Large Vessel Occlusion Acute Stroke Research Articles

The value of cardiopulmonary comorbidity in patients with acute large vessel occlusion stroke undergoing endovascular thrombectomy: a retrospective, observational cohort study

BackgroundChronic lung and heart diseases are more likely to lead an intensive end point after stroke onset. We aimed to investigate characteristics and outcomes of endovascular thrombectomy (EVT) in patients with acute large vessel occlusion stroke (ALVOS) and identify the role of comorbid chronic cardiopulmonary diseases in ALVOS pathogenesis.MethodsIn this single-center retrospective study, 191 consecutive patients who underwent EVT due to large vessel occlusion stroke in neurological intensive care unit were included. The chronic cardiopulmonary comorbidities and several conventional stroke risk factors were assessed. The primary efficacy outcome was functional independence (defined as a mRS of 0 to 2) at day 90. The primary safety outcomes were death within 90 days and the occurrence of symptomatic intracranial hemorrhage(sICH). Univariate analysis was applied to evaluate the relationship between factors and clinical outcomes, and logistic regression model were developed to predict the prognosis of ALVOS.ResultsEndovascular therapy in ALVOS patients with chronic cardiopulmonary diseases, as compared with those without comorbidity, was associated with an unfavorable shift in the NHISS 24 h after EVT [8(4,15.25) versus 12(7.5,18.5), P = 0.005] and the lower percentage of patients who were functionally independent at 90 days, defined as a score on the modified Rankin scale of 0 to 2 (51.6% versus 25.4%, P = 0.000). There was no significant between-group difference in the frequency of mortality (12.1% versus 14.9%, P = 0.580) and symptomatic intracranial hemorrhage (13.7% versus 19.4%, P = 0.302) or of serious adverse events. Moreover, a prediction model showed that existence of cardiopulmonary comorbidities (OR = 0.456, 95%CI 0.209 to 0.992, P = 0.048) was independently associated with functional independence at day 90.ConclusionsEVT was safe in ALVOS patients with chronic cardiopulmonary diseases, whereas the unfavorable outcomes were achieved in such patients. Moreover, cardiopulmonary comorbidity had certain clinical predictive value for worse stroke prognosis.

214 Technical and Clinical Outcomes in Patients With Short-term Repeated Mechanical Thrombectomy: An International Multicenter Study

INTRODUCTION: Endovascular thrombectomy (EVT) remains the standard of care for acute large vessel occlusion (LVO) stroke. However, the safety and efficacy of repeat EVT (rEVT) in recurrent LVO remains unclear. METHODS: Data were included from the Stroke Thrombectomy and Aneurysm Registry (STAR) with 21 stroke centers for EVT performed to treat LVO stroke from 2013-2022. Patients undergoing single or rEVT within 30 days were included. Propensity score matching was used to compare patients undergoing single versus rEVT. The primary outcome was the modified Rankin score(mRS) at 90 days, and secondary outcomes were successful recanalization, postprocedural hemorrhage and mortality. RESULTS: Out of a total of 7387 patients who underwent EVT for LVO stroke, 90(1.2%) patients underwent rEVT for the same vascular territory within 30 days. The average time to re-occlusion was 5.3±7.3 days, and 41(45.6%) patients required rEVT within 24hrs. Patients undergoing rEVT had comparable rate of good functional outcome and mortality rate, but with but higher rate of symptomatic intracranial hemorrhage compared to a matched cohort of patients undergoing single procedure. There was a significant reduction in NIHSS before rEVT and at discharge (ΔNIHSS=(-)5 ± 1; p = 0.006). The rate of successful recanalization was similar in single and rEVT groups (78% versus 80%, p = 0.78) and between index and rEVT performed on the same patients (79% versus 80%; p = 0.78). CONCLUSIONS: Short-term rEVT is associated with comparable functional outcomes but with higher rate of hemorrhagic conversion compared to patients undergoing single EVT.

