Revascularization results in the Interventional Management of Stroke II trial

Novel Risk Score to Predict Poor Outcome After Endovascular Treatment in Anterior Circulation Occlusive Acute Ischemic Stroke

BACKGROUND

We aimed to develop and validate a prognostic score to predict outcomes after endovascular treatment in acute ischemic stroke.

METHODS

The prognostic score was developed based on the ACTUAL (Endovascular Treatment for Acute Anterior Circulation Ischemic Stroke) registry. The validation cohort was derived from the Captor trial. Independent predictors of poor outcome after endovascular treatment were obtained from the least absolute shrinkage and selection operator regression and multivariable logistic regression. Corresponding regression coefficients were used to generate point scoring system. The area under the receiver operating characteristic curve and the Hosmer-Lemeshow goodness-of-fit test were used to assess model discrimination and calibration. The predictive properties of the developed prognostic score were validated and the discriminative power was compared with other validated tools.

RESULTS

A 17-point Age, Collateral Status, Blood glucose, Alberta Stroke Program Early Computed Tomography Score, and National Institutes of Health Stroke Scale score scale was developed from the set of independent predictors, including age, admission National Institutes of Health Stroke Scale score, Alberta Stroke Program Early Computed Tomography Score on initial computed tomography scan, blood glucose, and collateral status. The scale showed good discrimination in the derivation cohort (area under the receiver operating characteristic curve, 0.79 [95% CI, 0.75-0.82]) and validation cohorts (area under the receiver operating characteristic curve, 0.77 [95% CI, 0.70-0.84]). The scale was well calibrated (Hosmer-Lemeshow test) in the derivation cohort (P=0.57) and validation cohort (P=0.75).

CONCLUSIONS

The Age, Collateral Status, Blood glucose, Alberta Stroke Program Early Computed Tomography score, and National Institutes of Health Stroke Scale score scale is a valid tool for predicting outcomes and may be useful for endovascular stroke treatment in anterior circulation large vessel occlusions.

Advances in endovascular thrombectomy for the treatment of acute ischemic stroke

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

The relationship between blood urea nitrogen to creatinine ratio and hemorrhagic transformation in stroke patients treated with endovascular thrombectomy

BACKGROUND

This study aimed to determine the parameters associated with hemorrhagic transformation in EVT and its relationship with blood urea nitrogen to creatinine (BUN/Cr) ratio-based dehydration status.

METHODS

Patients' data treated with EVT in AIS were evaluated from the years 2018 to 2023. Venous blood samples were collected prior to operation and BUN/Cr ratio was calculated. Alberta stroke program early CT (ASPECT) and collateral scores were determined. Hemorrhagic transformation was assessed by brain computed tomography. Mortality and 90-day disability rates were determined. Parameters associated with hemorrhagic transformation were evaluated according to regression analysis models.

RESULTS

There were 146 patients with a mean age of 67.01 ± 14.34 in the study. The first-pass thrombectomy rate was 32.2 % (n = 47); and 80.8 % (n = 118) of all patients achieved complete recanalization. Symptom-to-puncture and puncture-to-recanalization times were associated with hemorrhagic transformation (p = 0.004, p = 0.012). In addition, initial NIHSS (p < 0.001), number of thrombectomy passes (p < 0.001), intra-arterial thrombolysis (p = 0.008), ASPECT score (p < 0.001), collateral score (p = 0.016), and serum glucose (p = 0.047) levels were associated with hemorrhagic transformation. Decreased glomerular filtration rate (p = 0.007) was associated with symptomatic hemorrhagic transformation. Multivariate regression analysis revealed that the major parameters for hemorrhagic transformation were initial NIHSS and number of thrombectomy passes (p = 0.035, p = 0.046). No relationship was observed between BUN/Cr ratio and hemorrhagic transformation (p = 0.910).

CONCLUSION

In this study, no relationship was detected between BUN/Cr ratio-based dehydration and hemorrhagic transformation in AIS patients treated with EVT. The main predictive factors for hemorrhagic transformation are high initial NIHSS and number of thrombectomy passes.

Modified Treatment in Brain Ischemia 2b Stopped or Continued After First-Pass Mechanical Thrombectomy for M1 Occlusions

BACKGROUND AND PURPOSE

The superiority of achieving modified Treatment in Cerebral Ischemia (mTICI) from multiple passes versus mTICI 2b from a single pass remains uncertain. We aimed to assess whether additional passes in M1 occlusion patients with a first-pass mTICI 2b score improved clinical and functional outcomes.

METHODS

We analyzed Registry Combined vs. Single Thrombectomy Techniques registry data of consecutive M1-occlusion patients, comparing outcomes of those with mTICI 2b-stopped after the first pass versus continued mechanical thrombectomy (MT) to improve angiographic results (mTICI 2b or mTICI 2c/3). We compared demographic, clinical, angiographic, and clinical outcome data (National Institute of Health Stroke Scale [NIHSS] at 24 h and modified Rankin Scale at 3 months).

RESULTS

Patients with first-pass mTICI 2b had lower NIHSS scores at admission, fewer left-side occlusions, and longer last-seen-well times. Endovascular techniques and time from groin puncture to revascularization were similar across groups. Patients with final mTICI 2c/3 had the highest distal embolism rates in a new territory (0% for mTICI2b-stopped vs. 3% for final mTICI2b-continued; 7.7% for final mTICI2c/3; p = 0.02). The groups had similar rates of death, symptomatic intracranial hemorrhage, same-area distal embolism, other MT-related complications, NIHSS at 24 h, NIHSS change from admission to 24 h, and same-territory distal embolism.

CONCLUSION

Achieving mTICI 2b after the first pass in M1-occlusion patients proved relevant. These patients had comparable clinical and functional outcomes and a lower risk of new territory distal embolisms compared to those with final mTICI 2c/3 scores.

SOFIA Aspiration System as first-line Technique (SOFAST): a prospective, multicenter study to assess the efficacy and safety of the 6 French SOFIA Flow Plus aspiration catheter for endovascular stroke thrombectomy

BACKGROUND

Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). The SOFAST study collected clinical evidence on the safety and efficacy of the 6 French SOFIA Flow Plus aspiration catheter (SOFIA 6F) when used as first-line treatment.

METHODS

This was a prospective, multicenter investigation to assess the safety and efficacy of SOFIA 6F used for first-line aspiration. Anterior circulation LVO stroke patients were enrolled. The primary endpoint was the final modified Thrombolysis in Cerebral Infarction (mTICI)≥2b rate. Secondary endpoints included first-pass and first-line mTICI≥2b rates, times from arteriotomy to clot contact and mTICI≥2b, and 90-day modified Rankin Scale (mRS)≤2. First-line and final mTICI scores were adjudicated by an independent imaging core lab. Safety events were assessed by an independent clinical events adjudicator.

RESULTS

A total of 108 patients were enrolled across 12 centers from July 2020 to June 2022. Median age was 67 years, median National Institutes of Health Stroke Scale (NIHSS) was 15.5, and 56.5% of patients received intravenous thrombolytics. At the end of the procedure, 97.2%, 85.2%, and 55.6% of patients achieved mTICI≥2b, ≥2c, and 3, respectively. With SOFIA 6F first-line aspiration, 87.0%, 79.6%, and 52.8% achieved mTICI≥2b, ≥2c, and 3, respectively. After the first pass, 75.0%, 70.4%, and 50.9% achieved mTICI≥2b, ≥2c, and 3, respectively. Median times from arteriotomy to clot contact and successful revascularization were 12 and 17 min, respectively. At 90 days, 66.7% of patients achieved mRS≤2.

CONCLUSIONS

First-line aspiration with SOFIA 6F is safe and effective with high revascularization rates and short procedure times.

Automated assessment of ischemic core on non-contrast computed tomography: a multicenter comparative analysis with CT perfusion

BACKGROUND

Application of machine learning (ML) algorithms has shown promising results in estimating ischemic core volumes using non-contrast CT (NCCT).

OBJECTIVE

To assess the performance of the e-Stroke Suite software (Brainomix) in assessing ischemic core volumes on NCCT compared with CT perfusion (CTP) in patients with acute ischemic stroke.

METHODS

In this retrospective multicenter study, patients with anterior circulation large vessel occlusions who underwent pretreatment NCCT and CTP, successful reperfusion (modified Thrombolysis in Cerbral Infarction ≥2b), and post-treatment MRI, were included from three stroke centers. Automated calculation of ischemic core volumes was obtained on NCCT scans using ML algorithm deployed by e-Stroke Suite and from CTP using Olea software (Olea Medical). Comparative analysis was performed between estimated core volumes on NCCT and CTP and against MRI calculated final infarct volume (FIV).

RESULTS

A total of 111 patients were included. Estimated ischemic core volumes (mean±SD, mL) were 20.4±19.0 on NCCT and 19.9±18.6 on CTP, not significantly different (P=0.82). There was moderate (r=0.40) and significant (P<0.001) correlation between estimated core on NCCT and CTP. The mean difference between FIV and estimated core volume on NCCT and CTP was 29.9±34.6 mL and 29.6±35.0 mL, respectively (P=0.94). Correlations between FIV and estimated core volume were similar for NCCT (r=0.30, P=0.001) and CTP (r=0.36, P<0.001).

CONCLUSIONS

Results show that ML-based estimated ischemic core volumes on NCCT are comparable to those obtained from concurrent CTP in magnitude and in degree of correlation with MR-assessed FIV.

Predicting poor functional outcomes for patients with large computed tomography perfusion core infarctions treated with endovascular thrombectomy

OBJECTIVE

Stroke patients with large core infarctions benefit from endovascular intervention, though only approximately 20% are functionally independent at 90 days. We studied prognostic factors for patients presenting with a large computed tomography perfusion (CTP) core.

METHODS

Retrospective analysis from a health system stroke registry, including consecutive thrombectomy patients treated within 24 hours from August 2020-December 2022 with an anterior circulation large vessel occlusion and CTP core infarct ≥50 milliliters. Logistic regression was used to determine independent predictors of 90-day modified Rankin Scale (mRS) score 4-6. The prognostic ability of previously reported scales was also assessed.

RESULTS

In 118 included patients, with mean age 64.3 ± 14.1 years, poor functional outcomes were present in 66 subjects (55.9%). The multivariable regression analysis demonstrated that higher presenting National Institutes of Health Stroke Scale (NIHSS) score (odds ratio [OR] 1.12, 95% confidence interval [CI] 1.02-1.23, p = 0.014), elevated glucose (OR 1.02, 95% CI 1.01-1.03, p = 0.002), absence of treatment with intravenous thrombolysis (OR 4.01, 95% CI 1.35-11.95, p = 0.013), and poor revascularization (OR 4.76, 95% CI 1.24-18.37, p = 0.023) were independently associated with primary outcome. The Charlotte Large artery occlusion Endovascular therapy Outcome Score (CLEOS) predicted 90-day mRS 4-6 (per 25-point increase, OR 1.22, 95% CI 1.10-1.34, p<0.001) and mRS 5-6 (per 25-point increase, OR 1.21, 95% CI 1.10-1.33, p<0.001). Nineteen of 20 (95%) patients with CLEOS ≥ 675 had 90-day mRS scores of 4-6, while 10 of 12 (83.3%) with CLEOS ≥ 725 had 90-day mRS scores of 5-6.

