Letter to the editor: Evaluating high-flow oxygen therapy after mechanical thrombectomy under general anesthesia in acute ischemic stroke: A retrospective single-center study.

Evaluating high-flow oxygen therapy after mechanical thrombectomy under general anesthesia in acute ischemic stroke: A retrospective single-center study

IntroductionBased on real-world case data, this study intends to explore and analyze the impact of rescue conscious sedation (CS) on the clinical outcomes of patients with anterior circulation acute ischemic stroke (AIS) receiving mechanical thrombectomy (MT).MethodsThis retrospective study enrolled patients with anterior circulation AIS who received MT and were treated with either single local anesthesia (LA) or rescue CS during MT between January 2018 and October 2021. We used univariate and multivariate logistic regression methods to compare the impact of LA and CS on the clinical outcomes of patients with AIS who received MT, including the mRS at 90 days, the incidence of poststroke pneumonia (PSP), the incidence of symptomatic intracranial cerebral hemorrhage (sICH), and the mortality rate.ResultsWe reviewed 314 patient cases with AIS who received MT. Of all patients, 164 met our search criteria. Eighty-nine patients received LA, and 75 patients received rescue CS. There was no significant difference between the two groups in the 90-day good prognosis (45.3% vs. 51.7%, p = 0.418) and mortality (17.3% vs. 22.5%, p = 0.414). Compared with the LA group, the incidence of postoperative pneumonia in the rescue CS group (44% vs. 25.8%, p = 0.015) was more significant. Multivariate stepwise logistic regression analysis revealed that intraoperative remedial CS was independently associated with PSP following MT. In a subgroup analysis, rescue CS was found to significantly increase the incidence of PSP in patients with dysphagia (OR = 7.307, 95% CI 2.144–24.906, p = 0.001). As the severity of the National Institutes of Health Stroke Scale (NIHSS) increased, intraoperative rescue CS was found to increase the risk of PSP (OR = 1.155, 95% CI 1.034–1.290, p = 0.011) by 5.1% compared to that of LA (OR = 1.104, 95% CI 1.013–1.204, p = 0.024).ConclusionCompared to LA, rescue CS during MT does not significantly improve the 90 days of good prognosis and reduce the incidence of sICH and mortality in patients with anterior circulation AIS. However, it has a significantly increased risk of poststroke pneumonia (PSP), particularly in patients with dysphagia.

Correction to: 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.

