Differences In Functional Independence Research Articles

Efficacy and safety outcomes of endovascular versus best medical treatment in posterior cerebral artery occlusion stroke

BackgroundThe management of acute ischemic stroke due to isolated posterior cerebral artery occlusion (iPCAO) remains a topic of debate. This study investigates the efficacy and safety of endovascular treatment (EVT)...

Functional Outcomes Associated With Blood Pressure Decrease After Endovascular Thrombectomy

The associations between blood pressure (BP) decreases induced by medication and functional outcomes in patients with successful endovascular thrombectomy remain uncertain. To evaluate whether BP reductions induced by intravenous BP medications are associated with poor functional outcomes at 3 months. This cohort study was a post hoc analysis of the Outcome in Patients Treated With Intra-Arterial Thrombectomy-Optimal Blood Pressure Control trial, a comparison of intensive and conventional BP management during the 24 hours after successful recanalization from June 18, 2020, to November 28, 2022. This study included 302 patients who underwent endovascular thrombectomy, achieved successful recanalization, and exhibited elevated BP within 2 hours of successful recanalization at 19 stroke centers in South Korea. A BP decrease was defined as at least 1 event of systolic BP less than 100 mm Hg. Patients were divided into medication-induced BP decrease (MIBD), spontaneous BP decrease (SpBD), and no BP decrease (NoBD) groups. The primary outcome was a modified Rankin scale score of 0 to 2 at 3 months, indicating functional independence. Primary safety outcomes were symptomatic intracerebral hemorrhage within 36 hours and mortality due to index stroke within 3 months. Of the 302 patients (median [IQR] age, 75 [66-82] years; 180 [59.6%] men), 47 (15.6%)were in the MIBD group, 39 (12.9%) were in the SpBD group, and 216 (71.5%) were in the NoBD group. After adjustment for confounders, the MIBD group exhibited a significantly smaller proportion of patients with functional independence at 3 months compared with the NoBD group (adjusted odds ratio [AOR], 0.45; 95% CI, 0.20-0.98). There was no significant difference in functional independence between the SpBD and NoBD groups (AOR, 1.41; 95% CI, 0.58-3.49). Compared with the NoBD group, the MIBD group demonstrated higher odds of mortality within 3 months (AOR, 5.15; 95% CI, 1.42-19.4). The incidence of symptomatic intracerebral hemorrhage was not significantly different among the groups (MIBD vs NoBD: AOR, 1.89; 95% CI, 0.54-5.88; SpBD vs NoBD: AOR, 2.75; 95% CI, 0.76-9.46). In this cohort study of patients with successful endovascular thrombectomy after stroke, MIBD within 24 hours after successful recanalization was associated with poor outcomes at 3 months. These findings suggested lowering systolic BP to below 100 mm Hg using BP medication might be harmful.

Systolic blood pressure reduction strategies in acute ischemic stroke patients following endovascular thrombectomy: a systematic review and meta-analysis

Background and AimsThere is no clear consensus on ideal systolic blood pressure (SBP) target post-endovascular thrombectomy (EVT) in patients with acute ischemic stroke. This study intends to investigate the relationship between reducing SBP and clinical outcomes and to determine the therapeutic efficacy of moderate and intensive SBP reduction post EVT. MethodsA comprehensive search was conducted across five electronic databases to identify studies relevant to our analysis. Data from these studies were then analyzed using pooled relative risk (RR) along with their corresponding 95 % confidence intervals (CI) for our categorical outcomes. functional independence at 90 days post-EVT was defined as a modified Rankin score (mRS) 0-2. ResultsOur meta-analysis included eight studies with 2922 patients: 1376 patients were treated with intensive SBP reduction, 306 with moderate SBP reduction, and 1243 with standard SBP reduction. There was no difference in the risk of functional independence at 90 days post-EVT with both intensive-SBP reduction (target 120-140 mmHg, relative risk (RR) =1.05, 95 % CI 0.82, 1.34, p = 0.72) and moderate-SBP reduction (>160 mm Hg) (RR= 0.95, 95 % CI 0.69, 1.31, p = 0.76) compared with standard SBP reduction (>180 mm Hg). The risk of symptomatic intracranial hemorrhage (sICH) did not significantly differ between standard-SBP reduction and intensive-SBP reduction (RR = 0.93, 95 % CI 0.66, 1.31, p = 0.36) or moderate-SBP reduction (0.72 (95 % CI [0.28, 1.87], p = 0.50) groups, respectively. Intensive-SBP reduction significantly decreased the risk of hemicraniectomy. ConclusionsWe did not identify any difference in functional independence at 90 days in acute ischemic stroke patients with either intensive-SBP reduction or moderate-SBP reduction compared with standard SBP reduction post-EVT.

