Circulation Large Vessel Occlusion Stroke Research Articles

Comparison of CT Perfusion Software Packages for Thrombectomy Eligibility.

Computed tomography perfusion (CTP) has played an important role in patient selection for mechanical thrombectomy (MT) in acute ischemic stroke. We aimed to investigate the agreement between perfusion parametric maps of 3 software packages - RAPID (RapidAI-IschemaView), Viz CTP(Viz.ai), and e-CTP(Brainomix) - in estimating baseline ischemic core volumes of near completely/completely reperfused patients. We retrospectively reviewed a prospectively maintained MT database to identify patients with anterior circulation large vessel occlusion strokes (LVOS) involving the internal carotid artery or middle cerebral artery M1-segment and interpretable CTP maps treated during September 2018 to November 2019. A subset of patients with near-complete/complete reperfusion (expanded thrombolysis in cerebral infarction [eTICI] 2c-3) was used to compare the pre-procedural prediction of final infarct volumes. In this analysis of 242 patients with LVOS, RAPID and Viz CTP relative cerebral blood flow (rCBF) < 30% values had substantial agreement (ρ = 0.767 [95% confidence interval [CI] = 0.71-0.81]) as well as for RAPID and e-CTP (ρ = 0.668 [95% CI = 0.61-0.71]). Excellent agreement was seen for time to maximum of the residue function (Tmax ) > 6 seconds between RAPID and Viz CTP (ρ = 0.811 [95% CI = 0.76-0.84]) and substantial for RAPID and e-CTP (ρ = 0.749 [95% CI = 0.69-0.79]). Final infarct volume (FIV) prediction (n = 136) was substantial in all 3 packages (RAPID ρ = 0.744; Viz CTP ρ = 0.711; and e-CTP ρ = 0.600). Perfusion parametric maps of the RAPID, Viz CTP, and e-CTP software have substantial agreement in predicting final infarct volume in near-completely/completely reperfused patients. ANN NEUROL 2023;94:848-855.

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.

Area Deprivation Index Predicts Early Severity and Infarct Growth Rate in Anterior Circulation Large Vessel Occlusion Stroke (S3.010)

<h3>Objective:</h3> We aimed to measure the social determinants of early stroke severity (NIHSS) and infarct growth rate (IGR) in anterior circulation large vessel occlusion (ACLVO) stroke using the Area Deprivation Index (ADI). <h3>Background:</h3> Socioeconomic status has been shown to affect the clinical outcome of neurological disease and stroke. Early NIHSS and IGR are highly variable across patients with ACLVO stroke but their determinants remain poorly understood. ADI data incorporates housing, education, income, and employment status at the census block groups level. <h3>Design/Methods:</h3> Single-center retrospective study of all patients with acute intracranial ICA or MCA occlusion and baseline CTP or MRI within 24 hours of stroke onset, from 2014–2017. IGR was calculated as the ischemic core volume/stroke onset to imaging time (ml/h). ADI was obtained from the University of Wisconsin dataset based on US Census data (v 3.2). Demographics, co-morbidities, admission NIHSS, and median income data were collected. Multivariable linear regression models tested the independent association between ADI and NIHSS (model 1) or IGR (model 2, including NIHSS). <h3>Results:</h3> 165 patients were included in the analysis, with mean age 71 (SD, 15), 40% male, median NIHSS 17 (IQR, 12–21), and mean ADI 62 (SD, 23.3). In model 1, ADI (coefficient 0.07, 95% CI 0.025–0.13, P=0.004) and age (coefficient 0.11, 95% CI 0.4—0.19, P=0.003) were independently associated with NIHSS. In model 2, ADI (coefficient 0.11, 95% CI 0.004–0.21, P=0.04) and NIHSS (coefficient 0.46, 95% CI 0.16–0.76, P=0.003) were independently associated with IGR. Median income, sex, diabetes or hypertension status were not associated with NIHSS or IGR in these models. <h3>Conclusions:</h3> ADI is independently associated with worse stroke severity and faster infarct progression of ACLVO stroke. These findings have potential implications for public health planning of stroke systems of care and enrollment in clinical trials of reperfusion therapies. <b>Disclosure:</b> The institution of Dr. Sari has received research support from NIH/NINDS. Dr. Dwairi has nothing to disclose. Mr. Thoma has nothing to disclose. Dr. Magnani has nothing to disclose. The institution of Dr. Rocha has received research support from NIH.