Objective ‒ to analyze our own experience of anesthetic management during mechanical thrombectomy (MTE) in patients with acute ischemic stroke (AIS) caused by large cerebral vessels occlusion. Materials and methods. Treatment of patients with AIS caused by large cerebral vessels occlusion was carried out in accordance with the recommendations of the European Stroke Organization (ESO). MTE was performed in 63 patients (23 women and 40 men aged 36 to 82 years, mean age ‒ 62.00 ± 16.31 years). The severity of neurological symptoms in the acute period of ischemic stroke was assessed over time using the National Institutes of Health Stroke Scale (NIHSS). The degree of disability due to stroke was assessed using a modified Rankine scale (mSR) before discharge and after 90 days. The results by mRS after 90 days were the most indicative. Early ischemic changes in the brain on computed tomograms were assessed using the Alberta Stroke Program Early CT score (ASPECTS). To reduce the time «onset-to groin time» (puncture of the femoral artery), all patients were immediately sent to the operating room upon hospitalization after neuroimaging. For MTE in 50 (79 %) cases conscious sedation with local anesthesia (sibazon, fentanyl) was used, in 13 (21%) cases ‒ general anesthesia (propofol, fentanyl, atracurium besylate). Regardless of the anesthesia method, vital signs were monitored and postoperative complications were assessed. The assessment of other important indicators related to the expiration of anesthesia was carried out: the time «onset-the the groin time» the time «from groin – to recanalization», the level of saturation, the stability of mean arterial pressure, the use of vasopressors or labetolol, the number of postoperative complications (pneumonia, dislocation with decompression craniotomy, nausea, myocardial infarction). Results. The algorithm for anesthetic management of the perioperative period included the anesthesia during MTE, postoperative anesthetic monitoring and correction of deviations over the next 72 hours. Mandatory components of anesthetic support of MTE were to maintain blood pressure of at least 140/90 mm Hg. before reperfusion and FiO2 0.45‒0.5%. Anesthetic management also included infusion therapy, prevention of vomiting and regurgitation, and symptomatic therapy. Special attention was paid to the control of hemodynamics in the postoperative period. The results of treatment according to mRS after 90 days showed that more than half of the patients ‒ 32 (50.8%) after MTE were independent of outside help (0‒2 points), 24 (38.1 %) ‒ 3‒5 points, 6 points (mortality) ‒ 7 (11.1 %). After general anesthesia during MTE, 2 (15.4 %) deaths were registered, after MTE with conscious sedation using ‒ 5 (10.0%). There more patients with the vasopressors or labetalol using and the number of postoperative pneumonia were identified in the group with general anesthesia. For other indicators, there was no statistically significant difference in the results depending on the type of anesthesia. There was no statistically significant difference in the results in depending on anesthesia method. Conclusions. The choice of the anesthesia method during MTE for large cerebral vessels should be individual. There was no statistically significant difference in the results in treatment of patients with AIS using MTE (in particular, in mortality), depending on the type of anesthetic management. It is also wasn’t found in the time «onset – to groin time» and the time «groin – to recanalization» with various methods of anesthesia. Indications of vital functions, saturation, mean arterial pressure in patients did not have a significant difference. Differences were revealed in terms of the vasopressors or labetolol using and the number of postoperative pneumonia, depending on the anesthesia type. The anesthesia team should be involved in patient management from the moment of hospitalization, regardless of the method of anesthesia. The results of AIS treatment depend on the initial NIHSS and ASPECTS scores, comorbidity, collateral development, perioperative complications, and the degree of reperfusion after surgery. Special attention should be paid to hemodynamics before and after reperfusion recovery after vessel recanalization, taking into account the degree of reperfusion. The influence of the type of anesthesia on the results of the treatment of AIS with the MTE using remains under the further discussion.

Introduction: Intravenous thrombolysis (IVT) is recommended for acute ischemic stroke (AIS) patients presenting within 4.5 hours of symptom onset. Since 2015, mechanical thrombectomy (MT) has been the standard of care for large vessel occlusions (LVO). While both treatments are often used in eligible patients, the added benefit of IVT prior to MT remains uncertain. It is hypothesized that IVT before MT may enhance reperfusion and improve functional outcomes, though this effect may vary based on vessel size, occlusion location, and timing of intervention. Methods: We conducted a single-center retrospective cohort study of 2,259 AIS patients who underwent MT between 2014 and 2025. Demographic, clinical, and procedural data were extracted from medical records. The primary outcome was 90-day functional status, assessed using modified Rankin Scale (mRS). Secondary outcomes included recanalization rates and symptomatic intracranial hemorrhage (sICH) rates. Continuous variables were reported as means (SD) and categorical variables as proportions. Continuous variables were compared using t tests and categorical variables via chi square. Logistic regression was used to evaluate associations between treatment strategy (IVT+MT vs. MT alone) and outcomes, with unadjusted and adjusted odds ratios calculated (adjusting for age, sex, hypertension, and diabetes). Results: Of 2259 patients who underwent MT (mean age 79.1, 50.7% female), 848 (37.5%) received IVT. The IVT group had higher odds of achieving good functional outcome defined as 90-day mRS of 0-2 (OR 1.18, 95% CI 0.99-1.41, p=0.066). After adjusting for confounders, this finding became statistically significant (aOR 1.36, 95% CI 1.19-1.68, p=0.005). Secondary outcomes include similar recanalization rates (aOR 0.87, 95% CI 0.73-1.04, p=0.127) and marginally lower odds of sICH in the IVT group (aOR 0.69, 95% CI 0.48-1.00, p=0.051). Subgroup analysis revealed that IVT was not associated with favorable functional outcome among medium vessel occlusion (MeVO) patients (OR 0.82, 95% CI 0.52–1.29), whereas in LVO patients IVT nearly doubled the odds of good outcome (OR 1.91, 95% CI 1.14–3.19, p=0.014). There was no significant differential interaction between IVT and the specific vessel occluded. Conclusions: In AIS, the combination of IVT and MT raises the odds of favorable functional outcomes compared to MT alone, especially in patients with LVO compared to MeVO regardless of specific vessel location without increasing sICH risk.