Abstract 25: Intravenous Thrombolysis for Acute Ischemic Stroke in Patients With Recent Direct Oral Anticoagulant Use: A Systematic Review and Meta-Analysis

Introduction: Intravenous thrombolysis (IVT) is efficacious treatment of acute ischemic stroke (AIS). However, certain circumstances associated with increased bleeding risk, such as recent direct oral anticoagulation (DOAC) intake limits its use. Nonetheless, emerging evidence has shown promising results in this patient group. We investigated the safety and efficacy of IVT in patients with AIS and recent DOAC use. Methods: We conducted systematic review and meta-analysis of proportions evaluating IVT with recent DOAC use. Outcomes of interest were symptomatic intracranial hemorrhage (sICH), any ICH, serious systemic bleeding (SSB), and 90-day functional independence (mRS 0-2). Moreover, we calculated pooled odds ratios (OR) for each outcome using a random effect meta-analysis to compare the rates between the patients with DOAC and non-DOAC upon IVT. Ultimately, we completed a sensitivity analysis for idarucizumab, NIHSS, and the timing of DOAC administration. Results: Our meta-analysis included 14 studies with 247079 patients (3610 in DOAC and 243469 in non-DOAC). In the DOAC group, the rate of sICH was 3% (95%CI 3 - 4%), any ICH was 12% (95%CI 7 - 19%), SSB 0.7% (95%CI 0 - 1%), and 90-day mRS 0-2 was 57% (95%CI 43 - 70%). No difference in the rates of sICH (3.4vs.3.5%; OR=0.95; 95%CI 0.67 - 1.36), any ICH (17.7vs.17.3%; OR=1.23; 95%CI 0.61 - 2.48), SSB (0.7vs.0.6%; OR=1.27; 95%CI 0.79 - 2.02), and 90-day mRS 0-2 (46.4vs.56.8%; OR=1.21; 95%CI 0.400 - 3.67) was found between DOAC and non-DOAC groups. Subgroup analysis revealed no significant difference in the sICH rate between idaricuzumab and no idaricizumab administration prior to IVT [Figure 1]. Conclusions: Our analysis demonstrated no significant difference in functional independence and hemorrhagic complication rates in AIS patients treated with IVT with recent DOAC compared to the no-DOAC group. Further prospective randomized clinical trials are needed to shed more light on this topic.

Effect of time delay in inter-hospital transfer on outcomes of endovascular treatment of acute ischemic stroke.

Endovascular treatment (EVT) with mechanical thrombectomy is the standard of care for large vessel occlusion (LVO) in acute ischemic stroke (AIS). The most common approach today is to perform EVT in a comprehensive stroke center (CSC) and transfer relevant patients for EVT from a primary stroke center (PSC). Rapid and efficient treatment of LVO is a key factor in achieving a good clinical outcome. We present our retrospective cohort of patients who underwent EVT between 2018 and 2021, including direct admissions and patients transferred from PSC. Primary endpoints were time intervals (door-to-puncture, onset-to-puncture, door-to-door) and favorable outcome (mRS ≤ 2) at 90 days. Secondary outcomes were successful recanalization, mortality rate, and symptomatic intracranial hemorrhage (sICH). Additional analysis was performed for transferred patients not treated with EVT; endpoints were time intervals, favorable outcomes, and reason for exclusion of EVT. Among a total of 405 patients, 272 were admitted directly to our EVT center and 133 were transferred; there was no significant difference between groups in the occluded vascular territory, baseline NIHSS, wake-up strokes, or thrombolysis rate. Directly admitted patients had a shorter door-to-puncture time than transferred patients (190 min vs. 293 min, p < 0.001). The median door-to-door shift time was 204 min. We found no significant difference in functional independence, successful recanalization rates, or sICH rates. The most common reason to exclude transferred patients from EVT was clinical or angiographic improvement (55.6% of patients). Our results show that transferring patients to the EVT center does not affect clinical outcomes, despite the expected delay in EVT. Reassessment of patients upon arrival at the CSC is crucial, and patient selection should be done based on both time and tissue window.

General anesthesia versus nongeneral anesthesia during endovascular therapy for acute ischemic stroke: A systematic review and meta-analysis.

