Acute Ischemic Stroke Research Articles

Multiphase CTA Collateral Score to Identify Intracranial Atherosclerotic Stenosis-Related Large Vessel Occlusion

Objective: Identification of acute ischemic stroke with large vessel occlusion (AIS-LVO) etiology is crucial for effective revascularization therapy. As collaterals are pivotal in maintaining cerebral perfusion in intracranial atherosclerotic stenosis (ICAS), we investigated whether multiphase CT angiography (mCTA) collateral score can be a diagnosis marker of ICAS-related LVO. Methods: We reviewed clinical and imaging data from 92 patients who presented with AIS-LVO and underwent mCTA (57 ICAS-related LVO and 35 embolic LVO). Logistic regression was used to identify ICAS-related LVO. The diagnostic accuracy of the mCTA collateral score for identifying ICAS-related LVO was determined using receiver operating characteristic (ROC) analysis. Results: Compared with patients with embolic LVO, those with ICAS-related LVO had a high median mCTA collateral score (4 vs. 3; P<0.0001). The multinomial logistic regression analysis revealed a significant increase in the mCTA collateral score (OR: 3.717, 95% CI: 2.009-6.876, P<0.0001) in patients with ICAS-related LVO. ROC analysis revealed that the optimal cutoff point of the mCTA collateral score to diagnosis the ICAS-related LVO was 3.5, the area under the curve (AUC) was 0.817 (95% CI: 0.736-0.899; P<0.0001), sensitivity was 80.7%, and specificity was 74.3%. Further analysis revealed that patients with a 4 to 5 mCTA collateral score exhibited a significantly higher median modified Rankin Scale (mRS) at discharge compared with those with a 0 to 3 score (P=0.0464). Conclusions: The mCTA collateral score may be associated with ICAS-related LVO and could be beneficial in identifying the etiology of AIS-LVO.

Prognostic significance of serum inflammatory markers in patients with acute ischemic stroke undergoing revascularization therapy.

This study aimed to evaluate the prognostic significance of serum inflammatory factor levels in patients with acute ischemic stroke undergoing revascularization therapy. The study included 94 patients with acute ischemic stroke who underwent revascularization therapy at our hospital. The primary outcome was the modified Rankin scale (mRS) score assessed three months post-treatment. Patients were categorized into two groups: those with a poor prognosis (mRS score > 2) and those with a good prognosis (mRS score≤2). The patients were divided into two groups based on the type of revascularization treatment received: thrombus extraction or intravenous thrombolysis. Logistic regression analysis was used to identify independent risk factors associated with the prognosis of patients treated with recanalization for acute ischemic stroke. Among the 94 patients, 59 had a good prognosis, and 35 had a poor prognosis. At admission, the patients in the good prognosis group exhibited lower NIHSS scores, shorter hospital stays, fewer previous cardiac events, lower LDL levels, fasting glucose, IL-6, and TNF-a compared to those in the poor prognosis group (all P < 0.05). Logistic regression analysis identified TNF-a (odd ratio (OD), 1.623; 95% confidence interval (CI), 1.282-1.933; P = 0.035) and IL-6 (OD, 1.055; 95% CI, 1.024-1.088, P = 0.023) as independent risk factors for poor prognosis in patients after revascularization. Additionally, pre-hospital NIHSS scores, IL-6, and TNF-a levels were significantly lower in the good prognosis group compared to the poor prognosis group, with these differences being statistically significant. IL-6 and TNF-α may serve as prognostic markers for outcomes following revascularization therapy in patients with acute ischemic stroke, including those receiving intravenous thrombolysis.

Effect of ginkgo diterpene lactone meglumine on the quality of life in patients with acute ischemic stroke.

Ginkgo diterpene lactone meglumine (GDLM) could improve the functional outcome after acute ischemic stroke (AIS). This study aimed to investigate the efficacy of GDLM on the quality of life in patients with AIS in China. This is a post hoc analysis of Efficacy and Safety of Ginkgo Diterpene Lactone Meglumine in Acute Ischemic Stroke trial. The quality of life was measured using the EuroQoL questionnaire, including EQ-5D and EQ visual analogue scale (EQ-VAS). The primary outcomes were changes in EQ-5D and EQ-VAS from baseline to day 14 and day 90 after randomization. A total of 3219 patients with completed data on outcomes were enrolled, with median age of 63years (interquartile range, 55-70) and 2,067 (64.2%) men. GDLM was associated with a significant decrease in scores of ED-5Q components (from 0 [no problem] to 3[extreme problem]), the mean difference between GDLM and placebo group was -0.14 for mobility, -0.11 for usual activities and self-care, -0.09 for pain/discomfort, and -0.34 for anxiety/depression on day 14, respectively. Similar results were observed on day 90. Additionally, there was statistically significant difference of changes in EQ-VAS between the GDLM group and the placebo group from baseline to day 14 (mean difference, 1.70; 95% confidence interval [CI], 0.78-2.62; P = 0.0003) and to day 90 after randomization (mean difference, 3.29; 95% CI, 2.37-4.22; P < 0.001). In this analysis of Chinese patients with AIS, GDLM could improve the 14-day and 90-day quality of life compared with the placebo. URL: https://www. gov . Unique identifier: NCT02526225. Registration Date: 2016-02-01.

