Reperfusion Rates Research Articles

Gender disparities in short-term outcomes of STEMI patients: the influence of universal health coverage

Abstract Background Even after the event, individuals recovering from ST-elevation myocardial infarction (STEMI) face lingering risks, including potential subsequent events and mortality. The introduction of Universal Health Coverage (UHC) seeks to enhance healthcare outcomes for all segments of the population. Purpose This study evaluates the effect of UHC on 30-day mortality in post-STEMI patients, focusing on medication access and treatment disparities. Using a gender-stratified approach, we analyze changes before and after UHC implementation to provide insights into the difference in therapy between genders and how gender influences healthcare outcomes for post-STEMI patients. Methods Analyzing two cohorts, Cohort 1 (211 STEMI patients, 2013-2014 pre-UHC) and Cohort 2 (365 STEMI patients, 2018-2020 post-UHC), this study employed the chi-square test to determine differences between genders and the Kaplan–Meier log-rank test to compare survival rates. Results Comparing pre- and post-UHC, we observed a significant increase in both medication and reperfusion therapy (p<0.001). However, even in both periods, women continued to have lower rates of medication and reperfusion compared to men (Men vs Women: Before UHC 14.3% vs 0%; After UHC 58.5% vs 47.9%). Within 30 days after the STEMI event, we noted a reduction in mortality rates across genders before and after UHC implementation, yet the decrease was less pronounced in women compared to men (Before UHC: Men 13.0%, Women 22.0%; After UHC: Men 8.2%, Women 18.3%). Conclusion UHC led to improvements in medication and reperfusion therapy for STEMI patients. Despite this progress, persistent gender disparities were observed, with women consistently having lower treatment rates. While mortality rates reduced for both genders, the decrease was less pronounced in women, especially after the implementation of UHC. These findings emphasize the need for targeted interventions to address gender-specific healthcare discrepancies within the scope of comprehensive health coverage.Baseline characteristicsMortality outcomes within 30 Days

Prognostic importance of persistent elevations in high-sensitivity troponin T in the early convalescent phase (two weeks) following high-risk myocardial infarction: insights from the PARADISE-MI trial

Abstract Introduction Myocardial infarction (MI) is defined by a rise and fall in cardiac troponin (cTn) with clinical evidence of acute myocardial ischemia. How often cTn remains elevated in high-risk patients stabilized following MI and the relation between convalescent cTn levels and subsequent clinical outcomes in these patients is unknown. Aims To evaluate the prognostic importance of high-sensitivity cTn T (hs-cTnT) in the early convalescent phase of a MI for a range of cardiovascular (CV) outcomes in patients enrolled in the Prospective ARNI vs ACE inhibitor trial to DetermIne Superiority in reducing heart failure Events after Myocardial Infarction (PARADISE-MI). Methods Patients ≥18 years without prior heart failure (HF) (n=5661) were randomized to sacubitril/valsartan or ramipril within 0.5 to 7 days of MI complicated by transient pulmonary congestion, LVEF ≤40%, or both. Hs-cTnT was measured using the Roche Elecsys Troponin T-high-sensitive assay in 1093 patients two weeks after randomization (median 2.6 weeks after the index MI). Associations between log (2)-transformed hs-cTnT and clinical outcomes were investigated in landmark analyses using Cox regression models adjusted for clinical covariates of known prognostic importance and NT-proBNP (Figure). Results Median week 2 hs-cTnT concentration was 34 ng/L [IQR 17-94 ng/L] and exceeded the 99th percentile upper reference limit in 69% of patients. Patients with persistently elevated hs-cTnT concentrations (n=753) were older, more likely men, more commonly had atrial fibrillation and lower estimated glomerular filtration rate and less likely had a prior MI. They more commonly had presented with ST-segment elevation MI and pulmonary congestion and had higher concentrations of NT-proBNP. Rates of primary reperfusion were similar. Log(2)-transformed hs-cTnT was only weakly correlated with LVEF (rho = -0.15, p<0.001), irrespective of the type of MI. hs-cTnT was independently and linearly associated with the primary composite outcome of CV death or incident HF (adj HR 1.17 per doubling; 95% CI, 1.03 – 1.34), all-cause death (adj HR 1.20; 95% CI, 1.01 – 1.44) and CV death (adj HR 1.25; 95% CI, 1.02 – 1.52) but not with non-CV death (adj HR 1.04; 95% CI, 0.70-1.54). hs-cTnT was not significantly associated with recurrent fatal or non-fatal MI (adj HR 1.00; 95% CI, 0.85-1.18) (Figure). Concentrations of week 2 hs-cTnT were not altered by sacubitril/valsartan relative to ramipril (+4%; 95% CI, -8% to 18%). Conclusions Persistent elevations in hs-cTnT during the early convalescent phase following high-risk MI are common and are associated with heightened risk of all-cause death, CV death and incident HF but not of recurrent MI or non-CV death. hs-cTnT measured ~2.5 weeks after high-risk MI provides incremental prognostic information beyond traditional risk factors and NT-proBNP.

