Risk Of sICH Research Articles

Mechanical thrombectomy versus medical management for acute basilar artery occlusions: A meta-analysis of randomized trials.

Basilar artery occlusion (BAO) stroke is a catastrophic clinical event that results in significant morbidity and mortality. Whether MT is superior in improving outcomes remains largely inconclusive. We performed a meta-analysis of randomized controlled trials (RCTs) to better understand the efficacy and safety of MT in treating BAO compared to medical management (MM). PubMed and EMBASE were searched to identify RCTs that directly compared the safety and efficacy of MT versus MM for patients with BAO. The primary outcome was modified Rankin scale (mRS) 0-3 at 3 months, and secondary outcome variables included National Institutes of Health Stroke Scale (NIHSS) at 24 hours, mRS 0-2 at 3 months, symptomatic intracranial hemorrhage (sICH), and 90-day mortality. Four RCTs with 988 patients (432 in the MM arm and 556 in the MT arm), were included. Patients receiving MT had significantly higher rate of mRS 0-2 (OR = 1.994, 95% CI: 1.319-3.012) and mRS 0-3 (OR = 2.259, 95% CI: 1.166-4.374) at 3 months in comparison to patients receiving MM. Mortality was also significantly reduced in the MT group (OR = 0.640, 95% CI: 0.493-0.831). However, increased odds of sICH were found in the MT group compared to the MM group (OR = 8.193, 95% CI: 2.451-27.389). No difference was observed in terms of NIHSS at 24 hours between the two arms. Despite the higher risk of sICH, MT was associated with superior functional outcomes and reduced mortality compared to MM in BAO patients. A revision of current guidelines for treatment of acute ischemic stroke from basilar artery occlusion should be considered.

Endovascular Treatment for Acute Basilar Artery Occlusion: A Fragility Index Meta-Analysis

High-quality evidence regarding the use of endovascular treatment (EVT) in patients with acute basilar artery occlusion (BAO) has been provided by recently completed randomized controlled clinical trials (RCTs). We conducted a systematic review and meta-analysis including all available RCTs that investigated efficacy and safety of EVT in addition to best medical treatment (BMT) versus BMT alone for BAO. The random-effects model was used, while the fragility index (FI) was calculated for dichotomous outcomes of interest. Four RCTs were included comprising a total of 988 patients with acute BAO (mean age: 65.6 years, 70% men, median NIHSS: 24, 39% pretreatment with intravenous thrombolysis). EVT was related to higher likelihood of good functional outcome (RR: 1.54; 95% CI: 1.16-2.05; I2 = 60%), functional independence (RR: 1.83; 95% CI: 1.08-3.08; I2 = 79%) and reduced disability at 3 months (adjusted common OR: 1.96; 95% CI: 1.26-3.05; I2 = 59%) compared to BMT alone. Despite that EVT was associated with a higher risk for symptomatic intracranial hemorrhage (RR: 7.78; 95% CI: 2.36-25.61; I2 = 0%) and any intracranial hemorrhage (RR: 2.85; 95% CI: 1.50-5.44; I2 = 16%), mortality at 3 months was lower among patients that received EVT plus BMT versus BMT alone (RR: 0.76; 95% CI: 0.65-0.89; I2 = 0%). However, sufficient robustness was not evident in any of the reported associations (FI < 10) including the overall effect regarding the primary outcome. The former associations were predominantly driven by RCTs with recruitment limited in China. EVT combined with BMT is associated with a higher likelihood of achieving good functional outcomes and a lower risk of death at 3 months compared to BMT alone, despite the higher risk of sICH. An individual-patient data meta-analysis is warranted to uncover and adjust for potential sources of heterogeneity and to provide further insight.

Baseline brain imaging signs in patients with ischaemic stroke by the presence of atrial fibrillation: the ENCHANTED trial

