Large Infarction Research Articles

Endovascular Treatment of Large Core Infarcts: no Limits?

Endovascular Treatment of Large Core Infarcts: no Limits?

Abstract 4120957: Endovascular Thrombectomy Versus Medical Management for Acute Ischemic Stroke with Large Infarct: An Updated Meta-Analysis of Randomized Controlled Trials

Background: Endovascular therapy (EVT) has revolutionized the treatment of acute ischemic stroke due to large vessel occlusions. Despite the increasing evidence for EVT, its efficacy remains understudied in patients with acute ischemic stroke with large infarcts. Patients with large-volume ischemic strokes are excluded from major randomized controlled trials (RCTs) despite contributing up to 25% of all acute ischemic strokes. Aim: This study aimed to compare clinical outcomes with endovascular thrombectomy versus medical management in patients with acute ischemic stroke with large infarct. Methods: We conducted a systematic literature review on PubMed, Embase, Scopus and Cochrane Library from inception to 15th May 2024 for RCTs. The inverse-variance random-effects model was used to pool odds ratio (OR) and risk ratio (RR) with 95% confidence intervals. The statistical significance was set at p<0.05. Results: 6 RCTs with 1887 patients (945: EVT and 942: medical management) were included. The mean age in both EVT and medical management groups was 70 ± 11.4 years. EVT was associated with a better modified Rankin Score (mRS) at 90 days [OR: 1.68; 95% CI: 1.38, 2.04; p<0.00001], mRS at 90 days (0-2) [OR: 2.47; 95% CI: 1.87, 3.27; p<0.00001], mRS at 90 days (0-3) [OR: 1.96; 95% CI: 1.56, 2.46; p<0.00001], and early neurological improvement [RR: 2.35; 95% CI: 1.79, 3.10; p<0.00001] compared to medical management. EVT was also associated with a higher risk of symptomatic intracranial hemorrhage [RR: 1.71; 95% CI: 1.09, 2.66; p=0.02]. The 90-day mortality [RR: 0.86; 95% CI: 0.72, 1.02; p=0.08] was comparable between the two groups. Conclusion: Patients with acute ischemic stroke with large infarct had superior functional outcomes with EVT as compared to medical management alone. However, EVT was associated with higher risks of symptomatic intracranial hemorrhage, with comparable 90-day mortality risk. Further large RCTs are warranted to evaluate the outcomes with EVT in acute ischemic stroke with large infarct.

New left ventricular thrombus and embolic events in left ventricular dysfunction postmyocardial infarction

Background: We aimed to assess the incidence and evolution of new left ventricular thrombus (LVT), and the incidence of manifest systemic embolism, in patients with severe left ventricular (LV) systolic dysfunction postacute anterior myocardial infarction (MI) who had been discharged on dual antiplatelet therapy. Methods: We prospectively included consecutive patients with postacute anterior MI and LV ejection fraction (LVEF) ≤35% or apical aneurysms or large infarctions with LVEF ≤40%. Transthoracic echocardiography (TTE) confirmed no LVT before hospital discharge, and a second TTE was performed at 30 days and a third one at 3 months. All TTE studies were prespecified to assess LVT, and the patients were screened for the development of clinically manifest systemic embolisms. Results: Two hundred and two consecutive patients (males 93%; mean age 55.2±6.4 years; mean LVEF 29.5±5.0%) were included. At 30 days (interquartile range: 2837 days), a new LVT was detected in 12 (5.9%) patients. Oral anticoagulant was added to all patients with LVT, and aspirin was continued in 5 (42.7%) patients for a month. The 3month TTE showed favorable evolution of LV size, LVEF and apical wall motion score index compared to the baseline. At 3 months, the LVT disappeared in 7 (58.3%) patients and 5 patients still had a mural LVT of smaller size, and none got new LVT. Among the group without LVT, one patient had a stroke, and another had a myocardial infarction and died. Conclusions: In contemporary practice, and using routine TTE, the incidence of new LVT in patients with severe LV dysfunction postacute anterior MI is low. They have a favorable LVT evolution with minor risk for clinically manifest systemic embolism.

