Endovascular Stroke Treatment Research Articles

Effectiveness of endovascular treatment for in-hospital stroke vs. community-onset stroke: a propensity score-matched analysis.

The effectiveness of endovascular treatment for in-hospital stroke remains debatable. We aimed to compare the outcomes between patients with in-hospital stroke and community-onset stroke who received endovascular treatment. This prospective registry-based cohort study included consecutive patients who underwent endovascular treatment from January 2013 to December 2022 and were registered in the Selection Criteria in Endovascular Thrombectomy and Thrombolytic Therapy study and Yonsei Stroke Cohort. Functional outcomes at day 90, radiological outcomes, and safety outcomes were compared between the in-hospital and community-onset groups using logistic regression and propensity score-matched analysis. Of 1,219 patients who underwent endovascular treatment, 117 (9.6%) had in-hospital stroke. Patients with in-hospital onset were more likely to have a pre-stroke disability and active cancer than those with community-onset. The interval from the last known well to puncture was shorter in the in-hospital group than in the community-onset group (155 vs. 355 min, p<0.001). No significant differences in successful recanalization or safety outcomes were observed between the groups; however, the in-hospital group exhibited worse functional outcomes and higher mortality at day 90 than the community-onset group (all p<0.05). After propensity score matching including baseline characteristics, functional outcomes after endovascular treatment did not differ between the groups (OR: 1.19, 95% CI 0.78-1.83, p=0.4). Safety outcomes did not significantly differ between the groups. Endovascular treatment is a safe and effective treatment for eligible patients with in-hospital stroke. Our results will help physicians in making decisions when planning treatment and counseling caregivers or patients.

Prediction of futile recanalisation after endovascular treatment in acute ischaemic stroke: development and validation of a hybrid machine learning model

BackgroundIdentification of futile recanalisation following endovascular therapy (EVT) in patients with acute ischaemic stroke is both crucial and challenging. Here, we present a novel risk stratification system based on hybrid...

Systemic Immune-Inflammation Response is Associated with Futile Recanalization After Endovascular Treatment.

Frequent incidence of futile recanalization decreases the benefit of endovascular treatment (EVT) in acute ischemic stroke. We hypothesized that the inflammation and immune response after ischemic are associated with futile recanalization. We aimed to investigate the correlation of admission systemic immune-inflammation index (SII) with futile recanalization post EVT. Patients with successful recanalization (modified Thrombolysis in Cerebral Ischemia angiographic score 2b-3) and maintained artery recanalized after 24h of EVT were chosen from a prospective nationwide registry study. Futile recanalization was defined as a poor functional outcome (modified Rankin Scale score 3-6) at 90days, irrespective of a successful recanalization. At admission, SII was calculated as (platelet count × neutrophil count)/lymphocyte count/100. Logistic regression analysis helped to test the relationship of SII with futile recanalization. Among the 1,002 patients included, futile recanalization occurred in 508 (50.70%). No matter whether tested as quartiles or continuous variables, SII was significantly associated with futile recanalization (P < 0.05), and for every one standard deviation increase of SII, the risk of futile recanalization elevated by 22.3% (odds ratio 1.223, 95% confidence interval 1.053-1.444, P = 0.0093). Moreover, no significant interactions could be observed between SII or SII quartiles and age, baseline National Institutes of Health Stroke Scale scores, onset-to-recanalization time, and modified Thrombolysis in Cerebral Ischemia angiographic scores (all P for interaction > 0.05). Early SII elevation was associated with an increased risk of futile recanalization among patients with EVT. Our results indicated that therapeutic drug targeting hyperreactive immune-inflammation response might be helpful for reducing the incidence of futile recanalization.

Endovascular therapy of acute vertebrobasilar occlusions: influence of first-line strategy in the Endovascular Treatment in Ischemic Stroke (ETIS) Registry

BackgroundThe choice of the first-line technique in vertebrobasilar occlusions (VBOs) remains challenging. We aimed to report outcomes in a large cohort of patients and to compare the efficacy and safety...

