Anterior Circulation Acute Ischemic Stroke Research Articles

Combined Selective Endovascular Brain Hypothermia with Edaravone Dexborneol versus Edaravone Dexborneol Alone for Endovascular Treatment in Acute Ischemic Stroke (SHE): Protocol for A Multicenter, Single-Blind, Randomized Controlled Study.

Introduction Selective endovascular brain hypothermia has been proposed as a potential neuroprotective strategy, however, its effectiveness is still not well established. The primary objective of this trial is to investigate the efficacy and safety of selective endovascular brain hypothermia with Edaravone Dexborneol for endovascular treatment in acute ischemic stroke (AIS). Methods The SHE study is a multi-center, single-blind, randomized controlled clinical trial. Patients with acute anterior circulation ischemic stroke who received endovascular treatment within 24 h after stroke onset and achieved successful recanalization will be enrolled and centrally randomized into combined selective endovascular brain hypothermia with edaravone dexborneol or edaravone dexborneol alone groups in a 1:1 ratio (n=564). Patients allocated to the hypothermia group will receive 300 ml cool saline at 4℃through guiding catheter (30 ml/min) into target vessel within 3 minutes after recanalization and then receive edaravone dexborneol (edaravone dexborneol 15 ml +NS 100 ml ivgtt bid for 10 to 14 days) within 24 hours after admission. The control group will receive 300 ml 37℃saline (30 ml/min) infused into target vessel through guiding catheter and then receive edaravone dexborneol. All patients enrolled will receive standard care according to current guidelines for stroke management. The primary outcome is the proportion of functional independence, defined as a mRS Score 0-2 at 90 days after randomization. Conclusion This is a randomized clinical trial with a large sample size to compare combined selective endovascular brain hypothermia and edaravone dexborneol with edaravone dexborneol alone in patients with acute anterior ischemic stroke. The SHE trial aims to provide further evidence of the benefit of selective endovascular brain hypothermia in AIS patients who received endovascular treatment.

Clinical Impact of Reperfusion Techniques and Occlusion Sites in Thrombectomy: Insights from the ASSIST Stroke Registry

BACKGROUND Mechanical thrombectomy has changed the landscape of acute ischemic stroke treatment, offering improved outcomes for patients with large vessel occlusions. The interplay between reperfusion techniques and occlusion sites remains a critical consideration in treatment decisions. This study investigates the impact of primary reperfusion techniques—stent retriever classic, stent retriever combination with aspiration, and direct aspiration—on procedural and clinical outcomes at different occlusion sites. METHODS Using data from the ASSIST registry, a prospective multinational initiative, patients with anterior circulation acute ischemic stroke with large vessel occlusions (n = 1477) were included. Three primary occlusion sites—M1 segment of the middle cerebral artery, M2 segment of the middle cerebral artery, and the internal carotid artery—were studied. Univariate tests and multivariable logistic regression models were used to assess associations between reperfusion techniques and procedural and clinical outcomes, including the expanded thrombolysis in cerebral infarction score and the modified Rankin Scale, stratified by occlusion site. RESULTS Achieving expanded thrombolysis in cerebral infarction ≥2c after first pass was lower in internal carotid artery occlusions (18.2%, P <0.0001) with direct aspiration alone compared with stent retriever classic (38.2%) or stent retriever combination with aspiration (43.3%), while no differences were seen for M1 segment of the middle cerebral artery ( P = 0.77) and M2 segment of the middle cerebral artery ( P = 0.29) occlusions. Bailout maneuvers, which were more frequent in the direct aspiration group for all occlusion sites, did not result in longer procedure times or different final recanalization outcomes in direct aspiration compared with stent retriever classic or stent retriever combination with aspiration. Overall, there were no differences in the rate of patients with modified Rankin Scale scores of 0–2 at 90 days. No differences in safety outcomes were observed. CONCLUSIONS This study provides insight into the complex relationship between reperfusion techniques and occlusion sites in patients with acute ischemic stroke and shows that certain techniques have advantages in certain occlusion sites. As the field evolves, further research is warranted to refine our understanding of these dynamics and inform clinical practice.