This study compares the safety and efficacy of general anesthesia (GA) and nongeneral anesthesia (non-GA) on functional outcomes in patients receiving endovascular therapy for ischemic stroke. All available studies on the anesthetic management of patients with acute ischemic stroke in PubMed, the Cochrane Central Register of Controlled Trials, and Embase were included. We also compared the clinical outcomes in the studies with subgroup analyses of the occlusion site (anterior vs. posterior circulation) and preretriever group versus retriever group. Functional independence, mortality, successful recanalization, hemodynamic instability, intracerebral hemorrhage, and respiratory complications were considered primary or secondary outcomes. A total of 24,606 patients in 60 studies were included. GA had a lower risk of 90-day functional independence (OR=0.67, 95% CI 0.58 to 0.77), higher risk of 90-day mortality (OR=1.29; 95% CI 1.15 to 1.45), and successful reperfusion (OR=1.18; 95% CI 1.94 to 6.82). However, there were no differences in functional independence and mortality between GA and non-GA at 90 days after the procedure. The study shows poorer results in the GA group, which may be due to the inclusion of nonrandomized studies. However, analysis of the RCTs suggested that the outcomes do not differ between the two groups (GA vs. non-GA). Thus, general anesthesia is as safe as nongeneral anesthesia under standardized management.

Value of intravenous thrombolysis in endovascular treatment for large-vessel anterior circulation stroke: individual participant data meta-analysis of six randomised trials

Intravenous thrombolysis is recommended before endovascular treatment, but its value has been questioned in patients who are admitted directly to centres capable of endovascular treatment. Existing randomised controlled trials have indicated non-inferiority of endovascular treatment alone or have been statistically inconclusive. We formed the Improving Reperfusion Strategies in Acute Ischaemic Stroke collaboration to assess non-inferiority of endovascular treatment alone versus intravenous thrombolysis plus endovascular treatment. We conducted a systematic review and individual participant data meta-analysis to establish non-inferiority of endovascular treatment alone versus intravenous thrombolysis plus endovascular treatment. We searched PubMed and MEDLINE with the terms "stroke", "endovascular treatment", "intravenous thrombolysis", and synonyms for articles published from database inception to March 9, 2023. We included randomised controlled trials on the topic of interest, without language restrictions. Authors of the identified trials agreed to take part, and individual participant data were provided by the principal investigators of the respective trials and collated centrally by the collaborators. Our primary outcome was the 90-day modified Rankin Scale (mRS) score. Non-inferiority of endovascular treatment alone was assessed using a lower boundary of 0·82 for the 95% CI around the adjusted common odds ratio (acOR) for shift towards improved outcome (analogous to 5% absolute difference in functional independence) with ordinal regression. We used mixed-effects models for all analyses. This study is registered with PROSPERO, CRD42023411986. We identified 1081 studies, and six studies (n=2313; 1153 participants randomly assigned to receive endovascular treatment alone and 1160 randomly assigned to receive intravenous thrombolysis and endovascular treatment) were eligible for analysis. The risk of bias of the included studies was low to moderate. Variability between studies was small, and mainly related to the choice and dose of the thrombolytic drug and country of execution. The median mRS score at 90 days was 3 (IQR 1-5) for participants who received endovascular treatment alone and 2 (1-4) for participants who received intravenous thrombolysis plus endovascular treatment (acOR 0·89, 95% CI 0·76-1·04). Any intracranial haemorrhage (0·82, 0·68-0·99) occurred less frequently with endovascular treatment alone than with intravenous thrombolysis plus endovascular treatment. Symptomatic intracranial haemorrhage and mortality rates did not differ significantly. We did not establish non-inferiority of endovascular treatment alone compared with intravenous thrombolysis plus endovascular treatment in patients presenting directly at endovascular treatment centres. Further research could focus on cost-effectiveness analysis and on individualised decisions when patient characteristics, medication shortages, or delays are expected to offset a potential benefit of administering intravenous thrombolysis before endovascular treatment. Stryker and Amsterdam University Medical Centers, University of Amsterdam.

TREAT‐AIS: A Multicenter National Registry

Background Endovascular thrombectomy (EVT) is the standard therapy for patients with acute ischemic stroke secondary to large‐artery occlusion. In January 2019, the Taiwan Stroke Society established a nationwide TREAT‐AIS (Taiwan Registry of Endovascular Thrombectomy for Acute Ischemic Stroke). Here, we provide the study design, current progress, and baseline data of TREAT‐AIS. Methods TREAT‐AIS is a multicenter prospective registration program in Taiwan. Patients aged ≥20 years who underwent EVT for acute ischemic stroke were recruited. The key items on the registration form were divided into general stroke demographics and EVT‐related sections. The main outcome of effectiveness was functional independence (modified Rankin Scale score, 0–2) at 3 months. The influence of sex on post‐EVT outcomes was also analyzed in the presented study. Results By the end of June 2022, there were 10 medical centers and 9 community hospitals participating in the TREAT‐AIS and a total of 1522 patients (mean±SD age, 71.2±13.6 years; men, 55.6%) being enrolled. The median National Institutes of Health Stroke Scale score on admission was 18 (interquartile range, 12–23). The major cause of stroke was cardioembolism (43.6%), followed by large‐artery atherosclerosis (36.8%) and an undetermined cause (15.4%). Functional independence at 3 months poststroke was achieved in 36.2% of the patients. Male patients were more likely to have functional independence at 3 months compared with female patients (40.4% versus 30.8%; P &lt;0.001). However, the sex difference in functional independence became nonsignificant (odds ratio, 1.12 [95% CI, 0.96–1.46] in men compared with women) after adjusting for age, National Institutes of Health Stroke Scale score at admission, and recanalization status after EVT. Conclusions This study demonstrated the current progress of the TREAT‐AIS in capturing real‐world EVT data in Taiwan. The TREAT‐AIS will provide valuable insights into the real‐world practice of EVT in patients with acute stroke and the related quality of care in Asian patients.