Blood-brain barrier profile pretreatment is associated with hemorrhagic transformation after endovascular reperfusion.

While advances in endovascular thrombectomy (EVT) have led to high reperfusion rates, most patients treated with EVT do not avoid disability. Post-reperfusion hemorrhagic transformation (HT) is a potential target for improving outcomes. This study examined pretreatment blood-brain barrier (BBB) disruption in tissue that would subsequently become part of the final infarct to evaluate its role in post-EVT HT. This post hoc analysis of the FRAME study, which enrolled patients with anterior large vessel occlusion who received EVT within 6 hours of onset, included patients if they had successful pretreatment MRI perfusion weighted imaging (PWI) and underwent successful EVT. BBB disruption was measured as the percent signal change due to gadolinium leakage on the PWI source images prior to thrombectomy. Mean permeability derangement (MPD) was defined as the average of all voxels in the stroke core that are two standard deviations above normal. The primary outcome was hemorrhagic transformation with parenchymal hematoma (PH). In total, 164 patients were included; mean age was 71 and 48% were female. PH occurred in 57 patients. Median MPD was 13.5% for patients with PH versus 3.6% for patients without (p < 0.0001). Elevated MPD was independently associated with PH with a 20% increased risk of PH for each 5% increase in MPD (OR 1.206; 95% CI 1.037:1.405; p = 0.0147, adjusted for NIHSS and procedure duration). Even in patients who are successfully recanalized in an early time window, pretreatment BBB disruption in regions that go on to infarct is associated with an increased risk of post-EVT HT.

Multicenter clinical trial evaluating the safety and efficacy of mechanical thrombectomy using the Versi Retriever

BackgroundThis study aimed to elucidate the safety and efficacy of mechanical thrombectomy using the Versi Retriever in patients with acute ischemic stroke (AIS).MethodsThis was a prospective, multicenter, single-arm study conducted...

Influence of Stroke-Onset Location on the Efficacy of Endovascular Thrombectomy: Comparison of Outcomes between In-Hospital versus Community-Onset Strokes.

Previous studies have suggested that patients experiencing an in-hospital stroke may face delays in treatment and worse outcomes compared with patients with community-onset strokes. However, most studies occurred when IV thrombolysis was the primary treatment. This study aimed to examine the outcomes of patients experiencing an in-hospital stroke in the endovascular thrombectomy era. This was a single-center retrospective cohort study of patients older than 18 years of age with acute ischemic stroke treated with endovascular thrombectomy within 12 hours of stroke onset from January 1, 2015, to April 30, 2021. Patients were classified into 2 groups: in-hospital strokes and community-onset strokes. We compared the time metrics of stroke care delivery, the rate of successful reperfusion, and functional outcome as scored using the mRS score at 90 days (favorable outcome was defined as mRS 0-2). Differences in proportions were assessed using the Fisher exact and χ2 tests as appropriate. For continuous variables, differences in medians between groups were evaluated using Mann-Whitney U tests. A total of 676 consecutive patients were included, with 69 (10%) comprising the in-hospital stroke group. Patients experiencing in-hospital stroke were more likely to have diabetes (36% versus 18%, P = .02) and less likely to receive thrombolysis (25% versus 68%, P < .001) than those in the community-onset stroke group, but they were otherwise similar. Patients with in-hospital stroke had significantly faster overall time metrics, most notably from stroke recognition to imaging (median, 70 [interquartile range, 38-141] minutes versus 121 [74-228] minutes, P < .001). Successful recanalization was achieved in >75% in both groups (P = .39), with a median NIHSS score at discharge of <4 (P = .18). The 90-day mRS was similar in both groups, with a trend toward higher in-hospital mortality in the in-hospital stroke group (P = .06). Patients with in-hospital stroke had shorter workflow delays to initiation of endovascular thrombectomy compared with their community counterparts but with a similar rate of successful recanalization and clinical outcomes. Most important, 90-day mortality and mRS scores were equivalent between in-hospital stroke and community-onset stroke groups.

