariate analysis did not demonstrate an association between CMB and the occurrence of sICH (7.5% in CMB+ group vs 8.6% in CMB group, p = 0.805). In multivariable models, CMBs' presence was not significantly associated with increased odds for sICH (-aOR- 1.19; 95% CI [0.43-3.27], p = 0.73). Only ASPECTs (aOR 0.71 per point increase; 95% CI [0.60-0.85], p < 0.001) and collaterals status (aOR 0.22 for adequate versus poor collaterals; 95% CI [0.06-0.93], p 0.019) were independently associated with sICH.

CONCLUSION

CMB presence and burden is not associated with increased occurrence of sICH after EVT. This result incites not to exclude patients with CMBs from EVT. The risk of sICH after EVT in patients with more than10 CMBs will require further investigation.

REGISTRATION

Registration-URL: http://www.

CLINICALTRIALS

gov ; Unique identifier: NCT01062698.

The prognostic value of ASPECTS in specific regions following mechanical thrombectomy in patients with acute ischemic stroke from large-vessel occlusion

Objective

The aim of this study is to investigate the relationship between the volume of specific regional infarction and the prognosis of patients who undergo mechanical thrombectomy (MT) for acute large vessel occlusion.

Methods

In this study, we collected the clinical and imaging features of patients with unilateral acute anterior circulation ischemic stroke from January 2021 to June 2023 in the Second Affiliated Hospital of Nanchang University. All patients underwent CT perfusion and non-contrast CT scan before MT. The ASPECTS was assessed based on imaging data, and artificial intelligence was used to obtain the percentage of infarction in each of the 10 regions of ASPECTS. According to the modified Rankin Scale, the patients were divided into the good prognosis group and poor prognosis group at the 90-day follow-up. Various indicators in the two groups were compared. Multivariable logistic regression was used to assess the risk factors for poor prognosis. The relationship between core infarction volume and the probability of poor prognosis was plotted to analyze the trend of poor prognosis with changes in the proportion of infarction volume. Finally, a receiver operating characteristic curve was constructed to analyze the predictive ability on poor prognosis.

Results

A total of 91 patients were included, with 58 patients having a good prognosis (mRS ≤ 2) and 33 patients having a poor prognosis (mRS ≥ 3). Multivariate analysis showed that NIHSS score and core infarction involving the internal capsule and M6 region were independent risk factors for poor prognosis. According to the linear correlation, a higher ratio of core infarction volume in the internal capsule or M6 region was linked to an increased risk of a poor prognosis. However, the non-linear analysis revealed that the prognostic impact of core infarction volume was significant when the ratio was greater than 69.7%. The ROC curve indicated that the combination of NIHSS score, infarct location, and the ratio of infarct volume has an AUC of 0.87, with a sensitivity of 84.8% and a specificity of 84.5%.

Conclusion

It is important to examine the location and volume of the infarct in the internal capsule and M6 when deciding whether to do a MT.

Efficacy of Endovascular Thrombectomy in Acute Basilar Artery Occlusion with Low PC-ASPECTS: A Nationwide Prospective Registry-Based Study

OBJECTIVE

We evaluated the efficacy of endovascular thrombectomy (EVT) on the functional outcome of patients with acute basilar artery occlusion and low posterior circulation acute stroke prognosis early computed tomography score (PC-ASPECTS).

METHODS

We identified patients with acute ischemic stroke due to basilar artery occlusion and PC-ASPECTS of 6 or less, presenting within 24 h between August 2008 and April 2022. The primary outcome was a favorable functional outcome, defined as a modified Rankin Scale (mRS) score of 0-3 at 90 days. The secondary outcomes included an mRS score of 0-2, a favorable shift in the ordinal mRS scale, the occurrence of symptomatic intracranial hemorrhage (sICH), and mortality at 90 days. We compared the outcome of patients treated with EVT and those without EVT, using the inverse probability of treatment weighting methods.

RESULTS

Out of 566 patients, 55.5% received EVT. In the EVT group, 106 (33.8%) achieved favorable outcomes, compared to 56 patients (22.2%) in the conservative group. EVT significantly increased the likelihood of achieving a favorable outcome compared to conservative treatment (relative risk [RR] 1.39, 95% confidence interval [CI], 1.11-1.74, p = 0.004). EVT was associated with a favorable shift in the mRS (RR 1.85, 95% CI, 1.49-2.29, p < 0.001) and reduced mortality without an increase in the risk of sICH. It did not have an impact on achieving an mRS score of 0-2.

INTERPRETATION

Patients with acute basilar artery occlusion and a PC-ASPECTS of 6 or less might benefit from EVT without an increasing sICH. ANN NEUROL 2024;95:788-799.

Regression analysis of bleeding factors and the correlation between FPE and NLR after mechanical thrombectomy for acute anterior circulation large vessel occlusion

Acute anterior circulation large vessel occlusion refers to a blockage in the blood flow of one of the major blood vessels in the anterior (front) part of the brain. Acute anterior circulation large vessel occlusion can lead to a range of symptoms, including sudden headache, difficulty speaking or understanding speech, weakness or numbness on one side of the body and loss of vision in one eye. According to relevant data, mechanical thrombectomy in the treatment of the large vessel recanalization rate can reach 70%. However, hemorrhage is one of the serious complications after mechanical thrombectomy, and it is the main factor leading to the deterioration of neurological function and death of patients after large blood vessels. Therefore, the risk factors of bleeding in patients were analyzed before surgery, and effective prevention during and after surgery had positive significance for patients undergoing mechanical thrombectomy. This study uses regression analysis to analyze the correlation between bleeding factors and FPE and NLR after mechanical thrombectomy for acute anterior circulation large vessel occlusion. We retrospectively analyzed 81 patients with acute anterior circulation large vessel occlusion who underwent mechanical embolization in our hospital from September 2019 to January 2022 and separated them into a bleeding group (46 patients) and a non-bleeding group (35 patients) based on the presence or absence of bleeding after surgery.

Frequency and predictors of decompressive craniectomy in ischemic stroke patients treated by mechanical thrombectomy in the ETIS registry

BACKGROUND AND AIMS

Mechanical thrombectomy (MT) for patients with acute ischemic stroke (AIS) is usually performed in a comprehensive stroke center with on-site neurosurgical expertise. The question of whether MT can be performed in a primary stroke center without a neurosurgical facility is debated. In this context, there is a need to determine the frequency, delay and predictors of neurosurgical procedures in patients treated by MT. This study aims to determine these factors.

METHODS

In total, 432 patients under 60years old, diagnosed with an acute ischemic stroke with a large vessel occlusion and treated by MT between January 2018 and December 2019 in six French stroke centers, were selected from the French clinical registry ETIS. Univariate and multivariate logistic regression models were used to identify predictive factors for decompressive craniectomy.

RESULTS

Among the 432 included patients, 43 (9.9%) patients with an anterior circulation infarct underwent decompressive craniectomy. Higher admission NIHSS (OR: 1.08 [95% CI: 1.02-1.16]), lower ASPECT (OR per 1 point of decrease 1.53 [1.31-1.79] P<0.001) and preadmission antiplatelet use (OR: 3.03 [1.31-7.01]) were independent risk factors for decompressive craniectomy. The risk of decompressive craniectomy increases to more than 30% with an ASPECT score<4, an NIHSS>16, and current antiplatelet use.

CONCLUSION

In this multicenter registry, 9% of acute ischemic stroke patients (<60years old) treated with MT, required decompressive craniectomy. Higher NIHSS score, lower ASPECT score, and preadmission antiplatelet use increase the risk of subsequent requirement for decompressive craniectomy.

Asymptomatic Intracerebral Hemorrhage Following Endovascular Stroke Therapy Is Not Benign: A Systematic Review and Meta-Analysis

BACKGROUND

Asymptomatic intracerebral hemorrhage (aICH) occurs in approximately 35% of patients with acute ischemic stroke after endovascular thrombectomy. Unlike symptomatic ICH, studies evaluating the effect of aICH on outcomes have been inconclusive. We performed a systematic review and meta-analysis to evaluate the long-term effects of postendovascular thrombectomy aICH.

METHODS AND RESULTS

The meta-analysis protocol was submitted to the International Prospective Register of Systematic Reviews a priori. PubMed, Scopus, and Web of Science were searched from inception through September 2023, yielding 312 studies. Two authors independently reviewed all abstracts. Included studies contained adult patients with ischemic stroke undergoing endovascular thrombectomy with follow-up imaging assessment of ICH reporting comparative outcomes according to aICH versus no ICH. After screening, 60 papers were fully reviewed, and 10 studies fulfilled inclusion criteria (n=5723 patients total, 1932 with aICH). Meta-analysis was performed using Cochrane RevMan v5.4. Effects were estimated by a random-effects model to estimate summary odds ratio (OR) of the effect of aICH versus no ICH on primary outcomes of 90-day modified Rankin Scale 3 to 6 and mortality. The presence of aICH was associated with a higher odds of 90-day mRS 3 to 6 (OR, 2.17 [95% CI, 1.81-2.60], P<0.0001, I2 46% Q 19.15) and mortality (OR, 1.72 [95% CI, 1.17-2.53], P:0.005, I2 79% Q 27.59) compared with no ICH. This difference was maintained following subgroup analysis according to hemorrhage classification and recanalization status.

