Large Infarction Research Articles

Right ventricular cardiomyocyte expansion accompanies cardiac regeneration in newborn mice after large left ventricular infarcts.

Cauterization of the root of the left coronary artery (LCA) in the neonatal heart on postnatal day 1 (P1) resulted in large, reproducible lesions of the left ventricle (LV), and an attendant marked adaptive response in the right ventricle (RV). The response of both chambers to LV myocardial infarction involved enhanced cardiomyocyte (CM) division and binucleation, as well as LV revascularization, leading to restored heart function within 7 days post surgery (7 dps). By contrast, infarction of P3 mice resulted in cardiac scarring without a significant regenerative and adaptive response of the LV and the RV, leading to subsequent heart failure and death within 7 dps. The prominent RV myocyte expansion in P1 mice involved an acute increase in pulmonary arterial pressure and a unique gene regulatory response, leading to an increase in RV mass and preserved heart function. Thus, distinct adaptive mechanisms in the RV, such as CM proliferation and RV expansion, enable marked cardiac regeneration of the infarcted LV at P1 and full functional recovery.

Enlarged Perivascular Spaces Predict Malignant Cerebral Edema after Acute Large Hemispheric Infarction

Introduction: Enlarged perivascular spaces (EPVS) are considered early manifestations of impaired clearance mechanisms in the brain; however, it is unclear whether EPVS are associated with the development of malignant cerebral edema (MCE) after large hemispheric infarction (LHI). Therefore, we investigated the predictive value of EPVS in predicting MCE in LHI. Methods: Patients suffering from acute LHI were consecutively enrolled. EPVS were rated after the stroke with validated rating scales from magnetic resonance images. Patients were divided into two groups according to the occurrence of MCE. Logistic regression was used to analyze the relationship between EPVS and MCE in the basal ganglia (BG) and centrum semiovale (CS) regions. Receiver operating characteristic (ROC) curves assessed the ability of EPVS individually and with other factors in predicting MCE. Results: We included a total of 255 patients, of whom 98 were MCE patients (58 [59.2%] males, aged 70 [range = 61.75–78] years) and found that atrial fibrillation, National Institutes of Health Stroke Scale score, infarct volume, neutrophil-lymphocyte ratio, and moderate-to-severe CS-EPVS were positively associated with MCE. After adjusting for confounds, moderate-to-severe CS-EPVS remained independent risk factor of MCE (odds ratio = 16.212, p < 0.001). According to the ROC analysis, MCE was highly suspected when CS-EPVS >14 (sensitivity = 0.82, specificity = 0.48), and the guiding value was higher when CS-EPVS combined with other MCE predictors (area under the curve = 0.90, sensitivity = 0.74, specificity = 0.90). Conclusion: CS-EPVS were important risk factor for MEC in patients with acute LHI and can help identify patients at risk for MCE.

Abstract 152: Endovascular Therapy versus Medical Management for Acute Ischemic Stroke With Large Infarct: A Time-Benefit Relationship Analysis

Objective: Recent randomized trials demonstrated the benefit of endovascular thrombectomy for acute ischemic stroke with large infarct. We aimed to characterize the effect of time to treatment on the benefit of endovascular therapy compared to medical management among patients with acute large ischemic stroke. Methods: Analysis the Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients with a Large Infarct Core trial (ANGEL-ASPECT), which was a multicenter, randomized trial at 46 comprehensive stroke centers in China from August 2020 to October 2022. Onset to arterial puncture time (OPT) associated with outcomes of endovascular therapy were analyzed as a category and continuous variable. The primary outcome was favorable outcome (modified Rankin scale 0-3) at 90 days. Secondary outcomes included degree of disability (modified Rankin scale range), symptomatic intracranial hemorrhage, any intracranial hemorrhage, and mortality. Results: Among 455 eligible patients, the median age was 68 years, and median Alberta Stroke Program Early Computed Tomography Score was 3 (interquartile range 3-4). Compared with medical management alone, endovascular therapy plus medical management was associated with higher rates of favorable outcome with OPT within 6 hours (44.4% vs 29.9%, adjusted odds ratio[aOR] 2.78 [95% confidence interval [CI] 1.22-6.32]), 6-12 hours (45.7% vs 29.6%, aOR 2.39 [95% CI 1.21-4.71]), but not in OPT beyond 12 hours (51.6% vs 41.4%, aOR 2.05 [95% CI, 0.88-4.77]). The benefit in favorable outcome became nonsignificant after OPT of 13 hours and 22 minutes. In three OPT intervals, the odds of better disability outcome with endovascular therapy plus medical management than medical management alone were observed; the rates of symptomatic intracranial hemorrhage and mortality were similar, though the rates of any intracranial hemorrhage increased. Conclusion: In patients with large cerebral infarction, endovascular therapy plus medical management was efficacious in improving functional outcomes with acceptable safety in a broad time window of 0 to 24 hours, but greater benefit was observed with earlier treatment. A pooled analysis with larger sample size is needed.