Functional Outcome Prediction of Acute Ischemic Stroke Based on the Oral and Gut Microbiota.

Although several studies have identified a distinct gut microbiota in individuals with acute ischemic stroke (AIS), there is a limited amount of research that has simultaneously investigated alterations in the oral and intestinal microbiota in AIS patients and their correlation with clinical prognosis. This was a prospective and observational single-center cohort study in which we included 160 AIS patients who were admitted within 24h after a stroke event. We collected oral and rectal swab samples for analysis using 16S rRNA high-throughput sequencing. Our study revealed that patients with unfavorable outcomes after AIS showed early disruptions in their oral and intestinal microbiota. Rectal swabs showed increased levels of facultatively anaerobic bacteria in patients with a poor prognosis, while the oral cavity exhibited higher levels of anaerobic and opportunistic pathogenic bacteria. By employing machine learning analysis, we found that the microbiota composition at both rectal and oral sites could predict early and long-term outcomes. Moreover, patients with a poor prognosis displayed increased oral bacterial colonization in the rectal microbiota and altered interactions between the oral and gut microbiota. This study reveals distinct rectal and oral bacteria that could predict unfavorable outcomes for AIS patients. Monitoring the microbiota of various body sites during the early stages after admission may hold prognostic value and inform personalized treatment strategies. The presence of oral bacteria colonizing the intestines during the acute phase of stroke could serve as an early indication of poor outcomes for AIS patients.

Efficacy and Safety of Sovateltide in Patients with Acute Cerebral Ischaemic Stroke: A Randomised, Double-Blind, Placebo-Controlled, Multicentre, Phase III Clinical Trial.

Sovateltide (Tycamzzi™), an endothelin-B (ET-B) receptor agonist, increases cerebral blood flow, has anti-apoptotic activity, and promotes neural repair following cerebral ischaemic stroke. The objectives of this study were to evaluate the efficacy and safety of sovateltide in adult participants with acute cerebral ischaemic stroke. This was a randomised, double-blind, placebo-controlled, multicentre, Phase III clinical trial of sovateltide in participants with cerebral ischaemic stroke receiving standard of care (SOC) in India. Patients aged 18-78 years presenting up to 24 h after the onset of symptoms with radiologic confirmation of ischaemic stroke and a National Institutes of Health Stroke Scale score (NIHSS) of ≥ 6were enrolled. Patients with recurrent stroke, receiving endovascular therapy, or with intracranial haemorrhage were excluded. The study drug (saline or sovateltide [0.3 µg/kg] was administered intravenously in three doses at 3 ± 1 h intervals on Days 1, 3, and 6, and follow-up was 90 days). The Multivariate Imputation by Chained Equations (MICE) was used to impute the missing assessments on the endpoints. An unpaired t-test, two-way analysis of variance with Tukey's multiple comparison test, and the Chi-square test were used for the statistical analysis. The objective was to determine at Day 90 (1) the number of patients with a modified Rankin Scale score (mRS) 0-2, and (2) the number of patients with an NIHSS 0-5 at 90 days. Patients were randomised with 80 patients in the sovateltide and 78 in the control group. Patients received the investigational drug at about 18 h of stroke onset in both control and sovateltide groups. The median NIHSS at randomisation was 10.00 (95% CI 9.99-11.65) in the control group and 9.00 (95% CI 9.11-10.46) in the sovateltide group. Seventy patients completed the 90-day follow-up in the control group and 67 in the sovateltide group. The proportion of intention-to-treat (ITT) patients with mRS 0-2 score at Day 90 post-randomisation was 22.67% higher (odds ratio [OR] 2.75, 95% CI 1.37-5.57); similarly, the proportion of patients with NIHSS score of 0-5 at Day 90 was 17.05% more (OR 2.67, 95% CI 1.27-5.90) in the sovateltide group than in the control group. An improvement of ≥ 2 points on the mRS was observed in 51.28% and 72.50% of patients in the control and sovateltide groups, respectively (OR 2.50, 95% CI 1.29-4.81). Seven of 78 patients (8.97%) in the control group and 7 of 80 (8.75%) in the sovateltide group developed intracranial haemorrhage (ICH). The adverse events were not related to sovateltide. The sovateltide group had a greater number of cerebral ischaemic stroke patients with lower mRS and NIHSS scores at 90 days post-treatment than the control group. This trial supported the regulatory approval of sovateltide in India, but a multinational RESPECT-ETB trial will be conducted for US approval. Clinical Trials Registry, India (CTRI/2019/09/021373) and the United States National Library of Medicine, ClinicalTrials.gov (NCT04047563).