To bridge or not to bridge: the role of intravenous thrombolysis in mechanical thrombectomy for large cerebral infarctions through a two-center cohort study and meta-analysis

BackgroundThe effectiveness and safety of intravenous thrombolysis before mechanical thrombectomy (MT) in large cerebral infarctions remains uncertain. This study compares bridging MT, which includes intravenous thrombolysis, to direct MT without it. MethodsData from 298 patients with anterior circulation large cerebral infarctions, assessed via non-enhanced CT (ASPECTS 0-5), who underwent MT in two-center cohort studies, were analyzed. Primary outcomes focused on independent ambulation (modified Rankin Scale scores 0-3) at 90 days post-stroke. Safety outcomes included parenchymal hemorrhage (PH) rates and mortality. We conducted a sensitivity analysis considering the timing from symptom onset to imaging within 4.5 hours. Additionally, a meta-analysis of 17 studies involving 3527 patients assessed the interventions' effectiveness and safety, with further scrutiny of high-quality studies (Newcastle-Ottawa Scale ratings 7-9) to increase robustness of results. ResultsNo significant differences were found in 90-day independent ambulation between the bridging MT and the direct MT group (adjusted odds ratio [aOR] 1.15, 95% CI 0.68-1.94). Rates of PH and mortality were also similar across groups. These outcomes were consistent in the subgroup imaged within 4.5 hours of symptom onset. The meta-analysis supported these outcomes, showing no improvement in ambulation (aOR 1.16, 95% CI 0.82-1.64) or reduction in PH with bridging MT. Further analysis of high-quality studies supported these results. ConclusionsThe cohort study and meta-analysis provide Class II evidence indicating no significant differences in functional outcomes or hemorrhagic risks between bridging and direct MT for large cerebral infarctions. This suggests that direct MT might be a viable alternative to bridging MT.

Endovascular Thrombectomy for Large Core Volume Acute Ischemic Stroke. Updated Systematic Review and Meta-Analysis

Background: Several recent studies assessed the efficacy and safety of endovascular thrombectomy (EVT) for patients with acute ischemic stroke caused by an anterior circulation large vessel occlusion (LVO) with large core infarct volumes. Methods: We performed a systematic review and meta-analysis from inception until July 2024 of all randomized clinical trials (RCTs) and observational studies to date comparing the efficacy and safety of EVT plus best medical management (MM) for acute ischemic stroke due to anterior circulation LVO with large core, versus MM alone. Primary efficacy outcome was optimal functional outcome defined by a 90-day modified Rankin scale score (mRS) of 0-2. Safety outcomes were risk of symptomatic intracranial hemorrhage (sICH) and 90-day mortality. Subgroup analyses were done by study design. Relative risk (RR) and 95% CIs were calculated using random-effects models and heterogeneity was assessed by I2 statistics. Results: A total of 16 studies with 3,717 participants met inclusion criteria (6 RCTs and 10 observational studies). The quality of the evidence was moderate to high. Compared with MM alone, EVT increased the outcome of mRS 0-2 (RR=2.91, 95% CI [2.12, 4.01], I2=63%), decreased mortality (RR=0.75 [0.63, 0.88], I2=60%), but did not influence the risk of sICH (I2=14%). When the analysis was restricted to data from RCTs (n=1,887), EVT increased the outcome of mRS 0-2 (RR=2.50 [1.89, 3.29], I2=8%) and sICH (RR=1.71 [1.09, 2.66], I2=0%) but did not affect mortality (I2=45%). In observational studies (n=1,830), patients receiving EVT had a higher likelihood of achieving a mRS 0-2 (RR=3.39 [1.98-5.79], I2=74%), lower mortality (RR=0.63 [1.49-0.82], I2=50%), but equal risk of sICH (I2=29) than those receiving MM alone. Conclusion: Among patients with LVO with large core infarct, EVT was associated with improved functional outcome at 90 days. When the analysis was restricted to RCTs, EVT increased the risk of sICH, but did not affect 90-day mortality. However, in real-world (observational) studies, EVT did not modify the risk of sICH but reduced 90-day mortality.

Anticoagulation Use and Endovascular Thrombectomy in Patients with Large Core Stroke: A Secondary Analysis of the SELECT2 Trial.