Abstract TP181: Endovascular Therapy for Acute Ischemic Stroke With Large Infarct: A Meta Analysis of Randomized Controlled Trials

Background: The efficacy of endovascular thrombectomy (EVT) in patients with large infarct among acute ischemic stroke patients has not been exclusively studied, with conflicting results till date. Objective: We sought to evaluate the outcomes comparing EVT and medical therapy among stroke patients with large infarcts. Methods: We performed a systematic literature search on PubMed, EMBASE, and Clinicaltrial.gov for relevant randomized controlled trials (RCTs) from inception until August 30th, 2023. Odds ratios (OR) were pooled using a random-effect model, and a p-value of &lt;0.05 was considered statistically significant. Results: A total of 3 randomized controlled trials with 1010 patients (509 in EVT and 501 in MT) were included in the analysis. Pooled analysis of primary and secondary endpoints showed that ET was associated with a significantly greater rate of MRS 0-2 (OR, 2.53(95%CI: 1.76-3.64), P&lt;0.001), MRS 0-3 (OR, 1.75(95%CI: 1.28-2.39), P&lt;0.001). ET group of patients were having a significantly higher risk of any intracranial hemorrhage (OR, 2.34(95%CI: 1.53-3.58), P&gt;0.001), and a trend of higher risk of incidence of symptomatic intracranial hemorrhage (OR, 1.83(95%CI: 0.90-3.70), P=0.09) compared to medical therapy. However, the risk of incidence of 90 days mortality (OR, 0.95(95%CI: 0.73-1.24), P=0.71), hemi craniotomy (OR, 0.97(95%CI: 0.45-2.12), P=0.95), and adverse cardiovascular event (OR, 1.68(95%CI: 0.50-5.59), P=0.40) was comparable between ET and MT group. Conclusion: Patients with large infarcts had better functional outcomes with ET than with MT alone. However, intracranial hemorrhage was higher among ET compared with MT group, while 90 days mortality being comparable between both groups of patients.

Abstract 84: Efficacy of Endovascular Therapy in Acute Ischemic Stroke by Alberta Stroke Program Early Computed Tomography Score and National Institutes of Health Stroke Scale-A Secondary Analysis of a Randomized Controlled Trial

Introduction and Aims: The ANGEL-ASPECT trial demonstrated the effectiveness of endovascular therapy (EVT) in acute ischemic stroke (AIS) patients with large infarct. We did a secondary analysis to explore the efficacy of EVT according to Alberta Stroke Program Early Computed Tomography Score (ASPECT) and National Institutes of Health Stroke Scale (NIHSS). Methods: ANGEL-ASPECT trial was a randomized clinical trial involving patients with acute anterior-circulation large-vessel occlusion and an ASPECT score of 3-5 or an infarct-core volume of 70-100ml. Patients were randomly assigned to EVT or standard medical treatment (SMT) alone. We categorized patients based on the combination of ASPECT (≤3 or 4-5) and NIHSS (&lt;20 or ≥20) into four groups: low ASPECT &amp; low NIHSS; low ASPECT &amp; high NIHSS; high ASPECT &amp; low NIHSS and high ASPECT &amp; high NIHSS. We assessed the efficacy of EVT using ordinal shift analysis of 90-day modified Rankin Scale (mRS). Results: Among 455 patients, the prevalence of the four groups were 190 (41.8%), 70 (15.4%), 157 (34.5%) and 38 (8.4%), respectively. A significant shift in the distribution of 90-days mRS toward better outcomes in favor of EVT was observed in patients with low ASPECT &amp; low NIHSS (common OR [cOR], 2.25; 95% CI, 1.34-3.76; P=0.002), and high ASPECT &amp; low NIHSS (cOR, 2.30; 95% CI, 1.31-4.05; P=0.004), but not in other two groups with high NIHSS (all P &gt;0.05). Conclusions: EVT was associated with better outcomes in AIS patients with large infarct and mild-to-moderate stroke severity (NIHSS &lt;20), but not in those with severe stroke severity (NIHSS ≥20). Stroke severity should be considered when planning EVT for AIS patients with large infarcts.

