Early Neurological Improvement Research Articles

Endovascular Thrombectomy Versus Intravenous Thrombolysis of Posterior Cerebral Artery Occlusion Stroke.

Posterior cerebral artery occlusion (PCAo) can cause long-term disability, yet randomized controlled trials to guide optimal reperfusion strategy are lacking. We compared the outcomes of PCAo patients treated with endovascular thrombectomy (EVT) with or without intravenous thrombolysis (IVT) to patients treated with IVT alone. From the multicenter retrospective Posterior cerebraL ArTery Occlusion (PLATO) registry, we included patients with isolated PCAo treated with reperfusion therapy within 24 hours of onset between January 2015 and August 2022. The primary outcome was the distribution of the modified Rankin Scale (mRS) at 3 months. Other outcomes comprised 3-month excellent (mRS 0-1) and independent outcome (mRS 0-2), early neurological improvement (ENI), mortality, and symptomatic intracranial hemorrhage (sICH). The treatments were compared using inverse probability weighted regression adjustment. Among 724 patients, 400 received EVT+/-IVT and 324 IVT alone (median age 74 years, 57.7% men). The median National Institutes of Health Stroke Scale score on admission was 7, and the occluded segment was P1 (43.9%), P2 (48.3%), P3-P4 (6.1%), bilateral (1.0%), or fetal posterior cerebral artery (0.7%). Compared to IVT alone, EVT+/-IVT was not associated with improved functional outcome (adjusted common odds ratio [OR] 1.07, 95% confidence interval [CI] 0.79-1.43). EVT increased the odds for ENI (adjusted OR [aOR] 1.49, 95% CI 1.05-2.12), sICH (aOR 2.87, 95% CI 1.23-6.72), and mortality (aOR 1.77, 95% CI 1.07-2.95). Despite higher odds for early improvement, EVT+/-IVT did not affect functional outcome compared to IVT alone after PCAo. This may be driven by the increased risk of sICH and mortality after EVT.

Outcomes and differences by occluded vessel after endovascular thrombectomy for isolated medium vessel occlusions

BackgroundThe outcomes of endovascular thrombectomy (EVT) for medium vessel occlusions (MeVOs) of specific vascular territories remain unknown. We aimed to investigate EVT outcomes by MeVO locations using the data from an ongoing international multicenter registry. MethodsPatients with isolated MeVO who underwent EVT between January 2013 and December 2022 were retrospectively analyzed. Isolated MeVO was defined as an occlusion of the A2 or A3 (A2/A3), M2 or M3, and P2 or P3 (P2/P3). Outcomes included a 90-day modified Rankin score (mRS) of 0–2, successful recanalization (modified Thrombolysis in Cerebral Infarction score ≥ 2b), early neurological deterioration (END) or improvement (ENI), and 90-day mortality. END was defined as a worsening of ≥4 points from the baseline National Institutes of Health Stroke Scale (NIHSS) score within 24 h of EVT, while ENI was defined as an improvement of ≥4 points from the baseline NIHSS score within 24 h of EVT. Results1744 MeVOs included. Compared to M2 occlusions (n = 1542, 88.4%), A2/A3 (n = 36, 2.1%) occlusions had lower odds of 90-day mRS 0–2 (adjusted odds ratio [aOR] 0.30, 95% confidence interval [CI] 0.11–0.80), and P2/P3 occlusions (n = 49, 2.8%) had lower odds of successful recanalization (aOR 0.19, 95% CI 0.07–0.50), and higher odds of END (aOR 3.53, 95% CI 1.35–9.25). Other outcomes showed no significant differences. ConclusionsA2/A3 occlusions were more likely to have worse outcomes compared to M2 occlusions after EVT for patients with isolated MeVOs.

Hybrid Clot Histomic-Transcriptomic Models Predict Functional Outcome After Mechanical Thrombectomy in Acute Ischemic Stroke.