Anterior circulation acute ischemic stroke due to vertebral artery ostial stenosis in a patient with congenital internal carotid artery agenesis: a case report

BackgroundCongenital agenesis of internal carotid artery (ICA) is a rare cerebrovascular variation entity. Most cases of congenital ICA agenesis are asymptomatic and discovered incidentally. Congenital ICA agenesis presenting as ischemic stroke is even rare.Case presentationAn 80-year-old male patient was admitted to our hospital due to sudden dysarthria and left limb weakness for 3.5 h. Based on emergency physical examination and head computed tomography (CT) scan results, acute ischemic stroke (AIS) of right cerebral hemisphere was suspected. Following intravenous thrombolysis with recombinant tissue plasminogen activator, right congenital agenesis of ICA was confirmed by CT and digital subtraction angiography. Additionally, there was a severe right vertebral artery ostial (VAO) stenosis. After ruling out common causes of AIS such as haematological diseases, arterial dissection, organic heart disease, immunological abnormality and underlying possible malignancies, we hypothesize that the severe stenosis of the right VAO may have contributed to the development of AIS in this case.ConclusionsWe present a case of right congenital ICA agenesis in which severe stenosis of the right VAO may have played a role in the development of AIS. This case underscores a rare scenario where a lesion in the posterior circulation leads to an infarction in the anterior circulation in the setting of congenital ICA agenesis.

Prognostic significance of carotid artery stenosis in anterior circulation ischemic stroke patients

BackgroundThe carotid artery stenosis (CAS) is a notable risk element for ischemic stroke, accounting for 10 to 20% of such cases. There is a deficiency in research studies exploring the prognostic impact of CAS specifically in the anterior circulation acute ischemic stroke (AIS). Therefore, we conducted this study to evaluate the prognostic impact of CAS in individuals with anterior circulation AIS. Patients were categorized into two groups, patients with both anterior circulation AIS and CAS in comparison to patients with anterior circulation AIS without CAS (control group). We compared patient characteristics, neuroimaging, and outcome evaluations using a modified Rankin Scale (mRS) and the National Institute Health Stroke Scale (NIHSS) in both groups. P-value < 0.05 meaning statistical significance.ResultsFifty patients were involved in the current study; of them, 25 patients with both anterior circulation AIS and CAS and 25 patients with anterior circulation AIS without CAS. Both groups were comparable concerning age, gender, co-morbidities of diabetes, hypertension, smoking, and dyslipidemia with p-value > 0.05. The mean NIHSS was significantly elevated the CAS group compared to the control group (p = 0.037). Our results showed that patients with CAS ≥ 70% were associated with an mRS > 2 and a significantly higher NIHSS compared to control. The regression analysis showed that occlusion > 1/3, CAS ≥ 70%, and higher NIHSS score were considered independent predictors of mRS > 2. The mortality rate was significantly elevated in the CAS group versus the control group (p < 0.05). Both bilateral and unilateral CAS groups were comparable regarding NIHSS and mRS values.ConclusionPatients with anterior circulation AIS who had CAS of 70% or more, whether unilateral or bilateral, showed a higher likelihood of increased mortality and more severe strokes, as evidenced by elevated NIHSS and mRS scores.

Characteristics, clinical profiles, and outcomes of patients undergoing endovascular thrombectomy: A retrospective study, Saudi Arabia

BackgroundStroke is a significant contributor to both mortality and compromised physical function. Endovascular thrombectomy (EVT) is now the recognized standard of care for anterior circulation acute ischemic stroke (AIS) with large vessel occlusion (LVO), especially when favorable brain images are evident within 24 h of symptom onset. This study elucidated the characteristics, clinical profiles, and outcomes of patients who underwent EVT for AIS. MethodologyIn this retrospective record-based cohort study, we reviewed the medical records of individuals who underwent EVT for AIS at King Fahad General Hospital in Jeddah, Saudi Arabia. The study, conducted from July 2022 through October 2023, encompassed a comprehensive analysis of clinical, radiological, and time-related factors and diverse outcomes. ResultsIn a cohort of 117 patients with a mean age of 58.5 years, 81 (69.2%) were male. Hypertension and diabetes mellitus were the most common risk factors, affecting 48.7% and 41% of the cohort, respectively. Approximately half of the patients had a favorable ASPECT Score (7–10), and 45.3% received intravenous tissue plasminogen activator (tPA). Nearly two-thirds achieved a modified thrombolysis in cerebral infarction (mTICI) score of 2b or higher, and 39.3% exhibited M1-middle cerebral artery (MCA) occlusion. The incidence of symptomatic hemorrhagic transformation was about 13%, whereas one-third of the patients attained a favorable mRs outcome (0–2). Factors such as advanced age, higher NIH Stroke Scale (NIHSS) scores, and prolonged hospital stays were associated with poorer outcomes. Conversely, the absence of hypertension and atrial fibrillation, along with higher TICI scores, significantly increased the likelihood of favorable outcomes, with P values of 0.015, 0.0490, and 0.025, respectively. ConclusionsIn our study, the examined patients who underwent EVT were younger in age, with clinical and radiological outcomes showing some degree of comparability to other publications. Notably, the absence of hypertension and atrial fibrillation, combined with a higher TICI score, was associated with an increased likelihood of achieving a favorable outcome.

