Rate Of Intracranial Hemorrhage Research Articles

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

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

Abstract WP184: Intravenous Thrombolysis Improves Outcomes in Stroke Patients With Unsuccessful Mechanical Thrombectomy

Introduction: The benefits of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients with unsuccessful mechanical thrombectomy (MT) are not well established. Methods: This study included patients from the Stroke Thrombectomy and Aneurysm Registry (STAR) who underwent MT for ICA, M1, or M2 occlusions with unsuccessful MT (mTICI score ≤ 2a). Patients who received IVT prior to MT were compared to those who received MT alone. Propensity score (PS) matching was performed using age, sex, premorbid modified Rankin Scale (mRS), admission National Institute of Health Stroke Scale (NIHSS), occluded vessel, ASPECTS score, mTICI score, and symptom onset to groin puncture time. The primary outcome was favorable 90-day outcomes (mRS 0-2). Results: Of 610 patients with unsuccessful MT, 219 were matched in each group. Median ages were 70 [IQR: 61 - 80] and 73 [IQR: 62 - 81] in the IVT + MT and MT alone groups, respectively. In the IVT + MT group. Final TICI scores of 0, 1, and 2a were achieved in 92 (42.0%), 33 (15.1%), and 94 (42.9%) patients, respectively, compared to 76 (34.7%), 29 (13.2%), and 114 (52.1%) in the MT alone group. The IVT + MT group showed a significantly. higher 90-day mRS of 0-2 (aOR: 2.54, 95% CI: 1.53-4.32) and mRS of 0-3 (aOR: 2.05, 95% CI: 1.36-3.12). There were no significant differences between the groups in intracranial hemorrhage (ICH), symptomatic ICH, or 90-day mortality rates. Conclusions: IVT is associated with improved functional outcomes in patients with unsuccessful MT. Ensuring that IVT is provided to all eligible stroke patients should remain a priority.

Abstract WMP90: Outcomes of Endovascular Treatment versus Best Medical Treatment for Acute Basilar-Artery Occlusion: Impacts of Etiology in the ATTENTION Randomized Trial

Objective: This study aimed to evaluate the efficacy and safety of endovascular treatment versus best medical treatment strategies in acute basilar artery occlusion with different stroke etiologies. Methods: The study was a post-hoc analysis of the Trial of Endovascular Treatment of Acute Basilar-artery Occlusion (ATTENTION), which was a multicenter, randomized trial at 36 centers in China from February 2021 to September 2022. Patients with acute basilar artery occlusion were classified into three groups according to stroke etiology: large-artery atherosclerosis (LAA), cardioembolism (CE), and undetermined/other determined cause (UC/ODC). The primary outcome was favorable outcome (modified Rankin scale 0-3) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage and 90-day mortality. Results: A total of 340 patients were included. Compared with best medical treatment, endovascular treatment was associated with higher rates of favorable outcome at 90 days in the LAA group (49.1% vs 23.8%; adjusted odds ratio [aOR] 2.79; 95% confidence interval [CI] 1.16-6.71), CE group (52.2% vs 30.8%; aOR 3.68; 95%CI 1.04-12.97), and UC/ODC group (37.5% vs 17.4%; aOR 5.73, 95%CI 1.99-16.48). The rate of symptomatic intracranial hemorrhage in patients receiving endovascular treatment with LAA, CE and UC/ODC was 8.3%, 2.2%, and 3.2%, respectively, and none of the best medical treatment patients. Endovascular treatment led to lower 90-day mortality than best medical treatment in LAA patients (33.3% vs 57.1%; aOR 0.41; 95% CI 0.19-0.91). Among patients receiving endovascular treatment, a better functional outcomes of CE etiology was found than the UC/ODC etiology (52.2% vs 37.5%; aOR 2.68; 95% CI 1.07-6.70); there was no differences in symptomatic intracranial hemorrhage and 90-day mortality among the three etiology subtypes. Conclusion: Endovascular treatment was associated with better outcomes than the best medical treatment in acute basilar artery occlusion patients regardless of stroke etiologies, but the benefits-risk ratios were different among etiologies. The stroke etiology might be an important factor in predicting the prognosis of thrombectomy in acute basilar artery occlusion.

