Large Vessel Occlusion Stroke Research Articles

POST‐UK (Adjunctive Intra‐Arterial Urokinase After Successful Endovascular Thrombectomy in Patients With Large‐Vessel Occlusion Stroke): Study Protocol of a Multicenter, Prospective, Randomized, Open‐Label, Blinded‐End Point Trial

BACKGROUND Intra‐arterial infusion of an adjunctive thrombolytic agent after macrovascular recanalization by endovascular thrombectomy was regarded as a promising strategy to promote outcomes of patients with stroke. Given the characteristics of urokinase as an affordable, available, and widely applied medication, especially in Eastern countries, this trial aims to assess the safety and efficacy of intra‐arterial urokinase as adjunct to endovascular thrombectomy in improving outcomes among patients with anterior large‐vessel occlusion stroke after excellent to complete reperfusion. METHODS The POST‐UK (Adjunctive Intra‐Arterial Urokinase After Successful Endovascular Thrombectomy in Patients With Large Vessel Occlusion Stroke) trial is a multicenter, prospective, randomized, open‐label, blinded‐end point trial conducted in China. The planned sample size is 498. Those eligible patients with anterior circulation large‐vessel occlusion stroke and achieving excellent to complete reperfusion by endovascular thrombectomy are planned to be consecutively randomized in a 1:1 ratio to the experimental group (a single dose of intra‐arterial urokinase) or to standard of care. RESULTS The primary outcome is a freedom from disability (modified Rankin Scale score of 0–1) at 90±7 days. The safety outcomes are mortality within 90±7 days and symptomatic intracranial hemorrhage within 48 hours. CONCLUSION The POST‐UK trial will provide valuable insight of efficacy and safety of intra‐arterial urokinase in patients with large‐vessel occlusion stroke after achieving excellent to complete reperfusion by endovascular thrombectomy.

Association of renal biomarkers with fast progressor phenotype and related outcomes in anterior circulation large vessel occlusion stroke

BackgroundRenal dysfunction is a known predictor of long-term functional dependency after anterior circulation large vessel occlusion (ACLVO) stroke. However, the impact of renal dysfunction on early infarct growth rate (IGR) has not been previously demonstrated. The objective of this study was to define the association of creatinine-based renal biomarkers with fast or slow progressor phenotypes and related clinical outcomes in ACLVO stroke.MethodsThis retrospective study examined patients with acute intracranial internal carotid artery or middle cerebral artery-M1 occlusions admitted between 2014 and 2019. Patients were included if they received baseline CT perfusion (CTP) or MRI on presentation within 24 h of estimated stroke onset. Infarct growth rate (IGR) was determined by ischemic core volume on CTP or MRI divided by time from stroke onset to imaging. IGR was used to stratify fast progressor (IGR ≥10 mL/h) and slow progressor (IGR < 10 mL/h) status. Renal dysfunction was assessed based on serum creatinine and estimated glomerular filtration rate (eGFR) on presenting laboratories. Logistic regression models, adjusted for significant covariates, identified independent associations between renal dysfunction biomarkers, progressor status, and clinical outcomes based on modified Rankin Scale (mRS) at 90 days.ResultsAmong 230 patients with ACLVO, 29% were fast progressors, with median serum creatinine levels higher than slow progressors (1.1 vs. 0.9 mg/dL, p < 0.05) and lower median eGFR (66.2 vs. 69.0 mL/min/1.73m2, p < 0.05). Elevated creatinine (≥1.2 mg/dL) was independently associated with fast progressor status (adjusted OR 2.37, 95% CI 1.18–4.77), worse 90-day mRS (adjusted OR 1.88, 95% CI 1.01–3.51) and mortality (adjusted OR 2.57, 95% CI 1.14–5.79). Reduced eGFR (<60 mL/min/1.73m2) was independently associated with fast progressor status (adjusted OR 2.38, 95% CI 1.14–4.94), but not with 90-day mRS or mortality.ConclusionSerum creatinine-based biomarkers of renal dysfunction were associated with fast progressor phenotype of ACLVO stroke, and worse clinical outcomes, which may help identify such patients earlier during emergency evaluation for expedited access to EVT. Future prospective studies are warranted to confirm and test implementation of these findings.

