Anterior Circulation Occlusion Research Articles

Comparison of Prior Bridging Intravenous Thrombolysis With Direct Endovascular Thrombectomy for Anterior Circulation Large Vessel Occlusion: Systematic Review and Meta-Analysis

Background: Whether bridging treatment combining intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) is superior to direct EVT alone for emergent large vessel occlusion (LVO) in the anterior circulation is unknown. A systematic review and a meta-analysis were performed to investigate and assess the effect and safety of bridging treatment vs. direct EVT in patients with LVO in the anterior circulation.Methods: PubMed, EMBASE, and the Cochrane library were searched to assess the effect and safety of bridging treatment and direct EVT in LVO. Functional independence, mortality, asymptomatic and symptomatic intracranial hemorrhage (aICH and sICH, respectively), and successful recanalization were evaluated. The risk ratio and the 95% CI were analyzed.Results: Among the eight studies included, there was no significant difference in the long-term functional independence (OR = 1.008, 95% CI = 0.845–1.204, P = 0.926), mortality (OR = 1.060, 95% CI = 0.840–1.336, P = 0.624), recanalization rate (OR = 1.015, 95% CI = 0.793–1.300, P = 0.905), and the incidence of sICH (OR = 1.320, 95% CI = 0.931–1.870, P = 0.119) between bridging therapy and direct EVT. After adjusting for confounding factors, bridging therapy showed a lower recanalization rate (effect size or ES = −0.377, 95% CI = −0.684 to −0.070, P = 0.016), but there was no significant difference in the long-term functional independence (ES = 0.057, 95% CI = −0.177 to 0.291, P = 0.634), mortality (ES = 0.693, 95% CI = −0.133 to 1.519, P = 0.100), and incidence of sICH (ES = −0.051, 95% CI = −0.687 to 0.585, P = 0.875) compared with direct EVT. Meanwhile, in the subgroup analysis of RCT, no significant difference was found in the long-term functional independence (OR = 0.927, 95% CI = 0.727–1.182, P = 0.539), recanalization rate (OR = 1.331, 95% CI = 0.948–1.867, P = 0.099), mortality (OR = 1.072, 95% CI = 0.776–1.481, P = 0.673), and sICH incidence (OR = 1.383, 95% CI = 0.806–2.374, P = 0.977) between patients receiving bridging therapy and those receiving direct DVT.Conclusion: For stroke patients with acute anterior circulation occlusion and who are eligible for intravenous thrombolysis, there is no significant difference in the clinical effect between direct EVT and bridging therapy, which needs to be verified by more randomized controlled trials.

Arterial Spin Labelling Patterns in Acute Large Vessel Occlusion Stroke

Background: Arterial spin labelling (ASL) is a noncontrast, magnetic resonance perfusion technique which can provide information about the parenchymal perfusion status and collaterals in acute stroke. Its role in the setting of large vessel occlusion (LVO) is underutilized due to the limited availability of magnetic resonance imaging (MRI) in the emergency settings. However, it might serve as an useful adjunct to other perfusion modalities in future. Objective: To study ASL perfusion patterns in anterior circulation LVO stroke and evaluate the presence of arterial transit artefacts (ATA) as a surrogate marker of collaterals. Methods: We performed a retrospective analysis of our mechanical thrombectomy database over the last 2 years for acute stroke cases in which ASL perfusion as part of MRI was performed. ASL perfusion patterns in acute LVO stroke were reviewed, with respect to presence of ATA and diffusion-weighted imaging (DWI)-ASL mismatch. Inter-rater reliability was analyzed between 2 readers of varying experience. Baseline variables were analyzed between those with and without ATA. Results: Out of 95 patients, 78 had anterior circulation occlusions, among which 27 had ASL. Type I (with ATAs) was seen in 11 patients and all of these had DWI mismatch. Type II (without ATAs) was seen in 16 patients. Of these, 15 had mismatch with DWI and only 1 had no mismatch. Inter-rater reliability for the detection of ATA on ASL was substantial (Cohen’s k—0.64). No statistical significance was noted between ATA and clinical outcomes. Conclusion: ASL patterns vary amongst patients with LVO stroke and can be classified based on the presence of ATA since resulting DWI mismatch actually indicates a pseudo-perfusion deficit.

Endovascular treatment in anterior circulation stroke beyond 6.5 hours after onset or time last seen well: results from the MR CLEAN Registry

BackgroundRandomised controlled trials with perfusion selection have shown benefit of endovascular treatment (EVT) for ischaemic stroke between 6 and 24 hours after symptom onset or time last seen well. However,...

