Ischemic Stroke Registry Research Articles

Endovascular treatment in pediatric stroke: an individual patient pooled analysis on presentation, management and outcomes

BackgroundThis study aimed to perform a comprehensive pooled analysis of all published series involving pediatric patients with large vessel occlusion (LVO) undergoing endovascular treatment (EVT) to study the disease landscape...

Endovascular Thrombectomy Versus Intravenous Alteplase For Distal Medium Vessel Occlusions: A Propensity Score‐Matched Analysis

Background The benefits of endovascular thrombectomy (EVT) for distal medium vessel occlusions (DMVOs) are not well established. This study aimed to determine the superiority of EVT over intravenous tissue‐type plasminogen activator (IV tPA) in the treatment of DMVOs. Methods This study analyzed data from the Kanagawa Intravenous and Endovascular Treatment of Acute Ischemic Stroke Registry, a prospective, multicenter, observational registry of acute ischemic stroke patients treated with EVT or IV tPA. The study evaluated patients with acute DMVOs who were treated with EVT and/or IV tPA. DMVOs was defined as occlusions in M2–M3 segment of the middle cerebral artery, anterior cerebral artery, or posterior cerebral artery. The analysis included primary DMVOs and excluded secondary DMVOs, such as distal embolism after recanalization of proximal vessel occlusion. Propensity score‐matched analysis was conducted to compare the outcomes between EVT and IV tPA alone. A good outcome was defined as a modified Rankin Scale score 0–2 or no worsening at 90 days. An excellent outcome was defined as an modified Rankin Scale score 0–1. Results The study included 1148 patients with DMVOs, of whom 816 were treated with EVT and 332 were IV tPA alone. Before propensity score matching, the incidence of good and excellent outcomes was significantly lower in EVT group (good outcomes: EVT 50.3% versus IV tPA 68.0%; P < 0.01; excellent outcomes: 39.8% versus 59.8%; P < 0.001). After propensity score matching, there were no significant differences between EVT and IV tPA groups in good outcomes (EVT 57.8% versus IV tPA 61.3%; P = 0.51), excellent outcomes (46.6% versus 55.0%; P = 0.17), all cerebral hemorrhage (11.6% versus 12.7%; P = 0.74), and symptomatic hemorrhage (2.9% versus 0.6%; P = 0.13). Subarachnoid hemorrhage was more frequent in EVT group (14.5% versus IV tPA 0%). Conclusion The benefits of EVT for acute DMVOs were similar to IV tPA alone. Randomized multicenter trials are warranted to establish the superiority of EVT over IV tPA alone for DMVOs.

Clinical and safety outcomes of acute stenting plus thrombectomy for carotid tandem lesions with large ischemic core

BackgroundWe evaluated the clinical and safety outcomes of emergent carotid artery stenting (eCAS) plus endovascular thrombectomy (EVT) among patients with anterior tandem lesion (TL) and large ischemic core (LIC).MethodsThis retrospective...

Number of passes and outcome of endovascular treatment of anterior circulation large core ischemic stroke: insights from the Endovascular Treatment in Ischemic Stroke (ETIS) registry

BackgroundThe effect of multiple attempts on the outcome of endovascular treatment (EVT) of anterior circulation large ischemic core (LIC) stroke has not been fully explored.MethodsWe analyzed data from the Endovascular...

Sex Differences in Prognosis of Childhood Arterial Ischemic Stroke: Results From Chinese Pediatric Ischemic Stroke Registry Multicenter Registry

BackgroundCurrent studies on the impact of sex in the prognosis of childhood arterial ischemic stroke (AIS) are limited. We aimed to explore the sex differences in outcomes in patients with childhood AIS. MethodsA retrospective analysis was conducted using the prospective data from the Chinese Pediatric Ischemic Stroke Registry. Baseline characteristics between sexes were compared in the total population cohort, propensity score (PS)-matched cohort, and inverse probability of treatment weighting cohort. Multivariate logistic regression and ordinal regression were used to analyze the association of sex with outcomes. Mixed-effects regression model was applied to further analyze the improvement in pediatric modified Rankin Scale (mRS) scores between sexes from 90 days to one year. Survival analysis was used to estimate the recurrence rates during the follow-up period. ResultsA total of 468 patients were finally included. Multivariate logistic regression showed that there were no significant differences between females and males in achieving favorable outcome (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.63 to 1.72), functional independence (OR 0.98, 95% CI 0.59 to 1.63), or shift to worse pediatric mRS scores (OR 0.83, 95% CI 0.59 to 1.17) at 90-day. Mixed-effects regression and survival analysis indicated that females and males exhibited comparable functional recovery from 90 days to one year and had similar recurrent risk during the follow-up period. ConclusionsThis nationally-representative observational study indicated that both male and female pediatric patients with AIS exhibited comparable similar clinical outcomes at 90 days, as well as similar improvements and risks of recurrence during the follow-up period.