CONCLUSIONS

The presence of aICH is associated with worse 90-day functional outcomes and higher mortality. Further studies to evaluate the factors predicting aICH and treatments aimed at reducing its occurrence are warranted.

Alterations of Hemostatic Molecular Markers During Acute Large Vessel Occlusion Stroke

BACKGROUND

This study aimed to investigate regional levels of TAT (thrombin-antithrombin complex), PIC (plasmin-α2 plasmin inhibitor complex), t-PAIC (tissue plasminogen activator-plasminogen activator inhibitor complex), sTM (soluble thrombomodulin), and D-dimer, along with their associations with clinical and procedural characteristics in patients with acute ischemic stroke undergoing endovascular thrombectomy.

METHODS AND RESULTS

We retrospectively analyzed 166 consecutive patients with acute ischemic stroke (62±11.54 years of age, 34.3% women) using prospectively maintained clinical databases and blood samples from local ischemic (proximal to thrombus) and systemic (femoral artery, self-control) arterial compartments. Levels of TAT, PIC, t-PAIC, and D-dimer were significantly elevated, whereas sTM was significantly reduced, in local ischemic regions compared with their systemic levels. Each 1-unit increase in ischemic TAT (adjusted odds ratio [aOR], 1.086 [95% CI, 1.03-1.145]; P=0.002; area under the curve [AUC], 0.833) and PIC (aOR, 1.337 [95% CI, 1.087-1.644]; P=0.006; AUC, 0.771) correlated significantly with higher symptomatic intracranial hemorrhage risk. Additionally, each 1-unit increase in ischemic TAT (aOR, 1.076 [95% CI, 1.016-1.139]; P=0.013; AUC, 0.797), PIC (aOR, 1.554 [95% CI, 1.194-2.022]; P=0.001; AUC, 0.798), and sTM (aOR, 0.769 [95% CI, 0.615-0.961]; P=0.021; AUC, 0.756) was significantly associated with an increased risk of an unfavorable 90-day outcome (modified Rankin scale of 3-6). These hemostatic molecules, individually or combined, significantly improved the predictive power of conventional risk factors, as evidenced by significant increases in net reclassification improvement and integrated discrimination improvement (all P<0.01).

CONCLUSIONS

We observed a hyperactive state of the coagulation-fibrinolysis system within the local ischemic region during hyperacute stroke. Rapid automated measurement of hemostatic molecular markers, particularly TAT, PIC, and sTM, during intra-arterial procedures may provide additional information for stroke risk stratification and therapeutic decision-making, and warrants further investigation.

Diagnostic accuracy of dual-energy computed tomography in the diagnosis of neurological complications after endovascular treatment of acute ischaemic stroke: a systematic review and meta-analysis

OBJECTIVES

To investigate dual-energy computed tomography's (DECT) diagnostic performance in detecting neurological complications following endovascular therapy (EVT) of acute ischaemic stroke (AIS).

METHODS

We performed the literature search using Web of Science, Scopus, PubMed, EBSCO, and Science Direct databases for published related studies. The selected studies estimated the validity of DECT in the detection of neurological complications after EVT for AIS. Study quality assessment was performed utilizing the Quality of Diagnostic Accuracy Studies-2 Tool. Our meta-analysis calculated the pooled sensitivity, negative likelihood ratio, specificity, and positive likelihood ratio for each detected complication. The summary receiver operating characteristics (sROC) curve was utilized to estimate the area under the curve (AUC).

RESULTS

Of 22 studies, 21 were included in the quantitative synthesis. In the detection of intracerebral haemorrhage (ICH), DECT pooled overall sensitivity and specificity were 69.9% (95% CI, 44.5%-86.8%) and 100% (95% CI, 92.1%-100%); whereas, in the detection of ischaemia, they were 85.9% (95% CI, 80.4%-90%) and 90.7% (95% CI, 87%-93.5%), respectively. On the sROC curve, AUC values of 0.954 and 0.952 were recorded for the detection of ICH and ischaemia, respectively.

CONCLUSIONS

DECT demonstrated high accuracy and specificity in the detection of neurological complications post-endovascular treatment of AIS. However, further prospective studies with a standardized reference test and a larger sample size are recommended to support these findings.

ADVANCES IN KNOWLEDGE

DECT is a rapid and valid imaging tool for the prediction of ICH and cerebral ischaemia after the EVT of AIS.

Glial Fibrillary Acidic Protein as a Potential Indicator for Symptomatic Intracranial Hemorrhage in Acute Ischemic Patients Undergoing Endovascular Thrombectomy

Background

The correlation between glial fibrillary acidic protein (GFAP) and symptomatic intracranial hemorrhage (sICH) in acute ischemic stroke (AIS) patients undergoing endovascular thrombectomy (EVT) treatment remains uncertain. We aimed to assess the association between levels of GFAP in the bloodstream and the occurrence of sICH.

Methods

Between June 2019 and May 2023, 142 consecutive AIS patients undergoing EVT at Stroke Center and 35 controls from the Physical Examination Center were retrospectively included. The levels of GFAP in the bloodstream were quantified using enzyme-linked immunosorbent assay prior to endovascular treatment (T1) and 24 h after the procedure (T2). The identification of sICH was based on the Heidelberg Bleeding Classification.

Results

Serum GFAP levels at T1 in AIS patients were significantly higher than those in the controls (0.249 [0.150-0.576] versus 0.065 [0.041-0.110] ng/mL, p = 0.001), and there was a notably elevation in GFAP levels at T2 compared to T1 (3.813 [1.474, 5.876] versus 0.249 [0.150-0.576] ng/mL, p = 0.001). Of the 142 AIS patients, 18 (14.5%) had sICH after EVT. Serum GFAP levels at T2 showed significant associations with sICH in both the unadjusted model (OR 1.513, 95% CI 1.269-1.805, p = 0.001) and multivariable adjusted model (OR 1.518, 95% CI 1.153-2.000, p = 0.003). Furthermore, the addition of GFAP at T2 to conventional model resulted in a significant enhancement of risk reclassification for sICH (integrated discrimination improvement [IDI] 0.183, 95% CI 0.070-0.295, p = 0.001).

Conclusion

Serum GFAP levels were notably increased in AIS patients 24 h after EVT. Elevated GFAP levels were correlated to an elevated risk of sICH. GFAP could potentially serve as a dependable indicator for sICH in AIS individuals who treated with EVT.

Relationship Between Liver Fibrosis and Increased Risk of Symptomatic Intracranial Hemorrhage in Ischemic Stroke Patients Undergoing Mechanical Thrombectomy

Background

Liver fibrosis has been reported to be associated with hematoma expansion and mortality in patients with intracerebral hemorrhage. This study aimed to detect the association between liver fibrosis and symptomatic intracranial hemorrhage (sICH) in ischemic stroke after mechanical thrombectomy (MT).

Methods

We retrospectively included patients with large artery occlusion in the anterior circulation and treated with MT at a single stroke center. The fibrosis-4 index (FIB-4) was used to assess the severity of liver fibrosis. sICH was diagnosed according to the Heidelberg Bleeding Classification criteria. Multivariate logistic regression and restricted cubic spline analysis were conducted to examine the relationship between liver fibrosis and sICH.

Results

Among the 578 patients (mean age, 70.1 years; 58.5% male) included in the study, 65 (11.2%) individuals were diagnosed with sICH. After adjusting for demographic characteristics and other potential confounders, a higher FIB-4 index was found to be independently associated with an increased risk of sICH (odds ratio: 1.306, 95% confidence interval: 1.127-1.512, P=0.001). Similar results were obtained when analyzing FIB-4 as a categorical variable.

Conclusion

This study demonstrated that there is a significant association between FIB-4 and the risk of sICH in patients with acute ischemic stroke who underwent MT. Therefore, liver fibrosis could serve as a valuable parameter in monitoring the risk of sICH following MT.

Effects of intravenous thrombolysis on stent retriever and aspiration thrombectomy outcomes: a systematic review and meta-analysis of the randomized controlled trials

BACKGROUND

Risks and benefits of intravenous thrombolysis (IVT) in patients undergoing mechanical thrombectomy (MT) have been a topic of interest. However, IVT's specific effects on stent retriever (SR) and aspiration thrombectomy (ASP) outcomes remain largely unexplored. In this meta-analysis, we aimed to investigate the effects of IVT on SR and ASP thrombectomy outcomes.