Influence of time to endovascular stroke treatment on outcomes in the early versus extended window paradigms.

The effect of time from stroke onset to thrombectomy in the extended time window remains poorly characterized. We aimed to analyze the relationship between time to treatment and clinical outcomes in the early versus extended time windows. Proximal anterior circulation occlusion patients from a multicentric prospective registry were categorized into early (≤6 h) or extended (>6-24 h) treatment window. Patients with baseline National Institutes of Health Stroke Scale (NIHSS) ≥ 10 and intracranial internal carotid artery or middle cerebral artery-M1-segment occlusion and pre-morbid modified Rankin scale (mRS) 0-1 ("DAWN-like" cohort) served as the population for the primary analysis. The relationship between time to treatment and 90-day mRS, analyzed in ordinal (mRS shift) and dichotomized (good outcome, mRS 0-2) fashion, was compared within and across the extended and early windows. A total of 1603 out of 2008 patients qualified. Despite longer time to treatment (9[7-13.9] vs. 3.4[2.5-4.3] h, p < 0.001), extended-window patients (n = 257) had similar rates of symptomatic intracranial hemorrhage (sICH; 0.8% vs. 1.7%, p = 0.293) and 90-day-mortality (10.5% vs. 9.6%, p = 0.714) with only slightly lower rates of 90-day good outcomes (50.4% vs. 57.6%, p = 0.047) versus early-window patients (n = 709). Time to treatment was associated with 90-day disability in both ordinal (adjusted odd ratio (aOR), ≥ 1-point mRS shift: 0.75; 95%CI [0.66-0.86], p < 0.001) and dichotomized (aOR, mRS 0-2: 0.73; 95%CI [0.62-0.86], p < 0.001) analyses in the early- but not in the extended-window (aOR, mRS shift: 0.96; 95%CI [0.90-1.02], p = 0.15; aOR, mRS0-2: 0.97; 95%CI [0.90-1.04], p = 0.41). Early-window patients had significantly lower 90-day functional disability (aOR, mRS shift: 1.533; 95%CI [1.138-2.065], p = 0.005) and a trend towards higher rates of good outcomes (aOR, mRS 0-2: 1.391; 95%CI [0.972-1.990], p = 0.071). The impact of time to thrombectomy on outcomes appears to be time dependent with a steep influence in the early followed by a less significant plateau in the extended window. However, every effort should be made to shorten treatment times regardless of ischemia duration.

Stable Clinical Outcomes When a Stroke Thrombectomy Program Is Started in an Experienced Cardiology Cath Lab.

This study analyzed the learning curve effect when a new stroke thrombectomy program was initiated in a cardiac cath lab in close cooperation with neurologists and radiologists. Mechanical thrombectomy has proven to be the best treatment option for ischemic stroke patients, but this method is not widely available. An endovascular treatment program for acute ischemic strokes was established in the cardiac cath lab of a tertiary university hospital in 2012. The decision to perform catheter-based thrombectomy was made by a neurologist and was based on acute stroke clinical symptoms and computed tomography angiographic findings. Patients with a large vessel occlusion of either anterior or posterior circulation were enrolled. The primary endpoint was the functional neurological outcome (Modified Rankin Scale [mRS] score) of the patient at 3months. A total of 333 patients were enrolled between October 2012 and December2019. The clinical (mRS) outcomes did not vary significantly across years 2012 to 2019 (mRS 0 to 2 was achieved in 47.9% of patients). Symptomatic intracerebral hemorrhage occurred in 19 patients (5.7%). Embolization in a new vascular territory occurred in 6 patients (1.8%). When a catheter-based thrombectomy program was initiated in an experienced cardiac cath lab in close cooperation between cardiologists, neurologists, and radiologists, outcomes were comparable to those of neuroradiology centers. The desired clinical results were achieved from the onset of the program, without any signs of a learning curve effect. These findings support the potential role of interventional cardiac cath labs in the treatment of acute stroke in regions where this therapy is not readily available due to the lack of neurointerventionalists.

Hypoperfusion intensity ratio for refinement of elderly patient selection for endovascular thrombectomy

BackgroundPatients ≥80-year-old presenting with large-vessel occlusion treated with endovascular thrombectomy (EVT) have worst outcomes than younger individuals. Improved patient selection in this age range is warranted. We investigated the hypoperfusion-intensity-ratio...