Abstract WP20: Hemorrhagic Conversion Patterns After Stroke Thrombolysis With Alteplase versus Tenecteplase Real-World Experience

Importance: Tenecteplase use is more prevalent as the thrombolytic drug of choice for acute ischemic stroke, with results demonstrating its non-inferiority compared to alteplase. However, there is conflicting data regarding intracranial hemorrhage risk. Objective: To determine the rate of symptomatic intracranial hemorrhage in ischemic stroke patients after thrombolysis with either tenecteplase or alteplase. Design: Retrospective cohort study. Setting: 15 Texas stroke centers. Participants: 431 patients that were eligible for thrombolytic therapy, and received either tenecteplase or alteplase. Exposure: Data was collected 90 days before and after the stroke center changed from alteplase to tenecteplase. Main Outcomes: Primary endpoint was to compare the incidence of sICH according to SITS-MOST/ECASS-3 criteria in the alteplase and tenecteplase groups. Secondary endpoint included the radiographic pattern of hemorrhagic conversion according to the Heidelberg bleeding classification (HBC). Results: Median age was 62.94 for alteplase and 64.45 for tenecteplase, females represented half of each cohort:110 for alteplase and 117 for tenecteplase. Half of patients received alteplase (n=216), 174 (81%) received alteplase within 3 hours versus 176 (82%) for tenecteplase. Endovascular thrombectomy was attempted in 34 patients (15%) receiving alteplase versus 26 patients (12%) receiving tenecteplase. 7 patients in the alteplase group (3.2%) and 14 (6.5%) in the tenecteplase group had sICH, with an odds ratio of 1.44 (95% CI 0.60-3.43; P=0.41). A higher NIHSS score on arrival (1.06; 95% CI 1.0004-1.131; P=0.04) was a statistically significant predictor of sICH. A two-sample proportion test on tenecteplase produced a statistically significant increase in HBC class 3 (P=0.040) over alteplase. Conclusions and Relevance: An increased rate of sICH was observed with a statistically significant increase in HBC class 3 with tenecteplase administration compared to alteplase. Suggested mechanisms of bleeding are hemorrhagic conversion in clinically silent infarcts and contusions underlying the lesions. This suggests a potential need to reevaluate the criteria for tenecteplase administration. Larger studies are required to confirm this data.

Abstract WP24: Safety of Tenecteplase vs Alteplase in Telestroke: A Large Multistate Experience (STAT)

Background: Prompt treatment with IV thrombolytics (IVT) in acute ischemic stroke (AIS) patients is critical for improved recovery and survival. Recently, hospital systems are switching to the IVT tenecteplase (TNK) instead of the FDA approved alteplase (tPA) for treatment. Multiple studies and meta-analyses evaluating the efficacy and safety of TNK demonstrate similar or superior outcomes when compared to tPA. TNK is not FDA approved for treatment leading to hesitation and attention on the complications profile including intracranial hemorrhage (ICH) rates. Methods: AIS consults seen in the ED by TeleSpecialists, LLC at 220 facilities (26 states) from January 1, 2022 to May 31, 2023 were extracted from the TeleCare by TeleSpecialists TM database. The encounters were reviewed for IVT candidate, door to needle (DTN) time, IVT used, advanced imaging, LVO, complication occurrence, complication type, symptomatic ICH, and ECASS II ICH score. Comparison of complications was performed between the two groups by IVT: TNK or tPA. Comparison of continuous variables was performed by student’s t-test for normally distributed data, and the Mann-Whitney test for nonnormally distributed data. Pearson's Chi-square test was employed for comparisons of categorical variables. Results: A total of 2305 TNK patients and 3337 tPA patients were extracted. DTN times were faster (37 min vs 42 min, p < 0.0001) and more total complications were seen in the TNK group (87 vs 80, p =0.0035). In nonLVO IVT patients, TNK group had more complications (57 vs 47, p 0.0078), specifically ICH (48 vs 35, p= 0.0036). In LVO IVT patients, TNK group did not have a statistically significant difference in ICH (21 vs 18, p =0.07). In IVT patients not accepted for NIR, TNK group had more complications (77 vs 69, p=0.005), specifically ICH (63 vs 51, p=0.0026). In IVT patients accepted for NIR, no significant differences were observed. There were no statistically significant differences in symptomatic ICH between groups. Conclusions: TNK group was found to have significantly more complications including ICH compared to tPA group driven by non-LVO patients. Closer analysis of potential for increased risk to non-LOV patients is warranted based on this data from the largest simultaneously collected data.

