Rate Of Hemorrhagic Transformation Research Articles

Rationale and Design of the Efficacy and Safety of Combination of Cilostazol and Gingko biloba Extract EGb 761 in patients with Acute Non-cardioembolic Ischemic Stroke (RENEW): A pilot and feasibility randomized controlled trial

BackgroundDual antiplatelet therapy with aspirin and clopidogrel is the standard treatment for acute ischemic stroke (AIS). Cilostazol has emerged as a safe alternative with pleiotropic effects that prevent stroke without increasing the risk of bleeding and has been shown to reduce neurological deterioration (ND) in the acute phase. Ginkgo biloba extract (EGb 761) has also been reported to improve neurological impairment following AIS. This trial aimed to evaluate the efficacy and safety of the combination of cilostazol and EGb 761 in reducing early stroke recurrence and ND in patients with non-cardioembolic AIS. MethodsThe RENEW trial is a prospective, randomized, active-controlled, double-blind, parallel, multicenter phase IV study. Five hundred patients with non-cardioembolic AIS presenting within 72 h of symptom onset will be randomized to receive either aspirin 100 mg and cilostazol 200 mg plus EGb 761 160 mg daily or aspirin 100 mg and clopidogrel 75 mg daily for 90 days. The primary outcomes included the combined ND rate during hospitalization and stroke recurrence within 90 days. Secondary outcomes included the rates of ND, recurrent AIS, hemorrhagic stroke, hemorrhagic transformation, functional outcomes (modified Rankin Scale 0–2), bleeding events, and changes in the dizziness handicap inventory scores. DiscussionThe RENEW trial is expected to provide evidence for the safety and efficacy of combining aspirin, cilostazol, and EGb 761 as an alternative to standard therapy for the acute management of non-cardioembolic AIS. Trial RegistrationThis trial was registered at ClinicalTrials.gov (NCT05445895).

Stroke Thrombolysis in the Elderly: A Moroccan Retrospective Study

Background: Age increases the risk of mortality and poor prognosis following a stroke. The benefits of intravenous thrombolysis (IVT) in elderly patients have been well established. However, the outcomes in daily clinical practice may differ from those reported in other studies. The objectives of our study are to evaluate the effectiveness and safety of thrombolysis in elderly stroke patients and provide local data that can inform clinical practices in similar settings and raise awareness about specific challenges in treating elderly patients with ischemic stroke. Methods: We conducted a retrospective, cross-sectional, descriptive, and analytical study in the neurology department of Hassan II University Hospital in Fez, Morocco, from May 2015 to March 2021. All elderly patients aged ≥ 80 years within 6 h of onset who received intravenous thrombolysis were recruited. The primary outcomes were the rate of hemorrhagic transformation, NIHSS score at 24 h after IV thrombolysis and the rate of death within the first 7 days. Secondary outcomes were functional status at 3 months, assessed using the modified Rankin Scale (mRS). Our results were interpreted in light of the main studies in the literature. Results: 41 patients (58.5 % female, aged 84 ± 3.5 y.o) all received IV thrombolysis (tenecteplase 85.4% vs alteplase 14.6%) were included. The mean NIHSS score before IV thrombolysis was 13 (range, 3-20) and that 24 h after IV thrombolysis was 10 (rang, 1-19). Hemorrhagic transformations occurred in 31.7% of the patients within 7 days after onset (9.8% HI1, 9.8% HI2, 2.4% PH1, 9.8% PH2), and all of these cases were asymptomatic. The rate of death within the first 7 days was 22%. Among living patients, the median three months mRS was 3. The mortality rate at three months was 26.8% (n=11). However, there was no significant association between these outcomes and the occurrence of ICH after IVT. Conclusion: Despite the higher mortality rate in our sample, IV thrombolysis ...

Endovascular Therapy in Large Core Ischemic Strokes: Real-World Indian Experience.

Large core acute ischemic strokes have predominantly been excluded from endovascular therapy (EVT) studies due to perceived higher risks of hemorrhage and poorer functional outcomes. However, recent randomized controlled trials (RCTs) indicate that EVT for large vessel occlusion (LVO) strokes improves functional outcomes compared to medical management alone, despite higher hemorrhagic transformation rates, with no corresponding increase in symptomatic intracerebral hemorrhage (sICH) rates. The real-world outcomes of this intervention in Indian patients remain underexplored. To evaluate the real-world outcomes of EVT for large core acute ischemic strokes with LVO in an Indian population. We conducted a single-center, retrospective observational study using a 7 years prospective database of EVT in anterior circulation stroke patients. Patients with Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 3-5 were included. Clinical and radiologic data were analyzed, with the primary endpoint being 90-day modified Rankin scale (mRS) scores. Safety outcomes included rates of sICH and mortality. Descriptive statistical analysis was done using Microsoft Excel. The study included 25 patients who met the inclusion criteria. Mean age of patients was 52.9 ± 14.3 years, and there were 13 (52%) males. Median ASPECTS was 5 (interquartile range 4-5). Successful recanalization, classified by modified Thrombolysis in Cerebral Infarction score, was 92%. Good functional recovery, that is, 90-day mRS 0-3, was achieved in nine (36%) patients. Safety outcomes: sICH was seen in four (16%) and mortality was reported in nine (36%) patients. Our results reaffirm findings from RCTs, provide updated real-world evidence, and suggest that EVT is a viable option to be considered in selected patients with large core ischemic infarcts.