Endovascular thrombectomy (EVT) safety and efficacy in patients with large core infarcts receiving oral anticoagulants (OAC) are unknown. In the SELECT2 trial (NCT03876457), 29 of 180 (16%; vitamin K antagonists 15, direct OACs 14) EVT, and 18 of 172 (10%; vitamin K antagonists 3, direct OACs 15) medical management (MM) patients reported OAC use at baseline. EVT was not associated with better clinical outcomes in the OAC group (EVT 6 [4-6] vs MM 5 [4-6], adjusted generalized odds ratio 0.89 [0.53-1.50]), but demonstrated significantly better outcomes in patients without OAC (EVT 4 [3-6] vs MM 5 [4-6], adjusted generalized odds ratio 1.87 [1.45-2.40], p = 0.02). The OAC group had higher comorbidities, including atrial fibrillation (70% vs 17%), congestive heart failure (28% vs 10%), and hypertension (87% vs 72%), suggesting increased frailty. However, the results were consistent after adjustment for these comorbidities, and was similar regardless of the type of OACs used. Whereas any hemorrhage rates were higher in the OAC group receiving EVT (86% in OAC vs 70% in no OAC), no parenchymal hemorrhage or symptomatic intracranial hemorrhage were observed with OAC use in both the EVT and MM arms. Although we did not find evidence that the effect was due to excess hemorrhage or confounded by underlying cardiac disease or older age, OAC use alone should not exclude patients from receiving EVT. Baseline comorbidities and ischemic injury extent should be considered while making individualized treatment decisions. ANN NEUROL 2024;96:887-894.

Clinical application of the modified Pullicino formula in endovascular thrombectomy in acute anterior circulation large cerebral infarction-A two-center retrospective study.

This study aimed to assess whether the modified Pullicino formula could be used as a screening indicator for measuring infarct volume before endovascular thrombectomy (EVT) and observe baseline factors affecting neurological recovery in patients with acute anterior circulation large-core cerebral infarction. The Pullicino formula × (1-22%) was applied to anterior circulation large cerebral infarctions with ASPECTS <6 to screen patients with infarct volumes of 70-150 mL. The outcomes were assessed by mRS score at 90 days, modified Treatment in Cerebral Ischemia (mTICI) score, symptomatic intracranial hemorrhage within 48 h, and death rate within 90 days. Significantly more patients in the EVT group with infarct volumes 70-150 mL had mRS ≤3 at 90 days than did the standard drug therapy (OR, 2.93; 95% CI, 1.08-7.89, p=0.03) and a significantly decreased mortality rate (OR, 0.36; 95% CI, 0.13-0.98; p=0.04), with 88.2% in patients with mTICI ≥2b. There was no significant difference in the intracranial hemorrhage. EVT (adjusted OR [aOR], 2.84; 95% CI, 1.15-7.01, p=0.02), infarct volume <150 mL (aOR, 3.47; 95% CI, 1.20-10.14, p=0.02), and intracranial atherosclerosis (aOR, 4.20; 95% CI, 1.24-14.04, p=0.02) were significantly associated with patient prognosis. Without commercial artificial intelligence software, the modified Pullicino formula can be used to calculate infarct volume and, in combination with ASPECTS <6, to select patients who may benefit from EVT.

Anomalous origin of right coronary artery from left anterior descending coronary artery presenting with syncope – a case report

Introduction and importance: Non-dominant right coronary artery (RCA) is supposed to be benign as it does not result in large myocardial infarction. Still, in this case, non-dominant RCA from left anterior descending (LAD) artery not only produces ischemia but also results in incessant ventricular tachycardia, which is a life-threatening arrhythmia because of compromised blood flow. However, RCA is free of atherosclerotic plaque, which is the main cause of ischemia/infarction and subsequent arrhythmia. Case presentation: A 21-year-old male was admitted to the emergency cardiology ward of the National Institute of Cardiology following an episode of syncope. The patient reported a sudden loss of consciousness without preceding symptoms. Clinical discussion: The present case highlights the importance of a comprehensive evaluation and diagnosis in the management of syncope in young patients. The case presented here revealed a rare finding of a single coronary artery with a left main origin and an anomalous RCA emerging from the LAD artery. This is a very unusual presentation, with less than 50 occurrences recorded in the medical literature. This abnormality is classified as a single coronary artery anomaly (CAA), which means that the coronary arteries arise from a single coronary ostium within the aorta. Conclusion: In conclusion, CAA is an uncommon cause of SCA that can easily be overlooked without a systematic approach. In this report, we discuss the case of a patient who was discovered to have an anomalous RCA that branched off from the LAD artery.

