Comparison of perfusion imaging parameters with and without symptom progression in mild stroke patients due to large/medium vessel occlusion.

ObjectivesTo investigate the safety and efficacy of endovascular treatment (EVT) for acute medium vessel occlusion (MeVO) in the anterior circulation and to explore the independent predictors of the 90-day good...

Concerning endovascular treatment for acute ischemic stroke with intracranial vessel occlusion, shortening the door-to-puncture time (DTP) improves the patient's outcome. To determine endovascular treatment, magnetic resonance angiography or computed tomography angiography is performed for occluded vessel detection. Another detection method of internal carotid artery (ICA) occlusion or middle cerebral artery first segment (M1) occlusion is ultrasound (US). Bilateral flow pattern analysis of common carotid arteries by US leads to the diagnosis of ICA or M1 occlusion within a few minutes. Moreover, it can be conducted in the emergency department. The addition of the US for the initial evaluation of vessel occlusion can shorten the DTP. In this study, we evaluated the effectiveness of carotid artery US imaging in detecting large vessel occlusion (LVO) and shortening the DTP. This is a retrospective case-control study. Our analysis was based on the data from 150 patients with LVO or medium vessel occlusion who underwent endovascular revascularization treatment at our hospital between January 2015 and December 2022. Among them, 104 patients who had an anterior circulation vessel occlusion were included. They were divided into the US evaluation group and the non-US evaluation group, and their characteristics, treatment time course, and outcomes were compared. This study included 104 patients with a median age of 81 years (interquartile range: 73-89 years), 57.7% were females, and the pre-stroke modified Rankin Scale (mRS) median was 0.5 (interquartile range: 0-3). Our cohort included advanced aged patients; therefore, this study included 56.7% of patients over 80 years old and 35.6% of pre-stroke mRS over 3. The US (US group) and non-US (non-US group) evaluation groups included 54 and 50 patients, respectively. As magnetic resonance imaging evaluation in the non-US group was performed over the 4.5 hours delayed arrival of patients from the last known well (LKW) to consider the evaluation of tPA administration, selection bias occurred. The US group included high National Institutes of Health Stroke Scale (NIHSS) patients (P = 0.0152) and more ICA occlusions (P = 0.0146). Onset (LKW) to door time was shorter in the US group (median, 75 min (35-146.5 minutes)) than the non-US group (median, 179 minutes (47.3-432.8 minutes); P = 0.0426), and the DTP was shorter for the US group (median, 75.5 minutes (63.8-87.3 minutes)) than for the non-US group (median, 85 minutes (67-129 minutes); P = 0.0102). Statistical difference was not seen in puncture to reperfusion time among the US group (median, 71.5 minutes (51-114 minutes)) and non-US group (median, 67 minutes (42.3-98.5 minutes); P = 0.5581). The onset (LKW) to reperfusion was shorter for the US group (median, 251 minutes (201-327.3 minutes)) than for the non-US group (median, 319 minutes (200-633.5 minutes); P = 0.0348). No statistical differences were seen for thrombolysis in cerebral infarction grade 2b-3 after treatment, improvement of NIHSS, and mRS at 90 days. US is a useful imaging method to identify an anterior circulation LVO. It can distinguish patients with severe internal carotid or middle cerebral artery occlusion from medium vessel occlusion or other peripheral vessel occlusions. US helps to shorten the DTP time of LVO.

Commentary

Introduction Mechanical thrombectomy (MT) for acute ischemic stroke (AIS) is very effective treatment in patients with high National Institutes of Health Stroke Scale (NIHSS) scores. However, disability can also be seen in patients with NIHSS scores of 0‐5. Besides, clinical deterioration as a result of stroke progression is quite common in patients with large vessel occlusion (LVO). Although there are studies investigating the effectivity of EVT in patients with low NIHSS scores, more comprehensive data are needed on patient selection and safety. In this study we aimed to determine the clinical outcome of patients with low NIHSS scores who underwent mechanical thrombectomy in our center. Methods We conducted a single‐center, retrospective study of a prospectively maintained database of stroke patients presenting with NIHSS scores of 0‐5. Patients who applied within 24 hours from the onset of symptoms were included in the study. Detailed clinical information of the patients such as age, sex and the presence of comorbidities, localization of occlusion, procedural measures were recorded. Clinical outcomes were evaluated with NIHSS scores at 24 hours and mRS 3 months. Results A total of 147 patients were enrolled in this study. Patient presenting with NIHSS<5 within 24 hours of onset and imaging modalities showing large or medium vessel occlusion and diffusion‐perfusion mismatch were evaluated for MT. The mean age was 62.75 ± 14.63 and 85 (57.8%) of the patients were male. A total of 8 (5.4%) patients had occlusion in extracranial ICA, 16 (10.9%) in ICA terminal, 49 (33.3%) in MCA M1, 52 (35.4%) in MCA M2 and 8 (5.4%) in M3, 3 (2.1%) in ACA, whereas 5 (3.4%) patients in basilar artery and 6 (4.1%) patients in PCA. The mean NIHSS on admission was 3.28 ± 1.37 and 3.29 ± 3.95 at 24 hours. The patients with mRS scores of 0‐2 were evaluated as functionally independent. The number of functionally independent patients at 90 days was 108 (79.4%), whereas 15 (10.2%) patients died. Conclusions: In this study low NIHSS patients with underlying vessel occlusion benefit from MT in terms of 3.month mRS. Still large cohort, randomized studies are warranted to show superiority to medical treatment.

