Parenchymal Hematoma Research Articles

Intraoperative ultrasonographic-guided surgery of intracerebral hemorrhage

Abstract Background The location of the cortical incision and maximum evacuations of parenchymal intracerebral hematoma are crucial points. Intraoperative ultrasonography is a real-time tool with great benefit at these points Methods A retrospective study of patients with parenchymal intracerebral hemorrhage that underwent evacuation using intraoperative ultrasound guidance was included. Preoperative clinical and radiological assessments were studied. The postoperative imaging and clinical outcome were assessed. A late follow-up after 6 months was done. Results The age of study patients ranged from 9 to 73 (mean 45.3 ± 20.4 years). There were 14 males (58.3%). The mean preoperative Glasgow Coma Scale (GCS) was 9.8 ± 2.9. The preoperative hematoma volume ranged from 32 to 135 cm3 with a mean of 68.5 ± 30.5 cm3. The rate of evacuation ranged from 90 to 100%. The mean postoperative GCS was 11.7 ± 2.5. None of the patients had a recurrent hemorrhage. There was a significant rate of evacuation of the hematomas (P value < 0.001*). Also, there was a marked improvement in postoperative GCS and the late modified Rankin Scale (P value < 0.001*). Conclusion Ultrasonography is a useful, efficient, real-time tool for the localization and evacuation of parenchymal intracerebral hemorrhage. It maximizes evacuation and decreases parenchymal insult. It is an important aid to the neurosurgeon.

Risk of delayed intracranial hemorrhage according to antithrombotic treatment in patients with traumatic brain injury: systematic review and meta-analysis

Abstract Background Antithrombotic treatment is a risk factor for the development of delayed (DICH) intracranial hemorrhage after head trauma. However, it is not known whether i) the risk of DICH differs according to antithrombotic treatments and ii) prescription of serial brain-CT after a first normal CT scan is indicated. Aim The aims of this study are: i) to evaluate the risk of DICH after traumatic brain injury (TBI) according to different antithrombotic treatments (vitamin K antagonist [VKA], direct oral anticoagulants [DOACs], antiplatelets [AP]); ii) to evaluate the usefulness of serial CT scans vs clinical observation to rule out a DICH. Methods Medline and Embase databases were searched from inception up to June 2022 to find studies that met the following characteristics: i) enrolling TBI patients admitted to emergency departments within 24 hours since trauma; ii) enrolling patients were receiving VKA, DOACs or APs at time of TBI; iii) had a normal brain-CT scan at admission. Primary study outcome was DICH, defined as the presence of subdural, epidural or parenchymal haematoma, subarachnoid haemorrhage or cerebral contusion. Results 3070 records were identified, and 27 observational studies were included. No significant difference in the risk of DICH was observed in patients receiving VKAs or DOACs (23 studies, 6078 patients) at time of TBI: 2.52% vs 2.01%, risk ratio (RR) 1.40, 95% CI 0.91;2.14, : 0% (Fig.1A). Similarly, no difference was observed between patients receiving VKAs or APs (10 studies, 3864 patients): 1.43% vs 1.54%, RR 0.92, CI 95% 0.40;2.14, : 0%; and between DOACs or APs (6 studies, 1916 patients): 0.87% vs AP 1.81 %, RR 0.62, 95% CI 0.10-3.71, = 0% (Fig. 1B). No studies comparing serial brain-CT vs clinical observation were found. Conclusion Our study shows that the risk of developing DICH after TBI does not differ across the antithrombotic treatments. Further studies should assess the role of serial brain-CT in this setting.

Abstract 194: Impact of Pre‐treatment Cerebral Microbleeds on the Outcomes of Endovascular Thrombectomy

Introduction Endovascular thrombectomy (EVT) is the gold standard treatment for patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO), and there are several factors that can influence the outcomes of EVT in AIS‐LVO patients. We conducted this meta‐analysis to investigate the effect of cerebral microbleeds (CMBs) on the functional and safety outcomes of EVT in patients with AIS caused by LVO. Methods We followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. We included observational studies that recruited AIS‐LVO patients, used susceptibility‐sensitive magnetic resonance imaging (MRI) to detect CMBs, and examined the association between them and predefined outcome events. The outcomes of interest included functional independence, revascularization success, and hemorrhagic adverse events. We conducted a meta‐analysis using the Mantel‐Haenszel method and calculated the risk ratios. Results Four studies involving 1,514 patients were included. A significant reduction in the likelihood of achieving a favorable functional outcome, as measured by the modified Rankin Scale (mRS), was observed in patients with CMBs (Risk Ratio (RR) 0.70, 95% Confidence Interval (CI): 0.53 ‐ 0.91, P=0.01). No significant differences were observed between the two groups in terms of successful revascularization (RR 0.93, 95% CI [0.74 to 1.17], P=0.51), mortality (RR 0.93, 95% CI [0.74 to 1.17], P=0.51), hemorrhagic transformation (RR 0.93, 95% CI [0.59 to 1.45], P=0.74), and parenchymal hematoma (RR 1.23, 95% CI [0.79 to 1.91], P=0.35). Conclusion The presence of CMBs significantly reduced the likelihood of achieving a favorable functional outcome after EVT in AIS‐LVO patients. However, CMBs did not impact the rates of successful revascularization, mortality, or the occurrence of various hemorrhagic complications. Future research should explore the mechanisms of this association and strategies to mitigate its impact.

