Large Artery Occlusion Research Articles

Transport strategy for ischaemic stroke patients with large vessel occlusion.

There are today two models of transporting patients with acute ischaemic stroke because of large artery occlusion (AIS-LVO): mothership (MS) and drip-and-ship (DS). Our aim was to evaluate our ongoing transport strategy (OT), which is an MS/DS hybrid. In our OT, the patient is transported directly to the CT of the Primary Stroke Centre (PSC), where intravenous thrombolysis (IVT) is administered. The patient then continues without delay to a Comprehensive Stroke Centre (CSC) with the same medical rescue team (MRT). The distance between our centres is 73 km. We retrospectively analysed data of 100 consecutive AIS-LVO patients treated with mechanical thrombectomy (MT) between January 2017 and October 2019. OT, MS and DS groups were compared. 31 patients were transported as MS, 32 as DS, and 37 as OT. DS had significantly longer time to groin puncture (185 min) compared to OT and MS (p < 0.0001). OT shortened time almost to MS level (OT 124 min, MS 110 min, p = 0.002. Time to IVT administration (from MRT departure) differed statistically significantly in favour of OT (OT 27 min, MS 63 min, p < 0.0001). Logistical change in PSC had a significant effect on decreasing the door-to-needle time (DNT) median from 37 min to 11 min (p < 0.0001). DNT reduction also occurred in patients with AIS and without an indication for MT. OT is highly effective, significantly reducing the time to IVT administration, and combining all the benefits, while eliminating all the disadvantages, of DS and MS. The OT concept gives all indicated patients a chance for MT to be performed, and does not overload the performing centre.

Quality analysis of YouTube videos on mechanical thrombectomy for acute ischemic stroke

ObjectivesAcute ischemic stroke is a leading cause of mortality and long-term disability. Mechanical thrombectomy can effectively treat large artery occlusions. This study aimed to evaluate the quality, reliability, and usefulness of videos on mechanical thrombectomy on YT using quantitative and qualitative analyses. Materials and methodsVideo searches were performed by entering the following keywords into the YT search bar: “endovascular thrombectomy,” “endovascular treatment of acute stroke,” “mechanical thrombectomy,” “stroke stent retriever,” and “stent retriever thrombectomy.” For each search term, the top 35 videos were reviewed. The videos were analyzed by two independent raters using the DISCERN and JAMA scoring systems. Qualitative and quantitative data were recorded for each video. ResultsA total of 150 videos were analyzed. The mean DISCERN score was 41.26, and the mean JAMA score was 1.42. Of the videos, 5.3% were categorized as very poor, 33.3% as poor, 44% as fair, 12% as good, and 5.3% as excellent. The videos that included qualitative features, such as clear information, symptomatology, diagnosis, treatment response, prognosis, etiology, epidemiology, diagram, and radiological image, had significantly higher DISCERN and JAMA scores than their counterparts. ConclusionA reliable and useful content is not available for individuals searching for information on mechanical thrombectomy on YT. In this paper, we highlighted key points for content creators to increase the quality and audience engagement statistics of their videos. Information provided in YT videos should be verified using more reliable sources.

Reperfusion Injury Is Associated With Poor Outcome in Patients With Recanalization After Thrombectomy.

The existence of cerebral reperfusion injury in human beings remains controversial. Thus, we aimed to explore the presence of reperfusion injury in acute ischemic stroke patients with recanalization after mechanical thrombectomy and analyzed its impact on neurological outcome. We reviewed our prospectively collected database CIPPIS (Comparison Influence to Prognosis of CTP and MRP in AIS Patients, NCT03367286), and enrolled anterior circulation large artery occlusion patients with recanalization after mechanical thrombectomy who underwent (1) computed tomography (CT) perfusion on admission and immediately after recanalization to determine reperfusion region, and (2) CT and/or magnetic resonance imaging (MRI) immediately and 24 hours after recanalization to determine lesion areas. The expansion of lesion between recanalization and 24 hours within reperfusion region was potentially caused by reperfusion, thus termed as radiological observed reperfusion injury (RORI). Based on the imaging modality immediately after recanalization, RORI was further divided into RORICT and RORIMRI. We first included a small cohort who had performed both CT and MRI immediately after recanalization to validate the consistency between RORICT and RORIMRI (Study 1). Then the association with RORICT and poor outcome, defined as 3-month modified Rankin Scale score of 3 to 6, was explored in a larger cohort (Study 2). Study 1 included 23 patients and good consistency was found between RORICT and RORIMRI (intraclass correlation=0.97, P<0.001). Among 226 patients included in Study 2, a total of 106 (46.9%) were identified with RORI. The ratio of RORI to reperfusion region was 30.1 (16.2, 51.0)% and was independently associated with poor outcome (odds ratio=1.55 per 10% [95% CI' 1.30-1.84]; P<0.001). Our findings suggested that RORI was relatively frequent in stroke patients with recanalization after mechanical thrombectomy and associated with poor outcome despite successful recanalization. URL: https://www. gov; Unique identifier: NCT03367286.