The use of thromboaspiration and combined treatment in patients with ischemic stroke in real-life clinical practice

The effectiveness of staged reperfusion therapy in real clinical practice requires clarification. Objective: to evaluate the efficacy and safety of mechanical thromboextraction and staged reperfusion therapy with alteplase in real clinical practice. Material and methods. The study included 106 patients who were retrospectively divided into two groups: Group I underwent staged reperfusion therapy (intravenous thrombolysis with alteplase followed by aspiration thromboextraction), Group II underwent thromboaspiration only. The clinical and functional results, incidence of hemorrhagic transformation and mortality rate were compared. Results. The groups did not differ in terms of demographic data, cardiovascular risk factors or stroke severity. Group II patients were characterized by a longer delay in reperfusion therapy (225 minutes versus 180 minutes) and a lower score on the Alberta Stroke Programme Early CT score (ASPECTS; 8.8 points versus 9.3 points). There were no differences in National Institutes of Health Stroke Scale (NIHSS) scores at day 28, dynamics of NIHSS scores, Rankin scores at day 28, rates of hemorrhagic transformation or mortality. In both groups, the deceased patients were older; in Group I they suffered more frequently from atrial fibrillation, in Group II – from diabetes mellitus type 2. In addition, mortality in Group II was associated with a higher severity of early signs of cerebral infarction.Conclusion. The results of the analysis of real-life clinical practice show the comparability of the efficacy and safety of staged reperfusion therapy and isolated thromboaspiration in a “natural” selection of patients.

Prediction of Futile Recanalization Following Mechanical Thrombectomy for Acute Ischemic Stroke Using Quantitative Electroencephalography: Temporal Delta/Alpha Power Ratio as an Independent Predictor

Objective: Previous studies have reported associations between quantitative electroencephalography (QEEG) parameters and acute ischemic stroke (AIS). However, the relationship between QEEG parameters and clinical outcomes in AIS patients with complete intracranial recanalization post-thrombectomy has been rarely explored. This study aims to evaluate the relationship between the QEEG parameter, specifically the regional delta/alpha power ratio (DAR), and futile recanalization (FR) in AIS patients with anterior circulation large vessel occlusion undergoing mechanical thrombectomy. Methods: A retrospective study was conducted on AIS patients with anterior circulation large artery occlusion who underwent mechanical thrombectomy and achieved complete vessel recanalization (mTICI 2b or 3) between May 2020 and October 2021. Patients with complete recanalization were categorized into effective recanalization and FR groups based on their modified Rankin scale (mRS) scores at three months. The FR group was defined as having an mRS score of 3–6 at three months, while the effective recanalization group had an mRS score of 0–2. Univariate analysis was performed to identify factors associated with FR, and factors with P < 0.05 were further analyzed using binary logistic regression to determine independent predictors of FR. Receiver operating characteristic (ROC) curve analysis was employed to assess the predictive ability of identified factors for FR. Results: Among 152 patients, 81 had effective recanalization, while 71 had FR, resulting in an FR rate of 46.7%. Univariate analysis revealed that baseline characteristics such as admission NIH stroke scale (NIHSS) score, neutrophil ratio, hemorrhagic transformation rate, number of thrombectomy passes, and time to recanalization were higher, whereas ASPECTS score was lower in the FR group compared to the effective recanalization group, all with statistical significance (P < 0.05). Electrophysiologically, DAR values in the affected frontal and temporal regions were significantly higher in the FR group compared to the effective recanalization group (P < 0.05). After adjusting for potential confounders, multivariable adjusted regression analysis demonstrated that regional DAR (odds ratio [OR] 1.205 [95% CI 1.041–1.396], P = 0.013), neutrophil ratio (OR 1.040 [95% CI 1.040–1.081], P = 0.042), ASPECTS score (OR 0.556 [95% CI 0.397–0.780], P = 0.001), and admission NIHSS score (OR 1.209 [95% CI 1.064–1.373], P = 0.004) were independent predictors of FR. ROC analysis indicated that combining regional DAR, especially temporal DAR, with other clinical factors could effectively predict adverse outcomes. Conclusion: Baseline characteristics including NIHSS score, ASPECTS score, and neutrophil ratio are independent predictors of FR, while electrophysiological characteristics, particularly temporal DAR of regional DAR, are closely associated with adverse outcomes at three months post-mechanical thrombectomy in AIS patients with anterior circulation large vessel occlusion. This shows that models incorporating temporal DAR can effectively predict FR.