Mediterranean Diet Prior to Ischemic Stroke and Potential Circulating Mediators of Favorable Outcomes.

Background/Objectives. A Mediterranean diet (MD) has been associated with neuroprotective effects. We aimed to assess the MD's association with stroke prognosis and the potential mediators involved. Methods. Seventy patients with acute anterior circulation ischemic stroke were included. Dietary patterns were evaluated using the MEDAS scale, a food-frequency questionnaire, and a 24 h recall. Circulating biomarkers including insulin resistance (HOMA index), adipokines (resistin, adiponectin, leptin), choline pathway metabolites (TMAO, betaine, choline), and endothelial progenitor cells (EPCs) were measured. Early neurological improvement (ENI) at 24 h, final infarct volume, and functional outcome at 3 months were assessed. Results. Adherence to MD and olive oil consumption were associated with a lower prevalence of diabetes and atherothrombotic stroke, and with lower levels of fasting glycemia, hemoglobinA1C, insulin resistance, and TMAO levels. Monounsaturated fatty acids and oleic acid consumption correlated with lower resistin levels, while olive oil consumption was significantly associated with EPC mobilization. Multivariate analysis showed that higher MD adherence was independently associated with ENI and good functional prognosis at 3 months. EPC mobilization, lower HOMA levels, and lower resistin levels were associated with ENI, a smaller infarct volume, and good functional outcome. Conclusions. MD was associated with better prognosis after ischemic stroke, potentially mediated by lower insulin resistance, increased EPC mobilization, and lower resistin levels, among other factors.

Value of the red blood cell distribution width (RDW) and neutrophil lymphocyte ratio (NLR) in the prediction of functional recovery and 3-month mortality following endovascular treatment for acute anterior circulation ischemic stroke

ObjectivesThe red blood cell distribution width (RDW) and neutrophil to lymphocyte ratio (NLR) have been linked to poor prognosis in patients with ischaemic stroke. However, no study has yet evaluated the prognostic role of RDW and NLR, or their combined effect on reperfusion in patients with endovascularly-treated acute ischaemic stroke. This study therefore aimed to analyse the impact of RDW and NLR on poor functional outcomes and failed reperfusion following endovascular treatment in patients with acute anterior circulation ischaemic stroke. MethodsA total of 275 patients with acute anterior circulation ischaemic stroke treated endovascularly between 2015 and 2018 were enrolled in this study. The relationships between RDW, NLR, and poor outcomes were analysed using univariate and multivariate logistic regression models and receiver operating characteristic (ROC) curve analysis. The Youden Index was applied to determine the cut-off value. ResultsMultivariate logistic regression analysis identified RDW (p = 0.015) and NLR (p = 0.015) as independent predictors of mortality at the 3rd month. ROC curve analysis of RDW revealed a cutoff value of 14.25 (p = 0.009) for poor clinical outcomes (modified Rankin scale [mRS] 3–6). Similarly, a cutoff value of 14.25 was found for mortality prediction (p = 0.003). The cutoff value for poor clinical outcome (mRS 3–6) in the NLR was determined as 5.93 (p = 0.003), whereas the cutoff value for mortality was set at 5.17 (p = 0.028). RDW also predicted failed reperfusion, with a cutoff value of 17.75 (p = 0.048). ConclusionsHigh RDW and NLR upon admission were identified as independent indicators of mortality in endovascularly treated acute anterior circulation ischemic stroke patients. Furthermore, the RDW could potentially predict failed reperfusion.

Prolonged Venous Transit Is Associated With Lower Likelihood of Favorable Clinical Recovery in Reperfused Anterior Circulation Large‐Vessel Occlusion Stroke

Background Unfavorable clinical outcomes in patients with acute ischemic stroke caused by large‐vessel occlusions despite successful reperfusion have been associated with poor venous outflow. The objective of this study is to assess the relationship between prolonged venous transit (PVT), a novel perfusion imaging surrogate for poor venous outflow, and likelihood of favorable clinical recovery. Methods In this retrospective review of prospectively collected data of consecutive patients (2017–2022) with successfully reperfused, anterior circulation acute ischemic stroke caused by large‐vessel occlusions, we assessed the association between PVT+, defined as time to maximum ≧10‐second timing delays within either the posterior superior sagittal sinus, torcula, or both regions on pretreatment perfusion imaging, and favorable clinical outcomes defined as 90‐day modified Rankin Scale score of 0 to 2. Patients were dichotomized into PVT+ and PVT− for analysis. Multivariable logistic regression analyses for favorable recovery were performed with demographic variables and stroke characteristics. Results A total of 127 consecutive patients (median age, 71 [interquartile range 61—77] years; 59.1% women) were included, and 40 of 127 (31.5%) were PVT+. PVT+ (adjusted odds ratio [aOR], 0.23 [95% CI, 0.07–0.81]; P = 0.02) and advanced age (aOR, 0.92 [95% CI, 0.88–0.97]; P = 0.01) were significantly associated with the primary outcome. Conclusion PVT+ was associated with a lower likelihood of achieving favorable clinical recovery in successfully reperfused patients with acute ischemic stroke caused by large vessel occlusion. PVT may serve as a clinically useful adjunctive imaging parameter.