Prognostic implications of intracranial haemorrhage on dual-energy CT immediately following endovascular treatment for acute ischemic stroke

ObjectiveTo describe the incidence, risk factors, and prognostic relevance of intracranial haemorrhage (ICH) immediately after endovascular treatment (EVT) for ischaemic stroke in the anterior circulation. MethodsEVT records from 2010 to 2019 were screened. Included patients underwent DECT within 3h post-EVT. Virtual native reconstructions were evaluated for ICH according to the Heidelberg criteria and grouped into Heidelberg classes (HCs): [HC1] haemorrhagic infarction (HI)1, HI2 and parenchymal haematoma (PH)1; [HC2] PH2; [HC3] i.a. intraventricular and subarachnoid haemorrhage. If ICH corresponding to multiple HCs was observed, we assumed that the (largest) parenchymal ICH would have the greatest prognostic impact. Hence, a single HC was attributed by the following order of severity: HC2, HC1, HC3. The primary outcome was the modified Rankin Scale (mRS) at 90 days. The effect of asymptomatic ICH (aICH) and symptomatic ICH (sICH) of (1) HC1 or HC2 and (2) HC3 on patient outcomes was evaluated with multivariable regression after multiple imputation. ResultsOut of 651 records, 498 patients were included. Eighty-one (16%) patients showed ICH on post-EVT DECT, of which 19 were classified as HC1 (21% symptomatic), 6 as HC2 (100% symptomatic), and 56 as HC3 (14% symptomatic). ICH development was mainly associated with unfavourable procedural characteristics. Both aICH and sICH of HC1 or HC2 were associated with the mRS (aICH: adjusted [a]cOR 4.92, 95%CI [1.48–16.35]; sICH: acOR 12.97, 95%CI [2.39–70.26]) and mortality (aICH: aOR 10.08, 95%CI [2.48–40.88]; sICH: aOR 9.92, 95%CI [1.48–66.31]). Likewise, sICH of HC3 was associated with the mRS and mortality (acOR 19.91, 95%CI [4.03–98.35], and aOR 13.23, 95%CI [2.27–77.18], respectively). aICH of HC3 was not significantly associated with the mRS or mortality (acOR 0.87, 95%CI [0.48–1.57], and cOR 0.84, 95%CI [0.32–2.20], respectively). ConclusionsImmediate post-EVT ICH is a frequent finding. Except for aICH of HC3, any ICH is associated with poor long-term clinical outcomes.

Key CT markers for predicting haemorrhagic transformation after ischaemic stroke: a prospective cohort study in China

ObjectivesLimited studies have systematically addressed the CT markers of predicting haemorrhagic transformation (HT). We aimed to (1) investigate the predictive ability of the imaging factors on multimodal CT for HT...

Low dose intravenous cangrelor versus glycoprotein IIb/IIIa inhibitors in endovascular treatment of tandem lesions