One-year morbidity and mortality in patients treated with standard-dose and low-dose apixaban after acute large vessel occlusion stroke

Although low-dose direct oral anticoagulants (DOACs) are recommended for patients at high risk of bleeding complications, it remains unclear whether the dose reduction in real-world setting is also appropriate in patients after large-vessel occlusion (LVO) stroke. This study hypothesized that patients with atrial fibrillation (AF) and LVO receiving low-dose DOACs have an increased risk of ischemic and hemorrhagic events. The study aimed to assess 1 year morbidity and mortality in patients treated with standard-dose and low-dose apixaban after LVO stroke. A post hoc analysis was performed using the acute LVO registry data, which enrolled patients with AF and LVO who received apixaban within 14 days of stroke onset. The incidences of ischemic events (ischemic stroke, acute coronary syndrome, acute myocardial infarction, and systemic embolism), major bleeding events, and death from any cause were compared between patients receiving standard- and low-dose apixaban. Of 643 patients diagnosed with LVO, 307 (47.7%) received low-dose apixaban. After adjustment for clinically relevant variables, no significant differences were observed in the incidence of ischemic events (adjusted hazard ratio [aHR]: 2.12, 95% confidence interval [CI] 0.75–6.02), major bleeding events (aHR: 1.17, 95% CI 0.50–2.73), and death from any cause (aHR: 1.95, 95% CI 0.78–4.89) between patients receiving standard- and low-dose apixaban. No significant differences were observed in the incidence of ischemic events, major bleeding events, or death from any cause between patients with AF and LVO receiving standard- and low-dose apixaban.

Utilizing RNA sequencing to identify gene expression markers of stroke-causing thrombi origin: A pilot study

IntroductionStroke embolic source have an unknown origin in 30-40% of cases. Mechanical thrombectomy for acute large vessel occlusion stroke has provided us with a method to directly retrieve the thrombi from patients for analysis. By collecting stroke-causing thrombi from known sources, we can then use high-throughput RNA sequencing (RNAseq) technology to directly measure the gene expression signatures of these clots. This may allow us to identify genetic markers to predict the cause of cryptogenic embolism. MethodsThis is a prospective study in which RNAseq was used to analyze cerebral thrombi retrieved by mechanical thrombectomy devices in acute ischemic stroke patients. Samples were separated into two groups based on known stroke thrombus etiology, including Carotid group (patients with ipsilateral >70% carotid stenosis) and Atrial fibrillation (AF) group (patients with atrial fibrillation). Gene expression was compared by RNAseq analysis between the groups. ResultsFrom October 2016 to September 2017, 8 thrombi (4 in Carotid group, 4 in Afib group) were included in this study. There were 131 genes that were significantly up- or down-regulated between the two groups defined as a false discovery rate ≤ 0.05 and a fold change ≥ 2. Twenty-six genes were selected as candidate gene biomarkers based on the criteria in the methods section. Candidate genes HSPA1B, which encodes a heatshock protein, and GPRC5B, which encodes a G-protein, showed the greatest fold differences in expression between the two groups. ConclusionThis study has shown that RNA sequencing of acute ischemic stroke thrombi is feasible and indentified potential novel biomarkers for identifying stroke-causing thrombi origin, especially in cryptogenic stroke.

Radiomics-Based Prediction of Collateral Status from CT Angiography of Patients Following a Large Vessel Occlusion Stroke.

A major driver of individual variation in long-term outcomes following a large vessel occlusion (LVO) stroke is the degree of collateral arterial circulation. We aimed to develop and evaluate machine-learning models that quantify LVO collateral status using admission computed tomography angiography (CTA) radiomics. We extracted 1116 radiomic features from the anterior circulation territories from admission CTAs of 600 patients experiencing an acute LVO stroke. We trained and validated multiple machine-learning models for the prediction of collateral status based on consensus from two neuroradiologists as ground truth. Models were first trained to predict (1) good vs. intermediate or poor, or (2) good vs. intermediate or poor collateral status. Then, model predictions were combined to determine a three-tier collateral score (good, intermediate, or poor). We used the receiver operating characteristics area under the curve (AUC) to evaluate prediction accuracy. We included 499 patients in training and 101 in an independent test cohort. The best-performing models achieved an averaged cross-validation AUC of 0.80 ± 0.05 for poor vs. intermediate/good collateral and 0.69 ± 0.05 for good vs. intermediate/poor, and AUC = 0.77 (0.67-0.87) and AUC = 0.78 (0.70-0.90) in the independent test cohort, respectively. The collateral scores predicted by the radiomics model were correlated with (rho = 0.45, p = 0.002) and were independent predictors of 3-month clinical outcome (p = 0.018) in the independent test cohort. Automated tools for the assessment of collateral status from admission CTA-such as the radiomics models described here-can generate clinically relevant and reproducible collateral scores to facilitate a timely treatment triage in patients experiencing an acute LVO stroke.

