Early Recanalization Research Articles

Analysis of Deep Vein Thrombosis: A Prospective Observational Study.

Objective This prospective observational study aimed to investigate the prevalence, acquired risk factors, and treatment outcomes of deep vein thrombosis (DVT) at a tertiary care center in India. Materials and methods Conducted from 2022 to 2024, the study included 100 patients diagnosed with lower extremity DVT. The study subjects included patients visiting the general surgery, vascular surgery, surgical gastroenterology, general medicine, emergency medicine, and obstetrics and gynecology departments with symptoms suggestive of DVT. The primary objectives were to evaluate the effectiveness of conventional anticoagulation and thrombolytic therapy as well as to assess the various acquired risk factors for DVT. Patients underwent comprehensive clinical and biochemical evaluations, including venous Doppler ultrasound, and were treated based on their clinical presentations. The study's primary end outcome was early recanalization rates on day 14 post-initiation of treatment and occurrence of post-thrombotic syndrome (PTS). Secondary outcome measures included duration of hospital stay, time taken to return to workand early complications. Results The highest incidence of DVT was in individuals in their forties, with a mean age of 44.84+/-11.71 years and a female preponderance of 58% (n=58). Key acquired risk factors identified included hypertension (25%; n=25), diabetes mellitus (20%; n=20), obesity (16%; n=16), and smoking (34%; n=34). Obesity (16%; n=16), a history of DVT (25%; n=25), trauma/immobilization (9%; n=9), pregnancy (10%; n=10), smoking (34%; n=34), and cancer (20%; n=20) were also identified as important acquired risk factors contributing to the occurrence of DVT. Amongst the study participants, 28% (n=28) had femoro-popliteal segment involvement, 36% (n=36) had calf vein thrombosis, and the remaining 36% (n=36) showed femoro-iliac segment thrombosis. Conventional anticoagulation was administered to 69% (n=69) of patients, while 31% (n=31) received thrombolytic therapy. Both treatments showed similar recanalization rates, but thrombolytic therapy was associated with a longer hospital stay (8.61+/-1.65 days; p=0.024; p<0.05) and return to work period (14.65+/-2.31 days; p=0.012; p<0.05). Post-thrombotic syndrome was less common in the thrombolytic therapy group (3%; n=3). Three patients died in the study, with the cause being pulmonary embolism. The descriptive statistics were computed to delineate the study sample. After completion of data collection, data analysis was achieved using SPSS for Windows, Version 16 (Released 2007; SPSS Inc., Chicago, United States), and the correlations sought after were achieved using the chi-square test of significance. Conclusion The study underscores the importance of recognizing and managing acquired risk factors for DVT, thereby facilitating early diagnosis and ultimately reducing morbidity and mortality. Understanding these factors and employing effective treatment strategies are crucial for better management and prevention of DVT, enhancing patient outcomes.

Early recanalization after tenecteplase versus alteplase: Experience in a large stroke network

IntroductionPreviously published data are conflicting regarding the ability of tenecteplase versus alteplase to produce early recanalization of an intracranial large vessel occlusion. We compared the performance of each thrombolytic in a stroke network. MethodsWe queried our prospectively collected code stroke registry for basilar, internal carotid, or proximal middle cerebral artery occlusion patients treated with intravenous thrombolysis from 11/17/2021-9/16/2023. The primary outcome was early recanalization, defined using angiographic or clinical criteria. Secondary and safety outcomes included 90-day functional independence and symptomatic intracranial hemorrhage. A multivariable regression analysis was performed to determine independent associations with the primary outcome. Results233 patients, with mean age 66.9 (16.6) years and median National Institutes of Health Stroke Scale score 15 (10-21), were included. One-hundred twenty-four of 233 (53.2 %) patients were treated with alteplase while 109/233 (46.8 %) were treated with tenecteplase. Endovascular thrombectomy was performed in 82 % of subjects. Early recanalization rates were similar between the groups (alteplase 22.6 %, tenecteplase 14.7 %; p = 0.14), as were rates of 90-day independent neurological function, symptomatic intracranial hemorrhage, and mortality. Patients with an internal carotid artery occlusion or with higher presenting stroke severity were less likely to achieve early recanalization. ConclusionsTenecteplase and alteplase have similar rates of early recanalization, 90-day functional independence, and safety outcomes in large vessel occlusion patients. Occlusion site and stroke severity predict response to thrombolysis. Future studies may investigate other factors associated with a positive response to thrombolytics as expanded treatment indications are explored.