Histologic and transcriptomic analyses of retrieved stroke clots have identified features associated with patient outcomes. Previous studies have demonstrated the predictive capacity of histology or expression features in isolation. Few studies, however, have investigated how paired histologic image features and expression patterns from the retrieved clots can improve understanding of clot pathobiology and our ability to predict long-term prognosis. We hypothesized that computational models trained using clot histomics and mRNA expression can predict early neurological improvement (ENI) and 90-day functional outcome (modified Rankin Scale Score, mRS) better than models developed using histological composition or expression data alone. We performed paired histological and transcriptomic analysis of 32 stroke clots. ENI was defined as a delta-National Institutes of Health Stroke Score/Scale > 4, and a good long-term outcome was defined as mRS ≤2 at 90 days after procedure. Clots were H&E-stained and whole-slide imaged at 40×. An established digital pathology pipeline was used to extract 237 histomic features and to compute clot percent composition (%Comp). When dichotomized by either the ENI or mRS thresholds, differentially expressed genes were identified as those with absolute fold-change >1.5 and q < 0.05. Machine learning with recursive feature elimination (RFE) was used to select clot features and evaluate computational models for outcome prognostication. For ENI, RFE identified 9 optimal histologic and transcriptomic features for the hybrid model, which achieved an accuracy of 90.8% (area under the curve [AUC] = 0.98 ± 0.08) in testing and outperformed models based on histomics (AUC = 0.94 ± 0.09), transcriptomics (AUC = 0.86 ± 0.16), or %Comp (AUC = 0.70 ± 0.15) alone. For mRS, RFE identified 7 optimal histomic and transcriptomic features for the hybrid model. This model achieved an accuracy of 93.7% (AUC = 0.94 ± 0.09) in testing, also outperforming models based on histomics (AUC = 0.90 ± 0.11), transcriptomics (AUC = 0.55 ± 0.27), or %Comp (AUC = 0.58 ± 0.16) alone. Hybrid models offer improved outcome prognostication for patients with stroke. Identified digital histology and mRNA signatures warrant further investigation as biomarkers of patient functional outcome after thrombectomy.

Enhanced versus standard hydration in acute ischaemic stroke: REVIVE - a randomised clinical trial.

Early neurological deterioration (END) within 72 hours of stroke onset is associated with poor prognosis. Optimising hydration might reduce the risk of END. To determine in acute ischaemic stroke patients if enhanced hydration versus standard hydration reduced the incidence of major (primary) and minor (secondary) END, as whether it increased the incidence of early neurological improvement (secondary), at 72 hours after admissionSample Size Estimate: 244 participants per arm. A prospective, double-blinded, multicentre, parallel-group, randomised controlled trial conducted at 4 hospitals from April 2014 to July 2020, with data analysed in August 2020. The sample size estimated was 488 participants (244 per arm). Ischaemic stroke patients with measurable neurological deficits of onset within 12 hours of emergency department presentation and blood urea nitrogen/creatinine (BUN/Cr) ratio ≥15 at point of admission were enrolled and randomised to 0.9% sodium chloride infusions of varying rates - enhanced hydration (20 mL/kg body weight, one-third given via bolus and remainder over 8 hours) versus standard hydration (60 mL/hour for 8 hours), followed by maintenance infusion of 40-80 mL/hour for the subsequent 64 hours. The primary outcome measure was the incidence of major early neurological deterioration at 72 hours after admission, defined as an increase in National Institutes of Health Stroke Scale of ≥4 points from baseline. 487 participants were randomised (median age 67 years; 287 females). At 72 hours: 7 (2.9%) in the enhanced-hydration arm and 5(2.0%) in the standard-hydration developed major early neurological deterioration (p=0.54). The incidence of minor early neurological deterioration and early neurological improvement did not differ between treatment arms. Enhanced hydration ratio did not reduce END or improve short term outcomes in acute ischaemic stroke. ClinicalTrials.gov (NCT02099383, https://clinicaltrials.gov/study/NCT02099383).

Decoding Molecular Mechanisms Underlying Outcomes After Ischemic Stroke Thrombectomy by RNA Sequencing of Retrieved Clots.