June 2023 Stroke Highlights.

June 2023 Stroke Highlights.

Endovascular Thrombectomy Beyond 24 Hours from Stroke Onset: A Systematic Review and Meta-Analysis (S24.001)

<h3>Objective:</h3> To assess the safety and efficacy of endovascular thrombectomy (EVT) &gt;24-h and compare clinical outcomes with patients treated &lt;24-h. <h3>Background:</h3> Trials have demonstrated the benefit of EVT up to 24-hours after acute ischemic stroke (AIS) onset. Recently, real-world observational studies reported that EVT was effective and safe beyond 24-h from AIS onset with comparable outcomes to EVT within 24-h. <h3>Design/Methods:</h3> A systematic search was performed in MEDLINE and EMBASE for studies published from inception to July 2022. Studies including patients with AIS who received EVT beyond 24-h from stroke onset were selected. We also included patients treated with EVT (&gt;24-h and &lt;24-h) from our institutional retrospective data. Outcomes of interest included functional independence (90-day mRS 0–2), successful recanalization (mTICI 2b-3), symptomatic intracerebral hemorrhage (sICH), and all-cause mortality at 90 days. First, a single-arm meta-analysis (MA) of proportions was conducted for studies with EVT &gt;24-h. Then, we performed a comparative MA between the &lt;24-h and &gt;24-h groups to calculate pooled odds ratios (OR) for each outcome. Statistical heterogeneity across studies was assessed with I² statistics. <h3>Results:</h3> Five studies with 298 patients treated &gt;24-h were included. Functional independence rate was 39% (95%CI 27–54%; I²=68%) and successful recanalization rate was 79% (95%CI 75–83%; I²=0%). Mortality and sICH rates were 25% (95%CI 20–30%; I²=0%) and 6% (95%CI 4–9%; I²=0%), respectively. We included 3272 patients (&gt;24-h = 179; &lt;24-h = 3093) in the comparative analysis. There was no significant difference in functional independence (OR 0.76; 95%CI 0.41–1.32), successful recanalization (OR 0.6; 95%CI 0.44–1.0), and mortality (OR 1.18; 95%CI 0.7–1.9) rates between patients who underwent EVT &lt;24-h versus &gt;24-h. <h3>Conclusions:</h3> Our findings prove that EVT beyond 24-h is safe and effective. Also, this MA did not demonstrate a significant difference between EVT beyond and within 24-h from stroke onset regarding functional independence, successful recanalization, and mortality. <b>Disclosure:</b> Dr. Rodriguez-Calienes has nothing to disclose. Mr. Vivanco-Suarez has nothing to disclose. Dr. Galecio-Castillo has nothing to disclose. Cynthia Zevallos has nothing to disclose. Mr. Malaga has nothing to disclose. Dr. Farooqui has nothing to disclose. Dr. Ortega Gutierrez has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for stryker. Dr. Ortega Gutierrez has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for medtronic. Dr. Ortega Gutierrez has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for microvention. Dr. Ortega Gutierrez has received personal compensation in the range of $0-$499 for serving as an officer or member of the Board of Directors for SVIN. The institution of Dr. Ortega Gutierrez has received research support from stryker. The institution of Dr. Ortega Gutierrez has received research support from Siemens. The institution of Dr. Ortega Gutierrez has received research support from IschemiaView. The institution of Dr. Ortega Gutierrez has received research support from Medtronic.