METHODS

In accordance with PRISMA guidelines, a systematic literature review was conducted using Medline, Embase, Scopus, Web of Science, and Cochrane Center of Clinical Trials databases. Outcomes of interest included successful recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2b), modified first pass efficacy (mFPE), functional independence (modified Rankin Scale (mRS) ≤2), symptomatic intracranial hemorrhage (sICH), and embolization to new territories (ENT).

RESULTS

Four randomized controlled trials with 1176 patients were included. SR and ASP resulted in similar mTICI ≥2b, mFPE, and mRS 0-2 rates in patients with and without IVT administration. SR without IVT was associated with a significantly lower rate of mFPE compared with the SR+IVT (RR 0.85, 95% CI 0.74 to 0.97). Furthermore, ASP without IVT resulted in a lower rate of mRS 0-2 than the ASP+IVT with a strong trend towards significance (RR 0.78, 95% CI 0.60 to 1.01). Finally, bridging therapy did not increase sICH and ENT rates after ASP or SR thrombectomy.

CONCLUSIONS

Our findings suggest that SR and ASP thrombectomy have comparable safety and efficacy profiles, regardless of prior IVT administration. Additionally, our results indicate that the addition of IVT may improve certain efficacy outcomes based on the employed first-line MT technique.

Common design and data elements reported in active mechanical thrombectomy trials focusing on distal medium vessel occlusions and minor strokes: a systematic review

BACKGROUND

Distal medium vessel occlusions (DMVOs) and minor strokes represent emerging frontiers in mechanical thrombectomy (MT). Although several randomized clinical trials (RCTs) are underway, the design characteristics of these trials and the specific questions they aim to address have not been extensively explored. This current study sought to investigate the design and data elements reported in active prospective DMVO and minor stroke studies.

METHODS

The ClinicalTrials.gov database was searched for ongoing prospective studies assessing the role of MT in patients with DMVOs or minor strokes. The Nested Knowledge AutoLit platform was utilized to categorize reported outcomes and inclusion/exclusion criteria. Frequencies of reported data elements were extracted from study protocols.

RESULTS

A total of 10 (8 DMVO and 2 minor stroke) studies enrolling 3520 patients were included. All DMVO studies employ different criteria regarding target occlusion locations. Five DMVO studies use stent retrievers as the first-line thrombectomy technique (62.5%, 5/8), while three studies allow any MT techniques, generally at the operator's discretion. Four DMVO studies permit intravenous thrombolysis (IVT) utilization in both intervention and control arms (50%, 4/8). The DISTALS trial excludes patients receiving IVT, while the DUSK trial and Tigertriever registry only enroll patients who are ineligible for IVT or for whom IVT failed to achieve reperfusion. DMVO studies exhibit notable heterogeneity in symptom onset duration thresholds for inclusion (<6 hours: 2 studies; <12 hours: 2 studies; <24 hours: 3 studies). Minor stroke trials employ similar inclusion criteria and outcome measures except for symptom duration thresholds for inclusion (8 hours for ENDOLOW and 23 hours for MOSTE).

CONCLUSIONS

There is considerable heterogeneity among active DMVO trials regarding potential target DMVO locations and time thresholds for inclusion based on the last known well time. Furthermore, our review indicates that the utility of aspiration thrombectomy in DMVOs and the advantages of MT without IVT over IVT alone will remain largely unexplored even after completion of active DMVO trials.

Effects of admission hyperglycemia and intravenous thrombolysis allocation in acute basilar artery occlusion after endovascular treatment: Analysis of the ATTENTION registry

This study was to investigate the admission hyperglycemia and modified effect of intravenous thrombolysis (IVT) on clinical outcomes in acute basilar artery occlusion (BAO) patients receiving endovascular treatment (EVT). We prospectively recruited acute BAO patients from 48 stroke centers across 22 Chinese provinces in the ATTENTION registry from 2017 to 2021. Hyperglycemia on admission was defined as glucose ≥7.8 ​mmol/L. We performed multivariable logistic regression analysis to evaluate the correlation of hyperglycemia on admission with the primary outcome defined as a modified Rankin scale (mRS) score of <4 ​at 90 days, and the secondary outcomes defined as successful recanalization, mRS 0-1 and 0-2 ​at 90 days. Safety outcomes were symptomatic intracranial hemorrhage (sICH) and mortality within 90 days. There were 1195 patients with acute BAO treated with EVT of whom 519 had hyperglycemia on admission. Hyperglycemia on admission was inversely associated with favorable neurological outcomes (mRS 0-3: adjusted odd ratio [aOR] 0.69, 95 ​% confidence intervals [CI] 0.54-0.89, P ​= ​0.004; mRS 0-1: aOR 0.67, 95 ​% CI 0.50-0.90, P ​= ​0.008; mRS 0-2: aOR 0.73, 95 ​% CI 0.56-0.95; P ​= ​0.02). Hyperglycemia on admission was not correlated to sICH nor successful recanalization. In the subgroup of BAO patients treated with direct EVT, those with hyperglycemia on admission had a higher mortality rate, and overall worse clinical outcomes at 90 days than patients without hyperglycemia. A significant interaction was observed between IVT and hyperglycemia on admission (Pinteraction ​= ​0.017). In patients with acute BAO treated with EVT, hyperglycemia on admission was associated with worse functional outcomes at 90 days but was not correlated with sICH nor successful recanalization. The effect of admission hyperglycemia appears to be modified by IVT allocation. Unique identifier: ChiCTR2000041117.

Association of Chinese visceral adiposity index with clinical outcome in patients after endovascular thrombectomy

BACKGROUND AND PURPOSE

The Chinese Visceral Adiposity Index (CVAI) is a reliable indicator of visceral adiposity dysfunction in the Chinese population. We aimed to evaluate the association between CVAI and clinical outcome in Chinese ischemic stroke patients who received endovascular thrombectomy (EVT).

METHODS

This study retrospectively included patients with large vessel occlusive stroke receiving EVT treatment in 2 China stroke centers. Baseline CVAI was calculated after admission. Patients with a modified Rankin scale score ≥ 3 at 3 months after ischemic stroke were defined as poor outcome. Binary multivariate logistic regression models were utilized to explore the association between CVAI and the risk of 90-day unfavorable outcome.

RESULTS

A total of 453 patients (mean age, 70.4  ± 12.1 years; 280 male) were included. During the 90-day follow-up, 236 (52.1 %) patients experienced poor outcome. After multivariable adjustment for potential confounders, increasing CVAI was associated with an increased risk of 90-day poor outcome (odds ratios, per-standard deviation increase: 1.521; 95 % confidence interval, 1.127-2.052; P = 0.006). Similar significant results were observed when the CVAI was analyzed as a categorical variable. Furthermore, the multiple-adjusted spline regression model showed an inverted J-shape association between CVAI and risk of unfavorable outcome (P = 0.048 for non-linearity).

CONCLUSIONS

This study demonstrated that CVAI is positively correlated with 90-day poor outcome in Chinese ischemic stroke patients after EVT.

Predicting symptomatic intracranial hemorrhage in anterior circulation stroke patients with contrast enhancement after thrombectomy: the CAGA score

BACKGROUND

The aim of the study was to establish a reliable scoring tool to identify the probability of symptomatic intracranial hemorrhage (sICH) in anterior circulation stroke patients with contrast enhancement (CE) on brain non-contrast CT (NCCT) after endovascular thrombectomy (EVT).

METHODS

We retrospectively reviewed consecutive patients with acute ischemic stroke (AIS) who had CE on NCCT immediately after EVT for anterior circulation large vessel occlusion (LVO). We used the Alberta stroke program early CT score (ASPECTS) scoring system to estimate the extent and location of CE. Multivariable logistic regression was performed to derive an sICH predictive score. The discrimination and calibration of this score were assessed using the area under the receiver operator characteristic curve, calibration curve, and decision curve analysis.

RESULTS

In this study, 194 of 322 (60.25%) anterior circulation AIS-LVO patients had CE on NCCT. After excluding 85 patients, 109 patients were enrolled in the final analysis. In multivariate regression analysis, age ≥70 years (adjusted OR (aOR) 9.23, 95% CI 2.43 to 34.97, P＜0.05), atrial fibrillation (AF) (aOR 4.17, 95% CI 1.33 to 13.12, P＜0.05), serum glucose ≥11.1 mmol/L (aOR 9.39, 95% CI 2.74 to 32.14, P＜0.05), CE-ASPECTS ＜5 (aOR 3.95, 95% CI 1.30 to 12.04 P＜0.05), and CE at the internal capsule (aOR 3.45, 95% CI 1.03 to 11.59, P＜0.05) and M1 region (aOR 3.65, 95% CI 1.13 to 11.80, P＜0.05) were associated with sICH. These variables were incorporated as the CE-age-glucose-AF (CAGA) score. The CAGA score demonstrated good discrimination and calibration in this cohort, as well as the fivefold cross validation.