Alterations of Hemostatic Molecular Markers During Acute Large Vessel Occlusion Stroke.

This study aimed to investigate regional levels of TAT (thrombin-antithrombin complex), PIC (plasmin-α2 plasmin inhibitor complex), t-PAIC (tissue plasminogen activator-plasminogen activator inhibitor complex), sTM (soluble thrombomodulin), and D-dimer, along with their associations with clinical and procedural characteristics in patients with acute ischemic stroke undergoing endovascular thrombectomy. We retrospectively analyzed 166 consecutive patients with acute ischemic stroke (62±11.54 years of age, 34.3% women) using prospectively maintained clinical databases and blood samples from local ischemic (proximal to thrombus) and systemic (femoral artery, self-control) arterial compartments. Levels of TAT, PIC, t-PAIC, and D-dimer were significantly elevated, whereas sTM was significantly reduced, in local ischemic regions compared with their systemic levels. Each 1-unit increase in ischemic TAT (adjusted odds ratio [aOR], 1.086 [95% CI, 1.03-1.145]; P=0.002; area under the curve [AUC], 0.833) and PIC (aOR, 1.337 [95% CI, 1.087-1.644]; P=0.006; AUC, 0.771) correlated significantly with higher symptomatic intracranial hemorrhage risk. Additionally, each 1-unit increase in ischemic TAT (aOR, 1.076 [95% CI, 1.016-1.139]; P=0.013; AUC, 0.797), PIC (aOR, 1.554 [95% CI, 1.194-2.022]; P=0.001; AUC, 0.798), and sTM (aOR, 0.769 [95% CI, 0.615-0.961]; P=0.021; AUC, 0.756) was significantly associated with an increased risk of an unfavorable 90-day outcome (modified Rankin scale of 3-6). These hemostatic molecules, individually or combined, significantly improved the predictive power of conventional risk factors, as evidenced by significant increases in net reclassification improvement and integrated discrimination improvement (all P<0.01). We observed a hyperactive state of the coagulation-fibrinolysis system within the local ischemic region during hyperacute stroke. Rapid automated measurement of hemostatic molecular markers, particularly TAT, PIC, and sTM, during intra-arterial procedures may provide additional information for stroke risk stratification and therapeutic decision-making, and warrants further investigation.

Impact of leukoaraiosis on the infarct growth rate and clinical outcome in acute large vessel occlusion stroke after endovascular thrombectomy.

As a marker of chronic cerebral small vessel disease, leukoaraiosis (LA) was reported to impact the recruitment of collaterals in acute ischemic stroke (AIS). We intended to explore the impact of LA on the infarct growth rate (IGR) and clinical outcome by impaired collateral development in AIS patients with large vessel occlusion (LVO) who underwent endovascular thrombectomy (EVT). Two hundred thirty-six AIS patients who underwent EVT were retrospectively reviewed. The severity of LA was graded using the Fazekas scale with non-contrast CT. IGR was calculated by the acute core volume on CT perfusion divided by the time from stroke onset to imaging. The collateral status after LVO was assessed using the ASITN/SIR collateral scale. The clinical outcomes after EVT were evaluated using a modified Rankin Scale (mRS). The Alberta stroke program early CT score (ASPECTS), the National Institutes of Health Stroke Scale (NIHSS) score at admission, and the modified treatment in cerebral infarction (mTICI) score after EVT were also included. Correlations between those factors were analyzed. Patients with severe LA had significantly larger core volume on CTP (p = 0.022) and lower collateral grade (p < 0.001). Faster IGR was significantly associated with higher LA severity (adjusted odds ratio [aOR]: 1.53; 95% CI: 1.02-2.33; p = 0.046), higher NIHSS (aOR: 1.04; 95% CI: 1.00-1.09; p = 0.032) and impaired collaterals (aOR: 2.26; 95% CI: 1.27-4.03; p = 0.005). In mediation analysis, collaterals explained 33% of the effect of LA on fast IGR. There was correlation between the severity of LA and mRS (p = 0.007). The increasing severity of LA is associated with impaired collateral status and fast infarct growth. These findings suggest that LA may become a predictive imaging biomarker for the likelihood of progression of tissue injury and clinical outcome after EVT in acute large vessel occlusion stroke.