Endovascular Treatment for M3 Occlusions

Introduction: Endovascular treatment (ET) has become most well-proven beneficial treatment for the M1-2 occlusions of the middle cerebral artery. Mortality and disability rates are high if large vessel occlusions are not treated. Even if these rates are lower in M3 occlusions, the important branch blockages can end with disability. Small vessels occlusions are difficult to detect and treatment for endovascular interventions. There are few studies on the effectiveness of endovascular treatment for M3 occlusions. In this study, our aim to assess the feasibility, safety, and preliminary efficacy of endovascular therapy for M3 occlusions. Methods: This study was conducted a retrospective analysis of a prospectively collected database in two-centers for acute ischemic stroke of anterior system between July 2015 and April 2020. Demographic, radiologic, procedural variables and outcome variables were collected in patients with who were taken endovascular therapy for acute ischemic stroke of anterior system. Middle cerebral artery is divided into the sections according to the course and angle of the middle cerebral artery. M3 (opercular) segment of the middle cerebral artery is after the circular sulcus of the insula. Results: The complete or near complete reperfusion (mTICI 2b-3) of m3 occlusion was achieved in 15 cases (38.5%). The complete (mTICI 3) reperfusion was achieved in 24 cases (61.5%). The complete or near complete reperfusion (mTICI 2b-3) of the other anterior circulation occlusion was achieved in 129 cases (65.9%) while the complete (mTICI 3) reperfusion was achieved in 50 cases (27%). Conclusions: This retrospective study demonstrates the ability of endovascularly treatment of M3 occlusions as effective, reliable and cost-effective. Funding Information: None. Declaration of Interests: None. Ethics Approval Statement: This study was approved by the local Institutional Review Board with a waiver of informed consent.

Abstract P505: Prediction of Infarct Volume at the 24 Hours After Late Window Presentation With Perfusion Imaging in Patients With Anterior Circulation Large Vessel Occlusion

Introduction: We sought to evaluate the accuracy of perfusion-weighted imaging (PWI) in late presenting patients for estimating the infarct volume at 24 hours after presentation. Methods: This is a secondary analysis of DEFUSE 3, which included stroke patients with anterior circulation occlusion within 6-16 hours of last known normal. The primary outcome is the final infarct volume on a 24-hour MRI scan (volume of DWI positive tissue), adjusted for the baseline infarct volume. We censored 3 patients with 24-hour follow-up MRI infarct volumes &gt;300 mL, which we considered non-physiologic for a hemispheric stroke. The primary predictors are the baseline volume of Tmax &gt;6s, Tmax &gt;10s, and hypoperfusion intensity ratio (HIR: Tmax10/Tmax6) on CT/MR perfusion at hospital admission. We stratified the cohort into 4 categories (untreated, TICI 0-2a, TICI 2b, and TICI3) and fit linear regression models to each of our predictors. Results: We included 147 patients, of which 69 were untreated, 17 had TICI 0-2a, 46 had TICI 2b, and 15 had TICI 3. In untreated patients, both HIR and Tmax10 volume were predictive of adjusted 24-hour follow-up infarct volume (Table). In treated patients, there were no consistent relationships between the perfusion imaging variables and adjusted final infarct volume (Table). Conclusion: For patients with late window anterior circulation large vessel occlusion stroke, HIR and Tmax10 volume appear to be reliable predictors of subsequent infarct volume in untreated patients. For patients treated with thrombectomy, further research is warranted to better understand the more complex relationship between baseline perfusion imaging and the 24 hour, and beyond, infarct volume.

Abstract P345: Perfusion-Guided Bridging Therapy in Strokes With Unknown Time of Onset and Large Vessel Occlusion

Introduction: Endovascular treatment (EVT) is the therapy of choice, in patients with unknown stroke onset (unwitnessed and wake-up strokes) and large vessel occlusion (LVO) with a favorable perfusion pattern. Whether bridging therapy (intravenous thrombolysis (IVT) and EVT) is superior to EVT alone remains unknown. Material and Methods: We retrospectively included all patients admitted to the Geneva University Hospital from 01.2016 to 06.2020 with i) stroke of unknown onset, due to ii) anterior circulation occlusion, with iii) favorable CT perfusion pattern based on the DEFUSE criteria (ischemic core volume&lt; 70ml; mismatch ratio &gt;= 1.8 and mismatch volume &gt;= 15ml), and iv) treated &lt; 4.5 hours after symptom recognition. As a standard of care, the patients fulfilling these inclusion criteria were treated with EVT and IVT or EVT alone when IVT was contraindicated. Outcome measures were any intracerebral bleeding (symptomatic or asymptomatic), mortality and favorable outcome (mRS 0-1) at three months. Results: 32 patients were included (17 treated with EVT alone and 15 with EVT and IVT). Mean age was 69±18 yo. Median NIHSS was 16 (IQR 12-20) and median time from symptom recognition to treatment was 184 (146-226) minutes. Median hypoperfused tissue volume (Tmax &gt; 6s) was 119 ml (80-151) and infarcted core (CBF ratio &lt;30%) 8 ml (0-27). After propensity score weighting, bridging therapy was not associated with an increased risk of intracerebral bleeding (p=0.72) or mortality (p=0.55). The proportion of favorable outcomes at three months was similar between treatment groups (p=0.78). Conclusion: These results suggest that IVT before EVT is a safe therapeutic option in patients with unknown stroke onset selected on perfusion imaging and treated &lt;4.5 hours after symptom recognition. Early administration of IVT may be particularly relevant before interhospital transfer to a comprehensive stroke center for EVT.