CONCLUSION

We report prognostic factors that can risk stratify thrombectomy patients with large CTP core infarctions.

Comparison of Thrombolysis In Cerebral Infarction (TICI) 2b and TICI 3 reperfusion in endovascular therapy for large ischemic anterior circulation strokes

BACKGROUND

Landmark thrombectomy trials have provided evidence that selected patients with large ischemic stroke benefit from successful endovascular therapy, commonly defined as incomplete (modified Thrombolysis In Cerebral Infarction (mTICI) 2b) or complete reperfusion (mTICI 3). We aimed to investigate whether mTICI 3 improves functional outcomes compared with mTICI 2b in large ischemic strokes.

METHODS

This retrospective multicenter cohort study was conducted to compare mTICI 2b versus mTICI 3 in large ischemic strokes in the anterior circulation. Patients enrolled in the German Stroke Registry between 2015-2021 were analyzed. Large ischemic stroke was defined as an Alberta Stroke Program Early CT Score (ASPECTS) of 3-5. Patients were matched by final mTICI grade using propensity score matching. Primary outcome was the 90-day modified Rankin Scale (mRS) score.

RESULTS

After matching, 226 patients were included. Baseline and imaging characteristics were balanced between mTICI 2b and mTICI 3 patients. There was no shift on the mRS favoring mTICI 3 compared with mTICI 2b in large ischemic strokes (adjusted common odds ratio (acOR) 1.12, 95% confidence interval (95% CI) 0.64 to 1.94, P=0.70). The rate of symptomatic intracranial hemorrhage was higher in mTICI 2b than in mTICI 3 patients (12.6% vs 4.5%, P=0.03). Mortality at 90 days did not differ between mTICI 3 and mTICI 2b (33.6% vs 37.2%; adjusted OR 0.69, 95% CI 0.33 to 1.45, P=0.33).

CONCLUSIONS

In endovascular therapy for large ischemic strokes, mTICI 3 was not associated with better 90-day functional outcomes compared with mTICI 2b. This study suggests that mTICI 2b might be warranted as the final angiographic result, questioning the benefit/risk ratio of additional maneuvers to seek for mTICI 3 in large ischemic strokes.

TRIAL REGISTRATION NUMBER

NCT03356392.

Impact of prodromal symptoms on the prognosis of patients with basilar artery occlusion treated with mechanical thrombectomy

INTRODUCTION

Even with reperfusion therapies, the prognosis of patients with basilar artery occlusion (BAO) related stroke remains poor. We aimed to test the hypothesis that the presence of prodromal symptoms, an easily available anamnestic data, is a key determinant of poor functional outcome.

PATIENTS AND METHODS

Data from patients with BAO treated in Lille, France, with mechanical thrombectomy (MT) between 2015 and 2021 were prospectively collected. The presence of prodromal symptoms was defined by previous transient neurological deficit or gradual progressive clinical worsening preceding a secondary sudden clinical worsening. We compared the characteristics of patients with and without prodromal symptoms. We built multivariate logistic regression models to study the association between the presence of prodromal symptoms and functional (mRS 0-3 and mortality), and procedural (successful recanalization and early reocclusion) outcomes.

RESULTS

Among the 180 patients, 63 (35%) had prodromal symptoms, most frequently a vertigo. Large artery atherosclerosis was the predominant cause of stroke (41.3%). The presence of prodromal symptoms was an independent predictor of worse 90-day functional outcome (mRS 0-3: 25.4% vs 47.0%, odds ratio (OR) 0.39; 95% confidence interval (CI) 0.16-0.86) and 90-day mortality (OR 2.17; 95% CI 1.02-4.65). Despite similar successful recanalization rate, the proportion of early basilar artery reocclusion was higher in patients with prodromal symptoms (23.8% vs 5.6%, p = 0.002).

DISCUSSION AND CONCLUSION

More than one third of BAO patients treated with MT had prodromal symptoms, especially patients with large-artery atherosclerosis. Clinicians should systematically screen for prodromal symptoms given the poor related functional outcome and increased risk of early basilar artery reocclusion.

Brush Sign on pre-treatment imaging is associated with good functional outcome in stroke patients treated with mechanical thrombectomy: A prospective monocentric study

BACKGROUND

The Brush Sign (BrS) is a radiological biomarker (MRI) showing signal decrease of subependymal and deep medullary veins on paramagnetic-sensitive magnetic resonance sequences. Previous studies have shown controversial results regarding the prognostic value of BrS. We aimed to assess whether BrS on T2*-weighted sequences could predict functional prognosis in patients treated with mechanical thrombectomy (MT).

METHODS

We included all consecutive patients with large artery occlusion related stroke in anterior circulation treated with MT between February 2020 and August 2022 at Reims University Hospital. Multivariable logistic regression models were used to investigate factors associated with BrS and its impact on outcomes.

RESULTS

Of the 327 included patients, 124 (37,9%) had a BrS on baseline MRI. Mean age was 72 ± 16 years and 184 (56,2 %) were female. In univariate analysis, BrS was associated with a younger age (67 vs 74; p<0.001), a higher NIHSS score (16(10-20) vs 13(8-19); p = 0.047) history of diabetes (15.3% vs 26.1 %; p = 0.022) and a shorter onset to MRI time (145.5 (111.3-188.5) vs 162 (126-220) p = 0.008). In multivariate analyses, patients with a BrS were younger (OR:0.970 (0.951 - 0.989)), tend to have a higher NIHSS score at baseline (OR:1.046 (1.000 - 1.094) and were less likely to have diabetes (OR: 0.433; 0.214-0.879). The presence of BrS was independently associated with functional independence (OR: 2.234(1.158-4,505) at 3 months but not with mortality nor with symptomatic intracerebral hemorrhage.

CONCLUSION

BrS on pre-treatment imaging could be considered as a biomarker of physiological adaptation to cerebral ischemia, allowing prolonged viability of brain tissue and might participate in the therapeutic decision.

Effect of continuous 2 MHz transcranial ultrasound as an adjunct to tenecteplase thrombolysis in acute anterior circulation ischemic stroke patients: an open labeled non-randomized clinical trial

The treatment of acute ischemic stroke has improved in last few decades. While meta-analyses of several trials have established the safety and efficacy of Intravenous (IV) Tenecteplase thrombolysis, concomitant continuous transcranial doppler (TCD) ultrasound administration has not been assessed in any clinical trial. The aim of this study was to determine the effects of continuous 2 MHz TCD ultrasound during IV Tenecteplase thrombolysis for Middle cerebral artery (MCA) stroke. A total of 19 patients were included, 13 received TCD ultrasound and 6 sham TCD with IV Tenecteplase. TCD spectrum and difference in Pre and post TCD parameters were measured. Asymptomatic hemorrhagic transformation of infarct was seen in two patients. There was no mortality or clinical worsening in the sonothrombolysis group as against sham sonothrombolysis group. Median of peak systolic velocity was increased in both the sonothrombolysis (P = 0.0002) and sham sonothrombolysis group (P-value = 0.001). The difference in change in mean flow velocity between two groups, sonothrombolysis (11 cm/sec) and sham sonothrombolysis (3.5 cm/sec) were also significantly different (P = 0.014). This pilot work has established safety of continuous 30 min TCD application along with IV Tenecteplase thrombolysis and it concludes that concomitant 2 MHz TCD ultrasound administration significantly increased the MCA blood flow compared to chemothrombolysis alone.CTRI Registered Number: CTRI/2021/02/031418.

Optimal Angiographic Goal and Number of Passes for Octogenarians Undergoing Endovascular Stroke Thrombectomy

BACKGROUND

The optimal recanalization goal and number of endovascular thrombectomy (EVT) passes for elderly patients with large vessel occlusion strokes is unclear.

METHODS

Consecutive patients 80 years or older undergoing EVT were identified from 2016 to 2022 at a single center. Clinical information, procedural details, and modified treatment in cerebral ischemia (mTICI) scores were collected. Primary outcome was modified Rankin scale (mRS) at 90 days. Bivariate and multivariable analyses were conducted to assess associations between mTICI scores, EVT passes, and 90-day outcomes.

RESULTS

One hundred twenty-six patients were identified. At 90 days, mTICI 2b recanalization resulted in high rates of poor outcomes (8.7% functional independence and 60.9% mortality) not significantly different from mTICI 0, 1 or 2a (median mRS 6 vs. 6, P = 0.61). Complete recanalization (mTICI 2c or 3) led to significantly better mRS outcomes at 90 days compared to mTICI 2b (median mRS 4 vs. 6, adjusted P = 0.038), with 26.8% functional independence and 37.8% mortality. In multivariable analysis, complete recanalization was significantly associated with better 90-day outcomes than mTICI 2b or lower recanalization (odds ratio 4.24 [95% Confidence interval 1.46-12.3]; P = 0.002), while the number of passes was not independently associated with worse outcomes (P = 0.98).

CONCLUSIONS

For octogenarians, mTICI 2b recanalization yields limited clinical benefit and results in poor 90-day outcomes. In contrast, complete recanalization is independently associated with significantly better outcomes. Thus, once the decision is made to pursue EVT in the elderly, mTICI 2c or better recanalization should be the angiographic goal. Providers should not withhold thrombectomy passes based on age alone.

Whole Blood Viscosity and Cerebral Blood Flow in Acute Ischemic Stroke

Existing effective treatments for ischemic stroke restore blood supply to the ischemic region using thrombolysis or mechanical removal of clot. However, it is increasingly recognized that successful removal of occlusive thrombus from the large artery-recanalization, may not always be accompanied by successful restoration of blood flow to the downstream tissues-reperfusion. Ultimately, brain tissue survival depends on cerebral perfusion, and a functioning microcirculation. Because capillary diameter is often equal to or smaller than an erythrocyte, microcirculation is largely dependent on erythrocyte rheological (hemorheological) factors such as whole blood viscosity (WBV). Several studies in the past have demonstrated elevated WBV in stroke compared with healthy controls. Also, elevated WBV has shown to be an independent risk factor for stroke. Elevated WBV leads to endothelial dysfunction, decreases nitric oxide-dependent flow-mediated vasodilation, and promotes hemostatic alterations/thrombosis, all leading to microcirculation sludging. Compromised microcirculation further leads to decreased cerebral perfusion. Hence, modulating WBV through pharmacological agents might be beneficial to improve cerebral perfusion in stroke. This review discusses the effect of elevated WBV on endothelial function, hemostatic alterations, and thrombosis leading to reduced cerebral perfusion in stroke.

The BAND score: A simple model for upfront prediction of poor outcomes despite successful stroke thrombectomy

BACKGROUND

While endovascular thrombectomy (EVT) is beneficial for patients with acute large vessel occlusion ischemic strokes, a significant portion of patients still do poorly despite successful recanalization. Identifying patients at high risk for poor outcomes can be helpful for future clinical trial design and optimizing acute stroke triage.