CONCLUSION

The CAGA score reliably predicted sICH in patients with CE on NCCT after EVT treatment.

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.

Symptomatic Intracranial Hemorrhage after Mechanical Thrombectomy - the Difference between Iso-Osmolar and Low-Osmolar Contrast Media

Objective

Symptomatic intracranial hemorrhage (SICH) after mechanical thrombectomy (MT) is generally considered a critical complication. Hemorrhagic transformation after ischemic stroke has also been associated with contrast media administration. The objective of our study was to evaluate correlations between contrast media type and incidence of SICH after MT.

Methods

Ninety-three consecutive patients (41 men; mean age, 80.2 years; range, 44-98 years) underwent MT reperfusion (expanded thrombolysis in cerebral infarction score, 2a-3) for acute large-vessel occlusion ischemic stroke within 8 h after symptom onset between April 2020 and July 2023 were retrospectively reviewed. Correlations between contrast media type (iso-osmolar or low-osmolar medium) and incidence of SICH were assessed.

Results

Contrast media were iso-osmolar in 60 cases or low-osmolar in 33 cases. The overall incidence of SICH was 5.5%. The frequency of SICH was significantly lower in the iso-osmolar group (1.7%) than in the low-osmolar group (12.1%; P = 0.033).

Conclusion

Iso-osmolar contrast media was associated with a lower incidence of SICH compared with low-osmolar contrast media in patients after MT.

Increased Neuron-Specific Enolase Level Predicts Symptomatic Intracranial Hemorrhage in Patients with Ischemic Stroke Treated with Endovascular Treatment

BACKGROUND

Neuron-specific enolase (NSE), which is a highly specific marker for neurons, could be a predictor for prognosis in patients with symptomatic intracranial hemorrhage (sICH) with acute ischemic stroke who are receiving endovascular treatment (EVT). This study aimed to investigate the relationship between NSE and sICH in patients with acute anterior circulation stroke undergoing EVT.

METHODS

A total of 215 consecutive patients with acute stroke treated with EVT were included. Patients with stroke and acute anterior circulation occlusion, receiving EVT treated at our hospital, were enrolled between January 2017 and August 2021. NSE level was measured on arrival at the neurology intensive care unit after EVT. The patients were divided into 2 groups according to whether sICH was present. Univariate and multivariate analyses were performed. NSE level was also incorporated into the TAG score (modified Thrombolysis in Cerebral Infarction score, Alberta Stroke Program Early CT Score, and glucose level), which was developed as a scoring system to predict sICH, and the prediction capability was compared with the TAG score alone. Causal inference was performed using the package DoWhy in Python to evaluate the causal relationship between NSE and sICH.

RESULTS

The area under the curve (AUC) value of NSE showed moderate accuracy, with an AUC value of 0.729 (95% confidence interval, 0.655-0.795; P < 0.001). The NSE cutoff value was set at 23.88 ng/mL. When the NSE level ≥23.88 ng/mL, the sensitivity was 58.33% and the specificity was 78.72% (P < 0.001). The AUC for the TAG + NSE score was 0.801 compared with an AUC of 0.632 for the TAG score (Z = 2.034; P = 0.042). A causal inference model using the DoWhy library shows a proportional relationship between NSE and the diagnosis of sICH.

CONCLUSIONS

This study is the first to show that increased NSE level is an independent predictor of sICH in patients with acute anterior circulation stroke who are undergoing endovascular treatment.

Hemorrhagic Coagulation Disorders and Ischemic Stroke: How to Reconcile Both?

Coagulation and fibrinolytic system disorders are conditions in which the blood's ability to clot is impaired, resulting in an increased risk of thrombosis or bleeding. Although these disorders are the expression of two opposing tendencies, they can often be associated with or be a consequence of each other, contributing to making the prognosis of acute cerebrovascular events more difficult. It is important to recognize those conditions that are characterized by dual alterations in the coagulation and fibrinolytic systems to reduce the prognostic impact of clinical conditions with difficult treatment and often unfortunate outcomes. Management of these individuals can be challenging, as clinicians must balance the need to prevent bleeding episodes with the potential risk of clot formation. Treatment decisions should be made on an individual basis, considering the specific bleeding disorder, its severity, and the patient's general medical condition. This review aims to deal with all those forms in which coagulation and fibrinolysis represent two sides of the same media in the correct management of patients with acute neurological syndrome. Precision medicine, personalized treatment, advanced anticoagulant strategies, and innovations in bleeding control represent future directions in the management of these complex pathologies in which stroke can be the evolution of two different acute events or be the first manifestation of an occult or unknown underlying pathology.

Risk factors and predictors of intracranial hemorrhage after mechanical thrombectomy in acute ischemic stroke: insights from the Stroke Thrombectomy and Aneurysm Registry (STAR)

BACKGROUND

Reducing intracranial hemorrhage (ICH) can improve patient outcome in acute ischemic stroke (AIS) intervention. We sought to identify ICH risk factors after AIS thrombectomy.

METHODS

This is a retrospective review of the Stroke Thrombectomy and Aneurysm Registry (STAR) database. All patients who underwent AIS thrombectomy with available ICH data were included. Multivariable regression models were developed to identify predictors of ICH after thrombectomy. Subgroup analyses were performed stratified by symptom status and European Cooperative Acute Stroke Study (ECASS) grade.

RESULTS

The study cohort comprised 6860 patients. Any ICH and symptomatic ICH (sICH) occurred in 25% and 7% of patients, respectively. Hemorrhagic infarction 1 (HI1) occurred in 36%, HI2 in 24%, parenchymal hemorrhage 1 (PH1) in 22%, and PH2 in 17% of patients classified by ECASS grade. Intraprocedural complications independently predicted any ICH (OR 3.8083, P<0.0001), PH1 (OR 1.9053, P=0.0195), and PH2 (OR 2.7347, P=0.0004). Race also independently predicted any ICH (black: OR 0.5180, P=0.0017; Hispanic: OR 0.4615, P=0.0148), sICH (non-white: OR 0.4349, P=0.0107), PH1 (non-white: OR 3.1668, P<0.0001), and PH2 (non-white: OR 1.8689, P=0.0176), with white as the reference. Primary mechanical thrombectomy technique also independently predicted ICH. ADAPT (A Direct Aspiration First Pass Technique) was a negative predictor of sICH (OR 0.2501, P<0.0001), with stent retriever as the reference.

CONCLUSIONS

This study identified ICH risk factors after AIS thrombectomy using real-world data. There was a propensity towards a reduced sICH risk with direct aspiration. Procedural complications and ethnicity were predictors congruent between categories of any ICH, sICH, PH1, and PH2. Further investigation of technique and ethnicity effects on ICH and outcomes after AIS thrombectomy is warranted.

Prognostic value of contrast staining on dual-energy CT after endovascular therapy in acute ischemic stroke: a meta-analysis

BACKGROUND

Contrast staining (CS) on dual-energy CT (DECT) is common after endovascular therapy (EVT) in acute ischemic stroke (AIS). We performed a meta-analysis to investigate the prognostic significance of CS detected by DECT after EVT in AIS.

METHOD

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science and Scopus databases were searched from inception to July 2023 for publications on the prognostic significance of CS on DECT after EVT in patients with AIS. Prognostic outcomes were hemorrhage transformation (HT) and poor functional outcome (modified Rankin Scale [mRS] Score of 3-6 at the 90-day follow-up). Data are presented as odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Eleven studies including 1123 cases of AIS were included. Pooled results indicated a higher risk of HT in patients with CS than in those without CS (OR = 2.22; 95% CI 1.41-3.51, P = 0.001; I2 = 45.4%). No association between CS and symptomatic HT was observed (OR = 2.10; 95% CI 0.64-6.95, P = 0.223; I2 = 67.3%). Moreover, there was also higher odds of poor functional outcome in patients with CS than in those without CS (OR = 2.76; 95% CI 1.53-4.97, P = 0.001; I2 = 44.9%).

CONCLUSIONS

The presence of contrast staining on DECT after EVT is associated with a higher risk of hemorrhage transformation and poor functional outcome. However, further high-quality studies with standardized processes are required to confirm these results.