"Chopperlysis": The effect of helicopter transport on reperfusion and outcomes in large vessel occlusion strokes.

In large vessel occlusion (LVO) stroke patients transferred to a comprehensive stroke center for thrombectomy, spontaneous reperfusion may occur during transport, and anecdotally more frequently in patients transferred via helicopter than by ground. This pattern has been more often observed in conjunction with tenecteplase (TNK) treatment prior to helicopter transport. We aim to explore the "chopperlysis" effect-how helicopter transport, particularly with thrombolytics, may affect reperfusion and clinical outcomes. A single thrombectomy capable center (TCC) registry of stroke patients was retrospectively reviewed. Included LVO patients were those who had been transferred to the TCC and received a digital subtraction angiography (DSA) upon arrival. The outcomes were rates of spontaneous reperfusion, distal clot migration, and 90-day good functional outcome. Data were summarized, and endpoints were compared between patients stratified by transport method and/or TNK treatment. Of 270 patients included, helicopter transport was associated with a higher rate of spontaneous reperfusion, particularly among patients not treated with TNK (p < 0.001). There was no significant difference in prevalence of distal clot migration between any subgroups (p > 0.37). Overall, TNK-treated patients had better functional outcomes, and this difference persisted exclusively in the helicopter-transported patients (p = 0.02). Helicopter transport was associated with a higher rate of spontaneous reperfusion. There is a potentially synergistic effect between TNK administration and helicopter transport, augmenting thrombolysis and improving long-term outcomes. Further analyses in larger cohorts may expand our understanding of this "chopperlysis" effect.

Continuous transcranial ultrasound in large vessel stroke: Image guidance for high-intensity focused sonothrombolysis.

Sonothrombolysis is a potential adjunctive therapy for large vessel occlusion (LVO) stroke. Bedside ultrasound image-guided high-intensity focused ultrasound (HIFU) therapy could deliver higher energy therapeutic ultrasound to the thrombus with higher precision than what was previously accomplished in human trials. The aim is to test the feasibility of diagnostic transcranial contrast-enhanced ultrasound (CEUS) to image the occlusion site and continuously maintain the guidance image on-target for a sufficient exposure time for HIFU to be effective during LVO stroke evaluation and treatment. This prospective, single center, observational cohort study included adult patients, presenting within 6 hours of stroke symptom onset, with LVO identified on computed tomography angiography (CTA). A hand-held CEUS imaging study was initiated following CTA and lasted up to 30 minutes. The primary outcome is the proportion of patients where a guidance CEUS image of the occlusion was achieved. A CEUS image of the occluded artery was obtained in 32/35 of the included patients. The median total imaging time was 23 minutes (interquartile range 15-30). Patients undergoing thrombectomy had a lower total imaging time (17 vs. 29.5 minutes, p=.002). When imaging was successful, on-target image was maintained for only 58% (standard deviation 23.8%) of total imaging time. No complications related to CEUS were observed. This feasibility study explored the use of diagnostic transcranial CEUS for continuous imaging of occlusion sites in LVO strokes. Challenges in maintaining target image during HIFU were identified, highlighting the need for technical advances for clinical application.

Association between basal ganglia infarction and hemorrhagic transformation after mechanical thrombectomy in acute ischemic stroke: insights from the DIRECT-MT trial

BackgroundAcute ischemic stroke (AIS) often leads to significant morbidity and mortality. Mechanical thrombectomy (MT) is an effective intervention for large vessel occlusion strokes. However, hemorrhagic transformation (HT) remains a critical...

Nomogram for predicting early neurological deterioration in patients with mild large and medium vessel occlusion stroke intended for medical management: a multicenter retrospective study

BackgroundAccurately forecasting early neurological deterioration of ischemic origin (ENDi) following medical management may aid in identifying candidates for thrombectomy. We aimed to develop and validate a nomogram to predict ENDi...