Abstract P479: A Tale of Two Clots: A Multicenter Study on Multiple Territory Thrombectomy

Introduction: The benefit of thrombectomy for large vessel occlusion (LVO) is well proven. There is minimal data on concurrent thrombectomy for multi-territory occlusions. Methods: We reviewed the STAR registry from 2015-8 for patients treated with either right and left sided thrombectomy or anterior and posterior circulation thrombectomy at 15 comprehensive stroke centers. Results: There were 4966 patients in the study period who had completed outcome data and LVO thrombectomy. 38 (0.8%) underwent endovascular thrombectomy for multi-territory occlusions. 26% had bilateral occlusions and 74% had anterior and posterior circulation occlusions. Among the 38, 50% were female, 49% were white, and 91% had a prestroke mRS&lt;3. 95% had an ASPECT score of &gt;6 and 55% received iv t-pa. 83% of patients had successful recanalization (TICI 2B/3) for both territories. The overall complication rate was 15%. 5% of patients had sICH or PH2. 26% of patients had a 90day mRS&lt;2. When controlling for admission NIHSS, baseline mRS, age, comorbidities, and ASPECT in logistic regression analysis, multiple territory compared to single territory did not predict increased risk of sICH (p=0.73, 95%CI: 0.2-3.3), rate of TICI2B/3 (OR for TICI2B+: 0.93, p=0.88, CI: 0.38 - 2.3), or worse outcome (OR for good outcome: 0.6, p=.212, CI: 0.3-1.3). On linear regression analysis for attempts and procedure time, multiple territory thrombectomy required significantly higher number of attempts (Coefficient +1.8, p=0.001) without a significantly longer procedure time (Coefficient = +10, p=0.244). Conclusion: With similar selection to single territory LVOs, good outcome can be achieved in multi-territory infarction with reasonable procedure time and no additional risk of hemorrhage or poor outcome.

Abstract P619: A Non-Linear Relationship Between Time From Onset to Endovascular Therapy and Outcomes in Patients With Acute Basilar Artery Occlusion in Clinical Practice

Objective: Faster time from onset to puncture (OPT) using endovascular therapy (EVT) in acute large-vessel occlusion of anterior circulation has been associated with better clinical outcomes. However, the relationship in acute basilar artery occlusion (BAO) is still not well delineated. Methods: We analyzed acute BAO patients receiving EVT from a nationwide registry of BASILAR (Endovascular Treatment for Acute Basilar Artery Occlusion study). The primary outcome was favorable functional outcome (defined as modified Rankin Scale score 0-3) at 90 days. Secondary outcomes included function independence (defined as modified Rankin Scale score 0-2), mortality and symptomatic intracerebral hemorrhage. The associations between OPT and outcomes were evaluated using multivariable logistic regression (OPT as a categorical variable) and restricted cubic spline regression (OPT as a continuous variable). Results: Among 639 eligible patients, the median age was 65 years, and median OPT was 328 mins (interquartile range, 220-490). Treatment within 4 hours were associated with higher rates of functional independence (adjusted OR, 0.60 [95% CI, 0.37-0.97] and 0.46 [95% CI, 0.22-0.97], respectively) and favorable outcome (adjusted OR, 0.63 [95% CI, 0.40-0.99] and 0.46 [95% CI, 0.24-0.96], respectively) compared with treatment within 4-8 hours and 8-12 hours. In the restricted cubic spline models, nonlinear relationships were consistently observed between OPT with favorable outcome, functional independence and mortality, with significant benefit loss throughout the first 10 hours but then a relative flat afterwards. However, the odds of symptomatic intracerebral hemorrhage did not significantly change with longer delay to EVT. Conclusion: Among patients with acute BAO in routine practice, earlier treatment with EVT was associated with better outcomes throughout the first 10 hours after onset, but benefit sustained unchanged afterwards. Future trials or pooled analysis of larger size BAO patients are needed to confirm these results.

