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

Clinical characteristics, Risk factors, and outcomes of Posterior circulation stroke: A retrospective study between younger and older adults in Saudi Arabia

INTRODUCTION

Posterior circulation stroke (PCS) may be less prevalent than its anterior counterpart but contributes to substantial morbidity and mortality. The aim was to characterize PCS's demographics, clinical presentation, management, and outcomes between younger and older adults in Saudi Arabia.

METHODS

This retrospective cohort study was conducted at two tertiary medical centers in Saudi Arabia between March 2016 and December 2020. All patients who presented with symptoms of posterior circulation stroke and had positive brain imaging were included.

RESULTS

The study involved 160 posterior circulation stroke patients, stratified into two age groups: 71 patients aged 18-59 years and 89 patients aged 60 years and above. The mean age of the entire cohort was 60.9 years, and 77 % were males. Hypertension was more prevalent in the older age group (88 % vs. 69 %, p=0.005), and smoking was significantly higher among younger patients (38 % vs. 15 %; p=0.0009). Only 22.4 % received thrombolysis and/or thrombectomy. Most strokes involved the posterior cerebral artery (45.6 %). Large artery atherosclerosis was the most common subtype. At discharge, younger patients had higher NIHSS compared to older patients.

CONCLUSION

Our investigation of 160 PCS patients in Saudi Arabia uncovers notable trends: a mere 22.4 % received thrombolysis and/or thrombectomy and a significant prevalence of posterior cerebral artery involvement due to large artery atherosclerosis. The study further reveals younger patients disproportionately had severe outcomes. Highlighting the need for improved stroke care and heightened awareness, this research contributes vital data to an underexplored domain, urging further study to optimize care and understand PCS dynamics in Saudi Arabia.

Trials of endovascular thrombectomy of basilar-artery occlusion compared to real-life data

BACKGROUND

Two recent clinical trials showed mechanical thrombectomy (MT) of basilar-artery occlusions (BAO) in stroke to be safe and effective: Endovascular Treatment for Acute BAO (ATTENTION) and BAO Chinese Endovascular (BAOCHE). The trials restricted patient inclusion on both age and pre-stroke mRS, and with both trials conducted in China, population differences may affect generalisability of the trial results.

METHODS

Consecutive patients with BAO undergoing MT were registered from 2017 to 2021 with retrospective data collection at a single centre with a predominantly Caucasian catchment population of 2.7 million. Age and pre-stroke modified Rankin Scale (mRS) were not absolute contraindications for MT. We present functional outcome as mRS at 90 days, patient characteristics and procedural safety compared to the trial intervention groups.

RESULTS

Of the 108 included patients, 50 % achieved mRS 0-3 at 90 days and mortality was 32 %, which was no different from ATTENTION (46 %, p = 0.40, 37 %, p = 0.31, respectively) and BAOCHE (46 %, p = 0.50, 31 %, p = 0.93). Pre-stroke mRS 0 was seen in 62 %, 89 %, and 77 % of the study patients, ATTENTION, and BAOCHE, respectively. Proximal segment BAO was less common (22 % vs. 31 %, p = 0.04, and 65 %, p < 0.01) and intracranial stenting less frequently used (9 % vs. 40 % and 55 %, p < 0.01) in study patients compared to ATTENTION and BAOCHE, respectively.

CONCLUSION

Outcome of MT in BAO stroke in a clinical patient cohort was similar to recent trials, despite broader patient inclusion and differences in both occluded BAO segment and use of stenting. Our study suggest that MT is safe and effective in a Caucasian population.

Sex differences in outcomes of endovascular therapy for acute vertebrobasilar occlusion: data from ANGEL-ACT Registry

BACKGROUND

Understanding sex disparities in stroke can identify gaps in clinical care. The objective of this study was to investigate whether sex differences could influence clinical outcomes of patients with acute vertebrobasilar artery occlusion (VBAO) who underwent endovascular therapy (EVT).

METHODS

Patients were selected from the ANGEL-ACT Registry. The primary outcome was favorable functional outcome (90-day modified Rankin Scale [mRS] 0-3). Secondary outcomes included 90-day mRS distribution, excellent outcome (mRS 0-1), functional independence (mRS 0-2), early neurological improvement, recanalization, intracranial hemorrhage, and mortality within 90 days. The above outcomes were compared by two adjustment models, including (1) multivariable logistics analysis adjusting for all baseline and procedural variables with a P < 0.05; (2) adjusting for the propensity score.