Predictors and outcome of early neurological deterioration after endovascular thrombectomy: a secondary analysis of the DIRECT-MT trial

BACKGROUND

There is uncertainty regarding the predictors of early neurological deterioration (END) after endovascular thrombectomy in patients with acute ischemic stroke (AIS). Limited studies have focused on the effect of END on functional outcome. Our aim was to determine the predictors of END after endovascular thrombectomy in AIS and its effect on functional outcome at 90 days.

METHODS

This is a secondary analysis of the DIRECT-MT trial. Patients who failed to complete endovascular thrombectomy were additionally excluded. END was defined as ≥4-point increase in National Institutes of Health Stroke Scale score between admission and 24 hours after endovascular thrombectomy. Multivariable logistic regression was used to identify predictors for END and its effect on the modified Rankin Scale (mRS) score at 90 days.

RESULTS

Of 591 patients enrolled, 111 (18.8%) had postoperative END, which was associated with higher ordinal mRS score at 90 days (adjusted common OR (aOR) 6.968, 95% CI 4.444 to 10.926). Non-modifiable factors included baseline Alberta Stroke Program Early CT Score (aOR 0.883, 95% CI 0.790 to 0.987), systolic blood pressure (aOR 1.017, 95% CI 1.006 to 1.028), glucose level (aOR 1.178, 95% CI 1.090 to 1.273), collateral status (aOR 0.238, 95% CI 0.093 to 0.608), occlusion site (aOR 0.496, 95% CI 0.290 to 0.851) and the presence of an anterior communicating artery (aOR 0.323, 95% CI 0.148 to 0.707). Admission-to-groin puncture time (aOR 1.010, 95% CI 1.003 to 1.017), general anesthesia (aOR 2.299, 95% CI 1.193 to 4.444), number of passes (aOR 1.561, 95% CI 1.243 to 1.961) and contrast extravasation (aOR 6.096, 95% CI 1.543 to 24.088) were modifiable predictors for END.

CONCLUSIONS

Postoperative END is associated with adverse functional outcome. Several non-modifiable and modifiable factors can predict END and support future treatment decision-making to improve the potential utility of endovascular thrombectomy.

TRIAL REGISTRATION NUMBER

DIRECT-MT ClinicalTrials.gov NCT03469206.

Higher Serum E-Selectin Levels Associated with Malignant Brain Edema after Endovascular Thrombectomy for Ischemic Stroke: A Pilot Study

Background and Purpose: Little is known about the effect of soluble adhesion molecules on malignant brain edema (MBE) after endovascular thrombectomy (EVT). This study aimed to explore the association between serum concentrations of E-selectin and the risk of MBE in patients who received EVT. Methods: Patients with a large vessel occlusion stroke in the anterior circulation who underwent EVT were prospectively recruited. Serum soluble E-selectin concentrations were measured after admission for all patients. MBE was defined as a midline shift of ≥5 mm on follow-up imaging within 72 h after surgery. Multivariate logistic regression analyses were performed to determine the association between E-selectin levels and the risk of MBE. Results: Among the 261 included patients (mean age, 69.7 ± 12.3 years; 166 males), 59 (22.6%) developed MBE. Increasing circulating E-selectin levels were associated with an increased risk of MBE after multivariable adjustment (odds ratios [OR], highest vs. lowest quartile: 3.593; 95% confidence interval [CI], 1.178-10.956; p = 0.025). We further observed a significantly positive association between E-selectin and MBE (per 1-standard deviation increase; OR, 1.988; 95% CI, 1.379-2.866, p = 0.001) when the E-selectin levels were analyzed as a continuous variable. Furthermore, the restricted cubic spline demonstrated a linear correlation between serum E-selectin levels and the risk of MBE (p < 0.001 for linearity). Conclusions: In this prospective study, circulating levels of E-selectin were associated with an increased risk of MBE after EVT. Further mechanistic studies are warranted to elucidate the pathophysiology underlying this association.

Association between intravenous tirofiban and intracranial hemorrhage in acute large vessel occlusion stroke: insight from the RESCUE BT randomized placebo-controlled trial

BACKGROUND

The aim of this study is to investigate the association between intravenous tirofiban and symptomatic intracranial hemorrhage (SICH) in patients with acute ischemic stroke (AIS) secondary to large vessel occlusion (LVO) receiving endovascular thrombectomy (EVT) within 24 h of time last known well (LKW).

METHODS

Patients with AIS-LVO who were randomly assigned to receive intravenous tirofiban or placebo before EVT within 24 h of time LKW and had follow-up brain non-contrast computed tomography within 24 h after stopping tirofiban treatment were derived from "RESCUE BT": a multicenter, randomized, placebo-controlled, double-blind trial. All eligible patients were divided into SICH and NO-SICH groups. Subgroup analyses were performed to explore for heterogeneity.

RESULTS

Of 945 patients included in this cohort, there were 76 (8.0%) in the SICH group and 869 (92.0%) in the NO-SICH group. The incidence of SICH was not higher in patients receiving intravenous tirofiban compared with placebo (adjusted risk ratio (RR), 1.51; 95% confidence interval (CI), 0.97-2.36; P = 0.07). Subgroup analyses showed that age greater than 67-year-old (adjusted RR, 2.18; 95% CI 1.18-4.00), NIHSS greater than 16 (adjusted RR, 1.88; 95% CI 1.06-3.34), and cardioembolism (adjusted RR, 3.73; 95% CI 1.66-8.35) were associated with increased SICH risk.

CONCLUSIONS

In patients with acute large vessel occlusion stroke, intravenous tirofiban before EVT within 24 h of time from last known well is not associated with increased risk of SICH. Patients who are older, have more severe neurological deficits, or with cardioembolism are at higher risk of SICH with intravenous tirofiban.

TRIAL REGISTRATION NUMBER

URL: http://www.chictr.org.cn ; Unique identifier: ChiCTR-INR-17014167.

Imaging mismatch between Alberta Stroke Program Early CT Score and perfusion imaging may be a good variable for endovascular treatment

OBJECTIVE

Some patients with acute large vessel occlusion (LVO) presented imaging mismatch, low Alberta Stroke Program Early CT Score (ASPECTS) with small ischemic core, or high ASPECTS with large ischemic core. The study was designed to explore whether patients with imaging mismatch could benefit from endovascular treatment (EVT).

METHODS

We retrospectively reviewed patients with LVO treated with EVT in our center from March 2018 to Jul 2020. Patients were divided into three groups, imaging mismatch, small ischemic core, and large ischemic core groups. Pooled analyses based on stroke onset to treatment time were done. Multivariate regression analysis was performed to explore the factors for good outcomes.

RESULTS

Sixty-eight of 419 patients with LVO presented with imaging mismatch, and 35 of those (51%) achieved good outcomes after EVT at 90-day. No significant differences were noted in good outcomes and symptomatic intracranial hemorrhage (sICH) between patients with imaging mismatch and small ischemic core. Compared with large ischemic core, patients with imaging mismatch presented lower risk of sICH (95% confidence interval (CI) 0.04-0.75, p = 0.011) within 6 h and higher proportion of good outcomes (95% CI 0.37-0.82, p = 0.002) at 6 to 24 h. Baseline NIHSS (odds ratio (OR) = 0.91, 95% CI 0.88-0.95)), ASPECTS (OR = 1.14, 95% CI 1.01-1.29), ischemic core (OR = 0.99, 95% CI 0.98-1.00), and sICH (OR = 61.61, 95% CI 8.09-461.32) were associated with good outcomes.

CONCLUSIONS

Patients with imaging mismatch treated within 24 h could benefit from EVT and without increasing the risk of sICH.

KEY POINTS

• Patients with imaging mismatch between ASPECTS and ischemic core could achieve good outcomes after endovascular treatment. • Compared with large ischemic core, patients with imaging mismatch presented lower risk of symptomatic hemorrhage within 6 h and higher proportion of good outcomes within 6-24 h. • Baseline NIHSS score, ASPECTS, ischemic core, and symptomatic intracranial hemorrhage were associated with good outcomes.

Endothelial Dysfunction and Parenchymal Hematoma in Ischemic Stroke Patients after Endovascular Thrombectomy

INTRODUCTION

Endothelial dysfunction (ED) may result in parenchymal injury and therefore worsen the outcomes of ischemic stroke. This study aimed to determine whether ED could predict parenchymal hematoma (PH) in ischemic stroke patients treated with endovascular thrombectomy (EVT).

METHODS

Patients with large artery occlusion in the anterior circulation and treated with EVT were prospectively enrolled from 2 stroke centers. Serum soluble intercellular adhesion molecule-1, soluble vascular cell adhesion molecule-1, soluble E-selectin, and von Willebrand factor (vWF) were tested and summed to a standardized score to reflect the levels of ED. PH was diagnosed according to the Heidelberg Bleeding Classification.