Background and Aim: Ischemic stroke (IS) remains a significant cause of death and disability worldwide. Over recent decades, management has evolved from supportive care to active reperfusion strategies, including intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rt-PA) and mechanical thrombectomy (MT). While IVT is the first-line treatment, its limited efficacy in large vessel occlusion (LVO), narrow therapeutic window, and bleeding risk have driven the development of endovascular approaches. This study evaluated clinical and procedural predictors of functional outcomes at discharge and 90 days in patients with LVO IS treated with MT, with or without IVT, in a real-world setting. Methods: We conducted a retrospective, single-center study at the Stroke Unit of Perugia Hospital, Italy, including all patients with anterior or posterior circulation LVO strokes treated with MT between January 2021 and December 2023. Demographics, vascular risk factors, stroke severity (National Institutes of Health Stroke Scale, NIHSS), neuroimaging findings, procedural variables, and outcomes were collected. Poor functional outcome was defined as modified Rankin Scale (mRS) ≥3 at discharge and at 90 days. Procedural success was defined as a modified Thrombolysis in Cerebral Infarction (mTICI) score of 2b–3. Patients with mRS ≤2 were compared to those with mRS ≥3 at both timepoints. Results: A total of 127 patients were included. The cohort had a mean age of 71.7 (±12.3) years; 73% had hypertension, 41.6% dyslipidemia, and 37.3% atrial fibrillation. 23 (18%) patients reached a mRS ≤2 while 104 (82%) a mRS ≥ 3 at discharge. At 90-day follow-up, 41 (32%) patients vs. 86 (68%) had a mRS ≤2 and ≥ 3, respectively. In-hospital mortality was 17.3%, with three additional deaths occurring by the 3-month follow-up (19.4%). Patients with poor outcomes were significantly older, more often affected by systemic hypertension, had higher NIHSS scores on admission, and had an IS due to a tandem occlusion (respectively, p=0.02, 0.01, 0.007, 0.003). At univariate analysis, at discharge, older age (OR 1.04, 95% CI 1.00-1.08, p=0.03), systemic hypertension (OR 3.19, 95% CI 1.24-8.24, p=0.02), higher NIHSS scores on admission (OR 1.26, 95% CI 1.11-1.47, p=0.001), tandem occlusion (OR 4.50, 95% CI 1.65-14.50, p=0.006), stenting (OR 11, 95% CI 2.16-201.24, p=0.02), general anesthesia (OR 5.44, 95% CI 2.03-14.78, p=0.001); IVT (OR 0.29, 95% CI 0.08-0.85, p=0.04), local anesthesia (OR 0.22, 95% CI 0.08-0.6, p=0.003), mTICI (OR 0.44, 95% CI 0.19-0.75, p=0.02). At univariate analysis, at 90-days follow-up, higher NIHSS scores on admission (OR 1.19, 95% CI 1.07-1.34, p=0.002), tandem occlusion (OR 2.40, 95% CI 1.12-5.32, p=0.03), stenting (OR 10.67, 95% CI 2.97-68.39, p=0.002), groin-to-recanalization time (OR 1.01, 95% CI 1.00-1.03, p=0.01), general anesthesia (OR 4.05, 95% CI 1.71-9.92, p=0.002); IVT (OR 0.36, 95% CI 0.15-0.82, p=0.02), local anesthesia (OR 0.28, 95% CI 0.11-0.66, p=0.004), mTICI (OR 0.51, 95% CI 0.31-0.74, p=0.002). At multivariate analysis, poor functional outcome at discharge was associated with baseline NIHSS (OR 1.25, 95% CI 1.07-1.51, p=0.01), general anesthesia (OR 7.11, 95% CI 1.72-33.55, p=0.01) and stenting procedure (OR 10.01, 95% CI 1.35-223.19, p=0.05). At 90-day follow-up, poor functional outcome was significantly associated with higher baseline NIHSS (OR 1.22, 95% CI 1.05-1.44, p=0.02), stenting procedure (OR 5.63, 95% CI 1.20-41.73, p=0.05) and groin-to-recanalization time (OR 1.01, 95% CI 1-1.03, p=0.05). IVT prior to MT was inversely associated with 90-day poor outcome (OR 0.26, 95% CI 0.06-0.92, p=0.05). Discussion: This study highlights the complex interplay of clinical and procedural factors influencing outcomes after MT. While randomized trials demonstrate MT efficacy in selected patients, real-world application reveals additional challenges. Stroke severity at admission remained a strong predictor of poor outcome, while general anesthesia, stenting, and tandem occlusion were linked to worse prognosis. Longer groin-to-recanalization times correlated with unfavorable results, emphasizing the importance of minimizing procedural delays. The type of sedation plays a role in this context. General anesthesia may increase time to reperfusion and cause perioperative hypotension, negatively affecting neurological recovery. Local or conscious sedation may reduce delays and allow for intraoperative neurological assessment. Strategies favoring local sedation, guided by a multidisciplinary consensus, could improve outcomes by aligning procedural efficiency with patient safety. Despite its limitations, IVT before MT was independently associated with favorable outcomes, supporting its continued use in eligible patients. These findings reinforce the value of a combined therapeutic approach in acute IS care. Conclusions: Predictors of poor functional outcome in IS patients treated with MT include higher stroke severity, use of general anesthesia, need for stenting, and longer procedural times. Bridging IVT appears to improve recovery. Although randomized trials support MT, individualized selection remains essential in real-world settings. Prospective multicenter studies are warranted to validate these findings and refine protocols for optimal stroke care.