Transradial versus transfemoral access for mechanical thrombectomy: A single institution experience.

There has been debate in the literature regarding the adoption of a "radial-first" approach for mechanical thrombectomy (MT) in acute ischemic stroke (AIS). Conflicting reports suggest that transradial access (TRA) may allow for shorter times to reperfusion while others conclude that long-term functional outcomes may favor transfemoral access (TFA). Here, we report a single-institution experience with the adoption of TRA as the primary route for acute stroke intervention. We retrospectively reviewed a single-institution database of patients undergoing MT for AIS from March 2020 to April 2023. This time period was selected to capture the change in clinical practice at our institution from TFA to TRA. Primary and secondary outcomes included technical success, procedural complications, and long-term functional outcomes. Patients were stratified into two cohorts from initial access. Cohorts were compared utilizing inferential statistics. A total of 192 consecutive cases were identified, with 80 in the TFA cohort and 112 in the TRA cohort. There was no difference in outcomes with respect to time from puncture to recanalization, rates of successful recanalization (TICI ≥ 2b), number of passes, rates of symptomatic intracranial hemorrhage (sICH), modified Rankin scale (mRS) at discharge and 90 days, and 90-day mortality (p ≥ 0.05, all). The TRA had a higher rate of access conversion (p < 0.001), while the TFA cohort had a higher rate of access site complications (p < 0.05).

The Relationship Between Type 2 Diabetes Mellitus and The Incidence of Acute Ischemic Stroke

Background: Ischemic stroke is a cerebrovascular disease characterized by focal or global neurological deficits with clinical signs lasting 24 hours or more caused by disruption of blood supply to the brain. Stroke is the second leading cause of death in the world with 6.7 million deaths every year. The prevalence of stroke in Indonesia according to Riskesdas in 2018 reached 10.9%, namely around 2,120,362 people in Indonesia. Type 2 diabetes mellitus is a major risk factor for ischemic stroke. Data from the International Diabetes Federation (IDF) shows that in 2021 there will be 537 million cases of DM in adults aged 20-79 years, with an estimated increase to 643 million in 2030. With the estimated number of sufferers of type 2 diabetes mellitus continuing to increase, it can be concluded that ischemic stroke sufferers also continue to increase. Methods: Observational analytic with cross-sectional design. Sampling was taken from medical record data at the Regional General Hospital. Dr. Chasbullah Abdulmadjid Bekasi City with a total of 87 patients who met the inclusion criteria Results: The results of research conducted using Chi-Square Analysis showed that there was no significant relationship between type 2 diabetes mellitus and acute ischemic stroke with a P value of 0.698. The results of the Pearson Chi-Square analysis and Fisher exact test accepted H0 and rejected H1 (there was no relationship). Conclusions: There is no significant relationship between type 2 diabetes mellitus and the incidence of acute ischemic stroke Keywords: Type 2 diabetes mellitus, Ischemic, Stroke

Association of Pretreatment Perfusion Imaging Parameters With 90-Day Excellent Functional Outcomes in Anterior Circulation Distal Medium Vessel Occlusion Stroke.