Abstract WP193: Endovascular Thrombectomy for DAWN- and DEFUSE 3 Ineligible Acute Ischemic Stroke Patients: A Systematic Review and Meta-Analysis

Background: The current evidence supports the benefits of endovascular treatment (EVT) in acute ischemic stroke (AIS) with large vessel occlusion (LVO). The DAWN and DEFUSE-3 trials expanded the EVT window up to 24 hours. A few real-world studies explored EVT outcomes in DAWN/DEFUSE-3 ineligible (NDND) patients. Methods: This meta-analysis investigated EVT outcomes in patients with late-window anterior circulation LVO, including both DAWN/DEFUSE-3 eligible (DD) and NDND patients. Nine studies were included, focusing on study characteristics, risk of bias, and outcomes. Results: Baseline characteristics showed comparable age, gender, comorbidities, NIHSS score, and ASPECTS between DD and NDND patients. NDND patients exhibited larger infarct volumes and higher atrial fibrillation rate. Successful reperfusion rates (TICI 2b-3) were comparable between the two groups (OR= 0.86; 95% CI= 0.40, 1.84; p = 0.689), with significant heterogeneity (I 2 = 73%; P = 0.002). Functional independence (90-day mRS score 0-2) was not significantly different between the two groups (OR= 1.12; 95% CI= 0.77, 1.63; p = 0.552) with notable heterogeneity (I 2 = 46%, p = 0.063). Symptomatic intracranial hemorrhage (sICH) rate was lower in the DD group as compared to NDND patients (OR= 0.49; 95% CI= 0.25, 0.93; p = 0.029) with no heterogeneity (I 2 = 0%, p = 0.552). 90-day mortality was lower in the DD group than in the NDND group (OR= 0.55; 95%-CI= 0.37, 0.82; p = 0.004) with no significant heterogeneity (I 2 = 0%, p = 0.536). Conclusion: While this meta-analysis showed comparable rates of functional independence between DD and NDND patients, the potential bias introduced by the higher rates of sICH and mortality in the latter group should prompt great care when offering EVT to NDND patients. Less restricted EVT eligibility criteria might yield positive outcomes in real-world practice in specific patients. However, increased risks of sICH and mortality in NDND patients warrant further investigation to optimize the risk-benefit balance in expanding EVT eligibility criteria.

Abstract WP31: Real World Comparison of Outcomes of IV Tenecteplase versus IV Alteplase for Acute Ischemic Stroke

Background: Tenecteplase (TNK) has been reported to be non-inferior to alteplase from a clinical outcome and safety standpoint according to recent studies. In our study, we compare the outcomes of IV TNK & IV alteplase for acute ischemic stroke patients. Materials and Methods: We evaluated acute AIS patients treated with IVT between10/2020-03/2023 at theDepartment of Neurology, Hackensack MeridianHealth, JFKMedical Center. All analyses was done using SPSS version 29 software. Results: Among the total 270 patients, 150(55.6%) received IV alteplase and 120(44.4%) received IV TNK. Major neurological improvement (defined as improvement in NIHSS score by 8 or more points at 24hours) was observed with TNK. Any intracranial hemorrhage was higher among patients treated with IV TNK compared to alteplase (25% versus 14.7%, p=0.024). Symptomatic intracranial hemorrhage(sICH) was higher inTNK group (8.3% versus3.3%, p=0.075). The proportion of routine discharge was higher among alteplase patients, while non-routine discharge was higher among TNK patients (51.7% vs. 28%, p<0.001). In the logistic regression analysis, patients treated with IV TNK were at a significantly higher risk of any intracranial hemorrhage(odds ratio[OR], 1.93, 95% confidence interval [CI]1.051-3.57, p=0.034). After adjusting for age, gender, NIHSS, thrombectomy, hypertension, diabetes, hyperlipidemia, CHF, previous TIA and previous stroke, there was anon-significant higher rate of intracranial hemorrhage. A nonsignificant decrease in the odds of symptomatic intracranial hemorrhage (sICH) was seen with TNK. There were significantly higher rates of non-routine discharge (OR, 3.078, 95% CI 1.8-5.19, p<0.001) and death (OR, 4.84, 95% CI1.20-19.66, p=0.002) inpatients treated with IV TNK. After adjusting for the above-mentioned factors, there was a significantly higher rate of non-routine discharge in the TNK group and a higher trend of death in the TNK group. Conclusions: We found that IV TNK was associated with higher rates of intracranial hemorrhage compared to IV alteplase in patients with acute ischemic stroke.