Mechanical thrombectomy (MT) is standard for acute ischemic stroke (AIS), with early studies suggesting that general anesthesia (GA) is associated with worse outcomes than monitored anesthesia care (MAC). Socioeconomic deprivation is also a risk factor for worse AIS outcomes. With improvements in MT and blood pressure (BP) management, it remains unclear if GA or socioeconomic deprivation are risk factors for worse outcomes after MT. We retrospectively analyzed 125 consecutive AIS patients presenting for MT at a comprehensive stroke center serving patients with high levels of socioeconomic deprivation. The primary objective was impact of GA versus MAC on functional independence at 90 days. Secondary outcomes included procedural BP, and impact of BP and socioeconomic deprivation (assessed by the area of deprivation index) on outcomes. A 90-day outcomes were similar in patients undergoing MT with GA or MAC. The area of deprivation index was similar in GA and MAC groups and in patients with good versus poor 90-day outcomes. There were similar numbers of patients with mean arterial pressure (MAP) <60 mm Hg in the MAC and GA groups (8 vs. 11; P =0.21), but more patients with MAP <70 mm Hg in the GA group (28 vs. 9; P <0.001). Median (interquartile range) duration of MAP <70 mm Hg was 10 (5 to 15) and 20 (10 to 36) minutes in the MAC and GA groups, respectively ( P <0.001); however, these MAPs were not associated with worse 90-day outcomes. Anesthesia and MAP did not affect MT outcomes. The cohort is unique based on an area of deprivation index in the higher deciles in the United States. While the area of deprivation index was not associated with worse outcomes, further study is warranted.

Large Vessel Occlusion Strokes After the DIRECT-MT and SKIP Trials: Is the Alteplase Syringe Half Empty or Half Full?

Response by Nguyen et al to Letter Regarding Article, "Mechanical Thrombectomy in the Era of the COVID-19 Pandemic: Emergency Preparedness for Neuroscience Teams: A Guidance Statement From the Society of Vascular and Interventional Neurology".