METHODS

Consecutive EVT patients were identified from 2016 to 2021 at a Comprehensive Stroke Center, and clinical information was recorded. Poor outcome was defined as a 90-day modified Rankin Scale (mRS) of 4 or greater despite achieving a modified thrombolysis in cerebral infarction (mTICI) score of 2b or greater. Multivariable regression analyses were used to identify risk factors for poor outcomes, and a scoring system was constructed.

RESULTS

483 patients with successful recanalization were identified. From a randomly selected training cohort (n = 357), the 10-point BAND score was constructed from independent risk factors for poor outcomes: baseline disability (1 point: baseline mRS ≥ 2), age (1 point: 60-69 years, 2 points: 70-79 years, 3 points: 80-84 years, 4 points: 85 years or older), NIHSS (2 points: 13-17, 3 points: 18-22, and 4 points: ≥ 23), and delay from last known normal (1 point: ≥ 6 h). The BAND score was significantly associated with rates of poor outcomes (p < 0.001), and it achieved an area under the receiver-operating characteristic curve (AUC) of 0.80 (95 %CI 0.76-0.85) in our training cohort and 0.78 (95 %CI 0.70-0.86) in our validation cohort (n = 126). Overall, the BAND score had a significantly higher AUC value than the widely validated THRIVE score and the THRIVE-EVT calculation (p = 0.001 and 0.029, respectively). Among patients with high BAND scores (7 or higher), 88.2 % had poor outcomes.

CONCLUSION

The BAND score is a simple tool to predict poor outcomes despite successful recanalization. Future studies are needed to confirm the BAND score's external validity.

Prognostic value of recanalization attempts in endovascular therapy for M2 segment middle cerebral artery occlusions

BACKGROUND

There is growing evidence suggesting efficacy of endovascular therapy for M2 occlusions of the middle cerebral artery. More than one recanalization attempt is often required to achieve successful reperfusion in M2 occlusions, associated with general concerns about the safety of multiple maneuvers in these medium vessel occlusions.

AIM

The aim of this study was to investigate the association between the number of recanalization attempts and functional outcomes in M2 occlusions in comparison with large vessel occlusions (LVO).

METHODS

Retrospective multicenter cohort study of patients who underwent endovascular therapy for primary M2 occlusions. Patients were enrolled in the German Stroke Registry at 1 of 25 comprehensive stroke centers between 2015 and 2021. The study cohort was subdivided into patients with unsuccessful reperfusion (mTICI 0-2a) and successful reperfusion (mTICI 2b-3) at first, second, third, fourth, or ⩾fifth recanalization attempt. Primary outcome was 90-day functional independence defined as modified Rankin Scale score of 0-2. Safety outcome was the occurrence of symptomatic intracranial hemorrhage. Internal carotid artery or M1 occlusions were defined as LVO and served as comparison group.

RESULTS

A total of 1078 patients with M2 occlusion were included. Successful reperfusion was observed in 87.1% and 90-day functional independence in 51.9%. The rate of functional independence decreased gradually with increasing number of recanalization attempts (p < 0.001). In both M2 occlusions and LVO, successful reperfusion within three attempts was associated with greater odds of functional independence, while success at ⩾fourth attempt was not. Patients with ⩾4 attempts exhibited higher rates of symptomatic intracranial hemorrhage in M2 occlusions (6.5% vs 2.7%, p = 0.02) and LVO (7.2% vs 3.5%, p < 0.001).

CONCLUSION

This study suggests a clinical benefit of successful reperfusion within three recanalization attempts in endovascular therapy for M2 occlusions, which was similar in LVO. Our findings reduce concerns about the risk-benefit ratio of multiple attempts in M2 medium vessel occlusions.

DATA ACCESS STATEMENT

The data that support the findings of this study are available on reasonable request after approval of the German Stroke Registry (GSR) steering committee.

CLINICAL TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov Identifier: NCT03356392.

Progressive microvascular failure in acute ischemic stroke: A systematic review, meta-analysis, and time-course analysis

This systematic review, meta-analysis, and novel time course analysis examines microvascular failure in the treatment of acute ischemic stroke (AIS) patients undergoing endovascular therapy (EVT) and/or thrombolytic administration for stroke management. A systematic review and meta-analysis following PRIMSA-2020 guidelines was conducted along with a novel curve-of-best fit analysis to elucidate the time-course of microvascular failure. Scopus and PubMed were searched using relevant keywords to identify studies that examine recanalization and reperfusion assessment of AIS patients following large vessel occlusion. Meta-analysis was conducted using a random-effects model. Curve-of-best-fit analysis of microvascular failure rate was performed with a negative exponential model. Twenty-seven studies with 1151 patients were included. Fourteen studies evaluated patients within a standard stroke onset-to-treatment time window (≤6 hours after last known normal) and thirteen studies had an extended time window (>6 hours). Our analysis yields a 22% event rate of microvascular failure following successful recanalization (95% CI: 16-30%). A negative exponential curve modeled a microvascular failure rate asymptote of 28.5% for standard time window studies, with no convergence of the model for extended time window studies. Progressive microvascular failure is a phenomenon that is increasingly identified in clinical studies of AIS patients undergoing revascularization treatment.

Pretreatment CT perfusion collateral parameters correlate with penumbra salvage in middle cerebral artery occlusion

BACKGROUND AND PURPOSE

Acute ischemic stroke due to large vessel occlusion (AIS-LVO) is a major cause of functional dependence. Collateral status (CS) is an important determinant of functional outcomes. Pretreatment CT perfusion (CTP) parameters serve as reliable surrogates of CS. Penumbra Salvage Index (PSI) is another parameter predictive of functional outcomes in AIS-LVO. The aim of this study is to assess the relationship of pretreatment CTP parameters with PSI.

METHODS

In this prospectively collected, retrospectively reviewed multicenter analysis, inclusion criteria were as follows: (1) CT angiography confirmed middle cerebral artery (MCA) M1-segment and proximal M2-segment occlusion from 9/1/2017 to 9/22/2022; (2) diagnostic CTP; and (3) available diagnostic Magnetic resonance Imaging (MRI) diffusion-weighted images. Pearson correlation analysis was performed to assess the association between cerebral blood volume (CBV) index and hypoperfusion intensity ratio (HIR) with PSI. p value ≤.05 was considered statistically significant.

RESULTS

In total, 131 patients (n = 86, M1 and n = 45, proximal M2 occlusion) met our inclusion criteria. CBV index showed a modest positive correlation with PSI (r = 0.34, p<.001) in patients with proximal MCA occlusion. Similar trends were noted in subgroup analysis of patients with M1 occlusion, and proximal M2 occlusion. Whereas, HIR did not have a strong trend or correlation with PSI.

CONCLUSION

CBV index correlates with PSI, whereas HIR does not. Future studies are needed to expand our understanding of the adjunct role of CBV index with other similar pretreatment CTP-based markers in clinical evaluation and decision-making in patients with MCA occlusion.

Perfusion Collateral Index versus Hypoperfusion Intensity Ratio in Assessment of Collaterals in Patients with Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Perfusion-based collateral indices such as the perfusion collateral index and the hypoperfusion intensity ratio have shown promise in the assessment of collaterals in patients with acute ischemic stroke. We aimed to compare the diagnostic performance of the perfusion collateral index and the hypoperfusion intensity ratio in collateral assessment compared with angiographic collaterals and outcome measures, including final infarct volume, infarct growth, and functional independence.

MATERIALS AND METHODS

Consecutive patients with acute ischemic stroke with anterior circulation proximal arterial occlusion who underwent endovascular thrombectomy and had pre- and posttreatment MRI were included. Using pretreatment MR perfusion, we calculated the perfusion collateral index and the hypoperfusion intensity ratio for each patient. The angiographic collaterals obtained from DSA were dichotomized to sufficient (American Society of Interventional and Therapeutic Neuroradiology [ASITN] scale 3-4) versus insufficient (ASITN scale 0-2). The association of collateral status determined by the perfusion collateral index and the hypoperfusion intensity ratio was assessed against angiographic collaterals and outcome measures.

RESULTS

A total of 98 patients met the inclusion criteria. Perfusion collateral index values were significantly higher in patients with sufficient angiographic collaterals (P < .001), while there was no significant (P = .46) difference in hypoperfusion intensity ratio values. Among patients with good (mRS 0-2) versus poor (mRS 3-6) functional outcome, the perfusion collateral index of ≥ 62 was present in 72% versus 31% (P = .003), while the hypoperfusion intensity ratio of ≤0.4 was present in 69% versus 56% (P = .52). The perfusion collateral index and the hypoperfusion intensity ratio were both significantly predictive of final infarct volume, but only the perfusion collateral index was significantly (P = .03) associated with infarct growth.

CONCLUSIONS

Results show that the perfusion collateral index outperforms the hypoperfusion intensity ratio in the assessment of collateral status, infarct growth, and determination of functional outcomes.

Comparison of clinical outcomes in patients with acute ischemic stroke who underwent endovascular treatment using different perfusion modalities: a real-world multicenter study

Background

Advanced perfusion modalities are increasingly popular for various diseases. However, few studies have focused on contrasting perfusion patterns.

Objective

This study aimed to compare the time efficiency and clinical outcomes of patients with acute ischemic stroke (AIS) who underwent endovascular treatment (EVT) before one-stop arterial spin labeling (ASL) and computed tomography perfusion (CTP) protocols.

Methods

This study retrospectively included 326 patients with AIS who had accepted EVT within 24 h of onset from four comprehensive stroke centers between October 2017 and September 2022. After 1:1 matching of the propensity scores, 202 patients were separated into two groups: the ASL group (n = 101) and the CTP group (n = 101).

Results

Functional independence at 90 days (modified Rankin Scale [mRS] 0-2; p = 0.574), onset-to-puncture time (p = 0.231), door-to-puncture time (p = 0.136), and door-to-perfusion time (p = 0.646) were not significantly different between the two groups. The proportion of EVT complications (31.7% in the ASL group vs. 14.9% in the CTP group, p = 0.005) and symptomatic intracranial hemorrhage (sICH) at 24 h (23.8% in the ASL group vs. 9.9% in the CTP group, p = 0.008) in the CTP group were lower than the ASL group. The ischemic core volume was a common predictor of favorable outcomes in both ASL (p < 0.001) and CTP (p < 0.001) groups.

Conclusion

There were no significant differences in time efficiency and efficacy outcomes between the two groups of patients receiving one-stop ASL and CTP. The proportion of sICH at 24 h and EVT complications of patients in the CTP group was lower than the ASL group. The ischemic core volume was an independent predictor for favorable outcomes.

Peri-procedural decrease in hemoglobin following mechanical thrombectomy for ischemic stroke

BACKGROUND

Peri-procedural blood loss and hemodilution occur in patients undergoing mechanical thrombectomy (MT) for ischemic stroke; however, its relationships with thrombectomy passes, procedure times, and clinical outcomes are unknown.

