Impact of Carotid Artery Tortuosity on Technical Aspects of Endovascular Thrombectomy in a Newly Established Thrombectomy-Capable Stroke Center.

BackgroundAccess to endovascular thrombectomy (EVT) for acute ischaemic stroke (AIS) and the outcome disparities in culturally and linguistically diverse (CALD) populations are understudied. South-Western Sydney (SWS), characterised by high prevalence of CALD populations, provides an ideal setting to explore these disparities. This study aimed to assess whether being born in a country where English is not the primary language (‘language other than English’; LOTE) affects access to EVT and outcomes for acute ischaemic stroke while also identifying demographic risk factors influencing stroke severity and outcomes.MethodsA retrospective cohort study was conducted on consecutive patients with AIS who underwent EVT at Liverpool Hospital, Sydney, from 2018 to 2023. Participants were categorised based on country-of-origin Australia/New Zealand/United Kingdom or LOTE. Primary outcomes included time metrics—onset-to-arrival (OTA) and arrival-to-puncture (ATP)—and 3-month modified Rankin Score (mRS). Statistical analyses included multivariate logistic regression to evaluate predictors of functional outcomes.ResultsOf 911 EVT referrals, 721 patients were included. LOTE patients (50.3%) were more likely to have diabetes mellitus (30% vs 16%; p<0.001) and presented with higher stroke severity (median National Institutes of Health Stroke Scale (NIHSS) 17 vs 14; p<0.001). They also experienced shorter ATP (158 vs 174 min; p=0.006). Patients requiring interpreters equally exhibited shorter ATP times (152 vs 170 min; p=0.01) and higher stroke severity. There was no significant disadvantage hailing from the LOTE group in OTA times and in any time metrics for subgroup analyses stratified by primary presenter status. However, LOTE patients had poorer 3-month outcomes (mRS ≤2: 46.5% vs 55.4%; p=0.021), which was associated with higher baseline NIHSS and diabetes in adjusted analyses.ConclusionLOTE patients in SWS undergoing EVT were not disadvantaged in hospital time metrics. Poorer 3-month functional outcomes in LOTE patients highlight the need for targeted strategies addressing risk factors, such as diabetes mellitus.

Pooled blood volume measured by final flat-panel detector computed tomography predicts outcome after endovascular thrombectomy for acute ischemic stroke

Using post-treatment methods to predict functional outcomes of acute ischemic stroke (AIS) patients undergoing endovascular thrombectomy (EVT) is crucial in stroke medicine. The National Institute of Health Stroke Scale (NIHSS) score at 24 h has been widely used; however, there is a paucity of data on using earlier NIHSS scores and their association with outcome. In this study, we aimed to investigate the usage of NIHSS at 1-h time window -ultra-early neurological improvement (UENI)- as a surrogate marker associated with the functional outcomes of AIS patients treated with EVT. We included 485 adults (≥18 years old) who underwent emergency EVT at four academic comprehensive stroke centers between 2020 and 2021. Patients with pre-EVT Alberta Stroke Program Early CT Score (ASPECTS) < 6, missing follow-up data, and missing data of the first hour NIHSS were excluded (n = 20). UENI was defined as post-EVT NIHSS reduction of 4 points or more or NIHSS as 0-1 within 1-h post-EVT. An mRS score of 0-2 after three months was defined as favorable outcome, and independent walking independence was defined as mRS of 3. A total of 465 patients were included in our final analysis. We identified 122 (26.2%) patients with UENI. While 82.79% of the patients with UENI achieved favorable functional outcomes at 3-months, only 32.36% of patients without UENI had favorable functional outcome (p < 0.0001). In addition, lower hospitalization costs were associated with patients who had UENI, compared to No-UENI (p = 0.003). A multivariate logistic regression analysis revealed that younger age (p < 0.0001), shorter last know normal to puncture time (LKNPT) (p = 0.013), higher pre-treatment ASPECTS (p = 0.039), final modified thrombolysis in cerebral infarction (mTICI) ≥2b (p = 0.002), and fewer number of EVT attempts (p = 0.002) were variables independently associated with UENI. The presence of UENI was independently associated with a better outcome OR: 7.999 (95% C.I. 4.415-14.495). UENI was observed in about a quarter of patients with AIS undergoing EVT. Younger age, shorter LKNPT, higher pre-treatment ASPECTS, final mTICI≥2b, and fewer number of EVT attempts, were independently associated with UENI. The presence of UENI was independently associated with better functional outcome at 3 months.