ObjectivesIntravenous (IV) periprocedural antiplatelet therapy (APT) for patients undergoing acute carotid stenting during mechanical thrombectomy (MT) is not fully investigated. We aimed to compare the safety profile of IV low dose cangrelor versus IV glycoprotein IIb/IIIa (GP-IIb/IIIa) inhibitors in patients with acute tandem lesions (TLs). Materials and methodsWe retrospectively identified all cases of periprocedural administration of IV cangrelor or GP-IIb/IIIa inhibitors during acute TLs intervention from a multicenter collaboration. Patients were divided in two groups according to the IV APT regimen at the time of MT procedure: 1) cangrelor and 2) GP-IIb/IIIa inhibitors (tirofiban and eptifibatide). Safety outcomes included rates of symptomatic intracranial hemorrhage (sICH), parenchymal hematoma type 1 and 2 (PH1-PH2), and hemorrhagic infarction type 1 and 2 (HI1-HI2). ResultsSixty-three patients received IV APT during MT, 30 were in the cangrelor group, and 33 were in the GP-IIb/IIIa inhibitors group. There were no significant differences in the rates of sICH (3.3% vs. 12.1%, aOR=0.21, 95%CI 0.02–2.18, p=0.229), HI1-HI2 (21.4% vs 42.4%, aOR=0.21, 95%CI 0.02–2.18, p=0.229), and PH1-PH2 (17.9% vs. 12.1%, aOR=1.63, 95%CI 0.29–9.83, p=0.577) between both treatment groups. However, there was a trend toward reduced hemorrhage rates with cangrelor. Cangrelor was associated with increased odds of complete reperfusion (aOR=5.86; 95%CI 1.57–26.62;p=0.013). ConclusionsIn this retrospective non-randomized cohort study, our findings suggest that low dose cangrelor has similar safety and increased rate of complete reperfusion compared to IV GP-IIb/IIIa inhibitors. Further prospective studies are warranted to confirm this association.

The impact of blood pressure variability on the development of parenchymal hematoma in acute cerebral infarction with atrial fibrillation.

Although blood pressure variability (BPV) and reperfusion are associated with parenchymal hematoma (PH) after stroke, the relationship between BPV and PH in atrial fibrillation (AF) patients who are at risk of reperfusion injury with frequent spontaneous recanalization is unknown. This study aimed to investigate whether BPV within the first 48 h is associated with PH within 72 h in patients with AF and stroke in terms of major vessel occlusion status. A total of 131 patients with AF that were admitted within 24 h after stroke onset were enrolled. PH was defined as a confluent hemorrhage with mass effect. The maximum (max), minimum (min), and average blood pressure (BP) during the first 48 h after admission were calculated. BPV was analyzed by using range between maximum and minimum (max-min), successive variation (SV), standard deviation (SD), and coefficient of variation (CV). All parameters were applied for systemic (SBP), diastolic (DBP), and pulse pressure (PP). After adjusting for confounding variables, various BPV parameters were associated with PH, including SBPmax (p = 0.0426), SBPSV (p = 0.0006), DBPmax-min (p = 0.0437), DBPSV (p = 0.0358), DBPSD (p = 0.0393), PPmax-min (p = 0.0478), PPSV (p < 0.0001), PPSD (p = 0.0034), and PPCV (p = 0.0120). The relationship remained significant in patients with a patent major vessel responsible for infarction but not in patients with an occluded major vessel. In conclusion, this study revealed that high BPV was associated with PH in patients with AF and acute stroke, particularly for those with a patent major vessel. The control of BP and BPV after stroke may be considered in patients with AF.

Intravenous thrombolysis with tenecteplase versus alteplase combined with endovascular treatment of anterior circulation tandem occlusions: A pooled analysis of ETIS and TETRIS.

Tandem occlusions are a singular large vessel occlusion entity involving specific endovascular and perioperative antithrombotic management. In this context, data on safety and efficacy of prior intravenous thrombolysis (IVT) with tenecteplase is scarce. We aimed to compare IVT with tenecteplase or alteplase in patients with acute tandem occlusions intended for endovascular treatment. A retrospective pooled analysis of two large observational registries (ETIS (Endovascular Treatment of Ischemic Stroke) and TETRIS (Tenecteplase Treatment in Ischemic Stroke)) was performed on consecutive patients presenting with anterior circulation tandem occlusion treated with IVT using either alteplase (ETIS) or tenecteplase (TETRIS) followed by endovascular treatment between January 2015 and June 2022. Sensitivity analyses on atherosclerosis related tandem occlusions and on patient treated with emergent carotid stenting were conducted. Propensity score overlap weighting analyses were performed. We analyzed 753 patients: 124 in the tenecteplase and 629 in the alteplase group. The overall odds of favorable outcome (3-month modified Rankin score 0-2) were comparable between both groups (49.4% vs 47.1%; OR = 1.10, 95%CI 0.85-1.41). Early recanalization, final successful recanalization and mortality favored the use of tenecteplase. The occurrence of any intracranial hemorrhage (ICH) was more frequent after tenecteplase use (OR = 2.24; 95%CI 1.75-2.86). However, risks of symptomatic ICH and parenchymal hematoma remained similar. In atherosclerotic tandems, favorable outcome, mortality, parenchymal hematoma, early recanalization, and final successful recanalization favored the tenecteplase group. In the carotid stenting subgroup, PH were less frequent in the tenecteplase group (OR = 0.18; 95%CI 0.05-0.69). In patients with tandem occlusions, IVT with tenecteplase seemed reasonably safe in particular with increased early recanalization rates. These findings remain preliminary and should be further confirmed in randomized trials.