METHODS

Consecutive patients undergoing MT for anterior circulation large-vessel occlusion ischemic strokes were identified at a Comprehensive Stroke Center. Clinical information, modified treatment in cerebral ischemia (mTICI) scores, and modified Rankin Scores (mRS) at 90 days were prospectively collected from 2012 to 2021. Hemoglobin measurements before and after MTs were collected retrospectively via chart review, and changes were quantified. Patients with new-onset severe anemia (defined as post-MT hemoglobin less than 10g/dL) were identified. Modified Rankin scale (mRS) at 90 days was used to measure clinical outcomes.

RESULTS

Four-hundred and forty-five patients were identified. Hemoglobin decreased 1.27 ± 1.05 g/dL after MT on average. Greater number of thrombectomy passes and longer procedure times were associated with larger decreases in hemoglobin (p < 0.001 and p = 0.002, respectively). 11.5% (51 of 445) of patients had new-onset severe anemia, and this incidence was significantly higher with more thrombectomy passes (6.4% for one pass, 11.9% for two passes, and 17.4% for three or more passes; p = 0.010). In multivariable analyses, new-onset severe anemia was associated with significantly higher odds of 90-day poor outcomes (mRS 3-6, OR 2.70 [95%CI 1.12-6.51], p = 0.027) and death (OR 2.73 [95%CI 1.06-7.04], p = 0.037) compared to mild post-MT anemia.

CONCLUSIONS

More thrombectomy passes and longer procedure times were significantly associated with larger peri-procedural decreases in hemoglobin. Patients with new-onset hemoglobin less than 10 g/dL are at risk of poor outcomes.

Risk factors and functional outcome were associated with hemorrhagic transformation after mechanical thrombectomy for acute large vessel occlusion stroke

BACKGROUND

Risk factors and functional outcome of hemorrhagic transformation (HT) after mechanical thrombectomy (MT) are to be elucidated in patients with acute large vessel occlusion stroke.

METHODS

We retrospectively analyzed data from 88 patients who underwent MT treatment. Independent risk factors of hemorrhagic infarction (HI), parenchymal hematoma (PH) and symptomatic intracranial hemorrhage (sICH) were implemented to determine. Association between HI, PH, sICH and mortality at 90 days after treatment were analyzed.

RESULTS

Of 88 patients, 44.3%had HT (N.=39). 64.1% had HI (N.=25), 35.9% had PH (N.=14) and 12.5% had sICH (N.=11). Independent risk factors for HI were associated with higher NIHSS Score (OR 1.190; 95% CI 1.073~1.319, P=0.001, per 1 score increase), history of coronary heart disease (OR 4.645; 95% CI 1.092~19.758, P=0.038), and use of intravenous thrombolysis (OR 3.438; 95% CI 1.029~11.483, P=0.045). Independent risk factors for PH were associated with higher NIHSS Score (OR 1.227; 95% CI 1.085~1.387, P=0.001, per 1 score increase) and history of oral antiplatelet and/or anticoagulation drugs (OR 6.694; 95% CI 1.245~35.977, P=0.027). Independent risk factors for sICH were associated with higher NIHSS Score (OR 1.393; 95% CI 1.138~1.704, P=0.001, per 1 score increase), increased systolic blood pressure (OR 1.061; 95% CI 1.006~1.120, P=0.030, per 1 mmHg increase) and history of coronary heart disease (OR 13.699; 95% CI 1.019~184.098, P=0.048). Patients who had PH were more likely to cause mortality at 90 days (OR 10.15; 95% CI 1.455~70.914, P=0.019).

CONCLUSIONS

Higher NIHSS Score was associated with HI, PH, and sICH. History of coronary heart was associated with HI and sICH. Use of intravenous thrombolysis was associated with HI. History of oral antiplatelet and/or anticoagulation drugs was associated with PH. Increased systolic blood pressure was associated with sICH. PHs was remarkably associated with mortality at 90 days.

Intensive vs Conventional Blood Pressure Lowering After Endovascular Thrombectomy in Acute Ischemic Stroke: The OPTIMAL-BP Randomized Clinical Trial

Importance

Optimal blood pressure (BP) control after successful reperfusion with endovascular thrombectomy (EVT) for patients with acute ischemic stroke is unclear.

Objective

To determine whether intensive BP management during the first 24 hours after successful reperfusion leads to better clinical outcomes than conventional BP management in patients who underwent EVT.

Design, Setting, and Participants

Multicenter, randomized, open-label trial with a blinded end-point evaluation, conducted across 19 stroke centers in South Korea from June 2020 to November 2022 (final follow-up, March 8, 2023). It included 306 patients with large vessel occlusion acute ischemic stroke treated with EVT and with a modified Thrombolysis in Cerebral Infarction score of 2b or greater (partial or complete reperfusion).

Interventions

Participants were randomly assigned to receive intensive BP management (systolic BP target <140 mm Hg; n = 155) or conventional management (systolic BP target 140-180 mm Hg; n = 150) for 24 hours after enrollment.

Main Outcomes and Measures

The primary outcome was functional independence at 3 months (modified Rankin Scale score of 0-2). The primary safety outcomes were symptomatic intracerebral hemorrhage within 36 hours and death related to the index stroke within 3 months.

Results

The trial was terminated early based on the recommendation of the data and safety monitoring board, which noted safety concerns. Among 306 randomized patients, 305 were confirmed eligible and 302 (99.0%) completed the trial (mean age, 73.0 years; 122 women [40.4%]). The intensive management group had a lower proportion achieving functional independence (39.4%) than the conventional management group (54.4%), with a significant risk difference (-15.1% [95% CI, -26.2% to -3.9%]) and adjusted odds ratio (0.56 [95% CI, 0.33-0.96]; P = .03). Rates of symptomatic intracerebral hemorrhage were 9.0% in the intensive group and 8.1% in the conventional group (risk difference, 1.0% [95% CI, -5.3% to 7.3%]; adjusted odds ratio, 1.10 [95% CI, 0.48-2.53]; P = .82). Death related to the index stroke within 3 months occurred in 7.7% of the intensive group and 5.4% of the conventional group (risk difference, 2.3% [95% CI, -3.3% to 7.9%]; adjusted odds ratio, 1.73 [95% CI, 0.61-4.92]; P = .31).

Conclusions and Relevance

Among patients who achieved successful reperfusion with EVT for acute ischemic stroke with large vessel occlusion, intensive BP management for 24 hours led to a lower likelihood of functional independence at 3 months compared with conventional BP management. These results suggest that intensive BP management should be avoided after successful EVT in acute ischemic stroke.

Trial Registration

ClinicalTrials.gov Identifier: NCT04205305.

Mildly elevated INR is associated with worse outcomes following mechanical thrombectomy for acute ischemic stroke

BACKGROUND

Elevated International Normalized Ratio (INR) is a marker of coagulopathy, but its impact on outcomes following mechanical thrombectomy (MT) in patients with stroke is unclear. This study investigates the impact of mild INR elevations on clinical outcomes following MT.

METHODS

In this retrospective cohort study, consecutive patients with stroke treated with MT were identified from 2015 to 2020 at a Comprehensive Stroke Center. Demographic information, past medical history, INR, National Institutes of Health Stroke Scale score, use of tissue plasminogen activator, and last known normal to arteriotomy time were recorded. Outcome measures included modified Thrombolysis in Cerebral Infarction (mTICI) score, modified Rankin Scale (mRS) score at 90 days, and intracerebral hemorrhage (ICH). Patients were divided into two groups: normal INR (0.8-1.1) and mildly elevated INR (1.2-1.7).

RESULTS

A total of 489 patients were included for analysis, of which 349 had normal INR and 140 had mildly elevated INR. After multivariable adjustments, mildly elevated INR was associated with lower odds of excellent outcomes (mRS 0-1, OR 0.24, p=0.009), lower odds of functional independence (mRS 0-2, OR 0.38, p=0.038), and higher odds of 90-day mortality (OR 3.45, p=0.018). Elevated INR was not associated with a higher likelihood of ICH, and there were no differences in rates of HI1, HI2, PH1, or PH2 hemorrhagic transformations; however, elevated INR was associated with significantly higher odds of 90-day mortality in patients with ICH (OR 6.22, p=0.024). This effect size was larger than in patients without ICH (OR 3.38, p<0.001).

CONCLUSION

In patients with stroke treated with MT, mildly elevated INR is associated with worse clinical outcomes after recanalization and may worsen the mortality risk of hemorrhagic transformations.

Clinical characteristics of endovascular treatment for acute ischemic stroke with atherosclerotic etiology: factors associating its clinical outcome

OBJECTIVE

Clinical characteristics of endovascular treatment (EVT) for acute ischemic stroke (AIS) secondary to atherosclerosis are not fully delineated. An optimal treatment strategy with considerations of stroke etiology has not yet been established. Here-in, we performed retrospective analysis of EVT for atherosclerotic AIS.

METHODS

Data from patients with AIS who underwent EVT between 2017 and 2022 were analyzed. Clinical characteristics, procedural data, and outcomes were assessed. Further analysis was conducted to elucidate the factors associated with clinical outcomes. And data of patients with poor clinical outcomes (mRS, 5 or 6) were evaluated further to determine the primary cause.

RESULTS

Among 194 patients who received EVT, 40 (20.6%) were diagnosed with AIS with an atherosclerotic etiology. The rates of successful reperfusion (TICI 2b or 3) and good clinical outcomes (mRS, 0-2) were 95.0% and 45.0%, respectively. No procedure-related complications were noted. Older age (p = 0.007), more severe baseline NIHSS score (p = 0.004), lesion in the posterior circulation (p = 0.025), and recanalization failure (p = 0.027) were more frequently observed in patients with poor clinical outcomes. Brainstem infarction and postprocedural intracerebral hemorrhage were the main reasons for poor clinical outcomes.

CONCLUSION

The EVT for atherosclerotic AIS were effective and safe. Older age, more severe NIHSS score, lesions in the posterior circulation, and recanalization failure were the factors associated with poor clinical outcomes. It is important to recognize that these factors may aggravate the clinical response to this promising therapy, even in patient successful recanalization was attained.

Sex Difference in Capillary Reperfusion After Transient Middle Cerebral Artery Occlusion in Diabetic Mice

BACKGROUND

Type 2 diabetes (DM2) exacerbates stroke injury, reduces efficacy of endovascular therapy, and worsens long-term functional outcome. Sex differences exist in stroke incidence, response to therapy, poststroke microvascular dysfunction, and functional recovery. In this study, we tested the hypotheses that poor outcome after stroke in the setting of DM2 is linked to impaired microvascular tissue reperfusion and that male and female DM2 mice exhibit different microvascular reperfusion response after transient middle cerebral artery occlusion (MCAO).

METHODS

Transient MCAO was induced for 60 minutes using an intraluminal filament in young adult DM2 and nondiabetic control male and female mice. Capillary flux in deep cortical layers was assessed using optical coherence tomography-based optical microangiography (OMAG), and associated regional brain infarct size was evaluated by hematoxylin and eosin staining.