Improving Stroke Outcome Prediction Using Molecular and Machine Learning Approaches in Large Vessel Occlusion.

Introduction: Predicting stroke outcomes in acute ischemic stroke (AIS) can be challenging, especially for patients with large vessel occlusion (LVO). Available tools such as infarct volume and the National Institute of Health Stroke Scale (NIHSS) have shown limited accuracy in predicting outcomes for this specific patient population. The present study aimed to confirm whether sudden metabolic changes due to blood-brain barrier (BBB) disruption during LVO reflect differences in circulating metabolites and RNA between small and large core strokes. The second objective was to evaluate whether integrating molecular markers with existing neurological and imaging tools can enhance outcome predictions in LVO strokes. Methods: The infarction volume in patients was measured using magnetic resonance diffusion-weighted images, and the 90-day stroke outcome was defined by a modified Rankin Scale (mRS). Differential expression patterns of miRNAs were identified by RNA sequencing of serum-driven exosomes. Nuclear magnetic resonance (NMR) spectroscopy was used to identify metabolites associated with AIS with small and large infarctions. Results: We identified 41 miRNAs and 11 metabolites to be significantly associated with infarct volume in a multivariate regression analysis after adjusting for the confounders. Eight miRNAs and ketone bodies correlated significantly with infarct volume, NIHSS (severity), and mRS (outcome). Through integrative analysis of clinical, radiological, and omics data using machine learning, our study identified 11 top features for predicting stroke outcomes with an accuracy of 0.81 and AUC of 0.91. Conclusions: Our study provides a future framework for advancing stroke therapeutics by incorporating molecular markers into the existing neurological and imaging tools to improve predictive efficacy and enhance patient outcomes.

Home and workforce reintegration one year after thrombectomy in acute stroke patients.

Endovascular thrombectomy (EVT) combined with intravenous thrombolysis is the current standard treatment for acute large-vessel occlusion stroke. Beyond clear clinical benefits in the acute and post-acute phases, comprehensive evaluations of long-term outcomes, including home and workforce reintegration, remain limited. This study aimed to assess home and workforce reintegration 1 year post-EVT in a cohort of acute stroke patients and explore their association with health-related quality of life (HRQoL). We conducted a prospective observational study of 404 patients undergoing EVT at a tertiary university medical center between October 2019 and December 2021. Patients' functional outcomes were evaluated using the modified Rankin Scale (mRS), and HRQoL was assessed via the European Quality of Life Five Dimension Scale (EQ-5D). Data on occupational and living status were collected through standardized telephone interviews at 3- and 12-months post-treatment. Of 357 patients with 12-month follow-up data, 33.6% had a favorable outcome (mRS 0-2). Among stroke survivors, the rate of home reintegration without nursing care was 42.1%, and workforce reintegration among previously employed patients was 43.3% at 12 months. Both outcomes were significantly associated with improved HRQoL. Lower neurological deficits and younger age were predictive of successful home and workforce reintegration. One year post-EVT, approximately 40%-50% of acute stroke patients successfully reintegrate into home and work settings. These findings underscore the need for ongoing support tailored to improving long-term reintegration and quality of life for stroke survivors. The data supporting the findings of the study are available from the corresponding author upon reasonable request and in accordance to European data privacy obligations.

Intra-arterial tenecteplase after successful endovascular therapy (ANGEL-TNK): protocol of a multicentre, open-label, blinded end-point, prospective, randomised trial

BackgroundDespite successful reperfusion after thrombectomy for large vessel occlusion (LVO) stroke, up to half of patients are dependent or dead at 3-month follow-up.The aim of the current study is to...