Direct synchronized cardioversion not independently associated with infarcts on cerebral magnetic resonance imaging and clinical outcomes in patients with atrial fibrillation

Abstract Background Direct synchronized cardioversion (DCV) is frequently performed in atrial fibrillation (AF). In general, DCV is considered a safe procedure. A rare, but feared complication following DCV is an overt ischemic stroke resulting from embolization of a left atrial clot to the cerebral circulation. Purpose The aim of the present study was to assess the association of DCV with infarcts on brain magnetic resonance imaging (bMRI) and clinical outcomes. Methods 2386 patients of the Swiss AF cohort were included. 1731 patients were evaluated by bMRI. DCVs were recorded by questionnaire. Patients were categorized by number of DCVs performed before enrollment (0,1,≥2). BMRI were conducted at baseline and after 2 years (n=1227) and analyzed for large noncortical or cortical infarcts (LNCCI) and small noncortical infarcts (SNCI). Clinical outcomes were recorded during follow-up. Associations of DCV and outcome-measures were assessed by multivariate analyses. Results There was no independent association between the number of DCV and infarct prevalence (LNCCI + SNCI) on baseline bMRI (DCV 1 vs. 0: OR 0.95 [95% CI 0.73-1.26]; DCV ≥2 vs. 0: OR 1.04 [0.73-1.51]) or between DCV performed during follow-up and new infarcts on bMRI at 2 years (OR 1.46 [0.54-3.31]). DCVs were not associated with overt stroke or transient ischemic attack (DCV 1 vs. 0: HR 1.35 [0.87-2.03]; DCV ≥2 vs. 0: HR 1.54 [0.95-2.49]), hospitalization for heart failure (DCV 1 vs. 0: HR 1.03 [0.80-1.33]; DCV ≥2 vs. 0: HR 1.03 [0.77-1.37]), or death (DCV 1 vs. 0: HR 0.85 [0.67-1.09]; DCV ≥2 vs. 0: HR 0.92 [0.70-1.22]). Conclusions There was no association between DCV performed before enrollment and cerebral infarcts on baseline bMRI or between DCV performed during follow-up and new infarcts at 2 years. Moreover, DCV were not associated with clinical events.

Clinical significance of 12-lead electrocardiogram QRS scores on admission in ST-segment elevation myocardial infarction

Abstract Background A QRS scoring system by 12-lead electrocardiography (ECG) is a quick and simple method to evaluate degree and extension of myocardial infarction. Previous studies have shown that high QRS scores (≥5) at hospitalization (before reperfusion) related to impaired myocardial reperfusion during percutaneous coronary intervention (PCI) and subsequent poor prognosis in patients with ST-segment elevation myocardial infarction (STEMI) (Figure 1). However, the pathogenesis and associated factors with high QRS scores remain poorly defined. Therefore, this study aimed to explore clinical and lesion characteristics associated with QRS scores at hospitalization in patients with STEMI. Methods This retrospective observational study enrolled 138 broad anterior-wall STEMI patients who underwent PCI in the proximal left anterior descending artery and achieved reperfusion within 3 hours of onset. Patients were divided by QRS scores at hospitalization into low (&amp;lt;5: n=97) and high (≥5: n=41) QRS-scores, and clinical and lesion characteristics were compared between the 2 groups. Lesion characteristics were evaluated by intravascular ultrasound (IVUS). Results Despite early phase of STEMI, QRS scores at hospitalization varied (3 [2-5] points). Clinical characteristics, including onset-to-door time (66 [41-101] min vs. 55 [42-76] min) and onset-to-reperfusion time (112 [88-145] min vs. 106 [81-120] min), were comparable between patients with low and high QRS-scores. In contrast, significantly higher percentages of lipid plaques, plaque rupture and large thrombus were seen at the culprit lesion sites in patients with high versus low QRS scores (Figure 2). As a result, patients with high QRS scores had higher incidence of no-reflow phenomenon during PCI (36.6% vs. 12.6%, p&amp;lt;0.05) and larger infarct size assessed by peak CK values (5333 [3307-7443] IU/l vs. 1941 [759-3559], p&amp;lt;0.05) compared with those with low QRS-scores. Conclusions High QRS scores at hospitalization were associated with vulnerable lesion characteristics, as well as impaired coronary reperfusion and large infarct size. Although the exact mechanisms of the associations require future studies, QRS scores may help risk stratification before reperfusion and prognostic prediction after reperfusion.Figure 1.Figure 2.