Renal function association with infarct growth rate in anterior circulation large vessel occlusion strokes (P6-5.017)

Renal function association with infarct growth rate in anterior circulation large vessel occlusion strokes (P6-5.017)

Vascular risk factors, cerebral collateral efficiency and burden of small vessel disease in anterior circulation large vessel occlusion stroke (P11-5.025)

<h3>Objective:</h3> To determine the association between cerebral collateral circulation status and cerebral small vessel disease (CSVD) burden. <h3>Background:</h3> Subclinical ischemia is thought to play a central role in CSVD pathogenesis. In patients with large vessel occlusion, good collaterals on initial presentation are associated with improved outcomes. The relationship between an increased burden of CSVD and collateral network has not been explored in the setting of thrombectomy. <h3>Design/Methods:</h3> This was a retrospective single-center cohort of consecutive patients with anterior circulation large vessel occlusions with available brain MRI and CT-Angiogram. We identified the burden of individual CSVD markers[white matter hyperintensities (WMH), cerebral microbleeds(CMB), lacunes, and enlarged perivascular spaces (EPVS)] and computed the global CSVD burden on MRI obtained in the acute stroke. We used the Tan Collateral score (CS) in CT-Angiogram to grade collaterals (0–3; 0=absent supply, 3=100% collateral supply). We performed univariable and multivariable adjusted analyses to explore the association between collaterals and CSVD. <h3>Results:</h3> 237 patients (66.1±16.8 years), 123(52%) female were included. Mean CS was 2(IQR 1–3). WMH (89%), basal ganglia EPVS (77%) and centrum semiovale EPVS (77%) were the most prevalent markers. Older age(beta=0.15, p&lt;0.0001) had the most potent association with individual CSVD markers and higher global CSVD burden. Older age(beta=−0.01, p=0.002) was associated with lower CS. Although a trend was detected between lower CS score and higher WMH burden, it did not reach statistical significance after adjusting for confounders (beta=−0.21, p=0.15). <h3>Conclusions:</h3> In this cohort of large vessel occlusion patients, we found that older age is associated with higher individual CSVD marker and global CSVD burden and poor collateral status. We did not find an overt association between CS and WMH or global CSVD burden. <b>Disclosure:</b> Dr. McMillan has nothing to disclose. Ms. Carvalho has nothing to disclose. Sarah Marchina has nothing to disclose. Dr. Cole has nothing to disclose. Dr. Selim has received personal compensation in the range of $500-$4,999 for serving as a Consultant for MedRhythms Inc.. Dr. Lioutas has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Qmetis. Dr. Lioutas has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for American Heart Association.

The BAND score: a simple upfront predictive model for futile recanalization to guide patient selection for endovascular thrombectomy during acute ischemic stroke triage (P8-5.004)