RESULTS

Compared to baseline, MCAO reduced absolute capillary red blood cell flux by 84% at 24 hours post-MCAO in male DM2 (P<0.001) but not male control mice. When normalized to pre-MCAO baseline, red blood cell flux 24 hours after stroke was 64% lower in male DM2 mice than male nondiabetic controls (P<0.01). In females, MCAO decreased capillary flux by 48% at 24 hours post-MCAO compared with baseline in DM2 (P<0.05) but not in control mice. Red blood cell flux of female DM2 mice did not differ from that of nondiabetic controls either before or 24 hours after MCAO. Furthermore, normalized capillary flux 24 hours after MCAO failed to differ between female DM2 mice and nondiabetic controls. Concomitantly, male but not female DM2 mice experienced 25% larger infarct in caudate-putamen versus respective nondiabetic controls (P<0.05).

CONCLUSIONS

DM2 impairs capillary perfusion and exacerbates ischemic deep brain injury in male but not female young adult mice. Premenopausal females appear to be protected against DM2-related capillary dysfunction and brain injury.

Early reocclusion after successful mechanical thrombectomy for large artery occlusion-related stroke

BACKGROUND AND PURPOSE

Despite initial successful recanalization after mechanical thrombectomy (MT), some patients with large artery occlusion (LAO)-related stroke will experience an early reocclusion of the injured vessel which may worsen their prognosis. We aimed to investigate the prevalence, associated factors and prognosis of early reocclusion after successful MT in a large prospective cohort of stroke patients with LAO.

METHODS

We included patients from the Lille reperfusion registry with LAO-related stroke involving M1 segment, internal carotid artery terminus or tandem ICA-M1 occlusion, with successful recanalization after MT and available 24 h imaging follow-up. Early reocclusion was defined as internal carotid artery terminus or M1 occlusion on 24 h magnetic resonance imaging (MRI) or computed tomography (CT) vascular imaging. Multivariable logistic regression models were used to investigate factors associated with early reocclusion and its impact on outcomes.

RESULTS

Between 2015 and 2020, 62 of 1015 included patients experienced an early reocclusion (6.1%). Age (odds ratio (OR) per 15 years decrease: 1.38 (1.05-1.81)) antiplatelet use (OR: 0.41 (0.19-0.89)), several device passes (OR: 2.13 (1.18-3.83)), atherosclerosis cause (OR: 2.38 (1.19-4.78)), and early clinical worsening (OR: 2.45 (1.18-5.07)) were independently associated with early reocclusion. Early reocclusion was independently associated with poor prognosis (OR: 7.15 (3.49-14.65)) and mortality (OR: 2.05 (1.07-3.91)) at 3 months.

CONCLUSION

Six percent of patients with LAO-related stroke and initial successful recanalization experienced early reocclusion. This event is associated with a 7-fold increased risk of poor functional outcome and a 2-fold increased risk of mortality. Further efforts are warranted to refine early detection of patients at risk of reocclusion and to improve their management.

Predictors of parenchymal hemorrhage after endovascular treatment in acute ischemic stroke: data from ANGEL-ACT Registry

BACKGROUND

Parenchymal hemorrhage (PH) is a troublesome complication after endovascular treatment (EVT).

OBJECTIVE

To investigate the incidence, independent predictors, and clinical impact of PH after EVT in patients with acute ischemic stroke (AIS) due to anterior circulation large vessel occlusion (LVO).

METHODS

Subjects were selected from the ANGEL-ACT Registry. PH was diagnosed according to the European Collaborative Acute Stroke Study classification. Logistic regression analyses were performed to determine the independent predictors of PH, as well as the association between PH and 90-day functional outcome assessed by modified Rankin Scale (mRS) score.

RESULTS

Of the 1227 enrolled patients, 147 (12.0%) were diagnosed with PH within 12-36 hours after EVT. On multivariable analysis, low admission Alberta Stroke Program Early CT score (ASPECTS)(adjusted OR (aOR)=1.13, 95% CI 1.02 to 1.26, p=0.020), serum glucose >7 mmol/L (aOR=1.82, 95% CI 1.16 to 2.84, p=0.009), and neutrophil-to-lymphocyte ratio (NLR; aOR=1.05, 95% CI 1.02 to 1.09, p=0.005) were associated with a high risk of PH, while underlying intracranial atherosclerotic stenosis (ICAS; aOR=0.42, 95% CI 0.22 to 0.81, p=0.009) and intracranial angioplasty/stenting (aOR=0.37, 95% CI 0.15 to 0.93, p=0.035) were associated with a low risk of PH. Furthermore, patients with PH were associated with a shift towards to worse functional outcome (mRS score 4 vs 3, adjusted common OR (acOR)=2.27, 95% CI 1.53 to 3.38, p<0.001).

CONCLUSIONS

In Chinese patients with AIS caused by anterior circulation LVO, the risk of PH was positively associated with low admission ASPECTS, serum glucose >7 mmol/L, and NLR, but negatively related to underlying ICAS and intracranial angioplasty/stenting.

TRIAL REGISTRATION NUMBER

NCT03370939.

Eloquence-based reperfusion scoring and its ability to predict post-thrombectomy disability and functional status

BACKGROUND

Angiographic reperfusion after endovascular thrombectomy in acute ischemic stroke is commonly graded using volume-based reperfusion scores such as the modified thrombolysis in cerebral infarct score. The location of non-reperfused regions is not included in modified thrombolysis in cerebral infarct score. We studied the predictive ability of an eloquence-based reperfusion score.

METHODS

Consecutive cases of endovascular thrombectomy for anterior circulation strokes performed between January 2018 and April 2020 were included. Digital subtraction angiograms were reviewed by two blinded neurointerventionalist operators. Incomplete reperfusion was further classified by lobar regions lacking reperfusion to create various cohorts. Outcomes were graded four to seven days post-procedure with the National Institute of Health Stroke Scale (NIHSS) and 90 days post-procedure with the modified Rankin Scale.

RESULTS

One hundred patients were identified. Via multivariate analysis, we found that frontal lobe non-reperfusion (mean difference (MD) = -1.60, p = 0.002) and occipital lobe non-reperfusion (MD = -1.68, p = 0.001) were associated with worse mental status improvement while left-sided stroke (MD = 2.02, p < 0.001) featured better improvement post-thrombectomy. Occipital lobe non-reperfusion (MD = -0.734, p = 0.009) was associated with the worse improvement of visual fields. The non-reperfusion of the frontal lobe was associated with a 1.732-worse NIHSS hemibody strength score (95% confidence interval (95%CI) = -3.39 to -0.072, p = 0.041). Worse improvement in NIHSS scores was found to be associated with frontal lobe non-reperfusion (MD = -5.34, 95%CI = -9.52 to -1.18, p = 0.013) and occipital lobe non-reperfusion (MD = -6.35, 95%CI = -10.4 to -2.31, p = 0.002). Odds of achieving modified Rankin Scale of 0-2 at 90 days were decreased with frontal lobe non-reperfusion (odds ratio (OR) = 0.279, 95%CI = 0.090-0.869, p = 0.028) and left laterality (OR = 0.376, 95%CI = 0.153-0.922, p = 0.033).

CONCLUSIONS

Eloquence-based reperfusion assessment is an important predictor for functional outcomes after thrombectomy.

Continuing early mTICI 2b recanalization may improve functional outcome but is associated with a higher risk of intracranial hemorrhage

Background

Successful reperfusion (mTICI 2c/3) and low number of passes are key determinants for good clinical outcome in acute large vessel occlusion. While final mTICI 2c/3 reperfusion is superior to partial reperfusion (mTICI 2b) it remains unclear if this is also true for the subgroup of patients with early mTICI 2b (achieved in ≤2 retrieval attempts) reperfusion who are secondarily improved to mTICI 2c/3. This study was designed to examine if early mTICI2b should be continued or stopped during mechanical thrombectomy (MT).

Methods

Nine hundred and thirteen ischemic stroke patients who received MT were retrospectively analyzed. Angiography runs following each recanalization attempt were scored for mTICI. The patients with early mTICI 2b reperfusions were dichotomized in “TICI2b-stopped” (MT withdrawal after mTICI 2b was achieved with first or second retrieval) and “TICI2b-continued” (MT was continued after mTICI 2b was achieved with first or second retrieval). Functional outcome was obtained after 90 days using the modified Rankin scale (mRS90).

Results

Of 362 Patients with a M1-occlusion, 100 patients fulfilled the inclusion criteria with an early mTICI 2b. 78/100 patients were included in the “TICI2b-stopped” group and 22/100 patients were in the “TICI2b-continued” group. Of these 22 patients, none had a final mTICI score lower than 2b and 11 patients had a final mTICI score of 2c/3. Regarding good functional outcome at mRS90, “TICI2b-continued” showed by trend a slight advantage of 40.1 vs. 35.6% in “TICI2b-stopped” but in multivariate logistic regression analysis adjusted for confounders, no significant difference was found between the two groups (OR 0.75, 95% CI 0.19–2.87, p = 0.67). Symptomatic intracranial hemorrhage was significantly higher in “TICI2b-continued” compared to “TICI2b-stopped” (31.8 vs. 10.3%, p = 0.031).

Conclusion

Successfully improving an early mTICI 2b to mTICI 2c/3 reperfusion is possible in a substantial number of patients and might improve functional outcome. However, an increase in symptomatic intracranial hemorrhage (SICH) due to further retrieval attempts may diminish the potential functional benefit to continue early mTICI 2b. To support this finding, further investigation with more power is needed to account for the low number of events regarding SICH.

Alberta Stroke Program Early CT Score applied to hyperdense lesion on noncontrast CT immediately post-thrombectomy is a predictor of poor outcome in acute ischemic stroke: A case-control study

We aimed to evaluate whether Alberta Stroke Program Early CT Score (ASPECTS) applied to hyperdense lesion on noncontrast CT obtained immediately post-thrombectomy (post-ASPECTS) is useful for predicting poor outcome. We retrospectively reviewed patients who underwent noncontrast CT (NCCT) immediately after mechanical thrombectomy between January 2017 and July 2020 in our comprehensive stroke center. We collected baseline NCCT and post-ASPECTS score. The sensitivity, specificity, and positive and negative predictive values of the post-ASPECTS in predicting clinical outcome were calculated. A total of 223 patients were included. The hyperdense lesion on NCCT immediately after endovascular thrombectomy presented in 85.7% (191/223) patients, poor clinical outcome was in 56.1% (112/191) of hyperdense lesion patients. Low post-ASPECTS was associated with poor outcome (OR 0.390; 95% CI 0.258-0.589; P = .001), with an AUCROC curve of 0.753 (95% CI 0.684-0.822), while baseline NCCT-ASPECTS was not (OR 0. 754; 95% CI 0. 497-1.144; P = .185). A score ≤ 7 in post-ASPECTS was the best cut-off to poor clinical outcome (sensitivity 84.8%; specificity 52.7%; positive predictive value 68.4%; negative predictive value 73.8%). Our results point to the proportion of patients who present hyperdense lesion on NCCT is very high, post-ASPECTS could predict poor clinical outcomes in patients with stroke treated with endovascular mechanical thrombectomy, and post-ASPECTS may achieved better predictive value than baseline ASPECTS.