Abstract WP203: Prediction of Outcome After Endovascular Therapy for Acute Ischemic Stroke: A Machine Learning Approach From Japan Stroke Data Bank

Introduction: Previous studies have demonstrated the predictive capabilities of machine learning (ML) models using clinical, imaging, and angiographic characteristics in determining the clinical outcome of patients undergoing endovascular treatment for acute ischemic stroke. We aimed to analyze a large-scale stroke registry and develop an ML model that solely utilizes clinical characteristics, without the need for imaging or angiographic data, to predict the outcome of patients treated with endovascular therapy for acute ischemic stroke. Methods: We conducted our analysis using data from the Japan Stroke Data Bank, a nationwide acute stroke registry containing individual patient data. A total of 4353 patients who underwent endovascular treatment for acute ischemic stroke between January 2016 and December 2020 were included in the study. Patient data from 2016 to 2019 were used as the derivation cohort, while data from 2020 were used as the validation cohort. An ML models were trained on 70% of the patients randomly selected from the derivation cohort and tested on the remaining 30%. The input variables for the ML models consisted of 138 clinical characteristics including neurological examination findings. Imaging, angiographic, and laboratory data were not utilized in the ML process. The primary outcome measure was good outcome at discharge, defined as a modified Rankin Scale score of 0-2. Results: Of the 4353 patients included in the study, 1520 patients (34.9%) achieved good outcome. The area under the curve for predicting good outcome was 0.76 for the test set in the derivation cohort and 0.78 for the validation cohort. The SHAP summary plot revealed that the top five major predictive contributors for good outcomes were pre-stroke modified Rankin Scale score, level of consciousness, age, stroke classification, and NIHSS score. Conclusions: Our findings demonstrate that an ML model utilizing solely clinical characteristics, without the inclusion of imaging or angiographic data, can accurately predict good outcomes at discharge for acute stroke patients treated with endovascular therapy. This approach has the potential to provide an aid in clinical decision-making before imaging examination.

Abstract WMP95: Anesthesia Modality in Endovascular Treatment for Distal Medium Vessel Occlusion Stroke: Intention-to-Treat Matched Analysis

Background: The optimal anesthesia modality during endovascular treatment (EVT) for distal medium vessel occlusion (DMVO) strokes is uncertain. We aimed to evaluate the impact of the anesthesia modality on procedural and clinical outcomes following EVT for DMVO strokes. Methods: This is a retrospective analysis of a prospectively collected database from 14 comprehensive stroke centers in the United States and Europe. Patients were included if they had DMVO due to MCA-M3/4, ACA-A1/A2-3, or PCA-P1/P2-3 and underwent EVT. The cohort was divided into two groups: general anesthesia (GA) and non-general anesthesia (non-GA). The primary analysis compared the two groups based on the intention-to-treat principle. The secondary analysis compared both groups according to the as-treated approach. We used propensity scores to balance the two groups at a 1:1 ratio. The primary outcome was the shift in the degree of disability as measured by the 90-day mRS. Secondary outcomes included successful reperfusion, mRS0-1, and mRS0-2 at 90-days. Safety measures included procedural complications, symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. Results: A total of 365 patients were eligible for analysis. In the intention-to-treat analysis (130 matched pairs), baseline demographic and clinical characteristics were balanced. There was no difference in the degree of disability (mRS ordinal shift; acOR 1.64, 95%-CI [0.78-3.46], P=0.19) between the two groups. GA had comparable rates of successful reperfusion (aOR2.66, 95%CI [0.75-9.42],P=0.13), 90-day mRS0-1 (aOR1.07, 95%CI[0.41-2.78],P=0.89), 90-day mRS0-2 (aOR1.46, 95%CI[0.60-3.55],P=0.41), procedural complications (aOR1.08, 95%CI[0.20-5.79],P=0.93), sICH (aOR3.28, 95%CI[0.81-13.34], P=0.10), and 90-day mortality (aOR0.82, 95%CI [0.35-1.95],P=0.66) compared to the non-GA group. Similarly, when comparing 150 matched pairs using the as-treated principle, GA and non-GA showed comparable outcomes. Conclusions: In patients with DMVO undergoing EVT, GA and non-GA had similar procedural and clinical outcomes, as well as safety measures. Further, larger controlled studies are warranted.