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

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

Preoperative and intraoperative tirofiban during endovascular thrombectomy in large vessel occlusion stroke due to large artery atherosclerosis.

The aim of this study is to investigate the efficacy and safety of preoperative versus intraoperative tirofiban in patients with large vessel occlusion (LVO) due to large artery atherosclerosis (LAA). This is a retrospective multicenter cohort study based on the RESCUE-RE (Registration Study for Critical Care of Acute Ischemic Stroke After Recanalization) trial enrolling patients with anterior circulation LVO classified as LAA within 24 h of onset. Patients were divided into three groups: preoperative tirofiban (PT), intraoperative tirofiban (IT), and no tirofiban (NT). Propensity score matching (PSM) was used to balance baseline characteristics. The efficacy outcomes included 90-day functional independence (modified Rankin Scale score = 0-2) and early partial recanalization (EPR; defined as a modified Thrombolysis in Cerebral Infarction score = 1-2a). The safety outcomes included symptomatic intracranial hemorrhage (sICH). A total of 104 matched triplets were obtained through PSM. Compared with NT, PT increased 90-day functional independence (60.8% vs. 42.3%, p = 0.008) and EPR (42.7% vs. 18.3%, p < 0.001) rate, with a tendency to increase the asymptomatic intracranial hemorrhage (aICH) proportion (28.8% vs. 18.3%, p = 0.072). Compared with IT, PT had a higher 90-day functional independence (60.8% vs. 45.2%, p = 0.025) and EPR (42.7% vs. 20.2%, p = 0.001) rate, with no significant difference in sICH (14.4% vs. 7.7%, p = 0.122) and aICH (28.8% vs. 21.2%, p = 0.200). Compared with NT, IT had a lower 90-day mortality rate (9.6% vs. 24.0%, p = 0.005). Tirofiban shows good adjuvant therapy potential in acute ischemic stroke-LVO due to LAA patients. PT is associated with higher rates of EPR and better therapeutic efficacy. In addition, EPR may be a potential way to improve prognosis.

Insights into Angiographic Recanalization of Large Arterial Occlusion: Institutional Experience with Mechanical Thrombectomy for Acute Ischemic Stroke.

Stroke is a leading cause of morbidity and mortality in humans. Most strokes are ischemic in nature and early recanalization of occluded vessels determines good outcomes. Recanalization of occluded vessels depends on many angiographic and demographic features. These factors need to be identified for better patient overall outcomes. Better preoperative knowledge of factors can help in customizing our treatment approach and explaining the prognosis to the guardians of the patients. We aim to share our institutional experience with mechanical thrombectomy (MT) for stroke and studied factors that affect an angiographic recanalization of vessels . A retrospective single-center study was conducted involving 104 patients who underwent MT at our institution between January 2016 and December 2019. Patient demographics, baseline characteristics, pre- and postprocedural imaging findings, and other clinical data were meticulously reviewed. We divided patients into successful recanalization (modified thrombolysis in cerebral ischemia [mTICI] 2b or 3) and unsuccessful recanalization (mTICI 2a or 1) groups and various factors were analyzed to evaluate their impact on recanalization rates. In the univariate analysis, a significant association was observed between successful recanalization and several factors: the absence of rheumatic heart disease (RHD) as a risk factor ( p = 0.035), the presence of a hyperdense vessel sign ( p = 0.003), and the use of treatment methods including aspiration ( p = 0.031), stent retriever ( p = 0.001), and Solumbra ( p = 0.019). However, in the multivariate analysis, none of these factors exhibited statistical significance. The presence of RHD is a risk factor associated with poor angiographic recanalization in all three MT treatment modalities. Based on the above variables we can guide the patients/relatives prior to MT procedure for their better outcome and risk-benefit ratio.

Second-dose intravenous thrombolysis with tenecteplase in alteplase-resistant medium-vessel-occlusion strokes: A retrospective and comparative study.