ASPECTS-based net water uptake predicts poor reperfusion and poor clinical outcomes in patients with ischemic stroke

OBJECTIVE

To investigate the value of automated Alberta Stroke Program Early CT Score (ASPECTS)-based net water uptake (NWU) to predict tissue-level reperfusion status and 90-day functional outcomes in acute ischemic stroke (AIS) patients after reperfusion therapy.

METHODS

One hundred and twelve patients with AIS who received reperfusion therapy were enrolled. ASPECTS-NWU was calculated from admission CT (NWU_admission) and follow-up CT (NWU_FCT), and the difference (ΔNWU) was calculated. Tissue-level reperfusion status was evaluated via follow-up arterial spin labeling imaging. The relationship between ASPECTS-NWU and tissue-level reperfusion was evaluated. Predictors of 90-day unfavorable outcomes (modified Rankin Scale score > 2) were assessed by multivariate logistic regression analysis and receiver operating characteristic (ROC) curves.

RESULTS

Poor reperfusion was observed in 40 patients (35.7%) after therapy. Those patients had significantly elevated NWU_FCT (median, 14.15% vs. 8.08%, p = 0.018) and higher ΔNWU (median, 4.12% vs. -2.03%, p < 0.001), compared to patients with good reperfusion. High ΔNWU was a significant marker of poor reperfusion despite successful recanalization. National Institutes of Health Stroke Scale score at admission (odds ratio [OR], 1.11; 95% confidence interval [CI] 1.03-1.20, p = 0.007) and ΔNWU (OR, 1.07; 95% CI 1.02-1.13, p = 0.008) were independently associated with unfavorable outcomes. An outcome prediction model including both parameters yields an area under the curve of 0.762 (sensitivity 70.3%, specificity, 84.2%).

CONCLUSIONS

Elevated NWU_FCT and higher ΔNWU were associated with poor tissue-level reperfusion after therapy. Higher ΔNWU was an independent predictor of poor reperfusion and unfavorable neurological outcomes despite successful recanalization.

KEY POINTS

• ASPECTS-NWU may provide pathophysiological information about tissue-level reperfusion status and offer prognostic benefits for patients with AIS after reperfusion therapy. • Elevated NWU_FCT and higher ΔNWU were correlated with poor tissue-level reperfusion after therapy. • A higher ΔNWU is an independent predictor of poor reperfusion and 90-day unfavorable outcomes despite successful recanalization.

Delays in initial workflow cause delayed initiation of mechanical thrombectomy in patients with in-hospital ischemic stroke

Objectives

The benefit of mechanical thrombectomy for acute ischemic stroke is highly time dependent. However, time to treatment is longer for in-hospital stroke patients than community-onset stroke patients. This study aimed to clarify the cause of this difference.

Methods

A retrospective single-center study was performed to analyze patients with large vessel occlusion who underwent mechanical thrombectomy between January 2017 and December 2019. Patients were divided into in-hospital stroke and community-onset stroke groups. Clinical characteristics and treatment time intervals were compared between groups.

Results

One hundred four patients were analyzed: 17 with in-hospital stroke and 87 with community-onset stroke. Patient characteristics did not significantly differ between groups. Median door (stroke recognition)-to-computed tomography time (36 min vs. 14 min, P<0.01) and door-to-puncture time (135 min vs. 117 min, P=0.02) were significantly longer in the in-hospital stroke group than the community-onset stroke group. However, median computed tomography-to-puncture time (104 min vs. 104 min, P=0.47) and puncture-to-reperfusion time (53 min vs. 38 min, P=0.17) did not significantly differ.

Conclusions

Longer door-to-puncture time in in-hospital stroke patients was mostly caused by longer door-to-computed tomography time, which is the initial part of the workflow. An in-hospital stroke protocol that places importance on early stroke specialist consultation and prompt transportation to the computed tomography scanner might hasten treatment and improve outcomes in patients with in-hospital stroke.

Effect of atrial fibrillation on outcomes after mechanical thrombectomy and long-term ischemic recurrence in patients with acute basilar artery occlusion

Introduction

According to the literature on anterior circulation, comorbid atrial fibrillation (AF) is not associated with a worse functional outcome, lower reperfusion rates, or higher rates of intracranial hemorrhage after mechanical thrombectomy (MT) compared to intravenous thrombolysis (IVT) or treatment with supportive care. However, data are limited for the effect of comorbid AF on procedural and clinical outcomes of acute basilar artery occlusion (ABAO) after MT. This study aimed to investigate the effect of atrial fibrillation on outcomes after MT and long-term ischemic recurrence in patients with ABAO.

Methods

We performed a registered study of the Endovascular Treatment for Acute Basilar Artery Occlusion Study (BASILAR, which is registered in the Chinese Clinical Trial Registry, http://www.chictr.org.cn; ChiCTR1800014759) from January 2014 to May 2019, which included 647 patients who underwent MT for ABAO, 136 of whom had comorbid AF. Prospectively defined baseline characteristics, procedural outcomes, and clinical outcomes were reported and compared.

Results

On multivariate analysis, AF predicted a shorter puncture-to-recanalization time, higher first-pass effect rate, and lower incidence of angioplasty and/or stenting (p < 0.01). AF had no effect on intracranial hemorrhage incidence [adjusted odds ratio (aOR), 1.093; 95% confidence interval (CI), 0.451–2.652], 90-day functional outcomes (adjusted common odds ratio, 0.915; 95% CI, 0.588–1.424), or mortality (aOR, 0.851; 95% CI, 0.491–1.475) after MT. The main findings were robust in the subgroup and 1-year follow-up analyses. Comorbid AF was the remaining predictor of ischemic recurrence (aOR, 4.076; 95% CI, 1.137–14.612).

Conclusions

The study revealed no significant difference in the safety and efficacy of MT for ABAO regardless of whether patients had comorbid AF. However, a higher proportion of patients with AF experienced ischemic recurrence within 1 year after MT.

Leaving the day behind: endovascular therapy beyond 24 h in acute stroke of the anterior and posterior circulation

Background:

There is little evidence of endovascular therapy (EVT) being performed in acute ischemic stroke beyond 24 h, and that evidence is limited to anterior circulation stroke.

Objective:

To extend evidence of efficacy and safety of EVT after more than 24 h in both anterior and posterior circulation stroke.

Methods:

Local, prospectively collected registries were screened for patients with acute ischemic stroke and large-vessel occlusion who had received either EVT > 24 h after last-seen-well but <24 h after symptom recognition (EVT_>24LSW) or EVT > 24 h since first (definitive) symptom recognition (EVT_>24DEF). Patients treated <24 h served as a group for comparison. Favorable outcome was defined as modified Rankin scale (mRS) 0–2 or return to prestroke mRS at 3 months.

Results:

Between January 2014 and August 2021, N = 2347 were treated with EVT at our comprehensive stroke center, of whom n = 43 met the inclusion criteria (EVT_>24LSW, n = 16, EVT_>24DEF, n = 27). EVT_>24LSW patients were treated at a median of 28.7 h [interquartile range (IQR) = 27.3–32.8] after last-seen-well and 7.3 h (IQR = 2.8–14.3) after symptom recognition; EVT_>24DEF patients were treated 52.5 h (IQR = 26.5–94.2) after first symptoms. Favorable outcome was achieved by 23.3% (10/43) in the EVT > 24 compared with 39.4% (886/2250) in the EVT < 24 group (p = 0.04). Bleeding rates were similar across groups. Mortality was also similar [EVT > 24, 27.9% (12/43) versus EVT < 24, 25.7% (584/2264), p = 0.727; posterior circulation, EVT > 24, 41.7% (5/12) versus EVT < 24, 36.5% (92/252) p = 0.764].

Conclusion:

In selected patients, EVT seems effective and safe beyond 24 h for both anterior and posterior circulation stroke.

Outcomes of endovascular treatment for acute ischaemic stroke in Mater Dei Hospital, Malta

INTRODUCTION

The aim of this study was to assess the outcomes of endovascular treatment for acute ischaemic stroke in Mater Dei Hospital, Malta and compare them with international data.

METHODS

A prospective review of all patients who underwent mechanical thrombectomy from 2015 to the end of 2019 was performed. Eligible patients had large vessel occlusion confirmed on computed tomography angiography. Demographical data, the National Institutes of Health stroke scale at presentation, endovascular procedure details and process times were analysed. The thrombolysis in cerebral infarction score was used to assess the degree of reperfusion. A thrombolysis in cerebral infarction score of 2b-3 was considered as successful recanalisation. Functional outcome (modified Rankin scale score) and mortality at 90 days were measured. Functional independence was defined as a modified Rankin scale score of 2 or less.

RESULTS

A total of 132 patients underwent endovascular treatment, one patient was excluded due to incomplete data. The mean age was 71 (range 25-94) years, and the mean National Institutes of Health stroke scale at presentation was 14. Of the 131 patients treated, 69 received intravenous thrombolysis. Successful recanalisation (thrombolysis in cerebral infarction score 2b-3) was achieved in 80% of patients (105/131); 53% of patients (69/131) achieved functional independence at 90 days, with a mortality of 21% at 90 days. Symptomatic intracranial haemorrhage was recorded in 16 patients (12%) There was a statistical difference in the functional independence and mortality rate in favour of the successful recanalisation group.

CONCLUSION

Our data are consistent with a favourable clinical outcome after successful recanalisation. Service in Malta is achieving favourable outcomes for patients treated with mechanical thrombectomy for acute ischaemic stroke.

Influence of cerebral microbleeds on mechanical thrombectomy outcomes

In ischemic stroke patients undergoing endovascular treatment (EVT), we aimed to test the hypothesis that cerebral microbleeds (CMBs) are associated with clinical outcomes, while estimating the mediating effects of hemorrhagic transformation (HT), small-vessel disease burden (white matter hyperintensities, WMH), and procedural success. From a multicenter EVT registry, patients who underwent pretreatment MR imaging were analyzed. They were trichotomized according to presence of CMBs (none vs. 1–4 vs. ≥ 5). The association between CMB burden and 3-month mRS was evaluated using multivariable ordinal logistic regression, and mediation analyses were conducted to estimate percent mediation. Of 577 patients, CMBs were present in 91 (15.8%); 67 (11.6%) had 1–4 CMBs, and 24 (4.2%) had ≥ 5. Increases in CMBs were associated with hemorrhagic complications (β = 0.27 [0.06–0.047], p = 0.010) in multivariable analysis. The CMB effect on outcome was partially mediated by post-procedural HT degree (percent mediation, 14% [0–42]), WMH (23% [7–57]) and lower rates of successful reperfusion (6% [0–25]). In conclusion, the influence of CMBs on clinical outcomes is mediated by small-vessel disease burden, post-procedural HT, and lower reperfusion rates, listed in order of percent mediation size.