Abstract TP207: Endovascular Treatment in the Late Time Window: Strict Perfusion Imaging Screening Criteria in Case Selection

Background and purpose: Clinical-imaging mismatch or perfusion imaging mismatch criteria per DAWN (Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention With Trevo) or DEFUSE-3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke), respectively were recommended for case selection for endovascular treatment (EVT) of acute ischemic stroke (AIS) in the late time window outside 6 hours of stroke onset. We aimed to compare the clinical functional outcomes in EVT patients with and without strict perfusion imaging screening criteria in the late time window. Methods: AIS patients with anterior circulation large vessel occlusion (LVO) presenting within 6 to 24h hours after symptom onset were selected from a retrospectively collected thrombectomy cohort database (RESTORE). According to the imaging criteria of DAWN and DEFUSE-3, we compared proportions of patients with a favorable functional outcome (defined as a modified Rankin Scale [mRS] score of 0-2) at 90 days between the DAWN or DEFUSE-3 patients (D/D) and the non-DAWN or DEFUSE-3 (non-D/D) patients. Results: Among 265 adult patients with anterior circulation LVO who received EVT within 6 to 24 hours after symptom onset, 142 patients met either DAWN or DEFUSE-3 imaging criteria. D/D group independently predicted favorable functional outcome at 90 days (50.7% vs. 35.0%, aOR 0.514; 95% CI 0.273-0.966, p=0.039) adjusted for age, sex, previous stroke, hypertension, atrial fibrillation, coronary heart disease, pre-EVT collateral score, successful recanalization, onset to CT time. Conclusions: In AIS patients with anterior circulation LVO in the late time window, our real world data support the guideline that DAWN or DEFUSE-3 imaging criteria are strongly recommended for EVT case selection.

Abstract WP200: Endovascular Therapy for Isolated Carotid Occlusion in the Neck

Background and Study Purpose: Existing guidelines on endovascular treatment (EVT) of acute ischemic stroke do not include isolated cervical internal carotid artery occlusions (CICAO). These occlusions are still treated, but the effect remains unclear. This study aimed to compare the baseline characteristics and treatment outcomes between patients with isolated CICAO and patients who underwent EVT due to occlusions mentioned in guidelines. Methods: A retrospective study was conducted on 1162 patients who underwent EVT due to ischemic stroke at Aarhus University Hospital between June 2017 and June 2022. Univariate analysis of outcomes and baseline characteristics were compared between patients with isolated CICAO and tandem occlusions or isolated CICAO and occlusion of the middle cerebral artery (M1)/intracerebral internal carotid artery (ICA-T). Results: 731 patients were eligible for inclusion. Patients with isolated CICAO were more likely male (67.8% vs 50.9%, p-value = 0.0009) and active smokers (42.2% vs 26.4%, p = 0.0016) compared to patients with M1/ICA-T occlusions where atrial fibrillation (35.5% vs. 23.5%, p = 0.0158) and an equal sex distribution was more frequently seen. The groups showed similar favorable outcomes and mortality. Notably, a statistically significant difference in mortality between patients with isolated CICAO (precent) and M1/ICA-T occlusions (percent) could not be excluded (p = 0.0584). Conclusion: Patients with isolated CICAO and M1/ICA-T occlusions seem to differ in sex, smoking status, and atrial fibrillation. This study did not find any differences between isolated CICAO and tandem occlusions. EVT appears beneficial in patients with isolated CICAO, however randomized-controlled trials are necessary to examine and compare the effect between occlusion sites.

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.

Abstract WP3: Serum Glucose Fluctuations is an Independent Predictor of Adverse Outcomes in Patients With Acute Ischemic Stroke Undergoing Endovascular Treatment

Background: Acute hyperglycemia may increase the rate of death or disability among acute ischemic stroke patients undergoing endovascular procedures. Objective: To explore the association between serum glucose fluctuation on post treatment symptomatic intracranial hemorrhage (sICH) and mortality. Methods: We analyzed consecutive acute ischemic stroke patients who underwent endovascular treatment over 30 months at a comprehensive stroke center. Serum glucose levels within the initial 24 hours were used to calculate the mean and standard deviation (SD). Patients were grouped by the standard deviation [SD] of the mean value of serum glucose, whether above or below 25%. Outcomes included sICH, and inpatient mortality, adjusted for confounders which included age, gender, baseline NIHSS, perfusion grade (TICI) intravenous thrombolysis, history of diabetes and HBA1c. Results: A total of 224 patients (mean age was 68.7 years (±14.3); 44.2% were women) underwent endovascular treatment. The proportion of sICH (16.7% vs. 3.28%; p=0.0006) and inpatient mortality (18.6% vs. 7.4%; p=0.0112) were higher in patients with SD exceeding 25. After adjusting for potential confounders, serum glucose SD above 25 was significantly associated with increased rate of sICH (odds ratio [OR] 5.2; 95% confidence interval [CI] 1.5-18.5; p=0.0112) and inpatient mortality (OR 3.5; 95% CI 1.3-9.8; p=0.0154). Conclusion: Serum glucose fluctuations within first 24 hours maybe be therapeutic target due to its association with increased risks of sICH and inpatient mortality following endovascular treatment in acute ischemic stroke.