Thrombectomy Alone or Alongside Intravenous Thrombolysis in Managing Acute Ischemic Stroke Caused by Basilar Artery Occlusion: A Multicenter Observational Study.

It remains unclear whether the combination of endovascular treatment (EVT) with intravenous thrombolysis (IVT) results in a more favorable functional outcome than EVT alone in managing cases of acute ischemic stroke (AIS) caused by basilar artery occlusion (BAO). Thus, this study aimed to compare the outcomes of two approaches-direct EVT (DEVT) and bridging therapy (IVT plus EVT)-in acute BAO patients presenting within 4.5 hours of stroke onset. This multicenter retrospective cohort study included 153 acute BAO patients presenting within 4.5 hours of stroke onset. Of these patients, 65 (42.5%) and 88 (57.5%) underwent DEVT and bridging therapy, respectively. The primary outcome was defined as good functional outcome (modified Rankin Scale, 0-3) at 90 days. Additionally, pre-operative clinical features, thrombectomy attempts, successful reperfusion rates, incidences of symptomatic intracranial hemorrhage (sICH), and mortality were compared between the two groups. At 90 days, the rate of good functional outcome was comparable between the DEVT (44.6%) and bridging-therapy (39.8%) groups (adjusted odds ratio [aOR], 1.12; 95% confidence interval [CI], 0.55-2.31; p = 0.753). The bridging-therapy group exhibited a lower percentage of patients requiring ≥ 3 attempts of stent retrieval (aOR, 0.39; 95% CI, 0.16-0.93; p = 0.034). Pre-operative clinical features, rate of successful reperfusion, sICH, and mortality were similar between the two groups. In patients with BAO-induced AIS, DEVT demonstrates a comparable functional outcome to bridging therapy within 4.5 hours of symptom onset, but IVT reduces the number of thrombectomy attempts. AIS, acute ischemic stroke; LVO, large-vessel occlusion; EVT, endovascular treatment; IVT, intravenous thrombolysis; BAO, basilar artery occlusion; DEVT, direct endovascular treatment; sICH, symptomatic intracranial hemorrhage; RCT, randomized controlled trial; IRIS, Improving Reperfusion Strategies in Ischemic Stroke; TOAST, Trial of ORG 10172 in Acute Stroke Treatment; mTICI, modified thrombolysis in cerebral infarction; SD, standard deviation; IQR, interquartile range; ICAS, intracranial atherosclerotic stenosis.

Higher intracranial positioning of an 8 Fr guide catheter improves efficacy of aspiration thrombectomy in large vessel occlusion stroke

BackgroundHigher positioning of a large bore guide catheter during endovascular thrombectomy (EVT) is hypothesized to potentially improve thrombectomy success.ObjectiveTo evaluate the safety and efficacy of intracranial guide catheter placement during...

Indirect bypass surgery as a line of management of pediatric moyamoya disease

Moyamoya disease (MMD) is a chronic, rare cerebrovascular disorder of unknown cause featured by extensive narrowing of the terminal internal carotid artery (ICA) and its main branches. As a compensatory mechanism, perforators dilate forming fragile collateral vessels that appear as an abnormal vascular network resembling ‘puff of smoke drifting in the air’ observed via angiography around stenotic area in the brain.Patients and methodsThe database of the current hospital was retrospectively studied. All patients with ischemic strokes owing to MMD treated with surgical revascularization between January 2015 and December 2022 were included. MMD was identified on catheter-based digital subtraction angiography (DSA) by the presence of stenosis at the terminal portions of both internal carotid arteries and the development of abnormal collateral “moyamoya vessels” around the base of the brain. Clinical, radiological and follow-up data were retrospectively analyzed.ResultsDuring the mentioned time window, nine patients were diagnosed with moyamoya disease among all pediatric patients with established diagnosis of ischemic stroke in our institute; six of them underwent surgery. Unilateral EDMS was performed in 5 cases (83.3%), while one patient (16.67%) underwent staged bilateral surgeries with no added neurological deficit.ConclusionIndirect revascularization surgery for pediatric moyamoya-related stroke patients has high rates of reperfusion and promising outcomes.