Acute ischemic strokes caused by distal medium vessel occlusions (DMVO) represent a significant proportion of all stroke cases, yet the predictors of excellent functional outcomes in these patients remain poorly understood. This study aims to identify pretreatment computed tomography perfusion (CTP) parameters associated with excellent functional outcomes, defined as a modified Rankin Scale (mRS) score of 0-1 at 90 days, in patients with anterior circulation DMVO. We conducted a retrospective multicenter study involving patients with anterior DMVO, from three stroke centers within the Johns Hopkins Medical Enterprise. Baseline demographic, clinical, and imaging data were collected, with CTP parameters analyzed using RAPIDAI software. Univariable and multivariable logistic regression models were used to identify predictors of excellent outcomes. Receiver operating characteristic (ROC) curves were constructed to assess the predictive accuracy of CTP parameters. Among the 82 patients (median age, 71 years; 57% female), occlusions were located in the M2 segment in 89%, M3 in 8.5%, and A2 in 2.4%. IVT was administered to 37% of patients, and EVT was attempted in 59%. Excellent outcomes at 90 days were achieved in 45% of patients. In univariate analysis, white race (OR, 4.14; 95% CI, 1.66-10.9; P=0.003), higher CBV index (OR per 0.1-unit change, 1.45; 95% CI, 1.08-2.05; P=0.022), and lower relative cerebral blood flow (rCBF < 20%) volumes (OR, 0.91; 95% CI, 0.81-0.98; P=0.038) were significantly associated with excellent outcomes. In multivariate analysis adjusting for age, sex, race, IVT administration, EVT attempted, dyslipidemia, and premorbid mRS, higher CBV index remained a significant independent predictor (OR per 0.1-unit change, 1.72; 95% CI, 1.14-2.81; P=0.017), and lower rCBF < 20% volume was associated with better outcomes (OR, 0.91; 95% CI, 0.80-0.98; P=0.05). The multivariate model demonstrated good predictive performance (area under the ROC curve, 80%; 95% CI, 70%-90%; P < 0.001). In patients with anterior circulation DMVO, a higher CBV index on pretreatment CTP is an independent predictor of excellent functional outcomes at 90 days. These findings suggest that CTP parameters, particularly the CBV index, may be useful in prognostic assessment for this stroke population. Further studies are needed to validate these results and optimize therapeutic approaches. ABC＝ definition; XYZ＝ definition.

Prolonged intracranial catheter dwell time exacerbates penumbral stress and worsens stroke thrombectomy outcomes

BackgroundThe duration of mechanical thrombectomy (MT) is a negative predictor of outcomes in acute ischemic stroke (AIS), yet the precise mechanisms are unclear. We investigated whether the placement of large-bore...

Predictive models for secondary epilepsy in patients with acute ischemic stroke within one year

Predictive models for secondary epilepsy in patients with acute ischemic stroke within one year

Predictive models for secondary epilepsy in patients with acute ischemic stroke within one year.

Post-stroke epilepsy (PSE) is a critical complication that worsens both prognosis and quality of life in patients with ischemic stroke. An interpretable machine learning model was developed to predict PSE using medical records from four hospitals in Chongqing. Medical records, imaging reports, and laboratory test results from 21,459 ischemic stroke patients were collected and analyzed. Univariable and multivariable statistical analyses identified key predictive factors. The dataset was split into a 70% training set and a 30% testing set. To address the class imbalance, the Synthetic Minority Oversampling Technique combined with Edited Nearest Neighbors was employed. Nine widely used machine learning algorithms were evaluated using relevant prediction metrics, with SHAP (SHapley Additive exPlanations) used to interpret the model and assess the contributions of different features. Regression analyses revealed that complications such as hydrocephalus, cerebral hernia, and deep vein thrombosis, as well as specific brain regions (frontal, parietal, and temporal lobes), significantly contributed to PSE. Factors such as age, gender, NIH Stroke Scale (NIHSS) scores, and laboratory results like WBC count and D-dimer levels were associated with increased PSE risk. Tree-based methods like Random Forest, XGBoost, and LightGBM showed strong predictive performance, achieving an AUC of 0.99. The model accurately predicts PSE risk, with tree-based models demonstrating superior performance. NIHSS score, WBC count, and D-dimer were identified as the most crucial predictors. The research is funded by Central University basic research young teachers and students research ability promotion sub-projec t(2023CDJYGRH-ZD06), and by Emergency Medicine Chongqing Key Laboratory Talent Innovation and development joint fund project (2024RCCX10).

Tenecteplase thrombolytic therapy for acute ischaemic stroke in China: a real-world, multicentre, retrospective, controlled study