In intracranial medium-vessel occlusions (MeVOs), intravenous thrombolysis (IVT) shows inconsistent effectiveness and endovascular interventions remains unproven. We evaluated a new therapeutic strategy based on a second IVT using tenecteplase for MeVOs without early recanalization post-alteplase. This retrospective, comparative study included consecutively low bleeding risk MeVO patients treated with alteplase 0.9 mg/kg at two stroke centers. One center used a conventional single-IVT approach; the other applied a dual-IVT strategy, incorporating a 1-h post-alteplase MRI and additional tenecteplase, 0.25 mg/kg, if occlusion persisted. Primary outcomes were 24-h successful recanalization for efficacy and symptomatic intracranial hemorrhage (sICH) for safety. Secondary outcomes included 3-month excellent outcomes (modified Rankin Scale score of 0-1). Comparisons were conducted in the overall cohort and a propensity score-matched subgroup. Among 146 patients in the dual-IVT group, 103 failed to achieve recanalization at 1 h and of these 96 met all eligible criteria and received additional tenecteplase. Successful recanalization at 24 h was higher in the 146 dual-IVT cohort patients than in the 148 single-IVT cohort patients (84% vs 61%, p < 0.0001), with similar sICH rate (3 vs 2, p = 0.68). Dual-IVT strategy was an independent predictor of 24-h successful recanalization (OR, 2.7 [95% CI, 1.52-4.88]; p < 0.001). Dual-IVT cohort patients achieved higher rates of excellent outcome (69% vs 44%, p < 0.0001). Propensity score matching analyses supported all these associations. In this retrospective study, a dual-IVT strategy in selected MeVO patients was associated with higher odds of 24-h recanalization, with no safety concerns. However, potential center-level confounding and biases seriously limit these findings' interpretation. ClinicalTrials.gov Identifier: NCT05809921.

Incomplete microvascular reperfusion in a swine model of recanalized acute ischemic stroke

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): CONTRAST CONSORTIUM (CVON, Dutch Heart Foundation) Background Incomplete microvascular reperfusion (IMR) could be a detrimental factor impairing regained functionality in stroke patients despite early recanalization. However, the presence of this phenomenon remains to be ascertained. Gyrencephalic large-animal models of acute ischemic stroke (AIS) such as swine are gaining attention as a next step in translation of preclinical to clinical stroke research, with brain anatomy and hemostasis more similar to humans. However, the occurrence and relevance of IMR in swine models of AIS is not well described yet, since most models do not include recanalization. Purpose We aimed to study the presence of IMR after brain ischemia in a translational swine model of AIS. Methods Anesthetized female Yorkshire-Landrace pigs (n=23) underwent craniotomy to occlude the right-sided middle cerebral arteries with aneurysm clips. Clips were released after 1 (n=5), 2 (n=5), and 4 (n=5) hours of occlusion to allow recanalization for 4 hours (recanalized AIS, n=15) or left in place for 8 hours (non-recanalized AIS, n=5). Three animals underwent the craniotomy without vessel clipping (Sham, n=3). 3D angiography was used to confirm occlusion and recanalization. Brains were collected after sacrifice, stained with TTC and then processed for histologic analysis. Infarct size was determined by TTC staining and expressed as percentage of the infarcted hemisphere. Histologic sections of the upper quadrant of the left and right hemispheres were immuno-stained with CD61 to visualize platelet aggregates in the microvasculature. Intravascular platelet aggregates (Figure 2A) were quantified using automated software analysis (Orbit) (CD61+ aggregates/mm2). Results All animals survived until the end of the procedure. Figure 1 shows differences in infarct size depending on the duration of occlusion (p=0.006). Figure 2 depicts an overall higher presence of platelet (CD61+) aggregates in the right hemisphere (infarct) compared to the left hemisphere (intact) (Figure 2B). There was a significant difference in platelet aggregates between left and right hemisphere but groupwise comparison showed only a trend (p=0.075) for more aggregates in the right hemisphere, compared to left, after 4 hours occlusion. Linear regression model could not identify whether infarct size and duration of occlusion were independent predictors of the number of platelet aggregates in the right hemisphere (p=0.191). Conclusions IMR occurs after brain ischemia in a swine model of AIS as a result of microvascular platelet aggregates. Further analysis and experiments are needed to elucidate which predictors can explain intravascular platelet aggregation.Infarct SizePlatelet aggregates

Abstract 2092: Ultrasound And Histology Protocol For Characterization Of Venous Stents Effect In Deep Veins In Vivo