Transcriptomic profiling has emerged as a powerful tool for exploring the molecular landscape of ischemic stroke clots and providing insights into the pathophysiological mechanisms underlying stroke progression and recovery. In this study, we aimed to investigate the relationship between stroke clot transcriptomes and stroke thrombectomy outcome, as measured by early neurological improvement (ENI) 30 (i.e., a 30% reduction in NIHSS at 24 h post-thrombectomy). We hypothesized that there exist distinct clot gene expression patterns between good and poor neurological outcomes. Transcriptomic analysis of 32 stroke clots retrieved by mechanical thrombectomy was conducted. Transcriptome data of these clots were analyzed to identify differentially expressed genes (DEGs), defined as those with a log(fold-change) ≥ 1.5 and q < 0.05 between samples with good and poor early neurological outcomes. Gene ontology and bioinformatics analyses were performed on genes with p < 0.01 to identify enriched biological processes and Ingenuity Pathway Analysis canonical pathways. Moreover, AUC analysis assessed the predictive power of DEGs for 90-day function outcome (mRS ≤ 2) and cellular composition of clot was predicted using CIBERSORT. We also assessed whether differential enrichment of immune cell types could indicate patient survival. A total of 41 DEGs were identified. Bioinformatics showed that enriched biological processes and pathways emphasized the chronic immune response and matrix metalloproteinase inhibition. Moreover, 25 of the DEGs were found to be significant predictors of 90-day mRS. These genes were indicative of monocytes enrichment and neutrophil depletion in patients with poorer outcomes. Our study revealed a distinct gene expression pattern and dysregulated biological pathways associated with ENI. This expression pattern was also predictive of long-term outcome, suggesting a biological link between those ENIs and 90-day mRS.

Endovascular thrombectomy versus intravenous thrombolysis for primary distal, medium vessel occlusion in acute ischemic stroke

Abstract Introduction In the absence of clinical trials, the benefit of endovascular therapy (EVT) on the treatment of acute ischemic stroke (AIS) with primary distal and medium vessel occlusions (DMVO) is still not well defined. The aim of the study is to evaluate EVT with or without intravenous thrombolysis (EVT ± IVT) in primary DMVO stroke in comparison with a control cohort treated with IVT alone. Methods We analysed all consecutive AIS with proven primary DMVO. Primary endpoints were excellent outcome, functional independence at 3 months follow-up, and early neurologic improvement at 1 day after treatment. Results One hundred and fourteen patients with DMVO strokes were included between 2019 and 2023. Propensity-weighted analysis showed no significant differences in EVT ± IVT vs IVT for the excellent outcome (adjusted OR [aOR], 1.575; 95% CI, 0.706–3.513), functional independence (aOR, 2.024; 95% CI, 0.845–4.848), early neurological improvement (aOR, 2.218; 95% CI, 0.937–5.247), mortality (aOR, 0.498; 95% CI, 0.177–1.406), symptomatic intracranial haemorrhage (aOR, 0.493; 95% CI, 0.102–2.385), and subarachnoid haemorrhage (aOR, 0.560; 95% CI, 0.143–2.187). The type of revascularization did not influence the percentage of cerebral volume lost (adjusted linear regression estimate, −19.171, t value, 11.562; p = 0.104). Conclusions This study supports the hypothesis that patients with primary DMVO stroke treated with EVT (±IVT) or IVT alone have comparable outcomes.

Outcomes and risk factors for infection after endovascular treatment in patients with acute ischemic stroke.

Infection is a common complication following acute ischemic stroke (AIS) and significantly contributes to poor functional outcomes after stroke. This study aimed to investigate the effects of infection after endovascular treatment (post-EVT infection) on clinical outcomes and risk factors in patients with AIS. We retrospectively analyzed AIS patients treated with endovascular treatment (EVT) between January 2016 and December 2022. A post-EVT infection was defined as any infection diagnosed within 7 days after EVT. The primary outcome was functional independence, defined as a modified Rankin scale (mRS) score of 0-2 at 90 days. A multivariable logistic regression analysis was conducted to determine independent predictors of post-EVT infection and the associations between post-EVT infection and clinical outcomes. A total of 675 patients were included in the analysis; 306 (45.3%) of them had post-EVT infections. Patients with post-EVT infection had a lower rate of functional independence than patients without infection (31% vs 65%, p = 0.006). In addition, patients with post-EVT infection achieved less early neurological improvement (ENI) after EVT (25.8% vs 47.4%, p < 0.001). For safety outcomes, the infection group had a higher incidence of any intracranial hemorrhage (23.9% vs 15.7%, p = 0.01) and symptomatic intracranial hemorrhage (10.1% vs 5.1%, p = 0.01). Unsuccessful recanalization (aOR 1.87, 95% CI 1.11-3.13; p = 0.02) and general anesthesia (aOR 2.22, 95% CI 1.25-3.95; p = 0.01) were identified as independent predictors for post-EVT infection in logistic regression analysis. AIS patients who develop post-EVT infections are more likely to experience poor clinical outcomes. Unsuccessful recanalization and general anesthesia were independent risk factors for the development of post-EVT infection.