Repeat thrombectomy after large vessel re-occlusion: a propensity score matched analysis of technical and clinical outcomes

BackgroundEndovascular thrombectomy (EVT) remains the standard of care for acute large vessel occlusion (LVO) stroke. However, the safety and efficacy of repeat thrombectomy (rEVT) in recurrent LVO remains unclear. This...

Endovascular thrombectomy is cost-saving in patients with acute ischemic stroke with large infarct.

Endovascular thrombectomy (EVT) is the standard of care for acute large vessel occlusion stroke. Recently, the ANGEL-ASPECT and SELECT 2 trials showed improved outcomes in patients with acute ischemic Stroke presenting with large infarcts. The cost-effectiveness of EVT for this subpopulation of stroke patients has only been calculated using data from the previously published RESCUE-Japan LIMIT trial. It is, therefore, limited in its generalizability to an international population. With this study we primarily simulated patient-level costs to analyze the economic potential of EVT for patients with large ischemic stroke from a public health payer perspective based on the recently published data and secondarily identified determinants of cost-effectiveness. Costs and outcome of patients treated with EVT or only with the best medical care based on the recent prospective clinical trials ANGEL-ASPECT, SELECT2 and RESCUE-Japan LIMIT. A A Markov model was developed using treamtment outcomes derived from the most recent available literature. Deterministic and probabilistic sensitivity analyses addressed uncertainty. Endovascular treatment resulted in an incremental gain of 1.32 QALYs per procedure with cost savings of $17,318 per patient. Lifetime costs resulted to be most sensitive to the costs of the endovascular procedure. EVT is a cost-saving (i.e., dominant) strategy for patients presenting with large ischemic cores defined by inclusion criteria of the recently published ANGEL-ASPECT, SELECT2, and RESCUE-Japan LIMIT trials in comparison to best medical care in our simulation. Prospective data of individual patients need to be collected to validate these results.

Risk of stroke in patients with prior VKA or DOAC: A population-based real-world registry analysis.

To date, risk assessment of suffering ischemic and hemorrhagic stroke in individuals under oral anticoagulation (OAC) is limited to hospital-based cohorts and patients with atrial fibrillation. Through the combination of three individual datasets, (1) the population-based Tyrolean Stroke Pathway database, prospectively documenting all (unselected) stroke patients in the entire federal state of the Tyrol and (2) nation-wide prescription data, detailing each reimbursed prescription in Austria as well as (3) the Austrian Stroke Unit Registry, a nation-wide registry comprising data on all patients admitted to any of the 38 stroke units in Austria, we assessed risk of stroke in patients with prior oral anticoagulation and compared characteristics of patients taking direct oral anticoagulants and Vitamin-K-Antagonists. In Austria, oral anticoagulant prescription reimbursements increased from 292,475 in 2015 to 389,407 in 2021. In the Tyrol, prior oral anticoagulation treatment was evident in 586 of 3861 (15.2%) patients with ischemic and 131 of 523 (25.0%) with hemorrhagic stroke, with 20% and 35% of those stroke patients respectively having prior oral anticoagulation due to other indications than non-valvular atrial fibrillation. Considering prescription rates, treatment with direct oral anticoagulants was associated with a reduced stroke risk compared to Vitamin-K-Antagonists, especially in ischemic (1.05% vs 0.62%; RR 0.59, p < 0.001) but also in hemorrhagic stroke, even if less pronounced (0.21% vs 0.14%; RR 0.68, p = 0.06). In Austria, prior intake of direct oral anticoagulants was associated with lower risk of suffering acute large vessel occlusion stroke (RR 0.79, p = 0.003). One in seven patients suffering ischemic and one in four suffering hemorrhagic stroke had prior oral anticoagulation treatment. Both ischemic and hemorrhagic strokes are less frequent in those with direct oral anticoagulant intake compared to those taking Vitamin-K-Antagonists. Establishment of clear standard operating procedures on how to best care for acute stroke patients with oral anticoagulation is essential.