Early and Delayed Infarct Growth in Patients Undergoing Mechanical Thrombectomy: A Prospective, Serial MRI Study.

We studied the evolution over time of diffusion weighted imaging (DWI) lesion volume and the factors involved on early and late infarct growth (EIG and LIG) in stroke patients undergoing endovascular treatment (EVT) according to the final revascularization grade. This is a prospective cohort of patients with anterior large artery occlusion undergoing EVT arriving at 1 comprehensive stroke center. Magnetic resonance imaging was performed on arrival (pre-EVT), <2 hours after EVT (post-EVT), and on day 5. DWI lesions and perfusion maps were evaluated. Arterial revascularization was assessed according to the modified Thrombolysis in Cerebral Infarction (mTICI) grades. We recorded National Institutes of Health Stroke Scale at arrival and at day 7. EIG was defined as (DWI volume post-EVT-DWI volume pre-EVT), and LIG was defined as (DWI volume at 5d-DWI volume post-EVT). Factors involved in EIG and LIG were tested via multivariable lineal models. We included 98 patients (mean age 70, median National Institutes of Health Stroke Scale score 17, final mTICI≥2b 86%). Median EIG and LIG were 48 and 63.3 mL in patients with final mTICI<2b, and 3.6 and 3.9 cc in patients with final mTICI≥2b. Both EIG and LIG were associated with higher National Institutes of Health Stroke Scale at day 7 (ρ=0.667; P<0.01 and ρ=0.614; P<0.01, respectively). In patients with final mTICI≥2b, each 10% increase in the volume of DWI pre-EVT and each extra pass leaded to growths of 9% (95% CI, 7%-10%) and 14% (95% CI, 2%-28%) in the DWI volume post-EVT, respectively. Furthermore, each 10% increase in the volume of DWI post-EVT, each extra pass, and each 10 mL increase in TMax6s post-EVT were associated with growths of 8% (95% CI, 6%-9%), 9% (95% CI, 0%-19%), and 12% (95% CI, 5%-20%) in the volume of DWI post-EVT, respectively. Infarct grows during and after EVT, especially in nonrecanalizers but also to a lesser extent in recanalizers. In recanalizers, number of passes and DWI volume influence EIG, while number of passes, DWI, and hypoperfused volume after the procedure determine LIG.

Analysis of failed mechanical thrombectomy with a focus on technical reasons: Ten years of experience in a single institution.

Mechanical thrombectomy (MT) is an effective treatment for patients suffering from acute ischemic stroke secondary to large vessel occlusion. However, recanalization failure rates of interventions were about 20% in literature studies. We report our experience of unsuccessful MT with a focus on technical reasons. From December 2010 to June 2021, six hundred eight patients with acute ischemic stroke due to large artery occlusion received MT using a stent retriever with or without an aspiration catheter in our institution. We divided the reasons for failure into six categories. We analyzed the reasons for failure by dividing our experience time into 3 periods. A total of 608 cases of thrombectomy for large vessel occlusion were identified in the study period. The successful recanalization rate was 90.4%. In most of the cases (20/57, 35%), the thrombus persisted despite several passes, and the second most common cause was termination of the procedure even after partial recanalization (10/57, 18%). Similar proportions of in-stent occlusion, distal embolization, and termination due to vessel rupture were observed. On analysis of three periods, the successful recanalization rate improved over time. MT fails due to various reasons, and intracranial artery stenosis is the main cause of MT failure. With the development of rescue techniques, the failure rate has gradually decreased. Further development of new devices and techniques could improve the recanalization rates.