A 42-year-old woman was referred to our institution with sudden onset of ataxia, facial paresis, horizontal gaze palsy, and progressive dysarthria. The patient worsened within a few minutes, with appearance of left hemiparesis. The National Institutes of Health Stroke Scale Score was 13. On computer tomography scan 2 hours after stroke onset, no brain stem lesion or intracranial bleeding was visible. Computed tomographic angiography revealed a mid basilar vessel occlusion, which suggested embolic basilar artery occlusion. A 4-vessel angiogram with a 5F diagnostic catheter confirmed the basilar artery occlusion and depicted more precisely the location of the thrombus (Figure 1A). Figure 1. A, Digital subtraction angiography after vertebral injection demonstrates a mid basilar vessel occlusion. B, The angiogram after placement of the stent from the left P1 segment (white arrow) into the basilar artery showed flow restoration of the basilar artery with a narrowing in the middle part of the vessel due to compression of the thrombus into the arterial wall (black arrows). C, …

The use of heparin during mechanical thrombectomy (MT) for acute large vessel occlusion ischemic stroke (LVO-AIS) is controversial, with no unified standard on its administration methods and efficacy. This study aims to investigate the effectiveness and safety of continuous intra-arterial infusion of heparin administration during MT in real-world practice. A single-center retrospective study included consecutive LVO stroke patients treated with mechanical thrombectomy at Chongqing University Central Hospital (August 2022-January 2024). Participants were stratified by intraprocedural heparin administration: (1) arterial heparin Group-continuous intra-arterial heparinization via high-pressure infusion (Heparin 1,000 IU was diluted in 500 ml of 0.9% sodium chloride solution and connected to both the guiding catheter and the intermediate catheter. The infusion bag was replaced as needed according to the duration of the procedure) at a conventional drip rate; (2) non-additional heparin Group-standard heparin solution flushing withoutusing additional anticoagulant. The main outcome were 3-months functional independence, defined as a modified Rankin Scale (mRS) ≤ 2. The main Safety outcome were defined as symptomatic intracranial hemorrhage (sICH) in 24 h. A total of 98 patients were eligible for analysis: 54 in the Arterial heparin Group and 44 in the Non-additional heparin Group. Continuous intra-arterial infusion of heparin administration during MT had a higher rates of functional independence (57.4 vs. 36.4%, adjusted P = 0.035), no significant impact on recanalization rate, sICH, distal embolization, or mortality (adjusted P > 0.05). However, the admission NIHSS score [odds ratio 1.225 (1.096-1.370), P < 0.01] was identified as independent predictor of unfavorable outcomes, while anticoagulant therapy during hospitalization [odds ratio 0.209 (0.067-0.653), P < 0.01] was a protective factor. Aspiration was a protective factor against sICH [odds ratio 0.009 (0.00-0.845), P = 0.042]. Our study suggests that continuous intra-arterial infusion of heparin administration during mechanical thrombectomy for acute large vessel occlusion ischemic stroke may be safe and is associated with higher rates of favorable outcomes. Further prospective research is needed to validate these findings.

Decompressive craniectomies (DCs) are recommended for the treatment of raised intracranial pressure after acute ischaemic stroke. Some studies have demonstrated improved outcomes with early decompressive craniectomy (< 48h from onset) in patients with malignant cerebral oedema following middle cerebral artery infarction. Limited data is available on suboccipital decompressive craniectomy after cerebellar infarction. Our primary objective was to determine whether the timing of DCs influenced functional outcomes at 6months. Our secondary objectives were to analyse whether age, gender, the territory of stroke, or preceding thrombectomy impacts functional outcome post-DC. We conducted a retrospective study of patients admitted between January 2014 and December 2020 who had DCs post-acute ischaemic stroke. Data was collected from ICU electronic records, individual patient charts, and the stroke database. Twenty-six patients had early DC (19 anterior/7 posterior) and 21 patients had late DC (17 anterior/4 posterior). There was no difference in the modified Rankin Scale (mRS) score of the two groups at 90 (p = 0.318) and 180 (p = 0.333) days post early vs late DC. Overall outcomes were poor, with 5 out of 46 patients (10.9%) having a mRS score ≤ 3 at 6months. There was no difference in mRS scores between the patients who had hemicraniectomies for anterior circulation stroke (n = 35) and suboccipital DC for posterior circulation stroke (n = 11) (p = 0.594). In this single-centre retrospective study, we found no significant difference in functional outcomes between patients who had early or late DC after ischaemic stroke.

