Large Vessel Occlusion Research Articles (Page 1)

Endovascular thrombectomy (EVT) is associated with considerable clinical benefits for patients after large vessel occlusion (LVO) stroke. However, EVT remains underused in Australia, particularly among the very elderly (aged ≥80 years). The aim of this study was to evaluate the cost-effectiveness and clinical effectiveness of EVT vs standard medical management among very elderly patients using real-world, observational data. A modeled cost-effectiveness study was conducted from the Australian health care perspective. Data from a retrospective cohort of patients aged 80 years or older treated with EVT at 4 comprehensive stroke centers across Australia and New Zealand, as well as data from the International Stroke Perfusion Imaging Registry, were used to inform our economic analyses. The distribution of 90-day modified Rankin Scale (mRS) outcomes after propensity score matching was used to inform a decision-analytic Markov model. Costs and utility data for calculating quality-adjusted life years (QALYs) were drawn from published sources. The primary outcome of this analysis was the incremental cost-effectiveness ratio (ICER) in terms of cost per QALY gained for EVT compared with medical management. Uncertainty was evaluated with deterministic and probabilistic sensitivity analyses. A total of 548 patients (mean age 85.1 years and 296 women [54%]) were included to inform the propensity score matching analysis. After propensity score matching, the proportion of patients with favorable (mRS score ≤2) outcomes was higher for EVT vs standard care (37% vs 18%). Based on the modeled cost-effectiveness analysis comprising a hypothetical sample of 10,000 patients, EVT was estimated to prevent 471 deaths over a period of 15 years. On a per-patient basis, EVT was associated with a gain of 0.95 years of life and 0.97 QALYs at a net cost of AU$3,399. That is, from a health care perspective, EVT is cost-effective for very elderly patients with LVO stroke (ICER: $3,508 per QALY). Sensitivity analyses supported the robustness of the model, with 100% of simulated ICERs falling below the commonly accepted Australian willingness-to-pay threshold of AU$50,000 per QALY. EVT is cost-effective and associated with considerable clinical benefits relative to standard medical management for very elderly patients with LVO stroke. Our findings support the provision of EVT to the very elderly.

ABSTRACT Background Despite successful recanalization rates exceeding 85% with mechanical thrombectomy, approximately half of acute ischemic stroke patients with large vessel occlusion experience futile recanalization—vessel reopening without meaningful functional recovery. Better predictive frameworks are needed. Methods We conducted a retrospective cohort study of 283 consecutive patients with large vessel occlusion stroke who achieved successful recanalization (mTICI ≥2b) between December 2022 and December 2023. The primary endpoint was futile recanalization, defined as modified Rankin Scale >3 at 90 days. Multivariable logistic regression identified independent predictors, while ROC analysis determined optimal cutoff values. Results Among 283 patients (mean age 67.2 ± 12.8 years, 54.4% male), 189 (66.8%) experienced futile recanalization. Independent predictors included advanced age (adjusted OR 1.048, 95% CI 1.021–1.076, p = 0.001), higher baseline NIHSS score (adjusted OR 1.132, 95% CI 1.078–1.189, p < 0.001), and antibiotic requirement during hospitalization (adjusted OR 2.891, 95% CI 1.587–5.267, p < 0.001). Antibiotics were initiated at median 3 days [IQR 2–5] post-admission. Optimal cutoff values were age > 68.5 years and NIHSS > 21.5. The predictive model demonstrated excellent discrimination (AUC 0.883, 95% CI 0.840–0.926) and good calibration (Hosmer-Lemeshow p = 0.287). Conclusions Advanced age, severe baseline neurological deficit, and systemic infectious complications independently predict futile recanalization following mechanical thrombectomy. These findings provide a clinically applicable framework for risk stratification, treatment optimization, and prognostic counseling in acute stroke care.