Mechanical thrombectomy in basilar artery occlusions: impact of first-line strategy as a function of the occlusion level

BackgroundRetrospective studies suggest the superiority of first-line contact aspiration (CA) thrombectomy over stent-retriever (SR) in basilar artery occlusions (BAO). We aimed to investigate the impact of first-line mechanical thrombectomy per...

Functional Outcomes and Symptomatic Intracranial Hemorrhage After Endovascular Treatment in Acute Vertebrobasilar Artery Occlusions: External Validation of Prediction Models

Background Vertebrobasilar artery occlusion (VBAO) is a severe type of stroke. Multiple prediction models for outcome and symptomatic intracranial hemorrhage (sICH) of patients with acute ischemic stroke treated with endovascular treatment have been developed to improve patient management, but few are based on VBAO. This study aimed to provide an overview of published models to predict functional outcome and sICH as well as to validate their ability in patients with acute VBAO treated with endovascular treatment. Methods We performed a systematic search to identify models either developed or validated to predict functional outcomes or sICH after endovascular treatment. Models were externally validated in the Posterior Circulation Ischemic Stroke Registry (PERSIST) study (n = 2422). Outcome measures included the modified Rankin Scale (mRS) score at 90 days and sICH. Model performance was evaluated with discrimination (c‐statistic) and calibration (slope and intercept). Results A total of 65 models were included in overview. The most frequently used predictors were baseline National Institutes of Health Stroke Scale score (n = 57), age (n = 45), and glucose (n = 32). In the external validation cohort, 777 of 2353 patients (33.0%) achieved mRS score 0–2 at 90 days, 1061 of 2353 patients (45.1%) patients achieved mRS score 0–3 at 90 days, and sICH occurred in 170 of 2422 patients (7.0%). Finally, 27 models were included in external validation. For functional outcome models focusing on mRS score 0–2/3–6, discrimination ranged from 0.63 to 0.66 and best calibrated model was SC (Stroke Checkerboard) (intercept, −0.13 [95% CI, −0.27 to 0.01]; slope, 0.92 [95% CI, 0.67–1.17]). For functional outcome models focusing on mRS score 0–3/4–6, discrimination ranged from 0.64 to 0.74 and best calibrated model was modified Houston Intra‐Arterial Therapy 2 (mHIAT2) (intercept, −0.12 [95% CI, −0.31 to 0.07]; slope, 0.85 [95% CI, 0.65–1.04]). For sICH models, discrimination ranged from 0.53 to 0.83 and best calibrated model was Thrombolysis in Cerebral Infarction score, Alberta Stroke Program Early CT Score, and glucose (TAG) (intercept, 0.13 [95% CI, −0.25 to 0.51]; slope, 0.93 [95% CI, 0.63–1.23]). Conclusions The currently published models are inadequate for predicting functional outcomes and sICH in patients with acute VBAO undergoing endovascular treatment and, therefore, there is a need for more effective models specifically developed for VBAO conditions.

Benefits of First Pass Recanalization in Basilar Strokes Based on Initial Clinical Severity.