Abstract TMP52: Modern Thin-Slice CT Perfusion Has High Sensitivity for Supratentorial Lacunar Stroke

Background: Lacunar stroke is a common form of ischaemic stroke with mechanisms poorly understood compared to large vessel stroke. Access to gold standard MRI is often limited in the acute setting. Acute diagnosis of lacunar stroke is difficult with conventional CT, as non-contrast CT and CT angiography have poor sensitivity. Previous studies have demonstrated only low to moderate sensitivity of CT perfusion (CTP). Aims: To test the accuracy of thin-slice CTP to detect lacunar stroke and compare the clinical and radiological characteristics to better understand the limitations of CTP for diagnosis of lacunar stroke. Methods: We reviewed thin-slice CTP (slice thickness &lt;=3mm) of cases presenting with an acute lacunar syndrome without large/medium vessel occlusion, or perfusion lesion detected by automated analysis. Cases presented to two comprehensive stroke centres in Sydney and Newcastle, NSW, Australia, between 2019 and 2022. CTP was reviewed by two independent reviewers, blinded to follow-up MRI but not the clinical syndrome. CTP and DWI were registered to a standard template and DWI lesions were manually segmented. CTP was further reviewed adjacent to DWI, and raw CTP values within the lesion was calculated. Results: We reviewed 394 cases of acute lacunar syndrome including 82 stroke mimics, 48 infratentorial and 250 supratentorial infarcts. Overall sensitivity was 76% and varied by infarct location. Sensitivity was lowest for brainstem (46%), moderate for thalamic (69%) and high for infarcts within the lenticulostriate perforator territory (84%). Factors associated with reduced sensitivity include small infarct volume, increased noise, or artefact, and infratentorial location. Conclusion: Thin-slice CTP has high sensitivity for detection of supratentorial lacunar infarcts however is more susceptible to noise and imaging artefact than larger infarcts. Advanced processing techniques show promise to improve overall diagnosis of lacunar stroke.

Abstract 40: Relationship of Collateral Status With Clinical Outcomes in Endovascular Thrombectomy for Large Core Stroke: A SELECT2 Subanalysis

Background: Previous studies demonstrating association of collateral status with clinical outcomes after endovascular thrombectomy (EVT) excluded patients with large core infarcts. We analyzed the association of collateral status with clinical outcomes and EVT treatment effect in SELECT2. Methods: In SELECT2, a central core lab adjudicated CT-angiographic collateral status using collateral scores (CS) by Tan et al. Patients were stratified based on CS into poor (CS 0-1) vs good (CS 2-3) collaterals. The primary outcome was the distribution of modified Rankin Scale score at 90-day follow-up. Models were adjusted for core volume, ASPECTS in addition to age, stroke severity and time to randomization. Results: Of 352 patients, 180 received EVT. Median collateral status was 2(IQR 1-2). Patients presenting &lt;6h after last known well (LKW) (n=100) had poorer collaterals than those presenting at 6-24 hours (n=252), median 1 (1-2) vs 2 (1-2), p&lt;0.001. Collateral status inversely correlated with CTP core volume (Rho=-0.32, p&lt;0.0001), but not with CT ASPECTS (Rho=0.07, p=0.16). Overall, point estimates favored EVT in patients with poor (CS 0-1) [aGenOR: 1.32, 95% CI: 0.98-1.79, p=0.068] and good (CS 2-3) collaterals [aGenOR: 1.97, 95% CI: 1.43-2.72, p&lt;0.001] without significant heterogeneity [p-interaction=0.094]. However, in the earlier 0-6h time window, there was evidence of treatment effect hetermogeneity with a larger treatment effect when good collaterals were present [aGenOR: 4.10, 95% CI: 1.81-9.29] and an absent treatment effect when only poor collaterals were observed [aGenOR: 1.26, 95% CI: 0.79-1.99], p-interaction=0.023. In the late time window, (6-12h), the EVT treatment effect did not differ significantly between poor collaterals (aGenOR: 1.35, 95% CI: 0.91-2.01) and good collaterals (aGenOR: 1.78, 95% CI: 1.24-2.56, p-interaction=0.50). Conclusion: Collateral status was worse in large core patients presenting in early (&lt;6 hours) window; and correlated with ischemic core volume but not ASPECTS. Collaterals status modified EVT treatment effect in the early but not the late time window, in which both good and poor collaterals still benefited from EVT. Clinicaltrials.gov registration: NCT03876457

Abstract TMP96: Clear Thrombectomy Score: An Index to Estimate Probability of Good Functional Outcome Following Endovascular Treatment in the Late Window for Anterior Circulation Occlusion