RESULTS

Of the 325 enrolled patients (mean age, 68.6 years; 207 men), 41 (12.6%) developed PH. Patients with PH had higher concentrations of soluble E-selectin, vWF, and ED sum score. After adjusting for demographic characteristics, National Institutes of Health Stroke Scale score, pretreatment Alberta stroke program early computed tomography score, and other potential confounders, the increased ED burden was associated with PH (odds ratio, 1.432; 95% confidence interval, 1.031-1.988; p = 0.032). Similar significant results were found in the sensitivity analysis. The multiple-adjusted spline regression model showed a linear association between the total ED score and PH (p = 0.001 for linearity). Adding the ED score to the conventional model significantly improved the risk prediction of PH (net reclassification improvement = 25.2%, p = 0.001; integrated discrimination index = 2.9%; p = 0.001).

CONCLUSIONS

This study demonstrated that ED might be related to PH. Introducing the ED score could increase the reliability of the PH risk model for stroke patients treated with EVT.

Mechanical Thrombectomy Versus Best Medical Treatment in the Late Time Window in Non-DEFUSE-Non-DAWN Patients: A Multicenter Cohort Study

BACKGROUND

We assessed the efficacy and safety of mechanical thrombectomy (MT) in adult stroke patients with anterior circulation large vessel occlusion presenting in the late time window not fulfilling the DEFUSE-3 (Thrombectomy for Stroke at 6 to 16 Hours With Selection by Perfusion Imaging trial) and DAWN (Thrombectomy 6 to 24 Hours After Stroke With a Mismatch Between Deficit and Infarct trial) inclusion criteria.

METHODS

Cohort study of adults with anterior circulation large vessel occlusion admitted between 6 and 24 hours after last-seen-well at 5 participating Swiss stroke centers between 2014 and 2021. Mismatch was assessed by computer tomography or magnetic resonance imaging perfusion with automated software (RAPID or OLEA). We excluded patients meeting DEFUSE-3 and DAWN inclusion criteria and compared those who underwent MT with those receiving best medical treatment alone by inverse probability of treatment weighting using the propensity score. The primary efficacy end point was a favorable functional outcome at 90 days, defined as a modified Rankin Scale score shift toward lower categories. The primary safety end point was symptomatic intracranial hemorrhage within 7 days of stroke onset; the secondary was all-cause mortality within 90 days.

RESULTS

Among 278 patients with anterior circulation large vessel occlusion presenting in the late time window, 190 (68%) did not meet the DEFUSE-3 and DAWN inclusion criteria and thus were included in the analyses. Of those, 102 (54%) received MT. In the inverse probability of treatment weighting analysis, patients in the MT group had higher odds of favorable outcomes compared with the best medical treatment alone group (modified Rankin Scale shift: acOR, 1.46 [1.02-2.10]; P=0.04) and lower odds of all-cause mortality within 90 days (aOR, 0.59 [0.37-0.93]; P=0.02). There were no significant differences in symptomatic intracranial hemorrhage (MT versus best medical treatment alone: 5% versus 2%, P=0.63).

CONCLUSIONS

Two out of 3 patients with anterior circulation large vessel occlusion presenting in the late time window did not meet the DEFUSE-3 and DAWN inclusion criteria. In these patients, MT was associated with higher odds of favorable functional outcomes without increased rates of symptomatic intracranial hemorrhage. These findings support the enrollment of patients into ongoing randomized trials on MT in the late window with more permissive inclusion criteria.

Are we improving? Temporal trends in outcomes for mechanical thrombectomy for stroke: A systematic review and meta-analysis of randomized trials

BACKGROUND

In 2015, mechanical thrombectomy (MT) was deemed the standard of care for acute ischemic stroke (AIS) in the anterior circulation due to large vessel occlusion (LVO). To determine if outcomes in patients treated with MT have changed, we conducted a systematic review and meta-analysis of published randomized controlled trials (RCTs).

METHODS

A systematic literature review of the English language literature was conducted using PubMed. We included RCTs that focused on patients with AIS treated with MT. The primary outcome of interest was good functional outcome defined as modified Rankin Scale (mRS) 0-2 at 90 days. Safety outcomes included rates of symptomatic intracranial hemorrhage (sICH) and mortality at 90 days. Using Joinpoint Regression Analysis Program, we calculated the average annual percent change (AAPC) for the outcomes of interest.

RESULTS

We included 23 RCTs with 5784 patients. The years of mid-enrollment among the included RCTs ranged from 2012-2020. There was an AAPC of +3.82% between 2012 and 2020 (95% CI 0.4 to 7.3; P-value = 0.033) in rates of good functional outcome. There was an AAPC of +6.98% between 2012 and 2020 (95% CI 0.5 to 13.9; P-value = 0.039) in rates of sICH. There was an AAPC of -0.49% between 2012 and 2020 (95% CI -4.4 to 3.5; P-value = 0.77) in rates of mortality.

CONCLUSION

Between 2012 and 2020, rates of good functional outcome and sICH increased, while rates of mortality remained consistent in RCTs investigating MT for AIS. Multiple factors likely influenced our results, including increased use of MT and utilization of adjunctive therapies alongside MT.

The prognostic value of caveolin-1 levels in ischemic stroke patients after mechanical thrombectomy

BACKGROUND AND PURPOSE

The impact of serum caveolin-1 (Cav-1) on clinical outcomes in patients after mechanical thrombectomy (MT) is unclear. We aimed to investigate the association between serum cav-1 levels and the 3-month functional outcome.

METHODS

We prospectively enrolled and analyzed patients with an anterior circulation large vessel occlusion who underwent MT. Serum cav-1 concentrations were tested after admission. The primary outcome was a 90-day modified Rankin Scale score of 3-6.

RESULTS

Of the 237 recruited patients (mean age, 69.7 ± 12.1 years; 152 male), 131 (55.3%) experienced a 90-day poor outcome. After adjustment for demographic characteristics and other covariates, patients with higher serum Cav-1 levels had a reduced risk of poor outcome at 3 months (Per 1-standard deviation increase; odd ratios [OR], 0.59; 95% confidence interval [CI], 0.39 - 0.89, P = 0.013). Elevated Cav-1 concentrations (Per 1-standard deviation increase; OR, 0.59; 95% CI, 0.40 - 0.88, P = 0.011) were significantly associated with a favorable shift in modified Rankin Scale score distribution. Similar results were confirmed when the Cav-1 levels were analyzed as a categorical variable. Furthermore, the restricted cubic spline showed a linear association between Cav-1 levels and 90-day poor outcome (P = 0.032 for linearity).

CONCLUSIONS

Increased serum Cav-1 levels were associated with improved prognosis at 3 months in ischemic stroke patients after MT, suggesting that Cav-1 may be a potential prognostic biomarker for ischemic stroke after reperfusion therapy.

Symptomatic Intracranial Hemorrhage After Endovascular Stroke Treatment: External Validation of Prediction Models

BACKGROUND

Symptomatic intracranial hemorrhage (sICH) is a severe complication of reperfusion therapy for ischemic stroke. Multiple models have been developed to predict sICH or intracranial hemorrhage (ICH) after reperfusion therapy. We provide an overview of published models and validate their ability to predict sICH in patients treated with endovascular treatment in daily clinical practice.

METHODS

We conducted a systematic search to identify models either developed or validated to predict sICH or ICH after reperfusion therapy (intravenous thrombolysis and/or endovascular treatment) for ischemic stroke. Models were externally validated in the MR CLEAN Registry (n=3180; Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands). The primary outcome was sICH according to the Heidelberg Bleeding Classification. Model performance was evaluated with discrimination (c-statistic, ideally 1; a c-statistic below 0.7 is considered poor in discrimination) and calibration (slope, ideally 1, and intercept, ideally 0).

RESULTS

We included 39 studies describing 40 models. The most frequently used predictors were baseline National Institutes of Health Stroke Scale (NIHSS; n=35), age (n=22), and glucose level (n=22). In the MR CLEAN Registry, sICH occurred in 188/3180 (5.9%) patients. Discrimination ranged from 0.51 (SPAN-100 [Stroke Prognostication Using Age and National Institutes of Health Stroke Scale]) to 0.61 (SITS-SICH [Safe Implementation of Treatments in Stroke Symptomatic Intracerebral Hemorrhage] and STARTING-SICH [STARTING Symptomatic Intracerebral Hemorrhage]). Best calibrated models were IST-3 (intercept, -0.15 [95% CI, -0.01 to -0.31]; slope, 0.80 [95% CI, 0.50-1.09]), SITS-SICH (intercept, 0.15 [95% CI, -0.01 to 0.30]; slope, 0.62 [95% CI, 0.38-0.87]), and STARTING-SICH (intercept, -0.03 [95% CI, -0.19 to 0.12]; slope, 0.56 [95% CI, 0.35-0.76]).