Abstract 44: DEVT: Endovascular Treatment Alone versus Intravenous Alteplase Plus Endovascular Treatment in Stroke

Background: In large vessel occlusion strokes, it is unknown whether the potential risks and added costs associated with intravenous alteplase before mechanical thrombectomy remain justifiable. Methods: In 33 stroke centers in China, patients presenting with proximal anterior circulation intracranial occlusion strokes within 4.5 hours from onset and eligible for intravenous thrombolysis underwent 1:1 randomization mechanical thrombectomy alone (primary-thrombectomy group) or standard dose of intravenous alteplase followed by mechanical thrombectomy (bridging-therapy group). The primary endpoint was non-inferiority of functional independence at 90 days (defined as score 0-2 on the modified Rankin scale). Non-inferiority was established with a margin of -0.1. Safety outcomes included the incidence of symptomatic intracerebral hemorrhage within 48 hours and 90-day mortality. Results: The trial was stopped early because of efficacy when 234 of a planned 970 patients had undergone randomization (116 to the primary-thrombectomy and 118 to the bridging-therapy group). The primary endpoint of functional independence at 90 days was achieved by 63(54.3%) patients in the primary-thrombectomy versus 55(46.6%) in the bridging-therapy group (incidence difference, 7.7%; 95% confidence interval, -5.1% to 20.5%), indicating that primary-thrombectomy was non-inferior to bridging-therapy (Z=2.7157, P non-inferiority =0.00330). No significant between-group differences were detected in symptomatic intracerebral hemorrhage (6.1% versus 6.8%) and 90-day mortality (17.2% versus 17.8%). Conclusions: In stroke patients with proximal anterior circulation occlusions within 4.5 hours from onset, mechanical thrombectomy alone was non-inferior to intravenous alteplase followed by mechanical thrombectomy in terms of 90-day functional independence. (Funded by the Natural Science Foundation of China and others; DEVT chictr.org.cn number, ChiCTR-IOR-17013568.)

Abstract P530: Safety of Intravenous Cangrelor in Acute Ischemic Stroke

Introduction: Mechanical Thrombectomy often requires immediate antiplatelet therapy when emergent stenting is needed. Intravenous cangrelor (CGR) is a potent reversible intravenous antiplatelet with a fast onset, a short half-life, and predictable pharmacokinetics. We sought to evaluate the safety and efficacy of this drug in MT patients. Methods: We performed a retrospective case control study at a CSC between 3/2016 and 4/2020. Patients who received intravenous CGR within 6 hours of admission (between 10/2019 - 4/2020) were compared with patients with anterior circulation tandem MCA occlusions who required stenting and oral antiplatelet therapy (between 3/16 - 10/19), prior to the availability of CGR at our facility. Results: We identified 35 patients, 12 of whom received IV CGR and 23 received acute oral antiplatelets for tandem occlusions. Average age of the cohort was 68.5 ± 13.4. Baseline characteristics including co-morbidities, rate of IV tPA, and time metrics were similar between the two groups. In the CGR group, nine patients had tandem anterior circulation occlusions, two had basilar occlusions, and one patient had an MCA occlusion secondary to severe stenosis. Eleven of the twelve patients in the CGR group required acute stenting. Intravenous CGR was used for an average of 20.2 hours after which patients were transitioned to aspirin and ticagrelor (33%) or clopidogrel (67%). Successful recanalization was achieved in all patients who received IV-CGR and in 95.7% of the tandem group. Final infarct volumes were comparable between the CGR and tandem cohorts (7.1 vs 15.5 ml; p=0.75). There were two cases of asymptomatic hemorrhage in both the CGR group and the tandem cohort, and one case of symptomatic ICH in the tandem cohort. Final functional outcomes (83.3% vs 60.9%; p=0.259) and mortality at three months (13% vs. 17%; p=1) were similar between the two groups. Conclusions: IV CGR is a promising medication for patients with acute ischemic stroke who require an immediate antiplatelet effect and is comparable in safety and efficacy to oral antiplatelets in the acute period of ischemic stroke. Larger prospective studies on the efficacy and safety of CGR in neurointervention are warranted.