Stroke thrombectomy for large infarcts with limited penumbra: Systematic review and meta-analysis of randomized trials.

Recent randomized trials have suggested that endovascular thrombectomy (EVT) is superior to medical management (MM) for stroke patients with large infarcts. However, whether or how perfusion metrics should be used to guide optimal patient selection for treatment is largely unknown. This was a meta-analysis of randomized controlled trials reporting the effectiveness of EVT for large infarcts stratified by perfusion mismatch profiles. Patients with mismatch ratio 1.2-1.8 or penumbra volume 10-15cc (intermediate mismatch) or mismatch ratio <1.2 or volume <10cc (low mismatch) were included. Odds of 90-day modified Rankin scale (mRS) 0 to 3 (good) and 5 to 6 (poor) were calculated and effect sizes were pooled using Mantel-Haenszel fixed-effects models. Two trials - SELECT2 and ANGEL-ASPECT - were included; 140 intermediate mismatch (75 EVT and 65 MM) and 60 low mismatch patients (23 EVT and 37 MM) were identified. EVT was significantly associated with higher odds of mRS 0 to 3 for intermediate mismatch (pooled OR 2.77 [95%CI 1.11-6.89], p=0.028; Figure 1), but not low mismatch (pooled OR 1.47 [95%CI 0.444.94], p=0.54; Figure 1). Similarly, in terms of 90-day poor outcomes (mRS 5 or 6), EVT for intermediate mismatch patients was significantly associated with lower odds (OR 0.49 [95%CI 0.24 to 0.99], p=0.046; Figure 2), while EVT for the low mismatch cohort was not (OR 0.66 [95%CI 0.22 to 1.96], p=0.45; Figure 2). There was no significant inter-study heterogeneity observed across study estimates. For patients with large infarcts, EVT appears to be likely beneficial for patients with perfusion mismatch ratio and volume of at least 1.2 and 10cc, but not for those with mismatch ratio <1.2 or volume <10cc. These data generally support the continued use of perfusion imaging to select patients with large infarcts for EVT if it is available at the treating institution. Future studies and trials should consider investigating the efficacy and safety of EVT for patients with large infarcts and low mismatch profiles. EVT = endovascular thrombectomy; MM = medical management; OR = odds ratio; CI = confidence interval.

Near Complete Reversal Of Large Diffusion-Weighted Imaging Lesion After Thrombectomy: A Case Report And Literature Review.

Diffusion-Weighted Imaging (DWI) plays a crucial role in acute ischemic stroke (AIS), as it is used to evaluate the ischemic lesions that are irreversibly damaged. The reversibility of DWI ischemic lesions has been noted in patients with AIS who undergo revascularization therapy. In addition, the occurrence of this phenomenon in large ischemic regions remains rare, particularly the near-complete reversal of large DWI lesion cases. A 58-year-old male presented with a generalized tonic-clonic seizure. Emergent magnetic resonance imaging (MRI) revealed an extremely large infarction lesion in the right hemisphere with an Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) value of 2 and occlusion of the terminal right internal carotid artery. The patient was immediately transferred to the Digital Subtraction Angiography (DSA) Unit for endovascular treatment with a stent retriever. After a rapid successful reperfusion with expanded treatment in cerebral infarction (eTICI) score of 3, the patient promptly recovered 24 hours after the procedure. A brain MRI was repeated after 8 days of admission, and interestingly, the DWI lesion showed significant reversal. The modified Rankin scale (mRS) at discharge was 2 and 1 at 90-day follow-up, respectively. Our case shows that the reversibility of DWI ischemic lesions can occur during the acute stroke phase, even in patients with extremely large regions, if rapid and successful reperfusion is achieved. The clinical implications of this phenomenon indicate that using DWI to evaluate the infarct core should be interpreted with caution.