Rescue stenting in refractory mechanical thrombectomy: A review

Despite advancements in mechanical thrombectomy (MT) in the treatment of large vessel occlusions, failure to achieve recanalization remains a challenge in 10 &amp;ndash; 30% of patients. Several underlying pathologies have been postulated in refractory MT, including intracranial atherosclerotic stenosis, intracranial dissection, and recalcitrant emboli. Rescue strategies to maximize recanalization rates, such as alternative access routes, local thrombolysis, stent-assisted angioplasty, and acute &amp;ldquo;rescue&amp;rdquo; stenting, have been proposed. Considered an emerging treatment strategy for refractory MT, rescue stenting (RS) has been shown in non-randomized observational studies as a safe and effective strategy for increasing reperfusion rates and consequently improving clinical outcomes. The effective use of RS approach requires consideration of patient-specific characteristics, clot characteristics, and lesion anatomy. This review provides an overview of the understanding of refractory MT, epidemiology, pathophysiology, current evidence supporting RS in the anterior and posterior circulation, stents used, endovascular techniques, patient selection criteria, antithrombotic use, risks, and complications.

Current and Future Roles of Glycoprotein IIb-IIIa Inhibitors in Primary Angioplasty for ST-Segment Elevation Myocardial Infarction.

Acute myocardial infarction still represents the major cause of mortality in high-income countries. Therefore, considerable efforts have been focused on the treatment of myocardial infarctions in the acute and long-term phase, with special attention being paid to reperfusion strategies and adjunctive antithrombotic therapies. In fact, despite the successful mechanical recanalization of the epicardial conduit, a substantial percentage of patients still experience poor myocardial reperfusion or acute/subacute in-stent thrombosis. Due the delayed onset of action of currently available oral antiplatelet therapies, glycoprotein (GP) IIb-IIIa inhibitors could be expected to improve clinical outcomes, especially when administrated in the early phase of the infarction, due to the larger platelet composition of fresh thrombi, the dynamic nature of early thrombi, and the larger amount of viable myocardium existing in the early, as compared to a delayed, phase. Considerable evidence has accumulated regarding the benefits from GP IIb-IIIa inhibitors on mortality, especially among high-risk patients and when administered as an upstream strategy. Therefore, based on currently available data, GP IIb-IIIa inhibitors can be considered when the drug can be administered within the first 3 h of symptom onset and among high-risk patients (e.g., those with advanced Killip class or an anterior myocardial infarction). Even though it is not universally accepted, in our opinion, this strategy should be implemented in a pre-hospital setting (in an ambulance) or as soon as possible when arriving at the hospital (at the Emergency Room or Coronary Care Unit, irrespective of whether they are in spoke or hub hospitals). A new, second-generation GP IIb-IIIa inhibitor (zalunfiban) appears to be highly suitable as a pre-hospital pharmacological facilitation strategy at the time of first medical contact due to its favourable features, including its simple subcutaneous administration, rapid onset of action (15 min), and limited time of action (with a half-life of ~1 h), which is likely to minimize the risk of bleeding. The ongoing CELEBRATE trial, including 2499 STEMI patients, may potentially provide compelling data to support the upstream treatment of STEMI patients undergoing mechanical reperfusion. In fact, although the current therapeutic target of increased rates of timely reperfusion has been achieved, the future goal in myocardial infarction treatment should be to achieve the most rapid reperfusion prior to primary percutaneous coronary intervention, thus further minimizing myocardial damage, or, in some cases, even preventing it completely, and improving survival.

Long-Term Hemorrhage and Reperfusion Rates of Coiled Aneurysms: A Single-Center Experience.