Abstract WP193: Endovascular Thrombectomy for DAWN- and DEFUSE 3 Ineligible Acute Ischemic Stroke Patients: A Systematic Review and Meta-Analysis

Background: The current evidence supports the benefits of endovascular treatment (EVT) in acute ischemic stroke (AIS) with large vessel occlusion (LVO). The DAWN and DEFUSE-3 trials expanded the EVT window up to 24 hours. A few real-world studies explored EVT outcomes in DAWN/DEFUSE-3 ineligible (NDND) patients. Methods: This meta-analysis investigated EVT outcomes in patients with late-window anterior circulation LVO, including both DAWN/DEFUSE-3 eligible (DD) and NDND patients. Nine studies were included, focusing on study characteristics, risk of bias, and outcomes. Results: Baseline characteristics showed comparable age, gender, comorbidities, NIHSS score, and ASPECTS between DD and NDND patients. NDND patients exhibited larger infarct volumes and higher atrial fibrillation rate. Successful reperfusion rates (TICI 2b-3) were comparable between the two groups (OR= 0.86; 95% CI= 0.40, 1.84; p = 0.689), with significant heterogeneity (I 2 = 73%; P = 0.002). Functional independence (90-day mRS score 0-2) was not significantly different between the two groups (OR= 1.12; 95% CI= 0.77, 1.63; p = 0.552) with notable heterogeneity (I 2 = 46%, p = 0.063). Symptomatic intracranial hemorrhage (sICH) rate was lower in the DD group as compared to NDND patients (OR= 0.49; 95% CI= 0.25, 0.93; p = 0.029) with no heterogeneity (I 2 = 0%, p = 0.552). 90-day mortality was lower in the DD group than in the NDND group (OR= 0.55; 95%-CI= 0.37, 0.82; p = 0.004) with no significant heterogeneity (I 2 = 0%, p = 0.536). Conclusion: While this meta-analysis showed comparable rates of functional independence between DD and NDND patients, the potential bias introduced by the higher rates of sICH and mortality in the latter group should prompt great care when offering EVT to NDND patients. Less restricted EVT eligibility criteria might yield positive outcomes in real-world practice in specific patients. However, increased risks of sICH and mortality in NDND patients warrant further investigation to optimize the risk-benefit balance in expanding EVT eligibility criteria.

Abstract WP79: Outcomes Of The Code Large Vessel Occlusion Process On Endovascular Intervention

Introduction: The code LVO alert was created to help decrease the time from arrival to MER for patients presenting with LVO stroke. The code LVO alerts the endovascular surgeon and team earlier in the stroke alert process with the goal of improving patient outcomes. The purpose of this study was to determine the impact of code LVO on stroke endovascular treatment times and patient outcomes. Methods: The code LVO is activated based on patient assessment. Criteria to call a code LVO includes a RACE score ≥ 5 or if a patient has disabling symptoms including aphasia, visual field cut or total limb weakness. The code LVO can be activated either as a prehospital alert or in the emergency department by either the provider or nurse. This notification makes the endovascular surgeon and team aware of a possible endovascular candidate prior to imaging to help reduce door to team activation, skin puncture, device, and reperfusion. We compared patients in 2022 that received MER with and without code LVO activation. Results: Eighteen patients with MER and code LVO activation were compared to 42 patients that received MER and no code LVO activation. Clinical and demographic characteristics were similar (p&gt;.05). When comparing the two groups, the code LVO activation decreased the door to activation by 26.8 minutes (p=.003), door to puncture by 31.5 minutes (p=.005), door to device by 34.5 minutes (p=.026), and door to reperfusion by 41.3 minutes (p=.013). The 90-day mRS score and 90-day mortality rate were similar. Conclusion: In conclusion, the code LVO activation significantly decreased MER treatment times but these improvements did not translate to improved patient outcomes. We identified opportunities to improve our patient outcomes by increasing code LVO activation on all patients meeting criteria.