Incidence of intracranial hemorrhagic complications after anterior circulation endovascular thrombectomy in relation to occlusion site: a nationwide observational register study

BackgroundIntracranial hemorrhage (ICH) is a potentially severe complication of endovascular thrombectomy (EVT). However, the relationship between the incidence and severity of ICH and vascular occlusion location is not well described.ObjectiveTo...

Safety of Intravenous Cangrelor Versus Dual Oral Antiplatelet Loading Therapy in Endovascular Treatment of Tandem Lesions: An Observational Cohort Study

Background Procedural intravenous cangrelor has been proposed as an effective platelet inhibition strategy for stenting in acute ischemic stroke. We aimed to compare the safety profile of low‐dose intravenous cangrelor versus dual oral antiplatelet therapy (DAPT) loading in patients with acute cervical tandem lesions. Methods We retrospectively identified cases from an international multicenter cohort who underwent intraprocedural administration of intravenous cangrelor (15 μg/kg followed by an infusion of 2 μg/kg per min) or DAPT loading during acute tandem lesions intervention. Safety outcomes included rates of symptomatic intracranial hemorrhage, parenchymal hematoma type 2, petechial hemorrhage, and in‐stent thrombosis. Inverse probability of treatment weighting matching was used to reduce confounding. Results From 691 patients, we included 195 patients, 30 of whom received intravenous cangrelor and 165 DAPT. The DAPT regimens were aspirin+clopidogrel (93.3%) or aspirin+ticagrelor (6.6%). After inverse probability of treatment weighting, the patients treated with cangrelor were not at greater odds of symptomatic intracranial hemorrhage (odds ratio [OR], 1.30 [95% CI, 0.09–17.3]; P =0.837), symptomatic intracranial hemorrhage–parenchymal hematoma type 2 (OR, 0.54 [95% CI, 0.05–4.98]; P =0.589), or petechial hemorrhage (OR, 1.11 [95% CI, 0.38–3.28]; P =0.836). Similarly, the rate of in‐stent thrombosis was not significantly different between the 2 groups (1.8% versus 0%; P =0.911). Conclusion Cangrelor at the half dose of the myocardial infarction protocol showed a similar safety profile compared with the commonly used DAPT loading protocols in patients with acute tandem lesions. Further studies with larger samples are warranted to elucidate the safety of antiplatelet therapy in tandem lesions.

Impact of pre-treatment cerebral microbleeds on the outcomes of endovascular thrombectomy: A systematic review and meta-analysis

Objective/AimTo investigate the effect of cerebral microbleeds (CMBs) on the functional and safety outcomes of endovascular thrombectomy (EVT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). MethodsThis study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines for systematic review and meta-analysis. We included observational studies that recruited AIS-LVO patients, used susceptibility-sensitive magnetic resonance imaging (MRI) to detect CMBs, and examined the association between them and predefined outcome events. The extracted data included study and population characteristics, risk of bias domains, and outcome measures. The outcomes of interest included functional independence, revascularization success, procedural and hemorrhagic adverse events. We conducted a meta-analysis using the Mantel-Haenszel method and calculated the risk ratios. ResultsFour studies with a total of 1,514 patients were included. A significant reduction in the likelihood of achieving a favorable functional outcome was observed in patients with CMBs (Risk ratio (RR) 0.69, 95% confidence interval (CI): 0.52 to 0.91, P=0.01). No significant differences were observed between the CMBs and no CMBs groups in terms of successful revascularization, mortality, intracranial hemorrhage (ICH), subarachnoid hemorrhage (SAH), and parenchymal hematoma. ConclusionsThe presence of CMBs significantly reduced the likelihood of achieving functional independence post-EVT in AIS-LVO patients. However, CMBs did not impact the rates of successful revascularization, mortality, or the occurrence of various hemorrhagic events. Future research should explore the mechanisms of this association and strategies to mitigate its impact.

