Recent outcomes of intravenous tissue plasminogen activator (t-PA) alone in the era of mechanical thrombectomy: A sub-analysis of the Kanagawa Intravenous and Endovascular Treatment (K-NET) registry.

Commentary

Introduction: Thrombectomy for acute ischemic stroke (AIS) is an important intervention, though the majority of eligible patients do not receive it. Drawing upon data from our high volume comprehensive stroke center, we identified barriers to recognizing patients with large vessel occlusion and subsequent impediments to treatment. Methods: This is a retrospective chart review of patients presenting with AIS within 24 hours to the 14 hospitals within the AHCS between January 2015 and December 2016. Demographic, National Institutes of Health Stroke Scale (NIHSS) score, vascular imaging, and thrombectomy data were collected and analyzed. Large vessel occlusion (LVO) involved the distal internal carotid artery (ICA), middle cerebral artery (M1), or basilar artery (BA). Results: Three thousand five hundred ninety- five AIS patients were identified. The median age was 61 years and 1863 (52%) were female. Two thousand one hundred eighty-three patients presented within 24 hours (61%): 1105 ≤ 6 hours. More than one third of AIS patients (773) did not have acute intracranial vascular imaging. Of 1410 patients with vascular imaging, 171 patients (12 %) had LVO. The site of occlusion was: M1, 86 patients (50.3%); distal ICA, 51 (30%); and BA, 27 (16%). Only 75 LVO patients (44%) had acute stroke intervention of whom 57 (77%) had mechanical thrombectomy, additional intra-arterial thrombolysis was given in 14 (19%) and 4 (5%) had intra-arterial thrombolysis as monotherapy. Successful revascularization (mTICI 2b-3) was achieved in 53 patients (70%). The main reasons that LVO patients did not receive acute stroke intervention include: late onset or unknown onset in 32 (35%), large core infarction 25 (27%), rapid improving NIHSS in 6 (7%), and unclear reason in 25 (17%), Conclusion: There are several reasons that LVO is under recognized: a non neurologist often evaluates the patient in the ER first and they might not be familiar with stroke protocol guidelines; some LVO patients have an atypical presentation; and some patients refuse intervention. Based on our data, there is a need for continuing education of stroke care providers, particularly in this period of changing interventional guidelines.

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

Objective: Our study aims to evaluate the impact of a stay-at-home order on stroke metrics during the 2019-novel coronavirus (COVID-19) pandemic. Methods: Data on baseline characteristics, stroke subtype, initial National Institutes of Health Stroke Scale (NIHSS) score, the time between last known well (LKW) to emergency department (ED) arrival, tissue plasminogen activator (tPA) administration, the involvement of large vessel occlusion (LVO), and whether mechanical thrombectomy (MT) was pursued in patients with acute stroke were extracted from 24 March to 23 April 2020 (the time period of a stay-at-home order was placed due to the COVID-19 pandemic as the study group) at a tertiary care hospital in West Michigan, USA, compared with data from 24 March to 23 April 2019 (control group). Results: Our study demonstrated a reduction in cases of acute ischemic stroke (AIS), although this did not reach statistical significance. However, there was an increase in hemorrhagic stroke (7.5% controls vs. 19.2% study group). The age of stroke patients was significantly younger during the period of the stay-at-home order compared to the control group. We identified a significant overall delay of ED arrivals from LKW in the study group. Additionally, an increased number of AIS patients with LVO in the study group (34.8%) was found compared to the control group (17.5%). A significantly increased number of patients received MT in the study group. Additionally, 11 patients were COVID-19 PCR-positive in the study group, 10 with AIS and only 1 with hemorrhagic stroke. Patients with COVID-19 had a high incidence of atrial fibrillation and hyperlipidemia. One AIS patient with COVID-19 rapidly developed cytotoxic edema with corresponding elevated inflammatory biomarkers. No statistical significance was noted when stroke subtype, LVO, and MT groups were compared. Conclusions: There was a trend of decreasing AIS admissions during the COVID-19 pandemic. There was also a significantly increased number of AIS patients with LVO who received MT, especially those with COVID-19. We conclude that cytokine storm resulting from SARS-CoV-2 infection might play a role in AIS patients with COVID-19.