Background and Purpose: Throughout the years, stroke has remained one of the primary causes of significant morbidity and mortality. Among the therapeutic options for acute stroke management, endovascular thrombectomy intended to remove the thrombi within the intracerebral vasculature and restore adequate perfusion to the surrounding penumbra. It was recommended for eligible patients who were within 6—24 hours after the onset of neurologic symptoms. In the Philippines, only a few tertiary healthcare institutions were able to offer and perform endovascular thrombectomies. The aim was to describe the profile and discharge outcomes of endovascular thrombectomy for acute ischemic stroke at a tertiary hospital in our country. Methodology: In this retrospective study, 924 patients were admitted for acute ischemic stroke from October 2018 - August 2021. However, only 31 patients underwent mechanical thrombectomy and their records were thoroughly reviewed. Clinical and functional outcomes were measured using the National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Score (MRS), respectively. Results: Among the patients included in the study, 29 subjects (93.5%) had moderate to severe disability (MRS 3-5) and 17 (54.8%) had moderate stroke (NIHSS 5-15) on admission. The identified site of the cerebrovascular thrombi was within the M1 segment of the middle cerebral artery (41.9%, n=13). The stent retriever approach was performed in 19 of the subjects (61.2%). Upon discharge, only 17 (22.6%) had favorable functional outcomes (MRS 0-2) and 6 (19.3%) resulted in mortality. Conclusion: Overall, endovascular thrombectomy is a promising treatment strategy for large vessel acute ischemic stroke in a developing country. Funding Information: This research did not receive any financial support or grant. Declaration of Interests: The authors of this study have nothing to disclose. The authors do not have any financial, commercial, legal, or professional relationship with organizations that can affect or influence the results of this research. Ethics Approval Statement: This study was submitted to the Institutional Review Board and gained ethical approval.

Relative Effect of Stroke Severity and Age on Outcomes of Mechanical Thrombectomy in Acute Ischemic Stroke.

Predictors of 30-day mortality after endovascular mechanical thrombectomy for acute ischemic stroke

BackgroundDespite recent advancements in the treatment of acute ischemic stroke (AIS) with large vessel occlusion (LVO), infarct progression over time and functional outcomes remain variable. This variation in outcomes may be partially attributed to an underlying state of chronic cerebral hypoperfusion and ischemia affecting small cerebral perforating arterioles, venules, and capillaries of the brain; broadly termed cerebral small vessel disease (CSVD). We investigated the association between CSVD burden and the degree of disability following successful recanalization with endovascular thrombectomy (EVT) in patients with AIS presenting with LVO.MethodologyWe conducted a single center retrospective analysis of all patients presenting with AIS LVO between May 2016 and May 2019. Patients who were premorbidly independent and presented within six hours from the last known well (LKW) with a proximal anterior circulation occlusion confirmed on computed tomography (CT) angiography of the head or neck were treated with EVT. Patients presenting after six hours and up to 24 hours from LKW with a target ischemic core to perfusion mismatch profile on CT or magnetic resonance (MR) perfusion, or a clinical imaging mismatch on MR diffusion-weighted imaging, were also treated. Patients with successful revascularization, defined as a thrombolysis in cerebral infarction score 2b or 3, were included and evaluated for CSVD burden. The presence of CSVD was quantified using the Fazekas scale (0-3). All patients were further evaluated for disability at 90 days using the modified Rankin Scale (mRS, range 0-6). An mRS score of ≤2 was defined as a good functional outcome.ResultsOf the 190 patients evaluated, absent (Fazekas grade 0), mild (Fazekas grade 1), moderate (Fazekas grade 2), and severe (Fazekas grade 3) CSVD was present in 33 (17.4%), 84 (44.2%), 35 (18.4%), and 38 (20.0%) patients, respectively. Patients with severe CSVD (Fazekas grade 3) were found to be older, had a higher presenting National Institute of Health Stroke Scale (NIHSS), and had greater proportions of preexisting atrial fibrillation and dementia compared to patients with no CSVD (Fazekas grade 0). Using a multivariate ordinal logistic regression model to adjust for age, presenting NIHSS, thrombus location, LKW to groin puncture time, use of tissue plasminogen activator, ischemic infarct volume, development of a symptomatic intracerebral hemorrhage, and treatment with hemicraniectomy, patients with Fazekas grade 3 were significantly more likely to have poor 90-day functional outcomes compared to patients with Fazekas grade 0 (odds ratio 10.25, 95% confidence interval [3.3-31.84]).ConclusionsBased on our analytical cohort of AIS LVO patients treated with EVT, we found that patients with severe CSVD burden had worse functional outcomes at 90 days and increased mortality. These results provide evidence that the burden of CSVD may be considered an independent risk factor of poor clinical outcome and a predictor of mortality in patients with AIS presenting with LVO, despite successful radiographic recanalization with EVT.

