Acute Anterior Circulation Large Vessel Occlusion Research Articles

Radiomics of intrathrombus and perithrombus regions for Post-EVT intracranial hemorrhage risk Prediction: A multicenter CT study

ObjectivesThis study aimed to assess the predictive performance of radiomics derived from computed tomography (CT) images of thrombus regions in predicting the risk of intracranial hemorrhage (ICH) following endovascular thrombectomy (EVT). Materials and MethodsThis retrospective multicenter study included 336 patients who underwent admission CT and EVT for acute anterior-circulation large vessel occlusion between December 2018 and December 2023. Follow-up imaging was performed 24 h post-procedure to evaluate the occurrence of ICH. 230 patients from centers A and B were randomly allocated into training and test groups in a 7:3 ratio, while the remaining 106 patients from center C comprised the validation cohort. Radiologists manually segmenting the thrombus on CT images, and the perithrombus region was defined by expanding the initial region of interest (ROI). A total of 428 radiomics features were extracted from both intrathrombus and perithrombus regions on CT images. The Mann–Whitney U test was used for feature selection, and least absolute shrinkage and selection operator (LASSO) regression was employed for model development, followed by validation using a 5-fold cross-validation approach. Model performance was assessed using the area under the curve (AUC) of the receiver operating characteristic (ROC). ResultsAmong the eligible patients, 128 (38.1 %) experienced ICH after EVT. The combined model exhibited superior performance in the training cohort (AUC: 0.913, 95 % CI: 0.861–0.965), test cohort (AUC: 0.868, 95 % CI: 0.775–0.962), and validation cohort (AUC: 0.850, 95 % CI: 0.768–0.912). Notably, in the validation group, both the perithrombus and combined models demonstrated higher predictive accuracy compared to the intrathrombus model (0.837 vs. 0.684, p = 0.02; AUC: 0.850 vs. 0.684, p = 0.01). ConclusionsRadiomics features derived from the perithrombus region significantly enhance the prediction of ICH after EVT, providing valuable insights for optimizing post-procedural clinical decisions. Clinical relevance statementThis study highlights the importance of radiomics extracted from intrathrombus and perithrombus region in predicting intracranial hemorrhagefollowing endovascular thrombectomy, which can aid in improving patient outcomes.

Importance of computed tomography perfusion on assessing collateral circulation and prognosis of patients with acute anterior circulation large vessel occlusion after endovascular therapy

This study probed the importance of computed tomography perfusion (CTP) on assessing collateral circulation and prognosis in patients with acute anterior circulation large vessel occlusion (AAC-LVO) after endovascular therapy (EVT). Retrospective analysis was performed on the case data of 124 AAC-LVO patients who achieved EVT in the First People's Hospital of Lianyungang. All patients received computed tomography (CT) examination. Based on the multi-phase computed tomography angiography (mCTA) score, patients were separated into poor collateral circulation group and good collateral circulation group. Based on modified Rankin scale (mRS) score, patients were separated into good prognosis group and poor prognosis group. The receiver operating characteristic (ROC) curve was used to measure the efficacy of CTP parameters in predicting good collateral circulation or good prognosis. Correlation between CTP parameters with mCTA collateral and 90-day mRS circulation score was analyzed using the Spearman correlation analysis. The age and admission national Institutes of Health stroke scale (NIHSS) scores of the good collateral circulation group were lower than the poor collateral circulation group, and low perfusion area volume with Tmax > 6 s (VTmax>6 s), infarct core area volume (VCBF<30 %)and hypoperfusion intensity ratio (HIR) were also lower. The mCTA collateral cycle score was negatively related to VTmax>6s, VCBF<30 % and HIR. The area under the curve (AUC) values of VTmax>6s and VCBF<30 % and HIR for predicting good collateral circulation were 0.763, 0.884 and 0.842, respectively, which suggested that perfusion parameters VTmax>6s, VCBF<30 % and HIR could effectively indicate the status of patients’ collateral circulation. Relative to the poor prognosis group, patients in the good prognosis group possessed lower admission NIHSS score, younger age, smaller final infarct volume, lower HIR, VCBF<30 %, VTmax>6 s, Alberta Stroke Program Early CT(ASPECT) score, and higher mCTA score. Spearman correlation analysis unveiled that ASPECT score, mCTA score and 90-day mRS were negatively correlated. The final infarct volume, perfusion parameters HIR and VCBF<30 % were positively correlated with 90-day mRS. ROC analysis showed that all variates had good prognostic value for acute anterior circulation great vessel occlusion patients, while VCBF<30 % and HIR had high diagnostic value for prognosis. To sum up, CTP can provide a comprehensive imaging assessment of the collateral circulation of patients with AAC-LVO and has a higher predictive value for the prognosis assessment of patients with EVT in terms of VCBF<30 %, HIR score and mCTA collateral circulation score.