Background: The endovascular approach has emerged as standard therapy for many intracranial aneurysms (IAs) to prevent hemorrhage, yet its long-term durability varies considerably. The aim of this study was to evaluate the safety and effectiveness of an initially deliberate endovascular approach regarding IA hemorrhage rates over a long-term follow-up period. Methods: This retrospective single-center study included all consecutive patients with endovascularly treated IAs who presented between January 2008 and December 2020 with a follow-up of at least 12 months. The primary endpoint was the proportion of patients with long-term IA hemorrhage rates and reperfusion. The secondary endpoint was treatment-related morbidity and mortality. Independent risk factors for IA reperfusion over the long term were analyzed using multivariate logistic regression. Results: Endovascular treatment was the therapy of choice for 333 patients with IAs, among whom 188 (57%) experienced rupture upon presentation. Complete coiling (Raymond I) was noted in 162 (49%) of the patients, with primary supportive devices being used in 51 (15%) patients. After a median (±SD) follow-up time of 34 ± 41 months (range 12-265 months), IA reperfusion was noted in 158 (47%), necessitating retreatment in 105 (32%) of the patients. Over the long term, hemorrhage was noted in four (1%) patients. Multivariate analysis revealed aneurysmal multilobarity (HR 1.8, 95%CI 1.2-2.7; p = 0.004) and a patient age of ≥50 years (HR 1.7, 95% CI 1.1-2.5, p = 0.01) as independent predictors of reperfusion over time. Intervention-related morbidity was noted in 16 (4.8%) patients, namely, thrombosis formation and contrast extravasation in 8 (2.4%) patients each, while no intervention-induced mortality was observed. Conclusion: In the long term, the hemorrhage rate in patients with IA with an initially more conservative endovascular approach is low. Therefore, a deliberate endovascular treatment approach might be justified.

Intracranial atherosclerotic disease mechanism indicates poor outcomes of thrombectomy in acute cerebral infarction with large vessel occlusion: A matched cohort study

BackgroundThrombectomy is a standard treatment for acute large vessel occlusion (LVO); however, its effectiveness in treating LVO related to intracranial atherosclerosis disease (ICAD) remains uncertain. This study aimed to compare thrombectomy outcomes in ICAD-related and embolic LVO, focusing on patients with similar symptom severities upon hospital admission. MethodsThis retrospective study was conducted at Jikei University Hospital and Jikei University Kashiwa Hospital between October 2017 and March 2023. Ischemic stroke patients with LVO who underwent thrombectomy were categorized into ICAD and embolism groups based on the occlusion mechanism. Groups were matched using National Institutes of Health Stroke Scale scores at the time of admission. A modified Rankin Scale score of 5 or 6 at 90 days after symptom onset was defined as a devastating outcome. The procedural outcomes and frequency of devastating outcomes were compared between the ICAD and embolism groups. ResultsThe study included 33 matched pairs were included. The ICAD group showed lower rates of successful reperfusion (43 % vs. 82 %, p = 0.001), and longer procedural times (median 88 min vs. 50 min, p < 0.001) than the embolism group. The ICAD group had a significantly higher frequency of devastating outcomes than the non-ICAD group (39 % vs. 15 %, p = 0.027). Multivariate analysis identified ICAD as an independent factor associated with devastating outcomes (OR, 3.804; 95 % confidence interval (95 %CI), 1.148–12.603; p = 0.029). ConclusionIn thrombectomy therapy, reperfusion rates and outcomes are significantly worse in patients with ICAD-LVO than in patients with embolic LVO.

Combining the deployment of only the distal basket segment of the EMBOTRAP III and an aspiration catheter for M2 occlusions: the ONE-SEG technique.