In-hospital stroke protocol outcomes before and after the implementation of neurological assessments by telemedicine: an observational case-control study.

Stroke is the second leading cause of global adult mortality and the primary cause of disability. A rapid assessment by a neurologist for general and reperfusion treatments in ischemic strokes is linked to decreased mortality and disability. Telestroke assessment is a strategy that allows for neurological consultations with experienced professionals, even in remote emergency contexts. No randomized studies have compared face-to-face neurological care outcomes with telestroke care. Whether neurologists in an institution achieve better results remotely than in person is also unknown. This study aimed to compare mortality and other outcomes commonly measured in stroke protocols for stroke patients assessed by a neurologist via face-to-face evaluations and telestroke assessment. Observational single-center retrospective study from August/2009 to February/2022, enrolling 2,689 patients with ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage. Group 1 (G1) comprised 2,437 patients with in-person neurological assessments, and Telemedicine Group 2 (G2) included 252 patients. The in-person group had higher admission NIHSS scores (G1, 3 (0; 36) vs. G2, 2 (0; 26), p < 0.001). The door-to-groin puncture time was lower in the in-person group than in the telestroke group (G1, 103 (42; 310) vs. G2, 151 (109; 340), p < 0.001). The telestroke group showed superior metrics for door-to-imaging time, symptomatic hemorrhagic transformation rate in ischemic stroke patients treated with intravenous thrombolysis, hospital stay duration, higher rates of intravenous thrombolysis and mechanical thrombectomy, and lower mortality. Symptomatic hemorrhagic transformation rate was smaller in the group evaluated via telestroke (G1, 5.1% vs. G2, 1.1%, p = 0.016). Intravenous thrombolysis and mechanical thrombectomy rates were significantly higher in telestroke group: (G1, 8.6% vs. G2, 18.2%, p < 0.001 and G1, 5.1% vs. G2, 10.4%, p = 0.002, respectively). Mortality was lower in the telestroke group than in the in-person group (G1, 11.1% vs. G2, 6.7%, p = 0.001). The percentage of patients with an mRS score of 0-2 at discharge was similar in both groups when adjusting for NIHSS score and age. The same neurological emergency team may assess stroke patients in-person or by telemedicine, with excellent outcome metrics. This study reaffirms telestroke as a safe tool in acute stroke care.

Late Lesion Growth following Endovascular Therapy: Is 24 h Too Early to Assess Acute Infarct Size Including the Effects of Secondary Injury?

Introduction: Stroke lesion volume on MRI or CT provides objective evidence of tissue injury as a consequence of ischemic stroke. Measurement of “final” lesion volume at 24-h following endovascular therapy (post-EVT) has been used in multiple studies as a surrogate for clinical outcome. However, despite successful recanalization, a significant proportion of patients do not experience favorable clinical outcome. The goals of this study were to quantify lesion growth during the first week after treatment, identify early predictors, and explore the association with clinical outcome. Methods: This is a prospective study of stroke patients at two centers who met the following criteria: (i) anterior large vessel occlusion acute ischemic stroke, (ii) attempted EVT, and (iii) had 3T MRI post-EVT at 24-h and 5-day. We defined “early” and “late” lesion growth as ≥10 mL lesion growth between baseline and 24-h diffusion-weighted imaging (DWI) and between 24-h DWI and 5-day fluid attenuated inversion recovery imaging, respectively. Complete reperfusion was defined as >90% reduction of the volume of tissue with perfusion delay (Tmax>6 s) between pre-EVT and 24-h post-EVT. Favorable clinical outcome was defined as modified Rankin scale (mRS) of 0–2 at 30 or 90 days. Results: One hundred twelve patients met study criteria with median age 67 years, 56% female, median admit NIHSS 19, 54% received IV or IA thrombolysis, 66% with M1 occlusion, and median baseline DWI volume 21.2 mL. Successful recanalization was achieved in 87%, and 68% had complete reperfusion, with an overall favorable clinical outcome rate of 53%. Nearly two-thirds (65%) of the patients did not have late lesion growth with a median volume change of −0.3 mL between 24-h and 5-day and an associated high rate of favorable clinical outcome (64%). However, ∼1/3 of patients (35%) did have significant late lesion growth despite successful recanalization (87%: 46% mTICI 2b/41% mTICI 3). Late lesion growth patients had a 27.4 mL change in late lesion volume and 30.1 mL change in early lesion volume. These patients had an increased hemorrhagic transformation (HT) rate of 68% with only 1 in 3 patients having favorable clinical outcome. Late lesion growth was independently associated with incomplete reperfusion, HT, and unfavorable outcome. Conclusion: Approximately 1 out of 3 patients had late lesion growth following EVT, with a favorable clinical outcome occurring in only 1 out of 3 of these patients. Most patients with no early lesion growth had no late lesion growth. Identification of patients with late lesion growth could be critical to guide clinical management and inform prognosis post-EVT. Additionally, it can serve as an imaging biomarker for the development of adjunctive therapies to mitigate reperfusion injury.