Comparison of Outcomes between Stent Retriever Combined with Contact Aspiration and Contact Aspiration Alone in Patients without Hyperdense Artery Sign/Susceptibility Vessel Sign

PurposeTo examine the relationship between hyperdense artery sign (HAS)/susceptibility vessel sign (SVS) and thrombus composition and evaluate the effect of HAS/SVS status on the association between first-line thrombectomy techniques and outcomes in patients with acute anterior circulation large vessel occlusion (LVO). Materials and MethodsFrom January 2018 to June 2021, 103 consecutive patients with acute anterior circulation LVO (75 [63.1%] men; median age, 66 years) who underwent thrombectomy and for whom the removed clot was available for histological analyses were retrospectively reviewed. The presence of HAS and SVS was assessed on unenhanced computed tomography (CT) and susceptibility-weighted imaging, respectively. Association of first-line thrombectomy techniques (stent retriever [SR] combined with contact aspiration [CA] vs CA alone) with outcomes was assessed according to HAS/SVS status. ResultsAmong the included patients, 55 (53.4%) were HAS/SVS-negative, and 69 (67.0%) underwent first-line SR + CA. Higher relative densities of fibrin/platelets (0.56 vs 0.51; P < .001) and lower relative densities of erythrocytes (0.32 vs 0.42; P < .001) were observed in HAS/SVS-negative patients compared with HAS/SVS-positive patients. First-line SR + CA was associated with reduced odds of distal embolization (adjusted odds ratio, 0.18; 95% CI, 0.04–0.83; P = .027) and a more favorable 90-day functional outcome (adjusted odds ratio, 5.29; 95% CI, 1.06–26.34; P = .042) in HAS/SVS-negative patients and a longer recanalization time (53 vs 25 minutes; P = .025) and higher risk of subarachnoid hemorrhage (24.2% vs 0%; P = .044) in HAS/SVS-positive patients. ConclusionsAbsence of HAS/SVS may indicate a higher density of fibrin/platelets in the thrombus, and first-line SR + CA yielded superior functional outcomes than CA alone in patients with acute LVO without HAS/SVS.

Endovascular therapy in acute ischaemic stroke with large infarction with matched or mismatched clinical-radiological severities: a post-hoc analysis of the ANGEL-ASPECT trial

Endovascular therapy (EVT) was demonstrated effective in acute large vessel occlusion (LVO) with large infarction. Revealing subgroups of patients who would or would not benefit from EVT will further inform patient selection for EVT. This post-hoc analysis of the ANGEL-ASPECT trial, a randomised controlled trial of 456 adult patients with acute anterior-circulation LVO and large infarction, defined by ASPECTS 3-5 or infarct core volume 70-100mL, enrolled from 46 centres across China, between October 2, 2020 and May 18, 2022. Patients were randomly assigned (1:1) to receiving EVT and medical management or medical management alone. One patient withdrew consent, 455 patients were included in this post-hoc analysis and categorised into 4 subgroups by lower or higher NIHSS (< or ≥16) and smaller or larger infarct core (< or ≥70mL). Those with lower NIHSS & smaller core, and higher NIHSS & larger core were considered clinical-radiological matched subgroups; otherwise clinical-radiological mismatched subgroups. Primary outcome was 90-day modified Rankin Scale (mRS). ANGEL-ASPECT is registered with ClinicalTrials.gov, NCT04551664. Overall, 139 (30.5%) patients had lower NIHSS & smaller core, 106 (23.3%) higher NIHSS & larger core, 130 (28.6%) higher NIHSS & smaller core, and 80 (17.6%) lower NIHSS & larger core. There was significant ordinal shift in the 90-day mRS toward a better outcome with EVT in clinical-radiological matched subgroups: lower NIHSS & smaller core (generalised OR, 1.76; 95% CI, 1.18-2.62; p=0.01) and higher NIHSS & larger core (1.64; 1.06-2.54; 0.01); but not in the two clinical-radiological mismatched subgroups. Our findings suggested that in patients with anterior-circulation LVO and large infarction, EVT was associated with improved 90-day functional outcomes in those with matched clinical and radiological severities, but not in those with mismatched clinical and radiological severities. Simultaneous consideration of stroke severity and infarct core volume may inform patient selection for EVT. Unrestricted grants from industry [Covidien Healthcare International Trading (Shanghai), Johnson & Johnson MedTech, Genesis MedTech (Shanghai), and Shanghai HeartCare Medical Technology].