Factors associated with hemorrhagic transformation after endovascular treatment despite early recanalization

PurposeTo identify new factors associated with hemorrhagic transformation (HT) despite early recanalization in patients with acute ischemic stroke treated with mechanical thrombectomy. MethodsWe retrospectively included patients with known onset of large vessel occlusion treated with mechanical thrombectomy +/− intravenous thrombolysis. Non-contrast CT was performed at 24 +/− 12 h from endovascular procedure. We collected data on patient characteristics, risk factors, radiological and treatment features, stroke severity on admission and discharge, carotid intima-media thickness (CIMT), Neutrophils-to-Lymphocytes ratio (NLR), white matter hyperintensities measured according to the Fazekas score on FLAIR MRI data. The main outcome measures were the incidence of HT and factors associated with it. Secondary outcome measures were symptomatic intracerebral hemorrhage and parenchymal hematoma. ResultsOf 874 patients, 472 met the inclusion criteria, 211 (44.7%) had HT. Factors significantly associated with increased risk of HT included onset-to-recanalization time, CIMT (normal/mild), ASPECT-MRI < 6, and a higher NLR. We found that beyond 7.67 h from onset-to-recanalization, the risk of HT increases and exceeds 50%. ASPECT-MRI, NLR, and CIMT independently predict HT despite early recanalization. ConclusionsWe identified novel factors associated with HT in patients with acute ischemic stroke of known onset treated with mechanical thrombectomy. We found that at 7.67 h from onset to recanalization, the risk of HT is >50%, and we identified factors responsible for HT despite early recanalization.

Mechanical thrombectomy beyond 24 hours from last known well in tandem lesions: A multicenter cohort study.

While recent studies suggest a benefit of mechanical thrombectomy (MT) for the treatment of patients with isolated large vessel occlusions presenting after 24 hours from the last known well (LKW), the effect of MT for acute cervical tandem lesions (TLs) beyond 24 hours remains unknown. We aimed to evaluate the safety and effectiveness of MT beyond 24 hours of LKW in patients with TLs. We conducted a subanalysis study of patients with anterior circulation TL enrolled in a large, multicenter registry between January 2015 and December 2020. Patients were divided into 2 groups: MT beyond 24 hours versus MT 0-24-hour window. Outcomes of interest were functional independence (90-day modified Rankin scale 0-2), complete reperfusion (modified thrombolysis in cerebral infarction 3), delta NIH Stroke Scale (NIHSS), symptomatic intracranial hemorrhage (sICH), parenchymal hematoma 2 (PH2), in-hospital mortality, and 90-day mortality. Inverse probability of treatment weighting (IPTW) was used to balance the groups. Overall, 589 participants were included, with 33 treated beyond 24 hours and 556 treated in the 0-24-hour window. After IPTW, we found no significant difference in the rates of achieving functional independence (odds ratio (OR) = 0.51; 95% confidence interval (CI) 0.22-1.16; p = 0.108), complete reperfusion (OR = 1.35; 95% CI 0.60-3.05; p = 0.464), sICH (OR = 1.96; 95% CI 0.37-10.5; p = 0.429), delta NIHSS (β = -3.61; 95% CI -8.11 to 0.87; p = 0.114), PH2 (OR = 1.46; 95% CI 0.29-7.27; p = 0.642), in-hospital mortality (OR = 1.74; 95% CI 0.52-5.86; p = 0.370), or 90-day mortality (OR = 1.37; 95% CI 0.49-3.83; p = 0.544) across both time windows. Our results suggest that MT appears to benefit patients with TLs beyond 24 hours from LKW. Future prospective studies are warranted.

Low Levels of Low-Density Lipoprotein Cholesterol Increase the Risk of Post-Thrombectomy Delayed Parenchymal Hematoma.

Low levels of low-density lipoprotein cholesterol (LDL-C) have been suggested to increase the risk of hemorrhagic transformation (HT) following acute ischemic stroke. However, the literature on the relationship between LDL-C levels and post-thrombectomy HT is sparse. The aim of our study is to investigate the association between LDL-C and delayed parenchymal hematoma (PH) that was not seen on immediate post-thrombectomy dual-energy computed tomography (DECT). A retrospective analysis was conducted on all patients with anterior circulation large vessel occlusion who underwent thrombectomy at a comprehensive stroke center from 2018-2021. Per institutional protocol, all patients received DECT immediately post-thrombectomy and magnetic resonance imaging or CT at 24 hours. The presence of immediate hemorrhage was assessed by DECT, while delayed PH was assessed by 24-hour imaging. Multivariable analysis was performed to identify predictors of delayed PH. Patients with hemorrhage on immediate post-thrombectomy DECT were excluded to select only those with delayed PH. Of 159 patients without hemorrhage on immediate post-thrombectomy DECT, 18 (11%) developed delayed PH on 24-hour imaging. In multivariable analysis, LDL-C (odds ratio [OR], 0.76; P=0.038; 95% confidence interval [CI], 0.59-0.99; per 10 mg/dL increase) independently predicted delayed PH. High-density lipoprotein cholesterol, triglyceride, and statin use were not associated. After adjusting for potential confounders, LDL-C ≤50 mg/dL was associated with an increased risk of delayed PH (OR, 5.38; P=0.004; 95% CI, 1.70-17.04), while LDL-C >100 mg/dL was protective (OR, 0.26; P=0.041; 95% CI, 0.07-0.96). LDL-C ≤50 mg/dL independently predicted delayed PH following thrombectomy and LDL-C >100 mg/dL was protective, irrespective of statin. Thus, patients with low LDL-C levels may warrant vigilant monitoring and necessary interventions, such as blood pressure control or anticoagulation management, following thrombectomy even in the absence of hemorrhage on immediate post-thrombectomy DECT.