Statin treatment in stroke patient with low‐density lipoprotein cholesterol levels below 70 mg/dL

Background and purposeThe effectiveness of hyperlipidemia treatment in strokes secondary prevention has been established. However, whether pretreatment with statins could confer protective effects when a patient's baseline low-density lipoprotein cholesterol (LDL-C) level is <70 mg/dL remains uncertain. Additionally, the ability of statin treatment to reduce poststroke complications, mortality, and recurrence in this patient group is unclear. Methods and resultsIn this retrospective observational study, we enrolled patients who had experienced an ischemic stroke with LDL-C levels <70 mg/dL. We analyzed the association of statin use with baseline characteristics, stroke severity, in-hospital complications, mortality rates, stroke recurrence rate, and mortality rate. Patients who used and patients who did not use statins were similar in terms of age and sex. Patients using statins had higher rates of diabetes mellitus, hypertension, prior stroke, and coronary artery disease but a lower incidence of atrial fibrillation. Stroke severity was less pronounced in those using statins. We also evaluated the relationship between in-hospital statin use and complications. We noted that in-hospital statin use was associated with lower rates of infection, hemorrhagic transformation, gastrointestinal hemorrhage, and mortality, as well as higher rates of positive functional outcomes. The 1-year recurrence rate was similar in both groups. ConclusionsStatin use is associated with milder strokes and improved poststroke outcomes, even in patients with well-controlled LDL levels. Neurologists may consider prescribing statins for patients with ischemic stroke who do not overt hyperlipidemia. Further research into potential underlying mechanisms is warranted.

Abstract TP240: Safety of Dabigatran in Patients With Acute Minor Non-Cardioembolic Ischemic Stroke or Transient Ischemic Attack and Cerebral Microbleeds: A Post Hoc Analysis of the DATAS-II Randomized Trial

Introduction: Cerebral microbleeds are reported to predict risk of hemorrhagic transformation (HT) in patients with acute ischemic stroke. We aimed to investigate whether the effect of dabigatran (vs. aspirin) in patients with acute minor non-cardioembolic ischemic stroke/TIA is modified by baseline microbleeds on MRI. Methods: This is a post hoc analysis of the DATAS-II trial that randomized 305 patients with acute minor non-cardioembolic ischemic stroke/TIA to dabigatran (150/110 mg twice daily) or aspirin (81 mg daily) for 30 days. MRIs of patients with T2*-weighted sequences on their baseline scans underwent blinded central adjudication for microbleeds. Results: A total of 251 participants (mean age=66±13 years, 36% women, median [IQR] time from symptom onset to randomization 40 [27-55] hours; mean NIHSS=1.5±1.9) were included in these analyses, of whom 82 (33%) had baseline microbleeds. On 30-day MRI, 6% (n=14) developed HT, and 80% (n=191) achieved mRS 0-1 at 90 days. In multivariable logistic regression analyses, we found no association between microbleeds and HT (adjusted odds ratio [aOR], 0.76; 95% CI, 0.18-3.23) on 30-day MRI or mRS 0-1 at 90 days (aOR, 1.54; 95% CI, 0.70-3.41). The rates of HT and mRS 0-1 in patients with microbleeds were 3% on dabigatran and 4% on aspirin (OR, 0.71; 95% CI, 0.06-8.17), and 74% on dabigatran and 84% on aspirin (OR, 0.54; 95% CI, 0.18-1.64), respectively. The presence, severity, or location of microbleeds did not modify the effect of dabigatran on these outcomes (p-interaction&gt;0.05). Conclusions: Early dabigatran treatment appears safe in patients with acute minor non-cardioembolic ischemic stroke/TIA and hemorrhage-prone cerebral small vessel disease marked by microbleeds on MRI.

Abstract WMP64: Late Lesion Growth Following Endovascular Therapy: Is 24 Hours Too Early to Assess Acute Infarct Size Including the Effects of Secondary Injury?

Background: Measurement of “final” lesion volume at 24hr following endovascular therapy (post-EVT) has been used in multiple studies as a surrogate for clinical outcome. However, despite successful recanalization, a significant proportion of patients do not experience favorable clinical outcome. Methods: This is a prospective study of acute ischemic stroke patients at two stroke centers who met the following criteria: i) anterior large vessel occlusion (LVO) acute ischemic stroke, ii) attempted EVT, iii) written informed consent obtained, and iv) had MRI post-EVT at 24hr and 5-day. We defined “Early” and “Late” lesion growth as ≥10mL lesion growth between baseline and 24hr DWI, and between 24hr DWI and 5-day FLAIR, respectively. Results: One hundred fourteen patients met study criteria with median age 67 years, 56% female, median admit NIHSS 19, 54% received IV or IA thrombolysis, 67% with M1 occlusion, and median baseline DWI volume 28.2mL. Successful recanalization was achieved in 86% and 67% had complete reperfusion, with an overall favorable clinical outcome rate of 54%. Nearly two thirds (65%) of the patients did not have Late lesion growth with a median volume change of -0.2mL between 24hr and 5-days and an associated high rate of favorable clinical outcome (65%). However, ~1/3 of patients (35%) did have significant Late lesion growth despite successful recanalization (85% TICI 2b/3). Late lesion growth patients had a 26.2mL change in Late lesion volume and 19.9mL change in Early lesion volume. These patients had an increased hemorrhagic transformation rate of 68% with only 1 in 3 patients having favorable clinical outcome. Late lesion growth was independently associated with incomplete reperfusion, hemorrhagic transformation, and unfavorable outcome even after adjusting for admit NIHSS and Early lesion growth. Conclusions: Approximately 1 out of 3 patients had Late lesion growth following EVT, with a favorable clinical outcome occurring in only 1 out of 3 of these patients. Identification of patients with Late lesion growth could be critical to guide clinical management and inform prognosis post-EVT. Additionally it can serve as an imaging biomarker for the development of adjunctive therapies to mitigate reperfusion injury.