Randomized trials demonstrating the benefits of thrombectomy for basilar artery occlusions have enrolled an insufficient number of patients with a National Institutes for Health Stroke Scale (NIHSS) score < 10 and shown discrepant results for patients with an NIHSS > 20. Achieving afirst pass recanalization (FPR) improves clinical outcomes in stroke. We aimed to evaluate the effect of the FPR on outcomes among basilar artery occlusion patients, characterized by prethrombectomy initial NIHSS score. We retrospectively analyzed the Endovascular Treatment in Ischemic Stroke (ETIS) registry of 279 basilar artery occlusion patients treated with thrombectomy from 6 participating centers. We compared the 90-day clinical outcomes of achieving aFPR versus no FPR, categorized by initial clinical severity: mild (NIHSS < 10), moderate (NIHSS 10-20) and severe (NIHSS > 20). We used Poisson regression with robust error variance to determine the effect of the NIHSS score on the association between FPR and outcomes. The FPR patients with NIHSS < 10 or NIHSS 10-20 were more likely to have afavorable clinical outcome (modified Rankin scale, mRS 0-3) than non-FPR patients (relative risk, RR = 1.32, 95% confidence interval, CI: 1.04, 1.66, p-value = 0.0213, and RR = 1.79, 95% CI: 1.26, 2.53, p-value = 0.0011, respectively). Asimilar benefit was not found in patients with severe symptoms. We found asignificantly lower risk of poor clinical outcome (mRS 4-6) in FPR patients with NIHSS 10-20, but not among patients with an NIHSS > 20. Achieving aFPR in basilar artery occlusion patients with mild (NIHSS < 10) or moderate (NIHSS 10-20) symptoms is associated with better clinical outcomes, but not in patients with severe symptoms. These results support the importance of further clinical trials on the benefits of thrombectomy in severe strokes.

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 WP119: Magnetic Resonance Imaging versus Computed Tomography Before Mechanical Thrombectomy for Acute Ischemic Stroke

Introduction: Magnetic resonance imaging (MRI) and computed tomography (CT) is useful for the evaluation of the ischemic core and penumbra. The indication for mechanical thrombectomy (MT) for acute ischemic stroke is determined by either or both imaging modalities. The selection of initial imaging modality is differed by the institute, and it is uncertain which imaging modality is superior before MT. In this study, we compared the clinical outcomes after MT by imaging modality in the K-NET registry (Kanagawa intravenous and endovascular treatment of acute ischemic stroke registry). Methods: The K-NET registry is a Japanese multicenter prospective registry study of patients treated with Intravenous thrombolysis with recombinant tissue plasminogen activator, endovascular treatment, or both for acute ischemic stroke. The present study is based on patients' data in the K-NET registry between January 2018 and June 2021. The inclusion criteria for the current analysis were as follows: (1) pre-modified Rankin score (mRS) 0-2; (2) patients transferred directly to primary stroke centers; (3) treated with MT; and (4) performed only CT or MRI for diagnosis of acute ischemic stroke before MT. The patients who performed both CT and MRI at admission were excluded. Unbalanced cohorts with a nonrandom distribution of patients were accounted for by using propensity score matching. Results: 2348 patients were enrolled in the registry during the period, and 753 patients were eligible for inclusion criteria. 498 (249 matched pairs) were included after propensity score-matched analysis. The baseline characteristics were well-balanced between the two groups. There was no difference in the final mTICI grade between the two groups. The time from image to puncture in the MRI group was significantly shorter than the CT group (52min versus 38min), and the time from image to recanalization was also significantly shorter in the MRI group (108min versus 88.5min). The rate of functional independence (90 days mRS 0-2) was higher in the MRI group versus the CT group (54.4% versus 43.8%, p=0.017). Conclusions: The selection of MRI before MT was associated with a shorter time from image to puncture and recanalization and a favorable outcome compared with CT.

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.

Evaluating outcome associations with race after mechanical thrombectomy: an analysis of the NVQI-QOD acute ischemic stroke registry

BackgroundMechanical thrombectomy has become the standard of care for acute ischemic stroke due to large vessel occlusions. Racial differences in outcomes after mechanical thrombectomy for acute ischemic stroke have not...

Investigation of Mechanical Thrombectomy in Elderly Patients over 85 Years Old: A Multicenter Study.

In Japan, which has a super-aging society, there are increasing opportunities to perform mechanical thrombectomy for the elderly; however, there is no recorded evidence of thrombectomy for the elderly. This study examined the usefulness of thrombectomy in the elderly. We retrospectively analyzed patient data using a multicenter acute ischemic stroke registry (NGT-FAST). We examined outcomes in patients 75 years and older who underwent thrombectomies between January 1, 2021, and December 31, 2021. The patients were divided into two groups: the 75-84-year-old group and the 85+-year-old group. There was no difference in the pretreatment National Institutes of Health Stroke Scale score or Alberta Stroke Program Early Computed Tomography Score between the two groups, but the 85+-year-old group had a significantly lower rate of pre-stroke modified Rankin Scale (mRS) score of 0-2. There were no differences in time from onset to treatment or effective recanalization rate, but complications tended to be more common in the 85+-year-old group. The number of patients with a good outcome at discharge (an mRS score of 0-3) was significantly lower in the 85+-year-old group than in the 75-84-year-old group. In addition, 90.9% of patients in the 85+-year-old group with a pre-stroke mRS score of 3 deteriorated after treatment. The pre-stroke mRS score is very important in determining the indication for thrombectomy in the elderly because their preoperative condition is more likely to influence the outcome than that of younger patients.