Futile recanalization after endovascular treatment in acute ischemic stroke with large ischemic core

BackgroundEndovascular therapy (EVT) is the treatment of choice for acute ischemic stroke (AIS) with large vessel occlusion. However, in many patients, successful EVT recanalization does not correspond to a clinical improvement, called futile recanalization (FR). We aimed to identify stroke risk factors and patient characteristics associated with FR in AIS with large core infarct (LCI).MethodsA total of 137 patients with AIS with LCI treated by EVT at a single stroke center were retrospectively included from January 2016 to June 2023. LCI was defined by Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECT) < 6. Patient age, sex, modified Rankin Scale (mRS), National Institutes of Health Stroke Scale (NIHSS), time to treatment, risk factors, and radiologic findings were collected, and potential associations with FR were analyzed. FR was defined as successful reperfusion with modified Thrombolysis in Cerebral Infarction (mTICI) ≥ 2b but without functional independence at 90 days (mRS ≥ 3). A multivariate logistic regression analysis was conducted on the clinical characteristics of patients, based on the presence or absence of FR, and the factors influencing FR.ResultsOf 137 patients, 120 showed successful recanalization (mTICI ≥ 2b). All patients were divided into FR (n = 80) and no FR (n = 40) groups. Older age (odds ratio [OR] 1.052, 95% confidence interval [CI] 1.002–1.105; p = 0.041), the higher the initial NIHSS score (OR 1.181, 95% CI 1.037–1.344; p = 0.012), and prior intravenous plasminogen activator (OR 0.310, 95% CI 0.118–0.813, p = 0.017) were independent influencing factors of FR.ConclusionsThe older age, the higher the initial NIHSS, and not receiving intravenous plasminogen activator were independently associated with FR in AIS with LCI. These factors could identify poor responders to EVT recanalization.

Cerebral venous sinus thrombosis - Current updates in the Asian context.

Background Cerebral venous sinus thrombosis (CVT) is a life-threatening cause of stroke in Asian countries. South Asia, comprising of India, Pakistan and Bangladesh and contributed to 40% of strokes in women. Major CVT registries are from the western nations, which differs from the Asian countries with respect to epidemiology, gender biases and risk factors. This review focusses on the various aspects of relevance in evaluation and management of patients with CVT in the Asian context. Summary The incidence of CVT is higher in Asia than in Western nations. Young age, female gender, especially in pregnancy and puerperal period, and dehydration appear to be the critical risk factors. Tropical infections like malaria, scrub typhus, and flaviviral encephalitis predispose to CVT. There is a higher prevalence of inherited thrombophilia in the Asian cohorts, contributing to prothrombotic states. Anticoagulation and supportive management offer excellent outcomes. Newer anticoagulants are safe and efficacious. In medically refractory cases, endovascular treatment offers modest benefits. Decompressive hemicraniectomy, when done early, offers mortality benefits in patients with large hemorrhagic venous infarctions. Key messages CVT is an important cause of stroke with high-burden in South Asian countries. Establishment of robust registries is the need of the hour; to study the natural history, course and outcomes and to develop management algorithms tailored to the available resources.

Comprehensive analysis of the impact of procedure time and the ‘golden hour’ in subpopulations of stroke thrombectomy patients

ObjectiveTo evaluate the effect of procedure time on thrombectomy outcomes in different subpopulations of patients undergoing endovascular thrombectomy (EVT), given the recently expanded indications for EVT.MethodsThis multicenter study included patients...

Granulocyte colony-stimulating factor for stem cell mobilisation in acute myocardial infarction: a randomised controlled trial

BackgroundTo determine whether granulocyte colony-stimulating factor (G-CSF) improves clinical outcomes after large ST-elevation myocardial infarction (STEMI) when administered early in patients with left ventricular (LV) dysfunction after successful percutaneous coronary...