<h3>Objective:</h3> To develop a clinical scoring system for upfront prediction of poor post-endovascular thrombectomy (EVT) outcomes during the acute stroke triage process. <h3>Background:</h3> Futile recanalization (FR) is an unfavorable outcome following successful EVT for acute ischemic stroke patients. There is currently no clinical scoring system that can accurately predict FR. <h3>Design/Methods:</h3> Consecutive EVT patients for anterior circulation large vessel occlusion strokes were identified from 2016 to 2021 at a Comprehensive Stroke Center, and clinical information was recorded. FR was defined as a 90-day modified Rankin Scale (mRS) of 4 or greater despite achieving modified thrombolysis in cerebral infarction (mTICI) score 2b or greater. Multivariable regression analyses were used to identify independent risk factors for FR, and a scoring system was constructed. <h3>Results:</h3> 619 patients were identified, and 483 patients with successful recanalization and available 90-day follow-up data were analyzed. Overall, FR was observed in 46.5% of patients. From a randomly selected training cohort (n=357), individual risk factors for FR were identified and used to construct the 10-point BAND score: baseline disability (1 point: baseline mRS ≥ 2), age (1 point: 60–69 years, 2 points: 70–79 years, 3 points: 80–84 years, 4 points: 85 years or older), NIHSS (2 points: 13–17, 3 points: 18–22, and 4 points: 23 or higher), and delay from last known normal (1 point: ≥6 hours). The BAND score achieved good predictability of FR with an area under the receiver-operating characteristic curve of 0.80 in our training cohort and 0.78 in our validation cohort. 88.2% of the total and 90.2% of patients 80 years or older with BAND ≥7 had a 90-day mRS of 4 or greater despite successful EVT recanalization. <h3>Conclusions:</h3> The BAND score is a simple clinical scoring system for prediction of FR, and it has potential to serve as a valuable triage tool for physicians in a real-world setting. <b>Disclosure:</b> Mr. Chen has received research support from National Institues of Health. Dr. Colasurdo has nothing to disclose. Dr. Phipps has nothing to disclose. The institution of Dr. Miller has received research support from Medtronic. The institution of Dr. Miller has received research support from Cerenovus, DePuy Synthes Products, Inc.. The institution of Dr. Miller has received research support from InSightec. The institution of Dr. Miller has received research support from Microvention. The institution of Dr. Miller has received research support from Microvention. The institution of Dr. Miller has received research support from InSightec. The institution of Dr. Miller has received research support from MicroVention. The institution of Dr. Miller has received research support from InSightec. The institution of Dr. Miller has received research support from Vesalio. Jacob Cherian has nothing to disclose. Dr. Marino Granados has nothing to disclose. Dr. Cronin has nothing to disclose. Dr. Wozniak has nothing to disclose. Dheeraj Gandhi has nothing to disclose. Dr. Chaturvedi has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Astra Zeneca. Dr. Chaturvedi has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for University of Calgary. Dr. Chaturvedi has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for American Heart Association. Dr. Chaturvedi has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Ramar &amp; Paradiso. Dr. Chaturvedi has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Cole, Scott, Kissane. The institution of Dr. Chaturvedi has received research support from NINDS. Gaurav Jindal has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Penumbra.

Lack of Pre-treatment Thrombolysis and Low ASPECTS are Associated with Poor Rates of Recanalization After Mechanical Thrombectomy (P8-5.025)

<h3>Objective:</h3> To identify factors associated with poor rates of recanalization in patients with large vessel occlusion ischemic stroke undergoing mechanical thrombectomy. <h3>Background:</h3> Mechanical thrombectomy (MT) has been effective in treating ischemic strokes due to large vessel occlusion (LVO). However, all patients with LVO who are deemed candidates for MT do not have successful rates of recanalization and a favorable outcome. Hence, we studied factors associated with an unfavorable outcome in patients undergoing MT. <h3>Design/Methods:</h3> We retrospectively analyzed forty patients with LVO ischemic stroke undergoing MT. We included patients with anterior circulation LVO strokes who were deemed candidates for MT. Patient underwent CTA imaging upon arrival in the emergency room. We collected important variables including initial NIHSS, pre-morbid modified Rankin Scale (mRS), administration of thrombolysis, location of LVO, ASPECTS, TICI (thrombolysis in cerebral infarction) score. Functional outcome was measured with NIHSS and mRS at discharge. <h3>Results:</h3> 40 patients with LVO who underwent MT (age 68 ±15); 62.4 % female; NIHSS 16). Patients were divided into four groups based on TICI scores into those with 0/1, 2b, 2c and 3. Variables including initial NIHSS, pre-morbid mRS, administration of thrombolysis, location of LVO, ASPECTS and TICI score were compared between these groups. In the TICI 0/1 group, patients had low ASPECTS on arrival and were not treated with thrombolysis prior to thrombectomy. They also had a higher NIHSS and mRS at discharge. <h3>Conclusions:</h3> Lack of pre-treatment thrombolysis and low ASPECTS on presentation were associated with poor rates of recanalization after mechanical thrombectomy. <b>Disclosure:</b> Dr. Peshwe has nothing to disclose. Dr. Alvi has nothing to disclose.