Cerebral Small Vessel Disease Burden and Futile Reperfusion after Endovascular Treatment for Patients with Acute Ischemic Stroke

Introduction: Cerebral small vessel disease (SVD) burden includes increased risk of poor functional outcomes after acute ischemic stroke (AIS). We aimed to investigate the impact of cerebral SVD on 3-month functional outcomes in patients with AIS who received endovascular treatment (EVT) and to determine whether SVD is associated with futile reperfusion (FR). Methods: Using a multicenter stroke registry, we analyzed consecutive patients with AIS with either intracranial and/or extracranial anterior circulation large artery occlusion, who were treated with EVT and achieved successful reperfusion (thrombolysis in cerebral infarction grade 2b–3). The cerebral SVD burden was evaluated using baseline brain magnetic resonance imaging using a modified Fazekas score (mFS). The main outcome variable was FR, defined as poor functional outcomes (modified Rankin scale 3–6) at 3 months after stroke, despite successful recanalization. Secondary outcomes included stroke progression/recurrence and any hemorrhagic transformation. Results: Among 10,890 patients with AIS, 577 (5.3%) received EVT within 12 h of onset, including 354 who met study eligibility criteria. FR was observed in 191 patients (53.5%) and was positively associated with SVD burden. After adjustment for covariates including age, sex, stroke etiology, initial stroke severity, collateral status, Alberta stroke program early CT score, initial serum glucose, systemic blood pressure, and vascular risk factors, mFS grade 3 was significantly associated with FR (odds ratio: 3.93, 95% confidence interval: 1.602–9.619; p = 0.003). Conclusions: We demonstrated that cerebral SVD assessed with baseline brain MRI is associated with the futility of successful recanalization after EVT and any hemorrhagic transformation but not with early stroke progression or recurrence. Nevertheless, our findings do not justify withholding EVT in otherwise eligible patients with AIS based on the presence of severe SVD.

Endovascular treatments for ischemic stroke

Highlights. Mechanical thrombectomy is the “gold standard” treatment of patients with large-vessel occlusions. Five randomized trials conducted in 2015 made a significant contribution to the development and introduction of mechanical thrombectomy into clinical practice. The DAWN and DEFUSE-3 trials have provided new insights into the pathophysiology of ischemic stroke and ensured the advancement in the therapeutic field.Abstract. Stroke is one of the leading causes of death and disability worldwide. The general strategy for the treatment of ischemic stroke is aimed at restoring blood flow to the ischemic regions of the brain. Intravenous thrombolysis has been the treatment for acute ischemic stroke since 1996. However, since 2015, as a result of 5 randomized trials, endovascular mechanical thrombectomy has become the gold standard for the treatment of patients with large cerebral artery occlusion. The DAWN and DEFUSE 3 trials have provided new insights into the pathophysiology of ischemic stroke, shifting the paradigm from “time = brain” to “collaterals = brain”. In this article, the authors will consider development of endovascular devices, modern mechanical thrombectomy techniques, and directions for further research of endovascular treatment for ischemic stroke.

Delayed filling of the superficial middle cerebral vein in acute large artery occlusion.

ObjectiveThis study aimed to determine whether baseline delayed filling of the superficial middle cerebral vein (SMCV) was an independent cause of stroke prognosis in patients with acute anterior large vessel occlusion (LVO).MethodsConsecutive patients with acute LVO [middle cerebral artery M1 ± intracranial internal carotid artery (ICA)] between March 2019 and May 2020 were included. Delayed SMCV was defined as delayed filling of SMCV in the affected side compared with the normal side throughout the venous phase on four-dimensional computed tomographic angiography (4D-CTA) reconstructed from CT perfusion imaging. The modified Rankin scale (mRS) was used to evaluate the prognosis of these patients 3 months after stroke.ResultsOf 54 patients in total, 47 (87.0%) patients presented with baseline delayed SMCV, and 36 (76.6%) patients achieved SMCV reversal (ipsilateral delayed SMCV reversed to bilateral symmetrical SMCV) after reperfusion therapy. Successful reperfusion was independently associated with SMCV reversal [odds ratio (OR) = 69.328, 95% confidence interval (CI) = 2.818–175.342]. A significant association between baseline SMCV delay and a 3-month poor outcome (OR = 19.623, 95% CI = 1.567–245.727, p = 0.021) was observed using a multivariable regression analysis. Compared with patients with persistent delayed SMCV, patients with reversed SMCV did not show a significant difference in the risk of a 3-month poor outcome (OR = 1.177, 95% CI = 0.147–9.448).ConclusionsIn patients with acute LVO, baseline delayed SMCV was an independent cause of poor stroke prognosis, and SMCV reversal cannot reverse the 3-month stroke prognosis. Therefore, the evaluation of baseline SMCV filling status should be strengthened in clinical practice.