Predicting Futile Recanalization After Endovascular Thrombectomy for Patients With Stroke With Large Cores: The SNAP Score.

We aimed to develop and validate a prediction score for futile recanalization (FR) for large vessel occlusion (LVO) presenting low Alberta Stroke Program Early Computed Tomography Score (ASPECTS) for patients who underwent endovascular thrombectomy (EVT). Patients with anterior circulation LVO with low ASPECTS (<6) who underwent successful EVT (modified treatment in cerebral ischemia score ≥2b) from Stroke Thrombectomy and Aneurysm Registry were retrospectively analyzed. FR was defined as 90-day modified Rankin Scale (mRS) scores ≥4 despite successful EVT. Multivariable logistic regression was used to identify independent predictors of FR, and they were used to create a clinical score. The performance of the score was assessed by receiver operating characteristic curve analyses. Of 219 patients, 170 and 49 patients were randomly assigned to the training and validation cohort, respectively. Independent predictors of FR identified in the training cohort were used to construct the SNAP score: site of occlusion (middle cerebral artery = 0, internal carotid artery = 1), National Institutes of Health Stroke Scale score at admission (≤10 = 0, 10 to 19 = 1, ≥20 = 2), age (<75 = 0, ≥75 = 2), and prestroke mRS score (0-3). Receiver operating characteristic curve analyses of the SNAP score in the training and validation cohorts showed areas under the curve of 0.79 (95% CI 0.72-0.86) and 0.79 (95% CI 0.65-0.92) for predicting FR, respectively. A SNAP score ≥5 had a positive predictive value of 92.1% [95% CI 78.8%-97.3%] for FR. The SNAP score may be useful in predicting FR after EVT in low-ASPECTS patients with LVO. It can provide patients, family members, and physicians with reliable outcome expectations among patients with acute ischemic stroke with large infarcts.

The move to 24/7 mechanical thrombectomy provision for ischaemic stroke: an observational study of the impact on referrals, activity, procedural efficacy, and safety at a supra-regional centre.

Health systems are striving to improve delivery of mechanical thrombectomy (MT) for ischaemic stroke. With the move to 24/7 provision, we aimed to assess (1) the change in referral and procedural frequency and timing, (2) reasons referrals did not proceed to MT, and (3) nocturnal procedural efficacy and safety. This was an observational study comparing 12-month data for an extended daytime service (2021/2022, hours, 0800-2000) to that for a 12-month period delivering 24/7 cover (2023-2024). Nocturnal and daytime outcomes (rate of recanalisation using modified TICI scoring), extent of postprocedural infarction (using ASPECTS grading), rate of early neurological improvement (using 24-h NIHSS change), 90-day mortality, and complicating symptomatic intracranial haemorrhage (SICH) in the latter period were compared. Both referrals (432 to 851) and procedural caseload (191 to 403) approximately doubled with the move to 24/7 cover; 36% of procedures occurred overnight (n= 145). The dominant reasons for referrals not proceeding to MT were a large core infarct (n= 144) or absence of a large vessel occlusion on baseline imaging (n= 140). There were no significant differences in successful recanalisation (TICI 2B/3: 85.5% vs 87.1%, P= .233), rates of postprocedural ASPECTS≥7 (74.9% vs 75.8%, P= .987), early neurological improvement (NIHSS reduction ≥30%: 43.4% vs 42.4%, P= .917), 90-day mortality (19.6% vs 18.6%, P= .896), or SICH (1.9% vs 4.1%, P= .214) obtained for daytime vs nighttime hours. 24/7 MT provision has resulted in a rapid rise in the number of patients who may benefit from MT. This service can be provided with an acceptable safety profile during nighttime hours in a high-volume comprehensive UK centre.

The value of electroencephalography features in the prognostic evaluation of large hemispheric infarction patients at different time intervals.