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.

Predictors of Outcome after Direct Aspiration of Basilar Artery Occlusion.

Background: Basilar artery occlusion (BAO) is a serious disease with a poor prognosis if left untreated. Endovascular therapy (EVT) is the most effective treatment that is able to reduce mortality and disability. Treatment results are influenced by a wide range of factors that have not been clearly identified. In the present study, direct aspiration was chosen as a first-line treatment. The safety and effectiveness of direct aspiration in BAO were determined, and factors affecting patient outcomes were identified. Methodology: Data for patients with BAO treated between November 2013 and December 2021 were evaluated using a database. The association between clinical and procedural parameters and functional outcome was assessed. Results: A total of 89 patients with BAO were identified. Full recanalization was achieved in 69.7% of cases and partial recanalization in 19.1%. Intracranial hemorrhage was detected in 11 (12.4%) patients, of which, eight (9.0%) patients experienced symptomatic intracranial hemorrhage. Patients with good outcomes presented with milder strokes (mean NIHSS score of 12.58 vs. 24.00, p < 0.001), had higher collateral scores (6.79 vs. 5.88, p = 0.016), more often achieved complete recanalization (87.9% vs. 58.9%, p = 0.009), and more often experienced early neurological improvement (66.7% vs. 26.8%, p < 0.001). On the contrary, patients with worse outcomes had higher serum glucose levels (p = 0.05), occlusion of the middle portion of the basilar artery (MAB) (30.3% vs. 53.6%, p = 0.033), longer thrombus lengths (10.51 vs. 16.48 mm, p = 0.046), and intracranial hemorrhage (p = 0.035). Conclusions: The present study results suggest that direct aspiration is a safe and effective treatment for patients with BAO. We identified several factors affecting the patients' outcome.

Anesthetic management for large vessel occlusion acute ischemic stroke with tandem lesions

BackgroundEndovascular therapy (EVT) stands as an established and effective intervention for acute ischemic stroke in patients harboring tandem lesions (TLs). However, the optimal anesthetic strategy for EVT in TL patients...

RE-OPEN: Randomised trial of biosimilar TNK versus TPA during endovascular therapy for acute ischaemic stroke due to large vessel occlusions

RationaleRapid and timely treatment with intravenous thrombolysis and endovascular treatment (EVT) in patients with acute ischaemic stroke (AIS) and large vessel occlusion (LVO) significantly improves patient outcomes. Bridging therapy is...

Clinical significance of the Microbleed Anatomical Rating Scale score in ischemic stroke patients treated with intravenous thrombolysis.