Endovascular therapy (EVT) for distal medium vessel occlusions requires prioritizing effectiveness and safety. We developed a technique combining the deployment of only the distal basket segment of the EMBOTRAP III and an aspiration catheter (AC) for M2 occlusions, called the "ONE-SEG technique," and evaluated its clinical and technical impacts. This was a retrospective review of 30 consecutive patients with M2 segment middle cerebral artery occlusion treated using the ONE-SEG technique. This method involves deploying the EMBOTRAP III through a microcatheter in only one segment and guiding the AC to the M2 origin or distal M1. The rates of final-pass expanded thrombolysis in cerebral infarction (eTICI) scores of 2c/3 or 2b/2c/3, safety (symptomatic intracranial hemorrhage [sICH]), and clinical outcomes (modified Rankin Scale [mRS] score 0-2, 0-3 at 90 days, and mortality at 90 days) were evaluated. Of the 30 cases, 36.7% were female, and the mean age was 75.6 ± 11.0 years. The ONE-SEG technique was used for 17 cases (56.7%, median NIHSS 10 [5-15.5]) with primary M2 occlusion and 13 cases (43.3%, median NIHSS 20 [14-22.5]) with secondary M2 occlusion after proximal thrombus removal. The successful final reperfusion rate (eTICI 2b/2c/3) was 90% overall (27/30 cases). One case (3.3%) developed sICH with secondary M2 occlusion. At 3 months, mRS scores 0-2 were seen in 64.7% of patients with primary M2 occlusion (11/17 cases) and in 23.1% (3/13 cases) with secondary M2 occlusion. EVT using the ONE-SEG technique appears to be safe and effective for M2 occlusion.

Treatment outcome of bridge mechanical thrombectomy with different IV-tPA dosages in the standard and extended time window in real-world practice.

Differences of treatment outcome between full or reduced dose of tissue plasminogen activator (tPA) for bridge mechanical thrombectomy (MT) in the extended time window have not been clearly established. We aimed to present real-world results of bridge MT with different tPA dosages in the standard and extended windows. Patients with anterior circulation stroke treated with MT between 2017 and 2021 at two stroke referral centers were retrospectively reviewed. Bridge MT with tPA were categorized as full (0.9mg/kg) or reduced (<0.9mg/kg) dose. Standard window (SW) cohort was defined as MT performed within 6h of acute ischemic stroke onset, while those beyond 6h as the extended window (EW) cohort. 90days Modified Rankin Scale (mRS) score, technical treatment success, in-hospital mortality, and post-treatment hemorrhage were analyzed. A total of 423 patients met the inclusion criteria, 218 of which treated in the SW, while 205 treated in the EW. Within the SW cohort, the full-dose tPA group demonstrated a higher proportion of good functional outcome (GFO) at 90days (mRS0-3) versus reduced (49% vs 21%, p = 0.0358). The overall GFO of SW was higher than that of the EW cohort (33% vs 20%, p = 0.0480). Within the EW cohort, GFO was similar between full and reduced dose groups. Successful reperfusion rate was lower in SW versus EW cohorts (39% vs 58%, p = 0.0199). In real-world practice, the GFO of bridge MT is better than MT alone. The tPA dosage is not a determining factor of GFO in EW MT.

Thrombin and NIR dual-responsive system driven by heat-gas for thrombus targeted therapy

Drug thrombolysis is the main means of clinical treatment for thrombotic-related diseases. However, serious bleeding complications caused by low drug delivery efficiency and secondary vascular embolism usually lead to unsatisfactory therapeutic effects. Herein, we constructed a thrombin and near-infrared (NIR) dual-responsive drug-loaded intelligent system to solve the above problems. The CREKA-modified polydopamine (PDA) nanoparticles (NPs) were crosslinked by thrombin-responsive peptide (Pep), to obtain Pep-PPC nanocarriers with special mesoporous nanostructures. Subsequently, NO donor BNN6 and thrombolytic drug UK were loaded on the surface and into the mesoporous of Pep-PPC, to get the multifunctional Pep-NO@PPC/UK. In vitro and in vivo results proved that Pep-NO@PPC/UK could effectively recognize and aggregate at the thrombus site via CREKA-mediated active targeting. Then local abundant thrombin cleaved the nanoplatform to release UK. Meanwhile, PDA converted NIR light into heat and synchronously triggered NO release. This transformed the DDS into a “heat-gas” dual propulsion nanomotor in situ, driving deep penetration of UK in thrombus tissue. Under the combined action of UK and PTT, arterial thrombosis rapidly dissolved with relatively low bleeding risk. More importantly, NO generated in situ could prevent re-embolism of blood vessels at the thrombolytic site by inhibiting activated platelet aggregation, ultimately improving vascular reperfusion rate through a combination of attack and defense mode.

Mediation Analysis of Acute Carotid Stenting in Tandem Lesions: Effect on Functional Outcome in a Multicenter Registry.