RESULTS

There were 347 acute VBAO patients treated with EVT included, of whom 72 (20.7%) were women and 275 (79.3%) were men. Women were older (72[63-76] vs. 62[53-69], P < 0.001) and had a higher rate of atrial fibrillation (31.9% vs. 8.7%, P < 0.001), lower rates of underlying intracranial atherosclerotic disease (30.6% vs. 51.3%, P = 0.007), and tandem occlusion (8.3% vs. 21.8%, P = 0.009) than men. The rate of favorable outcome (mRS 0-3) was similar between women and men (41.7% vs. 51.3%, adjusted odds ratio 1.56, 95%CI: 0.83-2.95, P = 0.171). There were no sex differences in other clinical outcomes (all P > 0.05).

CONCLUSIONS

In the ANGEL-ACT registry, the percentage of men with acute VBAO undergoing EVT was approximately fourfold higher than that of women with acute VBAO undergoing EVT. Sex differences did not modify the outcomes of acute VBAO after EVT.

Cost-Effectiveness of CT, CTA, MRI, and Specialized MRI for Evaluation of Patients Presenting to the Emergency Department With Dizziness

BACKGROUND. Underlying stroke is often misdiagnosed in patients presenting with dizziness. Although such patients are usually ineligible for acute stroke treatment, accurate diagnosis may still improve outcomes through selection of patients for secondary prevention measures. OBJECTIVE. The purpose of our study was to investigate the cost-effectiveness of differing neuroimaging approaches in the evaluation of patients presenting to the emergency department (ED) with dizziness who are not candidates for acute intervention. METHODS. A Markov decision-analytic model was constructed from a health care system perspective for the evaluation of a patient presenting to the ED with dizziness. Four diagnostic strategies were compared: noncontrast head CT, head and neck CTA, conventional brain MRI, and specialized brain MRI (including multiplanar high-resolution DWI). Differing long-term costs and outcomes related to stroke detection and secondary prevention measures were compared. Cost-effectiveness was calculated in terms of lifetime expenditures in 2022 U.S. dollars for each quality-adjusted life year (QALY); deterministic and probabilistic sensitivity analyses were performed. RESULTS. Specialized MRI resulted in the highest QALYs and was the most cost-effective strategy with US$13,477 greater cost and 0.48 greater QALYs compared with noncontrast head CT. Conventional MRI had the next-highest health benefit, although was dominated by extension with incremental cost of US$6757 and 0.25 QALY; CTA was also dominated by extension, with incremental cost of US$3952 for 0.13 QALY. Non-contrast CT alone had the lowest utility among the four imaging choices. In the deterministic sensitivity analyses, specialized MRI remained the most cost-effective strategy. Conventional MRI was more cost-effective than CTA across a wide range of model parameters, with incremental cost-effectiveness remaining less than US$30,000/QALY. Probabilistic sensitivity analysis yielded similar results as found in the base-case analysis, with specialized MRI being more cost-effective than conventional MRI, which in turn was more cost-effective than CTA. CONCLUSION. The use of MRI in patients presenting to the ED with dizziness improves stroke detection and selection for subsequent preventive measures. MRI-based evaluation leads to lower long-term costs and higher cumulative QALYs. CLINICAL IMPACT. MRI, incorporating specialized protocols when available, is the preferred approach for evaluation of patients presenting to the ED with dizziness, to establish a stroke diagnosis and to select patients for secondary prevention measures.

Endovascular thrombectomy for posterior cerebral artery strokes in the national inpatient sample (EaT PeCANpIeS) study

BACKGROUND

Posterior cerebral arteries with acute ischemic strokes (PCA-AISs) comprise around 2% of all acute ischemic strokes and may result in significant long-term deficits. Current guidance regarding endovascular thrombectomy (EVT) for PCA-AIS is insufficient as no published randomized trials exist.

METHODS

An analysis of the National Inpatient Sample database compared medical management versus EVT for PCA-AIS. Propensity score matching was applied to adjust for nonrandomization.

RESULTS

The study included 19,655 patients. Before matching, the EVT cohort had significantly higher National Institutes of Health Stroke Scale (NIHSS) (10.21 vs. 4.67, p < 0.001), had lower rates of favorable functional outcomes, functional independence, and higher rates of intracranial hemorrhage (ICH) and inpatient mortality. After matching, no differences in functional outcomes were identified, but revealed a higher proportion of ICH in the EVT group (17.45% vs. 8.98%, p < 0.001). However, NIHSS subgroup analysis identified improved functional outcomes associated with the EVT group who presented with an NIHSS between 10 and 19 both in terms of rates of favorable functional outcomes (35.56% vs. 12.09%, p < 0.001) and rates of functional independence (26.67% vs. 9.34%, p < 0.01). On further investigation, the clinical benefit, in the NIHSS 10-19 subgroup, was driven by patients receiving EVT in combination with intravenous thrombolysis (IVT).