Background and aimsTenecteplase (TNK) offers logistical advantages in stroke thrombolytic therapy with its single bolus administration compared with alteplase. We aim to investigate the real-world evidence regarding its safety and effectiveness in China.MethodsWe conducted a retrospective study on patients receiving alteplase or TNK for acute ischaemic stroke (AIS) within 4.5 hours of onset between 1 March 2019 and 1 October 2023, from 18 stroke centres in China. Using propensity score matching (PSM), TNK-treated patients were matched 1:1 with alteplase-treated patients. The primary outcome was the rate of symptomatic intracranial haemorrhage (sICH) within 72 hours post-thrombolysis. Secondary outcomes comprised the rate of parenchymal haemorrhage type 2, any intracranial haemorrhage, any systematic bleeding and mortality at 90 days, as well as 24-hour National Institutes of Health Stroke Scale (NIHSS), early neurological improvement at 24 hours, modified Rankin Scale (mRS) shift, percentage of mRS 0–1 and mRS 0–2 at 90 days.ResultsWe identified 1113 patients with AIS who received TNK and 2360 patients who received alteplase. Following PSM, 1113 TNK-treated patients with AIS were matched to 1113 patients treated with alteplase. No significant differences were observed in rates of sICH (1.8% vs 1.98%, p=0.864) or other safety outcomes. Moreover, TNK-treated patients demonstrated a lower rate of any intracranial haemorrhage (OR: 0.51, 95% CI: 0.31 to 0.86, p=0.012). A higher proportion of patients achieving early neurological improvement at 24 hours (OR: 1.76, 95% CI: 1.48 to 2.09, p=0.000), better 90-day mRS (OR: 0.67, 95% CI: 0.57 to 0.79, p=0.000) as well as higher percentages of 90-day mRS 0–1 (OR: 1.27, 95% CI: 1.05 to 1.54, p=0.012) and mRS 0–2 (OR: 1.41, 95% CI: 1.14 to 1.75, p=0.001) compared with alteplase.ConclusionsThrombolysis with TNK is not associated with an increased risk of sICH, and may result in better early neurological improvement and 90-day functional outcomes compared with alteplase in patients with AIS.

The role of neutrophils in tPA thrombolysis after stroke: a malicious troublemaker

Acute ischemic stroke represents a critical, life-threatening condition affecting the central nervous system. Intravenous thrombolysis with tissue plasminogen activator (tPA) remains a cornerstone for achieving vascular recanalization in such patients; however, its therapeutic utility is limited, with only approximately 10% of patients benefiting due to the narrow therapeutic window and significant risk of hemorrhagic transformation. Enhancing the efficacy of tPA thrombolysis is therefore imperative. Neutrophils have been identified as key modulators of thrombolytic outcomes, interacting with tPA post-stroke to influence treatment effectiveness. The binding of tPA to low-density lipoprotein receptor-related protein 1 (LRP-1) on neutrophil surfaces induces degranulation and formation of neutrophil extracellular traps (NETs). Conversely, neutrophils impede the thrombolytic action of tPA by obstructing its interaction with fibrin and activating platelets. These findings suggest that targeting neutrophils may hold promise for improving thrombolysis outcomes. This review explores the role of neutrophils in tPA-mediated thrombolysis following acute ischemic stroke, examines neutrophil-associated biomarkers, and outlines potential strategies for enhancing tPA efficacy.

Characteristics and In-Hospital Outcomes of Single-Vessel Coronary Disease Intervention: A Propensity-Matched Analysis of the National Inpatient Sample Database 2016–2020

Background/Objectives: Few studies have analyzed in-hospital complications and events following percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) procedures for patients who underwent these interventions for single-vessel coronary artery disease (CAD). This study aims to compare the outcomes of PCI and CABG in such patients using a large propensity-matched real-world database based on procedural codes. Methods: Adult patients receiving PCI or CABG for single-vessel CAD were identified from the 2016–2020 National Inpatient Sample (NIS) database. Any cases targeting multi-vessel disease or employing a multi-treatment approach were excluded using appropriate procedural codes. Differences in events and complications from admission to discharge were studied between the two procedures (PCI vs. CABG) via logistic regression analysis. Results: After propensity matching with 273,380 patients in both groups, complication risks such as cardiac tamponade (aOR: 3.6 [3.27–3.96]), acute kidney injury (aOR: 1.53 [1.51–1.56]), cardiogenic shock (aOR: 1.38 [1.34–1.40]), procedural bleeding (aOR: 1.75 [1.67–1.83]), acute ischemic stroke (aOR: 1.89 [1.80–1.97]), and all-cause mortality (aOR: 1.05 [1.02–1.08]) were higher among CABG patients. No differences were observed for events of cardiac perforation (aOR: 0.92, [0.84–1.01]). Conclusions: In this large real-world propensity-matched analysis, CABG was associated with higher risks of multiple in-hospital complications and all-cause mortality compared to PCI following a single-vessel coronary intervention.

Treatments and Patient Outcomes Following Stroke Center Expansion.