BackgroundMechanical thrombectomy (MT) is the standard of care for anterior circulation proximal large vessel occlusion (LVO) stroke with salvageable tissue. Here, the National Institutes of Health Stroke Scale (NIHSS) 24...

BackgroundBrain edema is a severe complication in patients with large vessel occlusion (LVO) that can reduce the effectiveness of endovascular therapy (EVT). This study aimed to investigate the association of the perfusion profile at baseline computed tomography (CT) perfusion with rapidly progressing brain edema (RPBE) after EVT in patients with acute anterior LVO.MethodsWe retrospectively reviewed consecutive data collected from 149 patients with anterior LVO who underwent EVT at our center. Brain edema was measured by the swelling score (0–6 score), and RPBE was defined as the swelling score increased by more than 2 scores within 24 h after EVT. We investigated the effect of RPBE on poor outcomes [National Institute of Health Stroke Scale (NIHSS) score and modified Rankin scale (mRS) score at discharge, the occurrence of hemorrhagic transformation, and mortality rate in the hospital] using the Mann–Whitney U-test and chi-square test. A multivariate logistic regression model was used to assess the relationship between perfusion imaging parameters and RPBE occurrence.ResultsOverall, 39 patients (26.2%) experienced RPBE after EVT. At discharge, RPBE was associated with higher NIHSS scores (Z = 3.52, 95% CI 2.0–12.0, P < 0.001) and higher mRS scores (Z = 3.67, 95% CI 0.0–1.0, P < 0.001) including the more frequent occurrence of hemorrhagic transformation (χ2 = 22.17, 95% CI 0.29–0.59, P < 0.001) and higher mortality rates in hospital (χ2 = 9.54, 95% CI 0.06–0.36, P = 0.002). Univariate analysis showed that intravenous thrombolysis, baseline ischemic core volume, and baseline mismatch ratio correlated with RPBE (all P < 0.05). After dividing the mismatch ratio into quartiles and performing a chi-square test between quartiles, we found that the occurrence of RPBE in Q4 (mismatch ratio > 11.3) was significantly lower than that in Q1 (mismatch ratio ≤ 3.0) (P < 0.05). The result of multivariate logistic regression analysis showed that compared with baseline mismatch ratio <5.1, baseline mismatch ratio between 5.1 and 11.3 (OR:3.85, 95% CI 1.06–14.29, P = 0.040), and mismatch ratio >11.3 (OR:5.26, 95% CI 1.28–20.00, P = 0.021) were independent protective factors for RPBE.ConclusionIn patients with anterior circulation LVO stroke undergoing successful EVT, a large mismatch ratio at baseline is a protective factor for RPBE, which is associated with poor outcomes.

BackgroundMedium vessel occlusions (MeVOs) comprise a large proportion of all stroke events. We performed a multicenter study of MIVI Q catheters, a novel design that optimizes suction forces without an...

