Large Vessel Acute Ischemic Stroke Research Articles

Abstract WP153: Factors Affecting Length of ICU Stay After Endovascular Thrombectomy for Acute Large Vessel Ischemic Stroke

Introduction: The advent of endovascular thrombectomy (EVT) for acute large vessel occlusion (LVO) ischemic stroke has reduced the overall ICU length of stay (LoS), especially for patients undergoing successful reperfusion. Prolonged ICU LoS is reported to be associated with worse clinical outcomes, but factors associated with prolonged LoS after MT are not established. Methods: A retrospective analysis of 499 patients undergoing EVT at a single large comprehensive stroke center from January 2015 to May 2020 was performed. Demographics, procedure variables, ICU LoS, ICU complications, and modified Rankin scale at discharge were collected. Multiple regression was used to identify independent variables affecting the ICU LoS. Additional analysis using t-test assuming unequal variances was performed for select variables. Results: The median age was 72 [61-82], 254 (51%) male & median NIHSS was 16 [10-20]. The average door-to-puncture time was 104 ±28 mins and the average procedure time 43.9 ±28.7. General anesthesia (GA) was administered in 257 (51%) patients. Successful reperfusion (TICI 2c-3) was achieved in 334 (67%) patients. Median ICU LoS was 3 days [1-5]. Patients with mRS 0-2 at discharge (33%) had shorter ICU LoS (2.8 vs 5.7, P<0.001). ASPECTS < 7 (6.9 vs 4.6, P=0.03), use of GA (6.2 vs 3.3 days, P<0.001) and ICU complications such as pulmonary embolism (PE) and pneumonia (10 vs 4 days; p <0.001) significantly increased the ICU LoS. Successful reperfusion significantly reduced ICU LoS (4.2 vs 5.8 days, p=0.015). After adjusting for age, sex, baseline NIHSS and ASPECTS, both the procedure time (b= 0.03, P=0.02) and final TICI score (b= -0.76, P=0.001) were independently associated with prolonged ICU LoS (R2=0.1, F=4, P<0.001). Conclusion: Pre-procedural factors such as poor ASPECTS (< 7), procedural factors such as the use of GA, prolonged procedure time, and TICI 0-2b reperfusion, and ICU complications such as pneumonia and PE are associated with prolonged ICU LoS.

Endogenous defense mechanism-based neuroprotection in large-vessel acute ischemic stroke: A hope for future.

Stroke is a leading cause of morbidity and mortality worldwide and a leading cause of disability. None of the neuroprotective agents have been approved internationally except edaravone in Japanese guidelines in acute ischemic stroke. We here discuss that there are two types of endogenous defense mechanisms (EDMs) after acute stroke for neuromodulation and neuroregeneration, and if both can be activated simultaneously, then we can have better recovery in stroke. We aimed to study the effect of combination of neuroprotection therapies acting on the two wings of EDM in acute large-vessel middle cerebral artery (LMCA) ischemic stroke. Sixty patients of LMCA stroke were enrolled and randomized within 72 h into two groups of 30 patients each. The control group received standard medical care without any neuroprotective agents while the intervention group received standard medical care combined with oral citicoline with vinpocetine for 3 months with initial 1 week intravenous and edaravone and cerebrolysin injection, started within 72 h of onset of stroke. Patients were assessed on the basis of the National Institutes of Health Stroke Scale, Fugl-Meyer Assessment Score, Glasgow Coma Scale, and Mini-Mental Status Examination at admission, discharge, and after 90 days. The intervention group showed significant and early improvements in motor as well as cognitive recovery. Combination therapy for neuroprotection which is acting on two pathways of EDM can be useful in functional recovery after acute ischemic stroke.

AutoML accurately predicts endovascular mechanical thrombectomy in acute large vessel ischemic stroke.