Safety and Effectiveness Analysis of Endovascular Treatment vs Standard Medication Treatment in Patients with Progressive AIS-LVO Stroke in the Ultra-late Time Window: A Propensity Score Matched Cohort Study

The time from onset to symptom deterioration in ischemic stroke often exceeds 24 hours, and this ultra-late time window is excluded from the endovascular treatment (EVT) guideline. This study aimed to explore the safety and efficacy of EVT in progressive acute ischemic stroke with large vessel occlusion (AIS-LVO) stroke patients with onset to symptom deterioration times of 24h-7 days. Progressive stroke patients with time window of 24h-7 days treated at our hospital over the past 6 years were retrospectively collected. Patients were categorized into EVT and standard medication treatment (SMT) group based on the treatment approach. Patients were matched using propensity score matching (PSM). Safety outcomes primarily included 3-month mortality and symptomatic intracranial hemorrhage (sICH), efficacy outcome primarily included functional independence (3-month mRS≤2). A total of 396 patients were included in the study, with 86(21.7%) in EVT and 310(78.3%) in SMT group. There were 140 remaining after PSM, with 70 in each group (50%). Compared to SMT group, EVT group had higher functional independence (52.9% vs 15.7%, OR=7.504, 95% CI 2.141-14.093, P<0.001) and lower 3-month mortality (14.3% vs 40.0%, OR=0.412, 95% CI 0.099-0.856, P<0.001). EVT was also associated with higher sICH (25.7% vs 5.7%, OR=9.926, 95% CI 1.874-36.547, P<0.001). For patients with progressive AIS-LVO in the ultra-late time window, EVT remains a viable treatment approach.

Insoluble Proteomics Analysis of Acute Intracranial Large Vessel Occlusive Thrombus.

Acute large vessel occlusion (LVO) stroke is highly prevalent and severe. Despite thrombolytic therapy, many patients experience substantial complications. Understanding the origins, constituents, and pathological processes involved in thrombus formation in acute intracranial large artery occlusion is crucial. To identify the characteristics of insoluble proteins from different sources of cerebral thrombus. This study included 13 patients with cardiogenic embolic thrombus (CE) and 15 with large artery atherosclerosis thrombus (LAA). High-performance liquid chromatography and liquid chromatography-tandem mass spectrometry were used to analyze insoluble proteins in thrombi. Bioinformatics analyses explored differential proteins and associated functional pathways. Least Absolute Shrinkage and Selection Operator and Random Forest identified biomarkers for diagnosing thrombus sources, validated by parallel reaction monitoring. We constructed an insoluble protein atlas of cerebral thrombi, identifying 6975 insoluble proteins, including 143 extracellular matrix (ECM)-related proteins. The enrichment pathways considerably varied between thrombi from different sources. Inflammation-related pathways, such as "acute inflammatory response," along with ECM-related pathways such as "laminin interactions," were notably upregulated in LAA compared to CE. Additionally, two biomarkers (IDH2, HSPG2) exhibited strong diagnostic performance (AUC = 1) and robustness. In the insoluble Proteomics of thrombus, we highlighted the crucial roles of immune responses and ECM proteins in thrombus formation, providing new insights into its mechanisms and potential drug development. Additionally, we identified two biomarkers that offer new methods for determining thrombus sources in patients with LVO.

Is Thrombectomy Effective for Large Vessel Occlusion Stroke Patients with Mild Symptoms? Meta-Analysis and Trial Sequential Analysis