Introduction: Randomized clinical trials evaluating the effects of endovascular treatment (EVT) for medium vessel occlusion (MeVO) are ongoing. However, it remains unclear how clinicians determine the indication for EVT in MeVO cases in real-world practice Hypothesis: We hypothesize that in actual clinical practice, there is a threshold of clinical symptoms and perfusion imaging findings that guide the decision to intervene with EVT for MeVO. Methods: We conducted a single-center retrospective registry from April 2019 to April 2024, enrolling consecutive patients with acute ischemic stroke due to MeVO. We compared the outcomes of MeVO patients who received EVT with those who received medical treatment (MT). The primary outcome was defined as a good functional outcome, indicated by a modified Rankin scale score of 0-2 at 90 days post-stroke onset. Secondary outcomes included exploring the optimal thresholds for EVT intervention in real-world clinical practice, based on clinical symptoms indicated by the National Institutes of Health Stroke Scale and perfusion imaging using RAPID software. Results: We analyzed 162 patients (EVT, n = 102; MT, n = 60). The mean age was 80 years, with 53.7% being men. Recombinant tissue plasminogen activator was used more frequently in the EVT group (42.2% vs. 18.3%). The median NIHSS was higher in the EVT group (median [interquartile range, IQR]; 13 [6–19] vs. 7 [2–14]). In terms of perfusion imaging, there was no significant difference between the two groups in CBF &lt; 30% (median [IQR]; 4 [0–17] vs. 4 [0–22]). However, the median T max &gt; 6 sec and mismatch volume were significantly higher in the EVT group (median [IQR]; 44 [27–82] vs. 28 [6–49] and 35 [21–55] vs. 12 [2–28], respectively). The primary outcome was not significantly different between the EVT and MT groups (41 [40.2%] vs. 25 [41.7%]; adjusted odds ratio [aOR]: 1.10 [95% CI: 0.42–2.89]). Receiver-operating characteristic analyses showed that the areas under the curves for NIHSS, CBF &lt; 30%, T max &gt; 6 sec, and mismatch volume were 0.64, 0.49, 0.68, and 0.74, respectively. Mismatch volume had the best discriminatory power with respect to EVT intervention, with a threshold of 20 ml. Conclusions: A mismatch volume of ≥ 20 ml may be a useful criterion for determining EVT intervention in MeVO cases in real-world practice.

Endovascular therapy (EVT) is the standard treatment for ischemic stroke caused by a large vessel occlusion (LVO). The effectiveness of EVT for distal medium vessel occlusions (MDVOs) is still uncertain, but newer, smaller devices show potential for EVT in MDVOs. The new Solitaire X 3 mm device offers a treatment option for MDVOs. Our study encompassed consecutive cases of primary and secondary MDVOs treated with the Solitaire X 3 mm stent-retriever as first-line EVT device between January and December 2022 at 12 European stroke centers. The primary endpoint was a first-pass near-complete or complete reperfusion, defined as a modified treatment in cerebral infarction (mTICI) score of 2c/3. Additionally, we examined reperfusion results, National Institutes of Health Stroke Scale (NIHSS) scores at 24 h and discharge, device malfunctions, complications and procedural technical parameters. Sixty-eight patients (38 women, mean age 72 ± 14 years) were included in our study. Median NIHSS at admission was 11 (IQR 6–16). In 53 (78%) cases, a primary combined approach was used as the frontline technique. Among all enrolled patients, first-pass mTICI 2c/3 was achieved in 22 (32%) and final mTICI 2c/3 in 46 (67.6%) patients after a median of 1.5 (IQR 1–2) passes. Final reperfusion mTICI 2b/3 was observed in 89.7% of our cases. We observed no device malfunctions. Median NIHSS at discharge was 2 (IQR 0–4), and no symptomatic intracranial hemorrhages were reported. Based on our analysis, the utilization of the Solitaire X 3 mm device appears to be both effective and safe for performing EVT in cases of MDVO stroke.

BackgroundEndovascular thrombectomy (EVT) is the standard-of-care for proximal large vessel occlusion (LVO) stroke. Data on technical and clinical outcomes in distal vessel occlusions (DVOs) remain limited.MethodsThis was a retrospective study...

要旨 標準的な外傷診療では生理学的機能の管理および安定化を重視しており，神経学的所見は見逃されやすい。内因性脳梗塞が先行した外傷症例の診療について検討した。症例は78歳の男性，階段2階の踊り場から転落した。右共同偏視，右片麻痺，Glasgow coma scale（GCS）12の意識障害を認めた。外傷全身computed tomography（CT）で頭蓋内に占拠性病変は認めず，動脈優位相で左中大脳動脈の造影欠損を認めた。急性期脳梗塞と診断し，機械的血栓回収療法を行った。外傷機転を介在する内因性脳梗塞では，見逃しや治療介入に時間を要する可能性がある。病院前脳卒中スケールが症状検出に役立つ可能性があり，頭頂部の動脈優位相を含む造影CT検査で主幹動脈閉塞の検索が可能である。画像評価には熟練を要するため，3次元画像処理を行うとともに，適切に専門医へコンサルトし早期診断治療へつなげることが重要である。