Quantitative assessment of hyperperfusion using arterial spin labeling to predict hemorrhagic transformation in acute ischemic stroke patients with mechanical endovascular therapy.

This study was aimed to quantitatively assess hyperperfusion using arterial spin labeling (ASL) to predict hemorrhagic transformation (HT) in acute ischemic stroke (AIS) patients. This study enrolled 98 AIS patients with anterior circulation large vessel occlusion within 24h of symptom onset. ASL was performed before mechanical endovascular therapy. On pre-treatment ASL maps, a region with relative cerebral blood flow (CBF) ≥ 1.4 was defined as an area of hyperperfusion. The maximum CBF (CBFmax) of hyperperfusion was calculated for each patient. A non-contrast CT scan was performed during the subacute phase for the evaluation of HT. Good clinical outcome was defined as a 90-day modified Rankin scale score of 0-2. The CBFmax of hyperperfusion (odds ratio, 1.023; 95% confidence interval [CI], 1.005-1.042; p = 0.012) was an independent risk factor for the status of HT. The CBFmax of hyperperfusion for HT showed an area under the curve of 0.735 (95% CI, 0.588-0.882) with optimal cutoff value, sensitivity, and specificity being 146.5mL/100g/min, 76.9%, and 69.6%, respectively. There was a statistically significant relationship between HT grades (from no HT to PH2) and CBFmax of hyperperfusion with a Spearman rank correlation of 0.446 (p = 0.001). In addition, low CBFmax of hyperperfusion were associated with good functional outcome (95% CI, 17.130-73.910; p = 0.002). High CBFmax of hyperperfusion was independently associated with subsequent HT and low CBFmax of hyperperfusion linked to good functional outcome. There was a positive correlation between HT grade and CBFmax. CLINICAL RELEVANCE STATEMENT: Arterial spin labeling is a noninvasive and contrast agent-independent technique, which is sensitive in detecting hyperperfusion. This study shows that the cerebral blood flow of hyperperfusion is associated with clinical prognosis, which will benefit more patients. • Quantitative assessment of hyperperfusion using pre-treatment arterial spin labeling to predict hemorrhagic transformation and prognosis in acute ischemic stroke patients. • The maximum cerebral blood flow of hyperperfusion was associated with hemorrhagic transformation and clinical prognosis and higher maximum cerebral blood flow of hyperperfusion was associated with higher grade hemorrhagic transformation. • The maximum cerebral blood flow of hyperperfusion can predict hemorrhagic transformation which enables timely intervention to prevent parenchymal hematoma.

Endovascular treatment of acute basilar artery occlusion: A systematic review and meta-analysis of first-line stent retriever versus direct aspiration.

The best choice between first-line aspiration and stent retriever for acute basilar artery occlusion remains controversial. This study aims to perform a systematic review and meta-analysis comparing the stent retriever and direct aspiration about reported recanalization rates and periprocedural complications. PubMed, Embase, Web of Science, Cochrane, and Clinical Trials were searched for the studies evaluating the efficacy and safety of first-line aspiration versus stent retriever for acute basilar artery occlusion. A standard software program (Stata Corporation) was used for end-point analyses. Statistical significance was defined as a p-value less than .05. A total of 11 studies were involved in the current study, including 1014 patients. Regarding postoperative recanalization, the pooled analysis identified a significant difference in successful recanalization (odds ratio [OR]=1.642; 95% confidence interval (95% CI): 1.099-2.453; p=.015) and complete recanalization (OR=3.525; 95% CI: 1.306-2.872; p=.001) between the two groups in favor of the first-line aspiration. Concerning the complications, the first-line aspiration could achieve a lower rate of total complication (OR=.359; 95% CI: .229-.563; p<.001) and hemorrhagic complication (OR=.446, 95% CI: .259-.769; p=.004) than stent retriever. No significant difference was observed in postoperative mortality (OR=.966; p=.880), subarachnoid hematoma (OR=.171; p=.094), and parenchymal hematoma (OR=.799; p=.720). In addition, the pooled results revealed a significant difference in procedure duration between the two groups in favor of aspiration (WMD=-27.630, 95% CI: -50.958 to -4.302; p=.020). However, there was no significant difference in favorable outcome (OR=1.149; p=.352) and rescue therapy (OR=1.440; p=.409) between the two groups. Given that the first-line aspiration was associated with a higher rate of postoperative recanalization, a lower risk of postoperative complication, and a faster duration of the procedure, these findings support the aspiration may be more secure than a stent retriever.