A canine thromboembolic model of anterior circulation large vessel occlusion stroke

PurposeTo develop a large animal preclinical model of thromboembolic stroke with stable, protracted large vessel occlusion (LVO) utilizing an autologous clot. Materials and methodsA reproducible canine model of large vessel occlusion stroke was established by endovascular placement of an autologous clot into the middle cerebral artery (MCA) of six adult hounds and confirmed using digital subtraction angiography (DSA). Infarct volume and evidence of hemorrhage were determined by magnetic resonance imaging (MRI) 7 h after occlusion and Thrombolysis in Cerebral Infarction scale (TICI) was assessed before and after clot placement and at 1, 6, 7, and 9 h after middle cerebral artery occlusion (MCAO). Heart rate (HR) and blood pressure (BP) were monitored continuously and invasively through an arterial sheath throughout the procedures and complete blood count and blood gas analysis completed at time of sacrifice. Histopathological findings at time of sacrifice were used to confirm stroke volume and hemorrhage. ResultsMCAO with resulting TICI 0 flow was observed in all six animals, verified by serial DSA, and lack of collateral flow persisted for 9 h after clot placement until time of sacrifice. The mean infarct volume was 47.0 ± 6.7% of the ipsilateral hemisphere and no events of spontaneous recanalization or clot autolysis were observed. ConclusionWe demonstrate a thromboembolic canine model of MCAO that is both feasible and results in consistent infarct volumes to generate a clinically relevant LVO. This model is important to evaluate treatment of LVO in acute ischemic stroke (AIS) outside the established 4.5 h recombinant tissue plasminogen activator (rTPA) therapeutic window utilizing a prolonged occlusive thrombus.

April 2023 Stroke Highlights.

April 2023 Stroke Highlights.

Prior anticoagulation and bridging thrombolysis improve outcomes in patients with atrial fibrillation undergoing endovascular thrombectomy for anterior circulation stroke

BackgroundWhere stroke occurs with pre-existing atrial fibrillation (AF)studies validating the safety and efficacy of bridging thrombolysis, and the use of endovascular thrombectomy (EVT) in the setting of prior anticoagulation, are...

Abstract Number ‐ 241: Simultaneous IV tPA During Thrombectomy Reduces Post‐Procedure Hypoperfusion Volumes in Anterior LVO Patients

Introduction Simultaneous tPA administration during mechanical thrombectomy may induce synergistic benefits (1). We aimed to characterize the hypoperfusion status after thrombectomy according to the timing of tPA administration and the degree of final recanalization. Methods We studied consecutive anterior circulation large vessel occlusion (LVO) stroke patients treated with mechanical thrombectomy who received a CT perfusion (CTP) immediately after endovascular procedure (2). Patients were divided in three groups according to: no iv tPA treatment (non‐tPA), tPA administration before 120 minutes (tPA&gt;120) or iv tPA administration within 120 min (tPA&lt; 120) of groin puncture. The extend of post‐procedure hypoperfusion (volume Tmax&gt;6s) and relative hypoperfusion reduction compared with admission CTP (volume post‐procedure – admission Tmax&gt;6s/admission Tmax&gt;6s) according to final TICI scores were compared between the three study groups. Results One hundred and sixty‐nine patients were included in the study, mean age 72 years and median baseline NIHSS of 15. Thirty (17.8%) patients received iv tPA more than 2h before groin puncture (tPA&gt;120), 32(18.9%) within 2h of the puncture (tPA &lt; 120) and 107(63.3%) were non‐tPA. No difference on stroke severity, pre‐procedure hypoperfusion volume or occlusion location before thrombectomy were detected between groups. The rate of complete recanalization (TICI 3, 38.5%) was also similar in the 3 study groups (p = 0.12). Overall, the post‐procedure hypoperfusion volume was significantly lower in the tPA&lt; 120 group (19.9±4.6cc vs 35.0±5.5, p = 0.04), and the relative hypoperfusion reduction was higher in tPA&lt; 120 (0.86 vs 0.66, p = 0.05) as compared to non‐tPA. No significant differences were detected between non‐tPA and tPA&gt;120 groups. For each final TICI score the post‐procedure hypoperfusion tended to be lower in the tPA&lt; 120‐group, with a stronger reduction in patients with lower degree of recanalization (Figure). Conclusions A reduction of post‐thrombectomy hypoperfusion volumes was detected in patients treated with iv tPA during or shortly before thrombectomy, which could be a surrogate marker of the beneficial effect of tPA on the microcirculation. The specific reperfusion synergistic effect of tPA and mechanical thrombectomy beyond LVO recanalization warrants future studies.