Abstract 31: Penumbra Consumption Rates Based on T Max Delay and Reperfusion Status: A Post-Hoc Analysis of the Defuse-3 Trial

Introduction: In patients with acute large vessel occlusion, the definition of penumbral tissue based on T max delay perfusion imaging is not well established in relation to late-window endovascular thrombectomy (EVT). In this study, we sought to evaluate penumbra consumption rates for T max delays in patients treated between 6 and 16 hours from last known normal. Methods: This is a secondary analysis of the DEFUSE-3 trial, which included patients with an acute ischemic stroke due to anterior circulation occlusion within 6-16 hours of last known normal. The primary outcome is percentage penumbra consumption defined as (24 hour infarct volume-core infarct volume)/(Tmax volume-baseline core volume). We stratified the cohort into 4 categories (untreated, TICI 0-2a, TICI 2b, and TICI3) and calculated penumbral consumption rates. Results: We included 143 patients, of which 66 were untreated, 16 had TICI 0-2a, 46 had TICI 2b, and 15 had TICI 3. In untreated patients, a median (IQR) of 48% (21% - 85%) of penumbral tissue was consumed based on Tmax6 as opposed to 160.6% (51% - 455.2%) of penumbral tissue based on Tmax10. On the contrary, in patients achieving TICI 3 reperfusion, a median (IQR) of 5.3% (1.1% - 14.6%) of penumbral tissue was consumed based on Tmax6 and 25.7% (3.2% - 72.1%) of penumbral tissue based on Tmax10. Conclusion: Contrary to prior studies, we show that at least 75% of penumbral tissue with Tmax &gt; 10 sec delay can be salvaged with successful reperfusion and new generation devices. In untreated patients, since infarct expansion can occur beyond 24 hours, future studies with delayed brain imaging are needed to determine the optimal T max delay threshold that defines penumbral tissue in patients with proximal anterior circulation large vessel occlusion.

MR CLEAN-LATE, a multicenter randomized clinical trial of endovascular treatment of acute ischemic stroke in The Netherlands for late arrivals: study protocol for a randomized controlled trial

BackgroundEndovascular therapy (EVT) for acute ischemic stroke due to proximal occlusion of the anterior intracranial circulation, started within 6 h from symptom onset, has been proven safe and effective. Recently, EVT has been proven effective beyond the 6-h time window in a highly selected population using CT perfusion or MR diffusion. Unfortunately, these imaging modalities are not available in every hospital, and strict selection criteria might exclude patients who could still benefit from EVT. The presence of collaterals on CT angiography (CTA) may offer a more pragmatic imaging criterion that predicts possible benefit from EVT beyond 6 h from time last known well. The aim of this study is to assess the safety and efficacy of EVT for patients treated between 6 and 24 h from time last known well after selection based on the presence of collateral flow.MethodsThe MR CLEAN-LATE trial is a multicenter, randomized, open-label, blinded endpoint trial, aiming to enroll 500 patients. We will investigate the efficacy of EVT between 6 and 24 h from time last known well in acute ischemic stroke due to a proximal intracranial anterior circulation occlusion confirmed by CTA or MRA. Patients with any collateral flow (poor, moderate, or good collaterals) on CTA will be included. The inclusion of poor collateral status will be restricted to a maximum of 100 patients. In line with the current Dutch guidelines, patients who fulfill the characteristics of included patients in DAWN and DEFUSE 3 will be excluded as they are eligible for EVT as standard care. The primary endpoint is functional outcome at 90 days, assessed with the modified Rankin Scale (mRS) score. Treatment effect will be estimated with ordinal logistic regression (shift analysis) on the mRS at 90 days. Secondary endpoints include clinical stroke severity at 24 h and 5–7 days assessed by the NIHSS, symptomatic intracranial hemorrhage, recanalization at 24 h, follow-up infarct size, and mortality at 90 days,DiscussionThis study will provide insight into whether EVT is safe and effective for patients treated between 6 and 24 h from time last known well after selection based on the presence of collateral flow on CTA.Trial registrationNL58246.078.17, ISRCTN19922220, Registered on 11 December 2017

Factors Associated with Poor Outcomes in Patients Undergoing Endovascular Therapy for Acute Ischemic Stroke due to Large-Vessel Occlusion in Acute Anterior Circulation: A Retrospective Study