Comparison of Characteristics and Outcomes Between Acute Ischemic Stroke Patients with Different Types of Heart Failure.

Acute ischemic stroke (AIS) can be complicated by heart failure involving preserved ejection fraction (HFpEF) or reduced ejection fraction (HFrEF), and whether or not the prognosis differs between the 2 types of patients remains unclear. We compared the clinical characteristics and outcomes of the 2 types of patients at 3 months after the stroke.We retrospectively analyzed patients who, between 1 January 2018 and 1 January 2021, experienced AIS that was complicated by HFrEF or HFpEF. All patients had been prospectively registered in the Chengdu Stroke Registry. Poor outcome was defined as a modified Rankin Scale (mRS) score of 2-6 at 3 months. Univariate and binary logistic regression was used to assess whether HFpEF was associated with a significantly worse prognosis than HFrEF.Among the final sample of 108 patients (60.2% men; mean age, 73.08 ± 10.82 years), 75 (69.4%) had HFpEF. Compared to HFrEF patients, those with HFpEF were older (P = 0.002), were more likely to have chronic kidney disease (P = 0.033), and were more likely to experience a poor outcome (P = 0.022). After adjustments, HFpEF was associated with significantly greater risk of poor outcome than HFrEF (OR 4.13, 95%CI 1.20-15.79, P = 0.029). However, rates of hemorrhagic transformation or mortality at 3 months after AIS did not differ significantly between the 2 types of heart failure (all P > 0.05).Patients with AIS involving HFpEF experience worse outcomes than those with HFrEF and therefore may require special monitoring and management. Our findings need to be verified in large prospective studies.

Effect of multidisciplinary refined time management combined with organized stroke management on the efficacy of intravenous thrombolysis in patients with acute ischemic stroke

This study aims to investigate the effects of multidisciplinary refined time management combined with organized stroke management in intravenous thrombolysis on patients with acute ischemic stroke. 226 acute ischemic stroke patients treated with intravenous thrombolysiswere selected for retrospective analysis. A Control group participants underwent organized stroke management, whereas study group participants underwent multidisciplinary refined time management based on the control group. The study group responded to intravenous thrombolysis for 24 hours at an overall rate of 92.92%, significantly higher than 79.65% in the control group (p &lt; 0.05). The time from onset to emergency, time for National Institute of Health Stroke Scale (NIHSS) scoring by emergency doctors, consultation time for neurologists, judgement time for head computed tomography (CT), interpretation time for examination results, communication time with family members to sign the consent form, and time from admission to medication in the study group were significantly shorter than that in control group (p &lt; 0.05). The incidence of hemorrhagic transformation, six-month mortality and six-month rehospitalization rate in the study group were significantly lower than those in the control group (p &lt; 0.05). Before thrombolysis, cerebrovascular reserve function and neurological function indexes in both groups were improved, and there was significant difference before and after thrombolysis in this group (p &gt; 0.05); After thrombolysis, mean blood flow velocity (MFV) and breath-holding index (BHI) in the study group were significantly higher than those in the control group (p &lt; 0.05); pulsatility index (PI) was lower than that in the control group, showing a significant difference (p &lt; 0.05); Serum nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF) and neurotrophin-3 (NT-3) were significantly higher than those in the control group (p &lt; 0.05). Multidisciplinary refined time management combined with organized stroke management can improve the effect of intravenous thrombolysis in acute ischemic stroke.

Effect of tirofiban combined with endovascular treatment on hemorrhagic transformation and neurological function in patients with ischemic stroke.