Thrombectomy for distal medium vessel occlusion stroke: Combined vs. single-device techniques - A systematic review and meta-analysis

BackgroundThe optimal mechanical thrombectomy technique for acute ischaemic stroke (AIS) caused by distal, medium vessel occlusion (DMVO) is uncertain. We performed a systematic review and meta-analysis evaluating the efficacy and safety of first-line thrombectomy with combined techniques, which entail simultaneous use of a stent retriever and aspiration catheter, vs. single-device techniques, whether stent retriever or direct aspiration alone, for DMVO-AIS patients.MethodsWe systematically searched the PubMed, Embase and Cochrane CENTRAL databases from inception until 2 September 2022 for studies comparing combined and single-device techniques in DMVO-AIS patients. We adopted the Distal Thrombectomy Summit Group's definition of DMVO. Our outcomes were the modified first-pass effect [mFPE; modified Thrombolysis in Cerebral Infarction (mTICI) 2b-3 at first-pass], first-pass effect (FPE; mTICI 2c-3 at first-pass), successful and complete final reperfusion (mTICI 2b-3 and 2c-3 at end of all procedures, respectively), 90-day functional independence (modified Rankin scale 0-2), 90-day mortality, and symptomatic intracranial hemorrhage (sICH).ResultsNine studies were included, with 477 patients receiving combined techniques, and 670 patients receiving single-device thrombectomy. Combined techniques achieved significantly higher odds of mFPE [odds ratio (OR), 2.12; 95% confidence interval (CI), 1.12–4.02; p = 0.021] and FPE (OR, 3.55; 95% CI, 1.97–6.38; p &amp;lt; 0.001), with lower odds of sICH (OR, 0.23; 95% CI 0.06–0.93; p = 0.040). There were no significant differences in final reperfusion, functional independence (OR, 1.19; 95% CI 0.87–1.63; p = 0.658), or mortality (OR, 0.94; 95% CI, 0.50–1.76; p = 0.850).ConclusionsIn DMVO-AIS patients, mechanical thrombectomy combining stent retrievers and aspiration catheters achieved higher odds of FPE and lower odds of sICH over single-device techniques. There were no differences in functional independence and mortality. Further trials are warranted to establish these findings.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/display_recor d.php?ID=CRD42022370160, identifier: CRD42022370160.

A study on endovascular treatment alone and bridging treatment for acute ischemic stroke

ObjectivesTo investigate whether intravenous thrombolysis (IVT) with alteplase (a recombinant tissue plasminogen activator, rt-PA) before endovascular treatment (EVT) is beneficial for acute ischemic stroke (AIS) patients in different periods.MethodsThis study enrolled a total of 140 patients hospitalized between 2019 and 2022 with AIS from large vessel occlusion (LVO) in the anterior circulation. Those patients were divided into the EVT alone group and IVT + EVT group, in which EVT was preceded by intravenous rt-PA. According to the time from onset to femoral artery puncture, the above two groups were divided into the following subgroups: < 4.5 h, between 4.5 and 6 h, between 6 and 8 h, and between 8 and 10 h. There were 78 patients in the EVT alone group and 62 patients in the IVT + EVT group.ResultsThere was no statistically significant difference in functional independence, recanalization rate, favorable outcome rate, or mortality between the EVT and IVT + EVT groups (P > 0.05). After adjusting for confounding factors, a lower incidence of intracerebral hemorrhage was observed in the EVT group (P < 0.05). A comparison of time-dependent efficacy between the two groups showed that within 6–8 h, there were statistically significant differences between admission and postoperation in the National Institutes of Health Stroke Scale scores at 24 h (P = 0.01) or 7 days (P = 0.02).ConclusionsAlthough there was no difference in clinical efficacy and safety between the abovementioned two groups, treatment with IVT + EVT could increase the risk of bleeding compared to EVT. Moreover, in the 6–8 h subgroup, the efficacy of EVT alone was better than that of IVT + EVT.

No sex difference was found in the safety and efficacy of intravenous alteplase before endovascular therapy.

Prior studies on sex disparities were post-hoc analyses, had limited treatment modalities, and had controversial findings. Our study aimed to examine whether sex difference modifies the effect of intravenous alteplase before endovascular therapy. We conducted a multicenter prospective cohort study of 850 eligible patients with acute ischemic stroke who underwent endovascular therapy. A propensity score was utilized as a covariate to achieve approximate randomization of alteplase pretreatment. The baseline characteristics of women and men were compared. Logistic regression with interaction terms, adjusted for potential confounders, was used to investigate the effect of sex on the prognosis of bridging therapy. In comparison to men, women were older [78.00 (70.00-84.00) vs. 67 (61.00-74.00), P < 0.001], had more atrial fibrillation (61.4 vs. 35.2%, P < 0.001), had a lower ASPECTS [10.00 (8.00-10.00) vs. 10 (9.00-10.00), P = 0.0047], and had a higher NIHSS score [17.00 (14.00-20.00) vs. 16 (13.00-19.00), P = 0.005]. Women tended to receive less bridging therapy (26.3 vs. 33%, P = 0.043) and more retrieval attempts [2.00 (1.00-2.00) vs. 1 (1.00-2.00), P = 0.026]. There was no sex difference in functional independence at 90 days after bridging therapy (OR 0.968, 95% CI 0.575-1.63), whereas men benefited more after EVT alone (OR 0.654, 95% CI 0.456-0.937). There were no sex-treatment interactions observed regardless of the location of the occlusion. There were no significant sex differences in all safety outcomes. Our study could not confirm that sex modifies the treatment effect of intravenous alteplase before endovascular therapy. At the same time, we advocate for women to seek timely medical treatment.