BackgroundWe aimed to assess the association of atrial fibrillation (AF) on outcomes in a post hoc analysis of the ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study) and how this association is modified by baseline imaging features.MethodsInverse probability of treatment weight was used to remove baseline imbalances between those with and without AF. The primary outcome was the modified Rankin Scale (mRS) scores at 90 days. Secondary outcomes were symptomatic intracerebral haemorrhage (sICH), early neurological deterioration or death within 24 h, and death at 90 days. The logistic regression model was used to determine the associations.ResultsOf the 3285 patients included in this analysis, 636 (19%) had AF at baseline. Compared with non-AF, AF was not significantly associated with an unfavourable shift of mRS (odds ratio 1.09; 95% confidence interval, 0.96–1.24), but with sICH (2.82; 1.78-4.48; IST-3 criteria), early neurological deterioration or death within 24 h (1.31; 1.01-1.70), and death (1.42; 1.12-1.79). Among patients with acute ischaemic signs (presence, extent, swelling and attenuation of acute lesions), AF was associated with the increased risk of all the poor outcomes (all P < 0.04 for interaction).ConclusionsWe found AF increased risk of sICH, early neurological deterioration or death and death, but not unfavourable functional recovery at day 90 after thrombolysis in patients with AIS. The presence of acute ischaemic brain imaging signs at stroke presentation could be used to improve risk stratification in the presence of AF.Trial registrationThe trial is registered at ClinicalTrials.gov (NCT01422616).

Management of Cervical Internal Carotid Artery Stenosis or Occlusion in Tandem Lesion with Acute Ischemic Stroke: Which Is More Appropriate Percutaneous Transluminal Angioplasty or Stent?

Carotid artery stenting (CAS) is the established treatment strategy of the cervical internal carotid artery (cICA) stenosis, but its use for acute tandem lesions remains controversial. We investigated the clinical and procedural outcomes of management of cICA lesions and evaluated the risk factors for complications. Fifty patients who underwent acute mechanical thrombectomy for tandem lesion between January 2014 and June 2022 were included. Treatment of the cICA lesion was classified into the CAS group or the non-CAS group. The risk factors for postoperative ischemic events or symptomatic intracranial hemorrhage (sICH) were analyzed. The CAS group included 36 patients (72%) and the non-CAS group 14 (28%). Postoperative complications were observed in 9 patients (18%). Thromboembolic complications occurred in 4 patients (29%) of the non-CAS group but in 1 patient (3%) of the CAS group. Severe calcification of the cICA (P= 0.04), non-CAS (P= 0.018), and more than 60% residual stenosis (P= 0.016) were significant risk factors associated with thromboembolic complications. sICH occurred in 4 patients (11%) of the CAS group but in none of the non-CAS group. More than 80% stenosis improvement was significantly associated with sICH (P= 0.049). Twenty-nine patients (58%) had a good clinical outcome at 90 days after onset. Acute CAS is effective for the management for cICA tandem lesions during mechanical thrombectomy, but care not to overextend may be important to reduce the risk of sICH. Severe calcification of the cICA may increase the risk of postoperative thromboembolic complications using non-CAS treatment.

Association of admission neutrophil serine proteinases levels with the outcomes of acute ischemic stroke: a prospective cohort study

BackgroundNeutrophil serine proteinases (NSPs), released by activated neutrophils, are key proteins involved in the pathophysiologic processes of stroke. NSPs are also implicated in the process and response of thrombolysis. This study aimed to analyze three NSPs (neutrophil elastase, cathepsin G, and proteinase 3) in relation to acute ischemic stroke (AIS) outcomes and in relation to the outcomes of patients treated with intravenous recombinant tissue plasminogen activator (IV-rtPA).MethodsAmong 736 patients prospectively recruited at the stroke center from 2018 to 2019, 342 patients diagnosed with confirmed AIS were included. Plasma neutrophil elastase (NE), cathepsin G (CTSG), and proteinase 3 (PR3) concentrations were measured on admission. The primary endpoint was unfavorable outcome defined as modified Rankin Scale score 3–6 at 3 months, and the secondary endpoints were symptomatic intracerebral hemorrhage (sICH) within 48 h, and mortality within 3 months. In the subgroup of patients who received IV-rtPA, post-thrombolysis early neurological improvement (ENI) (defined as National Institutes of Health Stroke Scale score = 0 or decrease of ≥ 4 within 24 h after thrombolysis) was also included as the secondary endpoint. Univariate and multivariate logistic regression analyses were performed to evaluate the association between NSPs levels and AIS outcomes.ResultsHigher NE and PR3 plasma levels were associated with the 3-month mortality and 3-month unfavorable outcome. Higher NE plasma levels were also associated with the risk of sICH after AIS. After adjusting for potential confounders, plasma NE level > 229.56 ng/mL (odds ratio [OR] = 4.478 [2.344–8.554]) and PR3 > 388.77 ng/mL (OR = 2.805 [1.504–5.231]) independently predicted the 3-month unfavorable outcome. Regarding rtPA treatment, patients with NE plasma concentration > 177.22 ng/mL (OR = 8.931 [2.330–34.238]) or PR3 > 388.77 ng/mL (OR = 4.275 [1.045–17.491]) were over 4 times more likely to suffer unfavorable outcomes after rtPA treatment. The addition of NE and PR3 to clinical predictors of unfavorable functional outcome after AIS and the outcome after rtPA treatment improved discrimination as well as reclassification (integrated discrimination improvement = 8.2% and 18.1%, continuous net reclassification improvement = 100.0% and 91.8%, respectively).ConclusionsPlasma NE and PR3 are novel and independent predictors of 3-month functional outcomes after AIS. Plasma NE and PR3 also possess predictive value to identify patients with unfavorable outcomes after rtPA treatment. NE is probably an important mediator of the effects of neutrophils on stroke outcomes, which worth further investigation.