Automated machine learning or autoML has been widely deployed in various industries. However, their adoption in healthcare, especially in clinical settings is constrained due to a lack of clear understanding and explainability. The aim of this study is to utilize autoML for the prediction of functional outcomes in patients who underwent mechanical thrombectomy and compare it with traditional ML models with a focus on the explainability of the trained models. A total of 156 patients of acute ischemic stroke with Large Vessel Occlusion (LVO) who underwent mechanical thrombectomy within 24 h of stroke onset were included in the study. A total of 34 treatment variables including clinical, demographic, imaging, and procedure-related data were extracted. Various conventional machine learning models such as decision tree classifier, logistic regression, random forest, kNN, and SVM as well as various autoML models such as AutoGluon, MLJAR, Auto-Sklearn, TPOT, and H2O were used to predict the modified Rankin score (mRS) at the time of patient discharge and 3 months follow-up. The sensitivity, specificity, accuracy, and AUC for traditional ML and autoML models were compared. The autoML models outperformed the traditional ML models. For the prediction of mRS at discharge, the highest testing accuracy obtained by traditional ML models for the decision tree classifier was 74.11%, whereas for autoML which was obtained through AutoGluon, it showed an accuracy of 88.23%. Similarly, for mRS at 3 months, the highest testing accuracy of traditional ML was that of the SVM classifier at 76.5%, whereas that of autoML was 85.18% obtained through MLJAR. The 24-h ASPECTS score was the most important predictor for mRS at discharge whereas for prediction of mRS at 3 months, the most important factor was mRS at discharge. Automated machine learning models based on multiple treatment variables can predict the functional outcome in patients more accurately than traditional ML models. The ease of clinical coding and deployment can assist clinicians in the critical decision-making process. We have developed a demo application which can be accessed at https://mrs-score-calculator.onrender.com/.

Toward Faster Revascularization in Large Vessel Acute Ischemic Stroke: Reducing Door-to-Groin Puncture Times

Toward Faster Revascularization in Large Vessel Acute Ischemic Stroke: Reducing Door-to-Groin Puncture Times

Toward Faster Revascularization in Large Vessel Acute Ischemic Stroke: Reducing Door-to-Groin Puncture Times

Stroke treatment has evolved immensely over the past 3 decades, with mechanical thrombectomy becoming the mainstay of treatment for large vessel occlusion (LVO). In this review, we describe the progression from PROACT I to the present day, and analyze existing literature to summarize the efficacy of current methods to treat LVO. We also describe the indications for mechanical thrombectomy and the strategies that have been implemented to enhance its efficacy, including a quality improvement project conducted at the Mayo Clinic. In addition, we discuss lessons from the implementation of mechanical thrombectomy and advancements in this technique over recent years.

Osteoarthritis is associated with lower likelihood of receiving stroke thrombectomy despite similar post-thrombectomy outcomes: a national study (P8-5.023)

<h3>Objective:</h3> To investigate whether osteoarthritis (OA) impacts stroke thrombectomy treatment rates or post-thrombectomy outcomes. <h3>Background:</h3> Osteoarthritis (OA) is a common condition affecting as many as 30 million Americans. While OA is not a direct risk factor for acute ischemic stroke, it can be associated with pre-stroke disability and influence patient selection for endovascular thrombectomy (EVT). Whether OA impacts post-EVT outcomes is currently unknown. <h3>Design/Methods:</h3> This was a retrospective study of the 2016–2019 National Inpatient Sample database. Adult patients with large vessel acute ischemic stroke were included. Patients with osteoarthritis were identified. Primary outcome was rate of EVT treatment in OA patients versus non-OA patients. Secondary outcomes include rates of discharge to home and in-hospital mortality after EVT treatment. Propensity score-matching (PSM) and multivariable logistic regression models were used to account for possible confounders. <h3>Results:</h3> 252,505 large vessel ischemic stroke patients were identified, of whom 21,500 patients (8.5% of study population) were diagnosed with OA. After PSM for 27 clinical variables, OA patients were 21.3% less likely to receive EVT than non-OA patients (14.4% vs. 18.3%, respectively; p&lt;0.001). In multivariable logistic regression analysis, OA was associated with 31% lower odds of receiving EVT (OR 0.69 [95%CI 0.63 to 0.76], p&lt;0.001), an effect size second only to dementia and larger than that of any other comorbidity captured in this study. Among patients who received EVT, multivariable logistic regression models showed that OA was not associated with different odds of being discharged home (OR 1.01 [95%CI 0.83 to 1.23], p=0.92); however, OA was associated with lower odds of in-hospital mortality compared to non-OA patients (OR 0.74 [95%CI 0.55 to 0.99], p=0.044). <h3>Conclusions:</h3> Large vessel ischemic stroke patients with OA were significantly less likely to receive EVT therapy despite similar post-EVT outcomes. These results warrant further investigation and prompt a critical review of current patient selection practices for EVT. <b>Disclosure:</b> Mr. Chen has received research support from National Institues of Health. Mr. Khunte has nothing to disclose. Dr. Colasurdo has nothing to disclose. Gaurav Jindal has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Penumbra. Ajay Malhotra, 9122 has nothing to disclose. Dheeraj Gandhi has nothing to disclose. Dr. Chaturvedi has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Astra Zeneca. Dr. Chaturvedi has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for University of Calgary. Dr. Chaturvedi has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for American Heart Association. Dr. Chaturvedi has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Ramar &amp; Paradiso. Dr. Chaturvedi has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Cole, Scott, Kissane. The institution of Dr. Chaturvedi has received research support from NINDS.