Abstract TP175: Older Age is Associated With Smaller Ischemic Core Volume and Slower Infarct Progression Despite High Clinical Severity in Anterior Circulation Large Vessel Occlusion Stroke

Background: Older patients with acute stroke due to anterior circulation large vessel occlusion (ACLVO) experience worse clinical outcomes. Fast progressors typically present early with high stroke severity and larger ischemic core volumes. However, the relationship between aging and early infarct growth rate is unknown. We examined the association between older age, baseline ischemic core volumes and fast or slow infarct growth during ACLVO. Methods: Retrospective study of patients with acute ICA or MCA occlusion across two academic centers in 2014-2019. Patients were included if they had baseline CTP or MRI within 24 hours after estimated stroke onset. Infarct growth rate (IGR) was calculated as ischemic core volume (ml) / stroke onset to imaging time (h). Fast or Slow progressor status was defined by IGR ≥ or &lt; 10 ml/h. Univariate comparisons were made across age tertiles. Multivariable linear and logistic regression analysis examined the association of age tertile with ischemic core volume and slow progressor status adjusting for sex, vascular co-morbidities and NIHSS. Results: We included 312 patients (57% female; age tertiles [T1-T3]: 33—66, 67—81, and 82—102). Older age was associated with decreasing ischemic core volume (median [range] ml: T1, 29 [0-253]; T2, 12 [0-406]; T3, 6 [0-244]; p&lt;0.001) and lower IGR (median [range] ml/h: T1, 5.8 [0-153]; T2, 2.6 [0-122.5]; T3, 0.6 [0-248]; p&lt;0.001). The frequency of slow progressors increased with age (N (%): T1, 65/107 (61); T2, 76/105 (72); T3, 78/100 (78); p=0.02). However, baseline NIHSS was numerically higher with older age (median [range]: T1, 16 [1-30]; T2, 17 [2-38]; T3, 18 [1-33]; p=0.22). In multivariable models, age tertile (T3 vs T1) and NIHSS were associated with: 1. ischemic core volume (age coefficient [95% CI], -18.9 [-36.1, -1.7], p=0.03; NIHSS coefficient [95% CI], 3.2[2.3, 4.1], p&lt;0.001); and 2. slow progressor status (age OR 2.63 [1.27, 5.43], p=0.009); NIHSS OR 0.91 [0.87, 0.95], p&lt;0.001). Conclusions: Older age was paradoxically associated with lower baseline core volumes and slow progressor status, despite high stroke severity during acute ACLVO, suggesting older patients may be more vulnerable to even slow infarct growth. Future studies are needed to confirm and extend the findings.

Abstract 84: Efficacy of Endovascular Therapy in Acute Ischemic Stroke by Alberta Stroke Program Early Computed Tomography Score and National Institutes of Health Stroke Scale-A Secondary Analysis of a Randomized Controlled Trial

Introduction and Aims: The ANGEL-ASPECT trial demonstrated the effectiveness of endovascular therapy (EVT) in acute ischemic stroke (AIS) patients with large infarct. We did a secondary analysis to explore the efficacy of EVT according to Alberta Stroke Program Early Computed Tomography Score (ASPECT) and National Institutes of Health Stroke Scale (NIHSS). Methods: ANGEL-ASPECT trial was a randomized clinical trial involving patients with acute anterior-circulation large-vessel occlusion and an ASPECT score of 3-5 or an infarct-core volume of 70-100ml. Patients were randomly assigned to EVT or standard medical treatment (SMT) alone. We categorized patients based on the combination of ASPECT (≤3 or 4-5) and NIHSS (&lt;20 or ≥20) into four groups: low ASPECT &amp; low NIHSS; low ASPECT &amp; high NIHSS; high ASPECT &amp; low NIHSS and high ASPECT &amp; high NIHSS. We assessed the efficacy of EVT using ordinal shift analysis of 90-day modified Rankin Scale (mRS). Results: Among 455 patients, the prevalence of the four groups were 190 (41.8%), 70 (15.4%), 157 (34.5%) and 38 (8.4%), respectively. A significant shift in the distribution of 90-days mRS toward better outcomes in favor of EVT was observed in patients with low ASPECT &amp; low NIHSS (common OR [cOR], 2.25; 95% CI, 1.34-3.76; P=0.002), and high ASPECT &amp; low NIHSS (cOR, 2.30; 95% CI, 1.31-4.05; P=0.004), but not in other two groups with high NIHSS (all P &gt;0.05). Conclusions: EVT was associated with better outcomes in AIS patients with large infarct and mild-to-moderate stroke severity (NIHSS &lt;20), but not in those with severe stroke severity (NIHSS ≥20). Stroke severity should be considered when planning EVT for AIS patients with large infarcts.

Outcome Comparison of Endovascular Treatment for Acute Large Vessel Occlusion Due to Large Artery Atherosclerosis and Cardioembolism in the Chinese Population: Data from the ANGEL Registry.