To evaluate the effect of Tirofiban combined with endovascular treatment on hemorrhagic transformation (HT) and neurological function in patients with ischemic stroke. A retrospective analysis was performed on 94 patients with ischemic stroke treated at Xi'an International Medical Center Hospital from January 2020 to January 2023. Among them, 45 patients underwent endovascular treatment only and served as the control group. Another 49 patients received Tirofiban in addition to endovascular treatment and they formed the study group. The pre-treatment and 14-day post-treatment NIHSS scores were compared between the two groups. The 24-hour HT rate and the incidence of post-treatment adverse events were also compared between the two groups. Multivariate Cox regression analysis was used to identify factors influencing patient prognosis. The NIHSS scores in the study group were significantly lower than those in the control group 14 days after treatment (P<0.05). There was no statistically significant difference in the 24-hour HT rate between the two groups (P>0.05). In addition, there were no significant differences in the incidence of adverse events between the two groups (P>0.05). Multivariate Cox regression analysis showed that treatment regimen, age, and time from onset to admission were independent factors affecting 90-day prognosis (P<0.01). A prognostic model based on β-coefficients was constructed: Cox risk = 2.729 * treatment regimen + 2.881 * age + 2.795 * time from onset to admission. The Cox risk was significantly lower in the good prognosis group compared to the poor prognosis group (P<0.0001), with an area under the curve of 0.925 in predicting patient prognosis. Tirofiban combined with endovascular treatment can improve quality of life, neurological function, and short-term prognosis in patients with ischemic stroke without increasing the incidence of adverse effects and HT.

Cerebral microbleeds and asundexian in non-cardioembolic ischemic stroke: Secondary analyses of the PACIFIC-STROKE randomized trial.

Cerebral microbleeds are magnetic imaging resonance (MRI) markers of hemorrhage-prone cerebral small vessel disease that predict future risk of ischemic stroke and intracranial hemorrhage (ICrH). There exist concerns about the net benefit of antithrombotic therapy in patients with microbleeds. We aimed to investigate the effects of an oral factor-XIa inhibitor (asundexian), that is hypothesized to inhibit thrombosis without compromising hemostasis, on the development of new microbleeds over time and interactions between microbleeds and asundexian treatment on clinical outcomes. We additionally assessed associations between baseline microbleeds and the risks of clinical and neuroimaging outcomes in patients with non-cardioembolic ischemic stroke. This is a secondary analysis of the PACIFIC-STROKE, international, multi-center Phase 2b double-blind, randomized clinical trial. PACIFIC-STROKE enrolled patients aged ⩾ 45 years with mild-to-moderate non-cardioembolic ischemic stroke who presented within 48 h of symptom onset for whom antiplatelet therapy was intended. Microbleeds were centrally adjudicated, and participants with an interpretable T2*-weighted sequence at their baseline MRI were included in this analysis. Patients were randomized to asundexian (10/20/50 mg daily) versus placebo plus standard antiplatelet treatment. Regression models were used to estimate the effects of (1) all pooled asundexian doses and (2) asundexian 50 mg daily on new microbleed formation on 26-week MRIs. Cox proportional hazards or regression models were additionally used to estimate interactions between treatment assignment and microbleeds for ischemic stroke/transient ischemic attack (TIA) (primary outcome), and ICrH, all-cause mortality, hemorrhagic transformation (HT), and new microbleeds (secondary outcomes). Of 1746 participants (mean age, 67.0 ± 10.0; 34% female) with baseline MRIs, 604 (35%) had microbleeds. During a median follow-up of 10.6 months, 7.0% (n = 122) had ischemic stroke/TIA, 0.5% (n = 8) ICrH, and 2.1% (n = 37) died. New microbleeds developed in 10.3% (n = 155) of participants with adequate follow-up MRIs and HT in 31.4% (n = 345). In the total sample of patients with adequate baseline and 26-week follow-up MRIs (n = 1507), new microbleeds occurred in 10.2% of patients assigned to any asundexian dose and 10.5% of patients assigned to placebo (OR, 0.96; 95% CI, 0.66-1.41). There were no interactions between microbleeds and treatment assignment for any of the outcomes (p for interaction > 0.05). The rates of new microbleeds, HT, and ICrH were numerically less in patients with microbleeds assigned to asundexian relative to placebo. The presence of microbleeds was associated with a higher risk of HT (aOR, 1.6; 95% CI, 1.2-2.1) and new microbleeds (aOR, 4.4; 95% CI, 3.0-6.3). Factor XIa inhibition with asundexian appears safe in patients with non-cardioembolic ischemic stroke and hemorrhage-prone cerebral small vessel disease marked by microbleeds on MRI. These preliminary findings will be confirmed in the ongoing OCEANIC-STROKE randomized trial. ClinicalTrials.gov Identifier: NCT04304508.