Associations of Osteoarthritis With Thrombectomy Utilization and Outcomes for Large Vessel Acute Ischemic Stroke.

Osteoarthritis and other musculoskeletal disorders are the leading causes of disability in the United States. While osteoarthritis is not a direct risk factor for stroke, osteoarthritis may impact patient selection for endovascular thrombectomy (EVT) due to prestroke disability. This study investigates associations of osteoarthritis with EVT utilization and outcomes. This was a large-scale cross-sectional study of the 2016 to 2019 National Inpatient Sample database. Adult patients with anterior large vessel ischemic strokes were identified. Patient demographics, stroke risk factors, stroke etiology, presence of osteoarthritis, medical comorbidities, EVT, intravenous thrombolysis treatments, and discharge destinations were recorded. Primary outcome was the rate of EVT treatment. Secondary outcomes include rates of discharge to home and in-hospital mortality. Propensity score matching and multivariable logistic regression models were used to account for possible confounders. Two hundred fifty-two thousand five hundred five patients were identified, of whom 8.5% (21 500 patients) had osteoarthritis. After propensity score matching for 32 clinical variables, osteoarthritis patients were found to be 17.3% less likely to receive EVT than non-osteoarthritis patients (14.4% versus 17.3%, respectively; P<0.001). In multivariable logistic regression analysis, osteoarthritis was associated with 22.6% lower odds of receiving EVT (OR, 0.77 [95% CI, 0.70-0.86]; P<0.001), an effect size larger than any medical comorbidity captured in this study other than dementia and nonstroke neurological disease. Among those treated with EVT, multivariable logistic regression models showed that osteoarthritis was not associated with different odds of being discharged home (OR, 0.99 [95% CI, 0.81-1.21]; P=0.93); however, osteoarthritis was marginally associated with lower odds of in-hospital mortality (OR, 0.74 [95% CI, 0.54-1.01]; P=0.054). Large vessel ischemic stroke patients with osteoarthritis were significantly less likely to receive EVT therapy despite similar post-EVT outcomes. These results warrant further investigation and prompt a critical review of current patient selection practices for stroke EVT therapy, specifically for patients with baseline disability due to musculoskeletal conditions such as osteoarthritis.

Age and composition of the thrombus retrieved by mechanical thrombectomy from patients with acute ischemic stroke are associated with revascularization and clinical outcomes