Advances in cerebral perfusion imaging techniques in acute ischemic stroke.

The application of cerebral perfusion imaging has demonstrated significant assessment benefits and an ability to establish an appropriate triage of patients with acute ischemic stroke (AIS) and large artery occlusion (LAO) in the extended time window. Computed tomography perfusion (CTP) and magnetic resonance imaging (MRI) are routinely used to determine the ischemic core, as well as the tissue at risk, to aid in therapeutic decision-making. However, the time required to transport patients to imaging extends the door-to-reperfusion time. C-arm cone-beam CT (CBCT) is a novel tomography technology that combines 2D radiography and 3D CT imaging based on the digital subtraction angiography platform. In comparison with CT or MRI perfusion techniques, CBCT combined with catheterized angiogram or therapy can serve as a "one-stop-shop" for the diagnosis and treatment of AIS, and greatly reduce the door to reperfusion time. Here, we review the current evidence on the efficacy and theoretical basis of CBCT, as well as other perfusion techniques, with the purpose to assist clinicians to establish an effective and repaid workflow for patients with AIS and LAO in clinical practice.

Application of modified PASS score in acute cerebral infarction due to large artery occlusion

Application of modified PASS score in acute cerebral infarction due to large artery occlusion

Investigating sphingolipids as biomarkers for the outcomes of acute ischemic stroke patients receiving endovascular treatment

Long-chain ceramides are associated with the mechanisms and clinical outcomes of acute ischemic stroke (AIS). This study aimed to investigate the plasma ceramides and sphingosine-1-phosphate in AIS patients undergoing endovascular thrombectomy (EVT) and their associations with outcomes. Plasma samples were collected from 75 AIS patients who underwent EVT before (T1), immediately after (T2), and 24h after (T3) the procedures and 19 controls that were matched with age, sex, and co-morbidities. The levels of ceramides with different fatty acyl chain lengths and sphingosine-1-phosphate were measured by UHPLC-ESI-MS/MS. A poor outcome was defined as a modified Rankin Scale score of 3-6at 3 months after stroke. The plasma levels of long-chain ceramides Cer (d18:1/16:0) at all three time points, Cer (d18:1/18:0) at T1 and T3, and Cer (d18:1/20:0) at T1 and very-long-chain ceramide Cer (d18:1/24:1) at T1 were significantly higher in AIS patients than those in the controls. In contrast, the plasma levels of sphingosine-1-phosphate in AIS patients were significantly lower than those in the controls at all three time points. Among the AIS patients, 34 (45.3%) had poor functional outcomes at 3 months poststroke. Multivariable analysis showed that higher levels of Cer (d18:1/16:0) and Cer (d18:1/18:0) at all three time points, Cer (d18:1/20:0) at T1 and T2, and Cer (d18:1/24:0) at T2 remained significantly associated with poor functional outcomes after adjustment for potential confounding factors. Plasma ceramides were elevated early in AIS patients with acute large artery occlusion. Furthermore, Cer (d18:1/16:0) and Cer (d18:1/18:0) could be early prognostic indicators for AIS patients undergoing EVT.

Levels of adhesion molecules and clinical outcomes in patients with ischemic stroke after mechanical thrombectomy.