Background: Endovascular thrombectomy (EVT) has established efficacy across a wide range of patient age, radiological findings, and clinical features. However, EVT may be less effective in extreme scenarios (e.g., large established infarction in later treatment windows), where there are currently limited data. Methods: A heterogeneous, multinational observational cohort (CLEAR registry) of consecutive adult patients ≥18 years old who underwent EVT for acute occlusion (2014-2022) of the internal carotid or proximal middle cerebral (M1 or M2) arteries was queried (n=64 sites). A high-fidelity model for predicting good functional outcome at 90 days (return to pre-stroke modified Rankin Scale [mRS] or mRS 0-2 after EVT) was developed using a binary, multivariable logit model with adaptive double lasso adjustment, which was validated using 5-fold cross validation and 1000 bootstrap sampling for confidence intervals. Results: At the time of the analysis, we evaluated 2953 patients from the registry treated with EVT, of which 1855 (63%) had complete covariate data for inclusion. The median National Institutes of Health Stroke Scale (NIHSS) score was 15 (IQR 9-20), with 14.0% having a pre-stroke mRS &gt;2, 8.3% having a NIHSS &lt;6, and 17.8% having an Alberta Stroke Program Early Computed Tomography Scale (ASPECTS) score ≤6. A good functional outcome occurred in 813 (43.8%) patients. Independent predictors of the primary outcome, with points allocated toward the final score, included younger age, higher ASPECTS, lower NIHSS, and time from last known well to arterial puncture. The areas under the curve for derivation and validation cohorts were 0.72 (95% CI 0.70-0.75) and 0.74 (95% CI 0.71-0.80), respectively. Discussion: The CLEAR thrombectomy score provides a simple, validated means of predicting good functional outcome following late-window, anterior circulation thrombectomy using routinely acquired clinical and imaging data. External validation is warranted.

Abstract TP133: Clot Burden Score Correlates Best With Hypoperfusion Volume and Predicts Final Infarct ASPECTS&lt;=3 in Anterior Circulation Ischemic Strokes

Purpose: Clot Burden Score (CBS) is a semiquantitative measure of thrombus extent on CTA for proximal anterior circulation strokes whose relationship with perfusion metrics has not been fully explored. CBS has potential added value during stroke triage if perfusion imaging is not available or suboptimal. We aimed to investigate if CBS is (1) correlated to perfusion estimates of infarct core volume, hypoperfusion volume, or collateral status, and (2) a predictor of final infarct extent without reperfusion therapy. Methods: Retrospective analysis included consecutive patients (1) arriving &lt;24 hours from onset, (2) with occlusion in the intracranial ICA, M1, M2, or A1 or combination, (3) with concurrent CTP, and (4) had followup CT or DWI during hospitalization. CBS is a 10-point negative ordinal scale: 2-points subtracted for occlusion of supraclinoid ICA, proximal M1, or distal M1, and 1-point subtracted for occlusion of infraclinoid ICA, A1, or M2. Correlation of CBS with perfusion metrics was evaluated using Spearman's rank test. Final infarct ASPECTS were scored for those without thrombolysis or thrombectomy. Multivariate logistic regression was used to identify predictors of final ASPECTS&lt;=3 (approximating &gt;=100mL). ROC analysis was evaluated to assess performance and optimal thresholds. Results: 222 patients included with median (IQR) age of 75 (65-84) and NIHSS of 18 (11-24). Median CBS was 7 (6-9) and best correlated to Tmax&gt;6s r=-0.579 (hypoperfusion volume), followed by HIR r=-0.401 (collateral status) and rCBF&lt;30% r=-0.306 (core volume), all p&lt;0.001. 71 (32.0%) untreated patients also had median CBS of 7 (6-9). CBS and Tmax&gt;6s had the strongest correlation to final ASPECTS in this subgroup, r=0.637 and r=-0.686 (both p&lt;0.001). 22 of these (30.1%) had final ASPECTS&lt;=3. Multivariate logistic regression including CBS, Tmax&gt;6s, HIR, baseline ASPECTS, and NIHSS showed only CBS as independent predictor of final ASPECTS&lt;=3 (p&lt;0.001). ROC AUC for CBS was 0.902 [95% CI: 0.819-0.985] with optimal threshold of &lt;=6 for sensitivity 86.4% and specificity 81.6%. Conclusion: CBS as a measure of thrombus extent correlates best with baseline hypoperfusion volume on CTP and independently predicts very large final infarcts (ASPECTS&lt;=3) without treatment.