Conflicting results were shown on the relationship between cerebral microbleeds (CMBs) burden and functional outcomes in patients treated with intravenous tissues plasminogen activator (IV tPA). We aimed to investigate the relationship between CMBs burden and functional outcomes using the Microbleed Anatomical Rating Scale (MARS) and determine its optimal cutoff value. A retrospective study was conducted to include patients treated with IV tPA in our stroke center, and the MARS was used to assess the CMBs burden. Other clinical data including demographic factors, stroke severity, vascular risk factors, and clinical outcomes were also documented. Another mediation analysis was performed to investigate whether early neurological improvement could mediate the association between MARS and functional outcomes. A total of 408 patients were included. A cutoff value of 1.5 could predict functional outcomes in patients treated with IV tPA. Based on that cutoff value, MARS showed an independent relationship with functional outcomes [adjusted OR (Odds Ratio) 0.841, 95% confidence interval (CI) 0.720-0.982, P = .029]. A shift analysis showed that higher MARS score (MARS ≥1.5) was related with poor functional outcome according to mRS score distribution (OR = 0.519, 95% CI 0.336-0.803, P = .003). Total effect (indirect + direct effect) was calculated and showed in figure. Early neurological improvement mediated 24% of the effect of MARS score on functional outcomes. Our study showed that MARS could be a potential method to assess the functional outcome based on CMBs in patients treated with IV tPA, and MARS score ≥ 1.5 might be an optimal threshold for poor functional outcome.

A Study of Factors Affecting Functional Outcomes in Patients With Successful Recanalization by Mechanical Thrombectomy.

Reperfusion therapy is typically performed in cases with acute cerebral infarction. Mechanical thrombectomy (MT) achieves superior recanalization and favorable outcomes. However, some patients have poor functional prognosis despite successful recanalization. We investigated factors affecting functional prognosis after MT with good reperfusion. Among the 205 consecutive cases with ischemic stroke treated with MT at our center from January 1, 2019 to March 31, 2021, 168 with successful recanalization were included. Factors affecting early neurological improvement (ENI) and modified Rankin Scale (mRS) scores were reviewed retrospectively. There were 93 (55%) cases with ENI and 75 (45%) without ENI. The times from onset to recombinant tissue-type plasminogen activator administration and recanalization in ENI cases were shorter than those in non-ENI cases. However, non-ENI cases had significantly higher Fazekas grades for white matter lesions. In multivariate analysis, the Fazekas grade was related to ENI (odds ratio [OR]=0.572, 95% confidence interval [CI]=0.345-0.948). The mRS score at discharge was 0-2 in 64 cases (good outcome) and 3-6 in 104 cases (poor outcome). Patients with a poor outcome had a significantly higher age, National Institutes of Health Stroke Scale (NIHSS) score, and Fazekas grade. Multivariate analysis revealed that the NIHSS score (OR=1.073, 95% CI=1.020-1.129) and Fazekas grade (OR=2.162, 95% CI=1.458-3.205) at hospitalization affected the mRS score at discharge. There is a correlation of greater severity of white matter lesions with poorer ENI and clinical outcomes at discharge post-MT.

Is Thrombectomy Worth It for Isolated Posterior Cerebral Artery Occlusion? Meta‐Analysis and Trial Sequential Analysis

Background Thrombectomy is well‐established management for acute ischemic stroke involving large vessel occlusion. However. the potential efficacy of thrombectomy for isolated posterior cerebral artery occlusion remains limited. The study aims to evaluate the benefits of thrombectomy for isolated posterior cerebral artery occlusion. Methods We searched PubMed, Cochrane, and Embase for articles published until September 2023. The primary outcome was good functional outcome at 3 months. The secondary outcomes included excellent functional outcome at 3 months and early neurological improvement. The safety outcomes were symptomatic intracerebral hemorrhage, and mortality at 3 months. Results Seven retrospective studies involving 2560 patients with isolated posterior cerebral artery occlusion were included (876 patients receiving thrombectomy). The odds ratio (OR) of good functional outcome at 3 months was 0.93 (95% CI, 0.68–1.28) between 2 groups. The OR of excellent functional outcome (OR 1.23; 95% CI 0.92–1.64) and early neurological improvement (OR 1.82; 95% CI 0.97–3.40) were not different between the 2 groups. Compared with patients with best medical management, those with thrombectomy demonstrated a significantly increased risk of mortality (OR 1.81; 95% CI 1.24–2.65), whereas the risk of symptomatic intracerebral hemorrhage (OR 2.033; 95% CI 0.996–4.148) did not show an increase. Additionally, the results of trial sequential analysis indicated all outcomes were inconclusive. Conclusion Thrombectomy stands as an available procedure for patients with isolated posterior cerebral artery occlusion; however, it shows no notable benefits in reducing symptomatic intracerebral hemorrhage risk or enhancing function and may raise mortality compared with standard medical management. Further randomized controlled trials are necessary to yield more conclusive evidence.