It is unclear how certified stroke center expansion contributes to improved access to stroke treatment and patient outcomes, and whether these outcomes differ by baseline stroke center access. To examine changes in rates of admission to stroke centers, receipt of thrombolysis and mechanical thrombectomy, and mortality when a community gains a newly certified stroke center within a 30-minute drive. This cohort study compared changes in patient outcomes when a community (defined by area zip code) experienced a stroke center expansion relative to the same community type that did not experience a change in access. Medicare fee-for-service beneficiaries with a primary diagnosis of acute ischemic stroke who were admitted to hospitals between January 1, 2009, and December 31, 2019, were included. The data analysis was performed between October 1, 2023, and September 9, 2024. New certification of a stroke center within a 30-minute driving time of a community. The main outcomes were rates of admission to a certified stroke center, receipt of thrombolytics (delivered using drip-and-ship and drip-and-stay methods), mechanical thrombectomy, and 30-day and 1-year mortality estimated using a linear probability model with community fixed effects. Among the 2 853 508 patients studied (mean [SD] age, 79.5 [8.5] years; 56% female), 66% lived in communities that had a stroke center nearby at baseline in 2009, and 34% lived in communities with no baseline access. For patients without baseline access, after stroke center expansion, the likelihood of admission to a stroke center increased by 38.98 percentage points (95% CI, 37.74-40.21 percentage points), and receipt of thrombolytics increased by 0.48 percentage points (95% CI, 0.24-0.73 percentage points). Thirty-day and 1-year mortality decreased by 0.28 percentage points (95% CI, -0.56 to -0.01) and 0.50 percentage points (95% CI, -0.84 to -0.15 percentage points), respectively, after expansion. For patients in communities with baseline stroke center access, expansion was associated with an increase of 9.37 percentage points (95% CI, 8.63-10.10 percentage points) in admission to a stroke center but no significant changes in other outcomes. In this cohort study, patients living in communities without baseline stroke center access experienced significant increases in stroke center admission and thrombolysis and a significant decrease in mortality after a stroke center expansion. Improvements were smaller in communities with preexisting stroke center access. These findings suggest that newly certified stroke centers may provide greater benefits to underserved areas and are an important consideration when deciding when and where to expand health care services.

Case Report: Delayed Cerebral Ischemia with Infarction following an Undiagnosed Aneurysmal Rupture - The Diagnostic and Management Challenge

Delayed Cerebral Ischemia (DCI) typically occurs a few days after a patient suffers subarachnoid hemorrhage and can lead to a range of poor outcomes. It is primarily driven by vasospasm and its delayed and variable presentation complicates diagnosis and treatment. Here we report a case of DCI in a 31-yearold man who presented with acute onset aphasia, right-sided weakness, and difficulty swallowing. He had experienced a severe headache accompanied by nausea and vomiting 5 days prior, with an initial NIH stroke scale score of 10. Imaging revealed a left internal carotid artery aneurysm and a watershed infarct between the anterior cerebral artery and middle cerebral artery. The patient was treated with aneurysmal coiling, intraarterial verapamil, and oral nimodipine for suspected DCI secondary to subarachnoid hemorrhage. Close monitoring of the patient and treatment led to the resolution of neurological deficits over the subsequent days., with imaging confirming reperfusion. This case presents a unique challenge due to the delayed presentation and vague history. Diagnosis and treatment of DCI following aneurysmal rupture are complicated due to its delayed and variable onset. It is crucial to consider acute aneurysmal subarachnoid hemorrhage and DCI when evaluating patients who present with multiple stroke-like symptoms over several days as the management and prognosis differ from other cases of acute ischemic stroke.

Abstract 4120957: Endovascular Thrombectomy Versus Medical Management for Acute Ischemic Stroke with Large Infarct: An Updated Meta-Analysis of Randomized Controlled Trials