Background and purposeData on adhesion molecule levels in patients treated with mechanical thrombectomy (MT) are scarce. We aimed to evaluate the association among adhesion molecule levels, symptomatic intracranial hemorrhage (sICH), and clinical outcome and to determine whether the sICH influences the association of adhesion molecules with functional outcome.MethodsPatients with large artery occlusion in the anterior circulation and treated with MT were prospectively recruited. Adhesion molecules, such as soluble intercellular adhesion molecule-1, soluble vascular cell adhesion molecule-1 (sVCAM-1), and soluble E-selectin (sE-selectin) were tested. An unfavorable outcome was defined as a 90-day modified Rankin Scale (mRS) score of 3–6. The sICH was diagnosed according to the Heidelberg Bleeding Classification within 72 h of endovascular treatment (EVT).ResultsOf the 310 enrolled patients (mean age, 68.5 years; 198 men), 46 (14.8%) experienced sICH and 173 (55.8%) experienced an unfavorable outcome at 90 days. After adjusting for potential confounders, patients with higher sVCAM-1 and sE-selectin levels had an increasing trend of sICH [4th quartile vs. 1st quartile for sVCAM-1; odds ratio (OR), 2.766, p = 0.085; sE-selectin; OR, 2.422, p = 0.086] and poor outcome (4th quartile vs. 1st quartile for sVCAM-1; OR, 2.614, p = 0.025; sE-selectin; OR, 2.325, p = 0.046). Furthermore, the sICH might partially mediate the worse functional outcome in patients with higher adhesion molecules levels (Sobel test, p < 0.001 for sVCAM-1 and p = 0.007 for sE-selectin).ConclusionsThere were significant relationships between levels of adhesion molecules and a 90-day poor outcome in patients with ischemic stroke treated with MT, which was partially mediated by sICH.

Systemic immune inflammatory index is an independent predictor for the requirement of decompressive craniectomy in large artery occlusion acute ischemic stroke patients after mechanical thrombectomy.

Background and purposeFollowing mechanical thrombectomy (MT), patients with large artery occlusive acute ischemic stroke (LAO-AIS) often have cerebral herniation due to its complications, resulting in poor prognosis. Decompressive craniectomy (DC) can markedly improve patient prognosis. This study aimed to verify the predictive value of clinical parameters such as the systemic immune-inflammatory index (SII) for DC in patients with LAO-AIS after MT.MethodsClinical data of a total of 173 patients with LAO-AIS treated with MT between January 2020 and January 2022 were retrospectively analyzed. Patients receiving DC were grouped into an experimental group or a control group (no DC). The patients were randomly divided into the training set (n = 126, 75%) and validation set (n = 43, 25%). Multivariate logistic regression was used to construct a nomogram predictive model.ResultsThe SII value in the experimental group (median: 2851.1×109/L) was significantly higher than that in the control group (median: 1898.6 × 109/L) (P = 0.019). Receiver operating characteristic (ROC) analyses showed that the best cutoff value of the SII was 2505.7 × 109/L with a sensitivity of 55%, a specificity of 75.8%, and an area under the curve (AUC) of 0.649. Multivariate logistic regression indicated that the SII was an independent predictor for performing DC in patients with LAO-AIS after MT (OR = 3.579, 95% CI = 1.360–9.422, P = 0.01). The AUC was 0.728 in the training set and 0.583 in the validation set. The average error of the calibration curve was 0.032 in the training set and 0.023 in the validation set. The average error was relatively small and consistent in the training set and validation set. The C-index of the nomogram was 0.804 suggesting good accuracy.ConclusionsThe SII at admission is an independent predictor for the requirement of DC in patients with LAO-AIS after MT. The SII-based nomogram helps doctors make decisions on whether DC is needed timely and rationally, and thereby may improve the prognosis of these patients.

Initial clinical experience with a novel mechanical thrombectomy device-the ThrombX retriever.

The ThrombX Retriever is a novel mechanical thrombectomy device that adjusts the distance between two mesh segments to axially hold thrombus. A post-market study assessed safety and performance in acute ischemic stroke patients with large artery occlusion. A single-arm prospective multi-center study enrolled patients at 5 European Centers. Patients had a symptomatic large-artery occlusion of the intracranial Internal Carotid or the Middle Cerebral Artery, M1 segment. The primary outcome measure was the modified treatment in cerebral infarction (mTICI) score, on the immediate post-procedure angiogram after up to three device passes. Key secondary outcome measures were the mTICI score after a single pass and functional independence, defined as an mRS score ≤ 2 at 90 days. Thirty patients (16 Females, mean age 72 years), with NIHSS 4-25 (mean 15.5) were treated. Twenty-eight (93%) achieved mTICI 2b-3 within 3 passes, and 24 (80%) were with the first pass (FP). FP mTICI 2c-3 reperfusion was achieved in 19 (63%) cases. Seventeen of 24 (71%) patients treated with a balloon guide and the ThrombX Retriever had a FP mTICI 2c-3 reperfusion. After all interventions, mTICI 2b-3 was seen in 30 (100%) patients. Twenty-one of the 29 (73%) patients with 90-day follow-up were functionally independent (mRS≤2). No device-related serious adverse events were observed. This preliminary study suggests the ThrombX Retriever is safe and has a high rate of substantial reperfusion. A larger prospective trial to assess the device effectiveness is planned.