Background: Deep venous stenting is a common strategy to treat deep vein thrombosis (DVT) decreasing future symptoms and complications. We propose a histopathological characterization of stents deployed in the inferior vena cava of rats and demonstrate how it correlates with ultrasound evaluation. Methods: Sprague Dawley rats (643±62g) were anesthetized (isoflurane). IVC diameter was measured by ultrasound on B mode. Through a midline laparotomy, infrarenal IVC side branches were ligated, posterior venous branches cauterized, micro-clips temporarily placed, and a U-stich is placed in the IVC. Using retrograde canulation of the IVC a sharpened guidewire with a stent sheath backloaded is inserted through the U-stich. The stent sheath is advanced with enough running room to deploy the venous self-expanding stent. After removal, U-stitch was tightened for hemostasis. No anticoagulation was used. Venous flow and patency were measured using a color/pulsed-wave Doppler 10-mHz probe post-procedure (PO) and 24 hours after (POD1). Vein wall thickness (VWT), in-stent-restenosis (ISR), and residual thrombosis percentage were quantified using trichrome staining at 7-, 14-, and 21-days. Results: Complete stent patency was observed in 50% of animals, partial patency in 15%, and obstruction in 35% after insertion. Table I. Recanalization at 1-day improved flow was observed in 41% of obstructed or partially patent stents. ISR was 6.2±3.8% of the luminal stent area (LSA), residual thrombosis in 29.9±23%, VWT mean 80±13.5 μm, no statistical differences found between timepoints. Figure 1. Conclusion: Characterization and follow-up of deep vein stents can be achieved by ultrasound and histology. This viable animal model can identify human pathological stent processes as early thrombosis, resolution, recanalization, and ISR. This model can reduce costs for feasibility studies to test novel stents and simulate real-life patency outcomes at multiple time points.

Large vessel occlusion detection by non-contrast CT using artificial ıntelligence

IntroductionComputer vision models have been used to diagnose some disorders using computer tomography (CT) and magnetic resonance (MR) images. In this work, our objective is to detect large and small brain vessel occlusion using a deep feature engineering model in acute of ischemic stroke.MethodsWe use our dataset. which contains 324 patient’s CT images with two classes; these classes are large and small brain vessel occlusion. We divided the collected image into horizontal and vertical patches. Then, pretrained AlexNet was utilized to extract deep features. Here, fc6 and fc7 (sixth and seventh fully connected layers) layers have been used to extract deep features from the created patches. The generated features from patches have been concatenated/merged to generate the final feature vector. In order to select the best combination from the generated final feature vector, an iterative selector (iterative neighborhood component analysis—INCA) has been used, and this selector has chosen 43 features. These 43 features have been used for classification. In the last phase, we used a kNN classifier with tenfold cross-validation.ResultsBy using 43 features and a kNN classifier, our AlexNet-based deep feature engineering model surprisingly attained 100% classification accuracy.ConclusionThe obtained perfect classification performance clearly demonstrated that our proposal could separate large and small brain vessel occlusion detection in non-contrast CT images. In this aspect, this model can assist neurology experts with the early recanalization chance.

Factors associated with recanalization and reintervention following below knee polidocanol endovenous microfoam ablation for great saphenous and small saphenous veins