Endovascular Treatment of Acute Ischemic Stroke After Cardiac Interventions in the United States

Ischemic stroke is a serious complication of cardiac intervention, including surgery and percutaneous procedures. Endovascular thrombectomy (EVT) is an effective treatment for ischemic stroke and may be particularly important for cardiac intervention patients who often cannot receive intravenous thrombolysis. To examine trends in EVT for ischemic stroke during hospitalization of patients with cardiac interventions vs those without in the United States. This cohort study involved a retrospective analysis using data for 4888 US hospitals from the 2016-2020 National Inpatient Sample database. Participants included adults (age ≥18 years) with ischemic stroke (per codes from the International Statistical Classification of Diseases, Tenth Revision, Clinical Modification), who were organized into study groups of hospitalized patients with cardiac interventions vs without. Individuals were excluded from the study if they had either procedure prior to admission, EVT prior to cardiac intervention, EVT more than 3 days after admission or cardiac intervention, or endocarditis. Data were analyzed from April 2023 to October 2023. Cardiac intervention during admission. The odds of undergoing EVT by cardiac intervention status were calculated using multivariable logistic regression. Adjustments were made for stroke severity in the subgroup of patients who had a National Institutes of Health Stroke Scale (NIHSS) score documented. As a secondary outcome, the odds of discharge home by EVT status after cardiac intervention were modeled. Among 634 407 hospitalizations, the mean (SD) age of the patients was 69.8 (14.1) years, 318 363 patients (50.2%) were male, and 316 044 (49.8%) were female. A total of 12 093 had a cardiac intervention. An NIHSS score was reported in 218 576 admissions, 216 035 (34.7%) without cardiac intervention and 2541 (21.0%) with cardiac intervention (P < .001). EVT was performed in 23 660 patients (3.8%) without cardiac intervention vs 194 (1.6%) of those with cardiac intervention (P < .001). After adjustment for potential confounders, EVT was less likely to be performed in stroke patients with cardiac intervention vs those without (adjusted odds ratio [aOR], 0.27; 95% CI, 0.23-0.31), which remained consistent after adjusting for NIHSS score (aOR, 0.28; 95% CI, 0.22-0.35). Among individuals with a cardiac intervention, receiving EVT was associated with a 2-fold higher chance of discharge home (aOR, 2.21; 95% CI, 1.14-4.29). In this study, patients hospitalized with ischemic stroke and cardiac intervention may be less than half as likely to receive EVT as those without cardiac intervention. Given the known benefit of EVT, there is a need to better understand the reasons for lower rates of EVT in this patient population.

Deep learning-based white matter lesion volume on CT is associated with outcome after acute ischemic stroke.

Intravenous thrombolysis (IVT) before endovascular treatment (EVT) for acute ischemic stroke might induce intracerebral hemorrhages which could negatively affect patient outcomes. Measuring white matter lesions size using deep learning (DL-WML) might help safely guide IVT administration. We aimed to develop, validate, and evaluate a DL-WML volume on CT compared to the Fazekas scale (WML-Faz) as a risk factor and IVT effect modifier in patients receiving EVT directly after IVT. We developed a deep-learning model for WML segmentation on CT and validated with internal and external test sets. In a post hoc analysis of the MR CLEAN No-IV trial, we associated DL-WML volume and WML-Faz with symptomatic-intracerebral hemorrhage (sICH) and 90-day functional outcome according to the modified Rankin Scale (mRS). We used multiplicative interaction terms between WML measures and IVT administration to evaluate IVT treatment effect modification. Regression models were used to report unadjusted and adjusted common odds ratios (cOR/acOR). In total, 516 patients from the MR CLEAN No-IV trial (male/female, 291/225; age median, 71 [IQR, 62-79]) were analyzed. Both DL-WML volume and WML-Faz are associated with sICH (DL-WML volume acOR, 1.78 [95%CI, 1.17; 2.70]; WML-Faz acOR, 1.53 95%CI [1.02; 2.31]) and mRS (DL-WML volume acOR, 0.70 [95%CI, 0.55; 0.87], WML-Faz acOR, 0.73 [95%CI 0.60; 0.88]). Only in the unadjusted IVT effect modification analysis WML-Faz was associated with more sICH if IVT was given (p= 0.046). Neither WML measure was associated with worse mRS if IVT was given. DL-WML volume and WML-Faz had a similar relationship with functional outcome and sICH. Although more sICH might occur in patients with more severe WML-Faz receiving IVT, no worse functional outcome was observed. White matter lesion severity on baseline CT in acute ischemic stroke patients has a similar predictive value if measured with deep learning or the Fazekas scale. Safe administration of intravenous thrombolysis using white matter lesion severity should be further studied. White matter damage is a predisposing risk factor for intracranial hemorrhage in patients with acute ischemic stroke but remains difficult to measure on CT. White matter lesion volume on CT measured with deep learning had a similar association with symptomatic intracerebral hemorrhages and worse functional outcome as the Fazekas scale. A patient-level meta-analysis is required to study the benefit of white matter lesion severity-based selection for intravenous thrombolysis before endovascular treatment.