IntroductionUnderstanding the composition of stroke thrombi retrieved by mechanical thrombectomy is essential to clarify the pathogenesis of stroke. However, it is difficult to evaluate thrombus composition precisely and objectively. Immunohistochemical staining was used to evaluate thrombus composition and age. Materials and methodsConsecutive thrombi (n = 108) retrieved from patients who underwent mechanical thrombectomy for acute large-vessel ischemic stroke were retrospectively analyzed. Lytic features of granulocytes and CD163 were estimated as indicators of the age of the cardioembolic (CE) thrombus. ResultsThe stroke subtypes were as follows: CE, 74 cases; large artery atherosclerosis, 11; undetermined etiology, 12; and other determined etiology, 11. There were no statistical differences in thrombi composition according to stroke subtypes. The fibrin area was positively correlated with the red blood cell (RBC) and platelet areas. The following analysis was performed using CE only. Regarding age, the thrombus was judged as fresh in 30.0 % and older in 70.0 % based on the lytic features. The RBC areas of older thrombi were smaller than those of fresh thrombi. The puncture-to-reperfusion time of older thrombi was longer than that of fresh thrombi. Platelet-rich thrombi were associated with a greater number of maneuvers, a smaller prevalence of TICI 3, and unfavorable functional outcomes compared to platelet-poor thrombi. The number of CD163 positive cells in thrombi with anticoagulants was higher than in those without anticoagulants. ConclusionThrombus composition correlated with revascularization and clinical outcomes. The composition of an acute ischemic thrombus may reflect the pathophysiology of stroke and influence treatment efficacy.

Abstract No. 240 Automated outcome prediction in mechanical thrombectomy for acute large vessel ischemic stroke using 3D convolutional neural networks applied to CT angiography

Accurate prediction of clinical outcomes of acute large vessel occlusions (LVO) would lead to better patient selection and treatment planning for mechanical thrombectomy (MT). We developed a deep learning pipeline that predicts thrombectomy passes, immediate perfusion quality via the Thrombolysis in Cerebral Infarction (TICI) score and functional outcome via the 30-day modified Rankin Scale (mRS).

Perspective: The Case for Acute Large Vessel Ischemic Stroke in COVID-19 Originating Within Thrombosed Pulmonary Venules.

The main burden of SARS-CoV-2 falls on the lungs but neurological manifestations, the most disabling of which are strokes and which correlate with disease severity, are common. We proffer a novel mechanism for acute COVID-19 stroke whereby pulmonary vein clots developing within the characteristic pulmonary intravascular thrombotic lesions can embolize to the brain. Appreciation of this mechanism requires an understanding of the tricompartmental model of lung parenchyma oxygenation (the alveolus, the bronchial artery, and the pulmonary artery), all of which are compromised in COVID-19. Of these 3 sources, the bronchial artery plays a crucial role in COVID-19 stroke because the unique collaterals from bronchial artery to pulmonary vein which exist under normal physiological conditions (and which maintain venous patency when the pulmonary artery is blocked by embolus) are occluded, thus leading to venular thrombosis in the presence of hypercoagulability. Dislodgement of clots from this source translocates the pathology to the brain and is a disease mechanism, formerly rare, which may account for many cases of large vessel occlusion stroke in COVID-19. This mechanism extends the concept of cardioembolic stroke from endocardium retrogradely into the pulmonary circulation with which the left cardiac chambers lie in direct continuity, and which is an accepted stroke mechanism under other circumstances such as lung lobectomy, where surgical ligation of the pulmonary vein creates a blind sac from which thrombi can embolize. The proposed model is supported by postmortem studies which have demonstrated venular thrombosis and by case reports of pulmonary vein thrombosis in COVID-19. This concept provides a more plausible cause for COVID-19 associated large vessel occlusion stroke than other putative mechanisms, such as cerebral endotheliitis, cytokine storm, and hypercoagulopathy, although it is acknowledged that the latter mechanism contributes to the genesis of pulmonary vein clots. Recognizing that extrapulmonary manifestations including stroke arise within thrombosed pulmonary veins is key to understanding of neurological manifestations of SARS-CoV-2 infection.

Transcarotid Access for Mechanical Thrombectomy in Acute Ischemic Stroke: A Meta-Analysis and Systematic Review