Studies on outcome comparison after endovascular treatment (EVT) for large vessel occlusion (LVO) between large artery atherosclerosis (LAA) and cardioembolism (CE) in the Asian population are scarce. We aimed to compare the baseline characteristics and clinical outcomes after EVT for anterior circulation LVO with LAA and CE in the Chinese population. Patients were selected from the ANGEL registry and divided into LAA and CE groups. The primary outcome was the 90-day modified Rankin Scale (mRS) 0-2. The secondary outcomes were 90-day mRS distribution, 90-day mRS 0-1, 90-day mRS 0-3, and early neurological improvement. The safety outcomes included death, symptomatic intracranial hemorrhage, and any intracranial hemorrhage. We conducted logistic regression models with adjustments to compare the outcomes. A total of 632 patients were included, of whom, 488 were in the LAA group and 144 were in the CE group. No significant difference in 90-day mRS 0-2 was observed between LAA and CE groups (55.7%vs.43.1%, odds ratio[OR] 1.19, 95% confidence interval(CI), 0.92-1.53, P=0.190). The LAA group exhibited a higher frequency of mRS 0-3 compared to the CE group (69.1% vs 32.6%, OR1.32, 95% CI 1.02-1.72, P=0.038). However, the incidence of death within 90 days did not significantly differ between the LAA and CE groups (10.9%vs.24.3%, OR0.91, 95% CI0.66-1.25, P=0.545), nor did the occurrences of symptomatic intracranial hemorrhage(SICH) (4.5%vs.9.7%,OR1.08, 95% CI 0.65-1.78, P=0.779) or intracranial hemorrhage(ICH) (21.9%vs.30.6%, OR 0.94, 95% CI0.71-1.25, P=0.680). Moreover, no significant disparities were detected in other outcomes between the two groups (All P>0.05). In the ANGEL registry, a higher prevalence of patients undergoing EVT for acute anterior circulation LVO with LAA was found than those with CE. However, our study revealed that the efficacy and safety of EVT remained consistent regardless of the stroke's etiology such as LAA or CE.

Application of a nomogram model for the prediction of 90-day poor outcomes following mechanical thrombectomy in patients with acute anterior circulation large-vessel occlusion.

The past decade has witnessed advancements in mechanical thrombectomy (MT) for acute large-vessel occlusions (LVOs). However, only approximately half of the patients with LVO undergoing MT show the best/independent 90-day favorable outcome. This study aimed to develop a nomogram for predicting 90-day poor outcomes in patients with LVO treated with MT. A total of 187 patients who received MT were retrospectively analyzed. Factors associated with 90-day poor outcomes (defined as mRS of 4-6) were determined by univariate and multivariate logistic regression analyzes. One best-fit nomogram was established to predict the risk of a 90-day poor outcome, and a concordance index was utilized to evaluate the performance of the model. Additionally, 145 patients from a single stroke center were retrospectively recruited as the validation cohort to test the newly established nomogram. The overall incidence of 90-day poor outcomes was 45.16%, affecting 84 of 186 patients in the training set. Moreover, five variables, namely, age (odds ratio [OR]: 1.049, 95% CI [1.016-1.083]; p = 0.003), glucose level (OR: 1.163, 95% CI [1.038-1.303]; p = 0.009), baseline National Institute of Health Stroke Scale (NIHSS) score (OR: 1.066, 95% CI [0.995-1.142]; p = 0.069), unsuccessful recanalization (defined as a TICI grade of 0 to 2a) (OR: 3.730, 95% CI [1.688-8.245]; p = 0.001), and early neurological deterioration (END, defined as an increase of ≥4 points between the baseline NIHSS score and the NIHSS score at 24 h after MT) (OR: 3.383, 95% CI [1.411-8.106]; p = 0.006), were included in the nomogram to predict the potential risk of poor outcomes at 90 days following MT in LVO patients, with a C-index of 0.763 (0.693-0.832) in the training set and 0.804 (0.719-0.889) in the validation set. The proposed nomogram provided clinical evidence for the effective control of these risk factors before or during the process of MT surgery in LVO patients.

Prognosis and Prediction of Asymptomatic Intracranial Hemorrhage After Endovascular Thrombectomy: A Multi-Center Study.