Background: Endovascular treatment (EVT) is an established method for managing large vessel occlusion (LVO), but its efficacy in patients with mild stroke (National Institutes of Health Stroke Scale [NIHSS] score &lt; 6) remains debated. Given the clinical problem of early neurological deterioration in approximately 10% of mild stroke patients, understanding the role of EVT in managing these patients is crucial. Our objective was to perform a meta-analysis with trial sequential analysis (TSA) focusing on mild stroke patients with LVO to determine whether EVT offers better outcomes than best medical therapy alone. Methods: A comprehensive search of PubMed, Cochrane, and Embase databases up to 12 December 2023 identified 14 retrospective and prospective cohort studies, including a total of 4436 patients with NIHSS scores less than 6 and presenting with LVO. Studies were categorized into crossover and non-crossover groups to prevent overestimation of the treatment effect. In the crossover group, patients initially treated with BMT were moved to EVT upon clinical deterioration. In the non-crossover group, patients remained in their initially assigned treatment. Meta-analysis and data extraction followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcome was achieving an excellent functional outcome, defined as a modified Rankin scale (mRS) score of 0–1 at 3 months. Secondary outcomes included good (mRS 0–2) and favorable (mRS 0–3) functional outcomes. Safety outcomes were symptomatic intracerebral hemorrhage (sICH) and mortality at 3 months. Results: In the crossover group, EVT did not significantly improve excellent functional outcomes, and TSA results were inconclusive. Conversely, in the non-crossover group, EVT significantly improved the excellent functional outcome rates at 3 months (65.0% vs. 53.7%; OR 1.62; 95% CI 1.13 to 2.32), supported by TSA. EVT increased the risk of sICH in both crossover and non-crossover groups, while mortality rates did not significantly differ between EVT and BMT groups. Conclusions: Our research indicates that thrombectomy may not significantly help mild stroke patients in recovering functional status and could increase the risk of sICH. The disparity in results between crossover and non-crossover studies highlights the critical need for the prompt identification of patients at risk of early neurological deterioration to minimize negative outcomes. Additional randomized controlled trials are essential to optimize the application of EVT in this patient population.

Angioplasty and/or stenting following successful mechanical thrombectomy for intracranial atherosclerosis-related emergent large vessel occlusive stroke (ASSET): protocol of a multicentre randomised trial

RationaleThe management of residual stenosis after mechanical thrombectomy in patients with intracranial atherosclerotic stenosis-related emerge large vessel occlusive (ICAS-LVO) stroke is still unclear question in clinical practice.AimTo demonstrate the design...

Factors associated with oropharyngeal dysphagia and unsuccessful nasogastric tube removal after endovascular thrombectomy for anterior circulation stroke.

To identify the predictive variables for post-stroke dysphagia (PSD) among anterior circulation large vessel occlusion (LVO) stroke patients who underwent endovascular thrombectomy (EVT). This retrospective cohort study enrolled hospitalized patients with anterior LVO stroke who underwent EVT between January 1, 2018 and October 31, 2022. PSD was defined as the unsuccessful removal of the nasogastric (NG) tube. Factors, such as premorbid characteristics, laboratory results, EVT, rehabilitation-related parameters, and neuro-imaging, were analyzed for correlations to PSD at 4 and 12weeks. The study enrolled 136 patients, with a mean age of 72.9 ± 13.0years, and 59 patients (43.4%) were male. At 4weeks, 47.1% of the patients needed an NG tube, and at 12weeks, 16.2% still required an NG tube. We found that lower albumin, lower body mass index (BMI), higher initial and 24-h post-EVT National Institute of Health Stroke Scale (NIHSS) scores, stroke-associated pneumonia, poor initial sitting balance and ability to sit up, insula or frontal operculum lesions, and bilateral hemisphere involvement were all associated with PSD at both 4 and 12weeks in the univariate logistic regression. Multivariate analysis revealed that significant predictors of unsuccessful NG tube removal at 4weeks included lower BMI (adjusted OR [aOR] 0.73, p = 0.005), hemorrhagic transformation (aOR 4.01, p = 0.0335), higher NIHSS scores at 24h post-EVT (aOR 1.13, p = 0.0288), poor initial sitting ability (aOR 0.52, p = 0.0231), insular cortex ischemia (aOR 7.26, p = 0.0056), and bilateral hemisphere involvement (aOR 41.19, p < 0.0001). At 12weeks, lower BMI (aOR 0.78, p = 0.0098), poor initial sitting balance (aOR 0.57, p = 0.0287), insular cortex lesions (aOR 4.83, p = 0.0092), and bilateral hemisphere involvement (aOR 4.07, p = 0.0139) remained significant predictors. In patients with anterior LVO following EVT, PSD was associated with lower BMI, higher NIHSS scores, poor initial sitting balance and sitting ability, insular lesions, and bilateral hemisphere involvement.