ObjectivesDespite the success of mechanical thrombectomy in large vessel acute ischemic stroke, recanalization may fail due to difficult anatomic access or peripheral arterial occlusive disease. In these cases, transcarotid access may be used as an alternative, but it has not gained prominence due to safety concerns. Our objective was to assess the efficacy and safety of transcarotid access for mechanical thrombectomy. Materials and MethodsPreferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to perform a systematic review with articles published from 2010 to 2020 summarizing pre-intervention characteristics, techniques utilized, and outcomes of patients undergoing mechanical thrombectomy via trans-carotid puncture. We performed a meta-analysis of clinical outcomes, reperfusion times and overall complications rates of trans-carotid approach. ResultsSix studies describing 80 total attempts at carotid access, 72 of which were successful (90% success rate), were included. Direct carotid puncture was most often used as a rescue technique (87% of patients) secondary to failed femoral access. Successful recanalization was achieved in 76% of patients. 90 day modified Rankin Scale ≤ 2 was achieved in 28% of patients. Carotid puncture-reperfusion time was 32 min (CI = 24–40, p < 0.001). Cervical complications occurred at a rate of 26.5% (95% CI = 17%–38%). Only 1.3% (1/80 patients) had a fatal outcome and 96% of complications required no intervention. ConclusionsOur results on the safety and efficacy of transcarotid access suggests that this approach is a viable alternative to failed thrombectomy when transfemoral or trans-radial access may be impractical.

Abstract 1122‐000059: Considering Transcarotid Access for Mechanical Thrombectomy in Acute Ischemic Stroke: A Meta‐Analysis and Systematic Review

Introduction : Despite the success of mechanical thrombectomy in large vessel acute ischemic stroke, there remain cases where recanalization fails due to difficult anatomic access or peripheral arterial occlusive disease. In these cases, transbrachial or transcarotid access may be considered as alternatives to the transfemoral or increasingly popular transradial route. Of these approaches, the transcarotid route has not gained prominence due to safety concerns despite its prior routine use in angiography. In this study, we conducted a systematic review and meta‐analysis of the literature in order to better summate the data on transcarotid access. Methods : Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines were used in order to perform a systematic review of articles published from 2010–2020 summarizing pre‐intervention characteristics of patients undergoing mechanical thrombectomy via transcarotid puncture. We performed a meta‐analysis focused on clinical outcomes, reperfusion times (in minutes), and overall complication rates of transcarotid access for mechanical thrombectomy. Pooled analyses were performed to examine predictors of complications and outcomes. Results : Six studies describing 72 patients, out of 80 attempts at carotid access (90% success rate), were included. Age ranged from the 5th to 9th decade (median 7.5). Initial National Institutes of Health Stroke Scale (NIHSS) score ranged from 4 to 28 (median 17). Direct carotid puncture was most often used as a rescue technique (86% of patients) secondary to failed femoral access. Successful recanalization was achieved in 85% of patients. Good 90‐day outcome (modified Rankin Scale ≤2) was achieved in 27% of patients. Median carotid puncture‐to‐reperfusion time was 32 minutes (CI = 24–40, p &lt; 0.001). Cervical complications occurred at a rate of 23% (CI = 14– 35%, p &lt; 0.001). Only one complication resulted in a fatal outcome and only one required an intervention (each 1.4%). Use of IV thrombolysis did not significantly predict better mTICI outcome. Complications were not predicted by use of IV thrombolysis or closure method. Carotid puncture as the primary access route was associated with significantly shorter procedure times and carotid puncture as a rescue route was associated with comparable procedure times to the classic femoral access route. Conclusions : Our results suggest that, despite current concerns about the use of transcarotid access, this technique can be considered a viable backup route in cases of failed transfemoral or transradial access. Though this method requires further research to better understand the variables that might play into clinical decision‐making for its use in acute stroke management, it is a promising area of study that could allow for thrombectomy in patients where it would otherwise be aborted.

Isolation of RNA from Acute Ischemic Stroke Clots Retrieved by Mechanical Thrombectomy.