Mechanical thrombectomy (MT) has become the standard treatment for acute ischemic stroke (AIS) with large vessel occlusion (LVO). First-pass (FP) reperfusion of the occluded vessel and fewer passes with stent retrievers show improvement in functional outcomes in stroke patients, while higher numbers of passes are associated with higher complication rates and worse outcomes. Studies indicate that a larger size of the stent-retriever is associated with a higher rate of first-pass reperfusion and improved clinical outcomes. In this retrospective study, we investigated the clinical performance of a recently developed and one of the largest stent-retrievers available in the treatment of LVO (pRESET 6-50, phenox GmbH, Bochum). All consecutive patients with ischemic stroke due to proximal large vessel occlusion treated with MT using the pRESET 6-50 stent-retriever in two tertiary stroke centers between 09/2021 and 07/2022 were included in this study. The reperfusion rate after MT was quantified by the modified thrombolysis in cerebral infarction (mTICI) score, and functional neurological outcome was evaluated with the National Institutes of Health Stroke Scale (NIHSS) score and the major early neurological recovery (mENR) rate after 24 h. Successful FP reperfusion was defined as mTICI ≥ 2b. Successful and complete reperfusion were defined as mTICI ≥ 2b and mTICI ≥ 2c, respectively. In total, 98 patients (52 men and 46 women) with a median age of 75 (range 25-95 years) were included. A total of 70 (72%) patients presented with an occlusion of the middle cerebral artery (MCA) in the M1 segment, 6 (6%) patients with an occlusion of the M2 segment, 17 (17%) patients with an occlusion of the internal carotid artery (ICA), and 5 (5%) patients with an occlusion of the obstructed basilar artery (BA). Successful FP reperfusion was achieved in 58 patients (62%). Successful and complete reperfusion were achieved in 95 (97%) and 82 (83%) patients, respectively. The median National Institutes of Health Stroke Scale (NIHSS) in all treated patients improved from 17 to 7.5. Major early neurological recovery (mENR) was observed in 34 patients (35.1%). MT with the pRESET 6-50 stent-retriever achieves high successful first-pass and final reperfusion rates in patients with AIS and LVO. The results of this study support the thesis to use large-format stent-retriever in proximal vessel occlusion MT whenever feasible in order to improve high FP and final reperfusion rate, which are known predictors of good clinical outcome.

Mechanical thrombectomy (MT), the standard of care for acute ischemic stroke (AIS) secondary to large vessel occlusion (LVO), is generally not offered to patients with large baseline infarct (core). Recent studies demonstrated MT benefit in patients with anterior circulation stroke and large core (i.e. Alberta Stroke Program Early Computed Tomography Score, ASPECTS 3-5). However, its benefit in patients with the largest core (ASPECTS 0-2) remains unproven. To compare the efficacy and safety of MT plus best medical treatment (BMT) and of BMT alone in patients with ASPECTS 0-5 (baseline computed tomography (CT) or magnetic resonance imaging (MRI)) and anterior circulation LVO within 7 h of last-seen-well. To detect with a two-sided test at 5% significance level (80% power) a common odds ratio of 1.65 for 1-point reduction in the 90-day modified Rankin Scale (mRS) score in the MT + BMT arm versus BMT arm and to anticipate 10% of patients with missing primary endpoint, 450 patients are planned to be included by 36 centers in France, Spain, and the United States. LArge Stroke Therapy Evaluation (LASTE) is an international, multicenter, Prospectively Randomized into two parallel (1:1) arms, Open-label, with Blinded Endpoint (PROBE design) trial. Eligibility criteria are diagnosis of AIS within 6.5 h of last-seen-well (or negative fluid-attenuated inversion recovery (FLAIR) if unknown stroke onset time), ASPECTS 0-5 (ASPECTS 4-5 for ⩾80-year-old patients), and LVO in the anterior circulation (intracranial internal carotid artery (ICA) and M1 or M1-M2 segment of the middle cerebral artery (MCA)). The primary endpoint is the day-90 mRS score distribution (shift analysis) with mRS categories 5 and 6 coalesced into one category. Secondary endpoints include day-180 mRS score, rates of 90-day and 180-day mRS score = 0-2 and 0-3, rate of decompressive craniectomy, the National Institutes of Health Stroke Scale (NIHSS) score change, revascularization and infarct volume growth at 24 h, and quality of life at day 90 and 180. Safety outcomes (90-day all-cause mortality, procedural complications, symptomatic intracerebral hemorrhage, and early NIHSS score worsening) are recorded. A dynamic balanced randomization (1:1) is used to distribute eligible patients into the experimental arm and control arm, by incorporating the center and these pre-specified factors: baseline ASPECTS (0-3 vs 4-5), age (⩽70 vs >70 years), baseline NIHSS (<20 vs ⩾20), intravenous thrombolysis (no vs yes), admission mode (Drip-and-Ship vs Mothership), occlusion site (intracranial ICA vs MCA-M1 or M1-M2), intravenous fibrinolysis (no vs yes), and last-seen-well to randomization time (0-4.5 vs >4.5-6.5 h). The LASTE trial will determine MT efficacy and safety in patients with ASPECTS 0-5 and LVO in the anterior circulation. LASTE Trial NCT03811769.