Comparative Evaluation of Imaging Modalities for Eligibility in Endovascular Treatment of Delayed Onset Acute Anterior Circulation Ischemic Stroke in Siriraj Hospital: A Retrospective Analysis

Objective: The goal of this study is to evaluate the consistency between CTP according to the endovascular therapy following imaging evaluation for ischemic stroke (DEFUSE-3) criteria and other standard computed tomography (CT) imaging modalities, such as multi-phase CT angiography (MCTA) and unenhanced computed tomography (UECT), in assessing patient eligibility for EVT as determined by neurointerventionists evaluations. Materials and Methods: This retrospective analysis included 64 patients with anterior circulation stroke and onset between 6 to 12 hours or unknown onset. Two neuro-interventionalists independently reviewed images and assessed eligibility for EVT based on the Alberta stroke program early CT score (ASPECTS) derived from UECT and collateral score obtained from MCTA. The results were then compared to CTP, utilizing the DEFUSE-3 criteria. Results: Out of the 64 cases analyzed (mean age: 69 years ± 13.9 [SD]), 61 met DEFUSE-3 criteria for EVT by CTP, while 54 were deemed eligible based on an ASPECTS ≥ 6 and collateral score ≥ 3. Agreement between the modalities was moderate (Kappa coefficient score 0.4). When patients with ASPECTS score &lt; 6 were excluded, concordance improved to perfect (Kappa coefficient score 1.0). Hence, concordance was significantly associated with ASPECTS scores ≥ 6 (P &lt; 0.001). Conclusion: In patients experiencing anterior circulation stroke with onset between 6 to 12 hours or unknown onset, excluding an ASPECTS score of 6 or higher, MCTA and UECT proved to be reliable for assessing endovascular treatment eligibility. These modalities may serve as substitutes for CTP and offer support in the clinical decisionmaking process.

A Randomized Trial on Hemodynamic Optimization of Cerebral Perfusion after Successful Endovascular Therapy in Patients with Acute Ischemic Stroke (HOPE)

Introduction: In patients with acute ischemic stroke (AIS) secondary to intracranial large vessel occlusion, optimal blood pressure (BP) management following endovascular treatment (EVT) has not yet been established. The randomized trial on Hemodynamic Optimization of Cerebral Perfusion after Successful Endovascular Therapy in Patients with Acute Ischemic Stroke (HOPE) (clinicaltrials.gov id: NCT04892511) aims to demonstrate whether hemodynamic optimization using different systolic BP targets following EVT according to the degree of final recanalization, is more effective than currently recommended BP management in improving functional outcomes of patients with AIS. Methods: HOPE is an investigator-initiated multicenter clinical trial with randomized allocation, open-label treatment, and blinded endpoint evaluation (PROBE). Patients with an anterior circulation AIS within 24 h of symptom onset, treated with EVT, and showing successful recanalization (mTICI ≥2b) at the end of the procedure, are equally allocated (1:1) to hemodynamic optimization according to the study protocol versus BP management according to current guidelines (≤180/105 mm Hg). The protocol includes two different targets of systolic BP depending on the recanalization status (mTICI = 2b: 140–160 mm Hg; mTICI = 2c/3: 100–140 mm Hg). The protocol is applied within the first 72 h and includes BP lowering as well as vasopressor therapies when needed. The primary outcome is the proportion of favorable outcome (modified Rankin Scale [mRS] 0–2) at 90 days. Secondary outcomes include the shift on the mRS score, neurological deterioration, symptomatic intracerebral hemorrhage, and mortality. Conclusion: The HOPE trial will provide new information on the safety and efficacy of different BP targets following EVT according to the degree of final recanalization in patients with AIS.

The benefit of optimizing recanalization during mechanical thrombectomy in patients with acute ischemic stroke depends on preprocedural tissue-level collateralization.