The impact of asymptomatic intracranial hemorrhage (aICH) on functional outcomes after endovascular thrombectomy (EVT) remains unclear, and tools for forecasting this complication are lacking. We aim to evaluate the clinical relevance of aICH and establish a prediction model. Data of patients who received EVT for acute anterior-circulation large vessel occlusion in 3 comprehensive hospitals were retrospectively analyzed. Asymptomatic intracranial hemorrhage was defined as any hemorrhage detected after EVT that did not fulfill the definition of symptomatic intracranial hemorrhage in the European Cooperative Acute Stroke Study. Logistic regression models were performed to assess the impact of aICH on 90-day functional outcomes and identify the predictors of aICH, which were then used to establish a prediction model. The discrimination, calibration, and clinical utility of the model were evaluated. This study included 460 patients, among whom 152 (33.0%) developed aICH after EVT. Asymptomatic intracranial hemorrhage was negatively associated with 90-day excellent outcomes (adjusted odds ratio [OR]: 0.414, 95% confidence interval [CI]: 0.230-0.745, p=0.003) and good outcome (adjusted OR: 0.603, 95% CI: 0.374-0.971, p=0.037), but not with mortality (adjusted OR: 1.110, 95% CI: 0.611-2.017, p=0.732) after adjusted for other predictors of functional outcome. Pre-stroke anticoagulant therapy (OR: 2.233, 95% CI: 1.073-4.647, p=0.032), Alberta stroke program early CT score (OR: 0.842, 95% CI: 0.754-0.939, p=0.002), site of occlusion (internal carotid artery occlusion as the reference; M1 segment of middle cerebral artery occlusion, OR: 2.827, 95% CI: 1.409-5.674, p=0.003; tandem occlusion, OR: 3.928, 95% CI: 1.752-8.806, p=0.001), intravenous thrombolysis (OR: 2.091, 95% CI: 1.362-3.209, p=0.001), and successful recanalization (OR: 0.383, 95% CI: 0.213-0.689, p=0.001) were identified as the predictors of aICH, which were incorporated into a nomogram model. The area under the receiver operating characteristic curve of the model was 0.707 (95% CI: 0.657-0.757), and the calibration plot demonstrated good consistency between actual observed and predicted probability of aICH. Decision curve analysis showed that patients might benefit from the model. Asymptomatic intracranial hemorrhage was negatively associated with favorable functional outcome after EVT. We established a nomogram model for predicting aICH, which requires external clinical validation. The impact of asymptomatic intracranial hemorrhage after endovascular thrombectomy on mid-term functional outcome has been controversial. We found that asymptomatic intracranial hemorrhage may also decreased the likelihood of 90-day favourable functional outcome after endovascular thrombectomy, supporting the notion that asymptomatic intracranial hemorrhage at the acute stage may not be benign. Moreover, we established a prediction model for this complication, which may improve clinical evaluation and management of patients who would receive endovascular thrombectomy for large vessel occlusion.

Effects of edaravone dexborneol on neurological function and serum inflammatory factor levels in patients with acute anterior circulation large vessel occlusion stroke.

The goal of this study is to evaluate and analyze the effects of edaravone (EDV) dexborneol on neurological function and serum inflammatory factor levels among patients with acute anterior circulation big artery blockage stroke. A total of 142 patients with acute anterior circulation large vessel occlusion (LVO) were randomly allocated to the study group (69 patients) or the control group (73 patients). In the study group, patients were treated with 37.5 mg EDV dexborneol twice a day for 10-14 days, based on the control group. The primary efficacy outcome was the National Institutes of Health Stroke Scale score change from baseline to 90 days and the proportion of modified Rankin Scale (mRS)score ≤1 at 90 days after randomization. The secondary outcome included the decrease in inflammatory factors at 14 days. The primary safety outcome was the incidence of hemorrhagic transformation assessed according to Heidelberg bleeding classification within 7 days. A higher percentage of patients with HIHSS score ≤5 at 90 days in the EDV dexcamphorol group was observed than in the control group (75.36% vs 64.38%; P = 0.015). A higher percentage of patients with mRS score ≤1 at 90 days in the EDV dexcamphorol group was observed than in the control group (63.77% vs 50.68%; P = 0.012). After treatment, the levels of IL-6 and hs-CRP were significantly lower following treatment and compared to the control group (P < 0.05). In patients receiving the EDV dexborneol group, a significantly decreased risk of radiographic intracranial hemorrhage was found compared with the control group (20.29% vs 39.73%; P = 0.0006). In conclusion, EDV dexborneol can improve the clinical outcomes of patients with acute anterior circulation LVO stroke, which can be used as an effective supplement to thrombectomy therapy.

Leptomeningeal Collaterals and Infarct Progression in Patients With Acute Large‐Vessel Occlusion and Low NIHSS

Background Approximately 10% of patients with acute ischemic stroke with large‐vessel occlusion (LVO) have mild neurological deficits. Although leptomeningeal collaterals (LMCs) are the major determinant of clinical outcomes for patients with acute ischemic stroke with LVO, the contribution of baseline LMC status to subsequent infarct progression in patients with mild stroke with LVO is poorly defined. Methods This observational study included patients with acute anterior circulation LVO and mild stroke symptoms (National Institutes of Health Stroke Scale &lt; 6) from a prospectively collected, multicenter, national stroke registry. The Alberta Stroke Program Early Computed Tomography Score was quantified on the initial and follow‐up images. An infarct progression, defined as any Alberta Stroke Program Early Computed Tomography Score decrease between the initial versus follow‐up scans, was categorized as either 0/1/2+. The LMCs on the baseline images were graded as good, fair, or poor. Results Of the 623 included patients (mean age, 67.6±13.4 years; 380 [61.0%] men; 186 [29.9%] with reperfusion treatment), the baseline LMC was graded as good in 331 (53.1%), fair in 219 (35.2%), and poor in 73 (11.7%). The Alberta Stroke Program Early Computed Tomography Score decrement was noted as 0 in 288 (46%) patients, 1 in 154 (24%), and 2+ in 181 (29%). A poor LMC was associated with an infarct progression (adjusted odds ratio, 2.05 [95% CI, 1.22–3.47]). Conclusions Poor collateral blood flow was associated with infarct progression in patients with acute ischemic stroke with LVO and mild symptoms. In this selective population, early assessment of collateral blood flow status can help in early detection of patients susceptible to infarct progression.