Endovascular thrombectomy (EVT) is the standard of care in acute ischemic stroke (AIS), yet functional outcomes remain suboptimal. Normobaric hyperoxia (NBHO) is a potential neuroprotective strategy. This study is the first systematic review and meta-analysis to assess NBHO as a potential neuroprotective adjunctive to improve outcomes in EVT-treated patients. A comprehensive search of electronic databases, including PubMed, Scopus, Cochrane, and Web of Science, was performed in February 2025. The inclusion criteria targeted randomized controlled trials (RCTs) comparing NBHO and EVT to EVT alone or with sham oxygen therapy. Statistical analyses were performed using RevMan software. Four RCTs comprising 648 patients with AIS due to large vessel occlusion in the anterior circulation were included in the study. For the primary efficacy endpoint of excellent functional outcome, defined as the number of patients who had a Modified Rankin Scale (mRS) score of ≤ 1 at 90 days, the overall odds ratio with a subgroup based on the oxygen delivery duration at 2, 4, and 6h was in favor of the NBHO group compared to the control (OR = 1.66, 95% CI [1.13, 2.45], P = 0.01, I2 = 0%). The subgroup of 4-hour oxygen delivery duration was the only significant subgroup (OR = 1.6, 95% CI [1.01, 2.51], P = 0.04). Safety outcomes showed no significant differences between the NBHO group and the control group across all reported measures. NBHO as an adjunct to EVT appears to be effective and safe. A 4-hour duration was found to be the most effective. Further RCTs are needed to confirm our results and establish the optimal treatment protocol.

Guidelines generally advise against reperfusion therapy in patients with mild stroke (NIHSS ≤ 5) and non-disabling symptoms. However, stroke severity can fluctuate, and clinical scores may not fully capture tissue at risk. Reliance on non-contrast CT (NCCT), potentially missing perfusion deficits or large vessel occlusions (LVOs). Advanced imaging-including CT angiography (CTA) and CT perfusion (CTP)-can reveal significant hypoperfusion in otherwise mild presentations. This study aimed to quantify the proportion of increased tissue-at-risk volumes (Tmax + 6s ≥ 15 mL) in patients with mild acute ischaemic stroke and identify associated factors and outcomes. We included consecutive AIS patients within 24h of onset from multicentre stroke registries in Australia and Indonesia. Only those with baseline NCCT, CTA, and CTP were analysed. Patients were stratified into NIHSS ≤ 5 and > 5. Tissue-at-risk was defined as Tmax + 6s ≥ 15 mL. Clinical, imaging, and outcome data were compared, and predictors of poor functional outcome (mRS 3-6 at 90-day) were assessed. Of 655 patients, 314 had NIHSS ≤ 5. Among these, 22.9% exhibited Tmax + 6s ≥ 15 mL, indicating significant hypoperfusion. This subgroup had worse 90-day outcomes (26.4% mRS 3-6 vs. 9.5%, p < 0.001). Tmax + 6s ≥ 15 mL, hypertension, and LVO were independently associated with poor outcome (adjusted ORs: 2.51, 3.15, and 2.74 respectively). ROC analysis demonstrated moderate discrimination of Tmax + 6s volume for poor functional outcome. A substantial proportion of mild stroke patients harbour treatable perfusion deficits. CT perfusion provides essential prognostic information beyond clinical severity, supporting its role in guiding therapeutic decisions-even in low NIHSS presentations where standard imaging may otherwise overlook tissue at risk.

BackgroundTimely identification of stroke etiology is crucial in managing large vessel occlusion (LVO) strokes. However, a substantial proportion remain cryptogenic despite comprehensive workup, raising concern about underdiagnosed cardioembolic sources. This study assessed the diagnostic contribution of early combined brain-cardiac CT imaging in patients with LVO stroke and explored imaging markers associated with each etiological subtype.Methods252 consecutive patients admitted for LVO stroke who underwent standardized acute-phase brain and cardiac CT imaging were included. Patients were classified as atheromatous, cardioembolic, or cryptogenic LVO stroke before and after consideration of cardiac CT results. Clinical and imaging characteristics of patients were compared according to final causes of stroke.ResultsCardiac CT led to etiological reclassification in 8 patients (3.2%), including 7 cryptogenic cases upgraded to cardioembolic due to detection of intracardiac thrombi in the absence of atrial fibrillation. Patients with cardioembolic LVO stroke (n=137,54%) were older, more frequently women, and had higher left atrial surface areas and volumes compared to atheromatous (n=40,16%) and cryptogenic cases (n=75, 30%). Epicardial adipose tissue volume was highest in atheromatous strokes while cryptogenic cases lacked markers of atrial cardiomyopathy. At follow-up, mortality was highest in the cardioembolic group.ConclusionsEarly brain-cardiac CT imaging enhances etiological classification in LVO strokes by identifying intracardiac thrombi and other cardioembolic markers missed by standard workup. A substantial subset of cryptogenic LVO strokes may represent a distinct pathophysiological entity. Broader adoption of cardiac CT could inform targeted stroke prevention strategies.