Background: Endovascular therapy (EVT) has revolutionized the treatment of acute ischemic stroke due to large vessel occlusions. Despite the increasing evidence for EVT, its efficacy remains understudied in patients with acute ischemic stroke with large infarcts. Patients with large-volume ischemic strokes are excluded from major randomized controlled trials (RCTs) despite contributing up to 25% of all acute ischemic strokes. Aim: This study aimed to compare clinical outcomes with endovascular thrombectomy versus medical management in patients with acute ischemic stroke with large infarct. Methods: We conducted a systematic literature review on PubMed, Embase, Scopus and Cochrane Library from inception to 15th May 2024 for RCTs. The inverse-variance random-effects model was used to pool odds ratio (OR) and risk ratio (RR) with 95% confidence intervals. The statistical significance was set at p&lt;0.05. Results: 6 RCTs with 1887 patients (945: EVT and 942: medical management) were included. The mean age in both EVT and medical management groups was 70 ± 11.4 years. EVT was associated with a better modified Rankin Score (mRS) at 90 days [OR: 1.68; 95% CI: 1.38, 2.04; p&lt;0.00001], mRS at 90 days (0-2) [OR: 2.47; 95% CI: 1.87, 3.27; p&lt;0.00001], mRS at 90 days (0-3) [OR: 1.96; 95% CI: 1.56, 2.46; p&lt;0.00001], and early neurological improvement [RR: 2.35; 95% CI: 1.79, 3.10; p&lt;0.00001] compared to medical management. EVT was also associated with a higher risk of symptomatic intracranial hemorrhage [RR: 1.71; 95% CI: 1.09, 2.66; p=0.02]. The 90-day mortality [RR: 0.86; 95% CI: 0.72, 1.02; p=0.08] was comparable between the two groups. Conclusion: Patients with acute ischemic stroke with large infarct had superior functional outcomes with EVT as compared to medical management alone. However, EVT was associated with higher risks of symptomatic intracranial hemorrhage, with comparable 90-day mortality risk. Further large RCTs are warranted to evaluate the outcomes with EVT in acute ischemic stroke with large infarct.

Effects of Social Determinants of Health on Acute Stroke Care Among Patients With Acute Ischemic Stroke: A Retrospective Cohort Study.

Social determinants of health (SDOH) are important contributors to poor stroke-related outcomes. While some have suggested that this association is driven by the increased incidence of stroke observed with poor SDOH, others have raised concerns regarding disparities in acute stroke care. This study aimed to determine the association between SDOH and the administration of thrombolytic therapy and mechanical thrombectomy among patients with acute ischemic stroke. A retrospective cohort analysis was conducted using Texas Emergency Department Public Use Data (2016-2019), including adult patients diagnosed with acute ischemic stroke. The risk ratios (RRs) of administering thrombolysis and thrombectomy based on variables representing SDOH and a collective measure (Social Vulnerability Index [SVI]) were computed using mixed-effects Poisson regression models accounting for the nested nature of patients in hospitals and neighborhoods. The Charlson comorbidity score was considered as a covariate. Of the 139,852 patients with ischemic stroke (female, 51.7%; White, 67.2%; Black, 16.6%; Hispanic, 25.1%), 16,831 (12.3%) received thrombolytic therapy and 5,951 (4.3%) received mechanical thrombectomy. Age older than 65 years (RR 0.578 [0.537-0.621]) vs 18-45 years, Black (RR 0.801 [0.761-0.844]) vs White, Hispanic (RR 0.936 [0.895-0.98]) vs non-Hispanic, Medicare/Medicaid/Veterans Affairs (VA) (RR 0.917 [0.882-0.954]) or uninsured (RR 0.883 [0.833-0.935]) vs private insurance, and rural (RR 0.782 [0.723-0.845]) vs urban dwelling were less likely to be associated with thrombolysis. Patients in the highest quintile based on the SVI were less likely to receive thrombolysis than those in the lowest quintile (RR 0.926 [0.867-0.989]). Patients were less likely to receive thrombectomy if they were 65 years and older (RR 0.787 [0.691-0.895]), belonged to the Black race (RR 0.745 [0.679-0.818]) or Hispanic ethnicity (RR 0.919 [0.851-0.992]), had Medicare/Medicaid/VA insurance (RR 0.909 [0.851-0.971]), or were from a rural area (RR 0.909 [0.851-0.971]). Similarly, SVI decreased the likelihood of undergoing mechanical thrombectomy (RR 0.842 [0.747-0.95]). Despite many improvements in stroke management, SDOH continue to be a significant driver of treatment access for acute ischemic stroke. While our findings are limited to Texas, our results should raise awareness and promote more studies regarding the effects of these SDOH at the national and international levels.

Tenecteplase vs Alteplase in Acute Ischemic Stroke Within 4.5 Hours: A Systematic Review and Meta-Analysis of Randomized Trials.