Successful Thrombectomy Improves Functional Outcome in Tandem Occlusions with a Large Ischemic Core

Emergent stenting in tandem occlusions and mechanical thrombectomy (MT) of acute ischemic stroke related to large vessel occlusion (LVO-AIS) with a large core are tested independently. We aim to assess the impact of reperfusion with MT in patients with LVO-AIS with a large core and a tandem occlusion and to compare the safety of reperfusion between large core with tandem and nontandem occlusions in current practice. We analyzed data of all consecutive patients included in the prospective Endovascular Treatment in Ischemic Stroke Registry in France between January 2015 and March 2023 who presented with a pretreatment ASPECTS (Alberta Stroke Program Early CT Score) of 0-5 and angiographically proven tandem occlusion. The primary end point was a favorable outcome defined by a modified Rankin Scale (mRS) score of 0-3 at 90 days. Among 262 included patients with a tandem occlusion and ASPECTS 0-5, 203 patients (77.5%) had a successful reperfusion (modified Thrombolysis in Cerebral Infarction grade 2b-3). Reperfused patients had a favorable shift in the overall mRS score distribution (adjusted odds ratio [aOR], 1.57 [1.22-2.03]; P < 0.001), higher rates of mRS score 0-3 (aOR, 7.03 [2.60-19.01]; P < 0.001) and mRS score 0-2 at 90 days (aOR, 3.85 [1.39-10.68]; P= 0.009) compared with nonreperfused. There was a trend between the occurrence of successful reperfusion and a decreased rate of symptomatic intracranial hemorrhage (aOR, 0.5 [0.22-1.13]; P= 0.096). Similar safety outcomes were observed after large core reperfusion in tandem and nontandem occlusions. Successful reperfusion was associated with a higher rate of favorable outcome in large core LVO-AIS with a tandem occlusion, with a safety profile similar to nontandem occlusion.

Efficacy and safety of thrombectomy for acute ischaemic stroke in patients with pre-stroke mRS scores of 2-3: Real-world evaluation from an open-label, prospective, multicentre, observational study.

This study assessed the efficacy and safety of thrombectomy for acute ischaemic stroke in a population with pre-stroke modified Rankin scale (mRS) scores of 2-3 using real-world data. Our sample set included 2313 consecutive patients enrolled in the Kanagawa Registry of Intravenous and Endovascular Treatment of Acute Ischemic Stroke registry between January 2018 and June 2020 in 40 stroke centres in Kanagawa Prefecture, Japan. Patients treated with intravenous tissue plasminogen activator (t-PA), thrombectomy, or both were included. Patients with pre-stroke mRS scores of 4-5 and those treated only with intra-arterial thrombolysis were excluded. The primary outcome of this study was an mRS score of 0-3 at 90 days after onset to assess the efficacy of thrombectomy for pre-stroke disabled individuals. We performed multivariate logistic regression analyses to investigate independent factors for a 90-day mRS score of 0-3. We also performed nearest-neighbour within-calliper matching between thrombectomy and t-PA only. After excluding patients meeting the exclusion criteria, we analysed data of 2136 consecutive patients, of which 315 (14.7%) had pre-stroke disabilities (mRS score 2-3). A 90-day mRS score of 0-3 was achieved by 33.3% of patients with pre-stroke mRS scores of 2-3. According to multivariate analysis, the National Institutes of Health Stroke Scale (NIHSS) score was an independent factor. Furthermore, after propensity-score matching, thrombectomy showed considerable superiority for achieving a 90-day mRS score of 0-3. Intravenous t-PA and especially thrombectomy were safe and effective for the population with pre-stroke disabilities, particularly for patients with low NIHSS scores.

Thrombectomy with or without Intravenous Thrombolytics in Basilar Artery Occlusion.