The clinical utility of dual-energy CT in post-thrombectomy care: Part 2, the predictive value of contrast density and volume for delayed hemorrhagic transformation

ObjectivesDual-energy CT allows differentiation between blood and iodinated contrast. This study aims to determine the predictive value of contrast density and volume on post-thrombectomy dual-energy CT for delayed hemorrhagic transformation and its impact on 90-day outcomes. Materials and MethodsA retrospective analysis was performed on patients who underwent thrombectomy for anterior circulation large-vessel occlusion at a comprehensive stroke center from 2018-2021. Per institutional protocol, all patients underwent dual-energy CT immediately post-thrombectomy and MRI or CT 24 hours afterward. The presence of hemorrhage and contrast staining was evaluated by dual-energy CT. Delayed hemorrhagic transformation was determined by 24-hour imaging and classified into petechial hemorrhage or parenchymal hematoma using ECASS III criteria. Univariable and multivariable analyses were performed to determine predictors and outcomes of delayed hemorrhagic transformation. ResultsOf 97 patients with contrast staining and without hemorrhage on dual-energy CT, 30 and 18 patients developed delayed petechial hemorrhage and delayed parenchymal hematoma, respectively. On multivariable analysis, delayed petechial hemorrhage was predicted by anticoagulant use (OR,3.53;p=0.021;95%CI,1.19-10.48) and maximum contrast density (OR,1.21;p=0.004;95%CI,1.06-1.37;per 10 HU increase), while delayed parenchymal hematoma was predicted by contrast volume (OR,1.37;p=0.023;95%CI,1.04-1.82;per 10 mL increase) and low-density lipoprotein (OR,0.97;p=0.043;95%CI,0.94-1.00;per 1 mg/dL increase). After adjusting for potential confounders, delayed parenchymal hematoma was associated with worse functional outcomes (OR,0.07;p=0.013;95%CI,0.01-0.58) and mortality (OR,7.83;p=0.008;95%CI,1.66-37.07), while delayed petechial hemorrhage was associated with neither. ConclusionContrast volume predicted delayed parenchymal hematoma, which was associated with worse functional outcomes and mortality. Contrast volume can serve as a useful predictor of delayed parenchymal hematoma following thrombectomy and may have implications for patient management.

Comparison of diffusion weighted imaging b0 with T2*-weighted gradient echo or susceptibility weighted imaging for intracranial hemorrhage detection after reperfusion therapy for ischemic stroke

PurposeDiffusion-weighted imaging (DWI) b0 may be able to substitute T2*-weighted gradient echo (GRE) or susceptibility-weighted imaging (SWI) in case of comparable detection of intracranial hemorrhage (ICH), thereby reducing MRI examination time. We evaluated the diagnostic accuracy of DWI b0 compared to T2*GRE or SWI for detection of ICH after reperfusion therapy for ischemic stroke.MethodsWe pooled 300 follow-up MRI scans acquired within 1 week after reperfusion therapy. Six neuroradiologists each rated DWI images (b0 and b1000; b0 as index test) of 100 patients and, after a minimum of 4 weeks, T2*GRE or SWI images (reference standard) paired with DWI images of the same patients. Readers assessed the presence of ICH (yes/no) and type of ICH according to the Heidelberg Bleeding Classification. We determined the sensitivity and specificity of DWI b0 for detection of any ICH, and the sensitivity for detection of hemorrhagic infarction (HI1 & HI2) and parenchymal hematoma (PH1 & PH2).ResultsWe analyzed 277 scans of ischemic stroke patients with complete image series and sufficient image quality (median age 65 years [interquartile range, 54–75], 158 [57%] men). For detection of any ICH on DWI b0, the sensitivity was 62% (95% CI: 50–76) and specificity 96% (95% CI: 93–99). The sensitivity of DWI b0 was 52% (95% CI: 28–68) for detection of hemorrhagic infarction and 84% (95% CI: 70–92) for parenchymal hematoma.ConclusionDWI b0 is inferior for detection of ICH compared to T2*GRE/SWI, especially for smaller and more subtle hemorrhages. Follow-up MRI protocols should include T2*GRE/SWI for detection of ICH after reperfusion therapy.