CONCLUSIONS

This analysis shows that current national practices utilize EVT for more severe PCA strokes. Clinical benefit was only detected in patients with moderate stroke severity (NIHSS 10-19) who were treated with combined EVT and IVT. Further work is needed to investigate the features of PCA-AIS that might benefit from EVT the most.

Post-ASPECTS and Post-PC-ASPECTS Predict the Outcome of Anterior and Posterior Ischemic Stroke Following Thrombectomy

Purpose

In this study, we aimed to determine whether post-Alberta Stroke Project Early CT Changes Score (post-ASPECTS) in anterior stroke and post-(posterior circulation) PC-ASPECTS in posterior stroke on CT can predict post-endovascular thrombectomy (EVT) functional outcomes among patients with acute ischemic stroke (AIS) after EVT.

Patients and Methods

A total of 247 consecutive patients aged 18 and over receiving EVT for LVO-related AIS were recruited into a prospective database. The data was retrospectively analyzed between March 2019 and February 2022 from two comprehensive tertiary care stroke centers: Foshan Sanshui District People's Hospital and First People's Hospital of Foshan in China. Patient parameters included EVT within 24 hr of symptom onset, premorbid modified Rankin scale (mRS) ≤2, presence of distal and terminal cerebral blood vessel occlusion, and subsequent 24-72-hr post-stroke onset CT scan. Univariate comparisons were performed using the Fisher's exact test or χ2 test for categorical variables and the Mann-Whitney U-test for continuous variables. Logistic regression analysis was performed to further analyze for adjusting for confounding factors. A p-value of ≤0.05 was statistically significant.

Results

Overall, 236 individuals with 196 anterior circulation ischemic strokes and 40 posterior strokes of basilar artery occlusion were examined. Post-ASPECTS in anterior stroke and post-pc-ASPECTS as strong positive markers of favorable outcome at 90 days post-EVT; and lower rates of inpatient mortality/hospice discharge, 90-day mortality, and 90-day poor outcome were observed. Moreover, patients in the post-ASPECTS ≥ 7 cohort experienced shorter door-to-recanalization time (DRT), puncture-to-recanalization time (PRT), and last known normal-to-puncture time (LKNPT).

Conclusion

Post-ASPECTS ≥7 in anterior circulation AIS and post-pc-ASPECTS ≥7 in posterior circulation can serve as strong prognostic markers of functional outcome after EVT.

First pass effect of mechanical thrombectomy for acute vertebrobasilar artery occlusion: data from the ANGEL-ACT registry

BACKGROUND

To explore the incidence, predictors, and association of first pass effect (FPE) on clinical outcomes of mechanical thrombectomy (MT) for acute vertebrobasilar artery occlusion (VBAO) in the Asian population.

METHODS

We selected patients from the ANGEL-ACT registry. We defined FPE as complete recanalization after one MT attempt without rescue treatment, multiple pass effect (MPE) as complete recanalization after >1 MT attempt or after one MT attempt with rescue treatment, and incomplete recanalization (ICR) as a modified Thrombolysis in Cerebral Ischemia score of 2b, independent of the number of MT attempts. We conducted multivariable logistic analyses to identify the independent predictors of FPE and to compare the outcomes, including favorable outcome, mortality within 90 days, and intracranial hemorrhage (ICH) among the FPE, MPE, and ICR groups.

RESULTS

Two hundred and seventy-nine patients, 68 with FPE (24.4%), 114 with MPE (40.9%), and 83 with ICR (29.7%), were included. Underlying intracranial atherosclerosis disease (ICAD) (adjusted OR (aOR) 0.16, 95% CI 0.08 to 0.34, P<0.001) was independently associated with a low chance of FPE. Furthermore, FPE was associated with a favorable outcome compared with MPE and ICR (MPE vs FPE, aOR 0.49, 95% CI 0.25 to 0.97, P=0.040; ICR vs FPE, aOR 0.38, 95% CI 0.18 to 0.81, P=0.012), and decreased mortality (MPE vs FPE, aOR 2.57, 95% CI 1.04 to 6.36, P=0.041) compared with MPE but similar mortality to ICR (P=0.374). No difference was found for ICH among the three groups (P>0.05).

CONCLUSIONS

FPE occurred in 24.4% of patients with VBAO in our cohort, which was associated with improved clinical outcomes compared with MPE and ICR. VBAO with underlying ICAD was less likely to achieve FPE.

TRIAL REGISTRATION NUMBER

NCT03370939.