To investigate factors associated with poor clinical outcomes in patients with acute ischemic stroke undergoing endovascular therapy. A retrospective review of 265 patients with acute ischemic stroke treated in the First Hospital of Jilin University between January 1, 2016, and November 1, 2019, was performed. The primary outcome was the proportion of patients with a modified Rankin score of 0-2 at 90 days. Univariate and multivariate analyses were performed to assess potential clinical factors associated with a poor 90-day outcome. The rates of successful revascularization, good prognosis, symptomatic intracranial hemorrhage, and mortality were 84.5%, 46.0%, 9.8%, and 12.8%, respectively. As per univariate analysis, age, diagnosis of atrial fibrillation, diagnosis of diabetes, high baseline glucose level, tandem occlusion, high National Institutes of Health Stroke Scale (NIHSS) score at admission, general anesthesia, number of passes, high NIHSS score on discharge, unsuccessful recanalization (modified treatment in cerebral ischemia score <2b), and development of symptomatic intracranial hemorrhage, hemorrhagic infarction, parenchymal hematoma, and subarachnoid hemorrhage were associated with poor prognosis. Tobacco use was positive in correlation with good prognosis in univariate analysis. Diabetes, tandem occlusion, high NIHSS score at admission, and general anesthesia were independent factors associated with a poor 90-day outcome in multivariate analysis. Diabetes, tandem occlusion, high NIHSS score at admission, and general anesthesia were independent risk factors associated with a poor 90-day outcome and should be considered a reference by neurointerventionalists in guiding their clinical decision-making.

Mechanical Thrombectomy for Acute Ischemic Stroke in Nepal

Stroke is one of the leading causes of mortality and the number one cause of dependency in the world. Endovascular therapy has emerged as promising treatment strategy in the patient with acute ischemic stroke due to large vessel occlusion in anterior circulation. Moreover, the time window for mechanical thrombectomy have also been expanded based on the recent DAWN and DEFUSE-3 trial. It is evident that this trend could dramatically increase the number of potential patients for the treatment. Moreover, advancement in stroke imaging have guided physicians to make wisest decision in identifying suitable patient who can get benefit from the recent treatment strategies. The stroke management is evolving and continues to improve, making better outcome of the patient possible. In context of our country Nepal, it is also necessary to educate and aware medical staffs including physicians, nurses, laboratory/ radiology personnel to design a proper acute stroke team to deliver successful therapy which will eventually make a sound impact in a large number of patients with stroke.&#x0D; Herein, we report a case of a 69-year-old gentleman who presented with right middle cerebral artery territory infarction within 3hours of onset of symptoms and underwent mechanical thrombectomy as a part of the treatment.

The role of CT texture analysis in predicting the clinical outcomes of acute ischemic stroke patients undergoing mechanical thrombectomy.

To evaluate the performance of CT-based texture analysis (TA) for predicting clinical outcomes of mechanical thrombectomy (MT) in acute ischemic stroke (AIS). This single-center, retrospective study contained 64 consecutive patients with AIS who underwent MT for large anterior circulation occlusion between December 2016 and January 2020. Patients were divided into 2 groups according to the modified Rankin scale (mRS) scores at 3 months as good outcome (mRS ≤ 2) and bad outcome (mRS > 2). Two observers examined the early ischemic changes for TA on baseline non-contrast CT images independently. Demographic, clinical, periprocedural, and texture variables were compared between the groups and ROC curves were made. Logistic regression analysis was used and a model was created to determine the independent predictors of a bad outcome. Sixty-four patients (32 female, 32 male; mean age 63.03 ± 14.42) were included in the study. Fourteen texture parameters were significantly different between patients with good and bad outcomes. The long-run high gray-level emphasis (LRHGE), which is a gray-level run-length matrix (GLRLM) feature, showed the highest sensitivity (80%) and specificity (70%) rates to predict disability. The GLRLM_LRHGE value of > 4885.0 and the time from onset to puncture of > 237.5 mi were found as independent predictors of the bad outcome. The diagnostic rate was 80.0% when using the combination of the GLRLM_LRHGE and the time from onset to puncture cutoff values. CT-based TA might be a promising modality to predict clinical outcome after MT in patients with AIS. • The gray-level run-length matrix parameters displayed higher diagnostic performance among the texture features. • The long-run high gray-level emphasis showed the highest sensitivity and specificity rates for predicting a bad outcome in stroke patients undergoing mechanical thrombectomy. • The gray-level run-length matrix_long-run high gray-level emphasis value of > 4885.0 (OR = 11.06; 95% CI = 2.51 - 48.77; p = 0.001) and the time from onset to puncture of > 237.5 min (OR = 8.55; 95% CI = 1.96 - 37.21; p = 0.004) were found as independent predictors of the bad outcome.