BackgroundThe suitability of mechanical thrombectomy (MT) for patients with acute mild ischemic stroke (AMIS) caused by large vessel occlusion (LVO) is controversial. This study evaluated MT in patients with AMIS and LVO.Material/MethodsForty-seven patients diagnosed as AMIS with LVO received MT or intravenous thrombolysis (IVT). Primary outcomes were National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale scores. Secondary outcomes were incidence of systemic complications and symptomatic intracranial hemorrhage.ResultsThere were no significant differences between IVT and MT groups for gender, age, risk factors of cerebrovascular disease, past history, NIHSS score at admission, blood pressure, and LVO sites. For all patients, the NIHSS scores at discharge were lower than those at admission. Patients with excellent outcomes were 66.6% (16/24) in the IVT group and 60.8% (14/23) in the MT group; favorable outcome rates were 75% (18/24) in the IVT group and 69.6% (16/23) in the MT group, with no significant differences between groups. Twelve patients (52.2%) in the MT group and 5 (20.8%) in the IVT group had systemic complications. Symptomatic intracranial hemorrhage was not detected in the IVT group, but manifested in 2 (8.7%) patients in the MT group. During 90-day follow-up, 1 patient died in each of the IVT and MT groups, with 4.2% and 4.4% mortality rates, respectively.ConclusionsThe efficacy of MT and IVT was comparable in AMIS patients with LVO. While MT had a higher incidence of systemic complications, its short- and long-term effects were equivalent to IVT.

The management of acute ischemic stroke has undergone a sea of change with the introduction of intravenous thrombolysis (IVT). Current guidelines state that the window period for IVT using rTPA is 4.5 hours. The MERCI, Multi Merci, and Penumbra trials in which patients with acute ischemic stroke were treated using endovascular treatment demonstrated better recanalisation in patients having a large vessel occlusion. However, recently published data from the three large trials IMS 3, Synthesis Expansion, and MR rescue, which compared endovascular treatment with intravenous therapy, failed to demonstrate superiority of endovascular treatment over IVT. In these trials, stent retrievers were used in very few patients. We present our results from a tertiary care center in India where patients are treated using intravenous as well as endovascular modalities. Among the 53 patients with acute ischemic stroke treated between 2010 and 2012, 23 were treated with IVT and 30 with endovascular methods. Stent retriever was used in majority of the endovascular cases.Aims:To compare the outcomes of acute ischemic stroke patients treated with IVT versus those who were managed using endovascular therapy. To evaluate outcomes of patients with acute ischemic stroke with a large vessel occlusion in whom endovascular modalities were used and to compare them with those of patients who were treated with IVT in presence of a large vessel occlusion.Settings and Design:Data of patients who underwent thrombolysis at our centre was collected over a 3-year period, that is, from 2010 to 2012. Endovascular treatment was done by an interventional neurologist.Materials and Methods:Data of patients with acute ischemic stroke who underwent IVT or endovascular treatment at our centre between 2010 and 2012 was analyzed. Parameters included age, National Institutes of Health Stroke Scale (NIHSS) on admission, door to needle time, stroke subtype, modality of treatment, outcome based on modified Rankin Scale (mRS) Score at 90 days follow up and mortality rates at 90 days.Statistical Analysis:Tabulated results were analysed using INSTAT Graphpad analyser. Data were analysed using paired and unpaired t-test, Chi-square test, and Fishers test as applicable. P value was considered significant when it was <0.05.Results:Upon comparison of the outcomes of patients with acute ischemic stroke and large vessel disease treated with endovascular therapy with those treated with IVT, it was found that the former group had better outcomes. We also found that in spite of there being a significant difference in the NIHSS on admission and a significant difference in the door to needle time, the outcomes of patients treated using intravenous or endovascular therapy were similar. There was no statistically significant difference in mortality rates between intravenous and endovascular groups.Conclusions:IVT is currently the standard of care in the management of acute ischemic stroke. Endovascular treatment during the window period is reserved for those patients with contraindication to IVT. In this study, we found that patients with documented large vessel disease with no evidence of cross flow through Willisian collaterals benefit from endovascular treatment. We recommend that all patients of acute ischemic stroke, be subjected to a baseline angiogram either computed tomography (CT) or magnetic resonance imaging (MRI) to document vessel status. This will help in identifying patients who may benefit from early endovascular treatment, if they fail to improve with IVT. Further, large trials using stent retrievers are needed, to prove that endovascular treatment is superior to IVT, in presence of documented large vessel disease.