Endovascular thrombectomy versus medical management for patients with large vessel stroke and infective endocarditis

BackgroundThe safety and efficacy of endovascular thrombectomy (EVT) for large vessel occlusion (LVO) strokes associated with infective endocarditis (IE) compared with medical management (MM) is unclear.MethodsIn this nationwide analysis of...

Admission hyperglycemia effect on symptomatic intracranial hemorrhage in tenecteplase versus alteplase before large vessel occlusion stroke thrombectomy

Admission hyperglycemia effect on symptomatic intracranial hemorrhage in tenecteplase versus alteplase before large vessel occlusion stroke thrombectomy

Insights into multilevel tissue-level collateral status using ColorViz maps from dual data sources in acute ischemic cerebrovascular diseases: A STARD-compliant retrospective study.

This study aims to explore the utility of ColorViz mapping from dual data sources for assessing arterial collateral circulation and predicting cerebral tissue-level collateral (TLC) in patients with acute ischemic cerebrovascular diseases. A retrospective study was conducted at a single center on a cohort of 79 patients diagnosed with acute ischemic cerebrovascular diseases between November 2021 and April 2022, who had undergone both multi-phase CT angiography (mCTA) and computed tomography perfusion (CTP). The quality of images and arterial collateral status depicted on ColorViz maps from dual data-sets (mCTA and CTP) were assessed using a "5-point scale" and a "10-point scale," respectively. The status of TLC was evaluated by analyzing multilevel hypoperfusion volume and the hypoperfusion intensity ratio (HIR). The Spearman correlation coefficient was employed to examine the association between arterial collateral status derived from dual data sources and TLC. Receiver operating characteristic curve analysis was used to determine the diagnostic efficacy in detecting large vessel occlusive acute ischemic stroke (LVO-AIS). The ColorViz maps derived from dual data sources facilitated comparable image quality, with over 95% of cases meeting diagnostic criteria, for the evaluation of arterial level collateral circulation. Patients with robust arterial collateral circulation, as determined by dual data sources, were more likely to exhibit favorable TLC status, as evidenced by reductions in hypoperfusion volume (Tmax > 4 seconds, Tmax > 6 seconds, Tmax > 8 seconds, and Tmax > 10 seconds, P < .05) and HIR (Tmax > 6 seconds/4 seconds, Tmax > 8 seconds/4 seconds, Tmax > 10 seconds/4 seconds, and Tmax > 8 seconds/6 seconds, P < .05). The sensitivity and specificity in detecting LVO-AIS was 60.00% and 97.73% for mCTA source maps, while 74.29% and 72.73% for CTP source maps (P > .05 based on De-Long test). In conclusion, this study indicates that ColorViz maps derived from both data sources are equally important in evaluating arterial collateral circulation and enhancing diagnostic efficiency in patients with LVO-AIS, as well as offering insights into the TLC status based on hypoperfusion volume and HIR.

Higher intracranial positioning of an 8 Fr guide catheter improves efficacy of aspiration thrombectomy in large vessel occlusion stroke

BackgroundHigher positioning of a large bore guide catheter during endovascular thrombectomy (EVT) is hypothesized to potentially improve thrombectomy success.ObjectiveTo evaluate the safety and efficacy of intracranial guide catheter placement during...

Early statin use is associated with improved survival and cardiovascular outcomes in patients with atrial fibrillation and recent ischaemic stroke: A propensity-matched analysis of a global federated health database.