Abstract 157: Endovascular Treatment of Acute Ischemic Stroke Patients With Tandem Lesions Presenting With Low Alberta Stroke Program Early Computed Tomography Score

Background and objective: The effect of endovascular therapy (EVT) in tandem lesion (TL) patients with baseline large core infarct is unclear. We investigated the safety and efficacy of EVT in TL patients with low ASPECTS (0-5). We also compared the safety of acute carotid stenting (CAS) in TLs with low ASPECTS. Methods: This prospective multicenter study from 16 centers included patients with anterior circulation TL from 2015-2020. Inclusion criteria were age ≥18 years, EVT for intracranial occlusion, and underwent treatment for extracranial ICA lesions with &gt;70% stenosis. Patients were divided into ASPECTS 0-5 and 6-10 groups. Inverse Probability of Treatment Weighting (IPTW) was used to assess the association of outcomes. Results: Of the 691 patients, 44 had an ASPECTS 0-5 and 505 had ASPECTS 6-10. After matching, there were decreased odds of favorable shift in mRS at 90 days (30.7% vs 48%, OR: 0.52, CI:0.29-0.97; p=0.002), higher rates of sICH (11.4% vs 3.6%, OR: 3.18, CI: 1.07-9.49; p=0.038), 90-day mortality (35.9% vs 16.3%; OR: 2.35, CI: 1.16-4.74; p=0.017) and comparable rates of successful reperfusion (79.5% vs 88.7%; OR: 0.73, CI: 0.33-1.63, p=0.45), excellent reperfusion (50% vs 49.1%; OR: 1.35, CI: 0.72-2.53; p=0.35) excellent reperfusion (50% vs 49.1%; OR: 1.35, CI: 0.72-2.53; p=0.35) in the ASPECTS 0-5 compared with 6-10. Among patients with ASPECTS 0-5, no significant differences were noted for sICH (OR: 0.31, CI: 0.03-3.05; p=0.32), PH2 (OR: 1.14, CI: 0.26-5.02; p=0.86), petechial hemorrhages (OR: 0.79, CI: 0.10-6.05; p=0.82), and 90-day mortality (OR: 0.68, CI: 0.14-3.45; p=0.6) in patients with stenting (18/44) versus no-stenting (25/44). Conclusion: This multicenter cohort study of AIS patients with TLs demonstrated poor outcomes for functional independence at 90 days and higher rates of sICH and mortality in patients with low ASPECTS (0-5). Among patients with ASPECTS 0-5, rates of sICH and mortality were similar in stenting and non-stenting groups.

Abstract 155: Critical Care Decisions After Large Core Cerebral Infarctions: A Secondary Analysis From the SELECT2 Trial

Background/hypothesis: The SELECT2 trial randomly assigned patients with LVO and large ischemic cores to either endovascular thrombectomy (EVT) or medical management (MM). This population is at high risk for cerebral edema and other complications, often leading to critical decisions about decompressive hemicraniectomy (DHC) or early withdrawal of care (WOC). We hypothesized that patients initially treated with EVT were more likely to get life-sustaining care regardless of recanalization success, presumably because initial treatment with EVT led toward an expectation of aggressive care, while those treated with MM expected futility. Methods: We analyzed the full SELECT2 study population using the as-treated principle, comparing the use of DHC and early (within 7 days from randomization) transition to comfort measures/WOC. We also compared these decisions based on recanalization success in those receiving EVT. We further tested baseline characteristics for association with these outcomes. Results: Patients treated with EVT were as likely to undergo DHC (aRR:1.19 [0.75-1.88], p=0.46) or WOC (aRR:0.94 [0.66-1.34], p=0.72) as those given MM (Table). Time to DHC was also similar (EVT 47[19-74] vs. MM 36[27-61] hours, p=0.95). Patients with successful (mTICI≥2b) recanalization were numerically less likely to undergo DHC than those with unsuccessful (TICI 0-2a) recanalization (aRR:0.66 [0.33-1.3], p=0.23), while WOC was similar (Table). Larger estimated core volumes were associated with both DHC and WOC, with DHC used more in younger and WOC more in older patients. Conclusions: In the SELECT2 trial of patients with large infarct cores, DHC was performed in ~1 in 6 and WOC in ~1 in 5, without an observed difference based on treatment with EVT or MM. The similar distribution of decisions to proceed with DHC or to change goals of care to acute palliative measures provides reassurance that the overall trial outcomes were not biased by open-label treatment allocation.