BackgroundPolidocanol endovenous microfoam (PEM) has been used to treat lower extremity venous reflux for almost one decade with specific advantages for below knee (BK) truncal veins where thermal ablation poses a risk of injury to adjacent nerves. The current literature of the BK segment often examines short-term outcomes with modest sample sizes. We aim to identify factors associated with recanalization and reintervention in this subset of patients. MethodsWe performed a retrospective study of a prospectively maintained database of patients from a single institution who underwent 1% PEM ablation for BK great saphenous vein (GSV) and small saphenous vein (SSV) reflux. Patients underwent duplex ultrasound (DU) within 7 days after injection, every 3 to 6 months for 1 year, and every 6 to 12 months thereafter. Patients with symptomatic recanalization underwent reintervention. The 26 patients lost to follow-up without DU after ablation were excluded. The factors associated with recanalization and reintervention were examined by multivariate and nonparametric analyses. ResultsBetween March 2018 and July 2023, 411 patients (166 male, 245 female) with 573 treated limbs (284 right, 289 left) met the study criteria. Of the 573 included limbs, 457 (79.8%) had undergone prior above knee saphenous ablations. A total of 554 BK GSV and 42 SSV ablations were performed. The most recent DU was performed at a mean of 231 ± 329 days. The overall recanalization rate was 10.6% (55 GSVs and 8 SSVs) at a mean follow-up of 104 ± 180 days. Comparing the closed and recanalized veins, we found no significant difference in age (P = .90), treated laterality (P = .14), patient body mass index (P = .59), preprocedural CEAP (clinical-etiology-anatomy-pathophysiology) score (P = .79), recanalization rate in GSVs vs SSVs (P = .06), or administered PEM volume (P = .24). The recanalized veins had significantly larger preprocedural diameters than the veins that remained closed (recanalized, 4.9 mm; closed, 4.3 mm; P = .001). Men had higher incidence of recanalization than women (men, 14.2%; women, 8%; P = .015). Anticoagulation use was associated with recanalization (odds ratio, 1.96; 95% confidence interval, 1.1-3.6; P = .03). Early recanalization at the first DU accounted for 31 failures (49.2%) and had a significantly lower administered PEM volume compared with later recanalization (early, 4 mL; late, 5 mL; P = .025). There were no significant differences between the 33 recanalized patients requiring reintervention (52.4%) and the 30 who did not. Twenty-four reinterventions were performed with PEM, 100% of which remained closed at a median of 160 days (interquartile range, 257 days). ConclusionsPEM is successful for the treatment of BK GSV and SSV reflux with a closure rate of 89% at a mean of 231 days and shows promise as salvage therapy. Most cases of recanalization were noted in the early postprocedure period and were associated with a lower PEM volume. A larger vein diameter, male sex, and anticoagulation use are associated with higher rates of recanalization.

Thrombus Imaging Characteristics to Predict Early Recanalization in Anterior Circulation Large Vessel Occlusion Stroke.

The early management of transferred patients with a large vessel occlusion (LVO) stroke could be improved by identifying patients who are likely to recanalize early. We aim to predict early recanalization based on patient clinical and thrombus imaging characteristics. We included 81 transferred anterior-circulation LVO patients with an early recanalization, defined as the resolution of the LVO or the migration to a distal location not reachable with endovascular treatment upon repeated radiological imaging. We compared their clinical and imaging characteristics with all (322) transferred patients with a persistent LVO in the MR CLEAN Registry. We measured distance from carotid terminus to thrombus (DT), thrombus length, density, and perviousness on baseline CT images. We built logistic regression models to predict early recanalization. We validated the predictive ability by computing the median area-under-the-curve (AUC) of the receiver operating characteristics curve for 100 5-fold cross-validations. The administration of intravenous thrombolysis (IVT), longer transfer times, more distal occlusions, and shorter, pervious, less dense thrombi were characteristic of early recanalization. After backward elimination, IVT administration, DT and thrombus density remained in the multivariable model, with an AUC of 0.77 (IQR 0.72-0.83). Baseline thrombus imaging characteristics are valuable in predicting early recanalization and can potentially be used to optimize repeated imaging workflow.

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...

ASSOCIATION OF THE TYPE OF INTRACEREBRAL HEMORRHAGE WITH SERIOUS COMPLICATIONS AND PREDICTIVE FACTORS FOR HEMORRHAGIC TRANSFORMATION AFTER THROMBOLYTIC TREATMENT IN PATIENTS WITH ACUTE ISCHEMIC STROKE