A Novel Nomogram for Predicting Malignant Cerebral Edema After Endovascular Thrombectomy in Acute Ischemic Stroke: A Retrospective Cohort Study

Malignant cerebral edema (MCE) is a common and feared complication after endovascular thrombectomy (EVT) in acute ischemic stroke (AIS). This study aimed to establish a nomogram to predict MCE in anterior circulation large vessel occlusion stroke (LVOS) patients receiving EVT in order to guide the postoperative medical care in the acute phase. In this retrospective cohort study, 381 patients with anterior circulation LVOS receiving EVT were screened from 636 hospitalized patients with LVOS at 2 stroke medical centers. Clinical baseline data and imaging data were collected within 2-5 days of admission to the hospital. The patients were divided into 2 groups based on whether MCE occurred after EVT. Multivariate logistic regression analysis was used to evaluate the independent risk factors for MCE and to establish a nomogram. Sixty-six patients out of 381 (17.32%) developed MCE. The independent risk factors for MCE included admission National Institutes of Health Stroke Scale (NIHSS) ≥16 (odds ratio [OR] 1.851; 95% CI 1.029-3.329; P= 0.038), ASPECT score (OR 0.621; 95% CI 0.519-0.744; P < 0.001), right hemisphere (OR 1.636; 95% CI 0.941-2.843; P= 0.079), collateral circulation (OR 0.155; 95% CI 0.074-0.324; P < 0.001), recanalization (OR 0.223; 95% CI 0.109-0.457; P < 0.001), hematocrit (OR, 0.937; 95% CI: 0.892-0.985; P=0.010), and glucose (OR 1.118; 95% CI 1.023-1.223; P= 0.036), which were adopted as parameters of the nomogram. The receiver operating characteristic curve analysis showed that the area under the curve of the nomogram in predicting MCE was 0.901(95% CI 0.848-0.940; P < 0.001). The Hosmer-Lemeshow test results were not significant (P= 0.685), demonstrating a good calibration of the nomogram. The novel nomogram composed of admission NIHSS, ASPECT scores, right hemisphere, collateral circulation, recanalization, hematocrit, and serum glucose provide a potential predictor for MCE in patients with AIS after EVT.

Abstract TMP96: Area Deprivation Index (ADI) And NIHSS Predicts The Infarct Growth Rate (IGR)