Abstract 230: Endovascular therapy for large core ischemic strokes: Meta‐analysis of randomized clinical trials

Introduction Background: Patients with acute strokes with large infarct size are traditionally excluded from endovascular therapies, as like as clinical care. However, questions remain with respect to the safety and efficacy of EVT in these patients. Methods We conducted a meta‐analysis based on pooled data from SELECT 2 trial [1], ANGEL‐ASPECT trial [2], RESCUE Japan [3], and HERMES study [4]. We explored the efficacy of EVT for large infarcts to achieve a favorable 90‐day modified Rankin Scale. Also, we compared favorable outcomes following EVT in those with a core infarct at baseline of more than 70 ml, delayed thrombectomy of more than 6 hours, older than 75 years, and those who received concomitant IV thrombolysis. We also examined the pooled rate of hemorrhagic transformation following EVT in large core strokes. Results This meta‐analysis showed a statistically significant higher rate of favorable outcome in subjects with extremely large infarct size who undergone EVT compared to those who were managed by medical therapy alone (RR: 1.41, 95% CI: [1.05‐1.98], p: 0.03). In the subgroups of patients with core size &gt; 70ml (RR: 1.51, 95% CI: [1.23‐1.87]), late window presentation (LKN to randomization ≥ 6 hours), (RR: 1.53, 95% CI: [1.27‐1.84]), or those 75 or older than 75 years old (RR: 1.43, 95% CI: [1.12‐1.84]), EVT was associated with higher rates of favorable 90‐day mRS score of 0‐3 compared to medical therapy alone. However, EVT was not associated with better outcomes in those who received IV thrombolysis (RR: 1.37, 95% CI: [0.93‐2.01]. Based on pooled data from SELECT‐2, ANGEL‐ASPECT, and RESCUE Japan trials, the overall rate of early symptomatic hemorrhagic transformation among cases with ASPECT 0‐5 in the thrombectomy group was not significantly higher compared to patients who were managed non‐surgically (OR 1.75, 95% CI: [0.89‐3.47]). Conclusion Endovascular therapy is a reasonable option for the management of large infarcts. EVT results in favorable outcome by a delayed thrombectomy for a large core infarct and in older patients.

Abstract 204: On Old Dogs and New Tricks: Connecticut Perfusion Predicts Hemorrhagic Transformation After Thrombectomy

Introduction Hemorrhagic transformation is a major complication of large vessel occlusion (LVO) recanalization after mechanical thrombectomy in acute ischemic stroke. We investigated whether computed tomography perfusion (CTP) derived hypoperfusion index ratio correlates with the rate of hemorrhagic transformation. Methods We conducted a retrospective cohort analysis of a prospectively maintained patient database. Included patients underwent mechanical thrombectomy for large vessel ischemic stroke from January 2019 to December 2022. Patients were separated into 2 groups depending on whether or not hemorrhagic transformation developed. Hypoperfusion index ratio on admission CTP was determined using VizAI software. Data were analyzed using Chi‐square and Mann‐Whitney U tests. Results Among the 289 patients included (median age, 72.5; 41.5% female), 55 (19%) had hemorrhagic transformation. Patients with hemorrhagic transformation had a significantly higher hypoperfusion index ratio (median, 0 vs 0.2; P= 0.004) compared with those with no hemorrhagic transformation. Multivariable analysis showed that for every 0.1 increase in the hypoperfusion index ratio, there was a significant 4.64‐fold increase in hemorrhagic transformation (OR 4.64; 95% CI 1.40 to 15.18; p=0.011). Conclusion In patients with LVO who underwent mechanical thrombectomy, a higher hypoperfusion index ratio on admission CTP was associated with an increased rate of hemorrhagic transformation. This suggests that the hypoperfusion index ratio could be used as a predictor for hemorrhagic transformation after mechanical thrombectomy.

Abstract 256: Proposal of multimodal CT‐based scoring system in prediction of hemorrhagic transformation in acute ischemic stroke

Introduction The routinely used computed tomography (CT)‐based workup in the setting of acute ischemic stroke (AIS) includes non‐contrast brain CT, CT angiography (CTA), and CT perfusion. Several CT, CTA, CTP‐based radiological biomarkers of hemorrhagic transformation (HT) were reported. To assess the predictive value of the combined multimodal CT parameters for HT after AIS and proposal of predictive scoring scale. Methods The source images of the NCCT, CTA and CTP of 282 AIS patients involving the anterior circulation (HT = 91, non‐HT = 191) were retrospectively reviewed and the following biomarkers were recorded and analyzed: Early subtle ischemic signs, hyperdense middle cerebral artery sign (HMCAS) and Alberta Stroke Program Early CT Score (ASPECTS) &lt; 7 in NCCT, large‐vessel occlusion (LVO), clot burden score (CBS) &lt; 6, large‐vessel occlusion, poor collateral score (CS) and Tmax &gt; 6 s ≥ 56.5 ml. A scoring system to predict HT based on these biomarkers was developed. Each biomarker counts for a single point with the total score ranging from 0 to 7. Results All the aforementioned multimodal CT biomarkers and the selected cut offs were significantly associated with higher HT risk. The calculated scores were statistically significant different between the HT and the non‐HT groups with AUC 0.761 (95% CI 0.703–0.819, P &lt; 0.0000001). Rates of HT were approximately five times higher in patients with score ≥ 3. Conclusion Multimodal CT‐based scoring system may provide highly reliable predictive model of hemorrhagic transformation in acute ischemic stroke.