Background: Accurate classification of postthrombolytic intracerebral hemorrhage (ICH) subtypes is vital for predicting stroke outcomes and managing ICH. Currently, the recommended classification criteria are the European Cooperative Acute Stroke Study III criteria, including two primary categories: hemorrhagic infarction (HI) and parenchymal hematoma (PH). Objectives: The primary objective of this study was to assess the contribution of various ICH subtypes to serious complications, with the secondary aim to identify associated predictors.Methods: The study examined medical records of patients with acute ischemic stroke receiving thrombolysis at Saraburi Hospital from 2014 to 2022. The logit model with the margins command assessed the association of ICH subtypes with serious complications, and multinomial logistic regression identified potential predictors for HI and PH. Results: Among 345 patients, HI-1, HI-2, PH-1 and PH-2 had prevalence rates of 3.2, 7.8, 4.9 and 7.5%, respectively, while 76.5% did not have ICH. PH-2 demonstrated the strongest correlation with inhospital mortality (adjusted risk ratio [RR] 2.83, 95% CI 1.56-5.13), invasive mechanical ventilator requirement (adjusted RR 3.93, 95% CI 2.09-7.39) and hematoma evacuation (adjusted RR 4.58, 95% CI 1.17-17.95) compared with patients of non-ICH. HI demonstrated a significant prolongation of hospitalization. (adjusted RR 3.30, 95% CI 1.53-7.12). Multinomial logistic regression analysis revealed that prior use of antiplatelet drugs, antihypertensive treatment before rt-PA, white blood cell count ≥11,750 cells/mm3 and baseline Alberta stroke program early CT scores ≤7 were independent predictors for PH. The adjusted odds ratios were 3.06 (95% CI, 1.23-7.57), 6.95 (95% CI, 2.62-18.45), 6.01 (95% CI, 2.17-16.65) and 5.01 (95% CI, 2.00-12.60), respectively. Conclusion: The PH-2 subtype was associated with the highest mortality, while our study demonstrated that the HI subtype, previously considered relatively benign with successful early recanalization, showed a significant prolongation of hospitalization compared with that of patients of non-ICH. High-risk patients of ICH require intensive monitoring to reduce complications.

Neurological Improvement by One-Thirds Is Associated With Early Recanalization in Stroke With Large Vessel Occlusion.

A proportion of large vessel occlusion strokes demonstrate early recanalization, obviating the initial intention to proceed to endovascular thrombectomy. Neurological improvement is a possible surrogate marker for reperfusion. We aimed to determine the optimal threshold of neurological improvement, as defined by the National Institutes of Health Stroke Scale (NIHSS), which best associates with early recanalization. We retrospectively analyzed consecutive patients with large vessel occlusion transferred from primary stroke centers to a tertiary comprehensive stroke center in Melbourne, Australia, for possible endovascular thrombectomy from January 2018 to December 2022. Absolute and percentage changes in NIHSS between transfer, as well as other definitions of neurological improvement, were compared using receiver operating characteristic curve analysis for association with recanalization as defined by the absence of occlusion in the internal carotid artery, middle cerebral artery (M1 or M2 segments), or basilar artery on repeat vascular imaging. Six hundred and fifty-four transferred patients with large vessel occlusion were included in the analysis: mean age was 68.8±14.0 years, 301 (46.0%) were women, and 338 (52%) received intravenous thrombolytics. The proportion of extracranial internal carotid artery, intracranial internal carotid artery, M1, proximal M2, and basilar artery occlusion was 18.8%, 13.6%, 48.3%, 15.0%, and 4.3%, respectively, on initial computed tomography angiogram. Median NIHSSprimary stroke center and NIHSScomprehensive stroke center scores were 15 (interquartile range, 9-18) and 13 (interquartile range, 8-19), respectively. Early recanalization occurred in 82 (13%) patients. NIHSS reduction of ≥33% was the best tradeoff between sensitivity (64%) and specificity (83%) for identifying recanalization. NIHSS reduction of ≥33% had the highest discriminative ability to predict recanalization (area under the curve, 0.735) in comparison with other definitions of neurological improvement. One-third neurological improvement between the primary hospital and tertiary center was the best predictor of early recanalization.

Abstract TP140: Effect of MR-Guided Perfusion Imaging Mismatch Profiles Within 6 Hours on Endovascular Thrombectomy Outcomes

Background: The treatment of acute ischemic stroke (AIS) aims to achieve early vascular recanalization and reperfusion of the penumbra. However, the effect of early penumbral imaging within 6 hours on clinical outcomes remains unclear. Objective: The objective of this study was to determine the effect of magnetic resonance-guided (MR-guided) perfusion imaging within 6 hours after symptom onset on endovascular thrombectomy outcomes in AIS patients. Methods: We prospectively collected the clinical information of consecutive AIS patients undergoing endovascular thrombectomy based on MR-guided perfusion imaging within 6 hours after symptom onset from AISRNA and EVTRNA studies. The primary outcome was defined as the poor outcome (mRS &gt; 2 within 90 days). The perfusion-weighted imaging/diffusion-weighted imaging (PWI/DWI) mismatch was assessed by an automated software. Results: We enrolled 84 patients (25 in the mismatch ≤ 1.8 group and 59 in the mismatch &gt; 1.8 group). Significant difference was found between the mismatch&gt;1.8 group and the mismatch≤1.8 group for the incidence of disabling stroke (mRS &gt; 2) within 90 days (40.7% vs. 68.0%, OR: 3.099, 95% CI: 1.154-8.323, P =0.025). Intracranial hemorrhage occurred in 8 patients (13.6%) in the mismatch &gt; 1.8 group and 10 patients in the mismatch ≤ 1.8 group (40.0%) (P = 0.010). The risk of severe cerebral edema was 2/59 (3.4%) vs. 7/25 (28.0%) (P = 0.004). These findings remained stable after adjustment. Conclusion: MR-guided perfusion imaging mismatch profiles within 6 hours after symptom onset may be feasible to improve clinical outcomes and reduce clinically ineffective reperfusion after endovascular thrombectomy.