Mechanical thrombectomy (MT) for large vessel acute ischemic stroke (AIS) has enabled biologic analyses of resected clots. While clot histology has been well-studied, little is known about gene expression within the tissue, which could shed light on stroke pathophysiology. In this methodological study, we develop a pipeline for obtaining useful RNA from AIS clots. A total of 73 clot samples retrieved by MT were collected and stored in RNALater and in 10% phosphate-buffered formalin. RNA was extracted from all samples using a modified Chemagen magnetic bead extraction protocol on the PerkinElmer Chemagic 360. RNA was interrogated by UV–Vis absorption and electrophoretic quality control analysis. All samples with sufficient volume underwent traditional qPCR analysis and samples with sufficient RNA quality were subjected to next-generation RNA sequencing on the Illumina NovaSeq platform. Whole blood RNA samples from three patients were used as controls, and H&E-stained histological sections of the clots were used to assess clot cellular makeup. Isolated mRNA was eluted into a volume of 140 µL and had a concentration ranging from 0.01 ng/µL to 46 ng/µL. Most mRNA samples were partially degraded, with RNA integrity numbers ranging from 0 to 9.5. The majority of samples (71/73) underwent qPCR analysis, which showed linear relationships between the expression of three housekeeping genes (GAPDH, GPI, and HPRT1) across all samples. Of these, 48 samples were used for RNA sequencing, which had moderate quality based on MultiQC evaluation (on average, ~35 M reads were sequenced). Analysis of clot histology showed that more acellular samples yielded RNA of lower quantity and quality. We obtained useful mRNA from AIS clot samples stored in RNALater. qPCR analysis could be performed in almost all cases, while sequencing data could only be performed in approximately two-thirds of the samples. Acellular clots tended to have lower RNA quantity and quality.

Inflammatory Biomarkers and Intracranial Hemorrhage after Endovascular Thrombectomy

Intracranial hemorrhage after endovascular thrombectomy is associated with poorer prognosis compared with those who do not develop the complication. Our study aims to determine predictors of post-EVT hemorrhage - more specifically, inflammatory biomarkers present in baseline serology. We performed a retrospective review of consecutive patients treated with EVT for acute large vessel ischemic stroke. The primary outcome of the study is the presence of ICH on the post-EVT scan. We used four definitions: the SITS-MOST criteria, the NINDS criteria, asymptomatic hemorrhage, and overall hemorrhage. We identified nonredundant predictors of outcome using backward elimination based on Akaike Information Criteria. We then assessed prediction accuracy using area under the receiver operating curve. Then we implemented variable importance ranking from logistic regression models using the drop in Naegelkerke R2 with the exclusion of each predictor. Our study demonstrates a 6.3% SITS (16/252) and 10.0% NINDS (25/252) sICH rate, as well as a 19.4% asymptomatic (49/252) and 29.4% (74/252) overall hemorrhage rate. Serologic markers that demonstrated association with post-EVT hemorrhage were: low lymphocyte count (SITS), high neutrophil count (NINDS, overall hemorrhage), low platelet to lymphocyte ratio (NINDS), and low total WBC (NINDS, asymptomatic hemorrhage). Higher neutrophil counts, low WBC counts, low lymphocyte counts, and low platelet to lymphoycyte ratio were baseline serology biomarkers that were associated with post-EVT hemorrhage. Our findings, particularly the association of diabetes mellitus and high neutrophil, support experimental data on the role of thromboinflammation in hemorrhagic transformation of large vessel occlusions.

Abstract P818: Increased Eligibility for Endovascular Therapy Following Intensive Door-To-Transfer Improvement Project

Background and Purpose: Early EVT for large vessel acute ischemic stroke is associated with reduced disability and mortality. Longer transfer times from the sending facility contribute to poorer EVT outcomes, and in some circumstances, patient ineligibility for EVT due to a completed stroke on arrival to the endovascular site. Reducing avoidable delays will result in overall improved EVT outcomes and reduce the frequency of completed stroke upon arrival. Methods: A multidisciplinary group utilized the Lean A3 process and PDCA improvement cycle to reduce transfer times. Avoidable delays and resources to expedite the transfers were identified. A standardized plan with defined roles and responsibilities, communication pathways, early transport team activation, and robust staff education were implemented. The PI team met weekly for 3 months to review each individual transfer, determine what went well and what did not, and to identify additional improvement opportunities. A weekly summary with feedback was provided to front line staff and managers. Staff involved in patient transfers that had a DIDO of 90 min or less were recognized with a “Brain Pin” and staff recognition certificate. Results: Since its implementation, 23 patients were transferred for potential EVT. Compared with 12 months prior to implementation, the DIDO median time was reduced from 119 minutes to 80.5 minutes, transfers were achieved in 90 min or less 61% (n=15) of the time vs. 27.2%, and percentage of EVT eligible patients increased from 58.3 to 78.3%. Conclusion: In conclusion, rapid reduction of DIDO times and increased patient eligibility for thrombectomy is attainable through an intensive multidisciplinary process improvement project. Implementing a standardized workflow that includes rapid identification of potential EVT transfers, early activation of the transport team, development of clear pathways of communication, defined roles and responsibilities within the team, and regular staff feedback are essential.