Observation versus intervention for Borden type I intracranial dural arteriovenous fistula: A pooled analysis of 469 patients.

While it is thought that Borden Type I intracranial dural arteriovenous fistula (dAVF) have a benign clinical course, their management remains controversial. A comparative meta-analysis was completed to evaluate the outcomes of intervention verses observation of Borden Type I intracranial dAVF. Outcome measures included: grade progression, worsening symptoms, death due to dAVF, permanent complications other than death, functional independence (mRS 0-2), and rate of death combined with permanent complication, were evaluated. Risk differences (RD) were determined using a random effects model. Three comparative studies combined with the authors' institutional experience resulted in a total of 469 patients, with 279 patients who underwent intervention and 190 who were observed. There was no significant difference in dAVF grade progression between the intervention and observation arms, 1.8% vs. 0.7%, respectively (RD: 0.01, 95% CI: -0.02 to 0.04, P = 0.49), or in symptom progression occurring in 31/279 (11.1%) intervention patients and 11/190 (5.8%) observation patients (RD: 0.03, CI: -0.02 to 0.09, P = 0.28). There was also no significant difference in functional independence on follow up. However, there was a significantly higher risk of dAVF related death, permanent complication from either intervention or dAVF related ICH or stroke in the intervention group (11/279, 3.9%) compared to the observation group (0/190, 0%) (RD: 0.04, CI: 0.1 to 0.06, P = 0.007). Intervention of Borden Type I dAVF results in a higher risk of death or permanent complication, which should be strongly considered when deciding on management of these lesions.

Aerobic exercise for HIV-associated neurocognitive disorders in individuals on antiretroviral therapy: A randomised controlled trial

Introduction The increasing burden of self-limiting forms of HIV-associated neurocognitive disorder (HAND) in the antiretroviral therapy era calls for adjunctive interventions. The study aimed to determine the effects of a 12-week aerobic exercise programme on HAND. Methods This is a parallel-group, randomized controlled trial with concealed allocation and intention-to-treat analysis. This study was a clinic-based programme. Seventy-three patients with HAND were enrolled in the trial. The intervention comprised a moderate-intensity aerobic exercise, 20–60 min per session, three times per week, for twelve weeks. The control group received exercise education. Prevalence of HAND constituted the primary outcome. HAND was identified and classified following the Frascati criteria. We computed the odds ratio and number needed-to-treat to estimate the treatment effect. Results There were 73 patients (38 in exercise and 35 in control arm). Individuals in the exercise arm recorded a significantly higher reduction in working memory deficit (OR = 5.14; CI = 2.6–10.4; NNT = 6) but not in attention-deficit (OR = 0.31, CI = 0.2–0.5; NNT = −5) compared to the control group at twelve-week. Reductions in attention deficit (OR = 1.55, 95 CI = 1.0–2.4; NNT = 5) and HAND prevalence (OR = 1.8, 95 CI = 1.2–2.8); NNT = 8) were significantly higher in the exercise group compared the control group at three-month. No significant between-group difference in functional independence was observed immediately after exercise (p > 0.05). Discussion The neuroprotective effects of aerobic exercise appear selective and vary with cognitive abilities impaired and aerobic capacity, with a greater change occurring with improved aerobic capacity. Conclusion Individuals with working memory and attention deficits may benefit more from moderate-intensity aerobic exercise.

Perfusion Imaging for Endovascular Thrombectomy in Acute Ischemic Stroke Is Associated With Improved Functional Outcomes in the Early and Late Time Windows.