Proteomic analysis of jugular venous blood in acute large vessel occlusion stroke with futile recanalization

Futile recanalization (FR) after endovascular treatment (EVT) remains a significant challenge for acute ischemic stroke (AIS) with large vessel occlusion (LVO). The pathogenesis of FR has not been well elucidated. We prospectively enrolled anterior circulation LVO-AIS patients who achieved successful recanalization after EVT. The jugular venous blood ipsilateral to stroke was collected before and immediately after recanalization. Plasma proteomic analysis based on liquid chromatography-mass spectrometry was performed using data-independent acquisition method. Differentially expressed proteins (DEPs) among patients with or without FR in the whole or propensity score matching (PSM) cohorts were screened according to the absolute value of fold change ≥1.5 and P value <0.05. We identified 104 and 34 DEPs between patients with or without FR in the whole cohort and PSM cohort, respectively. Bioinformatic analysis indicated that the identified proteins were primarily related to specific biological processes including immune response, complement activation, oxidative stress, lipid metabolism, protein ubiquitylation as well as autophagy, suggesting that these may be mechanisms in FR pathogenesis. Collectively, we discovered proteins that may be potential research targets for FR. The combination of proteomic and bioinformatic analysis could provide a better understanding of the pathogenesis of FR in a comprehensive manner.

Endovascular treatment for young patients with acute large vessel occlusion stroke in China: analysis of the ANGEL-ACT registry.

The incidence of acute ischemic stroke caused by large vessel occlusion is relatively infrequent in the young adult population. We sought to evaluate their clinical outcomes after endovascular treatment (EVT) and stroke etiology compared with older patients. We examined data from the ANGEL-ACT registry, a nationwide study in China focusing on EVT for acute ischemic stroke. We compared two age groups: <50 years old and ≥50 years old. Our analysis focused on outcome measures such as the 90-day modified Rankin Scale (mRS) score, mortality, and symptomatic intracranial hemorrhage (sICH). We adjusted for confounding variables. We included 1,691 patients, and 216 patients (13%) were <50 years old. Young patients had lower median National Institutes of Health Stroke Scale (NIHSS) scores (14 vs. 17, P < 0.001) and fewer cardiovascular comorbidities than older patients. Underlying intracranial atherosclerosis disease (ICAD) was higher in young patients (39.4 vs. 28.7%, P = 0.001). Clinical outcome was less favorable in older compared to younger patients (mRS shift: 0.76 [95% confidence interval (CI), 0.58-0.99]); functional independence [mRS score 0-2] 61% vs. 39% (adjusted odds ratio (OR), 0.7 [95% CI, 0.51-0.97]). Mortality and sICH did not differ between groups. Onset to puncture time (OTP) was longer in young patients (357 min vs. 294 min, P = 0.001). An estimated 13% of patients who underwent endovascular thrombectomy for acute ischemic stroke were <50 years old. Symptomatic underlying ICAD was more prevalent in the younger patient population. Despite a prehospital delay, younger patients exhibited more favorable outcomes than their older counterparts.

Associations between basic physiological observations recorded pre-thrombectomy and functional outcome: a systematic review and meta-analysis