Two randomized trials demonstrated the benefit of endovascular therapy (EVT) in patients suffering from a stroke due to a basilar artery occlusion (BAO). However, intravenous thrombolytic (IVT) use before EVT was low in these trials, questioning the added value of this treatment in this setting. We sought to investigate the efficacy and safety of EVT alone compared to IVT + EVT in stroke patients with a BAO. We analyzed data from the Endovascular Treatment in Ischemic Stroke registry, a prospective, observational, multicenter study of acute ischemic stroke patients treated with EVT in 21 centers in France between 1 January 2015 and 31 December 2021. We included patients with BAO and/or intracranial vertebral artery occlusion and compared patients treated with EVT alone versus IVT + EVT after propensity score (PS) matching. Variables selected for the PS were pre-stroke mRS, dyslipidemia, diabetes, anticoagulation, admission mode, baseline NIHSS and ASPECTS, type of anesthesia, and time from symptom onset to puncture. Efficacy outcomes were good functional outcome (modified Rankin Scale [mRS] 0-3) and functional independence (mRS 0-2) at 90 days. Safety outcomes were symptomatic intracranial hemorrhages and all-cause mortality at 90 days. Among 385 patients, 243 (134 EVT alone and 109 IVT + EVT) were included after PS matching. There was no difference between EVT alone and IVT + EVT regarding good functional outcome (adjusted odd ratio [aOR] labeling = 1.27, 95% confidence interval [CI], 0.68-2.37, p = 0.45) and functional independence (aOR = 1.50, 95% CI, 0.79-2.85, p = 0.21). Symptomatic intracranial hemorrhage and all-cause mortality were also similar between the two groups (aOR = 0.42, 95% CI, 0.10-1.79, p = 0.24 and aOR = 0.56, 95% CI, 0.29-1.10, p = 0.09, respectively). In this PS matching analysis, EVT alone seemed to lead to similar neurological recovery than IVT + EVT, with comparable safety profile. However, given our sample size and the observational nature of this study, further studies are needed to confirm these findings. ANN NEUROL 2023.

Best medical management versus intravenous thrombolysis for mild non-disabling ischemic stroke: A prospective noninferiority registry study

ObjectivesThe efficacy and safety of intravenous thrombolysis uncertain in patients with non-disabling mild ischemic stroke. Our aim was to investigate whether best medical management only is noninferior to intravenous thrombolysis plus best medical management therapy for achieving favorable functional outcome at 90 days. Materials and methodsIn a prospective acute ischemic stroke registry from 2018 through 2020, 314 non-disabling mild ischemic stroke patients received best medical management only and 638 underwent intravenous thrombolysis plus best medical management. The primary outcome was modified Rankin Scale ≤1 at Day 90. The noninferiority margin was −5%. Secondary outcomes of hemorrhagic transformation, early neurologic deterioration and mortality were also evaluated. ResultsThe best medical management only was noninferior to the combined therapy of intravenous thrombolysis and best medical management with regard to the primary outcome (unadjusted risk difference, 1.16%; 95% CI, −3.48% ∼ 5.8%; p = 0.0046 for noninferiority; adjusted risk difference, 3.01%; 95% CI, −3.39% ∼ 9.41%). After propensity score matching, p < 0.0001 for noninferiority. RD, 4.03%; 95% CI, −1.59% ∼ 9.69%. p < 0.0001 for noninferiority. Adjusted RD, 5.23%; 95% CI, −1.88% ∼ 9.97%. The occurrence of hemorrhagic transformation was significantly increased in the group of combination therapy (OR, 4.26; 95% CI, 1.30 to 13.99; p = 0.008), while no significant difference was detected in early neurologic deterioration (OR, 1.11; 95% CI, 0.49–2.52; p = 0.808) and mortality (OR, 0.57; 95% CI, 0.20 to 1.69; p = 0.214) between groups. ConclusionsIn the present study, we found the best medical management only was noninferior to the combination therapy of intravenous thrombolysis plus best medical management for non-disabling mild ischemic stroke within 4.5 h after onset. Best medical management may be a treatment of choice for non-disabling mild ischemic stroke patients. Further randomized controlled studies are warranted.

Temporal trends in results of endovascular treatment of anterior intracranial large cerebral vessel occlusion: A 7-year study.