Endovascular thrombectomy for acute ischemic stroke

This review describes the evolution of endovascular treatment for acute ischemic stroke, current state of the art, and the challenges for the next decade. The rapid development of endovascular thrombectomy (EVT), from the first attempts into standard of care on a global scale, is one of the major achievements in modern medicine. It was possible thanks to the establishment of a scientific framework for patient selection, assessment of stroke severity and outcome, technical development by dedicated physicians and the MedTech industry, including noninvasive imaging for patient selection, and radiological outcome evaluation. A series of randomized controlled trials on EVT in addition to intravenous thrombolytics, with overwhelmingly positive results for anterior circulation stroke within 6 h of onset regardless of patient characteristics with a number needed to treat of less than 3 for any positive shift in outcome, paved the way for a rapid introduction of EVT into clinical practice. Within the "extended" time window of 6-24 h, the effect has been even greater for patients with salvageable brain tissue according to perfusion imaging with a number needed to treat below 2. Even so, EVT is only available for a small portion of stroke patients, and successfully recanalized EVT patients do not always achieve excellent functional outcome. The major challenges in the years to come include rapid prehospital detection of stroke symptoms, adequate clinical and radiological diagnosis of severe ischemic stroke cases, enabling effective recanalization by EVT in dedicated angiosuites, followed by personalized post-EVT stroke care.

Effect of Intra-arterial Alteplase vs Placebo Following Successful Thrombectomy on Functional Outcomes in Patients With Large Vessel Occlusion Acute Ischemic Stroke: The CHOICE Randomized Clinical Trial

IMPORTANCE

It is estimated that only 27% of patients with acute ischemic stroke and large vessel occlusion who undergo successful reperfusion after mechanical thrombectomy are disability free at 90 days. An incomplete microcirculatory reperfusion might contribute to these suboptimal clinical benefits.

OBJECTIVE

To investigate whether treatment with adjunct intra-arterial alteplase after thrombectomy improves outcomes following reperfusion.

DESIGN, SETTING, AND PARTICIPANTS

Phase 2b randomized, double-blind, placebo-controlled trial performed from December 2018 through May 2021 in 7 stroke centers in Catalonia, Spain. The study included 121 patients with large vessel occlusion acute ischemic stroke treated with thrombectomy within 24 hours after stroke onset and with an expanded Treatment in Cerebral Ischemia angiographic score of 2b50 to 3.

INTERVENTIONS

Participants were randomized to receive intra-arterial alteplase (0.225 mg/kg; maximum dose, 22.5 mg) infused over 15 to 30 minutes (n = 61) or placebo (n = 52).

MAIN OUTCOMES AND MEASURES

The primary outcome was the difference in proportion of patients achieving a score of 0 or 1 on the 90-day modified Rankin Scale (range, 0 [no symptoms] to 6 [death]) in all patients treated as randomized. Safety outcomes included rate of symptomatic intracranial hemorrhage and death.

RESULTS

The study was terminated early for inability to maintain placebo availability and enrollment rate because of the COVID-19 pandemic. Of 1825 patients with acute ischemic stroke treated with thrombectomy at the 7 study sites, 748 (41%) patients fulfilled the angiographic criteria, 121 (7%) patients were randomized (mean age, 70.6 [SD, 13.7] years; 57 women [47%]), and 113 (6%) were treated as randomized. The proportion of participants with a modified Rankin Scale score of 0 or 1 at 90 days was 59.0% (36/61) with alteplase and 40.4% (21/52) with placebo (adjusted risk difference, 18.4%; 95% CI, 0.3%-36.4%; P = .047). The proportion of patients with symptomatic intracranial hemorrhage within 24 hours was 0% with alteplase and 3.8% with placebo (risk difference, -3.8%; 95% CI, -13.2% to 2.5%). Ninety-day mortality was 8% with alteplase and 15% with placebo (risk difference, -7.2%; 95% CI, -19.2% to 4.8%).

CONCLUSIONS AND RELEVANCE

Among patients with large vessel occlusion acute ischemic stroke and successful reperfusion following thrombectomy, the use of adjunct intra-arterial alteplase compared with placebo resulted in a greater likelihood of excellent neurological outcome at 90 days. However, because of study limitations, these findings should be interpreted as preliminary and require replication.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03876119; EudraCT Number: 2018-002195-40.

Safety, Pharmacokinetics and Pharmacodynamics of DS-1040, in Combination with Thrombectomy, in Japanese Patients with Acute Ischemic Stroke

Background and Objectives

DS-1040 is a novel inhibitor of the activated form of thrombin-activatable fibrinolysis inhibitor that may have therapeutic potential in thromboembolic diseases, such as acute ischemic stroke (AIS) or pulmonary embolism. We undertook a Phase I clinical trial to investigate the safety, pharmacokinetics, and pharmacodynamics of DS-1040 in Japanese patients who were eligible for thrombectomy following AIS.

Methods

The trial enrolled patients with AIS due to large vessel occlusion, who were planned for thrombectomy within 8 h of symptom onset. Subjects were randomized to receive a single intravenous infusion of placebo or DS-1040 (0.6, 1.2, 2.4 or 4.8 mg) in a sequential-cohort design. The primary endpoints were the incidence of intracranial hemorrhage (ICH) and major extracranial bleeding within 36 and 96 h, respectively, of treatment initiation. Treatment-emergent adverse events (TEAEs) and pharmacokinetic/pharmacodynamic parameters were also assessed.

Results

Nine patients received placebo and 32 patients received DS-1040. There were no cases of symptomatic ICH or major extracranial bleeding with either placebo or DS-1040 after 36 and 96 h. One patient, who received DS-1040 0.6 mg, experienced a subarachnoid hemorrhage that was considered to be drug-related. Three patients died (2 placebo, 1 DS-1040), but no deaths were adjudicated as study drug-related. In vivo exposure to DS-1040 increased in proportion to dosage, but no clear dose-response relationship was seen for D-dimer levels and thrombin-activatable fibrinolysis inhibitor activity.

Conclusions

Single doses of DS-1040 0.6–4.8 mg were well tolerated in Japanese patients with AIS undergoing thrombectomy.

Clinical trial registration number

NCT03198715; JapicCTI-163164.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40261-021-01112-8.

Effects of clinical outcomes by modification of patient selection protocol based on premorbid independence for mechanical thrombectomy in older adult patients

OBJECTIVES:

MATERIALS AND METHODS:

RESULTS:

CONCLUSION:

Renewing the Call for Reforms to Medical Device Safety-The Case of Penumbra

IMPORTANCE

Strengthening premarket and postmarket surveillance of medical devices has long been an area of focus for health policy makers. The recent class I recall (the most serious of the US Food and Drug Administration [FDA] recalls) of reperfusion catheters manufactured by Penumbra, a US-based medical device company, illustrates issues of device safety and oversight that mandate attention.

OBJECTIVES

To review the regulatory history and clinical evidence of the Penumbra JET 7 Reperfusion Catheter with Xtra Flex Technology (JET 7) and use the device recall as a case study of the challenges associated with clinical evaluation, transparency, and oversight of medical devices in the US.

EVIDENCE

Regulatory history and clinical evidence for the Penumbra medical devices were analyzed through a qualitative review of decision letters in the Access FDA database for medical devices and medical device reports in the Manufacturer and User Facility Device Experience database and a review of market data (eg, earnings calls, company communications) and clinical literature.

FINDINGS

The JET 7 device was subjected to a class I recall following more than 200 adverse event reports, 14 of which involved patient deaths. Regulatory analysis indicated that each of the Penumbra reperfusion catheters was cleared under the 510(k) pathway (which allows devices to be authorized with limited to no clinical evidence), with limited submission of either new clinical or animal data. Clinical evidence for Penumbra devices was generated from nonrandomized, single-arm trials with small sample sizes. The regulatory issues raised by JET 7 are reflective of broader challenges for medical device regulation. Opportunities for reform include strengthening premarket evidence requirements, requiring safety reporting with unique device identifiers, and mandating active methods of postmarket surveillance.

CONCLUSIONS AND RELEVANCE

The case study of JET 7 highlights the long-standing gaps in medical device oversight and renews the impetus to build on the Institute of Medicine recommendations and reform FDA medical device regulation to protect public health.

Red Cell Distribution Width as a Predictor of One-Year Prognosis and Mortality of Endovascular Therapy for Acute Anterior Circulation Ischemic Stroke

OBJECTIVES

To investigate if Red cell distribution width (RDW) can predict long-term prognosis in patients with acute ischemic stroke (AIS) receiving endovascular therapy (EVT).

METHODS

In this study, 102 AIS patients treated with EVT were retrospectively recruited. Clinical profiles and prognoses were collected for all patients. The patients were grouped following the modified ranking scale (MRS) scoring system as given below: a group of favorable functional outcome: 0-2; and a group of unfavorable functional outcome: 3-6.

RESULTS

In multivariate logistic regression, RDW (odds ratio [OR] = 2.799, 95 % confidence interval [CI] = 1.425-5.489; p = 0.003) was an independent predictor of unfavorable functional outcome, and it (OR, 1.929; 95% CI, 1.075-3.458; p = 0.028) was also an independent biomarker for all-cause mortality. The best predictive RDW cut-off value was 13.05% (sensitivity: 93.1%, specificity: 60.3%, AUC: 0.806, p < 0.001).

CONCLUSIONS

The results imply that pre-RDW is a reliable predictor of one-year prognosis and mortality after EVT in acute anterior circulation stroke patients.

Endovascular Treatment in Acute Ischemic Stroke with Large Vessel Occlusion According to Different Stroke Subtypes: Data from ANGEL-ACT Registry

Introduction

Endovascular treatment’s (EVT) safety and efficacy have been proven in treating acute ischemic stroke (AIS) due to large vessel occlusion (LVO). However, limited data exist in different stroke subtypes. We aimed to investigate the differences in efficacy and safety of EVT for acute LVO according to different stroke subtypes.

Methods

A total of 1635 AIS patients with LVO undergoing EVT from a prospective cohort of the Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke (ANGEL-ACT) registry were classified into three types according to the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria. We compared the primary outcome: 90-day modified Rankin Scale (mRS) score, the secondary outcomes: 90-day mRS (0–1, 0–2, and 0–3), successful recanalization (mTICI 2b/3), and complete recanalization (mTICI 3), and the safety outcomes: death within 90 days, parenchymal hemorrhage (PH), and symptomatic intracranial hemorrhage (SICH) among the three subtypes of stroke patients. Then, multivariable logistic regression models adjusting for potential baseline-confounding variables to determine the associations between stroke subtypes and safety and efficacy endpoints were performed. Finally, we performed subgroup analyses to explore discrepancies in the relationships.