Introduction: Socioeconomic status has been shown to affect the clinical outcome of cardiovascular disease and stroke. Early clinical severity and infarct growth rate (IGR) are highly variable across patients with anterior circulation large vessel occlusion (ACLVO) stroke but remain poorly understood. We aimed to measure the social determinants of early NIHSS and IGR in ACLVO stroke using the Area Deprivation Index (ADI), which incorporates housing, education, income, and employment status at the neighborhood level. Methods: Single-center retrospective study of all patients with acute intracranial ICA or proximal MCA occlusion and baseline CTP or MRI within 24 hours of stroke onset from 2014-2017. IGR (ischemic core volume / stroke onset to core imaging time, ml / hours) was calculated. Demographics, co-morbidities, admission NIHSS, ADI, and median income data were collected. Multivariable linear regression models tested the independent association between ADI and NIHSS (model 1) or IGR (model 2, including NIHSS). Results: A total of 165 patients were included in the analysis, with mean age 71 (SD, 15), 40 % male sex and median NIHSS 17(IQR, 12--21). In model 1, ADI (coefficient 0.07, 95% CI 0.025-0.13, P=0.004) and age (coefficient 0.11, 95% CI 0.4—0.19, P=0.003) were the only independent predictors of NIHSS. In model 2, ADI (coefficient 0.11, 95% CI 0.004-0.21, P=0.04) and NIHSS (coefficient 0.46, 95% CI 0.16-0.76, P=0.003) were the only independent predictors of IGR. Median income, sex, diabetes or hypertension status were not independently associated with NIHSS or IGR in these models. Conclusions: ADI is independently associated with worse stroke severity and faster infarct progression of ACLVO stroke. These findings have possibly important implications for public health care planning of stroke systems of care and enrollment in clinical trials of reperfusion therapies.

Abstract 24: Primary Results Of The Preset For Occlusive Stroke Treatment (prost) Randomized Clinical Trial

Importance: Clinical trials focusing on new mechanical thrombectomy (MT) technologies have been typically single-arm studies using historical comparison data to determine the safety and efficacy of the novel device. To date, there has not been a contemporaneous prospective, randomized, controlled study comparing standard to newer designed stent-retrievers. Objective: To evaluate the safety and efficacy of the pRESET (phenox Ltd) compared to the Solitaire (Medtronic Corp) thrombectomy devices in the treatment of large vessel occlusion strokes (LVOS). Methods: Multicenter, prospective, randomized, open-label, blinded endpoint, core lab adjudicated, non-inferiority trial that enrolled 340 patients from October 2019 to February 2022 across 19 US &amp; 5 German sites. Patients aged ≥ 18 years with either anterior or posterior circulation LVOS were included up to 8 hours after symptom onset. Patients were randomly assigned in a 1:1 ratio to either pRESET or Solitaire for the first three device passes.The Primary Endpoint was the proportion of patients achieving a modified Rankin Scale score of 0-2, analyzed by intent to treat with a non-inferiority margin of 0.125 based on the lower bound 95% Confidence Interval. The Primary Safety Endpoint was the proportion of subjects with device- or procedure-related symptomatic intracerebral hemorrhage at 24 (-8/+12) hours as per the SITS-MOST criteria. Secondary Outcome Measures included the rates of (1) Successful Revascularization (defined as expanded Thrombolysis in Cerebrovascular Infarction [eTICI] ≥2b50 ≤3 passes of the assigned device; (2) eTICI ≥2c following the first pass of the assigned device; (3) 90-day mortality and (4) Distribution of 90-day mRS across the entire spectrum of disability (ordinal shift). Results: The study database was locked in August 2022. The analysis is ongoing and the final results will be presented at the 2023 International Stroke Conference. Conclusions and Relevance: PROST is the first randomized clinical trial aiming to compare a novel versus an established stent-retriever technology, establishing a new scientific benchmark for stroke device trials. (ClinicalTrials.gov: NCT03994822).

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

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

Large mismatch profile predicts rapidly progressing brain edema in acute anterior circulation large vessel occlusion patients undergoing endovascular thrombectomy.