Feasibility of early radial artery occlusion recanalization and reuse through transradial access for neuroendovascular procedures

BackgroundRadial artery occlusion (RAO) remains a significant limitation of neuroendovascular procedures peformed through transradial access (TRA) when radial artery needs to be reused. Instances of early RAO recanalization to successfully complete neuroendovascular procedures have been rarely documented.Materials and methodsDocuments and imaging data were extracted retrospectively for all patients who underwent TRA diagnostic angiography and neuroendovascular procedures in our center from June 2022 to February 2023. The patients with early RAO who required repeat TRA were included.ResultsA total of 46 patients underwent repeat TRA, and 13 consecutive patients who experienced early RAO after angiography as confirmed by ultrasonography were enrolled in this study. The occluded radial arteries were successfully recanalized, and subsequent neuroendovascular procedures were carried out successful. During an average follow-up time of 7.1 months, no patients exhibited symptomatic RAO, dissection, hematoma or pseudoaneurysm.ConclusionsEarly RAO recanalization and reused for neuroendovascular procedures through TRA is feasible. A visually guided and stable puncture process plays a crucial role in successfully recanalizing early RAO.

Subtyping treatment response of tirofiban in acute ischemic stroke based on neuroimaging features.

In a previously published clinical trial, we demonstrated that tirofiban was effective and safe in acute ischemic stroke (AIS) patients who did not undergo early recanalization treatments. We aimed to evaluate neuroimaging characteristics and their clinical significance to guide tirofiban treatment. In this post hoc analysis, location of infarcts (anterior circulation stroke [ACS] vs. posterior circulation stroke [PCS]), degree of cerebral artery stenosis (≤69% vs. ≥70% or occlusion), total infarct volume, and ASPECTS were used to predict the treatment effects of tirofiban, defined as the proportions of excellent and favorable functional outcome (modified Rankin Scale [mRS] score of 0-1, 0-2) at 90 days. ACS patients were more likely to achieve excellent (OR 2.08; 95% CI 1.25-3.45; p = 0.004) and favorable functional outcome (OR 2.28; 95% CI 1.24-4.22; p = 0.008) when treated with tirofiban. However, there was no significant difference in PCS patients between tirofiban and the control group. For patients with severe stenosis (≥70% or occlusion), tirofiban treatment improved the proportion of good outcomes (OR 2.84; 95% CI 1.44-5.60; p = 0.002 for mRS 0-1; OR 2.42; 95% CI 1.22-4.77; p = 0.011 for mRS 0-2). Meanwhile, we found that tirofiban improved outcome in patients with ASPECTS 8-10 and was independent of total infarct volume. These findings support the hypothesis that patients with ACS and severe stenosis may be recommended for tirofiban treatment, which can be predicted independent of total infarct volume.

Intravenous thrombolysis with tenecteplase versus alteplase combined with endovascular treatment of anterior circulation tandem occlusions: A pooled analysis of ETIS and TETRIS.