A Nomogram to Predict Lifestyle Factors for Recurrence of Large-Vessel Ischemic Stroke.

BackgroundStroke is the leading cause of morbidity and mortality in China. Recurrent stroke (RS) could occur in a significant portion of patients with ischemic stroke with devastating consequence.MethodsTo investigate the association between lifestyle and the risk of RS in Chinese patients with acute large-vessel ischemic stroke (ALVIS). A total of 258 patients with ALVIS were recruited in the study (median age 63 years, 30.6% female), and followed for a median of 366 days. The primary outcomes were first RS. Cox Regression and Akaike information criterion were used to establish the best-fit nomograms.ResultsDuring follow-up, 38 of 258 (14.7%) participants had the primary endpoint event. After adjusting for confounding factors in multivariate Cox regression analysis, healthy lifestyles, including bland diet (hazard ratio [HR], 0.365; 95% CI, 0.138–0.965), daily fruit consumption (HR, 0.474; 95% CI, 0.238–0.945), good sleep (HR, 0.364; 95% CI, 0.180–0.739), housework: HR (0.461; 95% CI, 0.200–1.065), and HDL (HR, 0.329; 95% CI, 0.130–0.831) were associated with significantly decreased risk for RS after ALVIS, while smoking was associated with a substantial increase in RS risk (HR, 2.590; 95% CI, 1.340–5.005) and included into the nomogram. A weighted point (from 0 to 100) was given to each risk factor, and the total points could be used to predict the probability of RS for the patient.ConclusionThe nomogram shows that healthy lifestyles (bland diet, daily fruit consumption, good sleep, cigarette cessation, and housework) were important for reducing RS in patients with ALVIS.

Prediction of Clinical Outcome in Patients with Large-Vessel Acute Ischemic Stroke: Performance of Machine Learning versus SPAN-100.

Traditional statistical models and pretreatment scoring systems have been used to predict the outcome for acute ischemic stroke patients (AIS). Our aim was to select the most relevant features in terms of outcome prediction on the basis of machine learning algorithms for patients with acute ischemic stroke and to compare the performance between multiple models and the Stroke Prognostication Using Age and National Institutes of Health Stroke Scale (SPAN-100) index model. A retrospective multicenter cohort of 1431 patients with acute ischemic stroke was subdivided into recanalized and nonrecanalized patients. Extreme Gradient Boosting machine learning models were built to predict the mRS score at 90 days using clinical, imaging, combined, and best-performing features. Feature selection was performed using the relative weight and frequency of occurrence in the models. The model with the best performance was compared with the SPAN-100 index model using area under the receiver operating curve analysis. In 3 groups of patients, the baseline NIHSS was the most significant predictor of outcome among all the parameters, with relative weights of 0.36∼0.69; ischemic core volume on CTP ranked as the most important imaging biomarker with relative weights of 0.29∼0.47. The model with the best-performing features had a better performance than the other machine learning models. The area under the curve of the model with the best-performing features was higher than SPAN-100 model and reached statistical significance for the total (P < .05) and the nonrecanalized patients (P < .001). Machine learning-based feature selection can identify parameters with higher performance in outcome prediction. Machine learning models with the best-performing features, especially advanced CTP data, had superior performance of the recovery outcome prediction for patients with stroke at admission in comparison with SPAN-100.

NIHSS Consciousness Score Combined with ASPECTS is a Favorable Predictor of Functional Outcome post Endovascular Recanalization in Stroke Patients.