Brain edema is a severe complication in patients with large vessel occlusion (LVO) that can reduce the effectiveness of endovascular therapy (EVT). This study aimed to investigate the association of the perfusion profile at baseline computed tomography (CT) perfusion with rapidly progressing brain edema (RPBE) after EVT in patients with acute anterior LVO. We retrospectively reviewed consecutive data collected from 149 patients with anterior LVO who underwent EVT at our center. Brain edema was measured by the swelling score (0-6 score), and RPBE was defined as the swelling score increased by more than 2 scores within 24 h after EVT. We investigated the effect of RPBE on poor outcomes [National Institute of Health Stroke Scale (NIHSS) score and modified Rankin scale (mRS) score at discharge, the occurrence of hemorrhagic transformation, and mortality rate in the hospital] using the Mann-Whitney U-test and chi-square test. A multivariate logistic regression model was used to assess the relationship between perfusion imaging parameters and RPBE occurrence. Overall, 39 patients (26.2%) experienced RPBE after EVT. At discharge, RPBE was associated with higher NIHSS scores (Z = 3.52, 95% CI 2.0-12.0, P < 0.001) and higher mRS scores (Z = 3.67, 95% CI 0.0-1.0, P < 0.001) including the more frequent occurrence of hemorrhagic transformation (χ2 = 22.17, 95% CI 0.29-0.59, P < 0.001) and higher mortality rates in hospital (χ2 = 9.54, 95% CI 0.06-0.36, P = 0.002). Univariate analysis showed that intravenous thrombolysis, baseline ischemic core volume, and baseline mismatch ratio correlated with RPBE (all P < 0.05). After dividing the mismatch ratio into quartiles and performing a chi-square test between quartiles, we found that the occurrence of RPBE in Q4 (mismatch ratio > 11.3) was significantly lower than that in Q1 (mismatch ratio ≤ 3.0) (P < 0.05). The result of multivariate logistic regression analysis showed that compared with baseline mismatch ratio <5.1, baseline mismatch ratio between 5.1 and 11.3 (OR:3.85, 95% CI 1.06-14.29, P = 0.040), and mismatch ratio >11.3 (OR:5.26, 95% CI 1.28-20.00, P = 0.021) were independent protective factors for RPBE. In patients with anterior circulation LVO stroke undergoing successful EVT, a large mismatch ratio at baseline is a protective factor for RPBE, which is associated with poor outcomes.

General anesthesia vs procedural sedation for failed NeuroThrombectomy undergoing rescue stenting: intention to treat analysis

BackgroundThere is little data available to guide optimal anesthesia management during rescue intracranial angioplasty and stenting (ICAS) for failed mechanical thrombectomy (MT). We sought to compare the procedural safety and...

CT after interhospital transfer in acute ischemic stroke: Imaging findings and impact of prior intravenous contrast administration.

Large vessel occlusion (LVO) stroke patients routinely undergo interhospital transfer to endovascular thrombectomy capable centers. Imaging is often repeated with residual intravenous (IV) iodine contrast at post-transfer assessment. We determined imaging findings and the impact of residual contrast on secondary imaging. Anterior circulation LVO stroke patients were selected out of a consecutive cohort. Directly admitted patients were contrast naïve, and transferred patients had previously received IV iodine contrast for stroke assessment at the referring hospital. Two independent readers rated the visibility of residual contrast on non-contrast computed tomography (CT) after transfer and assessed the hyperdense vessel sign. Multivariate linear regression analysis was used to investigate the association of the Alberta Stroke Program Early CT score (ASPECTS) with prior contrast administration, time from symptom onset (TFSO), and CTP ischemic core volume in both directly admitted and transferred patients. We included 161 patients, with 62 (39%) transferred and 99 (62%) directly admitted patients. Compared between these groups, transferred patients had a longer TFSO-to-imaging at our institution (median: 212 vs. 75 min, p < 0.001) and lower ASPECTS (median: 8 vs. 9, p < 0.001). Regression analysis presented an independent association of ASPECTS with prior contrast administration (β = -0.25, p = 0.004) but not with TFSO (β = -0.03, p = 0.65). Intergroup comparison between transferred and directly admitted patients pointed toward a stronger association between ASPECTS and CTP ischemic core volume in transferred patients (β = -0.39 vs. β = -0.58, p = 0.06). Detectability of the hyperdense vessel sign was substantially lower after transfer (66 vs. 10%, p < 0.001). Imaging alterations due to residual IV contrast are frequent in clinical practice and render the hyperdense vessel sign largely indetectable. Larger studies are needed to clarify the influence on the association between ASPECTS and ischemic core.