Outcome prediction value of critical area perfusion score for acute basilar artery occlusion

PURPOSE

To investigate the performance of the Critical Area Perfusion Score (CAPS), based on computed tomography perfusion (CTP) time to maximum (Tmax) > 10s maps, to predict the outcome in acute basilar artery occlusion (BAO) in patients undergoing endovascular treatment (EVT).

METHODS

We perform a retrospective analysis of a prospectively collected database of acute BAO treated with EVT in a comprehensive stroke center. The favorable outcome was defined as the 90-day modified Rankin Scale (mRS) ≤ 3. We performed the logistic regression analysis to find the independent predictors of the favorable outcome. Then, we used receiver operating characteristic analyses to assess the predictive value of the imaging parameters, including CAPS, Posterior Circulation Alberta Stroke Program Early CT Score (PC-ASPECTS), pons midbrain index (PMI), posterior circulation computed tomography angiography (PC-CTA) score, Basilar Artery on Computed Tomography Angiography (BATMAN) score, and CTP parameters. Finally, the Delong test was used to compare the area under the curve (AUC) of CAPS against the other imaging parameters.

RESULTS

Of the 65 enrolled patients, the incidence of the favorable outcome was 44.6% (29/65). Low CAPS (per 1- point increased odds ratio [OR], 0.43; 95% confidence interval [CI], 0.22-0.86; P = 0.017) and admission National Institutes of Health Stroke Scale (NIHSS) (per 1- point increased OR, 0.80; 95% CI, 0.70-0.91; P = 0.001) were independently associated with favorable outcome. The AUC of CAPS was 0.83 (95% CI, 0.74-0.93; P < 0.001) with ≤ 3 cut-off value, 89.66% sensitivity, 77.22% specificity, and 80.00% accuracy, which was greater than the other imaging parameters (All P for Delong test < 0.05).

CONCLUSIONS

CAPS was the most accurate imaging-based outcome predictor in acute BAO patients. Future large prospective multicenter studies are needed to verify these results.

Pearls for the Emergency Clinician: Posterior Circulation Stroke

BACKGROUND

Posterior circulation (PC) stroke in adults is a rare, frequently misdiagnosed, serious condition that carries a high rate of morbidity.

OBJECTIVE OF THE REVIEW

This review evaluates the presentation, diagnosis, and management of PC stroke in the emergency department (ED) based on current evidence.

DISCUSSION

PC stroke presents most commonly with dizziness or vertigo and must be distinguished from more benign diagnoses. Emergency clinicians should consider this condition in patients with dizziness, even in younger patients and those who do not have traditional stroke risk factors. Neurologic examination for focal neurologic deficit, dysmetria, dysarthria, ataxia, and truncal ataxia is essential, as is the differentiation of acute vestibular syndrome vs. spontaneous episodic vestibular syndrome vs. triggered episodic vestibular syndrome. The HINTS (head impulse, nystagmus, and test of skew) examination can be useful for identifying dizziness presentations concerning for stroke when performed by those with appropriate training. However, it should only be used in patients with continuous dizziness who have ongoing nystagmus. Contrast tomography (CT), CT angiography, and CT perfusion have limited sensitivity for identifying PC strokes, and although magnetic resonance imaging is the gold standard, it may miss some PC strokes early in their course. Thrombolysis is recommended in patients presenting within the appropriate time window for thrombolytic therapy, and although some data suggest endovascular therapy for basilar artery and posterior cerebral artery infarcts is beneficial, its applicability for all PC strokes remains to be determined.

CONCLUSIONS

An understanding of PC stroke can assist emergency clinicians in diagnosing and managing this disease.

Radiation Exposure Reduction by Digital Variance Angiography in Lower Limb Angiography: A Randomized Controlled Trial

BACKGROUND

digital variance angiography (DVA) provides higher image quality than digital subtraction angiography (DSA). This study investigates whether the quality reserve of DVA allows for radiation dose reduction during lower limb angiography (LLA), and compares the performance of two DVA algorithms.

METHODS

this prospective block-randomized controlled study enrolled 114 peripheral arterial disease patients undergoing LLA into normal dose (ND, 1.2 µGy/frame, n = 57) or low-dose (LD, 0.36 µGy/frame, n = 57) groups. DSA images were generated in both groups, DVA1 and DVA2 images were generated in the LD group. Total and DSA-related radiation dose area product (DAP) were analyzed. Image quality was assessed on a 5-grade Likert scale by six readers.