Abstract WP15: Early Neurological Improvement in Ischemic Stroke and Risk of Cardiac Complications

Introduction: Cardiac complications are seen in 15-20% of acute ischemic strokes (AIS). We hypothesized that early neurologic improvement (ENI) with or without revascularization would be associated with lower risk of cardiac complications after AIS. Methods: We retrospectively screened consecutive AIS patients for elevated initial cardiac troponin (cTn) and ≥1 additional cTn within 48h. Minor strokes (NIHSS≤3) or comorbidities impacting cTn were excluded from primary analysis. ENI was defined as ≥4 pt improvement in NIHSS or 24h NIHSS≤ 1. Post-stroke acute myocardial injury (PSAMI) refers to dynamic cTn pattern (rise/fall&gt;20% in serial cTn levels) in the absence of acute atherosclerotic coronary disease or cardiac death. Secondary analysis assessed full range of NIHSS at baseline and at 24h in relation to cardiac outcomes. Results: Of 2,609 patients screened, 165 (ENI=62, no-ENI=103) were included in our primary analysis. (Fig.1). In patients with ENI, a dynamic cTn pattern and PSAMI were present in 55% (n=34) and 34% (n=21) respectively, compared to 45% (n=46) and 24% (n=25) in the no-ENI group ( P =0.20 and P =0.18). Adjusted regression analysis did not show any statistical association of cardiac outcomes with ENI. Secondary analysis including NIHSS≤3, was associated with a 4-fold greater risk of PSAMI in NIHSS &gt;15 at 24h (Fig.1). Analysis of patients intervened with MT or tPA (n=77) also showed no statistical association between ENI and PSAMI (Fig 1.) Conclusion: SENI was not associated with a lower risk of cardiac complications after AIS. NIHSS at 24 hours was a strong predictor of PSAMI. Larger studies should investigate if revascularization decreases risk of PSAMI.

Abstract TP192: Combined Intra-Venous and Intra-Arterial Thrombolysis versus Intra-Venous Thrombolysis Alone in Stroke Patients Undergoing Mechanical Thrombectomy for Large Vessel Occlusion: A Propensity-Matched Analysis

Introduction: The combination of intravenous or intra-arterial thrombolysis with mechanical thrombectomy (MT) for acute ischemic stroke (AIS) has been thoroughly investigated. However, no study has explored the outcomes of combining both intravenous and intra-arterial thrombolysis with MT. Methods: Data from Stroke Thrombectomy and Aneurysm Registry (STAR) from 2013 to 2023 was utilized. We compared AIS patients with LVO who underwent MT with combined intra-venous and intra-arterial thrombolysis (IV+IA) and with intra-venous thrombolysis alone (IV). We performed propensity score (PS) matching between the two groups using age, sex, premorbid mRS, admission NIHSS, occluded vessel, ASPECTS score, time from symptoms onset to arterial puncture, and frontline technique. Primary outcomes were any intracranial hemorrhage (ICH) and symptomatic ICH (sICH). Secondary outcomes included successful recanalization (mTICI ≥2C), early neurological improvement (defined as 4 or more points improvement in NIHSS score in 24 hours), 90-day modified Rankin Scale (mRS) 0-2, mRS 0-1, and mortality. Results: A total of 2495 LVO-related AIS patients were included, consisting of the IA+IV group (n = 266) and the IV group (n = 2228). Propensity matching yielded 192 well-matched patients in each group. No significant differences were observed between the groups in either ICH or sICH (odds ratio [OR]: 0.96, 95% confidence interval [CI]: 0.61-1.52, p = 0.60; OR: 0.92, 95% CI: 0.42-2.03, p &gt; 0.90, respectively). The IA+IV group had a significantly lower proportion of successful recanalization (OR: 0.41, 95% CI: 0.27-0.62, p &lt; 0.001), and early neurological improvement (OR: 0.55, 95% CI: 0.30-1.00). However, 90-day mRS 0-2, mRS 0-1, and mortality rates showed no significant differences between the two groups. Conclusion: The findings of this study suggest that the combined use of IA and IV thrombolysis in AIS patients undergoing MT is safe. Although the IA+IV group demonstrated lower rates of recanalization and early neurological improvement, long-term functional outcomes and mortality rates were comparable to the IV-thrombolysis group, indicating a potential delayed benefit of additional IA thrombolysis therapy.