Thrombolysis in Patients With Large‐Vessel Occlusion Directly Admitted or Transferred to a Thrombectomy Center: A Population‐Based Study

Background Our goal is to evaluate whether the administration of thrombolytic treatment has varying effects on clinical and radiological outcomes in patients with large‐vessel occlusion stroke, based on the type of stroke center where the treatment was given (thrombectomy‐capable center versus local stroke center). Methods We included patients with an acute ischemic large‐vessel occlusion stroke who were directly admitted to thrombectomy‐capable centers and treated with endovascular thrombectomy, or were transferred from local stroke centers as thrombectomy candidates, in Catalonia, Spain, between 2017 and 2021. The primary outcome was the shift analysis on the modified Rankin scale score at 90 days. Secondary outcomes included death at 90 days and the rate of parenchymal hemorrhage and successful reperfusion. Inverse‐probability weighting clustered at the type of stroke center was used to estimate the effects. Results The analysis included 2268 patients directly admitted to thrombectomy‐capable centers, of whom 975 (49%) were treated with thrombolysis, and 938 patients transferred from local stroke centers, of whom 580 (66%) were treated with thrombolysis and 616 (67%) were treated with thrombectomy. Mean age was 72 (SD ±13) years, median National Institute of Health Stroke Scale score was 17 (interquartile range, 12–21), and 1363 patients were women (48%). Patients treated with intravenous thrombolysis were younger, had shorter time from onset to first image, higher Alberta Stroke Program Early Computed Tomography Score, and lower rates of wake‐up stroke, atrial fibrillation, and anticoagulation intake. Patients treated with thrombolysis had better functional outcome at 90 days, with no difference between patients directly admitted to thrombectomy‐capable centers (adjusted common odds ratio [acOR], 1.50 [95% CI, 1.24–1.81]) and patients transferred from local stroke centers (acOR, 1.44 [95% CI, 1.04–2.01]). Patients treated with intravenous thrombolysis had lower death rate, higher rate of parenchymal hematoma, and similar rate of successful reperfusion, with no difference according to type of center ( P interaction &gt;0.1). Conclusion Administration of intravenous thrombolysis in patients with a large‐vessel stroke with intention of thrombectomy was associated with lower degrees of disability, lower death rate, and higher rates of parenchymal hematoma both in thrombectomy‐capable centers and in local stroke centers.

Early-versus-Late Endovascular Stroke Treatment: Similar Frequencies of Nonrevascularization and Postprocedural Cerebrovascular Complications in a Large Single-Center Cohort Study.

Endovascular treatment of acute ischemic stroke is now performed more frequently in the late window in radiologically selected patients. However, little is known about whether the frequency and clinical impact of incomplete recanalization and postprocedural cerebrovascular complications differ between early and late windows in the real world. We retrospectively reviewed all patients with acute ischemic stroke receiving endovascular treatment within 24 hours from 2015 to 2019 and included in the Acute STroke Registry and Analysis of Lausanne. We compared rates of incomplete recanalization and postprocedural cerebrovascular complications (parenchymal hematoma, ischemic mass effect, and 24-hour re-occlusion) in the early (<6 hours) versus late window (6-24 hours, including patients with unknown onset) populations and correlated them with the 3-month clinical outcome. Among 701 patients with acute ischemic stroke receiving endovascular treatment, 29.2% had late endovascular treatment. Overall, incomplete recanalization occurred in 56 patients (8%), and 126 patients (18%) had at least 1 postprocedural cerebrovascular complication. The frequency of incomplete recanalization was similar in early and late endovascular treatment (7.5% versus 9.3%, adjusted P =.66), as was the occurrence of any postprocedural cerebrovascular complication (16.9% versus 20.5%, adjusted P = .36). When analyzing single postprocedural cerebrovascular complications, rates of parenchymal hematoma and ischemic mass effect were similar (adjusted P = .71, adjusted P = .79, respectively), but 24-hour re-occlusion seemed somewhat more frequent in late endovascular treatment (4% versus 8.3%, unadjusted P = .02, adjusted P = .40). The adjusted 3-month clinical outcome in patients with incomplete recanalization or postprocedural cerebrovascular complications was comparable between early and late groups (adjusted P = .67, adjusted P = .23, respectively). The frequency of incomplete recanalization and of cerebrovascular complications occurring after endovascular treatment is similar in early and well-selected late patients receiving endovascular treatment. Our results demonstrate the technical success and safety of endovascular treatment in well-selected late patients with acute ischemic stroke.