The benefits and risks of acute reperfusion therapy (RT) in acute ischaemic stroke (AIS) remain uncertain in older patients, especially in nonagenarians. We aimed to assess the impact of RT in this population. Single-center retrospective cohort study comparing patients ≥ 90years old admitted to a Stroke Unit (2008-2018) with AIS, submitted or not to RT [intravenous thrombolysis(IVT), mechanical thrombectomy(MT) or both]. Baseline characteristics, in-hospital complications and 3-month outcomes were compared. The primary outcome was 3-month "favorable outcome", defined as modified Rankin Scale score 0-2 or equal to pre-stroke. Secondary outcomes were haemorrhagic transformation (HT) and 3months mortality. We included 167 patients (median age 92years, 66.5% females); 46.1% underwent RT (59 IVT, 11 MT, 7 both). RT group had higher admission National Institutes of Health Stroke Scale (NIHSS) (16 versus 9.5, p < 0.001). Favorable outcome occurred in only 22% of patients, with no differences between groups; its odds decreased with higher NIHSS scores (OR 0.80, 95%CI 0.73-0.87, p < 0.001) and with the development of in-hospital respiratory infection (OR 0.22, 95%CI 0.07-0.67, p = 0.007). HT occurred in 16.2% of patients, being more prevalent (26.0% versus 7.8%, p = 0.001), symptomatic (14.3% versus 3.3%, p = 0.011) and severe (PH1/2 15.6% versus 2.2%, p = 0.012) in the RT group, although it did not influence the primary outcome. Mortality was 32% at 3months, with no difference between groups. Although patients submitted to RT had worse admission NIHSS and increased HT, they had similar functional outcome at 3months. Stroke severity and in-hospital respiratory infections were the most important predictors of 3months' functional outcome.

Land of confusion: anaesthetic management during thrombectomy for acute ischaemic stroke

Marc Fisher MD Kennedy Lees MD Section Editors: On September 26, 2008, the New England Journal of Medicine published the results of the European Cooperative Stroke Study (ECASS) III,1 the first randomized, placebo-controlled trial to demonstrate safe and effective use of intravenous recombinant tissue plasminogen activator (rtPA) to treat patients with acute ischemic stroke (AIS) beyond 3 hours from stroke onset. The ECASS investigators studied the safety and efficacy of administering intravenous rtPA to patients with AIS 3 to 4.5 hours after AIS onset. Using the modified Rankin Scale score at 90 days after stroke occurrence as the primary end point of the study, the investigators demonstrated a modest, statistically significant increase in the likelihood of having normal or near normal recovery (modified Rankin Scale=0 or 1) in favor of rtPA treatment compared with placebo (unadjusted OR, 1.34; 95% CI, 1.02 to 1.76; P =0.04). So, what impact will the results of the study have on acute stroke management and stroke research in the United States and elsewhere? With regard to the first part of the question, the answer is complex. First, the ECASS III results will hopefully help to increase the number of thrombolysis eligible patients with AIS who receive rtPA. Twelve years after the US Food and Drug Administration approved the management of AIS within 3 hours of symptom onset as an indication for the use of intravenous rtPA, less than 5% of patients with AIS are being treated worldwide with rtPA within 3 hours of stroke onset. One of the major factors contributing to this parlous state of affairs has been disagreement among healthcare professionals about the validity of the results of the National Institutes of Neurological Disorders and Stroke (NINDS) trial of rtPA for acute stroke.2 In the late 1990s, the stroke community unexpectedly …