Background:The impact on clinical outcomes of patient selection using perfusion imaging for endovascular thrombectomy (EVT) in patients with acute ischemic stroke presenting beyond 6 hours from onset remains undetermined in routine clinical practice.Methods:Patients from a national stroke registry that underwent EVT selected with or without perfusion imaging (noncontrast computed tomography/computed tomography angiography) in the early (<6 hours) and late (6–24 hours) time windows, between October 2015 and March 2020, were compared. The primary outcome was the ordinal shift in the modified Rankin Scale score at hospital discharge. Other outcomes included functional independence (modified Rankin Scale score ≤2) and in-hospital mortality, symptomatic intracerebral hemorrhage, successful reperfusion (Thrombolysis in Cerebral Infarction score 2b–3), early neurological deterioration, futile recanalization (modified Rankin Scale score 4–6 despite successful reperfusion) and procedural time metrics. Multivariable analyses were performed, adjusted for age, sex, baseline stroke severity, prestroke disability, intravenous thrombolysis, mode of anesthesia (Model 1) and including EVT technique, balloon guide catheter, and center (Model 2).Results:We included 4249 patients, 3203 in the early window (593 with perfusion versus 2610 without perfusion) and 1046 in the late window (378 with perfusion versus 668 without perfusion). Within the late window, patients with perfusion imaging had a shift towards better functional outcome at discharge compared with those without perfusion imaging (adjusted common odds ratio [OR], 1.45 [95% CI, 1.16–1.83]; P=0.001). There was no significant difference in functional independence (29.3% with perfusion versus 24.8% without; P=0.210) or in the safety outcome measures of symptomatic intracerebral hemorrhage (P=0.53) and in-hospital mortality (10.6% with perfusion versus 14.3% without; P=0.053). In the early time window, patients with perfusion imaging had significantly improved odds of functional outcome (adjusted common OR, 1.51 [95% CI, 1.28–1.78]; P=0.0001) and functional independence (41.6% versus 33.6%, adjusted OR, 1.31 [95% CI, 1.08–1.59]; P=0.006). Perfusion imaging was associated with lower odds of futile recanalization in both time windows (late: adjusted OR, 0.70 [95% CI, 0.50–0.97]; P=0.034; early: adjusted OR, 0.80 [95% CI, 0.65–0.99]; P=0.047).Conclusions:In this real-world study, acquisition of perfusion imaging for EVT was associated with improvement in functional disability in the early and late time windows compared with nonperfusion neuroimaging. These indirect comparisons should be interpreted with caution while awaiting confirmatory data from prospective randomized trials.

Abstract 13170: Mechanical Thrombectomy or Bridging Therapy for Anterior Circulation Large Vessel Occlusion Strokes?

Introduction: The superiority of intravenous thrombolysis plus mechanical thrombectomy in combination, also known as bridging therapy (BT), relative to mechanical thrombectomy (MT) alone in large vessel occlusion (LVO) stroke has not been established. Hypothesis: BT may have similar efficacy an safety profiles as MT for anterior circulation LVO. Methods: A systematic search of biomedical literature databases was performed up to March 2021, to identify prospective and retrospective studies that reported the rates for functional independence (defined as modified Rankin Scale 0-2) and mortality at 90 days, in-hospital symptomatic hemorrhage (sICH), and successful recanalization rates for MT and BT. Effect size was represented by odds ratio (OR) and analysis was done using random effects meta-analyses. Heterogeneity was assessed by I 2 and Cochrane’s Q statistics. Results: Overall, 35 studies with 11,332 patients were included in the analysis. Mean age ± standard deviation for BT and MT was 69±12 and 70±12 years, respectively. BT group had 28% higher odds for functional independence (OR=1.28, 95% CI 1.13-1.46, I 2 =53%), 33% higher odds of successful reperfusion (OR=1.33, 95% CI=1.13-1.56, I 2 =43%) and a 31% decrease in odds for mortality (OR=0.69, 95% CI 0.59-0.81, I 2 =49%) compared with MT. The sICH prevalence was similar between groups (OR=1.03, 95% CI=0.87-1.22, I 2 =0%). When only RCTs with intention-to-treat analysis comparing BT to MT were included in the analysis (n=1,633), there were no differences in functional independence (OR=0.99, 95% CI=0.81-1.20, I 2 =0%), successful reperfusion (OR=1.33, 95% CI=0.95-1.87, I 2 =0%), sICH (OR=1.23, 95% CI=0.82-1.83, I 2 =0%) or mortality (OR=0.94, 95% CI=0.72-1.21, I 2 =0%) between the groups. Conclusions: The odds for functional independence, successful reperfusion and mortality favored the use of BT over MT. The study had medium heterogeneity and low quality of the evidence. However, when the analysis was restricted to RCTs intention to treat analyses, BT and MT had similar efficacy and safety outcomes, with no heterogeneity.