The effect of intravenous thrombolysis on patients with successful thrombectomy depends on final reperfusion grade: A retrospective study.

Although intravenous thrombolysis (IVT) has not shown confirmative effects on the outcomes of patients receiving successful thrombectomy, it might influence the outcomes of a subset of these patients. This study aims to evaluate whether the effects of IVT depend on final reperfusion grade in patients with successful thrombectomy. This is a single-center, retrospective analysis of patients with an acute anterior circulation large-vessel occlusion and a successful thrombectomy between January 2020 and June 2022. Final reperfusion grade was evaluated by the modified Thrombolysis in Cerebral Infarction (mTICI) score, which was dichotomized into incomplete (mTICI 2b) and complete (mTICI 3) reperfusion. The primary outcome was functional independence (90-day modified Rankin Scale score 0-2). Safety outcomes were 24-h symptomatic intracranial hemorrhage and 90-day all-cause mortality. Multivariable logistic regression analyses were used to assess the interactions between IVT treatment and final reperfusion grade on outcomes. When comparing all 167 patients enrolled in the study, IVT did not influence the extent of functional independence (adjusted OR: 1.38; 95% CI: 0.65-2.95; p = 0.397). The effect of IVT on functional independence depended on final reperfusion grade (p = 0.016). IVT benefited patients with incomplete reperfusion (adjusted OR: 3.70; 95% CI 1.21-11.30; p = 0.022), but not those with complete reperfusion (adjusted OR: 0.48, 95% CI: 0.14-1.59; p = 0.229). IVT was not associated with 24-h symptomatic intracerebral hemorrhage (p = 0.190) or 90-day all-cause mortality (p = 0.545). The effect of IVT on functional independence depended on final reperfusion grade in patients with successful thrombectomy. IVT appeared to benefit patients with incomplete reperfusion, but not those with complete reperfusion. Because reperfusion grade cannot be determined prior to endovascular treatment, this study argues against withholding IVT in IVT-eligible patients.

Endovascular treatment versus medical management for mild stroke with acute anterior circulation large vessel occlusion: a meta-analysis

BackgroundThe effectiveness of endovascular treatment (EVT) in patients with mild stroke (National Institutes of Health Stroke Scale score ≤5) and acute anterior circulation large vessel occlusion (AACLVO) remains unknown.ObjectiveTo conduct...

Abstract WP50: Stress Hyperglycemia And Early Neurological Deterioration In Patients With Acute LVO And Low NIHSS

Introduction: Stress hyperglycemia is an essential survival response. However, it is associated with poor prognosis after ischemic stroke, and its contribution to collateral failure is not well defined. We investigated whether stress hyperglycemia would be associated with early neurological deterioration (END) in acute large vessel occlusion (LVO) patients who present with mild neurological deficit. Methods: From a multicenter stroke registry, ischemic stroke patients with acute anterior circulation LVO and mild symptoms (NIHSS&lt;6) were included and were grouped by a history of diabetes before the index stroke. Stress hyperglycemia ratio (SHR) was calculated as a ratio of serum glucose at arrival over glycosylated hemoglobin. END was defined as an increase in total NIHSS≥2 or any increase in the NIHSS consciousness or motor sub-scores. Results: Among a total of 731 mild LVO patients (mean age 68.0±12.9 years; 62.7% male), 172 (23.5%) had a history of diabetes, and 73 (10.0%) were newly diagnosed with diabetes during admission. The SHR was higher in known diabetic patients compared to no-DM / newly diagnosed diabetic patients (24.3±8.5 vs. 21.8±5.6, p-value&lt;0.01). END occurred in 94 (12.9%) patients. The second (T2) and third (T3) tertile groups of SHR were more likely to experience END than the lowest tertile group (adjusted odds ratio (aOR) 2.29 [95% confidence interval (CI), 1.26-4.17] for T2; aOR 1.85 [95% CI 1.01-3.39] for T3). The association was maintained in the no-DM / newly diagnosed diabetic subgroup but not in cases with a history of diabetes (p for interaction=0.047). [Figure] Conclusions: Stress hyperglycemia was associated with END in acute LVO patients with low NIHSS, especially in the subgroup of patients without or newly diagnosed diabetes. In patients without a history of diabetes, where the physiologic response to hyperglycemia may currently be preserved, intensive glycemic control may benefit in maintaining leptomeningeal collaterals.

Incidence of Atrial Fibrillation in Large Vessel Occlusion and Large Embolic Stroke of Undetermined Source.