Functional and Safety Outcomes of Carotid Artery Stenting and Mechanical Thrombectomy for Large Vessel Occlusion Ischemic Stroke With Tandem Lesions

Approximately 10% to 20% of large vessel occlusion (LVO) strokes involve tandem lesions (TLs), defined as concomitant intracranial LVO and stenosis or occlusion of the cervical internal carotid artery. Mechanical thrombectomy (MT) may benefit patients with TLs; however, optimal management and procedural strategy of the cervical lesion remain unclear. To evaluate the association of carotid artery stenting (CAS) vs no stenting and medical management with functional and safety outcomes among patients with TL-LVOs. This cross-sectional study included consecutive patients with acute anterior circulation TLs admitted across 17 stroke centers in the US and Spain between January 1, 2015, and December 31, 2020. Data analysis was performed from August 2021 to February 2022. Inclusion criteria were age of 18 years or older, endovascular therapy for intracranial occlusion, and presence of extracranial internal carotid artery stenosis (>50%) demonstrated on pre-MT computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography. Patients with TLs were divided into CAS vs nonstenting groups. Primary clinical and safety outcomes were 90-day functional independence measured by a modified Rankin Scale (mRS) score of 0 to 2 and symptomatic intracranial hemorrhage (sICH), respectively. Secondary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction score ≥2b), discharge mRS score, ordinal mRS score, and mortality at 90 days. Of 685 patients, 623 (mean [SD] age, 67 [12.2] years; 406 [65.2%] male) were included in the analysis, of whom 363 (58.4%) were in the CAS group and 260 (41.6%) were in the nonstenting group. The CAS group had a lower proportion of patients with atrial fibrillation (38 [10.6%] vs 49 [19.2%], P = .002), a higher proportion of preprocedural degree of cervical stenosis on digital subtraction angiography (90%-99%: 107 [32.2%] vs 42 [20.5%], P < .001) and atherosclerotic disease (296 [82.0%] vs 194 [74.6%], P = .003), a lower median (IQR) National Institutes of Health Stroke Scale score (15 [10-19] vs 17 [13-21], P < .001), and similar rates of intravenous thrombolysis and stroke time metrics when compared with the nonstenting group. After adjustment for confounders, the odds of favorable functional outcome (adjusted odds ratio [aOR], 1.67; 95% CI, 1.20-2.40; P = .007), favorable shift in mRS scores (aOR, 1.46; 95% CI, 1.02-2.10; P = .04), and successful reperfusion (aOR, 1.70; 95% CI, 1.02-3.60; P = .002) were significantly higher for the CAS group compared with the nonstenting group. Both groups had similar odds of sICH (aOR, 0.90; 95% CI, 0.46-2.40; P = .87) and 90-day mortality (aOR, 0.78; 95% CI, 0.50-1.20; P = .27). No heterogeneity was noted for 90-day functional outcome and sICH in prespecified subgroups. In this multicenter, international cross-sectional study, CAS of the cervical lesion during MT was associated with improvement in functional outcomes and reperfusion rates without an increased risk of sICH and mortality in patients with TLs.