Abstract WP231: The Incidence of Intracranial Hemorrhage in Patients Anticoagulated With Factor Xa Inhibitors (FXai): A Multi-Country Observational Study (AXIOM ICH)

Background: Intracranial haemorrhage (ICH) is associated with significant long-term morbidity, high healthcare costs and mortality. There is a paucity of accurate national incidence rate data on ICH, fatal ICH and ICH sub-types in patients on FXai anticoagulants (e.g. rivaroxaban and apixaban). Aim: To describe patient characteristics and incidence of ICH following the initial use of FXai in an ongoing multi-country study. Methods: A retrospective observational cohort analysis of electronic health records from new users of FXai in the UK and Canada. Individuals with FXai prescriptions for a therapeutic indication such as venous thromboembolism, atrial fibrillation (AF), and/or non-mechanical cardiac-valve replacement, were included. Demographic and clinical data were summarised using descriptive statistics, and incidence rates for ICH events were reported per 100 person-years with 95% confidence intervals. Subgroups have been analysed. Results: In the UK and Canada, there were a total of 383,433 new users of FXai; average age 69 years, 54% male, average BMI 29 kg/m 2 and 88% of patients used an oral FXai. The most common indication was AF (73%). 1650 and 438 ICH events were reported in the UK and Canada, with 1-year incidence rates of 0.56 and 0.72 per 100 person-years, 27% and 26% were fatal (Table), respectively. Event rates remain elevated in the years following FXai initiation. Conclusions: Findings indicate incidence rates of ICH in patients treated with FXai were consistent over time, approximately 0.64 per 100 person-years or 1:160 patients per year throughout the course of treatment. Case fatality rates are high, around 27%, remaining elevated in the years following FXai initiation.

Abstract TP197: Impact of First-Pass Effect on Clinical Outcomes in Stroke Patients With Low Aspects

Introduction: The first-pass effect (FPE), defined as a complete or near-complete recanalization after a single pass of a mechanical thrombectomy (MT) device, has been linked to favorable clinical outcomes. However, its effectiveness in acute ischemic stroke (AIS) patients with low ASPECTS (Alberta Stroke Program Early CT Score 2-5) has not been validated. Method: We utilized data from STAR, a multicenter database of 84 centers worldwide, to conduct a retrospective, cohort study on patients who underwent MT for internal carotid artery (ICA) or M1 occlusion presenting with ASPECTS 2-5. We compared the outcomes of patients who achieved FPE (successful recanalization with an mTICI score of 2c or higher in one pass) to those who did not. The primary outcome was a 90-day favorable outcome, defined as mRS 0-3. Secondary outcomes included any intracranial hemorrhage (ICH), symptomatic ICH (sICH), and 90-day mortality. Results: Out of 10,229 patients in the STAR database, 250 patients met our inclusion criteria. Among those, 60 (24%) achieved FPE. There were no significant differences between the two groups in baseline, imaging, and procedural characteristics. FPE was significantly associated with higher odds of 90-day mRS 0-3 (adjusted odds ratio (aOR): 2.17, 95% confidence interval (CI): 1.04 - 4.20; P-value: 0.04) and lower rates of ICH (OR: 0.49, 95% CI: 0.25 - 0.93, P-value: 0.03). However, there was no significant difference in sICH rates (OR: 0.84, 95% CI: 0.31 - 2.04, P-value: 0.70). Conclusion: Achieving FPE in AIS stroke patients with low ASPECTS was associated with significantly higher rates of good functional outcomes and lower rates of ICH.

Thrombolytic Treatment in Wake-Up Stroke: A Propensity Score-Matched Analysis of Treatment Effectiveness in the Norwegian Stroke Registry.