CONCLUSIONS

The investigated models to predict sICH or ICH discriminate poorly between patients with a low and high risk of sICH after endovascular treatment in daily clinical practice and are, therefore, not clinically useful for this patient population.

Effectiveness and safety of mechanical thrombectomy for acute ischaemic stroke in Latin American countries: A systematic review

OBJECTIVE

To describe the use, effectiveness, and safety outcomes of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) in Latin American countries.

MATERIALS AND METHODS

Studies reporting MT outcomes for AIS in Latin America were identified in CINAHL, MEDLINE, Web of Science, SciELO, EMBASE, and LILACS databases. Synthesis was conducted according to effectiveness (recanalization rates) and safety measures (mortality and functional independence at 90 days).

RESULTS

Seventeen studies were included, mainly from public and university hospitals. MT utilization varied from 2.6% to 50.1%, while successful recanalization ranged from 63% to 95%. Functional independence 90 days after stroke (a modified Rankin scale score of 0 to 2) was achieved in less than 40% across most studies. Mortality rates were below 30%; studies with posterior circulation strokes reported higher mortality rates. The randomized trial reported better health outcomes for functional independence among patients in the MT group (OR 2.28; 95% CI, 1.41 - 3.69), favoring MT over standard care.

CONCLUSIONS

The included studies had great methodological heterogeneity due to differences in study design, the MT time window, and stroke location. The only randomized trial showed improved functional independence and lower mortality rates with MT than with standard care. The rest of the studies reported similar findings to available literature. Efforts to improve stroke care are reflected in improved patient outcomes in the region. Future studies should consider standard time window criteria and reduce the risk of bias by including representative samples and comparison groups.

Predictors of intracranial hemorrhage after mechanical thrombectomy using a stent-retriever for anterior circulation ischemic stroke: A retrospective study

Intracranial hemorrhage (ICH) after mechanical thrombectomy (MT) is a potentially catastrophic complication. We aimed to identify predictors of hemorrhagic complications following MT using a stent-retriever (SR) for acute ischemic stroke (AIS) patients due to large vessel occlusion of anterior circulation. In consecutive AIS patients, the clinical and procedural variables were retrospectively analyzed. ICH was evaluated on computed tomography performed 24 hours following MT and dichotomized into asymptomatic ICH and symptomatic intracranial hemorrhage (SICH) depending on the presence of neurological deterioration. Using univariate and multivariate analyses, the predictors of ICH and SICH were identified. The optimal cutoff value for predicting SICH was determined by receiver operating characteristic (ROC) analysis. Among 135 patients, ICH was detected in 52 (38.5%), and 17 (12.6%) were classified as having SICH. We found that serum glucose level (odds ratio [OR] 1.016, P = .011) and number of SR passes (OR 2.607, P < .001) were significantly correlated with ICH. Independent predictors of SICH included the baseline Alberta stroke program early computed tomography score (ASPECTS) (OR 0.485, P = .042), time from stroke onset to groin puncture (OTP) (OR 1.033, P = .016), and number of SR passes (OR 2.342, P = .038). In ROC analysis, baseline ASPECTS ≤ 7, OTP > 280 minutes, and SR passes > 3 were the optimal cutoff values for predicting SICH. In conclusion, serum glucose level and SR pass serve as predictors for any form of ICH in large vessel occlusion-induced AIS patients undergoing MT. Moreover, patients with lower ASPECTS, prolonged OTP, and multiple SR passes are more vulnerable to SICH.

Risk factors of hemorrhagic transformation in acute ischaemic stroke: A systematic review and meta-analysis

Background

Hemorrhagic transformation (HT) following reperfusion therapies for acute ischaemic stroke often predicts a poor prognosis. This systematic review and meta-analysis aims to identify risk factors for HT, and how these vary with hyperacute treatment [intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT)].

Methods

Electronic databases PubMed and EMBASE were used to search relevant studies. Pooled odds ratio (OR) with 95% confidence interval (CI) were estimated.

Results

A total of 120 studies were included. Atrial fibrillation and NIHSS score were common predictors for any intracerebral hemorrhage (ICH) after reperfusion therapies (both IVT and EVT), while a hyperdense artery sign (OR = 2.605, 95% CI 1.212-5.599, I ² = 0.0%) and number of thrombectomy passes (OR = 1.151, 95% CI 1.041-1.272, I ² = 54.3%) were predictors of any ICH after IVT and EVT, respectively. Common predictors for symptomatic ICH (sICH) after reperfusion therapies were age and serum glucose level. Atrial fibrillation (OR = 3.867, 95% CI 1.970-7.591, I ² = 29.1%), NIHSS score (OR = 1.082, 95% CI 1.060-1.105, I ² = 54.5%) and onset-to-treatment time (OR = 1.003, 95% CI 1.001-1.005, I ² = 0.0%) were predictors of sICH after IVT. Alberta Stroke Program Early CT score (ASPECTS) (OR = 0.686, 95% CI 0.565-0.833, I ² =77.6%) and number of thrombectomy passes (OR = 1.374, 95% CI 1.012-1.866, I ² = 86.4%) were predictors of sICH after EVT.

Conclusion

Several predictors of ICH were identified, which varied by treatment type. Studies based on larger and multi-center data sets should be prioritized to confirm the results.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=268927, identifier: CRD42021268927.

Poor venous outflow profiles increase the risk of reperfusion hemorrhage after endovascular treatment

To investigate whether unfavorable cerebral venous outflow (VO) predicts reperfusion hemorrhage after endovascular treatment (EVT), we conducted a retrospective multicenter cohort study of patients with acute ischemic stroke and large vessel occlusion (AIS-LVO). 629 AIS-LVO patients met inclusion criteria. VO profiles were assessed on admission CT angiography using the Cortical Vein Opacification Score (COVES). Unfavorable VO was defined as COVES ≤ 2. Reperfusion hemorrhages on follow-up imaging were subdivided into no hemorrhage (noRH), hemorrhagic infarction (HI) and parenchymal hematoma (PH). Patients with PH and HI less frequently achieved good clinical outcomes defined as 90-day modified Rankin Scale scores of ≤ 2 (PH: 13.6% vs. HI: 24.6% vs. noRH: 44.1%; p < 0.001). The occurrence of HI and PH on follow-up imaging was more likely in patients with unfavorable compared to patients with favorable VO (HI: 25.1% vs. 17.4%, p = 0.023; PH: 18.3% vs. 8.5%; p = <0.001). In multivariable regression analyses, unfavorable VO increased the likelihood of PH (aOR: 1.84; 95% CI: 1.03-3.37, p = 0.044) and HI (aOR: 2.05; 95% CI: 1.25-3.43, p = 0.005), independent of age, sex, admission National Institutes Health Stroke Scale scores and arterial collateral status. We conclude that unfavorable VO was associated with the occurrence of HI and PH, both related to worse clinical outcomes.

A Novel Metabolic Score for Insulin Resistance and Symptomatic Intracranial Hemorrhage in Ischemic Stroke Patients After Endovascular Thrombectomy

BACKGROUND AND PURPOSE

Insulin resistance plays a pivotal role in the pathophysiology of ischemic stroke. This study aimed to determine the relationship between the novel metabolic score for insulin resistance (METS-IR) and symptomatic intracranial hemorrhage (sICH) after endovascular thrombectomy (EVT) in stroke patients.

METHODS

We retrospectively included patients with large artery occlusion in the anterior circulation and treated by EVT from 2 stroke centers (Nanjing First Hospital from September 2019 to April 2022, and Jinling Hospital from September 2019 to July 2021). The METS-IR was used as an alternative marker of insulin resistance and calculated using laboratory data after admission. sICH was diagnosed according to the Heidelberg Bleeding Classification.

RESULTS

Of the 410 enrolled patients (mean age, 69.8 ± 11.7 years; 60.7% men), 50 (12.2%) were diagnosed as sICH. After adjusting for demographic characteristics, poor collateral status, and other potential confounders, higher METS-IR was revealed to be independently associated with sICH (odds ratio, 1.076; 95% confidence interval, 1.034-1.120; P = 0.001). Similar significant results were obtained when defining METS-IR as a categorical variable. The restricted cubic spline uncovered a linear relationship between METS-IR and sICH (P < 0.001 for linearity). Furthermore, adding METS-IR to the conventional model significantly improved the risk prediction for sICH (net reclassification improvement = 15.8%, P = 0.035; integrated discrimination index = 2.6%; P = 0.017).

CONCLUSION

This study demonstrated a significant association between METS-IR score and sICH in ischemic stroke patients treated with EVT. It could help monitor and manage sICH in patients after EVT.