To evaluate the efficacy and safety of mechanical thrombectomy performed beyond 24 hours from symptom onset in patients with acute ischemic stroke (AIS) and large vessel occlusion (LVO). In this retrospective cohort study, patients with LVO-related AIS who underwent mechanical thrombectomy within 72 hours of onset were enrolled from the multicenter Chinese Acute Stroke Evaluation and Management (CASE-Ⅱ) online database (January 2017 to December 2024). Patients were stratified into the beyond 24-hour thrombectomy group and the within 24-hour thrombectomy group based on the time from onset to mechanical thrombectomy. Propensity score matching (PSM) was used to balance baseline characteristics between the two groups. Binary logistic regression and generalized linear models were employed to compare 3-month neurological functional outcomes and safety outcomes between the groups. Sensitivity analyses were conducted separately in patients undergoing mechanical thrombectomy within the extended time window (6-24 hours) and in those receiving mechanical thrombectomy alone (without prior intravenous thrombolysis). Subgroup analyses were performed based on age, presence of atrial fibrillation, use of oral anticoagulants, pre-stroke modified Rankin scale (mRS) score, baseline National Institutes of Health Stroke Scale (NIHSS) score, and occlusion site. Of the 9121 patients included, 277 underwent mechanical thrombectomy beyond 24 hours and 8844 within 24 hours. After PSM, 534 patients were analyzed (267 per group). No significant difference was found in the rate of 3-month functional independence (mRS score 0-2) between the beyond 24-hour and within 24-hour thrombectomy groups, both before and after matching (OR=0.977, 95%CI: 0.753-1.268, P=0.861; OR=1.151, 95%CI: 0.712-1.549, P=0.804, respectively). The rates of 24-hour symptomatic intracranial hemorrhage, 24-hour parenchymal hemorrhage, and 3-month all-cause mortality also showed no significant differences between the two groups (all P>0.05). Sensitivity analyses among patients in the extended time window (6-24 hours) and those receiving mechanical thrombectomy alone yielded similar results, with no significant differences in functional or safety outcomes (all P>0.05). Subgroup analyses revealed no significant heterogeneity in the 3-month functional outcome across various baseline characteristics (all P>0.05). For AIS patients with LVO, the efficacy and safety of mechanical thrombectomy performed beyond 24 hours appear comparable to those of mechanical thrombectomy performed within 24 hours.

Asymptomatic Intracranial Hemorrhage Is Associated With Poor Outcomes After Mechanical Thrombectomy for Large Vessel Occlusion