Previous clinical trials found improved outcome of thrombolytic treatment in patients with ischemic wake-up stroke (WUS) selected by advanced imaging techniques. The authors assessed the effectiveness of thrombolytic treatment in patients with WUS in a nationwide stroke registry. Using propensity score matching, the authors assessed the effectiveness and safety of thrombolytic treatment versus no thrombolytic treatment in 726 patients (363 matched pairs) with WUS in the Norwegian Stroke Registry in 2014 to 2019. Thrombolytic treatment in WUS versus known-onset stroke was compared in 730 patients (365 matched pairs). Functional outcomes were assessed by the modified Rankin Scale (mRS) at 3 months. A significant benefit of thrombolytic treatment in WUS was seen in ordinal analysis (odds ratio [OR], 1.48 [95% CI, 1.15-1.91]; P=0.003) and for mRS 0 to 2 (OR, 1.81 [95% CI, 1.29-2.52]; P=0.001) but not for mRS 0 or 1 (OR, 1.32 [95% CI, 1.00-1.74]; P=0.050). The proportion of patients with mRS 0 or 1 was lower in patients with WUS who underwent thrombolysis versus those with known-onset stroke (50.4% versus 59.5%; OR, 0.69 [95% CI, 0.52-0.93]; P=0.013), while outcomes were similar between groups for mRS 0 to 2 and ordinal analysis. Symptomatic intracranial hemorrhage after thrombolytic treatment occurred in 4.4% of patients with WUS and 3.9% of patients with known-onset stroke (OR, 1.14 [95% CI, 0.54-2.41]; P=0.726). Thrombolytic treatment in patients with WUS was associated with improved functional outcome compared with patients with no thrombolytic treatment and was not associated with increased rates of symptomatic intracranial hemorrhage compared with known-onset stroke. The results indicate that thrombolytic treatment is effective and safe in WUS in a real-life setting.

Changing or Retaining Direct Oral Anticoagulant After Ischemic Stroke Despite Direct Oral Anticoagulant Treatment.

The optimal antithrombotic strategies for patients with atrial fibrillation who experience ischemic stroke (IS) despite direct oral anticoagulant (DOAC) therapy remain inconclusive. This study compared outcomes for patients with DOAC treatment failure who changed or retained their prestroke DOAC. This retrospective cohort study analyzed data from the National Health Insurance Research Database from 2012 to 2020. Patients with atrial fibrillation who experienced IS during DOAC therapy were assigned to either (1) the DOAC-change group: changing prestroke DOAC or (2) the DOAC-retain group: retaining prestroke DOAC. The primary outcome was a composite of recurrent IS and transient ischemic attack. The secondary outcomes included intracranial hemorrhage, major bleeding, systemic thromboembolism, and all-cause death. Propensity score-based inverse probability of treatment weighting was applied to balance the baseline characteristics between the DOAC-change and DOAC-retain groups. The Cox proportional hazards model compared the risk of outcomes between the 2 groups. In total, 1979 patients were enrolled (609 DOAC-change patients and 1370 DOAC-retain patients). The incidence rates of recurrent IS or transient ischemic attack were 7.20 and 6.56 per 100 person-years in the DOAC-change and DOAC-retain groups, respectively (hazard ratio [HR], 1.07 [95% CI, 0.87-1.30]). A nonsignificantly higher incidence rate of intracranial hemorrhage was observed in the DOAC-change group compared with the DOAC-retain group (0.75 versus 0.53 per 100-person-years; HR, 1.49 [95% CI, 0.78-2.83]). The systemic thromboembolism, major bleeding, and death rates were comparable between the DOAC-change and DOAC-retain groups. Changing prestroke DOAC does not reduce the risk of recurrent cerebral ischemia in patients with atrial fibrillation who develop IS during DOAC therapy. However, future studies should continue to observe the potential trends of increased intracranial hemorrhage risk.

IV Thrombolysis for central retinal artery occlusion – Real-world experience from a comprehensive stroke center