Although revascularization rates after endovascular thrombectomy for large vessel acute ischemic stroke (AIS) are high (71%), only 46% of patients achieve functional independence at 90 days. The present study was designed to explore a new method for predicting the functional prognosis of AIS patients after endovascular recanalization. A total of 200 anterior circulation stroke patients who received endovascular therapy were enrolled. Logistic regression analysis of clinical characteristics on functional independence were performed. The predictive power of sub-items in National Institute of Health stroke scale (NIHSS) and the combination of NIHSS consciousness and Alberta Stroke Program Early CT Score (ASPECTS) on functional independence were assessed by Receiver Operating Characteristic (ROC) curves and the latter was compared with 3 previously published prediction models by AUC (the area under ROC curve). The AUC for the NIHSS consciousness score to predict functional independence was higher than whole NIHSS and other sub-items (0.716 v 0.705, 0.586, 0.573, 0.552 and 0.559). Low NIHSS consciousness score, high ASPECTS score, short time from onset to recanalization, and high rate of successful recanalization were demonstrated to be significantly associated with the functional independence (OR 0.697, 2.226, 0.994 and 28.643). The prediction power of the combination was significantly better than NIHSS and ASPECTS alone (AUC 0.793 v 0.705 and 0.752). Compared with 3 other prediction models, the combination was found to be the strongest predictor for functional independence (AUC 0.793 v 0.791, 0.671 and 0.564). NIHSS which has been shown to be a strong predictor of functional outcomes after endovascular recanalization is largely dependent on the consciousness component. NIHSS consciousness score combined with ASPECTS appears to be a favorable predictor of functional independence. These findings may have broad reaching effects for isolated centers around the world without advanced imaging for triage and prognostication.

Endovascular Thrombectomy for Acute Ischemic Stroke in the Filipino Population: A Clinical Experience From a Single Tertiary Center in Metro Manila, Philippines

Background and Purpose: Throughout the years, stroke has remained one of the primary causes of significant morbidity and mortality. Among the therapeutic options for acute stroke management, endovascular thrombectomy intended to remove the thrombi within the intracerebral vasculature and restore adequate perfusion to the surrounding penumbra. It was recommended for eligible patients who were within 6—24 hours after the onset of neurologic symptoms. In the Philippines, only a few tertiary healthcare institutions were able to offer and perform endovascular thrombectomies. The aim was to describe the profile and discharge outcomes of endovascular thrombectomy for acute ischemic stroke at a tertiary hospital in our country. Methodology: In this retrospective study, 924 patients were admitted for acute ischemic stroke from October 2018 - August 2021. However, only 31 patients underwent mechanical thrombectomy and their records were thoroughly reviewed. Clinical and functional outcomes were measured using the National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Score (MRS), respectively. Results: Among the patients included in the study, 29 subjects (93.5%) had moderate to severe disability (MRS 3-5) and 17 (54.8%) had moderate stroke (NIHSS 5-15) on admission. The identified site of the cerebrovascular thrombi was within the M1 segment of the middle cerebral artery (41.9%, n=13). The stent retriever approach was performed in 19 of the subjects (61.2%). Upon discharge, only 17 (22.6%) had favorable functional outcomes (MRS 0-2) and 6 (19.3%) resulted in mortality. Conclusion: Overall, endovascular thrombectomy is a promising treatment strategy for large vessel acute ischemic stroke in a developing country. Funding Information: This research did not receive any financial support or grant. Declaration of Interests: The authors of this study have nothing to disclose. The authors do not have any financial, commercial, legal, or professional relationship with organizations that can affect or influence the results of this research. Ethics Approval Statement: This study was submitted to the Institutional Review Board and gained ethical approval.

COVID-19 Associated Large Vessel Thrombosis and Ischemic Stroke: A Case Series

The novel severe acute respiratory syndrome coronavirus (SARS-COV-2) affects different people in different ways. Most infected people will develop mild to moderate respiratory flu-like illness and recover without the need for hospitalization. However, one of the not uncommonly observed extrapulmonary associations with SARS-COV-2 is developing severe large-vessel acute ischemic stroke. Moreover, COVID-19 virus-linked Cerebrovascular Accidents (CVA) were more severe and resulted in a higher risk for severe disability and mortality following acute insult. Although the pathophysiology is not fully understood, the neuro-targeting nature of SARS-COV-2 due to vascular injury and the hyperimmune response were plausible proposed mechanisms. Further research is warranted to have a deep insight into the possible mechanisms. Herein, we review the current literature and describe five patients we have encountered during the SARS-COV-2 viral pandemic.