The current European Stroke Organisation expedited recommendation on tenecteplase (TNK) for acute ischemic stroke (AIS) advocates that TNK 0.25 mg/kg can be used alternatively to alteplase (tissue plasminogen activator [TPA]) for AIS of <4.5 hours duration, based on a meta-analytical approach establishing noninferiority. Since the publication of these guidelines, 4 additional randomized controlled clinical trials (RCTs) have provided further insight. We conducted an updated systematic review and meta-analysis including all available RCTs that investigated efficacy and safety of TNK 0.25 mg/kg compared with TPA for the treatment of AIS within 4.5 hours of onset. The primary outcome was defined as the excellent functional outcome at 3 months (modified Rankin Scale [mRS] score 0-1), whereas good functional outcome (mRS score 0-2), reduced disability at 3 months (≥1-point reduction across all mRS scores), symptomatic intracranial hemorrhage (sICH), and 3-month mortality were evaluated as secondary outcomes. Pooled estimates were calculated with random-effects model. A prespecified subgroup analysis was performed stratifying for TNK formulation, that is, original TNK vs biocopy: recombinant human TNK tissue-type plasminogen activator that is available in China and has a different production process. Eleven RCTs were included comprising a total of 3,788 patients treated with TNK vs 3,757 patients treated with TPA. TNK was associated with higher likelihood of excellent functional outcome (risk ratio [RR] 1.05, 95% CI 1.01-1.10; p = 0.012; I2 = 0%; risk difference 2.95%; 95% CI 0.76%-5.14%; p = 0.008; I2 = 0%) and reduced disability at 3 months (common odds ratio 1.10, 95% CI 1.01-1.19; p = 0.034; I2 = 0%) compared with TPA while good functional outcome (RR 1.03, 95% CI 0.99-1.07; p = 0.142; I2 = 28%) was similar between the groups. Regarding safety outcomes, similar rates of sICH (RR 1.12, 95% CI 0.83-1.53; p = 0.456; I2 = 0%) and 3-month mortality (RR 0.97, 95% CI 0.82-1.15; p = 0.727; I2 = 12%) were observed. When stratified for TNK regimen (original vs biocopy), statistical significance in achieving an excellent functional outcome at 3 months was retained for the original TNK (RR 1.05, 95% CI 1.00-1.10; p = 0.044; I2 = 0%). The updated meta-analysis confirms similar safety between TNK 0.25 mg/kg and TPA, while showing that TNK is superior to TPA regarding excellent functional outcome and reduced disability at 3 months. These findings support transitioning to TNK in clinical practice.

Abstract 4135142: Sex-Based Differences in In-Hospital Complications Among Older Patients With Prior Myocardial Infarction Undergoing Cardiac Resynchronization Therapy-Defibrillator Implantation; An Analysis of 13695 Procedures in the United States

Introduction: Cardiac Resynchronization Therapy-Defibrillator (CRT-D) use has increased over the past two decades. As this procedure often also involves patients with a prior history of myocardial infarction(MI), we aim to evaluate potential sex-based disparities in short-term complications among the elderly. Methods: Our sample consisted of patients ages &gt;60 years with a prior history of myocardial infarction undergoing CRT-D. The data was extracted via the 2016-2021 National Inpatient Sample(NIS). Adjusted odds ratios(aOR) of in-hospital complications between Females and Males were estimated using multivariable regression analyses, taking into account potential confounders. Results: Out of 13695 CRT-D procedures among older patients (ages &gt;60 years), 2880(21.0%) were Females, with 10815(79.0%) Males. The median age of all patients was 74.0 years(mean of 73.99 years). Females were at higher odds of experiencing cardiogenic shock (aOR 1.231, 95% CI 1.013-1.495, p=0.036), cardiac arrest(aOR 1.413, 95% CI 1.150-1.737, p=0.001), pericardial effusion(aOR 2.334, 95% CI 1.704-3.198,p=0.000), and pneumothorax(aOR 2.107, 95%CI 1.089-4.075, p=0.027) than Males. No differences were reported in events of acute kidney injury (AKI)(aOR 0.923,95%CI 0.832-1.024, p=0.132), acute ischemic stroke (AIS)(aOR 1.166, 95%CI 0.585-2.324,p=0.662), pleural effusion(aOR 0.827,95%CI 0.618-1.107, p=0.203), and sepsis(aOR 0.743,95%CI 0.506-1.092,p=0.130) between the two sexes. Furthermore, we found sex-based disparities in mortality as 1.6% of Females (vs. 1.0% of Males, aOR 1.729, 95% CI 1.161-2.576, p&lt;0.01) did not survive their hospitalization. Finally, our analysis noted that Males and Females did not have any differences in mean lengths of stay(LOS)(Males: 6.06 days vs. Females: 6.26 days, p=0.056). Conclusion: Our results confirm that among the elderly with a prior history of MI, Females are prone to a poor prognosis with multiple complications during CRT-D implantations, including pericardial effusion, cardiac arrest, cardiogenic shock, and all-cause mortality. It is vital to advocate for additional studies to understand the various factors predisposing females to these complications and bring forward adequate measures to prevent them.