The best management of acute ischemic stroke patients with a minor stroke and large vessel occlusion is still uncertain. Specific clinical and radiological data may help to select patients who benefit from Endovascular Therapy (EVT). We aimed to evaluate the relevance of NIHSS subitems for predicting potential benefit of EVT after intravenous thrombolysis (IVT)("bridging treatment") versus IVT alone. We extracted demographic, clinical, risk factor, radiological, revascularization and outcome data from consecutive patients with M1 or proximal M2 middle cerebral artery occlusion and admission NIHSS scores of 0-5 points treated with IVT+/-EVT between May 2005 and March 2021 from nine prospectively-constructed stroke registries from seven French and two Swiss comprehensive stroke centers. Adjusted interaction analyses were performed between admission NIHSS subitems and revascularization modality for two primary outcomes at 3 months: non-excellent functional outcome (mRS 2-6) and difference in NIHSS score between 3 months and admission RESULTS: Of the 533 patients included (median age 68.2 years, 46% women, median admission NIHSS score 3), 136 (25.5%) patients initially received bridging therapy and 397 (74.5%) IVT alone. Adjusted interaction analysis revealed that only facial palsy on admission was more frequently associated with excellent outcome in patients treated by IVT alone versus bridging therapy (OR=0.47, 95%CI=0.24-0.91, p=0.013). Regarding NIHSS-difference at 3 months, no single NIHSS subitems interacted with the type of revascularization. This retrospective multicenter analysis found that NIHSS subitems at admission had little value in predicting patients who might benefit from bridging therapy as opposed to IVT alone. Further research is needed to identify better markers for selecting EVT responders with minor strokes.

Background: In an open pilot study, we studied the safety and efficacy of treatment with the nonpeptide glycoprotein IIb/IIIa antagonist tirofiban in patients with progressive ischemic stroke. The rationale for the use of tirofiban in progressive stroke is the effect on vessel patency and microcircu lation. Methods: Patients with acute ischemic stroke and progression of ≥2 points on the National Institute of Health Stroke Scale (NIHSS) in the first 96 h after stroke onset were treated with intravenous tirofiban. Serial NIHSS measurements and intra- and extracerebral bleeding complications were recorded. Results: Progressive stroke was observed in 35 patients with a mean progression of 5.4 (SD 4.1) points on the NIHSS. No severe bleeding complications occurred during tirofiban treatment. Analysis of variance revealed a significant interaction between stroke etiology (small-vessel vs. large-vessel occlusion) and NIHSS during treatment with tirofiban: patients with small-vessel occlusion showed significant improvement, while patients with large-vessel occlusion did not. The mean NIHSS improvement after tirofiban infusion was 3.4 (SD 3.4) for small-vessel occlusion versus 0.8 (SD 4.2) for large-vessel occlusion (p = 0.048). Conclusion: Treatment with tirofiban was well tolerated in patients with progressive stroke. However, only patients with small-vessel occlusion recovered significantly during infusion of tirofiban. The effect of tirofiban in progressive stroke and different subgroups of stroke deserves to be studied in a randomized controlled trial.

Clinical effect of successful reperfusion in patients presenting with NIHSS < 6 and large vessel occlusion

The purpose of this study was to determine whether acute diffusion-weighted imaging (DWI) and mean transit time (MTT) lesion volumes and presenting National Institutes of Health Stroke Scale (NIHSS) can identify patients with acute ischemic stroke who will have a high probability of good and poor outcomes. Fifty-four patients with acute ischemic stroke who had MRI within 9 hours of symptom onset and 3-month follow-up with modified Rankin scale were evaluated. Acute DWI and MTT lesion volumes and baseline NIHSS scores were calculated. Clinical outcomes were considered good if the modified Rankin Scale was 0 to 2. The 33 of 54 (61%) patients with good outcomes had significantly smaller DWI lesion volumes (P=0.0001), smaller MTT lesion volumes (P<0.0001), and lower NIHSS scores (P<0.0001) compared with those with poor outcomes. Receiver operating characteristic curves for DWI, MTT, and NIHSS relative to poor outcome had areas under the curve of 0.889, 0.854, and 0.930, respectively, which were not significantly different. DWI and MTT lesion volumes predicted outcome better than mismatch volume or percentage mismatch. All patients with a DWI volume >72 mL (13 of 54) and an NIHSS score >20 (6 of 54) had poor outcomes. All patients with an MTT volume of <47 mL (16 of 54) and an NIHSS score <8 (17 of 54) had good outcomes. Combining clinical and imaging thresholds improved prognostic yield (70%) over clinical (43%) or imaging (54%) thresholds alone (P=0.01). Combining quantitative DWI and MTT with NIHSS predicts good and poor outcomes with high probability and is superior to NIHSS alone.