Abstract Number ‐ 21: Mechanical Thrombectomy versus Medical Management in Patients with acute LVO and Pre‐morbid Disability: Meta‐analysis

Introduction Actual guidelines offer little guidance for endovascular treatment of patients with acute ischemic stroke (AIS) and pre‐morbid disability (PMD). Often, patients with a mRS &gt;2 are not considered for mechanical thrombectomy (MT) and might not be given the best chance of achieving recovery. Three recent meta‐analysis have showed conflicting results regarding the benefit of MT, while persistently showing a significant increase in mortality. Methods We conducted a systematic search in Embase, Medline, and Web of Science for studies of patients with AIS and PMD who were treated with MT or MM. We included all definitions of PMD, main outcomes were favorable functionality at 90‐days (mRS 0–2 or return to baseline mRS), symptomatic ICH, and mortality. We performed meta‐analyses using a random‐effect model, and I2 to evaluate heterogeneity. Subgroup analyses were used when appropriate. Results 2 studies contained data comparing PMD patients treated with MT versus MM, 14 studies contained data only of patients treated with MT, and 10 only of patients treated with MM; they provided data of 1071 patients in the MT group and 4547 in the MM group. Pooled rates in the MT group were 28% (95% CI 0.24‐0.32) for favorable functionality, 7% (95% CI 0.04‐0.12) for sICH, 43% (95% CI 0.36‐0.51) for 90‐days mortality, 18% (95% CI 0.14‐0.23) for intra‐hospital mortality, and pooled reperfusion rate (mTICI 0–2) of 80% (95% CI 0.72‐0.86). In a meta‐analysis of proportion with the treatments modalities as subgroups, including only studies with a similar definition of PMD, we obtained: for favorable functionality, MT = 26% (95% CI 0.23‐0.30) vs. MM = 35% (95% CI 0.22‐0.51); for sICH, MT = 6% (95% CI 0.05‐0.08) vs. MM = 6% (95% CI 0.05‐0.08); for 90‐days mortality, MT = 48% (95% CI 0.44‐0.52) vs. MM = 34% (95% CI 0.27‐0.41); and for in‐hospital mortality, MT = 18% (95% CI 0.14‐0.23) vs. MM = 22% (95% CI 0.17‐0.28). Additionally, meta‐analysis for 90‐days mortality in MT studies, showed a pooled rate of 49% (95% CI 0.45‐0.53) for the high tPA rate subgroup, and 30% (95% CI 0.19‐0.44) for the low tPA rate subgroup. Conclusions Up to one third of PMD patients who undergo MT might achieve favorable functionality, without increasing the risk of sICH and with rates similar to those obtained with MM. Furthermore, we observed a high 90‐day mortality rate, in both MT and MM groups. In subgroups exploration, there is trend of high tPA rates to be associated with the increased mortality. It is urgent to identify PMD patients who will benefit from MT and factors associated with poor outcomes.

Predictors of outcome after endovascular treatment for tandem occlusions: a single center retrospective analysis

BackgroundThe endovascular treatment procedure in tandem occlusions (TO) is complex compared to single occlusion (SO) and optimal management remains uncertain. The aim of this study was to identify clinical and procedural factors that may be associated to efficacy and safety in the management of TO and compare functional outcome in TO and SO stroke patients.MethodsThis is a retrospective single center study of medium (MeVO) and large vessel occlusion (LVO) of the anterior circulation. Clinical, imaging, and interventional data were analyzed to identify predictive factors for symptomatic intracranial hemorrhage (sICH) and functional outcome after endovascular treatment (EVT) in TO. Functional outcome in TO and SO patients was compared.ResultsOf 662 anterior circulation stroke patients with MeVO and LVO stroke, 90 (14%) had TO. Stenting was performed in 73 (81%) of TO patients. Stent thromboses occurred in 8 (11%) patients. Successful reperfusion with modified thrombolysis in cerebral infarction (mTICI) ≥ 2b was achieved in 82 (91%). SICH occurred in seven (8%). The strongest predictors for sICH were diabetes mellitus and number of stent retriever passes. Good functional clinical outcome (mRS ≤ 2) at 90-day follow up was similar in TO and SO patients (58% vs 59% respectively). General anesthesia (GA) was associated with good functional outcome whereas hemorrhage in the infarcted tissue, lower mTICI score and history of smoking were associated with poor outcome.ConclusionsThe risk of sICH was increased in patients with diabetes mellitus and those with extra stent-retriever attempts. Functional clinical outcomes in patients with TO were comparable to patients with SO.