Large vessel occlusion (LVO) stroke is a common presentation of acute ischemic strokeand is often unknown or cryptogenic in etiology. There is a strong association between atrial fibrillation (AF) and cryptogenic LVO stroke, making it a unique stroke subgroup. Therefore, we propose that any LVO stroke meeting the criteria for an embolic stroke of an undetermined source (ESUS) be classified as large ESUS (LESUS). The purpose of this retrospective cohort study was to report the etiology of anterior LVO strokes that underwent endovascular thrombectomy. This was a single-center retrospective cohort study characterizing the etiology of acute anterior circulation LVO strokes that received emergent endovascular thrombectomy from 2011 to 2018. Patients with LESUS designation at hospital discharge were changed to cardioembolic etiology if AF was discovered during the two-year follow-up period. Results: Overall, 155 (45%) of 307 patients in the study were found to have AF. New onset AF was discovered in 12 (23%) of 53 LESUS patients after hospitalization. Furthermore, eight (35%) of 23 LESUS patients who received extended cardiac monitoring were found to have AF. Nearly half the patients with LVO stroke who received endovascular thrombectomy were found to have AF. With the use of extended cardiac monitoring devices after hospitalization, AF is frequently discovered in patients with LESUS and may change the secondary stroke prevention strategy.

Predictors of Mechanical Thrombectomy for Anterior Circulation Emergent Large-Vessel Occlusion in the Older Adults.

Few studies have reported the clinical outcomes of older adult patients with acute anterior circulation large-vessel occlusion (LVO) who underwent mechanical thrombectomy (MT). Therefore, we investigated the safety, functional outcomes, and predictors of MT for anterior circulation LVO in older adults. We enrolled patients with acute anterior circulation LVO from May 2018 to October 2021 in this retrospective study. Patients were divided into older (≥80 years) and young (<80 years) groups. Multivariable logistic regression analyses determined the safety, functional outcomes, and predictors of MT for anterior circulation LVO. We divided 1182 patients with acute ischemic stroke into young (18-79 years; 1028 patients) and older (≥80 years; 154 patients) groups. Compared with the young group, the older group had more unfavorable functional outcomes and increased mortality (P = .003). In the older adult patients, lower initial NIHSS score and higher ASPECTS were correlated with good outcomes. On the contrary, higher initial NIHSS score and lower ASPECTS were related to increased mortality. No difference was detected in symptomatic intracranial hemorrhage within 48 h between two groups. Increasing age was associated with lower rates of favorable functional outcomes and higher mortality rates. The lower initial NIHSS score combined with the higher ASPECTS may predict functional outcomes post-thrombectomy in older adults.

Association between Infarct Location and Hemorrhagic Transformation of Acute Ischemic Stroke following Successful Recanalization after Mechanical Thrombectomy.

The association between infarct location and hemorrhagic transformation of acute ischemic stroke after mechanical thrombectomy is not understood. We aimed to evaluate the association between CTP-based ischemic core variables at admission and hemorrhagic transformation after a successful thrombectomy. We retrospectively analyzed patients who underwent endovascular thrombectomy for acute anterior circulation large-vessel occlusion between October 2019 and June 2021. We enrolled 146 patients with visible ischemic core on pretreatment CTP who had successful reperfusion. The ischemic core infarct territories were classified into the cortical and subcortical areas and then qualitatively and quantitatively analyzed by CTP. Logistic regression and receiver operating characteristic curve analyses were performed to determine the association between ischemic core variables and hemorrhagic transformation. Of the 146 patients analyzed, 72 (49.3%) had hemorrhagic transformation and 23 (15.8%) had symptomatic intracerebral hemorrhage. Multivariate analysis showed that subcortical infarcts were independently associated with hemorrhagic transformation (OR, 8.06; 95% CI, 2.31-28.10; P = .001) and subcortical infarct volume was independently linked to symptomatic intracerebral hemorrhage (OR, 1.05; 95% CI, 1.01-1.09; P = .039). The receiver operating characteristic curve indicated that subcortical infarcts can predict hemorrhagic transformation accurately (area under the curve = 0.755; 95% CI, 0.68-0.82; P < .001) and subcortical infarct volume can predict symptomatic intracerebral hemorrhage (area under the curve = 0.694; 95% CI, 0.61-0.77; P = .002). Subcortical infarcts seen on CTP at admission are associated with hemorrhagic transformation in patients after successful thrombectomy, and subcortical infarct volume may influence the risk of symptomatic intracerebral hemorrhage.

Overall cerebral small vessel disease burden is associated with outcome of acute ischemic stroke after mechanical thrombectomy.