Tandem occlusions are a singular large vessel occlusion entity involving specific endovascular and perioperative antithrombotic management. In this context, data on safety and efficacy of prior intravenous thrombolysis (IVT) with tenecteplase is scarce. We aimed to compare IVT with tenecteplase or alteplase in patients with acute tandem occlusions intended for endovascular treatment. A retrospective pooled analysis of two large observational registries (ETIS (Endovascular Treatment of Ischemic Stroke) and TETRIS (Tenecteplase Treatment in Ischemic Stroke)) was performed on consecutive patients presenting with anterior circulation tandem occlusion treated with IVT using either alteplase (ETIS) or tenecteplase (TETRIS) followed by endovascular treatment between January 2015 and June 2022. Sensitivity analyses on atherosclerosis related tandem occlusions and on patient treated with emergent carotid stenting were conducted. Propensity score overlap weighting analyses were performed. We analyzed 753 patients: 124 in the tenecteplase and 629 in the alteplase group. The overall odds of favorable outcome (3-month modified Rankin score 0-2) were comparable between both groups (49.4% vs 47.1%; OR = 1.10, 95%CI 0.85-1.41). Early recanalization, final successful recanalization and mortality favored the use of tenecteplase. The occurrence of any intracranial hemorrhage (ICH) was more frequent after tenecteplase use (OR = 2.24; 95%CI 1.75-2.86). However, risks of symptomatic ICH and parenchymal hematoma remained similar. In atherosclerotic tandems, favorable outcome, mortality, parenchymal hematoma, early recanalization, and final successful recanalization favored the tenecteplase group. In the carotid stenting subgroup, PH were less frequent in the tenecteplase group (OR = 0.18; 95%CI 0.05-0.69). In patients with tandem occlusions, IVT with tenecteplase seemed reasonably safe in particular with increased early recanalization rates. These findings remain preliminary and should be further confirmed in randomized trials.

Progression from Early Minor Recanalization to Major Recanalization in Ruptured Intracranial Aneurysms After Successful Coil Embolization: Risk Factors and Proposal of a Novel Predicting Variable

The risk factors for the progression from early minor recanalization to major recanalization are not well established. Herein, we evaluated ruptured intracranial aneurysms (IAs) with minor recanalization within 1year of coiling and their progression to major recurrence. We retrospectively reviewed our database of coiled IAs and searched for ruptured saccular IAs that were successfully embolized without residual sacs. We selected IAs with minor recanalization confirmed on radiological studies within 1year of coil embolization. All the IA cases had a follow-up period longer than 36months based on the radiological results. Minor recanalization occurred in 45 IAs within 1year of coil embolization. Among them, 14 IAs (31.1%) progressed to major recanalization, and 31 remained stable. Progression to major recanalization was detected 12months after minor recanalization in 2 patients, 24months in 7 patients, and 36months in 5 patients. Moreover, the progression to major recanalization occurred more frequently in IAs at the posterior location (P= 0.024, odds ratio 11.20) and IAs with a proportional forced area>9mm2 (P= 0.002, odds ratio 17.13), which was a newly proposed variable in the present study. Our results showed that approximately one third of the ruptured IAs with early minor recanalization after coiling progressed to major recanalization within 3years. Physicians should focus on the progression of ruptured IAs from minor to major recanalization, especially those with a posterior circulation location and a proportional forced area >9mm2.

Factors associated with hemorrhagic transformation after endovascular treatment despite early recanalization

PurposeTo identify new factors associated with hemorrhagic transformation (HT) despite early recanalization in patients with acute ischemic stroke treated with mechanical thrombectomy. MethodsWe retrospectively included patients with known onset of large vessel occlusion treated with mechanical thrombectomy +/− intravenous thrombolysis. Non-contrast CT was performed at 24 +/− 12 h from endovascular procedure. We collected data on patient characteristics, risk factors, radiological and treatment features, stroke severity on admission and discharge, carotid intima-media thickness (CIMT), Neutrophils-to-Lymphocytes ratio (NLR), white matter hyperintensities measured according to the Fazekas score on FLAIR MRI data. The main outcome measures were the incidence of HT and factors associated with it. Secondary outcome measures were symptomatic intracerebral hemorrhage and parenchymal hematoma. ResultsOf 874 patients, 472 met the inclusion criteria, 211 (44.7%) had HT. Factors significantly associated with increased risk of HT included onset-to-recanalization time, CIMT (normal/mild), ASPECT-MRI < 6, and a higher NLR. We found that beyond 7.67 h from onset-to-recanalization, the risk of HT increases and exceeds 50%. ASPECT-MRI, NLR, and CIMT independently predict HT despite early recanalization. ConclusionsWe identified novel factors associated with HT in patients with acute ischemic stroke of known onset treated with mechanical thrombectomy. We found that at 7.67 h from onset to recanalization, the risk of HT is >50%, and we identified factors responsible for HT despite early recanalization.