Children with congenital or acquired cardiac disease are at increased risk for both ischemic and hemorrhagic stroke. This review covers the epidemiology, presentation, acute management, and outcomes of stroke in children with heart disease. The major advances in endovascular thrombectomy for adults with large vessel occlusions (LVOs) have had significant ramifications for children with cardioembolic stroke, who often present with LVO. Several large registry studies have shown that thrombectomy likely improves outcomes for children with LVO, including those with acquired or congenital heart disease. Improving both primary and secondary stroke prevention remains both vital and challenging; as more children with congenital heart disease survive into adulthood, studies show that they remain at increased risk for stroke and may be susceptible to earlier frailty and cognitive impairment. Children with cardiac disease have a lifelong increased risk of stroke. While new interventions such as thrombectomy may improve outcomes, more research is needed to improve long term neurologic outcomes in this population.

Objectives To investigate the association between dynamic changes in estimated glomerular filtration rate (eGFR) and in-hospital mortality risk in patients with acute ischemic stroke due to large vessel occlusion (LVO-AIS) undergoing endovascular therapy (EVT). Methods This retrospective cohort study consecutively enrolled 329 patients with anterior circulation LVO-AIS who underwent EVT between January 2018 and January 2025. The eGFR was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) 2009 equation at admission (baseline), and on days 1 and 3 post-EVT. The primary outcome was all-cause in-hospital mortality. Multivariable logistic regression models and restricted cubic spline regression were employed to assess the association between eGFR and outcomes. Subgroup analyses with interaction testing were conducted to evaluate the consistency of this association across different patient populations. Results Of the 329 patients, 49 (14.9%) died during hospitalization. Baseline eGFR was not significantly associated with mortality ( P = 0.223), whereas post-EVT eGFR demonstrated a pronounced time-dependent association. Patients who died exhibited a progressive decline in eGFR ( P &amp;lt; 0.05), while survivors showed a modest increase ( P &amp;lt; 0.01). After comprehensive adjustment for confounders, each 1 mL/min/1.73 m 2 decrease in day-3 eGFR was associated with a 3% increase in mortality risk ( P &amp;lt; 0.001); moderate-to-severe renal dysfunction (eGFR &amp;lt; 60 mL/min/1.73 m 2 ) on day 3 was associated with a 4.3-fold increased risk of death ( P &amp;lt; 0.001). Subgroup analyses revealed consistent associations across subgroups, with no significant interactions (all P for interaction &amp;gt; 0.05). Furthermore, post-EVT eGFR decline was significantly associated with increased risk of symptomatic intracerebral hemorrhage (sICH) ( P &amp;lt; 0.001), but not with hemorrhagic transformation (HT). Conclusion Dynamic decline in eGFR, particularly the level on day 3 post-EVT, is independently associated with in-hospital mortality in LVO-AIS patients undergoing EVT, exhibiting a clear dose-response relationship.