Forced suction thrombectomy in patients with acute ischemic stroke using the SOFIA Plus device.

Objective Stent retrieval thrombectomy has recently been the standard treatment for acute ischemic stroke with large artery occlusion. However, the development of catheters for suction thrombectomy has recently led to results comparable to that of stent retrieval thrombectomy (SRT). This study aimed to analyze the safety and efficacy of forced suction thrombectomy (FST) using the SOFIA Plus (MicroVention Terumo, Tustin, CA, USA) device.Methods We included patients with acute ischemic stroke who underwent FST using the SOFIA Plus device at our institution. Medical records and angiographic data were reviewed, and the results of this study were compared with those of other FST studies.Results A total of 35 patients were included in this study. The occlusion sites were the internal carotid artery terminal (4), M1 segment (20), and posterior circulation (11). Of the 35 patients, FST was performed in only 21 (60%) patients, and the remaining 14 (40%) patients underwent SRT and FST. In all cases, the recanalization rate was 100%, and the average time from groin puncture to recanalization was 21±4.94 min. In particular, the average time required to reach the SOFIA Plus lesions from the groin puncture was 10.44±5.06 min and about 67% of the FST patients were recanalized at the first attempt. Three-months modified Rankin Scale (mRS) score of ≤2 was observed in 52% of the patients.Conclusions Forced suction thrombectomy using the SOFIA Plus yielded a high recanalization rate within a shorter time. In particular, the recanalization rate was higher than that reported in previous studies using other types of suction devices.

The Charlotte large artery occlusion endovascular therapy outcome score predicts outcome after basilar artery thrombectomy.

The Charlotte Large artery occlusion Endovascular therapy Outcome Score (CLEOS) and Totaled Health Risks in Vascular Events (THRIVE) predict functional outcomes after anterior circulation endovascular thrombectomy (EVT). We evaluated the performance of CLEOS and THRIVE in patients presenting with an acute basilar artery occlusion (BAO) treated with EVT. We conducted a retrospective analysis of a health system's stroke registry. Patients presenting with an acute BAO treated with EVT and evaluated with pre-thrombectomy CT perfusion (CTP) from January 2017 to December 2021 were included. CLEOS=(5×age)+(10×National Institutes of Health Stroke Scale [NIHSS])+Glucose-(150×CTP cerebral blood volume index) and THRIVE (0-9 points)=age 60-79years, 1 point; age≥80years, 2 points; NIHSS 11-20, 2 points; NIHSS≥21, 4 points; hypertension, diabetes mellitus, atrial fibrillation, 1 point each. Multivariable logistic regression was performed for the ability of CLEOS and THRIVE to predict the primary outcome, modified Rankin Scale score 3-6. Fifty-seven patients had mean age 66.6 (±14.9) years and median NIHSS 15.5 (5-24). In the multivariable regression analysis, increased CLEOS was associated with significantly higher odds of a poor functional outcome (odds ratio [OR]=1.0011, 95% confidence interval [CI]: 1.0003-1.0019, p=.008), whereas THRIVE was not (OR=1.0326, 95% CI: 0.9478-1.1250, p=.466). CLEOS&gt;503 best predicted poor outcomes. A higher CLEOS score was associated with elevated odds of a poor 90-day functional outcome in our cohort of acute BAO patients treated with EVT.

Type of anaesthesia for acute ischaemic stroke endovascular treatment.

Type of anaesthesia for acute ischaemic stroke endovascular treatment.

The association between stress hyperglycemia ratio and outcome of patients with acute ischemic stroke undergoing endovascular treatment