To investigate the association between the overall cerebral small vessel disease (CSVD) burden and the therapeutic outcome of mechanical thrombectomy (MT) in patients with acute anterior circulation large-vessel occlusion stroke. Data of patients who achieved successful revascularization after MT for acute anterior circulation large-vessel occlusion stroke in the Ningbo Medical Center Lihuili Hospital between April 2017 and January 2022 were retrospectively analyzed. The overall CSVD burden was evaluated by total CSVD score based on MRI images. According to the 90-day modified Rankin Scale (mRS) score, the participants were divided into the Good outcome group (mRS score 0-2) and Poor outcome group (mRS score 3-6). Multivariate Logistic regression was applied to assess the relationship between the overal CSVD burdern and 90-day outcome. In total, 145 eligible patients were included and classified into the Good outcome group (n = 77, 62.3% males, mean age: 64.92 ± 13.67 years) and Poor outcome group (n = 68, 50% males, mean age: 69.76 ± 10.88 years). Symptomatic intracranial hemorrhage (OR = 2.788, 95%CI: 1.143-8.745, P = 0.048), poor preoperative collateral status (OR = 3.619, 95%CI: 1.670-7.844, P = 0.001), and high total CSVD score (score 2: OR = 3.800, 95%CI: 1.173 = 12.311, P = 0.026; score 3: OR = 7.529, 95%CI: 1.555-36.460, P = 0.012) were independently prognostic for poor 90-day outcome in patients receiving MT. This study identified that the overall CSVD burden was independently associated with the prognosis of patients receiving MT for acute anterior circulation large-vessel occlusion stroke.

Quantitative Intracerebral Iodine Extravasation in Risk Stratification for Intracranial Hemorrhage in Patients with Acute Ischemic Stroke.

Intracerebral hemorrhage poses a severe threat to the outcomes in patients with postthrombectomy acute stroke. We aimed to compare the absolute intracerebral iodine concentration and normalized iodine concentration ratio in predicting intracerebral hemorrhage in patients postthrombectomy. Patients with acute anterior circulation large-vessel occlusion who underwent mechanical thrombectomy and had successful recanalization were retrospectively included in the study. Dual-energy CT was performed within 1 hour after mechanical thrombectomy. Postprocessing was performed to measure the absolute intracerebral iodine concentration and the normalized iodine concentration ratio. The correlation between the absolute intracerebral iodine concentration and the normalized iodine concentration ratio was analyzed using the Spearman rank correlation coefficient. We compared the area under the receiver operating characteristic curve of the absolute intracerebral iodine concentration and the normalized iodine concentration ratio using the DeLong test. We included 138 patients with successful recanalization. Of 43 patients who did not have parenchymal contrast staining on postthrombectomy dual-energy CT, 5 (11.6%) developed intracerebral hemorrhage. Among patients (95/138, 68.8%) with parenchymal contrast staining, 37 (38.9%, 37/95) developed intracerebral hemorrhage. The absolute intracerebral iodine concentration was significantly correlated with the normalized iodine concentration ratio (ρ = 0.807; 95% CI, 0.718-0.867; P < .001). The cutoffs of the normalized iodine concentration ratio and absolute intracerebral iodine concentration for identifying patients with intracerebral hemorrhage development were 222.8%, with a sensitivity of 67.6% and specificity of 76.4%, and 2.7 mg I/mL, with a sensitivity of 75.7% and specificity of 65.5%, respectively. No significant difference was found between the areas under the receiver operating characteristic curve for the absolute intracerebral iodine concentration and the normalized iodine concentration ratio (0.753 versus 0.738) (P = .694). The hemorrhagic transformation predictive power of the normalized iodine concentration ratio is similar to that of the absolute intracerebral iodine concentration in patients with successful recanalization.

In-Hospital Intravenous Thrombolysis Offers No Benefit in Mechanical Thrombectomy in Optimized Tertiary Stroke Center Setting

PurposeMechanical thrombectomy (MT) is the first-line treatment in acute stroke patients presenting with large vessel occlusion (LVO). The efficacy of intravenous thrombolysis (IVT) prior to MT is being contested. The objective of this study was to evaluate the efficacy of MT without IVT in patients with no contraindications to IVT presenting directly to a tertiary stroke center with acute anterior circulation LVO.Materials and MethodsWe collected the data of 106 acute stroke patients who underwent MT in a single high-volume stroke center. Patients with anterior circulation LVO eligible for IVT and directly admitted to our institution who subsequently underwent MT were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of intravenous thrombolysis on 3-month clinical outcome (mRS) was analyzed with univariate tests and binary and ordinal logistic regression analysis.ResultsFifty-eight out of the 106 patients received IVT + MT. These patients had 2.6-fold higher odds of poorer clinical outcome in mRS shift analysis (p = 0.01) compared to MT-only patients who had excellent 3-month clinical outcome (mRS 0–1) three times more often (p = 0.009). There were no significant differences between the groups in process times, mTICI, or number of hemorrhagic complications. A trend of less distal embolization and higher number of device passes was observed among the MT-only patients.ConclusionsMT without prior IVT was associated with an improved overall three-month clinical outcome in acute anterior circulation LVO patients.