Introduction: Acute ischemic stroke (AIS) with large vessel occlusion (LVO) benefits from mechanical thrombectomy (MT), but the majority of Americans require interhospital transfer for MT. Thrombolysis at the spoke hospital with the patient transferred to the hub for MT is a model known as “drip-and-ship.” In contrast, “mothership” patients present directly to MT capable centers and have immediate access to MT. We sought to evaluate the effects of thrombolysis dwell time (time for the drug to work) and drip-and-ship versus mothership status on recanalization rates. Methods: Among 385 patients who received thrombolysis for AIS at our academic comprehensive stroke center from January 1, 2023 to June 30 2024, 76 patients had LVO and repeat vessel imaging available to evaluate for recanalization status. Thrombolysis dwell time was defined as the time from administration of thrombolysis to repeat vascular imaging. Recanalization was defined as complete resolution of the occlusion. Partial recanalization was defined as some recanalization (i.e. M1 transformed into M2). Patients without vascular imaging or without repeat vessel imaging were excluded. Data was collected on demographics, last known normal time (LKN), National Institutes of Health Stroke Scale (NIHSS), thrombolysis administration time, and repeat vascular imaging results. Results: Among 76 AIS LVO patients, the mean age was 68.8 years (range, 25.1 to 96.8), and 40 (52.6%) were women. The mean initial NIHSS was 14.7 (range, 0 to 34). Twenty-three (30%) were mothership and 53 (69.7%) were drip-and-ship. The mean time from LKN to thrombolysis was 2.2 hours (range, 0 to 4.9). The site of LVO occlusion was as follows: 56 (76.7%) M1, 8 (10.5%) M2s occlusions, 5 (6.6%) carotid terminus, 5 (6.6%) basilar, and 2 (2.6%) PCA occlusions. In 69 (90.8%), repeat vascular imaging was cerebral angiogram. There were 7 (9.2%) complete recanalization, and 20 (26.2%) partial recanalization. Mothership status was associated with lower rates of partial recanalization (8.7% vs 34%, p 0.016) and shorter mean thrombolysis dwell time (0.9 hours vs 2.7 hours, p &lt; 0.0001) compared to drip-and-ship status. Conclusions: In LVO AIS patients who receive thrombolysis, drip-and ship status is associated with higher partial recanalization rates and longer thrombolysis drug dwell time compared to mothership status. This may impact strategy for recruitment of sites in clinical trials.

Background and Purpose: The optimal acute management of patients with large vessel occlusion (LVO) and minor clinical deficits on admission [National Institutes of Health Stroke Scale (NIHSS) ≤ 4] remains to be elucidated. The aim of the present study was to investigate the prognostic factors and therapeutic management of those patients.Methods: In this retrospective cohort study, we investigated (1) all patients with acute ischemic stroke due to an LVO who underwent mechanical thrombectomy (MT) and (2) all patients with minor clinical deficits (NIHSS ≤ 4) on admission due to an LVO between January 2013 and December 2016 at the University Medical Center Erlangen. We dichotomized management of patients with minor deficits treated with MT for analysis according to immediate mechanical thrombectomy (IT) and initial medical management with rescue intervention (MM) in case of secondary deterioration. Primary endpoints were secondary deterioration, in-hospital mortality, and functional outcome on day 90 (dichotomized modified Rankin Scale 0–2: favorable, 3–6: poor).Results: Two hundred twenty-three patients (83% with anterior circulation stroke, 13 (6%) with minor deficits) treated with MT and 88 patients with minor deficits due to LVO [13 (15%) treated with MT] were included. Secondary deterioration (n = 19) was independently associated with poor outcome in patients with minor deficits and LVO [odds ratio (OR), 0.060; 95% confidence interval (CI), 0.013–0.280], which in turn was associated with the occlusion site [especially M1 occlusion: 11 (58%) vs. 3 (4%) in patients without secondary deterioration, p < 0.0001]. IT (n = 8) was associated with a lower intrahospital mortality compared to MM (n = 5; 13 vs. 80%; OR, 0.036; 95% CI, 0.002–0.741). Seven of eight patients with IT survived until discharge, with 29% showing a favorable functional outcome on day 90.Conclusions: Secondary deterioration is associated with poor outcome in patients with LVO and minor deficits, which in turn was associated with occlusion site. Future randomized controlled trials should assess whether selected patients, depending on occlusion site and associated characteristics, may benefit from MT.