Technical improvements in devices, changes in angiographic grading scales and various confounding factors have made difficult the detection of the temporal evolution of angiographic and clinical results after endovascular treatment (EVT) for acute ischemic Stroke (AIS). We analyzed this evolution in time using the Endovascular Treatment in Ischemic Stroke (ETIS) registry. We analyzed the efficacy outcomes of EVT performed from January 2015 to January 2022, and modelized the temporal trends using mixed logistic regression models, further adjusted for age, intravenous thrombolysis prior to EVT, general anesthesia, occlusion site, balloon catheter use and the type of first-line EVT strategy. We assessed heterogeneity in temporal trends according to occlusion site, balloon catheter use, cardio embolic etiology, age (<80 years vs ⩾80 years) and first-line EVT strategy. Among 6104 patients treated from 2015 to 2021, the rates of successful reperfusion (71.1%-89.6%) and of complete first pass effect (FPE) (4.6%-28.9%) increase, whereas the rates of patients with >3 EVT device passes (43.1%-17.5%) and favorable outcome (35.8%-28.9%) decrease significantly over time. A significant heterogeneity in temporal trends in successful reperfusion according to the first-line EVT strategy was found (p-het = 0.018). The temporal trend of increasing successful reperfusion rate was only significant in patients treated with contact aspiration in first-line (adjusted overall effect p = 0.010). In this 7-year-old large registry of ischemic stroke cases treated with EVT, we observed a significant increase with time in the rate of recanalization whereas there was a tendency toward a decrease in the rate of favorable outcome over the same period.

Does MRI add value in selecting patients for thrombectomy beyond the 6 h window? A matched-control analysis.

Controversy exists regarding the need of advanced imaging for patient selection in the extended window. To analyze the effect of initial imaging modalities on clinical outcomes of patients underwent MT in the extended window. This was a retrospective analysis of a prospective registry, the Endovascular Treatment Key Technique and Emergency Workflow Improvement of Acute Ischemic Stroke (ANGEL-ACT) registry which was conducted at 111 hospitals between November 2017 and March 2019 in China. Primary study cohort and Guideline like cohort were identified, in each cohort, two imaging modalities for patient selection in 6 to 24 h window were defined: (1) NCCT ± CTA, (2) MRI. Guideline-like cohort were further screened based on key features of the DAWN and DEFUSE 3 trials. The primary outcome was 90 day mRS. The safety outcomes were sICH, any ICH and 90-day mortality. After adjusting for covariates, there were no significant differences in 90 day mRS or any safety outcomes between two imaging modalities groups in both cohorts. All outcome measures of mixed-effects logistic regression model were consistent with propensity score matching model. Our results indicate that patients presented with anterior large vessel occlusion in the extended time window can potentially benefit from MT even in the absence of MRI selection. This conclusion needs to be verified by the prospective randomized clinical trials.

First‐Pass Effect With Aspiration Thrombectomy With the Penumbra System in Patients With Acute Ischemic Stroke: A Core Laboratory–Adjudicated Subset Analysis of the COMPLETE Registry

Background In patients with acute ischemic stroke, minimizing the time to revascularization can minimize neuronal death. First‐pass effect (FPE), defined as successful or complete revascularization of an occluded target vessel with 1 pass of a mechanical thrombectomy device(s), reduces the time to revascularization. The objective of this study was to determine the FPE rate, compare cases in which FPE was versus was not achieved, and determine predictors of good functional outcome at 90 days, in patients with large‐vessel occlusion acute ischemic stroke treated with the Penumbra System (Penumbra, Inc). Methods This study is a subset analysis of the COMPLETE (International Acute Ischemic Stroke Registry With the Penumbra System Aspiration Including the 3D [3‐Dimensional] Revascularization Device) registry, a global, prospective, multicenter, observational registry. FPE rates were calculated. Subgroups who achieved versus did not achieve FPE were compared. Variables independently associated with good functional outcome at 90 days were determined. Results A total of 648 patients were included. FPE was achieved with a revascularization definition of modified thrombolysis in cerebral infarction score 2b to 3 in 56.8% of patients, with modified thrombolysis in cerebral infarction score 2c to 3 in 41.5%, and with modified thrombolysis in cerebral infarction score 3 in 31.8%. The percentage of patients who achieved good functional outcome at 90 days was higher for patients who achieved FPE than for patients who did not ( P &lt;0.01). Achieving FPE with modified thrombolysis in cerebral infarction score 2b to 3 was an independent predictor for good functional outcome at 90 days (adjusted odds ratio, 1.64; P =0.045). Conclusions For aspiration thrombectomy with the Penumbra System, achieving FPE was associated with a significantly higher rate of good functional outcome.