Predictors and Prognosis of Early Neurological Outcomes on Patients with Vertebrobasilar Artery Occlusion Undergoing Endovascular Treatment

Introduction: This research explored the factors influencing early neurological outcomes (ENO) in patients who had vertebrobasilar artery occlusion (VBAO) and received endovascular treatment (EVT), as well as examining the causal influence of ENO on the prognosis of VBAO patients. Methods: A retrospective review was carried out on patients from 65 Chinese stroke centers, all within 24 h of the estimated occlusion time. ENO includes early neurological improvement (ENI) and early neurological deterioration (END), defined as a decrease or an increase of at least 4 points in NIHSS score between baseline and 24 h after EVT. Death within 24 h after EVT was also considered as END. END was further divided into explained END and unexplained END (unEND). Independent predictors of ENO and the association between ENO and outcomes in patients with VBAO were determined using center-adjusted analyses. The study developed a multivariate logistic regression model to examine the comparative risk of unEND versus explained END on the clinical outcomes in VBAO patients. Results: A total of 2,257 patients were included. Glasgow Coma Scale (GCS) (OR: 1.16, 95% CI: 1.03–1.30) and successful reperfusion (OR: 1.15, 95% CI: 1.02–1.30) were associated with ENI. Baseline NIHSS (OR: 0.60, 95% CI: 0.53–0.68), successful reperfusion (OR: 0.79, 95% CI: 0.71–0.89), and puncture to reperfusion time (OR: 1.17, 95% CI: 1.03–1.33) were associated with END. When examining 3-month prognostic indexes, both END and ENI were found to be linked to the 3-month outcomes, but in opposite directions. A subgroup analysis of END suggested that unEND typically demonstrated a more favorable prognosis compared to explained END, although the prognosis remained generally unfavorable. Conclusions: ENO, whether they manifested as early improvement or deterioration, were linked to the prognosis of VBAO patients undergoing EVT. The outcomes after unEND were more favorable than those following explained END.

Impact of Day 1 carotid patency on outcome in dissection-related tandem occlusions treated with mechanical thrombectomy

The clinical benefit of mechanical thrombectomy(MT) for stroke patients with tandem occlusion is similar to that of isolated intracranial occlusions. However, the management of cervical internal carotid artery(ICA) occlusion during the MT, particularly in the setting of carotid dissection, remains controversial. We aimed to investigate the clinical impact of cervical ICA patency at day 1 on 3-month functional outcome. We collected data from the Endovascular Treatment in Ischemic Stroke, a prospective national registry in 30 French centers performing MT between January 2015 and January 2022. Inclusion criteria were consecutive tandem occlusions related to cervical ICA dissection treated with MT. Tandem occlusions of other etiology, isolated cervical ICA occlusions without intracranial thrombus and patients without day-1 ICA imaging were excluded. Primary endpoint was the 3-month functional outcome. Secondary endpoints included intracranial hemorrhage(ICH), excellent outcome, mortality and early neurological improvement. A sensitivity analysis was performed in patients with intracranial favorable recanalization after MT. During the study period, 137 patients were included of which 89(65%) presented ICA patency at day 1. The odds of favorable outcome did not significantly differ between patients with patent and occluded ICA at day 1(68.7 vs 59.1%;aOR=1.30;95%CI 0.56-3.00,p=0.54). Excellent outcome, early neurological improvement, mortality and ICH were also comparable between groups. Sensitivity analysis showed similar results. ICA patency at day 1 in patients with tandem occlusions related to dissection did not seem to influence functional outcome. Endovascular recanalization of the cervical ICA including stenting might not be systematically required in this setting.

Outcome Comparison of Endovascular Treatment for Acute Large Vessel Occlusion Due to Large Artery Atherosclerosis and Cardioembolism in the Chinese Population: Data from the ANGEL Registry.