Results

EVT of cardioembolic LVO (CE-LVO) had a higher rate of mTICI 3 (71.7% vs. 65.9% and 63.2%; P = 0.024) and a higher rate of PH (13.8% vs. 5.4% and 6.7%; P < 0.001) when compared to other stroke subtypes. Even multivariable analysis demonstrated that CE-LVO was associated with mTICI 3 [adjusted odds ratio (OR), 1.50 (95% CI 1.04–2.17)] and PH [adjusted OR, 1.97 (95% CI 1.09–3.55)]. However, the 90-day mRS distribution and 90-day mRS (0–1, 0–2, and 0–3) did not differ among the stroke subtypes, and nor did the SICH (P > 0.05).

Conclusions

Functional outcomes were similar among different stroke subtypes. Despite a higher rate of complete recanalization, there is an increased risk of parenchymal hemorrhage in CE-LVO.

Trial Registration

Clinical trial registration number: NCT03370939.

CT Perfusion collateral index in assessment of collaterals in acute ischemic stroke with delayed presentation: Comparison to single phase CTA

BACKGROUND & PURPOSE

Perfusion collateral index (PCI) has been recently defined as a promising measure of collateral status. We sought to compare collateral status assessed via CT-PCI in comparison to single-phase CTA and their relationship to outcome measures including final infarction volume, final recanalization status and functional outcome in ELVO patients.

METHODS

ELVO patients with anterior circulation large vessel occlusion who had baseline CTA and CT perfusion and underwent endovascular treatment were included. Collateral status was assessed on CTA. PCI from CT perfusion was calculated in each patient and an optimal threshold to separate good vs insufficient collaterals was identified using DSA as reference. The collateral status determined by CTA and PCI were assessed against 3 measured outcomes: 1) final infarction volume; 2) final recanalization status defined by TICI scores; 3) functional outcome measured by 90-day mRS.

RESULTS

A total of 53 patients met inclusion criteria. Excellent recanalization defined by TICI ≥2C was achieved in 36 (68%) patients and 23 patients (43%) had good functional outcome (mRS ≤2). While having good collaterals on both CTA and CTP-PCI was associated with significantly (p<0.05) smaller final infarction volume, only good collaterals status determined by CTP-PCI was associated with achieving excellent recanalization (p = 0.001) and good functional outcome (p = 0.003).

CONCLUSION

CTP-based PCI outperforms CTA collateral scores in determination of excellent recanalization and good functional outcome and may be a promising imaging marker of collateral status in patients with delayed presentation of AIS.

Biomarkers of Technical Success After Embolectomy for Acute Stroke

PURPOSE OF THE REVIEW

Stent retrievers and large-bore aspiration catheters have doubled substantial reperfusion rates compared to first-generation devices. This has been accompanied by a 3-fold reduction in procedural time to revascularization. To measure future thrombectomy improvements, new benchmarks for technical efficacy are needed. This review summarizes the recent literature concerning biomarkers of procedural success and harm and highlights future directions.

RECENT FINDINGS

Expanded Treatment in Cerebral Ischemia (eTICI), which incorporates scores for greater levels of reperfusion, improves outcome prediction. Core laboratory-adjudicated studies show that outcomes following eTICI 2c (90%-99% reperfusion) are superior to eTICI 2b50 and nearly equivalent to eTICI 3. Moreover, eTICI 2c improves scale reliability. Studies also confirm the importance of rapid revascularization, whether measured as first pass effect or procedural duration under 30 minutes. Distal embolization is a complication that impedes the extent and speed of revascularization, but few studies have reported its per-pass occurrence. Distal embolization and emboli to new territory should be measured after each thrombectomy maneuver. Collaterals have been shown to be an important modifier of thrombectomy benefit. A drawback of the currently accepted collateral grading scale is that it does not discriminate among the broad spectrum of partial collateralization. Important questions that require investigation include reasons for failed revascularization, the utility of a global Treatment in Cerebral Ischemia scale, and the optimal grading system for vertebrobasilar occlusions.

SUMMARY

Emerging data support a lead technical efficacy endpoint that combines the extent and speed of reperfusion. Efforts are needed to better characterize angiographic measures of treatment harm and of collateralization.

Safety and outcomes of endovascular treatment in patients with very severe acute ischemic stroke

BACKGROUND

Patients with anterior circulation ischemic strokes due to large vessel occlusion (AIS-LVO) and very severe neurological deficits (National Institutes of Health Stroke Scale (NIHSS) score > 25) were under-represented in clinical trials on endovascular treatment (EVT). We aimed to evaluate safety and outcomes of EVT in patients with very severe vs. severe (NIHSS score 15-25) neurological deficits.

METHODS

We included consecutive patients undergoing EVT for AIS-LVO between January 2015 and December 2019 at Lille University Hospital. We compared rates of parenchymal hemorrhage (PH), symptomatic intracranial hemorrhage (SICH), procedural complications, and 90-day mortality between patients with very severe vs. severe neurological deficit using univariable and multivariable logistic regression analyses. Functional outcome (90-days modified Rankin Scale) was compared between groups using ordinal logistic regression analysis.

RESULTS

Among 1484 patients treated with EVT, 108 (7%) had pre-treatment NIHSS scores > 25, 873 (59%) with NIHSS scores 15-25 and 503 (34%) with NIHSS scores < 15. Rates of PH, SICH, successful recanalization, and procedural complications were similar in patients with NIHSS scores > 25 and NIHSS 15-25. Patients with NIHSS > 25 had a lower likelihood of improved functional outcome (_adjcommon OR 0.31[95% CI 0.21-0.47]) and higher odds of mortality at 90 days (_adjOR 2.3 [95% CI 1.5-3.7]) compared to patients with NIHSS 15-25. Successful recanalization was associated with better functional outcome (_adjcommon OR 3.8 [95% CI 1.4-10.4]), and lower odds of mortality (_adjOR 0.3 [95% CI 0.1-0.9]) in patients with very severe stroke. The therapeutic effect of recanalization on functional outcome and mortality was similar in both groups.

CONCLUSIONS

In patients with very severe neurological deficit, EVT was safe and successful recanalization was strongly associated with better functional outcome at 90 days.

Unexplained early neurological deterioration after endovascular treatment for acute large vessel occlusion: incidence, predictors, and clinical impact: Data from ANGEL-ACT registry

BACKGROUND

Early neurological deterioration (END) may occur in some patients with acute large vessel occlusion (LVO) undergoing endovascular treatment (EVT). Despite several clear causes of END, such as symptomatic intracranial hemorrhage, failure of recanalization, and intraprocedure complications, a particular END, termed unexplained END (END_unexplained), exists. We aimed to investigate the incidence, independent predictors, and clinical impact of END_unexplained after EVT in patients with acute LVO.

METHODS

Subjects were selected from the ANGEL-ACT registry. END_unexplained was defined as ≥4-point increase in the National Institutes of Health Stroke Scale (NIHSS) score between baseline and 24 hours after EVT, without the causes listed above. Logistic regression analyses were performed to determine the independent predictors of END_unexplained, as well as the association between END_unexplained and 90-day outcomes assessed by modified Rankin Scale (mRS) score.

RESULTS

Among the 1557 enrolled patients, the incidence of END_unexplained was 4.3% (67/1557). Admission NIHSS ≤8 (OR=6.88, 95% CI 3.86 to 12.26, p<0.001), general anesthesia (OR=3.15, 95% CI 1.81 to 5.48, p<0.001), admission neutrophil to lymphocyte ratio >5 (OR=2.82, 95% CI 1.61 to 4.94, p<0.001), and number of EVT attempts >3 (OR=2.11, 95% CI 1.14 to 3.89, p=0.018) were associated independently with a high risk of END_unexplained. Furthermore, patients with END_unexplained were associated with a shift toward worse 90-day outcomes (mRS 5 vs 3, common OR=5.24, 95% CI 3.22 to 8.52, p<0.001).

CONCLUSIONS

END_unexplained associated with poor 90day outcomes occurred in 4.3% of patients with acute LVO undergoing EVT. Several independent predictors of END_unexplained were identified in this study, which should be considered in daily practice to improve acute LVO management.

CLINICAL TRIAL REGISTRATION

http://wwwclinicaltrialsgov NCT03370939.

Efficacy of a Direct Aspiration First-Pass Technique (ADAPT) for Endovascular Treatment in Different Etiologies of Large Vessel Occlusion: Embolism vs. Intracranial Atherosclerotic Stenosis

Background and Aims: Aspiration thrombectomy is an effective method of recanalizing large vessel occlusion (LVO). However, the efficacy of a direct aspiration first-pass technique (ADAPT) for recanalization of LVO of different etiologies is not properly understood.

Methods: The prospectively collected database on ADAPT was reviewed retrospectively. We defined two groups of enrolled patients: the embolism-related occlusions (EMB-O) group and the intracranial atherosclerotic stenosis (ICAS)-related occlusion (ICAS-O) group. Baseline characteristics, procedural variables, and post-procedural variables were collected. Multivariate logistic regression analysis was used to identify first-pass recanalization predictors.

Results: Of 114 registered patients, 94 were eligible for this study (51 patients in the EMB-O group and 43 patients in the ICAS-O group). Achieving successful reperfusion immediately after direct aspiration was more frequent in the EMB-O group than in the ICAS-O group (64.71 vs. 27.91%, respectively, p = 0.006), with fewer additional rescue treatments needed (35.29 vs. 70.09%, respectively, p = 0.001). The EMB-O group also showed a higher final successful reperfusion rate (96.8 vs. 74.41%, p = 0.006). However, the 90-day good functional outcomes were not affected by the groups. Independent predictors of first-pass success of aspiration included the isolated middle cerebral artery site of occlusion, embolic etiology, and use of larger bore catheters.

Conclusions: The efficacy of ADAPT recanalization approach was better in EMB-O than in ICAS-O. In case of embolic etiology and the isolated MCA site of occlusion, using a larger aspiration catheter for direct aspiration thrombectomy may be reasonable.

autoTICI: Automatic Brain Tissue Reperfusion Scoring on 2D DSA Images of Acute Ischemic Stroke Patients

The Thrombolysis in Cerebral Infarction (TICI) score is an important metric for reperfusion therapy assessment in acute ischemic stroke. It is commonly used as a technical outcome measure after endovascular treatment (EVT). Existing TICI scores are defined in coarse ordinal grades based on visual inspection, leading to inter- and intra-observer variation. In this work, we present autoTICI, an automatic and quantitative TICI scoring method. First, each digital subtraction angiography (DSA) acquisition is separated into four phases (non-contrast, arterial, parenchymal and venous phase) using a multi-path convolutional neural network (CNN), which exploits spatio-temporal features. The network also incorporates sequence level label dependencies in the form of a state-transition matrix. Next, a minimum intensity map (MINIP) is computed using the motion corrected arterial and parenchymal frames. On the MINIP image, vessel, perfusion and background pixels are segmented. Finally, we quantify the autoTICI score as the ratio of reperfused pixels after EVT. On a routinely acquired multi-center dataset, the proposed autoTICI shows good correlation with the extended TICI (eTICI) reference with an average area under the curve (AUC) score of 0.81. The AUC score is 0.90 with respect to the dichotomized eTICI. In terms of clinical outcome prediction, we demonstrate that autoTICI is overall comparable to eTICI.