Introduction : Mechanical thrombectomy (MT) has become the standard treatment of acute ischemic stroke (AIS) caused by large vessel occlusion (LVO), with different techniques used to achieve revascularization of the occluded vessel. However, early re‐occlusion of the target vessels could still take place in a considerable proportion of patients who already underwent MT for LVO. Therefore, we conducted this systematic review and individual participant data (IPD) meta‐analysis to provide more comprehensive evidence regarding the efficacy of repeat thrombectomy for recurrent LVO in early after successful first‐time MT. Methods : A computerized search on MEDLINE via PubMed, SCOPUS, Web of Science, EMBASE, and Cochrane library using the relevant keywords was performed. The retrieved references were screened, and the relevant data were extracted. STATA and SPSS were used to perform this IPD meta‐analysis. Results : Twenty studies were included, of which ten studies were observational studies (n = 21,251 patients) and 10 cases reports (n = 10 patients). Out of the included patients, 266 patients (62.78% females) were identified with recurrent LVO. The overall prevalence of recurrent LVO was 1.6%, 95% CI (1.0% to 2.8%), p&lt;0.001. The mean age of the included patients was 65.67±16.23 years. Cardiac embolism was the most common cause of stroke in both times (52%). The median number of days between the first and second LVO was 15 days (IQR: 4–191). Regarding the National Institute of Health Stroke Scale (NIHSS), the first and second MT reduced it significantly (MD = ‐8.91, 95% CI: ‐10.02 to ‐7.82) and (MD = ‐5.97, 95% CI: ‐7.53 to ‐4.43), respectively, with a significant difference between both procedures (p = 0.001). The mean ASPECT after the first MT was 8.65±1.45, and after the second MT was 8.01±1.88. A significant weak correlation was observed between the ASPECT of first MT and NIHSS before it (r = ‐0.270, p = 0.001). Based on the thrombolysis in cerebral infarction (TICI) grading system, the first MT resulted in 57.3% complete perfusion, 42.1% partially filling, and 0.7% no/minimal filling, while the second MT resulted in 48% complete perfusion, 30% partially filling, and 6.67% no/minimal filling, with a significant difference between both MTs (p = 0.042). Regarding the modified Rankin scale (mRS) at 90 days after the first MT, “0” was the most frequent outcome (26.9%), followed by “2” (13.0%), “1” (12.4%), and “4” (7.3%). On the other hand, the 90‐day mRS after the second MT was categorized as the following: “6” in 13.5%, “3” in 13.5%, “2” in 11.9%, “1” in 11.9%, and “4” in 9.3%. Conclusions : In properly selected patients with recurrent LVO, repeated MT appears to be feasible and safe. A prior MT procedure should not discourage aggressive treatment as these patients may achieve similar rates of good clinical outcomes as those who undergo single MT.

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.

BACKGROUND: Acute ischemic stroke (AIS) is the most common type of stroke. The endovascular treatment of AIS depends on stroke subtype, whether caused by large vessel occlusion (LVO) or not. We presented a case of AIS due to LVO that has complication in the form of symptomatic intracerebral hemorrhage (sICH) after an intra-arterial mechanical thrombectomy. CASE PRESENTATION: An 80-year-old woman was admitted to the emergency department with sudden onset left side weakness since &lt;1 h before admission, when the patient had woke up in the morning. The patient had history of hypertension, diabetes mellitus, and dyslipidemia. She also had cardiac disorders in the form of non-valvular atrial fibrillation with 55% left ventricular ejection fraction (LVEF). Her blood pressure was 148/84 mmHg, heart rate was 65 beats/minute, respiratory rate was 17 times/min, and body temperature was 36.2°C. Glasgow coma scale (GCS) was E3V4M5; National Institutes of Health Stroke Scale (NIHSS) was 15. She had moderate aphasia. Head CT scan did not show any hyper- or hypodens areas and Alberta Stroke Program Early CT score was 10. RAPID automated CT perfusion using Quantitative Software showed that the mismatch volume was 192 ml and the mismatch ratio was 7.4. Endovascular therapy in the form of intra-arterial mechanical thrombectomy was performed, and blood flow in the right internal carotid artery (ICA) was restored with the score of Modified Thrombolysis in Cerebral Infarction (mTICI) was III. Follow-up non-contrast head CT scan was performed and revealed acute infarction with hemorrhagic transformation in the middle cerebral artery (MCA) territory. CONCLUSION: Early and accurate treatment of AIS is paramount. Endovascular treatment in the form of intra-arterial mechanical thrombectomy is the current treatment recommendation in LVO although there is a risk of symptomatic intracerebral hemorrhage, as in this case.