IntroductionMechanical thrombectomy results in more favourable functional outcomes for patients with acute large vessel occlusion (LVO) stroke. Key clinical determinants of thrombectomy outcome include symptom severity, age and time from onset to treatment, but associations have also been reported with baseline physiological observations including systolic/diastolic blood pressure (SBP/DBP), blood/serum glucose, atrial fibrillation and conscious level. As these items are routinely available during initial emergency assessment, they might help to inform early prehospital and hospital triage decisions if evidence consistently shows associations with post-thrombectomy outcome. We undertook a meta-analysis of studies reporting pre-thrombectomy physiological observations and functional outcome.MethodPRISMA guidelines were followed to search electronic bibliographies, select articles and extract data. Medline, PubMed, Cochrane HTA, Cochrane Central and Embase were searched. Included articles were observational or interventional thrombectomy studies published between 01/08/2004-19/04/2023 reporting 3-month modified Rankin Scale, split as favourable (0–2) and unfavourable (3–6). A modified version of the Quality in Prognostic Studies (QUIPS) tool was used to assess risk of bias. RevMan 5 was used to calculate Inverse Variance with Weighted Mean Differences (WMD) and Mantel-Haenszel Odds Ratios (OR) for continuous and categorical factors respectively.ResultsThirty seven studies were eligible from 8,687 records. Significant associations were found between unfavourable outcome and higher blood/serum glucose as a continuous (WMD = 1.34 mmol/l (95%CI 0.97 to 1.72); 19 studies; n = 3122) and categorical (OR = 2.44 (95%CI 1.9 to 3.14) variable; 6 studies; n = 5481), higher SBP (WMD = 2.98 mmHg (95%CI 0.86 to 5.11); 16 studies; n = 4,400), atrial fibrillation (OR = 1.48 (95%CI 1.08 to 2.03); 3 studies; n = 736), and lower Glasgow Coma Scale (WMD = −2.72 (95%CI −4.01 to −1.44); 2 studies; n = 99). No association was found with DBP (WMD = 0.36 mmHg (95%CI −0.76 to 1.49); 13 studies; n = 3,614).ConclusionBasic physiological observations might assist early triage decisions for thrombectomy and could be used in combination with other information to avoid futile treatment and ambulance transfers. It is important to acknowledge that data were only from thrombectomy treated patients in hospital settings and it cannot be assumed that the predictors identified are independent or that modification can change outcome. Further work is needed to establish the optimal combination of prognostic factors for clinical care decisions.

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.

Predictive value of net water uptake with respect to early neurological improvement after endovascular treatment in patients with acute anterior circulation large vessel occlusion stroke

Objective: To investigate the value of net water uptake (NWU) for predicting early neurological improvement (ENI) after endovascular treatment in patients with acute anterior circulation large vessel occlusion stroke. Methods: A case-control study. A total of 132 patients (80 men, 52 women, median age 68 years) with acute anterior circulation large vessel occlusive stroke receiving endovascular treatment were retrospectively analyzed at Jinling Hospital from October 2014 to September 2019. Patients were divided into two groups based on the occurrence of ENI, which was defined as either an improvement of NIHSS score of ≥4 points, or an NIHSS score of 0 or 1 at 24 hours after endovascular treatment. The rank sum test, Chi square test, and other methods were used to compare differences in baseline characteristics between the two groups. Logistic regression analysis was used to investigate independent predictors of postoperative ENI. Receiver operating characteristic curve analysis used to assess the capacity of NWU to predict ENI. Results: Of the 132 patients in the study, ENI occurred in 47 and did not occur in 85. In multivariate logistic regression analysis age [odds ratio (OR)=0.940, 95% confidence interval (CI) 0.903-0.979, P=0.003], time from stroke onset to puncture (OR=0.995, 95%CI 0.991-0.999, P=0.025), time from puncture to recanalization/end of operation (OR=0.985, 95%CI 0.974-0.996, P=0.007), NWU (OR=0.762, 95%CI 0.620-0.937, P=0.010), and mTICI (OR=1.644, 95%CI 1.043-2.590, P=0.032) were predictive factors for ENI. Receiver operating characteristic curve analysis indicated that NWU could effectively predict ENI (area under the curve=0.642, 95%CI 0.543-0.741, P=0.007), and prediction accuracy was improved when it was combined with other clinical parameters. Conclusion: NWU is an independent predictor of ENI in patients with acute anterior circulation large vessel occlusive stroke undergoing endovascular treatment.

Safety and efficacy analysis of endovascular thrombectomy in patients with large vascular occlusion with low Alberta Stroke Program Early Computed Tomography Score