ObjectivesCentral retinal artery occlusion (CRAO) is a stroke of the retina potentially amenable to intravenous thrombolysis (IVT). We aimed to determine feasibility of an emergency treatment protocol and risk profile of IVT for CRAO in a comprehensive stroke center (CSC). MethodsWe performed a retrospective, observational cohort study including patients with acute CRAO admitted to a CSC over 4 years. Patients are offered IVT if they present with acute vision loss of ≤ 20/200 in the affected eye, have no other cause of vision loss (incorporating a dilated ophthalmologic exam), and meet criteria akin to acute ischemic stroke. We collected socio-demographic data, triage data, time from onset to presentation, IVT candidacy, and rates of symptomatic intracranial hemorrhage (sICH)- or extracranial hemorrhage. Results36 patients presented within the study period, mean (standard deviation (SD)) age of 70.7 (10), 52 % female, and median time (Q1, Q3) to ED presentation of 13.5 (4.3, 18.8) h. Patients within 4.5 h from onset presented more commonly directly to our ED (66.6 % vs 37.1 %, p = 0.1). Nine patients (25 %) presented within the 4.5 h window. Of those eligible, 7 (77 %) received IVT. There were no events of intracranial or extracranial hemorrhage. ConclusionsOur study confirmed that IVT for acute CRAO is feasible. We found a high rate of treatment with IVT of those eligible. However, because 75 % of patients presented outside the treatment window, continued educational efforts are needed to improve rapid triage to emergency departments to facilitate evaluation for possible candidacy with IVT.

Endovascular thrombectomy for posterior cerebral artery strokes in the national inpatient sample (EaT PeCANpIeS) study.

Posterior cerebral arteries with acute ischemic strokes (PCA-AISs) comprise around 2% of all acute ischemic strokes and may result in significant long-term deficits. Current guidance regarding endovascular thrombectomy (EVT) for PCA-AIS is insufficient as no published randomized trials exist. An analysis of the National Inpatient Sample database compared medical management versus EVT for PCA-AIS. Propensity score matching was applied to adjust for nonrandomization. The study included 19,655 patients. Before matching, the EVT cohort had significantly higher National Institutes of Health Stroke Scale (NIHSS) (10.21 vs. 4.67, p < 0.001), had lower rates of favorable functional outcomes, functional independence, and higher rates of intracranial hemorrhage (ICH) and inpatient mortality. After matching, no differences in functional outcomes were identified, but revealed a higher proportion of ICH in the EVT group (17.45% vs. 8.98%, p < 0.001). However, NIHSS subgroup analysis identified improved functional outcomes associated with the EVT group who presented with an NIHSS between 10 and 19 both in terms of rates of favorable functional outcomes (35.56% vs. 12.09%, p < 0.001) and rates of functional independence (26.67% vs. 9.34%, p < 0.01). On further investigation, the clinical benefit, in the NIHSS 10-19 subgroup, was driven by patients receiving EVT in combination with intravenous thrombolysis (IVT). This analysis shows that current national practices utilize EVT for more severe PCA strokes. Clinical benefit was only detected in patients with moderate stroke severity (NIHSS 10-19) who were treated with combined EVT and IVT. Further work is needed to investigate the features of PCA-AIS that might benefit from EVT the most.

Repeat thrombectomy after large vessel re-occlusion: a propensity score matched analysis of technical and clinical outcomes

BackgroundEndovascular thrombectomy (EVT) remains the standard of care for acute large vessel occlusion (LVO) stroke. However, the safety and efficacy of repeat thrombectomy (rEVT) in recurrent LVO remains unclear. This...

Associations between NIHSS sub-item scores and prognosis and intracranial hemorrhage after endovascular therapy for acute anterior circulation ischemic stroke.

The relationship between sub-item scores on the National Institutes of Health Stroke Scale (NIHSS) scores and prognosis and intracranial hemorrhage in patients with acute ischemic stroke undergoing endovascular treatment (EVT) has been insufficiently studied. The aim of this study was to investigate the correlation between NIHSS sub-item scores, prognosis, and intracranial hemorrhage. This study included patients with acute anterior circulation ischemic stroke undergoing EVT between February 2019 and April 2022. The outcomes included functional independence, defined as a modified Rankin Scale (mRS) score ≤ 2 at 3 months after EVT, intracranial hemorrhage within 24 h after EVT, and mortality within 3 months. A multivariate regression analysis was performed, including NIHSS sub-item scores and other adjusted variables. A total of 568 patients were enrolled. Of the 568 patients, 239 (45%) achieved functional independence at 3 months after EVT. The median age in this group was 63 years (IQR 52-69) and 176 (73.6%) were male patients. Intracranial hemorrhage within 24 h after EVT occurred in 170 (30%) patients. The median age in this group was 65 years (IQR 56-71) and 105 (61.8%) were male patients. In a multivariate analysis adjusted for age, gender, and factors with a value of p of <0.05, the NIHSS limb movement sub-item score was strongly associated with prognosis at 3 months (OR 0.833, 95% CI 0.758-0.915) and intracranial hemorrhage within 24 h after EVT (OR 1.161, 95% CI 1.037-1.300). Higher limb movement sub-item scores on the NIHSS were independently associated with a poorer prognosis at 3 months and a higher rate of intracranial hemorrhage within 24 h after EVT among patients with acute anterior circulation ischemic stroke.