Current evidence suggests that acute carotid artery stenting (CAS) for cervical lesions is associated with better functional outcomes in patients with acute stroke with tandem lesions (TLs) treated with endovascular therapy (EVT). However, the underlying causal pathophysiologic mechanism of this relationship compared with a non-CAS strategy remains unclear. We aimed to determine whether, and to what degree, reperfusion mediates the relationship between acute CAS and functional outcome in patients with TLs. This subanalysis stems from a multicenter retrospective cohort study across 16 stroke centers from January 2015 to December 2020. Patients with anterior circulation TLs who underwent EVT were included. Successful reperfusion was defined as a modified Thrombolysis in Cerebral Infarction scale ≥2B by the local team at each participating center. Mediation analysis was conducted to examine the potential causal pathway in which the relationship between acute CAS and functional outcome (90-day modified Rankin Scale) is mediated by successful reperfusion. A total of 570 patients were included, with a median age (interquartile range) of 68 (59-76), among whom 180 (31.6%) were female. Among these patients, 354 (62.1%) underwent acute CAS and 244 (47.4%) had a favorable functional outcome. The remaining 216 (37.9%) patients were in the non-CAS group. The CAS group had significantly higher rates of successful reperfusion (91.2% vs 85.1%; p = 0.025) and favorable functional outcomes (52% vs 29%; p = 0.003) compared with the non-CAS group. Successful reperfusion was a strong predictor of functional outcome (adjusted common odds ratio [acOR] 4.88; 95% CI 2.91-8.17; p < 0.001). Successful reperfusion partially mediated the relationship between acute CAS and functional outcome, as acute CAS remained significantly associated with functional outcome after adjustment for successful reperfusion (acOR 1.89; 95% CI 1.27-2.83; p = 0.002). Successful reperfusion explained 25% (95% CI 3%-67%) of the relationship between acute CAS and functional outcome. In patients with TL undergoing EVT, successful reperfusion predicted favorable functional outcomes when CAS was performed compared with non-CAS. A considerable proportion (25%) of the treatment effect of acute CAS on functional outcome was found to be mediated by improvement of successful reperfusion rates.

Heparin pretreatment in ST segment elevation myocardial infarction: a systematic review and meta-analysis.

Unfractionated heparin (UFH) is frequently administered before percutaneous coronary intervention in patients with ST segment elevation myocardial infarction (STEMI). Current guidelines, however, do not provide clear recommendations for UFH pretreatment before arrival at the coronary catheterization laboratory. Between June and July 2023, we systematically searched PubMed, Embase, and Cochrane databases for studies comparing UFH pretreatments in patients with STEMI. A random-effects meta-analysis and meta-regression analyses were performed. Fourteen studies were included, of which four were randomized clinical trials. A total of 76 446 patients were included: 31 238 in the pretreatment group and 39 208 in the control group. Our meta-analysis revealed lower all-cause mortality for the pretreatment strategy when compared with the control group, albeit with high heterogeneity [pooled odds ratio (OR) = 0.61, 95% confidence interval (CI): 0.49-0.76, P < 0.01; I2 = 77%]; lower in-hospital cardiogenic shock (pooled OR = 0.68, 95% CI: 0.58-0.78, P < 0.21; I2 = 27%) and a higher rate of spontaneous reperfusion events (pooled OR = 1.68, 95% CI: 1.47-1.91, P < 0.01; I2 = 79%). In terms of major bleeding, the UFH pretreatment strategy further revealed a decreased rate of events (pooled OR = 0.85, 95% CI: 0.73-0.99, P = 0.40; I2 = 4%). Our study suggests that UFH pretreatment in patients with STEMI undergoing primary percutaneous coronary intervention was associated with reduced all-cause mortality, cardiogenic shock, enhancing reperfusion rates while diminishing major bleeding events.

Interhospital Transfer for Endovascular Stroke Treatment in Canada: Results From the OPTIMISE Registry.