Background: Sex-related disparities in long-term outcomes after large vessel occlusion (LVO) following mechanical thrombectomy (MT) have been repeatedly shown. Notably, a lower likelihood of achieving functional independence 90 days post-stroke has been found in women. However, most studies showed equal outcomes for both sexes after MT. It remains unclear whether there are sex differences in the prognostic values of clinical and neuroradiological parameters. Our investigation aimed to discern the divergent prognostic values of multiple markers between sexes. Methods: We retrospectively examined 183 stroke patients with LVO who received MT. Using multivariable logistic regression models, we investigated sex-specific associations of various parameters, including ASPECTS, lesion core volume, penumbra volume, collateral status, and time to reperfusion, concerning outcomes at discharge and 90 days post-stroke. Results: We observed no significant difference between men and women in achieving a favorable outcome defined as modified Rankin Scale (mRS) 0–2. However, when considering the full mRS, women exhibited less favorable overall outcomes. In women, NIHSS, TICI score, and penumbra volume were associated with outcome, whereas in men, core lesion volume and ASPECTS were associated. Age was the only factor associated with outcome in both sexes. Conclusions: Considering the full spectrum of mRS may provide more sophisticated understanding of sex-related outcome differences. Further, these findings highlight the importance sex-specific prognostic factors in outcome assessment. Unraveling sex-specific prognostic biomarkers of recovery has the potential to advance precision medicine and personalized clinical management in stroke.

Background Currently, for patients with large-vessel occlusion (LVO) strokes, the standard treatment approach involves using alteplase (ALT) as a bridge to endovascular mechanical thrombectomy (MT). Tenecteplase (TNK) is a novel fibrinolytic agent. Our research is focused on evaluating and comparing the efficacy and safety of TNK and ALT in patients with acute ischemic stroke (AIS) and large-vessel occlusion before they undergo MT. Methods The study’s research plan was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the number CRD42025643339. The entire process adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, guaranteeing high-quality and standardized reporting and analysis. Results In total, 7 studies involving 4,580 patients were incorporated. Patients treated with TNK exhibited comparable rates of functional independence at 90 days (odds ratio 1.23, 95% confidence interval 0.90–1.68, p = 0.2), post-MT recanalization (1.18, 0.93–1.51, p = 0.18), symptomatic intracerebral hemorrhage (sICH; 1.01, 0.62–1.65, p = 0.98) and mortality within 90 days (0.77, 0.51–1.18, p = 0.24) to those treated with alteplase. However, compared to alteplase-treated patients, those treated with TNK had higher rates of early recanalization (1.28, 1.06–1.53, p = 0.009), and a lower incidence of intracranial hemorrhage (ICH; 1.83, 1.26–2.66, p = 0.002). Conclusion Regarding of functional independence at 90 days, post-MT recanalization, sICH and 90-day mortality in AIS patients undergoing MT, there were essentially no difference between TNK and ALT. However, TNK might be more effective than ALT in achieving early recanalization, and it may also reduce the risks of ICH. Clinical trial registration Unique Identifier: CRD42025643339, Publicly Accessible URL: https://www.crd.york.ac.uk/PROSPERO/ .

Background: Intravenous thrombolysis before mechanical thrombectomy may enhance reperfusion before, during, and after the procedure but also increase the risk of intracranial hemorrhage. Tenecteplase (TNK), a genetically modified variant of alteplase with greater fibrin specificity and a longer half-life, allows single-bolus administration, offering practical and pharmacological advantages. These features have sparked interest in its use for acute stroke. However, its impact on outcomes when used prior to mechanical thrombectomy in large vessel occlusion (LVO) remains to be fully defined. Methods: We conducted a comprehensive meta-analysis of five clinical trials, including a total of 1,389 patients with acute ischemic stroke who received intravenous TNK prior to mechanical thrombectomy. A meta-analysis of proportions was performed using a random-effects model to calculate pooled estimates and 95% confidence intervals (CIs). Primary efficacy outcomes included successful reperfusion both before and after thrombectomy, and excellent functional recovery—defined as a modified Rankin Scale (mRS) score of 0–1 at 90 days. Functional independence, defined as mRS 0–2 at 90 days, was also assessed. Safety outcomes included any intracranial hemorrhage (ICH) within 48 hours and all-cause mortality at 90 days. Results: Successful reperfusion before thrombectomy was observed in 14% of patients (95% CI, 9%–22%), while post-thrombectomy reperfusion was achieved in 85% (95% CI, 75%–91%), indicating a potential benefit of TNK in enhancing recanalization. At 90 days, 37% of patients (95% CI, 27%–49%) achieved excellent functional outcomes (mRS 0–1). Functional independence (mRS 0–2) was achieved in 50.7% of patients (95% CI, 44.2%–57.2%). Mortality at 90 days was 11% (95% CI, 5%–24%). However, intracranial hemorrhage within 48 hours occurred in 37% (95% CI, 27%–49%), raising safety considerations. Conclusions: This meta-analysis of five clinical trials suggests that intravenous tenecteplase prior to mechanical thrombectomy is associated with favorable reperfusion and functional outcomes in patients with LVO stroke. However, the elevated risk of intracranial hemorrhage findings supports the importance of careful patient selection. These findings support the continued investigation of TNK in randomized controlled trials to further define its safety and efficacy profile in acute stroke care.