Investigation of fatal traumatic head injuries.

Traumatic head injuries (THIs) are one of the major causes of death in forensic cases. The aim of this study was to investigate the characteristics of patients with fatal THIs. In this study, a total of 311 patients with fatal THIs, who underwent postmortem examinations and/or autopsies, were retrospectively analyzed. Cases were evaluated based on sex, age group, incident origin, cause of the incident, presence of skull fracture, type of fractured bone (if any), fracture localization and pattern, presence and type of intracranial lesion (if any), and cause of death. Out of the patients, 242 (77.8%) were male and 69 (22.2%) were female. Accidents accounted for 235 (75.6%) of the incidents, with in-vehicle traffic accidents causing 117 (37.6%). In 221 cases (71.1%), intracranial lesions and skull fractures were observed together. The most common fractures were base fractures (171 cases) and temporal bone fractures (153 cases). The rate of intracranial hemorrhage was lower in the adult age group (69.7%) compared to the older age group (92.6%). The results obtained in this study indicate that the cause of the incident, type of fracture, presence of skull base fracture, and multiple skull fractures increase the likelihood of fatalities. The occurrence of skull fractures reduces intracranial pressure, thereby decreasing the incidence of intracranial lesions. The development and effective enforcement of road traffic safety policies and regulations will reduce the incidence of fatalities.

Reoperation-requiring postoperative intracranial haemorrhage after posterior fossa craniotomy: Retrospective case-series

IntroductionStudies report rates of treatment-requiring postoperative intracranial haemorrhage after craniotomy around 1–2%, but do not distinguish between supratentorial and posterior fossa operations. Reports about intracranial haemorrhages’ temporal occurrence show conflicting results. Recommendations for duration of postoperative monitoring vary. Research questionTo determine the rate, temporal pattern and clinical presentation of reoperation-requiring postoperative intracranial posterior fossa haemorrhage. Material and methods: This retrospective case-series identified cases operated with posterior fossa craniotomy or craniectomy between January 1, 2007 and December 31, 2021 by an electronic search in the patient administrative database, and collected data about patient- and treatment characteristics, postoperative monitoring, and the occurrence of haemorrhagic and other serious postoperative complications. ResultsWe included 62 (n = 34, 55% women) cases with mean age 48 (interquartile range 50) years operated for tumours (n = 34, 55%), Chiari malformations (n = 18, 29%), ischemic stroke (n = 6, 10%) and other lesions (n = 3, 5%). One (2%) 66-year-old woman who was a daily smoker operated with decompressive craniectomy and infarct resection, developed a reoperation-requiring postoperative intracranial haemorrhage after 25.5 h. In four (6%) cases, other serious complications requiring reoperation or transfer from the post anaesthesia care unit or regular bed wards to the intensive care unit occurred after 0.5, 6, 9 and 54 h, respectively. Discussion and conclusionTreatment-requiring postoperative intracranial haemorrhage and other serious complications after posterior fossa craniotomies occur over a wide timespan and are difficult to capture with a standardized postoperative monitoring time. This indicates that the duration of monitoring should be individualized based on assessment of risk factors.

Factors associated with the initial intracranial hemorrhage occurrence in patients with cerebral venous thrombosis