Thrombolysis in Cerebral Infarction (TICI) 3 represents the optimal angiographic outcome following mechanical thrombectomy (MT) for acute ischemic stroke (AIS). Although it is known to yield better outcomes than TICI 2b, the influence of preprocedural cerebral hemodynamics on the clinical advantage of TICI 3 over TICI 2b remains unexplored. This single-center retrospective analysis involved patients with anterior circulation AIS who underwent successful recanalization during MT at the Comprehensive Stroke Center, University Hospital, Krakow between January 2019 and July 2023. We assessed the benefit of achieving TICI 2c/3 over TICI 2b on the basis of preprocedural computed perfusion imaging results, primarily focusing on early infarct volume (EIV) and tissue-level collaterals indicated by hypoperfusion intensity ratio (HIR). Good functional outcome (GFO) was defined as a modified Rankin Score < 3 on day 90. The study comprised 612 patients, of whom 467 (76.3%) achieved TICI 2c/3. GFO was more frequent in the TICI 2c/3 group (54.5% vs 69.4%, p < 0.001). There was interaction between the recanalization status and both HIR (Pi = 0.042) and EIV (Pi = 0.012) in predicting GFO, with disproportionately higher impact of HIR and EIV in TICI 2b group. The benefit from TICI 2c/3 over TICI 2b was insignificant among patients with good collaterals, defined by HIR < 0.3 (odds ratio:1.36 [0.58-3.18], p = 0.483). TICI 2c/3 improves patient functional outcomes compared to TICI 2b regardless of EIV. However, such angiographic improvement may be clinically futile in patients with good tissue-level collateralization. Our findings suggest that preprocedural HIR should be considered when optimization of recanalization is considered during MT.

HERMES-24 Score Derivation and Validation for Simple and Robust Outcome Prediction After Large Vessel Occlusion Treatment.

Clinicians need simple and highly predictive prognostic scores to assist practical decision-making. We aimed to develop a simple outcome prediction score applied 24 hours after anterior circulation acute ischemic stroke treatment with endovascular thrombectomy and validate it in patients treated both with and without endovascular thrombectomy. Using the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) collaboration data set (n=1764), patients in the endovascular thrombectomy arm were divided randomly into a derivation cohort (n=430) and a validation cohort (n=441). From a set of candidate predictors, logistic regression modeling using forward variable selection was used to select a model that was both parsimonious and highly predictive for modified Rankin Scale (mRS) ≤2 at 90 days. The score was validated in validation cohort, control arm (n=893), and external validation cohorts from the ESCAPE-NA1 (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischaemic Stroke; n=1066) and INTERRSeCT (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography; n=614). In the derivation cohort, we selected 2 significant predictors of mRS ≤2 (National Institutes of Health Stroke Scale score at 24 hours and age [β-coefficient, 0.34 and 0.06]) and derived the HERMES-24 score: age (years)/10+National Institutes of Health Stroke Scale score at 24 hours. The HERMES-24 score was highly predictive for mRS ≤2 (c-statistic 0.907 [95% CI, 0.879-0.935]) in the derivation cohort. In the validation cohort and the control arm, the HERMES-24 score predicts mRS ≤2 (c-statistic, 0.914 [95% CI, 0.886-0.944] and 0.909 [95% CI, 0.887-0.930]). Observed provability of mRS ≤2 ranged between 3.1% and 3.4% when HERMES-24 score ≥25, while it ranged between 90.6% and 93.0% when HERMES-24 score <10 in the derivation cohort, validation cohort, and control arm. The HERMES-24 score also showed c-statistics of 0.894 and 0.889 for mRS ≤2 in the ESCAPE-NA1 and INTERRSeCT populations. The post-treatment HERMES-24 score is a simple validated score that predicts a 3-month outcome after anterior circulation large vessel occlusion stroke regardless of intervention, which helps prognostic discussion with families on day 2.

Multi-phase computed tomography angiography combined with inflammation index to predict clinical functional prognosis in patients with acute ischemic stroke

In this study, we investigated the feasibility of the Alberta Stroke Program Early CT Score (ASPECTS) and multiphase computed tomography angiography (mCTA) lateral branch circulation grading combined with clinical and laboratory indicators to predict the clinical prognosis of patients with acute ischemic stroke after 90 days. The clinical data of 80 patients with acute anterior circulation ischemic stroke were retrospectively analyzed and divided into the good prognosis (37 cases) and poor prognosis groups (43 cases) according to their clinical function score at 90 days after discharge. Various factors, including basic imaging parameters (ASPECTS), occluded vessel location, affected side location and clinical indicators (time from onset to computed tomography examination, height, weight, body mass index, previous hypertension, and degree of hypertension and diabetes mellitus), laboratory blood rutine, and biochemical tests (white blood count, neutrophil count, lymphocyte count, neutrophil-to-lymphocyte ratio, hematocrit test, platelet count, international normalized ratio, blood glucose, triglycerides, uric acid, and D-dimer) were considered in the analysis. Logistic regression analysis showed that the mCTA score, hypertension, and neutrophil count were significant independent predictors. A nomogram of the mCTA score, hypertension, and neutrophil count may predict functional recovery after 90 days in patients with acute ischemic stroke.