A comparative study between direct mechanical thrombectomy and bridging therapy in patients with atrial fibrillation associated anterior circulation large vessel occlusion stroke

From January 1, 2015 to December 31, 2021, 94 patients who were diagnosed with atrial fibrillation (AF) associated anterior circulation large vessel occlusion stroke and underwent mechanical thrombectomy in the First Affiliated Hospital of Dalian Medical University were retrospectively collected, including 52 patients in the direct mechanical thrombectomy (dMT) group and 42 patients in the bridging therapy (BT) group. All patients received stent thrombectomy, and the BT group received intravenous thrombolytic therapy with alteplase within 4.5 hours.There were no significant differences in 7 d National Institute of Health Stroke Scale (NIHSS) score[12.0 (5.2, 42.0) vs 10.0 (6.0, 25.8)], incidence of hemorrhage transformation [44.2%(23/52) vs 45.2%(19/42)], symptomatic intracranial hemorrhage[11.5%(6/52) vs 11.9%(5/42)],90 d mortality[34.6% (18/52) vs 38.1% (16/42)]between the two groups(all P>0.05). The rate of 90 d good prognosis in dMT and BT groups was 36.5% (19/52) and 35.7% (15/42), respectively, and the difference was not statistically significant(OR=1.45, 95%CI: 0.39-3.37, P=0.805). The number of stent passes[2(1,3) vs 1(1,2)] and the vessel recanalization time [(81±41)min vs (57±29)min] in the BT subgroup of middle cerebral artery (MCA) occlusion were longer than those in the dMT group (both P<0.05).Therefore, direct thrombectomy has similar efficacy and safety as bridging therapy in the treatment of AF related anterior circulation large vessel occlusive stroke, which is worthy of further research and verification.

Mechanical Thrombectomy in the Late Presentation of Anterior Circulation Large Vessel Occlusion Stroke: A Guideline From the Society of Vascular and Interventional Neurology Guidelines and Practice Standards Committee

Background Recent clinical trials investigating endovascular therapy in the extended time window have opened new treatment paradigms for patients with late‐presenting large vessel occlusion stroke. The aim of this guideline is to provide up‐to‐date recommendations for the diagnosis, selection, and medical or endovascular treatment of patients with large vessel occlusion presenting in the extended time window. Methods The Society of Vascular and Interventional Neurology Guidelines and Practice Standards committee assembled a writing group and recruited interdisciplinary experts to review and evaluate the current literature. Recommendations were assigned by the writing group using the Society of Vascular and Interventional Neurology Guidelines and Practice Standards Class of Recommendation/Level of Evidence algorithm and Society of Vascular and Interventional Neurology Guidelines and Practice Standards guideline format. The final guideline was approved by all members of the writing group, the Guidelines and Practice Standards committee, and the Society of Vascular and Interventional Neurology board of directors. Results Literature review yielded 3 high‐quality randomized trials and several observational studies that have been extracted to derive the enclosed summary recommendations. In patients with large vessel occlusion presenting in the 6‐ to 24‐hour window and with clinical–imaging mismatch as defined by the DAWN (Diffusion‐Weighted Imaging or Computed Tomography Perfusion Assessment With Clinical Mismatch in the Triage of Wake‐Up and Late Presenting Strokes Undergoing Neurointervention With Trevo) and DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke) studies, endovascular therapy is recommended. Noncontrast computed tomography can be used to evaluate infarct size as the sole imaging modality for patient selection, particularly when access to computed tomography perfusion or magnetic resonance imaging is limited or if their performance would incur substantial delay to treatment. In addition, several clinical questions were reviewed based on the available evidence and consensus grading. Conclusions These guidelines provide practical recommendations based on recent evidence on the diagnosis, selection, and treatment of patients with large vessel occlusion stroke presenting in the extended time window.