Background: Stroke is a leading cause of long-term disability and death, where time to treatment drastically affects outcomes. Rapid detection and transport to appropriate stroke centers is essential, particularly for severe stroke subtypes such as large vessel occlusion or subarachnoid hemorrhage. Emergency Medical Services (EMS) are the first point of contact for many stroke patients, making prehospital triage an important determinant of timely care. Current screening tools such as the Cincinnati Prehospital Stroke Scale are inconsistently applied, lack sensitivity, and do not account for stroke severity. Machine learning (ML)-based clinical decision support tools could enable earlier and more accurate stroke detection in real time. Research Questions: We hypothesized that analysis of prehospital EMS data using ML could lead to accurate and timely recognition of stroke and its subtypes with superior accuracy compared to existing screening tools. Methods: We conducted a retrospective analysis of 8,796 EMS encounters from 4,754 unique patients transported to a university-affiliated emergency department between 2015-2020. Stroke (n=192; 2.2%) and severe stroke (n=131; 1.5%) outcomes were determined using ICD-10 and CPT codes. Inputs for ML model included demographics, vital signs, and dispatch characteristics. Three ML models – random forest (RF), XGBoost (XGB), and a sequential neural network (SNN) – were trained for binary classification of stroke and severe stroke. Performance was assessed using ROC-AUC and PR-AUC with 5,000 bootstrap resamples. Sensitivity and specificity were evaluated across thresholds. SHAP values were used to interpret model predictions and identify influential features. Results: RF performed best for stroke (ROC-AUC: 0.827 [95% CI: 0.771-0.881]; PR-AUC: 0.230), while XGB performed best for severe stroke (ROC-AUC: 0.871 [95% CI: 0.803-0.929]; PR-AUC: 0.237), as shown in Figures 1 and 2 . Literature-reported CPSS (81.1% sensitivity, 51.7% specificity) and VAN (81% sensitivity, 38% specificity) benchmarks were overlaid for visual comparison. ML models showed improved performance and favorable tradeoffs across thresholds. Top features included systolic/diastolic blood pressure, Glasgow Coma Scale, pulse, age, and dispatch codes. Conclusions: Machine learning using structured EMS data improves prehospital stroke and severe stroke detection. Future models incorporating glucose, ECG results, or free-text notes may improve precision and support real-time triage.

Background: Large vascular occlusion (LVO) strokes account for a significant proportion of ischemic strokes, with considerable morbidity and death. While sex-based differences in stroke presentation and treatment have been discovered, comprehensive national data on gender-specific outcomes after LVO remain scarce. Objective: To evaluate gender-specific differences in in-hospital outcomes, interventions, and mortality among patients hospitalized with acute ischemic stroke due to large vessel occlusion using the National Inpatient Sample. Methods: We performed a retrospective cohort analysis of the National Inpatient Sample (2016-2020) to identify adult patients (≥18 years) with acute ischemic stroke owing to LVO using ICD-10-CM codes (I63.x) and procedure codes for mechanical thrombectomy (03CG3ZZ, 03CG4ZZ). The patients were split into sexes. The main outcome was inpatient mortality. Secondary outcomes were thrombectomy, thrombolysis, discharge status, length of stay (LOS), and total hospital expenditures. Demographics, comorbidities, and hospital characteristics were all adjusted by multivariate logistic regression. Results: A total of 52,491 weighted hospitalizations for LVO were investigated (53.8% female, 46.2% male). Women were significantly older (mean age 74.2 vs. 68.5 years, p &lt; p&lt;0.001) and had higher rates of atrial fibrillation and hypertension. After adjusting, women had a lower risk of receiving mechanical thrombectomy (aOR 0.87; 95% CI: 0.84-0.91) and IV thrombolysis (aOR 0.90; 95% CI: 0.86-0.94). Despite this, women had higher in-hospital death rates (aOR 1.15; 95% CI: 1.09-1.22). Women were less likely to be discharged home (aOR 0.82; 95% CI: 0.78-0.86) and had a greater length of stay (+1.2 days, p&lt;0.01). Total charges were comparable for both sexes. Conclusion: Significant gender inequalities exist in the care and outcomes of LVO stroke hospitalizations in the U.S. Women are less likely to receive revascularization treatment and have inferior in-hospital outcomes despite comparable healthcare resource usage. These findings concentrated strategies to minimize sex-based disparities in stroke therapy and increase equity in acute neurovascular intervention.