Rescue Stenting of Isolated Middle Cerebral Artery (MCA) Dissections (MCAD) with Antithrombogenic Coated Stents and Mono-Antiplatelet Therapy (MAPT).

Objective: Acute ischemic stroke (AIS) is a leading cause of death, but isolated middle cerebral artery dissection (MCAD) is rarely reported. The aim of this article is to sum up the current information on this pathology and to explore the technical aspects of its endovascular treatment with emphasis on novel coated, antithrombogenic stents and antiplatelet management. Another part of this article offers our experience with the problematics represented by a small sample group of patients with an MCAD diagnosis who were treated in our center. Methods: We conducted literature research and a retrospective review of patients treated for anterior circulation AIS at our comprehensive stroke center from January 2022 to March 2024. The cohort included 16 patients diagnosed with isolated MCAD, 9 received antithrombogenic coated stents, while 7 received bare metal stents. Pharmacological management of coated stents involved the use of Cangrelor for acute antiplatelet therapy, transitioning to oral Ticagrelor. Results: Among the 16 patients treated, those with antithrombogenic coated stents showed no major complications and had a lower incidence of intracranial hemorrhage compared to the bare metal stent group. The average National Institutes of Health Stroke Scale (NIHSS) score at discharge improved in both groups. Functional outcomes and mortality rates were slightly better in the coated stent group, but no statistical significance was proven. Conclusions: Antithrombogenic coated stents, in conjunction with MAPT, demonstrated a safe and effective option for treating isolated MCAD. These stents offer promising potential for improved outcomes and reduced complications compared to traditional treatments. Further multicentric studies with larger cohorts are recommended to validate these findings.

Non-contrast CT radiomics-clinical machine learning model for futile recanalization after endovascular treatment in anterior circulation acute ischemic stroke

ObjectiveTo establish a machine learning model based on radiomics and clinical features derived from non-contrast CT to predict futile recanalization (FR) in patients with anterior circulation acute ischemic stroke (AIS) undergoing endovascular treatment.MethodsA retrospective analysis was conducted on 174 patients who underwent endovascular treatment for acute anterior circulation ischemic stroke between January 2020 and December 2023. FR was defined as successful recanalization but poor prognosis at 90 days (modified Rankin Scale, mRS 4–6). Radiomic features were extracted from non-contrast CT and selected using the least absolute shrinkage and selection operator (LASSO) regression method. Logistic regression (LR) model was used to build models based on radiomic and clinical features. A radiomics-clinical nomogram model was developed, and the predictive performance of the models was evaluated using area under the curve (AUC), accuracy, sensitivity, and specificity.ResultsA total of 174 patients were included. 2016 radiomic features were extracted from non-contrast CT, and 9 features were selected to build the radiomics model. Univariate and stepwise multivariate analyses identified admission NIHSS score, hemorrhagic transformation, NLR, and admission blood glucose as independent factors for building the clinical model. The AUC of the radiomics-clinical nomogram model in the training and testing cohorts were 0.860 (95%CI 0.801–0.919) and 0.775 (95%CI 0.605–0.945), respectively.ConclusionThe radiomics-clinical nomogram model based on non-contrast CT demonstrated satisfactory performance in predicting futile recanalization in patients with anterior circulation acute ischemic stroke.

Predictors of symptomatic intracerebral hemorrhage after endovascular treatment for acute ischemic stroke due to tandem lesion in anterior circulation