Interhospital transfer for patients with stroke due to large vessel occlusion for endovascular thrombectomy (EVT) has been associated with treatment delays. We analyzed data from Optimizing Patient Treatment in Major Ischemic Stroke With EVT, a quality improvement registry to support EVT implementation in Canada. We assessed for unadjusted differences in baseline characteristics, time metrics, and procedural outcomes between patients with large vessel occlusion transferred for EVT and those directly admitted to an EVT-capable center. Between January 1, 2018, and December 31, 2021, a total of 6803 patients received EVT at 20 participating centers (median age, 73 years; 50% women; and 50% treated with intravenous thrombolysis). Patients transferred for EVT (n=3376) had lower rates of M2 occlusion (22% versus 27%) and higher rates of basilar occlusion (9% versus 5%) compared with those patients presenting directly at an EVT-capable center (n=3373). Door-to-needle times were shorter in patients receiving intravenous thrombolysis before transfer compared with those presenting directly to an EVT center (32 versus 36 minutes). Patients transferred for EVT had shorter door-to-arterial access times (37 versus 87 minutes) but longer last seen normal-to-arterial access times (322 versus 181 minutes) compared with those presenting directly to an EVT-capable center. No differences in arterial access-to-reperfusion times, successful reperfusion rates (85% versus 86%), or adverse periprocedural events were found between the 2 groups. Patients transferred to EVT centers had a similar likelihood for good functional outcome (modified Rankin Scale score, 0-2; 41% versus 43%; risk ratio, 0.95 [95% CI, 0.88-1.01]; adjusted risk ratio, 0.98 [95% CI, 0.91-1.05]) and a higher risk for all-cause mortality at 90 days (29% versus 25%; risk ratio, 1.15 [95% CI, 1.05-1.27]; adjusted risk ratio, 1.14 [95% CI, 1.03-1.28]) compared with patients presenting directly to an EVT center. Patients transferred for EVT experience significant delays from the time they were last seen normal to the initiation of EVT.

Non-invasive optical and laboratory hematologic biomarkers correlate in patients with sickle cell disease.

The goal of this study is to identify non-invasive optical hemodynamic biomarkers that can index laboratory hematology measurements in sickle cell disease (SCD). We acquired frequency-domain NIRS (FD-NIRS) and diffuse correlation spectroscopy (DCS) data from the forearms and foreheads of 17 participants in a randomized, double-blind, placebo-controlled trial evaluating effects of isoquercetin (IQ) on thromboinflammation in SCD. We observed multiple, significant correlations between optical and hematology biomarkers including cerebral tissue oxygen saturation (StO2) and hematocrit (HCT); oxyhemoglobin ([O2Hb]) recovery rate and intercellular adhesion molecule 1 (ICAM-1); and blood flow index (BFI) reperfusion rate and coagulation index (CI). The potential of these non-invasive optical biomarkers for assessing vascular pathophysiology for the management of SCD warrants further exploration.

Single-Centre Experience with Endovascular Therapy in Acute Occlusion of ICAS: Preferred Stent Thrombectomy Versus Preferred Angioplasty.

The preferred endovascular therapy (EVT) for large-vessel occlusion in intracranial atherosclerosis (ICAS) is unknown. We compared the efficacy of preferred stent thrombectomy and preferred angioplasty in patients with acute large-vessel occlusion in ICAS. Data from consecutive EVT patients (May 2020 to September 2023) with acute middle cerebral artery occlusion in ICAS were retrospectively analyzed. Preferred angioplasty was performed if there was a preoperative "microcatheter first-pass effect;" otherwise, preferred stent thrombectomy was performed. Analyses were grouped according to the two EVT treatments. Clinical data of all patients, including the time from puncture to recanalization, rate of successful reperfusion, early neurological improvement, intracranial hemorrhage, and modified Rankin Scale score at 90 days, were recorded and analyzed. Six-two patients were enrolled in this study (mean age was 60.66±13.21y, 22.6% female). The preferred angioplasty group had a higher first-pass recanalization rate than the preferred stent thrombectomy group (61.3% vs. 21.9%, P<0.001) and a higher proportion of patients who were functionally independent (defined as a modified Rankin Scale score of 0 to 3) at 90 days [odds ratio,3.681; 95% confidence interval (CI):1.009 to 13.428; P=0.048]. There was no significant difference between the groups in the time from puncture to recanalization, the frequency of successful reperfusion, and early neurological improvement, or intracranial hemorrhage (P>0.05). This study suggests that for acute middle cerebral artery occlusion in ICAS, preferred angioplasty may be a safe and effective procedure.