Introduction: Acute ischemic stroke is a known complication of aortic dissection (AD), either by extension, thromboembolism, or cerebral hypoperfusion. The incidence ranges from 6–32% among patients with AD. Case Presentation: A 42-year-old male with a history of hypertension and chronic Stanford type A/DeBakey I AD post aortic arch and valve repair (11 years prior), with thoracoabdominal dissection and aneurysmal changes, presented with difficulty in speech and unsteady gait. Blood pressure (BP) was 183/102 mmHg. ECG showed normal sinus rhythm. The last well-known was 45 minutes before the presentation; the National Institutes of Health stroke scale (NIHSS) was 6. The non-contrast CT head was unremarkable; CT angio showed left M2 MCA occlusion in the Sylvian fissure, Stanford type A AD with flaps crossing the origins of the brachiocephalic, left common carotid, and left subclavian. CT head perfusion revealed 65 cc of ischemic penumbra in the left MCA territory and a core infarct of 7 cc. MRI of the brain revealed an acute infarct in the left frontal and parietal lobes; CT chest/abdomen/pelvis showed an aneurysmal thoracoabdominal aorta (descending: 6x5.9 cm; suprarenal: 4.1x4 cm; infrarenal: 5.4x6.1 cm) with mural thrombus in the false lumen. On day 0, his mental status declined, NIHSS increased to 16 and he required intubation. He was taken for emergent percutaneous intracranial mechanical thrombectomy (MT) through left carotid artery access by vascular surgery, followed by interventional neurology rescue and achieved thrombolysis in cerebral ischemia score (TICI) 2C. He was extubated on day 1, and NIHSS improved to 3 over the next 3 days. Discussion: In our patient, chronic AD with mural thrombus, chronic tobacco use, hypertension, and dyslipidemia increased the risk of stroke. Intravenous thrombolysis among patients with AD can lead to serious complications, including aortic rupture and cardiac tamponade. MT may improve neurologic outcomes. AIS secondary to large vessel occlusion in our patient led to worsening neurological function, which was significantly improved after MT with near-complete reperfusion. In our patient, carotid access was chosen as femoral access poses a high risk in AD. MT is a standard intervention secondary to large vessel occlusion, but data regarding the efficacy of MT among patients with AD is sparse. He was discharged on apixaban; antihypertensives were optimized, and cardiology follow-up was arranged for elective aortic repair.