BackgroundEndovascular treatment (EVT) of tandem lesion (TL) in the anterior circulation acute ischemic stroke (IS) usually requires periprocedural antithrombotic treatment and early initiation of dual antiplatelet therapy (DAPT) after carotid stenting. However, it may contribute to an occurrence of symptomatic intracerebral hemorrhage (SICH) in some cases. We investigated factors influencing the SICH occurrence and assessed the possible predictors of SICH after EVT. MethodsIS patients with TL in the anterior circulation treated with EVT were enrolled in the multicenter retrospective ASCENT study. A good three-month clinical outcome was scored as 0–2 points in modified Rankin Scale (mRS) and recanalization using the TICI scale. SICH was assessed using the SITS-MOST criteria. Logistic regression analysis was used for the assessment of possible predictors of SICH with adjustment for potential confounders. ResultsIn total, 300 (68.7 % males, mean age 67.3 ± 10.2 years) patients with median of admission NIHSS 17 were analyzed. Recanalization (TICI 2b-3) was achieved in 290 (96.7 %) patients and 176 (58.7 %) had mRS 0–2. SICH occurred in 25 (8.3 %) patients. Patients with SICH did not differ from those without SICH in the rate of periprocedural antithrombotic treatment (64 vs. 57.5 %, p = 0.526) and in the rate of DAPT started within the first 12 h after EVT (20 vs. 42.2 %, p = 0.087). After adjustment, admission NIHSS and admission glycemia were found as the only predictors of SICH after EVT. ConclusionAdmission NIHSS and glycemia were found as the only predictors of SICH after EVT for TL. No associations between periprocedural antithrombotic treatment, early start of DAPT after EVT and SICH occurrence were found.

Systemic-inflammatory indices and clinical outcomes in patients with anterior circulation acute ischemic stroke undergoing successful endovascular thrombectomy

BackgroundThere is a lack of comprehensive profile assessment on complete blood count (CBC)-derived systemic-inflammatory indices, and their correlations with clinical outcome in patients with anterior circulation acute ischemic stroke (AIS) who achieved successful recanalization by endovascular thrombectomy (EVT). MethodsPatients with anterior circulation AIS caused by large vessel occlusion (AIS-LVO) were retrospectively screened from December 2018 to December 2022. Systemic-inflammatory indices including ratios of neutrophil-to-lymphocyte (NLR), monocyte-to-lymphocyte (MLR), platelet-to-lymphocyte (PLR), and platelet-to-neutrophil (PNR), systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and aggregate inflammation systemic index (AISI) on admission and the first day post-EVT were calculated. Their correlations with symptomatic intracranial hemorrhage (sICH) and unfavorable 90-day functional outcome (modified Rankin Scale score of 3–6) were analyzed. ResultsA total of 482 patients [65 (IQR, 56–72) years; 33 % female] were enrolled, of which 231 (47.9 %) had unfavorable 90-day outcome and 50 (10.4 %) developed sICH. Day 1 neutrophil and monocyte counts, NLR, MLR, PLR, SII, SIRI, and AISI were increased, while lymphocyte and PNR were decreased compared to their admission levels. In multivariate analyses, neutrophil count, NLR, SII, and AISI on day 1 were independently associated with 90-day functional outcome. Moreover, day 1 neutrophil count, NLR, MLR, PLR, PNR, SII, and SIRI were independently linked to the occurrence of sICH. No admission variables were identified as independent risk factors for patient outcomes. ConclusionCBC-derived systemic-inflammatory indices measured on the first day after successful EVT are predictive of 90-day functional outcome and the sICH occurrence in patients with anterior circulation AIS-LVO.

Endovascular Thrombectomy for Large Ischemic Strokes with ASPECTS 0–2: a Meta-analysis of Randomized Controlled Trials

PurposeRandomized controlled trials (RCTs) demonstrated a treatment effect of endovascular thrombectomy in acute ischemic stroke with large infarct, commonly defined as an Alberta Stroke Program Early CT Score (ASPECTS) of 3–5. However, data on endovascular thrombectomy in patients with very low ASPECTS of 0–2 remain scarce.MethodsWe conducted a systematic review and meta-analysis of RCTs comparing endovascular thrombectomy versus medical treatment alone in acute ischemic anterior circulation stroke with very large infarct, defined as ASPECTS of 0–2. The primary outcome was the shift toward better functional outcomes on the 90-day modified Rankin Scale (mRS). Random effects meta-analysis was performed using the generic inverse variance method.ResultsLiterature research identified four RCTs which evaluated the treatment effect of endovascular thrombectomy for large infarcts and provided a subgroup analysis of the mRS shift in patients with ASPECTS of 0–2. The pooled analysis showed a significant shift toward better 90-day mRS scores in favor of endovascular thrombectomy (pooled odds ratio, 1.62, 95% confidence interval, 1.29–2.04, P < 0.001).ConclusionThis meta-analysis suggests a treatment effect of endovascular thrombectomy in specific patients with very low ASPECTS of 0–2, challenging the use of ASPECTS for treatment selection in acute ischemic stroke due to large vessel occlusion. An individual patient meta-analysis of RCTs would strengthen evidence in the treatment of patients with ASPECTS of 0–2.Graphic abstract

Predictors of good functional outcome in ischaemic stroke patients without delayed neurological improvement after mechanical thrombectomy.