A prospective, multicentre, registry study of RECO in the endovascular treatment of acute ischaemic stroke

The RECO is a novel endovascular treatment (EVT) device that adjusts the distance between two mesh segments to axially hold the thrombus. We organized this postmarket study to assess the safety and performance of RECO in acute ischaemic stroke (AIS) patients with large vessel occlusion (LVO). This was a single-arm prospective multicentre study that enrolled patients as first-line patients treated with RECO at 9 stroke centres. The primary outcome measures included functional independence at 90 days (mRS 0–2), symptomatic intracranial haemorrhage (sICH), time from puncture to recanalization and time from symptom onset to recanalization. The secondary outcome measures were a modified thrombolysis in cerebral infarction (mTICI) score of 2b or 3 after the first attempt and at the end of the procedure and the all-cause mortality rate within 90 days. From May 22, 2020, to July 30, 2022, a total of 268 consecutive patients were enrolled in the registry. The median puncture-to-recanalization time was 64 (IQR, 45–92), and the symptom onset-to-recanalization time was 328 min (IQR, 228–469). RECO achieved successful reperfusion (mTICI 2b-3) after the first pass in 133 of 268 patients (49.6%). At the end of the operation, 96.6% of the patients reached mTICI 2b-3, and 97.4% of the patients ultimately achieved successful reperfusion. Sixteen (7.2%) patients had sICH. A total of 132 (49.3%) patients achieved functional independence at 90 days, and the all-cause mortality rate within 90 days was 17.5%. In this clinical experience, the RECO device achieved a high rate of complete recanalization with a good safety profile and favourable 90-day clinical outcomes.Clinical trial registration: URL: https://www.clinicaltrials.gov/; Unique identifier: NCT04840719.

Predictors of Good Clinical Outcome After Endovascular Treatment for Acute Ischemic Stroke due to Tandem Lesion in Anterior Circulation: Results from the ASCENT Study

PurposeEndovascular treatment (EVT) of tandem lesion (TL) in anterior circulation (AC) acute ischemic stroke (AIS) represents still a clinical challenge. We aimed to evaluate selected factors related to EVT and assess other possible predictors of good clinical outcome besides the generally known ones.MethodsAIS patients with TL in AC treated with EVT were enrolled in the multicenter retrospective ASCENT study. A good three-month clinical outcome was scored as 0–2 points in modified Rankin Scale (mRS) and achieved recanalization using the TICI scale. Symptomatic intracerebral hemorrhage (SICH) was assessed using the SITS-MOST criteria. Logistic regression analysis was used for the assessment of possible predictors of mRS 0–2 with adjustment for potential confounders.ResultsIn total, 300 (68.7% males, mean age 67.3 ± 10.2 years) patients with median of admission NIHSS 17 were analyzed. Recanalization (TICI 2b-3) was achieved in 290 (96.7%) patients and 176 (58.7%) had mRS 0–2. Besides the age, admission NIHSS and SICH, admission glycemia (p = 0.005, OR: 0.884) the stent patency within the first 30 days after EVT (p = 0.0003, OR: 0.219), dual antiplatelet therapy (DAPT) started within 12 h after EVT (p < 0.0001, OR: 5.006) and statin therapy started within 24 h after stenting (p < 0.0001, OR: 5.558) were found as other predictors.ConclusionAdmission glycemia, start of DAPT within 12 h and statin therapy within 24 h after EVT, and stent patency within the first 30 days after EVT were found as other predictors of good three-month clinical outcome in AIS patients treated with EVT for TL.Graphical

Intravenous Thrombolysis before Complete Angiographic Reperfusion: Beyond Angiographic Assessment to Target Microvascular Obstruction?