ObjectivesStudies focusing on intracranial hemorrhage (ICH) in patients with cerebral venous thrombosis (CVT) are limited; thus, we aimed to identify factors associated with the occurrence of ICH in Thai patients with CVT. MethodsThis retrospective cohort study recruited patients with CVT admitted to a tertiary university-based hospital between 2002 and 2022. The baseline characteristics, clinical presentations, radiographic findings, and etiologies were compared between the ICH and non-ICH groups. The factors with p < 0.2 in the univariate analysis were further analyzed using multivariable logistic regression analysis to identify independent factors associated with ICH in patients with CVT. ResultsOf 228 screenings, 202 patients were eligible. The incidence rate of ICH was 36.63%. The ICH group showed a higher prevalence of focal neurological deficits (63.51% vs. 26.56%, p < 0.001), seizures (68.92% vs. 21.88%, p < 0.001), dependency status at admission (60.81% vs. 39.84%, p = 0.004), superior sagittal sinus thrombosis (71.62% vs. 39.07%, p < 0.001), superficial cortical vein thrombosis (36.49% vs. 10.16%, p < 0.001), and hormonal use (17.57% vs. 7.03%, p = 0.021) than the non-ICH group. In contrast, the ICH group showed a lower prevalence of isolated increased intracranial pressure (10.81% vs. 21.88%, p = 0.048) than the non-ICH group. Seizures (adjusted odds ratio [aOR], 4.537; 95% confidence interval [CI], 2.085–9.874; p < 0.001), focal neurological deficits (aOR, 2.431; 95% CI, 1.057–5.593; p = 0.037), and superior sagittal sinus thrombosis (aOR, 1.922; 95% CI, 1.913–4.045; p = 0.045) were independently associated with ICH in the multivariable logistic regression analysis. ConclusionsSeizures, focal neurological deficits, and superior sagittal sinus thrombosis are associated with ICH in patients with CVT.

Effects of tirofiban on large vessel occlusion stroke are modified by etiology and renal function.

Renal function can modify the outcomes of large vessel occlusion (LVO) stroke across stroke etiologies in disparate degrees. The presence of renal function deficit can also impair the pharmacokinetics of tirofiban. Hence, this study aimed to investigate the roles of renal function in determining efficacy and safety of intravenous tirofiban before endovascular treatment (EVT) for acute ischemic stroke patients with large vessel occlusion (LVO). This study was a post hoc exploratory analysis of the RESCUE-BT trial. The primary outcome was the proportion of patients achieving functional independence (modified Rankin scale 0-2) at 90 days, and the primary safety outcome was the rate of symptomatic intracranial hemorrhage (sICH). Among 908 individuals with available serum creatinine, decreased estimated glomerular filtration rate (eGFR) status was noted more commonly in patients with cardioembolic stroke (CE), while large artery atherosclerosis (LAA) was predominant in patients with normal renal function. In LAA with normal renal function, tirofiban was associated with higher rates of functional independence at 90 days (41.67% vs 59.80%, p = 0.003). However, for LVO patients with renal dysfunction, tirofiban did not improve functional outcomes for any of the etiologies (LAA, p = 0.876; CE, p = 0.662; others, p = 0.894) and significantly increased the risk of sICH among non-LAA patients (p = 0.020). Mediation analysis showed tirofiban reduced thrombectomy passes (12.27%) and drug/placebo to recanalization time (14.25%) mediated its effects on functional independence. This present study demonstrated the importance of evaluating renal function before administering intravenous tirofiban among patients with LVO who are planned to undergo EVT.

Outcomes of mechanical thrombectomy in acute stroke patients with atrial fibrillation detected after stroke versus known atrial fibrillation

We aim to compare the outcomes in patients with atrial fibrillation detected after stroke (AFDAS) and their counterparts with known AF (KAF) presenting with large vessel occlusion (LVO) treated with mechanical thrombectomy (MT). This observational, prospective study included consecutive patients with acute LVO ischemic stroke of the anterior circulation with AFDAS, KAF and without AF. The primary study outcome was functional independence at 90 days after stroke. The secondary study outcomes were variation of the NIHSS score at 24 h, rate of successful reperfusion, death at 90 days and rate of immediate complications post-procedure. Overall, our cohort included 518 patients with acute ischemic stroke and LVO treated with MT, with 289 (56.8%) without a diagnosis of AF; 107 (21%) with AFDAS; 122 (22.2%) with KAF. There was no significant difference in terms of functional independence at 90 days after stroke between the three groups. Regarding the secondary study outcome, the rate of symptomatic intracranial haemorrhage (sICH) and/or parenchymal hematoma (PH) were significantly higher in the group of patients without AF (respectively, P = 0.030 and < 0.010). Logistic regression analysis showed that the subtypes of AF were not statistically significantly associated with functional independence at 90 days after stroke and with the likelihood of any ICH. Our results suggest that the subtypes of AF are not associated with clinical and safety outcomes of MT in patients with acute stroke and LVO. Further studies are needed to confirm our findings.