Background/Objectives: Downstream occlusion (DOC) is a commonly observed, yet frequently overlooked, angiographic event during mechanical thrombectomy (MT) for acute large vessel occlusion (LVO). This phenomenon has the potential to complicate procedures and influence outcomes. However, its prevalence, predictors, and endovascular trajectories remain poorly understood. Methods: A retrospective analysis of 703 patients who underwent MT for acute intracranial LVO between 2010 and 2021 at a tertiary stroke center was conducted. DOC was angiographically identified as a newly developed occlusion in a downstream artery following recanalization of the primary occlusion. Multivariate logistic regression was employed to analyze the clinical and procedural predictors of DOC. Endovascular and clinical outcomes were compared between patients with and without DOC. The DOC trajectory, including immediate reperfusion status, subsequent recanalization attempts, and final outcomes, was analyzed based on the occlusion location. Results: DOC was identified in 254 patients (36.1%). Atrial fibrillation and proximal occlusion were independently associated with DOC. Despite DOC adversely affecting endovascular procedural details, patients with DOC demonstrated comparable rates of final successful recanalization (92.5% vs. 91.3%; p = 0.577) and 90-day functional independence (40.2% vs. 46.3%; p = 0.114). Notably, about half of the patients exhibited an immediate modified Thrombolysis In Cerebral Infarction (mTICI) grade 2b at the time of DOC. Further recanalization attempts were undertaken in 67.7% of DOC cases, resulting in enhanced mTICI grades in 76.7% of cases and achieving final successful recanalization in 94.2% of cases. The functional advantages of additional recanalization attempts varied depending on DOC location but were generally limited. Conclusions: Despite its procedural complexity, DOC did not significantly compromise final recanalization or functional outcomes. Many cases were effectively managed with additional endovascular treatment, highlighting the importance of achieving sufficient final recanalization.

Prolonged venous transit (PVT), indicative of impaired venous outflow, is linked to poor outcomes in acute ischemic stroke due to large-vessel occlusion (AIS-LVO) treated with mechanical thrombectomy (MT). This study investigated the prognostic significance of PVT in AIS-LVO patients achieving near-complete or complete reperfusion (mTICI 2c or 3). Retrospective analysis of a prospective registry included AIS-LVO patients with anterior circulation occlusions, mTICI 2c or 3 after MT, and 90-day modified Rankin Scale (mRS) scores. PVT, defined as Tmax ≥ 10s in the posterior superior sagittal sinus or torcula on pretreatment CT perfusion, was assessed. Outcomes were favorable recovery (mRS 0-2), excellent recovery (mRS 0-1), and 90-day mortality. Among 81 patients, 25 (31%) were PVT + and 56 (69%) were PVT-. Baseline characteristics were similar. PVT + patients had higher discharge NIH Stroke Scale scores and worse 90-day mRS scores (median mRS, 4.00 vs. 1.00; P < 0.001). Multivariable analysis showed PVT + independently predicted lower odds of favorable (OR, 0.18; 95% CI, 0.04-0.65; P = 0.013) and excellent outcomes (OR, 0.12; 95% CI, 0.02-0.52; P = 0.008) and higher 90-day mortality (OR, 4.11; 95% CI, 1.08-17.0; P = 0.041). PVT is a strong negative prognostic marker in AIS-LVO patients with excellent reperfusion, associated with reduced functional recovery and increased 90-day mortality. PVT assessment may identify high-risk patients despite successful MT.

Over the past decades, ischemic stroke research has primarily focused on achieving rapid reperfusion. Endovascular thrombectomy has revolutionized the treatment paradigm for patients with large vessel occlusion, with recent trials showing benefit even in patients with large core at baseline. These findings have led some to advocate for reperfusion in all cases, regardless of infarct size and severity. We critically examine this line of reasoning and introduce 2 important caveats. First, in an individual patient, reperfusion does not necessarily or uniformly translate into meaningful improvement and favorable outcomes. The concept of futile reperfusion is real. As a corollary, trial results capture average effects, and individuals have a wider range of outcomes. Furthermore, results are often reported as relative rather than absolute treatment effects. As baseline prognosis worsens, the absolute likelihood of a good outcome may fall below a threshold where the intervention is no longer justified, despite a favorable relative treatment effect. Second, in a small subset of patients, reperfusion may actively worsen outcome; this is harmful reperfusion. While additional harm may seem negligible in such a high-risk population, this rationale is flawed as it encourages therapeutic actionism and violates the foundational medical ethical principle of primum non nocere. To advance patient care, we must move beyond a one-size-fits-all reperfusion model that focuses only on vessel reopening. Some patients might have infarcts that are simply too large (eg, >150 mL), ischemia that is too severe (eg, severe noncontrast computed tomography hypodensity), or comorbidities that overwhelm any potential benefit. A more nuanced approach requires a better understanding of tissue viability, perfusion physiology, and ischemic damage. This would allow for refined patient selection by leveraging advanced imaging and large-scale data sets to develop accurate models to predict treatment effect, that is, beneficial, futile, and harmful reperfusion.