ABSTRACTBackgroundDeep vein thrombosis (DVT) is a frequent complication following endovascular thrombectomy (EVT) in patients with acute ischaemic stroke (AIS), potentially leading to fatal pulmonary embolism (PE). Identifying patients early at high risk for DVT is clinically important. This study developed and validated a nomogram combining laboratory findings and clinical characteristics to predict the risk of lower‐extremity DVT after EVT in patients with AIS.MethodsThis retrospective multicentre observational study was conducted in two tertiary hospitals in China, enrolling 640 patients who underwent ultrasonography for DVT diagnosis within 10 days following EVT. Data on medical history, examination and laboratory results were collected for logistic regression analyses to develop a DVT risk nomogram.ResultsLogistic regression analyses identified critical predictors of DVT: lower limb National Institutes of Health Stroke Scale (NIHSS) score ≥ 2, elevated D‐dimer levels (≥ 1.62 mg/L) and prolonged puncture‐to‐recanalization time (PRT ≥ 66 min). The nomogram demonstrated good discriminative ability (AUC 0.741–0.822) and clinical utility across internal and external validation cohorts. Additionally, the presence of DVT was significantly associated with reduced functional independence at 90 days post‐EVT, highlighting the negative impact of DVT on patient recovery (OR = 3.85; 95% CI: 2.18–6.78; p < 0.001).ConclusionThe study provides a practical clinical tool for early detection and intervention in patients with AIS at high risk for DVT following EVT. Early identification and intervention may help improve outcomes in patients with AIS undergoing EVT.Relevance to Clinical PracticeThis nomogram helps in the early detection and proactive management of DVT in AIS patients, which can reduce severe complications and improve patient recovery outcomes.Patient or Public ContributionNo patient or public contributions were involved in this study due to its retrospective design, where data were utilised from existing medical records without direct patient interaction.

IntroductionAcute cerebral ischaemia with main cerebral artery occlusion requires treatment with intravenous tissue plasminogen activator administration and/or endovascular thrombectomy. However, some patients fail to recover even after recanalisation because of...

Endovascular thrombectomy for acute ischemic stroke: A single-center experience in Taiwan.

Stroke has remained one of the primary causes of significant morbidity and mortality. Among the therapeutic options for acute stroke management, endovascular thrombectomy is intended to remove the thrombi within the intracerebral vasculature and restore adequate perfusion to the surrounding penumbra. It is recommended up to 24 hours from onset of neurologic symptom. In the Philippines, only a few tertiary healthcare institutions are able to offer and perform endovascular thrombectomies. The aim was to describe the profile and discharge outcomes of endovascular thrombectomy for acute ischemic stroke at a tertiary hospital in our country. We conducted a retrospective records review among 924 patients admitted for acute ischemic stroke from October 2018 to August 2021 who underwent mechanical thrombectomy. Clinical and functional outcomes were measured using the National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Score (mRS). Among 31 patients included in the study, 29 subjects (93.5%) had moderate to severe disability (mRS 3-5), and 25 (80.6%) had moderate stroke (NIHSS 6-21) on admission. The identified site of the cerebrovascular thrombi was within the M1 segment of the middle cerebral artery (41.9%, n=13). The stent retriever approach was performed in 19 participants (61.2%). Upon discharge, only 7 (22.6%) had favorable functional outcomes (MRS 0-2), and 9 (29.0%) resulted in mortality. Successful reperfusion was achieved in 92.3% of the patients. Overall, endovascular thrombectomy is a possible treatment option for large vessel acute ischemic stroke in developing countries.