Objectives: To investigate the correlation between stress hyperglycemia ratio (SHR) and outcomes in patients with acute ischemic stroke treated with endovascular treatment. Methods: In a multicenter registration study for RESCUE-RE (a registration study for critical care of acute ischemic stroke after recanalization), eligible patients with large vessel occlusion stroke within 24 hours after onset who received endovascular treatment between July 2018 and May 2019 were enrolled. SHR was calculated as the fasting glucose concentration divided by the estimated average glucose concentration and then categorized into four groups according to the quartiles (group Q1, group Q2, group Q3 and group Q4). The primary outcome was poor neurological outcomeat day 90 fromstroke onset [defined as modified Rankin scale (mRS) of 3-6]. Secondary outcomes included early neurological deterioration (END), death within 3 months after stroke onset, and symptomatic intracranial hemorrhage.Multivariable logistic and Cox regression modelswere used to assess the correlation between quartiles of SHR and prognosis in patients with endovascular treatment. Results: A total of 592 patients were enrolled in the study, with a mean age of (63±12) years, and 68.07% were male.The median National Institute of Health stroke scale(NIHSS) score on admission was15(11, 20), and the median SHR was 1.23 (1.07, 1.47), with SHR<1.07 in group Q1, 1.07≤SHR<1.23 in group Q2, 1.23≤SHR<1.47 in group Q3 and SHR≥1.47 in group Q4, respectively. The rate of complete recanalization was lower in group Q4 than that of group Q1 (70.27% vs 83.67%, P=0.026). After fully adjusted for potential covariates, the risk of poor neurological outcome at day 90 from stroke onset in group Q4 was 2.38 folds that of group Q1(adjusted OR= 2.38, 95%CI: 1.57-3.57,P=0.003). The risk of death within 3 months of patients in group Q4 was 1.80 times that of the patients in group Q1, but the difference was not statistically significant(adjusted HR=1.80, 95%CI: 0.90-3.62, P=0.098). Conclusion: Higher SHR was correlated with poor neurological outcome at 3 months in large artery occlusion related acute ischemic stroke patients receiving endovascular therapy.

High serum total cholesterol associated with good outcome in endovascular thrombectomy for acute large artery occlusion.

The effect of cholesterol on the functional outcome after endovascular thrombectomy (EVT) is still controversial. This study aimed to investigate whether the lipid profile is associated with the EVT prognosis. We retrospectively analyzed patients with emergent large vessel occlusion who underwent EVT. The blood lipid levels were measured in the fasting state, 1day after admission. We divided patients into terciles of serum total cholesterol (TC) levels and compared the clinical characteristics among the groups. The factors associated with a good outcome at 3months (modified Rankin scale 0-2) were investigated, considering the stroke mechanism and recanalization status. Among 274 patients, good outcomes were observed in 108 (39.4%) patients. Low initial severity (odds ratio (OR), 0.91, 95% confidence interval (CI), 0.858-0.954; p < 0.001) and high TC level (1.35, 1.034-1.758; p = 0.041) were associated with good outcomes. In patients with cardioembolism, young age (0.95, 0.915-0.991; p = 0.021), low initial severity (0.92, 0.857-0.988; p = 0.024), and high TC level (1.60, 1.019-2.499; p = 0.036) were associated with good outcomes. The lipid profile was not associated with a functional outcome in those with large artery atherosclerosis. In patients with complete recanalization, young age (0.97, 0.941-0.994; p = 0.016), low initial severity (0.91, 0.864-0.961; p = 0.001), absence of diabetes (0.45, 0.218-0.947; p = 0.035) or any hemorrhage (0.33, 0.142-0.760; p = 0.009), and high TC level (1.40, 1.031-1.879; p = 0.031) were associated with good outcomes. A high TC level was associated with favorable outcomes after EVT, especially in patients with cardioembolism and complete recanalization.

Reperfusion therapy in acute ischemic stroke

Background: Until mid-2010, intravenous thrombolysis remains the only reperfusion therapy for acute ischemic stroke. In 2015, the five pivotal endovascular recanalization therapy (ERT) trials demonstrated that ERT improved the prognosis of acute ischemic stroke with large artery occlusion within 6 hours after onset. Currently, ERT has been established as a crucial acute ischemic stroke treatment option. The prognosis of acute ischemic stroke is known to be time-dependent. Several studies addressed that ERT expands the time window for reperfusion therapy; thereby, improving prognosis.Current Concepts: Recent randomized clinical trials revealed that ERT improved the outcome in patients even within the late time window of up to 24 hours of stroke onset. The trials enrolled participants who had target mismatch, defined as either clinical-core or perfusion-core mismatch, which prompted an update of the national guidelines in several countries. To select the patients with stroke who were eligible for ERT, advanced imaging tools could be recommended.Discussion and Conclusion: According to the updated ERT guidelines, stroke centers were recommended to establish an appropriate imaging protocol and strategy for patients with acute ischemic stroke who were within the late time window. Additionally, if ERT is further practiced nationally, more manpower and infrastructure for patients with stroke should be supported at the stroke center.