Impact of Risk Factors and a New Transfer Pathway on Endovascular Thrombectomy Outcomes in Acute Ischemic Stroke.

The Impact of the Bypass Transport Method on Clinical Outcomes after Large Vessel Occlusion: A Pooled-Proportion Meta-Analysis.

Endovascular treatment (EVT) for intracranial atherosclerotic disease (ICAD)-related acute large vessel occlusion (LVO) has not been established in patients with posterior circulation occlusion. This study aimed to investigate the disparities in clinical outcomes after EVT between anterior and posterior circulation ICAD-related LVO. Using nationwide data from the retrospective multicenter registry, we conducted a post hoc analysis of 451 patients with acute ischemic stroke and ICAD-related LVO. Patients were categorized into the anterior (occlusion of the internal carotid artery or M1 or M2 segment of the middle cerebral artery) and posterior (occlusion of the basilar or intracranial vertebral arteries) groups. The primary outcome was a modified Rankin Scale score of 0 to 2 at 90 days. The posterior group exhibited a higher proportion of male patients, National Institute of Health Stroke Scale score, and prevalence of diabetes and hyperlipidemia. Although the onset-to-door and door-to-puncture times were comparable, the procedure time was significantly longer in the posterior group than in the anterior group (59 [33-99] vs 46 [29-72], P = .009). The use of stent retrievers was less frequent, and balloon angioplasty was more common in the posterior group. Adjusted analyses revealed that the posterior group had lower odds of achieving an modified Rankin Scale score of 0 to 2 at 90 days (adjusted odds ratio: 0.54, 95% CI: 0.31-0.95, P = .03) and a higher mortality rate (adjusted hazard ratio: 2.97, 95% CI: 1.27-6.95, P = .01) than the anterior group. Poorer clinical outcomes were associated with EVT for ICAD-related LVO in the posterior circulation. These findings emphasize the need to optimize treatment strategies for this patient population to improve overall prognosis.

Acute ischemic stroke (AIS) is a significant cause of morbidity and mortality among older adults, with its incidence, severity, and complication rates increasing with age. Endovascular thrombectomy (EVT) is the standard treatment for AIS due to a large vessel occlusion (LVO), but many landmark trials have excluded patients aged 80 years and older, resulting in a gap in the available evidence. Nonetheless, meaningful recovery is possible when successful recanalization is achieved, especially in patients with good pre-stroke functionality. When making EVT decisions for older adults, it is crucial to consider the unique challenges presented by this population. These challenges include age-related vascular changes, comorbidities, declining organ function, polypharmacy, altered drug responses, frailty, and baseline cognitive impairment. Anesthesiologists play a crucial role in optimizing outcomes through rapid assessment, careful physiological management, and effective multidisciplinary coordination. Both general anesthesia (GA) and conscious sedation (CS) are valid options for EVT, with the choice depending on patient factors, the complexity of the procedure, and the expertise of the institution. While GA may enhance recanalization rates and improve outcomes, it also carries increased risks such as delayed time from door to groin, hypotension, and a higher incidence of postoperative delirium and pneumonia. In contrast, CS may offer a safer alternative in selected cases, although it can limit the effectiveness of the procedure, potentially impacting reperfusion success. The impact of specific anesthetic agents on outcomes for older patients is still unclear. In addition, age-related changes in cardiovascular, respiratory, renal, and neurological functions, along with polypharmacy, contribute to an increased risk of hemodynamic instability and drug interactions. Older patients also face a higher risk of perioperative complications, such as delirium and cognitive dysfunction, which complicate the management of anesthesia. However, anesthesiologists can positively influence outcomes by managing modifiable factors such as, maintaining blood pressure within guideline-based targets, keeping blood glucose levels between 140 and 200 mg/dL, ensuring normoxia and normocapnia, avoiding hyperthermia, and anticipating technical challenges posed by tortuous, atherosclerotic vessels and resistant clots. This review aims to thoroughly examine anesthesia management for EVT in older adults.