This study aimed to construct an optimal dynamic nomogram for predicting malignant brain edema (MBE) in acute ischemic stroke (AIS) patients after endovascular thrombectomy (ET).We enrolled AIS patients after ET from May 2017 to April 2021. MBE was defined as a midline shift of >5 mm at the septum pellucidum or pineal gland based on follow-up computed tomography within 5 days after ET. Multivariate logistic regression and LASSO (least absolute shrinkage and selection operator) regression were used to construct the nomogram. The area under the receiver operating characteristic curve (AUC) and decisioncurve analysis were used to compare our nomogram with two previous risk models for predicting brain edema after ET.MBE developed in 72 (21.9%) of the 329 eligible patients. Our dynamic web-based nomogram (https://successful.shinyapps.io/DynNomapp/) consisted of five parameters: basal cistern effacement, postoperative National Institutes of Health Stroke Scale (NIHSS) score, brain atrophy, hypoattenuation area, and stroke etiology. The nomogram showed good discrimination ability, with a C-index (Harrell's concordance index) of 0.925 (95% confidence interval=0.890-0.961), and good calibration (Hosmer-Lemeshow test, p=0.386). All variables had variance inflation factors of <1.5 and tolerances of >0.7, suggesting no significant collinearity among them. The AUC of our nomogram (0.925) was superior to those of Xiang-liang Chen and colleagues (0.843) and Ming-yang Du and colleagues (0.728).Our web-based dynamic nomogram reliably predicted the risk of MBE in AIS patients after ET, and hence is worthy of further evaluation.

Background and PurposeThis study aimed to construct an optimal dynamic nomogram for predicting malignant brain edema (MBE) in acute ischemic stroke (AIS) patients after endovascular thrombectomy (ET).MethodsWe enrolled AIS patients after ET from May 2017 to April 2021. MBE was defined as a midline shift of >5 mm at the septum pellucidum or pineal gland based on follow-up computed tomography within 5 days after ET. Multivariate logistic regression and LASSO (least absolute shrinkage and selection operator) regression were used to construct the nomogram. The area under the receiver operating characteristic curve (AUC) and decision-curve analysis were used to compare our nomogram with two previous risk models for predicting brain edema after ET.ResultsMBE developed in 72 (21.9%) of the 329 eligible patients. Our dynamic web-based nomogram (https://successful.shinyapps.io/DynNomapp/) consisted of five parameters: basal cistern effacement, postoperative National Institutes of Health Stroke Scale (NIHSS) score, brain atrophy, hypoattenuation area, and stroke etiology. The nomogram showed good discrimination ability, with a C-index (Harrell’s concordance index) of 0.925 (95% confidence interval=0.890–0.961), and good calibration (Hosmer-Lemeshow test, p=0.386). All variables had variance inflation factors of <1.5 and tolerances of >0.7, suggesting no significant collinearity among them. The AUC of our nomogram (0.925) was superior to those of Xiang-liang Chen and colleagues (0.843) and Ming-yang Du and colleagues (0.728).ConclusionsOur web-based dynamic nomogram reliably predicted the risk of MBE in AIS patients after ET, and hence is worthy of further evaluation.

General anesthesia versus sedation for endovascular thrombectomy: Meta-analysis and trial sequential analysis of randomized controlled trials

BackgroundThere is a paucity of data and a belief that endovascular thrombectomy (EVT) has low efficacy for acute ischemic stroke (AIS) in patients with cancer. We aimed to critically compare...