RESULTS

the total and DSA-related DAP were reduced by 38% and 61% in the LD group. The overall visual evaluation scores (median (IQR)) of LD-DSA (3.50 (1.17)) were significantly lower than the ND-DSA scores (3.83 (1.00), p < 0.001). There was no difference between ND-DSA and LD-DVA1 (3.83 (1.17)), but the LD-DVA2 scores were significantly higher (4.00 (0.83), p < 0.01). The difference between LD-DVA2 and LD-DVA1 was also significant (p < 0.001).

CONCLUSIONS

DVA significantly reduced the total and DSA-related radiation dose in LLA, without affecting the image quality. LD-DVA2 images outperformed LD-DVA1, therefore DVA2 might be especially beneficial in lower limb interventions.

Delayed low cerebellar perfusion status is associated with poor outcomes in top-of-basilar occlusion treated with thrombectomy

Background and purpose

Top-of-basilar artery occlusion (TOB) is one of the most devastating strokes despite successful mechanical thrombectomy (MT). We aimed to investigate the impact of initial low cerebellum perfusion delay on the outcomes of TOB treated with MT.

Methods

We included patients who underwent MT for TOB. Clinical and peri-procedural variables were obtained. Perfusion delay in the low cerebellum was defined as (1) time-to-maximum (Tmax) >10 s lesions or (2) relative time-to-peak (rTTP) map >9.5 s with a diameter of ≥6 mm in the low cerebellum. The good functional outcome was defined as the achievement of a modified Rankin Scale score of 0-3 at 3 months after stroke.

Results

Among the 42 included patients, 24 (57.1%) patients showed perfusion delay in the low cerebellum. The admission National Institutes of Health Stroke Scale (NIHSS) score was significantly higher in those with perfusion delay [17 (12-24) vs. 8 (6-15), P = 0.002]. Accordingly, the proportion of good functional outcomes was lower in those with perfusion delay than in those without [5 (20.8%) vs. 13 (72.2%), P = 0.003]. From the multivariable analysis, the admission NIHSS score [odds ratio (OR) = 0.86, 95% confidence intervals (CIs) = 0.75-0.98, P = 0.021] and low cerebellum perfusion delay (OR = 0.18, 95% Cis = 0.04-0.86, P = 0.031) were independently associated with the 3-month functional outcomes.

Conclusion

We found that initial perfusion delay proximal to TOB in the low cerebellum might be a predictor for poor functional outcomes in TOB treated with MT.

Predictors of poor outcome after endovascular treatment for acute vertebrobasilar occlusion: data from ANGEL-ACT registry

PURPOSE

Acute vertebrobasilar artery occlusion (VBAO) is a catastrophic disease for patients. There is evidence that the eventual patient outcome depends on patient-specific and procedural factors. This study aimed to identify the incidence and independent predictors of the 90-day poor outcome in VBAO after endovascular treatment (EVT).

METHODS

Subjects were selected from the ANGEL-ACT registry. The 90-day poor outcome was defined as a 90-day modified Rankin Scale (mRS) of 4 to 6. Logistic regression analyses were performed to determine the independent predictors of the 90-day poor outcome.

RESULTS

Of the 347 enrolled patients with acute VBAO undergoing EVT, 176 (50.7%) experienced the 90-day poor outcome. Multivariate logistic regression indicated that only the use of general anesthesia (GA) (odds ratio [OR] = 2.04; 95% confidence interval [CI], 1.23-3.37; P = 0.006) and heparin during the procedure (OR =1.74; 95% CI, 1.06-2.86; P = 0.028), admission National Institute of Health Stroke Scale (NIHSS) ≥ 26 (OR=3.96; 95% CI, 2.37-6.61; P < 0.001), and time from onset to puncture (OTP) ≥ 395 min (OR=1.91; 95% CI, 1.14-3.20; P = 0.014) and procedure duration ≥ 102 min (OR = 1.70; 95% CI, 1.04-2.79; P = 0.036) were independent predictors of the 90-day poor outcome after EVT. Furthermore, admission NIHSS (OR > 36 vs. ≤ 11 = 9.01, P for trend < 0.001), OTP (OR > 441min vs. ≤ 210 min = 2.71, P for trend = 0.023), and procedure duration (OR > 145 min vs. ≤ 59 min = 2.77, P for trend = 0.031) were significantly associated with increasing risk of the 90-day poor outcome.

CONCLUSIONS

Poor outcome after EVT at 90 days occurred in 50.7% of acute VBAO patients from the ANGEL-ACT registry. Our study found several predictors of the 90-day poor outcome which should be highly considered in daily practice to improve acute VBAO management. CLINICAL TRIAL REGISTRATION : http://www.

CLINICALTRIALS

gov . Unique identifier: NCT03370939.