Objective: To evaluate the safety and efficacy of endovascular thrombectomy (EVT) in acute anterior circulation large vessel occlusive stroke (ALVOS) and explore the related influencing factors for prognoses in patients with low Alberta Stroke Program Early Computed Tomography Score (ASPECT). Methods: Patients with acute ALVOS who underwent EVT in Yijishan Hospital of Wannan Medical College from January 2019 to June 2022 were sequentially enrolled. (1) Patients were divided into a low ASPECT group (0-5) and a non-low ASPECT group (6-10), and the differences between the two groups were compared with respect to incidence of perioperative complications and good prognosis rate [modified Rankin scale (mRS) score≤2] 90 days after onset. (2) According to the prognoses 90 days after onset, the low ASPECT group was divided into the good prognosis (mRS score≤2) and poor prognosis (mRS score>2) subgroup. Univariate analysis and multivariate logistic regression analysis were used to investigate the independent risk factors for prognoses of the low ASPECT patients after EVT. Results: A total of 582 patients [age 26-94(69±11) years, 345 male patients (59.3%)] were enrolled for analysis. The baseline ASPECT score was 8 (7, 10), and the baseline NIHSS score was 14 (11, 18). Among them, 102 (17.5%) patients were in the low ASPECT score group and 480 (82.5%) patients were in the non-low ASPECT score group. In the total cohort, patients in the low ASPECT score group had a higher incidence of symptomatic intracranial hemorrhage, lower 90-day good prognosis rate, and higher 90-day mortality rate. Further, propensity score matching statistical analysis showed that patients in the low ASPECT score group had a significantly higher incidence of malignant brain edema after EVT treatment (40.0% vs. 17.6%, χ2=9.13, P=0.003), and a significantly lower 90-day good prognosis rate (24.7% vs. 41.6%, χ2=4.96, P=0.026), but there was no significant difference in the incidence of symptomatic intracranial hemorrhage and 90-day mortality between the two groups (40.3% vs. 26.0%, χ2=3.55, P=0.060). Among 102 patients with low ASPECT score, 22 (21.6%) patients had good prognosis and 80 (78.4%) had poor prognosis. Multivariate logistic regression analysis showed that history of atrial fibrillation (OR=4.478, 95%CI 1.186-16.913, P=0.027) was an independent risk factor for poor prognosis of EVT in patients with low ASPECT score, while good collateral circulation (grade 2 vs. grade 0: OR=0.206, 95%CI 0.051-0.842, P=0.028) was a protective factor for good prognosis of EVT in patients with low ASPECT score. Conclusions: Although the 90-day good prognosis rate of EVT treatment for patients with low ASPECT score was lower than that of the non-low ASPECT group, 21.6% patients still benefitted from EVT treatment, especially patients with non-atrial fibrillation and good collateral circulation. Future studies involving more patients are needed to validate our observations.

Association between left atrial enlargement and poor cerebral collaterals in large vessel occlusion

ObjectivesLeft atrial enlargement (LAE) is a known risk factor for atrial fibrillation, a common cause of large vessel occlusion (LVO) leading to ischemic stroke. While robust cerebral collaterals protect penumbral tissue from infarction, the effect of structural heart disease on cerebral collaterals remains uncertain. This study aims to investigate the association between LAE and cerebral collaterals in patients with acute LVO stroke. Materials and methodsWe conducted a retrospective study of consecutive patients with middle cerebral and/or internal carotid LVO who underwent endovascular thrombectomy (EVT) between 2012 to 2020. Consecutive patients with echocardiography and computed tomography angiography (CTA) of the head were included. Multivariate logistic regression analysis was performed to evaluate the relationship between LAE and poor cerebral collaterals, adjusting for demographics (age, sex, race) and vascular risk factors (hypertension, diabetes and smoking). ResultsThe study included 235 patients with mean age of 69±15 years and an initial mean National Institutes of Health Stroke Scale score of 18. Of these, 89 (37.9 %) had LAE, and 105 (44.7 %) had poor collaterals. Patients with LAE were more likely to have poor collaterals compared to those without LAE (58.4 % vs 36.3 %, P = 0.001). LAE was independently associated with higher odds of poor collaterals (odds ratio, 2.47; P = 0.001), even after adjusting for covariables (odds ratio 1.84, P = 0.048). ConclusionsOur study demonstrated a significant association between LAE and poor cerebral collaterals in patients with LVO stroke undergoing EVT. Further research is warranted to explore potential shared mechanisms, such as endothelial dysfunction, underlying this heart-brain association.