This study aimed to identify predictors of 90-day good functional outcome (GFO) in patients with acute ischaemic stroke (AIS) who were treated with mechanical thrombectomy but did not achieve a delayed neurological improvement (DNI). In-hospital neurological improvement in patients with AIS is consistently associated with long- -term GFO. Patients who experience neither early nor delayed neurological improvement can still achieve long-term GFO, but predictors of such an outcome have not been studied. This single-centre retrospective study involved 307 patients with anterior circulation AIS treated with mechanical thrombectomy. Multiple clinical, biochemical, radiological, and treatment-related variables were collected and analysed. DNI on day 7 was defined as at least a 10-point reduction in the National Institutes of Health Stroke Scale (NIHSS) score or NIHSS score < 2. GFO on day 90 was defined as a modified Rankin Scale (mRS) score ≤ 2. We compared the characteristics of patients with and without DNI, with special attention paid to patients who achieved 90-GFO despite a lack of DNI. Multivariate analyses were then performed to establish independent predictors of 90-day GFO among patients without DNI. DNI occurred in 150 out of 307 patients (48.7%) and significantly increased the odds for 90-day GFO (odds ratio [OR]: 13.99; p < 0.001). Among patients without DNI, 41.4% achieved 90-day GFO. Younger age (OR: 0.96; 95% confidence interval [CI]: 0.93-0.99; p = 0.008), lower baseline NIHSS score (OR: 0.80; 95% CI: 0.73-0.89; p < 0.001), treatment with intravenous thrombolysis (OR: 3.06; 95% CI: 1.25-7.49; p = 0.014), lack of an undetermined aetiology (OR: 0.40; 95% CI: 0.16-0.998; p = 0.050), lack of pneumonia (OR: 0.08; 95% CI: 0.02-0.31; p < 0.001), and higher haemoglobin concentration on admission (OR: 1.31; 95% CI: 1.04-1.69; p = 0.024) were identified as predictors of 90-day GFO in this subgroup. Almost half of patients with AIS in anterior circulation treated with mechanical thrombectomy experience DNI, which is a good predictor of 90-day GFO. Furthermore, 40% of patients without DNI achieve 90-day GFO which can be independently predicted by younger age, lower baseline NIHSS score, treatment with intravenous thrombolysis, higher haemoglobin concentration on admission, lack of undetermined ischaemic stroke aetiology, and lack of pneumonia.

Serial ASPECTS to predict stroke-associated pneumonia after thrombolysis in patients with acute ischemic stroke.

Stroke-associated pneumonia (SAP) is a serious complication in stroke patients, significantly increasing mortality. The Alberta Stroke Program Early CT Score (ASPECTS) is a recognized predictor of acute ischemic stroke outcomes. We aimed to investigate the performance of serial ASPECTS assessments (baseline ASPECTS, 24-h ASPECTS, and change in ASPECTS) for predicting SAP in patients with thrombolyzed acute anterior circulation ischemic stroke (AACIS). A retrospective observational cohort study of adult patients with thrombolyzed AACIS was conducted. Baseline and 24-h ASPECTS using non-contrast computed tomography (NCCT), complications of stroke, including SAP and swallowing dysfunction using the Modified Water Swallowing test, were collected. Baseline and 24-h ASPECTS were evaluated by a certified neurologist and neuroradiologist. The predictive performance was determined based on the receiver operating characteristic curve (ROC). Multivariable logistic regression analyses were employed to assess the impact of serial ASPECTS assessment on predicting SAP. Of the 345 patients with thrombolyzed AACIS in our study, 18.4% (64/345) experienced SAP. The patients' median age was 62 years [interquartile range (IQR): 52-73], with 53.4% being male. The median NIHSS score was 11 points (IQR: 8-17). The ROC analysis revealed areas under the curve for predicting SAP with baseline ASPECTS, 24-h ASPECTS, and change in ASPECTS were 0.75 (95% CI, 0.69-0.82), 0.84 (95% CI, 0.79-0.89), and 0.82 (95% CI, 0.76-0.87), respectively. Of the three measures, 24-h ASPECTS was a better predictor of SAP (odds ratio: 5.33, 95%CI: 2.08-13.67, p < 0.001) and had a higher sensitivity (0.84 [95%CI, 0.74-0.92]) and specificity (0.79 [95%CI, 0.74-0.84]) than both baseline ASPECTS and change in ASPECTS. 24-h NCCT-ASPECTS outperformed both baseline ASPECTS and change in ASPECTS for predicting SAP. Notably, 24-h ASPECTS, with a cut-off value of ≤6, exhibited good predictive performance and emerged as the better predictor for SAP.