Large Hemispheric Infarction (LHI) is a devastating disease with high mortality. This study aimed to use electroencephalography (EEG) to evaluate the death risk of LHI patients and identify suitable evaluation time. This study retrospectively collected clinical and EEG data from 73 LHI patients, dividing them into death and survival group at discharge. EEG data was classified as 1-5 days and 6-14 days after onset according to the time intervals of cerebral edema. Regression and receiver operator characteristic curve (ROC) analysis were applied to explore the impact of temporal changes in various EEG and clinical features on death. The areas under ROC curve (AUC) of death prediction for non-α frequency on non-infarct side at 6-14 days after onset was significantly higher than that at 1-5 days (p = 0.004). And there was no significant difference between the AUC of seizure activity for death prediction at 1-5 days and 6-14 days (p = 0.418). Multivariate regression analysis revealed that non-α frequency on non-infarct side and seizure activity at 6-14 days after onset were the independent risk factors for the death of LHI patients. Additionally, above two EEG features significantly improved the death predictive efficacy of clinical features in LHI patients with the integrated discrimination improvement index (IDI) of 0.174 (p = 0.015) and the net reclassification improvement (NRI) of 1.314 (p<0.001). Non-α frequency on non-infarct side and seizure activity were reliable indicators for death prediction. 6-14 days after onset was the better time window for death evaluation of LHI patients through EEG.

7087 An Unusual Movement Disorder, Case of Diabetic Striatopathy!

Abstract Disclosure: S. Azmat: None. O. Lodhi: None. R. Safi: None. H. harb: None. H. Ashok: None. M.F. Siddiqui: None. J.L. Gilden: None. Background: Non-ketotic Hyperglycemia Hemichorea-Hemiballismus Syndrome (NKH-CB) is rare complication of poorly controlled diabetes mellitus (DM) characterized by continuous, irregular jerky movements localized to one side of the body. It is commonly seen in type 2 DM and is often presented in females of East Asian descent. NKH-CB is often misdiagnosed due to its rarity and radiographic features easily mistaken for intracerebral hemorrhage.Case: A 70-year-old Latino male with type 2 diabetes mellitus, hypertension, bipolar disorder and past history of two cerebrovascular accidents presented to ED with non-radiating, midsternal chest pain. ACS was ruled out with negative serial troponins and normal EKG. Vital signs were significant for elevated blood pressure 151/64 mmHg. Labs showed blood glucose=447 mg/dL. Physical examination revealed large amplitude involuntary movements in left upper and lower extremities and facial region. He also veered to the left when ambulating. The patient reported that these abnormal movements were occurring for last three weeks although sensation was preserved bilaterally. Code stroke was called; non-contrast CT showed unilateral hyper density of the right caudate and putamen with no evidence of acute intracranial hemorrhage or large arterial territory infarction. CT Angiogram did not show any signs of stenosis or occlusion. He received intravenous fluids and 8 units lispro insulin in ED. Was admitted for further evaluation and received basal/bolus insulin therapy with target blood glucose of 140-160 mg%. He also received risperidone for his mental condition. Subsequent testing revealed hemoglobin A1C of 16.9% (reference range: &amp;lt; 5.7%). MRI Brian showed unilateral T1 hyperintensity involving right caudate and putamen corresponding to the hypodensity seen on CT. Neurology service was consulted. Based on clinical signs/symptoms coupled with neuroimaging, he was diagnosed with non-ketotic Hyperglycemia Hemichorea-Hemiballismus Syndrome. On day 2 with resolution of hyperglycemia, amplitude and frequency of involuntary arm movements were minimal. The patient was discharged with Lantus 7 and metformin 1000 mg for DM and risperidone for symptoms management. Conclusion: Diabetic neuropathy is commonly known to result in small and/or large fiber sensorimotor polyneuropathy, proximal motor, and acute mononeuropathies as well as entrapments, radiculopathies, autonomic neuropathies, and even cognitive disorders. This case describes rare case of simultaneous NKH-CB with history of CVA and antipsychotic medication use in a patient with poorly controlled DM which resolved with treatment of hyperglycemia. Thus offers valuable insights into the diagnostic challenges associated with this condition as well as potential links to other neurological complications. One should also remain vigilant of potential onset of seizures commonly seen with NKH. Presentation: 6/3/2024