Statins reduce recurrent stroke and cardiovascular events in patients with non-cardioembolic stroke. The benefits of statins in patients with AF and recent IS remain unclear. We aimed to investigate the benefits of statins in patients with AF and recent IS. This retrospective, cohort study was conducted using deidentified electronic medical records within TriNetX platform. Patients with AF and recent IS, who received statins within 28 days of their index stroke were propensity score-matched with those who did not. Patients were followed up for up to 2 years. Primary outcomes were the 2-year risk of recurrent IS, all-cause mortality and the composite outcome of all-cause mortality, recurrent IS, transient ischaemic attack (TIA), and acute myocardial infarction (MI). Secondary outcomes were the 2-year risk of TIA, intracranial haemorrhage (ICH), acute MI, and hospital readmission. Cox regression analyses were used to calculate hazard ratios (HRs) with 95% confidence intervals (95%CI). Of 20,902 patients with AF and recent IS, 7500 (35.9%) received statins within 28 days of their stroke and 13,402 (64.1%) did not. 11,182 patients (mean age 73.7 ± 11.5; 5277 (47.2%) female) remained after propensity score matching. Patients who received early statins had significantly lower risk of recurrent IS (HR: 0.45, 95%CI: 0.41-0.48, p < 0.001), mortality (HR: 0.75, 95%CI: 0.66-0.84, p < 0.001), the composite outcome (HR: 0.48, 95%CI: 0.45-0.52, p < 0.001), TIA (HR: 0.37, 95%CI: 0.30-0.44, p < 0.001), ICH (HR: 0.59, 95%CI: 0.47-0.72, p < 0.001 ), acute MI (HR: 0.35, 95%CI: 0.30-0.42, p < 0.001) and hospital readmission (HR: 0.46, 95%CI: 0.42-0.50, <0.001). Beneficial effects of early statins were evident in the elderly, different ethnic groups, statin dose intensity, and AF subtypes, large vessel occlusion and embolic strokes and within the context of statin lipophilicity, optimal LDL-cholesterol levels, various cardiovascular comorbidities, treatment with intravenous thrombolysis or endovascular thrombectomy, and NIHSS 0-5 and NIHSS > 5 subgroups. Patients with AF and recent IS, who received early statins, had a lower risk of recurrent stroke, death, and other cardiovascular outcomes including ICH, compared to those who did not.

Iatrogenic arterial vasospasm during mechanical thrombectomy requiring treatment with intra-arterial nimodipine might be associated with worse outcomes.

Vasospasm is a common iatrogenic event during mechanical thrombectomy (MT). In such circumstances, intra-arterial nimodipine administration is occasionally considered. However, its use in the treatment of iatrogenic vasospasm during MT has been poorly studied. We investigated the impact of iatrogenic vasospasm treated with intra-arterial nimodipine on outcomes after MT for large vessel occlusion stroke. We conducted a retrospective analysis of the multicenter observational registry Endovascular Treatment in Ischemic Stroke (ETIS). Consecutive patients treated with MT between January 2015 and December 2022 were included. Patients treated with medical treatment alone, without MT, were excluded. We also excluded patients who received another insitu vasodilator molecule during the procedure. Outcomes were compared according to the occurrence of cervical and/or intracranial arterial vasospasm requiring intraoperative use of insitu nimodipine based on operator's decision, using a propensity score approach. The primary outcome was a modified Rankin Scale (mRS) score of 0-2 at 90 days. Secondary outcomes included excellent outcome (mRS score 0-1), final recanalization, mortality, intracranial hemorrhage and procedural complications. Secondary analyses were performed according to the vasospasm location (intracranial or cervical). Among 13,678 patients in the registry during the study period, 434 received intra-arterial nimodipine for the treatment of MT-related vasospasm. In the main analysis, comparable odds of favorable outcome were observed, whereas excellent outcome was significantly less frequent in the group with vasospasm requiring nimodipine (adjusted odds ratio [aOR] 0.78, 95% confidence interval [CI] 0.63-0.97). Perfect recanalization, defined as a final modified Thrombolysis In Cerebral Infarction score of 3 (aOR 0.63, 95% CI 0.42-0.93), was also rarer in the vasospasm group. Intracranial vasospasm treated with nimodipine was significantly associated with worse clinical outcome (aOR 0.64, 95% CI 0.45-0.92), in contrast to the cervical location (aOR 1.37, 95% CI 0.54-3.08). Arterial vasospasm occurring during the MT procedure and requiring intra-arterial nimodipine administration was associated with worse outcomes, especially in case of intracranial vasospasm. Although this study cannot formally differentiate whether the negative consequences were due to the vasospasm itself, or nimodipine administration or both, there might be an important signal toward a substantial clinical impact of iatrogenic vasospasm during MT.