Abstract TP130: Prevalence of Fast Progressors of Infarct Growth in Anterior Circulation Large Vessel Occlusions &lt;6 Hours From Onset

Background/Purpose: Fast progressors (FP) of infarct growth in anterior circulation large vessel occlusions (LVO) may be prevalent in the &lt;6h period depending on how it is defined. The 3 recently completed randomized trials of endovascular thrombectomy (EVT) on large infarct core volumes (ICV) all used ASPECTS criterion of 3-5 which approximates 70-100mL in absolute volume. We aimed to investigate the prevalence of FP in LVO &lt;6h and how many of these were at or on pace to reach the 70mL or 100mL ICV threshold for EVT selection. Methods: We retrospectively included consecutive stroke patients arriving &lt;6h from symptom onset with ICA and/or M1 occlusion on CTA and had concurrent CT perfusion (CTP). RAPID AI software generated maps of ICV depicted as rCBF&lt;30% and critical hypoperfusion depicted as Tmax&gt;6s. Infarct growth rate (IGR) was calculated as ICV/onset-to-imaging time. FP was defined at 2 levels: as "FP70" with IGR &gt;11.7mL/h (which would result in an ICV &gt;70mL by 6h) and had &gt;=70mL of overall hypoperfusion present; and as "FP100" with IGR &gt;16.7mL/h (which would result in an ICV &gt;100mL by 6h) and had &gt;=100mL of overall hypoperfusion present. Results: 108 patients were included with median (IQR) age of 75.5 (67-85), NIHSS of 20 (12-24), onset time of 2h (1.5-4), median ICV of 11mL (0-40), hypoperfusion volume of 122mL (70-164), and mismatch volume of 86.5mL (58-130). The sites of LVO were ICA 12 (11.1%), M1 73 (67.6%), and both 23 (21.3%). Median IGR for the cohort was 3.8mL/h (0-16.4). 31 FP70 were found (28.7%, 95% CI: 19.5-40.7%) with median IGR of 31.3mL/h (16.8-42). 14 of these (45.2%, 95% CI: 24.7-75.8%) already had ICV&gt;70mL upon arrival, with median of 100mL (86-156) and 8 of 14 also showed mismatch ratio &lt;1.8. 25 FP100 were found (23.1%, 95% CI: 16.2-36.9%) with median IGR of 38.7mL/h (24.6-51.4). 8 of these (32.0%, 95% CI: 13.8-63.1%) already had ICV&gt;100mL upon arrival, with median of 138mL (101-172) and 5 of 8 also showed mismatch ratio &lt;1.8. Conclusion: In a cohort of acute anterior circulation LVO strokes &lt;6h from onset, the vast majority were good candidates for EVT with small to medium size core volumes. However, ~25% were fast progressors that may require more caution in selection, with ICV at or on pace to reach 70-100mL thresholds by 6h.

Hemorrhage in sinus vein thrombosis: the "cashew sign"

Intracerebral hemorrhages are quite common in sinus vein thrombosis (SVT). The morphology of these hemorrhages may vary from small localized juxtacortical lesions and subarachnoid hemorrhages to large hemorrhagic infarcts (Coutinho, van den Berg et al. 2014). In this presentation, we aimed to emphasize venous hemorrhage and the "cashew sign" seen in SVT.

Risk factors, clinical presentation and 1-year outcome of ischemic stroke caused by small artery disease

BackgroundThe prevalence of ischemic stroke (IS) caused by small-artery disease (SAD) is increasing recently. The present study aimed to report the risk factors, clinical presentations and outcome in patients presented with IS due to SAD with follow up for one year. The present study included 100 patients with IS due to SAD diagnosed on the basis of clinical and radiological findings. All patients were submitted to careful history taking, thorough clinical examination and standard laboratory work-up. Assessment of neurological functions was achieved using the National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS). Cognitive functions were evaluated using Trail making test, Stroop color word test, Arithmetic test, Vocabulary test, Wechsler adult intelligence scale IV digit span forward assessment and backward assessment. Magnetic resonance imaging (MRI) was done using a standard 1.5 Tesla unit. According to radiological findings, patients were classified into three groups: GI (n = 40) with IS due to SAD, GII (n = 30) with IS due to SAD plus internal watershed infarcts and GIII (n = 30) with IS due to SAD plus large artery infarctions (n = 30).ResultsComparison between the three groups regarding the reported risk factors identified significantly lower frequency of hyperlipidemia in GI patients as compared to GII and GIII patients (35.0% versus 60.0% and 66.7% respectively, p = 0.018). Clinically, it was shown that GI patients had significantly higher frequency of dizziness, dysphasia and tinnitus in comparison to the other two groups. It was also shown that those patients had significantly lower mean cortical thickness at the end of follow up (3.12 ± 0.9 versus 2.22 ± 0.8, p = 0.031). Finally, MRI brain volumetric study showed significantly decreased total cerebral cortical volume (TCCV) (589,456 ± 1689 versus 559,152 ± 1459) and total cerebral white matter volume (TCWMV) (521,546 ± 1785 versus 501,306 ± 1259) at the end of follow up.ConclusionsIschemic stroke caused by small artery disease is related to poor outcome with deterioration of cognitive functions.