Updates in mechanical thrombectomy

Stroke is a leading cause of morbidity and mortality. The advent of mechanical thrombectomy has largely improved patient outcomes. This article reviews the features and outcomes associated with aspiration, stent retrievers, and combination catheters used in current practice. There is also a discussion on clinical considerations based on anatomical features and clot composition. The reperfusion grading scale and outcome metrics commonly used following thrombectomy when a patient is still in the hospital are reviewed. Lastly, there are proposed discharge and outpatient follow-up goals in caring for patients hospitalized for a stroke.

Association of platelet-to-lymphocyte ratio and neutrophil-to-lymphocyte ratio with outcomes in stroke patients achieving successful recanalization by endovascular thrombectomy

Objective

Serum inflammatory biomarkers play crucial roles in the development of acute ischemic stroke (AIS). In this study, we explored the association between inflammatory biomarkers including platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), and monocyte-to-lymphocyte ratio (MLR), and clinical outcomes in AIS patients who achieved successful recanalization.

Methods

Patients with AIS who underwent endovascular thrombectomy (EVT) and achieved a modified thrombolysis in the cerebral infarction scale of 2b or 3 were screened from a prospective cohort at our institution between January 2013 and June 2021. Data on blood parameters and other baseline characteristics were collected. The functional outcome was an unfavorable outcome defined by a modified Rankin Scale of 3-6 at the 3-month follow up. Other clinical outcomes included symptomatic intracranial hemorrhage (sICH) and 3-month mortality. Multivariable logistic regression analysis was performed to evaluate the effects of PLR, NLR, and MLR on clinical outcomes.

Results

A total of 796 patients were enrolled, of which 89 (11.2%) developed sICH, 465 (58.4%) had unfavorable outcomes at 3 months, and 168 (12.1%) died at the 3-month follow up. After adjusting for confounding variables, a higher NLR (OR, 1.076; 95% confidence interval [CI], 1.037-1.117; p < 0.001) and PLR (OR, 1.001; 95%CI, 1.000-1.003; p = 0.045) were significantly associated with unfavorable outcomes, the area under the receiver operating characteristic curve of NLR and PLR was 0.622 and 0.564, respectively. However, NLR, PLR, and MLR were not independently associated with sICH and 3-month mortality (all adjusted p > 0.05).

Conclusion

Overall, our results indicate that higher PLR and NLR were independently associated with unfavorable functional outcomes in AIS patients with successful recanalization after EVT; however, the underlying mechanisms are yet to be elucidated.

Contrast Neurotoxicity and its Association with Symptomatic Intracranial Hemorrhage After Mechanical Thrombectomy

PURPOSE

Despite improved techniques and sophisticated postinterventional care, symptomatic intracranial hemorrhage (sICH) remains the most feared complication of mechanical thrombectomy (MT). Based on peri-interventional parameters, we aimed to discover which patients have a higher risk of sICH.

METHODS

From March 2017 until March 2020 consecutive patients with acute ischemic stroke (AIS) and confirmed large-vessel occlusion who underwent MT were analyzed retrospectively. Demographic, clinical, and radiological variables and parameters specific to thrombectomy were reviewed. A univariate analysis was performed and statistically significant variables were included in a logistic regression model to identify independent factors predictive of sICH.

RESULTS

A total of 236 patients with confirmed large-vessel occlusion were included and 22 (9.3%) had sICH. Univariate predictors of sICH included diabetes mellitus, glucose > 11.1 mmol/L, creatinine clearance (CrCl) ≤ 30 ml/min/1.73, ASPECTS indicating pretreatment infarct size, acute internal carotid artery (ICA) occlusion, stent implantation, tirofiban use, time from symptom onset to groin puncture > 4.5 h and high contrast medium consumption. In the adjusted analysis, ASPECTS < 6 (OR 3.673, p = 0.041), and amount of contrast injected ≥ 140 ml (OR 5.412, p = 0.003) were independent predictors of sICH, but not any more baseline glucose > 11.1 mmol/L (OR 1.467, p = 0.584), CrCl ≤ 30 ml/min/1.73 (OR 4.177, p = 0.069), acute ICA occlusion (OR 2.079, p = 0.181), stent implantation (OR 0.465, p = 0.512), tirofiban use (OR 5.164, p = 0.167), and time from onset-to-groin puncture (OR 1.453, p = 0.514).

CONCLUSION

The amount of contrast medium used is a modifiable factor associated with sICH. This association is novel and may be related to the neurotoxicity of the contrast medium disrupting the blood-brain barrier.

Predictors of Symptomatic Intracranial Hemorrhage after Endovascular Thrombectomy in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

INTRODUCTION

This meta-analysis assessed the predictors of symptomatic intracranial hemorrhage (sICH) after endovascular thrombectomy (EVT) for patients with acute ischemic stroke.

METHODS

PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science were searched for studies published from inception to February 16, 2021. We included studies that evaluated the predictors of sICH after EVT. The random-effect model or fixed-effect model was used to pool the estimates according to the heterogeneity.

RESULTS

A total of 25 cohort studies, involving 15,324 patients, were included in this meta-analysis. The total incidence of sICH was 6.72 percent. Age (MD = 2.57, 95% CI: 1.53-3.61; p < 0.00001), higher initial NIHSS score (MD = 1.71, 95% CI: 1.35-2.08, p < 0.00001), higher initial systolic blood pressure (MD = 7.40, 95% CI: 5.11-9.69, p < 0.00001), diabetes mellitus (OR = 1.36, 95% CI: 1.10-1.69, p = 0.005), poor collaterals (OR = 3.26, 95% CI: 2.35-4.51; p < 0.0001), internal carotid artery occlusion (OR = 1.55, 95% CI: 1.26-1.90; p < 0.0001), longer procedure time (MD = 18.92, 95% CI: 11.49-26.35; p < 0.0001), and passes of retriever >3 (OR = 3.39, 95% CI: 2.45-4.71; p < 0.0001) were predictors of sICH, while modified thrombolysis in cerebral infarction score ≥2b (OR = 0.61, 95% CI: 0.46-0.79; p = 0.0002) was associated with a decreased risk of sICH. There were no significant differences in the female gender, initial serum glucose, initial ASPECT score, atrial fibrillation, oral anticoagulants, antiplatelet therapy, intravenous thrombolysis, general anesthesia, neutrophil-to-lymphocyte ratio, and emergent stenting.

CONCLUSIONS

This study identified many predictors of sICH. Some of the results lack robust evidence given the limitations of the study. Therefore, larger cohort studies are needed to confirm these predictors.

Endovascular treatment vs drug therapy alone in patients with mild ischemic stroke and large infarct cores

BACKGROUND

Treatment decision making is strictly associated with the outcomes in patients with ischemic stroke who show a large core infarct. Medical care alone may result in suboptimal treatment efficacy, and endovascular treatment may be accompanied by safety issues. Whether endovascular treatment is superior to medical care is not well investigated in the clinical studies.

AIM

To investigate the efficacy of endovascular treatment and drug therapy alone in mild ischemic stroke patients with large infarct cores.

METHODS

Fifty patients with mild ischemic stroke and 50 patients with acute ischemic stroke caused by anterior large vessel occlusion were selected at the First Affiliated Hospital of Hebei North University between January 2021 and December 2021. Patients were divided into an endovascular therapy group and a drug therapy group according to different treatment methods. In the endovascular therapy group, there were 28 patients with minor stroke and 22 patients with large infarct cores. The drug therapy group had 22 patients with minor stroke and 28 patients with large infarct cores. The National Institutes of Health Stroke Scale (NIHSS) scores were collected and compared between the two groups immediately after the operation and 24 h and 7 d after the operation. The modified Rankin scale (mRS) and/or activity of daily living were assessed at hospital discharge.

RESULTS

There was no significant difference in NIHSS scores between the two groups before the operation (P > 0.05). NIHSS scores were lower in the endovascular therapy group than in the drug therapy group at 24 h and 7 d after the operation and at hospital discharge (all P < 0.05). The incidence of early neurologic deterioration was significantly lower in the endovascular therapy group than in the drug therapy group (P < 0.05). At hospital discharge, the mRS score was lower in the endovascular treatment group than in the drug therapy group, and the activity of daily living score was better in the endovascular treatment group than in the drug therapy group (all P < 0.05). During a follow-up of 3 mo, 17 patients (34.0%) had good prognosis (mRS ≤ 2), 33 patients (66.0%) had poor prognosis (mRS > 2), and 11 patients (22.0%) died. In the medical treatment group, 16 patients (mRS ≤ 2) had good prognosis (32.0%), 34 patients (mRS > 2) had poor prognosis (68.0%), and 14 patients (28.0%) died. There was no significant difference in prognosis and mortality between the two groups (P > 0.05).

CONCLUSION

Endovascular therapy can improve NIHSS score and mRS score in patients with mild ischemic stroke and large infarct cores. It is suitable for clinical application.