Recent data have suggested that ineffective tissue reperfusion despite successful angiographic reperfusion was partly responsible for unfavorable outcomes after endovascular therapy (EVT) and might be modulated by intravenous thrombolysis (IVT) use before EVT. To specifically decipher the effect played by IVT before EVT, we compared the clinical and safety outcomes of patients who experienced a complete reperfusion at the end of EVT according to IVT use before EVT. The Endovascular Treatment in Ischemic Stroke (ETIS) registry is an ongoing, prospective, observational study at 21 centers that perform EVT in France. Patients were included if they had an anterior large vessel occlusion of the intracranial internal carotid artery or middle cerebral artery (M1/M2 segments) and complete reperfusion (expanded Thrombolysis in Cerebral Infarction score = 3) with EVT within 6 hours, between January 2015 and December 2021. The cohort was divided into two groups according to IVT use before EVT, and propensity score matching (PSM) was used to balance the two groups. Primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included favorable outcome (mRS 0-2) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage and 90-day mortality. Outcomes were estimated with multivariate logistic models adjusted for age, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and time from symptom onset to puncture. Among 5,429 patients included in the ETIS registry, 1,093 were included in the study, including 651 patients with complete recanalization treated with IVT before EVT. After PSM, 488 patients treated with IVT before EVT were compared to 337 patients without IVT. In the matched cohort analysis, the IVT+EVT group had a favorable shift in the overall mRS score distribution (adjusted odds ratio [aOR] = 1.41, 95% confidence interval [CI] = 1.04-1.91, p = 0.023) and higher rates of favorable outcome (61.1% vs 48.7%, aOR = 1.49, 95% CI = 1.02-2.20, p = 0.041) at 90 days compared with the EVT alone group. Rates of symptomatic intracerebral hemorrhage were comparable between both groups (6.0% vs 4.3%, aOR = 1.16, 95% CI = 0.53-2.54, p = 0.709). In clinical practice, even after complete angiographic reperfusion by EVT, prior IVT use improves clinical outcomes of patients without increasing bleeding risk. ANN NEUROL 2024;95:762-773.

DACA Aneurysm Presenting as Ischemic Stroke

AbstractAneurysms rarely present with features of ischemic stroke. The data on treatment of such strokes is limited. We present a case of multiple aneurysms and an ischemic stroke caused by distal anterior cerebral artery (DACA) aneurysm treated with flow diverter placement, the first case of endovascular treatment of DACA aneurysmal ischemic stroke reported to our knowledge.

Sex differences in outcomes after endovascular treatment in posterior circulation stroke: results from the MR CLEAN Registry

BackgroundWomen with anterior circulation large vessel occlusion (LVO) have been reported to have worse outcomes after endovascular treatment (EVT) than men. Whether these disparities also exist in LVO of the...

Postoperative neutrophil-to-lymphocyte ratio predicts malignant cerebral edema following endovascular treatment for acute ischemic stroke.

Malignant cerebral edema (MCE) is one of serious complications with high mortality following endovascular treatment (EVT) for acute ischemic stroke (AIS) with large vessel occlusion. We aimed to investigate the relationship between postoperative neutrophil-to-lymphocyte ratio (NLR) and MCE after EVT. The clinical and imaging data of 175 patients with AIS of anterior circulation after EVT were studied. Admission and postoperative NLR were determined. The presence of MCE was evaluated on the computed tomography performed 24 h following EVT. The clinical outcomes were measured using the modified Rankin Scale (mRS) at 90-day after onset. Univariate and multivariate regression analyses were used to analyze the relationship between postoperative NLR and MCE. Optimal cutoff values of postoperative NLR to predict MCE were defined using receiver operating characteristic analysis. MCE was observed in 24% of the patients who underwent EVT and was associated with a lower rate of favorable clinical outcomes at 90-day. Multivariate logistic regression analysis demonstrated that baseline Alberta Stroke Program Early CT Score (ASPECT) score (OR = 0.614, 95% CI 0.502-0.750, p = 0.001), serum glucose (OR = 1.181, 95% CI 1.015-1.374, p = 0.031), and postoperative NLR (OR = 1.043, 95% CI 1.002-1.086, p = 0.041) were independently associated with MCE following EVT for AIS with large vessel occlusion. Postoperative NLR had an area under the receiver operating characteristic curve of 0.743 for prediction MCE, and the optimal cutoff value was 6.15, with a sensitivity and specificity of 86.8% and 55%. Elevated postoperative NLR is independently associated with malignant brain edema following EVT for AIS with large vessel occlusion, and may serve as an early predictive indicator for MCE after EVT.