Mechanical Thrombectomy for All LVO – Is It Feasible? – Recent Evidence to Expand the Current Stroke Guidelines

Mechanical thrombectomy (MT) has established its role as a standard care of acute ischemic stroke due to large vessel occlusion (LVO). Current early stroke management guidelines have defined certain selection criteria for LVO patients undergoing MT to achieve the most benefit. However, it is still uncertain if some other LVO patients who do not meet these criteria can also benefit from MT. In this review, we research the latest evidence on efficacy and safety of MT for LVO in various unique stroke populations, such as advanced age, pre-stroke disability, LVO with minor stroke, large infarct volume, poor mismatch profile, very late time window, posterior circulation LVO and distal medium-sized vessel occlusions. By comparing the benefits and risks of MT with best medical management only, we may develop further subgroup-specific criteria to expand our capacity to best treat these unique LVO populations.

Development and validation of a prognostic computed tomography scoring model for functional outcomes in patients with large hemispheric infarction following decompressive craniectomy.

There is no established prognostic scoring system developed for patients with large hemispheric infarction (LHI) following decompressive craniectomy (DC) based on imaging characteristics. The present study aimed to develop and validate a new computed tomography scoring model to assess the 6-month risk of poor functional outcomes (modified-Rankin scale [mRS] score of 4-6) in patients with LHI receiving DC. This retrospective cohort study included patients at two tertiary stroke centers. A prediction model was developed based on a multivariable logistic regression. The final risk factors included the ASPECTS (Alberta Stroke Program Early Computed Tomography Score), longitudinal fissure cistern, Sylvian fissure cistern, and additional vascular territory involvement. 1,000 bootstrap resamples and temporal validation were implemented as validations for the scoring system. Of the 100 individuals included in the development cohort, 71 had poor functional outcomes. The scoring model presented excellent discrimination and calibration with C-index = 0.87 for the development cohort, and C-index = 0.83 for the temporal validation cohort with non-significant Hosmer-Lemeshow goodness-of-fit test. The scoring model also showed an improved AUC compared to the ASPECTS. For each point in the score model, the adjusted risk of poor functional outcomes increase by 47.8% (OR = 1.48, p < 0.001). The scores were inversely correlated with MAP (mean arterial pressure, paired t-test, p = 0.0015) and CPP (cerebral perfusion pressure, rho = -0.17, p = 0.04). In patients with LHI following DC, the score system is an excellent predictor of poor functional outcomes and is associated with CPP and MAP, which might be worth considering in clinical settings after further external validation.

Cardiovascular magnetic resonance imaging-derived intraventricular pressure gradients in ST-segment elevation myocardial infarction: a long-term follow-up study.

Recently, novel post-processing tools have become available that measure intraventricular pressure gradients (IVPGs) on routinely obtained long-axis cine cardiac magnetic resonance (CMR) images. IVPGs provide a comprehensive overview of both systolic and diastolic left ventricular (LV) functions. Whether IVPGs are associated with clinical outcome after ST-elevation myocardial infarction (STEMI) is currently unknown. Here, we investigated the association between CMR-derived LV-IVPGs and major adverse cardiovascular events (MACE) in a large reperfused STEMI cohort with long-term outcome. In this prospectively enrolled multi-centre cohort study, 307 patients underwent CMR within 14 days after the first STEMI. LV-IVPGs (from apex-to-base) were estimated on the long-axis cine images. During a median follow-up of 9.7 (5.9-12.5) years, MACE (i.e. composite of cardiovascular death and de novo heart failure hospitalisation) occurred in 49 patients (16.0%). These patients had larger infarcts, more often microvascular injury, and impaired LV-IVPGs. In univariable Cox regression, overall LV-IVPG was significantly associated with MACE and remained significantly associated after adjustment for common clinical risk factors (hazard ratio (HR) 0.873, 95% confidence interval (CI) 0.794-0.961, P = 0.005) and myocardial injury parameters (HR 0.906, 95% CI 0.825-0.995, P = 0.038). However, adjusted for LV ejection fraction and LV global longitudinal strain (GLS), overall LV-IVPG does not provide additional prognostic information (HR 0.959, 95% CI 0.866-1.063, P = 0.426). Early after STEMI, CMR-derived LV-IVPGs are univariably associated with MACE and this association remains significant after adjustment for common clinical risk factors and measures of infarct severity. However, LV-IVPGs do not add prognostic value to LV ejection fraction and LV GLS.