Severe Cerebral Small Vessel Disease Burden Is Associated With Poor Outcomes After Endovascular Thrombectomy in Acute Ischemic Stroke With Large Vessel Occlusion.

BackgroundDespite recent advancements in the treatment of acute ischemic stroke (AIS) with large vessel occlusion (LVO), infarct progression over time and functional outcomes remain variable. This variation in outcomes may be partially attributed to an underlying state of chronic cerebral hypoperfusion and ischemia affecting small cerebral perforating arterioles, venules, and capillaries of the brain; broadly termed cerebral small vessel disease (CSVD). We investigated the association between CSVD burden and the degree of disability following successful recanalization with endovascular thrombectomy (EVT) in patients with AIS presenting with LVO.MethodologyWe conducted a single center retrospective analysis of all patients presenting with AIS LVO between May 2016 and May 2019. Patients who were premorbidly independent and presented within six hours from the last known well (LKW) with a proximal anterior circulation occlusion confirmed on computed tomography (CT) angiography of the head or neck were treated with EVT. Patients presenting after six hours and up to 24 hours from LKW with a target ischemic core to perfusion mismatch profile on CT or magnetic resonance (MR) perfusion, or a clinical imaging mismatch on MR diffusion-weighted imaging, were also treated. Patients with successful revascularization, defined as a thrombolysis in cerebral infarction score 2b or 3, were included and evaluated for CSVD burden. The presence of CSVD was quantified using the Fazekas scale (0-3). All patients were further evaluated for disability at 90 days using the modified Rankin Scale (mRS, range 0-6). An mRS score of ≤2 was defined as a good functional outcome.ResultsOf the 190 patients evaluated, absent (Fazekas grade 0), mild (Fazekas grade 1), moderate (Fazekas grade 2), and severe (Fazekas grade 3) CSVD was present in 33 (17.4%), 84 (44.2%), 35 (18.4%), and 38 (20.0%) patients, respectively. Patients with severe CSVD (Fazekas grade 3) were found to be older, had a higher presenting National Institute of Health Stroke Scale (NIHSS), and had greater proportions of preexisting atrial fibrillation and dementia compared to patients with no CSVD (Fazekas grade 0). Using a multivariate ordinal logistic regression model to adjust for age, presenting NIHSS, thrombus location, LKW to groin puncture time, use of tissue plasminogen activator, ischemic infarct volume, development of a symptomatic intracerebral hemorrhage, and treatment with hemicraniectomy, patients with Fazekas grade 3 were significantly more likely to have poor 90-day functional outcomes compared to patients with Fazekas grade 0 (odds ratio 10.25, 95% confidence interval [3.3-31.84]).ConclusionsBased on our analytical cohort of AIS LVO patients treated with EVT, we found that patients with severe CSVD burden had worse functional outcomes at 90 days and increased mortality. These results provide evidence that the burden of CSVD may be considered an independent risk factor of poor clinical outcome and a predictor of mortality in patients with AIS presenting with LVO, despite successful radiographic recanalization with EVT.

Serum Albumin Levels and Clinical Outcomes Among Ischemic Stroke Patients Treated with Endovascular Thrombectomy.

Background and AimsAlbumin levels have been reported to be associated with all-cause and cardiovascular mortality. The aim of this study was to investigate the association between serum albumin and prognosis of ischemic stroke patients after endovascular thrombectomy (EVT) treatment.MethodsPatients with EVT due to large artery occlusion in anterior circulation were selected from ACTUAL (endovascular treatment for acute anterior circulation) ischemic stroke multicenter registry in China. Serum albumin levels were measured within 24 h of admission. The primary outcome was poor functional outcome (modified Rankin scale score of 3–6) at three months. Secondary outcomes were symptomatic intracranial hemorrhage (sICH) and three-month mortality.ResultsA total of 605 patients (mean age, 64.2 years; 59.3% male) were enrolled. Up to three months after stroke, 342 patients (56.5%) developed poor functional outcome. After multivariate adjustment for demographic characteristics, National Institutes of Health stroke score, and other potential confounders, the odds ratio for the lowest tertile of serum albumin levels was 2.43 (95%CI, 1.18−5.01; P=0.046) for poor functional outcome, compared with the highest category. Restricted cubic spline regression demonstrated a linear association between albumin levels and poor functional outcome (P for linearity=0.017). Subgroup analyses further confirmed these results. Similar significant findings were also found in the association of serum albumin with mortality, but not with sICH.ConclusionDecreased serum albumin levels were independently associated with poor prognosis at 90 days after acute large vessel occlusion stroke in anterior circulation treated with EVT.