Studies on outcome comparison after endovascular treatment (EVT) for large vessel occlusion (LVO) between large artery atherosclerosis (LAA) and cardioembolism (CE) in the Asian population are scarce. We aimed to compare the baseline characteristics and clinical outcomes after EVT for anterior circulation LVO with LAA and CE in the Chinese population. Patients were selected from the ANGEL registry and divided into LAA and CE groups. The primary outcome was the 90-day modified Rankin Scale (mRS) 0-2. The secondary outcomes were 90-day mRS distribution, 90-day mRS 0-1, 90-day mRS 0-3, and early neurological improvement. The safety outcomes included death, symptomatic intracranial hemorrhage, and any intracranial hemorrhage. We conducted logistic regression models with adjustments to compare the outcomes. A total of 632 patients were included, of whom, 488 were in the LAA group and 144 were in the CE group. No significant difference in 90-day mRS 0-2 was observed between LAA and CE groups (55.7%vs.43.1%, odds ratio[OR] 1.19, 95% confidence interval(CI), 0.92-1.53, P=0.190). The LAA group exhibited a higher frequency of mRS 0-3 compared to the CE group (69.1% vs 32.6%, OR1.32, 95% CI 1.02-1.72, P=0.038). However, the incidence of death within 90 days did not significantly differ between the LAA and CE groups (10.9%vs.24.3%, OR0.91, 95% CI0.66-1.25, P=0.545), nor did the occurrences of symptomatic intracranial hemorrhage(SICH) (4.5%vs.9.7%,OR1.08, 95% CI 0.65-1.78, P=0.779) or intracranial hemorrhage(ICH) (21.9%vs.30.6%, OR 0.94, 95% CI0.71-1.25, P=0.680). Moreover, no significant disparities were detected in other outcomes between the two groups (All P>0.05). In the ANGEL registry, a higher prevalence of patients undergoing EVT for acute anterior circulation LVO with LAA was found than those with CE. However, our study revealed that the efficacy and safety of EVT remained consistent regardless of the stroke's etiology such as LAA or CE.

Abstract WMP15: Do Changes in Blood Brain Barrier Permeability Mediate the Association Between White Matter Hyperintensities and Post-Stroke Clinical Outcome?

Introduction: White matter hyperintensities (WMH) are associated with worse clinical outcomes after stroke. Our objective was to test whether blood brain barrier (BBB) permeability mediates the association between WMH and clinical outcome. Methods: In acute ischemic stroke patients who received tPA but not EVT, we quantified WMH volume on baseline FLAIR MRI scans using a deep learning algorithm and calculated WMH fraction (WMH volume/total intracranial volume). Hyperintense acute reperfusion injury marker (HARM) was evaluated for presence and severity at 24 hours on post-gadolinium FLAIR. Using logistic regression, we tested the associations between WMH fraction, presence and severity of HARM, and clinical outcomes. Finally, we used structural equation models to evaluate whether severe HARM mediated the relationship between WMH fraction and clinical outcomes including early neurological improvement (ENI), hemorrhagic transformation (HT), discharge NIHSS (dNIHSS), and 90-day modified Rankin Scale (mRS)). Results: Of 264 patients included in this study, (mean age 68 years, 44% female) 26% had severe HARM at 24 hours post-stroke and 25% had any HT (&lt;5% with PH2). WMH fraction was associated with a higher risk of severe HARM (OR: 1.35, 95% CI: 1.03-1.78) after adjusting for demographics, vascular risk factors, plus NIHSS and infarct volume. WMH fraction was associated with dNIHSS, HT, and 90-day mRS in minimally adjusted models. In a mediation analysis, severe HARM explained a significant portion of the associations between WMH fraction and dNIHSS (35% mediation), 90-day mRS (28% mediation), or HT (40% mediation), each, in our demographics-adjusted models. Conclusions: Severe HARM partially mediates a significant portion of WMH’s effects on post-stroke clinical outcomes. Future studies should evaluate the mechanism behind this association and how the longitudinal effects of WMH on the BBB may be prevented.