Abstract 234: Antithrombotic use in Emergent Cervical Carotid Artery Stenting in Thrombectomy

Introduction Current literature suggests a benefit in functional outcomes and reperfusion rates when carotid artery stenting (CAS) and mechanical thrombectomy (MT) are performed emergently. However, rates of symptomatic intracranial hemorrhages have been inconclusive. Antithrombotic protocols used in CAS and MT tend to be heterogenous among physicians. There is no standardized data on antithrombotic therapy use during CAS and MT procedures with less associated rates of symptomatic hemorrhagic transformation. We aimed to compare the efficacy and safety of antithrombotic use in patients requiring CAS and MT. Additionally, we sought to analyze clinical and mortality outcomes in CAS and MT retrospectively at our institution. Methods We searched for patients who underwent emergency cervical ICA stent placement and intracranial thrombectomy with stent‐retriever and/or aspiration devices in our institution between 2019‐2023. Clinicoangiographic and antithrombotic data were analyzed. Good clinical outcomes were a &lt; 4 points of NIHSS at 24 hours, mRS (0‐3) at 90 days, and disposition to home or inpatient rehabilitation. Characteristics of hemorrhagic transformation (HT) according to the European Cooperative Acute Stroke Study (ECASS). Clinical, radiographic, and mortality outcomes were described. Results Twenty‐seven patients were treated. The mean age was 64 years, nine females: mean occlusion time 400 minutes, mean fluoro time 32 minutes. Fourteen patients received IV tissue‐type plasminogen (tPA) activator. The admission NIHSS score mean was 16. Stent placement was feasible in all cases. Thrombolysis in Cerebral Infarction score of 2B was achieved in 18 patients (66.7%); the rest had a TICI 3 score. Twelve patients had improved 4 NIHSS points between admission and 24 hours. Dual antiplatelet therapy with aspirin and clopidogrel was used in 15 patients before stenting. While six patients received aspirin and ticagrelor, and the rest received eptifibatide drip. Seven (26%) patients had symptomatic intracranial hemorrhages. Antithrombotic type of treatment had no significant association with bad outcomes (p‐value: 0.872), neither did IV tPA use (p‐value: 0.853). Fourteen patients had good clinical outcomes (mRS 0‐3) at discharge, while eight died. At 90 days follow‐up, the median mRS was 3. Conclusion Our analysis suggests no significant association between symptomatic hemorrhagic transformation with IV tPA or heterogenous antithrombotic use. Our retrospective study has several limitations, including sample size and heterogeneous pathology. Larger studies are needed to stratify symptomatic hemorrhages' high‐risk profile in CAS and MT.

Prior Thrombectomy Does Not Affect the Surgical Complication Rate of Decompressive Hemicraniectomy in Patients with Malignant Ischemic Stroke

BackgroundEven though mechanical recanalization techniques have dramatically improved acute stroke care since the pivotal trials of decompressive hemicraniectomy for malignant courses of ischemic stroke, decompressive hemicraniectomy remains a mainstay of malignant stroke treatment. However, it is still unclear whether prior thrombectomy, which in most cases is associated with application of antiplatelets and/or anticoagulants, affects the surgical complication rate of decompressive hemicraniectomy and whether conclusions derived from prior trials of decompressive hemicraniectomy are still valid in times of modern stroke care.MethodsA total of 103 consecutive patients who received a decompressive hemicraniectomy for malignant middle cerebral artery infarction were evaluated in this retrospective cohort study. Surgical and functional outcomes of patients who had received mechanical recanalization before surgery (thrombectomy group, n = 49) and of patients who had not received mechanical recanalization (medical group, n = 54) were compared.ResultsThe baseline characteristics of the two groups did significantly differ regarding preoperative systemic thrombolysis (63.3% in the thrombectomy group vs. 18.5% in the medical group, p < 0.001), the rate of hemorrhagic transformation (44.9% vs. 24.1%, p = 0.04) and the preoperative Glasgow Coma Score (median of 7 in the thrombectomy group vs. 12 in the medical group, p = 0.04) were similar to those of prior randomized controlled trials of decompressive hemicraniectomy. There was no significant difference in the rates of surgical complications (10.2% in the thrombectomy group vs. 11.1% in the medical group), revision surgery within the first 30 days after surgery (4.1% vs. 5.6%, respectively), and functional outcome (median modified Rankin Score of 4 at 5 and 14 months in both groups) between the two groups.ConclusionsA prior mechanical recanalization with possibly associated systemic thrombolysis does not affect the early surgical complication rate and the functional outcome after decompressive hemicraniectomy for malignant ischemic stroke. Patient characteristics have not changed significantly since the introduction of mechanical recanalization; therefore, the results from former large randomized controlled trials are still valid in the modern era of stroke care.

Circle of Willis integrity in acute middle cerebral artery occlusion: does the posterior communicating artery matter?

BackgroundCollateral circulation is an important determinant of outcome in people with acute ischemic stroke due to large vessel occlusion (LVO).ObjectiveTo explore the impact of the circle of Willis (CW) anatomical...