Abstract TP329: Early Initiation of Oral Antihypertensives Reduces Intensive Care Unit Stay and Hospital Cost in Patients With Hypertensive Intracerebral Hemorrhage

Background and Purpose: Intravenous nicardipine infusion is effective for intensive blood pressure (BP) control in patients with hypertensive intracerebral hemorrhage (ICH). However, its use requires close hemodynamic monitoring in the intensive care unit (ICU). Prompt transition from nicardipine infusion to oral antihypertensives may reduce ICU length of stay (LOS). This study aimed to examine the effect of early verse late initiation of oral antihypertensives on hospital resource utilization in patients with hypertensive ICH. Methods: This is a retrospective study of patients with hypertensive ICH and initial systolic BP ≥ 180 mmHg from January 1, 2013 to December 31, 2017. Only patients who received nicardipine infusion were included. Based on timing of receiving oral antihypertensives within or after 24 hours of emergency department arrival, patients were divided into study or control group, respectively. Baseline characteristics, duration of nicardipine infusion, ICU and hospital LOS, functional outcome at hospital discharge, and the cost were compared between the 2 groups using univariate and multivariate analysis to adjust for dependent variables. Results: A total of 166 patients (90 in study group, 76 in control group) were identified. There was no significant difference in demographic features, past medical history or initial SBP between the 2 groups. Patients in study group had lower initial NIHSS and ICH scores but higher GCS score than those in the control group. Using multivariant regression analysisto adjust for initial SBP, NIHSS, GCS and ICH scores, early initiation of oral antihypertensives was associated with significant shorter ICU LOS (median 2 vs 5, p =0.004), decreased duration of nicardipine infusion (55.5 ±60.1 vs 121.6 ±141.3, P =0.002), less pharmaceutical cost (median $14207 vs $ 29299, p =0.007) and total hospital cost (median $ 24564 vs $ 47366, p =0.007). After adjustment of confounders, there was also no significant difference in functional independence (mRS 0-2, 42.2% vs 17.1%, p =0.112) or mortality (6.7% vs 13.2%, p = 0.789) between the 2 groups. Conclusions: Early initiation of oral antihypertensive therapy is associated with reduced resource utilization and hospital cost in patients with hypertensive ICH.

Minimal Clinically Important Differences in Functional Independence After a Knowledge Translation Intervention in Stroke Rehabilitation

ObjectiveTo examine the odds of persons with stroke achieving minimal clinically important difference (MCID) in functional independence during inpatient rehabilitation relative to cognitive impairment (CI) severity, site, and rehabilitation teams’ exposure to a Cognitive Orientation to daily Occupational Performance (CO-OP) knowledge translation (KT) intervention. DesignA pre-post observational study was conducted using data from a centralized referral system. Our research team implemented a CO-OP KT intervention as part of a larger study aimed at training teams to use the CO-OP approach. SettingFive inpatient rehabilitation units. ParticipantsCases extracted from a centralized referral system from the 5 participating units. InterventionsNot applicable. Main Outcome MeasuresThe FIM instrument data from 12 months preintervention and 6 months postintervention were analyzed. A logistic regression was performed to determine the odds ratios (ORs) for achieving MCID based on sample cohort (historical control not exposed to CO-OP KT vs post-CO-OP KT intervention), controlling for site and severity of CI. ResultsA model that considered the intervention, admission score, CI severity, and site was the best fit for the cases analyzed. Those with severe CI were less likely to achieve FIM total MCID compared to those with no CI (P=<.001; OR=.18; 95% confidence interval, .09-.39). Taking site and CI into account, cases post CO-OP KT intervention were significantly more likely to achieve MCID on FIM motor (P=.048; OR=1.4; 95% confidence interval, 1.00-1.98) than historical controls. ConclusionThe CO-OP KT intervention is associated with increased odds of achieving MCID in the FIM motor subscale in inpatient stroke rehabilitation.

Endovascular thrombectomy in patients with intracranial large artery occlusion and atrial fibrillation

Objective: To investigate the safety and efficacy of mechanical thrombectomy in patients with atrial fibrillation complicated with acute intracranial arterial occlusion. Methods: Fifty-eight patients with atrial fibrillation complicated with acute intracranial arterial occlusion in the intervention group of East (Endovascular Therapy for Acute ischemic Stroke Trial) were analyzed. According to the TOAST (Trial of Org 10 172 in Acute Stroke Treatment) classification, patients were divided into ICAS (Intracranial Atherosclerotic Stenosis) group and cardiogenic embolism group. Clinical characteristics, treatment methods and clinical prognosis were compared between ICAS group and cardiogenic embolism group. Results: A total of 58 patients with atrial fibrillation complicated with acute intracranial arterial occlusion were included in this study, including 46 patients in the cardiogenic embolism group (79%) and 12 patients in the ICAS group (21%). The pre-hospital transport time in ICAS group was longer than that in cardiogenic embolism group (P<0.05).Patency rate in patients with atrial fibrillation complicated with acute intracranial arterial occlusion was 98.3% (57/58), The rate of patients with the 90-day function independent (mRS 0-2) was 51.7% (30/58). There were no statistically significant differences in functional independence, mortality rate, ICH and sICH at 90 days between the cardiogenic embolism group and the ICAS group. Conclusions: Mechanical thrombectomy is an effective method to treat patients with atrial fibrillation complicated with acute intracranial arterial occlusion.