Effect of computed tomography vs. computed tomography perfusion on mechanical thrombectomy outcomes within 6hours.

It is unclear which selection strategy, plain CT vs. CT perfusion (CTP), is more powerful in predicting outcome after mechanical thrombectomy (MT). We aimed to compare the effect of plain CT and CTP in predicting outcome after MT within 6h. We conducted a prospective analysis of a retrospective cohort from our single-center study, which had occlusion of the internal carotid artery and middle cerebral artery up to the proximal M2 segment and received MT within 6h. According to the Alberta Stroke Program Early CT Score (ASPECTS), patients were divided into a high-ASPECTS group (≥ 6) and a low ASPECTS group (< 6). Similarly, patients were divided into mismatch and no-mismatch groups according to the DEFUSE3 criteria for CTP. A good outcome was defined as a 90-day modified Rankin Scale (mRS) score of ≤ 3. Univariate and binary logistic regression analyses were used to investigate the association between different imaging modality and 90-day mRS score, and mortalities, respectively. The high ASPECTS group included 307 patients (89.2%). The mismatch group included 189 (54.9%) patients meeting the DEFUSE3 criterion. Compared to the low ASPECTS group, the high ASPECTS group had a good outcome (odds ratio (OR), 2.285; [95% confidence interval (CI) (1.106, 4.723)], p = 0.026) and lower mortality (OR, 0.350; [95% CI (0.163, 0.752)], p = 0.007). However, there were no significant differences in good outcomes and mortality between the mismatch and no-mismatch groups. Compared with plain CT, CTP does not provide additional benefits in the selection of patients suitable for MT within 6h. CT perfusion is not superior to plain CT for the prediction of clinical outcomes when selecting patients for mechanical thrombectomy in the first 6h. In that clinical setting, plain CT may be safe in the absence of perfusion data. •The advantage of CT perfusion (CTP) over CT in pre-mechanical thrombectomy (MT) screening has not been proven for patients witha large infarct core. •CTP is not better than plain CT in predicting good outcome following MT within 6h. •Plain CT is sufficient for selecting patients suitable for MT within 6h of large artery occlusion.

Endovascular thrombectomy is cost-saving in patients with acute ischemic stroke with large infarct.

Endovascular thrombectomy (EVT) is the standard of care for acute large vessel occlusion stroke. Recently, the ANGEL-ASPECT and SELECT 2 trials showed improved outcomes in patients with acute ischemic Stroke presenting with large infarcts. The cost-effectiveness of EVT for this subpopulation of stroke patients has only been calculated using data from the previously published RESCUE-Japan LIMIT trial. It is, therefore, limited in its generalizability to an international population. With this study we primarily simulated patient-level costs to analyze the economic potential of EVT for patients with large ischemic stroke from a public health payer perspective based on the recently published data and secondarily identified determinants of cost-effectiveness. Costs and outcome of patients treated with EVT or only with the best medical care based on the recent prospective clinical trials ANGEL-ASPECT, SELECT2 and RESCUE-Japan LIMIT. A A Markov model was developed using treamtment outcomes derived from the most recent available literature. Deterministic and probabilistic sensitivity analyses addressed uncertainty. Endovascular treatment resulted in an incremental gain of 1.32 QALYs per procedure with cost savings of $17,318 per patient. Lifetime costs resulted to be most sensitive to the costs of the endovascular procedure. EVT is a cost-saving (i.e., dominant) strategy for patients presenting with large ischemic cores defined by inclusion criteria of the recently published ANGEL-ASPECT, SELECT2, and RESCUE-Japan LIMIT trials in comparison to best medical care in our simulation. Prospective data of individual patients need to be collected to validate these results.

Comprometimento cognitivo vascular e demência: uma revisão narrativa

ABSTRACT Vascular cognitive impairment (VCI) is the second most common cause of cognitive impairment after Alzheimer's disease. The VCI spectrum involves a decline in cognition attributable to vascular pathologies (e.g., large infarcts or hemorrhages, microinfarcts, microbleeds, lacunar infarcts, white matter hyperintensities, and perivascular space dilation). Pathophysiological mechanisms include direct tissue injury, small vessel disease, inflammaging (inflammation + aging), atrophy, and altered neurotransmission. VCI is diagnosed using distinct clinical and radiological criteria. It may lead to long-term disability and reduced quality of life. An essential factor for reducing cognitive impairment incidence is preventing stroke by managing traditional and non-traditional cerebrovascular risk factors. This article reviews the spectrum of VCI, epidemiology, risk factors, pathophysiology, diagnosis, available treatment, and preventive strategies.