Immediate and 90-Day Clinical Outcome of Patients with Acute Stroke Treated with the NeVa-Vesalio Mechanical Thrombectomy Device: A Retrospective Case Series

The NeVaTM stent-retriever is a newly designed mechanical thrombectomy device for the treatment of acute ischemic stroke caused by large vessel occlusion. We investigate the procedural characteristics and patients' clinical outcome at discharge and at 90 days of follow-up. We retrospectively reviewed a cohort of 75 patients (median age: 74 years) treated with the NeVaTM device for acute large vessel occlusion stroke. Per pass modified Treatment in Cerebral Infarction (mTICI) scores, procedural complications and clinical outcome parameters including National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS) and mortality were analysed, based on patients' electronic medical records. Complete first pass effect was observed in 24 (32%) patients. Vasospasm, repeated re-thrombosis, failure to advance the NeVaTM device through the microcatheter and symptomatic intracranial hemorrhage were observed in n=2, n=1, n=1 and n=2 patient(s) respectively. The rate of complete (mTICI 2c-3) reperfusion were achieved in n=61 (81,33%) patients with a median number of 2 passes (1; 3). Median NIHSS on admission, after 24 hours and after 5-10 days or at discharge were of 19 (15; 23), 11 (4; 19) and 3 (2; 13.5) respectively. The number of patients with a functional mRS score (mRS score 0-2) at 90 days of follow-up was n=29 (39%) CONCLUSION: Endovascular stroke management with use of the Neva-Vesalio stent-retriever may be associated with a 90 days functional mRS score in nearly 40% of treated patients.

Expert consensus on technical strategies for interventional treatment of acute large vessel occlusive stroke in China

Ischemic stroke caused by acute large vessel occlusion is associated with high rates of disability and mortality. Endovascular interventional therapy is evidently an effective treatment for occlusion of large cerebral vessels within the relevant time window, but there is no established methodological standard for recanalization interventional therapy. The Professional Committee of Interventional Neurology in Chinese Research Hospital Association organized cerebrovascular disease experts in China and developed the expert consensus described herein, to provide a reference for clinicians to formulate technical strategies for recanalization of acute cerebral vascular occlusion.

Association Between Thrombectomy and Functional Outcomes in Pediatric Patients With Acute Ischemic Stroke From Large Vessel Occlusion

Pediatric large vessel occlusion (LVO) stroke has a poor natural history. However, uptake of mechanical thrombectomy is hindered by a lack of clinical trial data in children. A randomized clinical trial is not feasible due to small sample sizes and absence of equipoise. To evaluate whether pediatric patients with acute LVO stroke who undergo thrombectomy have better clinical outcomes than matched patients managed conservatively. This matched case-control study used pooled stroke registry data from 5 tertiary referral hospitals in Australia and Canada from January 2011 to April 2022. Patients were aged 1 month to younger than 18 years with acute LVO stroke. Pooled data identified 31 thrombectomy patients and 46 control patients. Five patients undergoing thrombectomy with basilar artery occlusion were excluded due to insufficient controls. Using a hierarchal matching system (site of occlusion, age group, side of occlusion, and sex), deidentified consensus matching of patients and controls was undertaken while blinded to clinical outcome. Data were analyzed from July to November 2022. In the case cohort, mechanical thrombectomy was undertaken for management of acute LVO stroke. The control cohort received medical treatment only. The primary outcome was the functional clinical status 3 months following stroke, measured by the pediatric modified Rankin Scale (mRS). Clinical outcomes were compared between groups using ordinal regression analysis. Of 52 included patients, 31 (60%) were male, and the mean (SD) age was 10.3 (4.4) years. Matching was achieved for 26 children undergoing thrombectomy with 26 controls. There was no significant difference between groups for site or side of occlusion, age, sex, etiology, thrombolysis status, baseline Alberta Stroke Programme Early CT Score, or time since last seen well to presentation. Patients undergoing thrombectomy had superior clinical outcomes than control patients at 3 months on the pediatric mRS (odds ratio, 3.76; 95% CI, 1.32-10.67; P = .01). These superior outcomes were maintained at final follow-up (odds ratio, 3.65; 95% CI, 1.25-10.68; P = .02). In the absence of a randomized clinical trial, this case-control study demonstrates better clinical outcomes with thrombectomy than medical management alone for pediatric patients aged 2 to 18 years with anterior circulation LVO stroke.