Low-dose vs. standard-dose alteplase for Chinese patients with acute ischemic stroke: A propensity score analysis.

Previous studies have stimulated debates on low-dose alteplase administration in acute ischemic stroke (AIS) among the Asian population. We sought to evaluate the safety and efficacy of low-dose alteplase in Chinese patients with AIS using a real-world registry. We analyzed data from the Shanghai Stroke Service System. Patients receiving alteplase intravenous thrombolysis within 4.5 hours were included. These patients were divided into the low-dose alteplase group (0.55-0.65 mg/kg) and the standard-dose alteplase group (0.85-0.95 mg/kg). Baseline imbalances were adjusted by using the propensity score matching. The primary outcome was mortality or disability, which was defined as the modified Rankin scale (mRS) score ranging from 2 to 6 at discharge. The secondary outcomes were in-hospital mortality, symptomatic intracranial hemorrhage (sICH) and functional independence (mRS score 0-2). From January 2019 to December 2020, a total of 1,334 patients were enrolled and 368 (27.6%) were treated with low-dose alteplase. The median age of the patients was 71 years, and 38.8% were female. Our study showed that the low-dose group had significantly higher rates of death or disability (adjusted odds ratio (aOR) = 1.49, 95% confidence interval (CI) [1.12, 1.98]) and less functional independence (aOR = 0.71, 95%CI [0.52, 0.97]) than the standard-dose group. There was no significant difference in sICH or in-hospital mortality between the standard-dose and low-dose alteplase groups. Low-dose alteplase was related to a poor functional outcome without lowering the risk of sICH, compared with standard-dose alteplase for AIS patients in China.

Abstract 89: Mechanical Thrombectomy Or Medical Management Alone For Isolated Posterior Cerebral Artery Occlusion. An International Multicentric Observational Study.

Introduction: Whether endovascular therapy (EVT) added on best medical management (BMM, including intravenous thrombolysis [IVT] if indicated), as compared to BMM alone, is beneficial in acute ischemic stroke (AIS) with isolated posterior cerebral artery occlusion is unknown. Methods: We conducted a multicenter international observational study of consecutive AIS patients admitted within 6hrs from last seen well in 26 stroke centers in France, Switzerland and USA with isolated proximal posterior cerebral artery strokes (P1 or P2 occlusions) and treated either with EVT+BMM or BMM alone. Propensity score with inverse probability of treatment weighting was used to account for baseline between-groups differences. The primary outcome was 3-month good functional outcome (modified Rankin score [mRS] 0-2). Secondary outcomes were excellent functional outcome (mRS 0-1) and symptomatic intracranial hemorrhage (sICH) at 24hrs. We searched for an interaction between treatment group and (1) occlusion site (P1 vs . P2), (2) NIHSS score (&lt;10 vs. ≥10), and (3) IVT use. Results: Overall, 810 AIS patients were included (180 and 630 in the EVT+BMM and BMM alone groups, respectively). Median age was 74yo (IQR 63-83), 352 (44%) were female, median NIHSS was 6 (IQR 4-10), 594 (73%) received IVT, and occlusion site was P1 in 205 (25%) and P2 in 605 (75%) patients. Baseline clinical and radiological data were similar between the 2 groups following propensity-score weighting. EVT was not associated with good (adjusted OR=0.86; 95%CI: 0.67-1.09; P =0.21) or excellent (adjusted OR=1.10; 95%CI: 0.87-1.39; P =0.42) functional outcome but was associated with higher risk of sICH (OR=2.71; 95%CI: 1.41-5.21; P =0.003). No interaction was found between EVT effect and (1) NIHSS score, (2) occlusion site, or (3) IVT use for either outcome. Conclusion: In our population of AIS patients with isolated P1 or P2 occlusion, EVT was not associated with higher rates of good or excellent functional outcome as compared to BMM alone. However, EVT was associated with higher rates of sICH. Randomized trials are warranted.

Abstract WMP1: Complications Of Intravenous Tenecteplase For The Treatment Of Acute Ischemic Stroke: A Systematic Review And Meta-Analysis

Introduction: Prior systematic reviews have focused on a comparison of efficacy endpoints between tenecteplase (TNK) and alteplase. The objectives of this study are to determine whether the rate of treatment complications differs between patients treated with the two agents. Methods: This systematic review (CRD42022303835) was performed according to PRISMA guidelines. We included prospective, interventional studies and prospective and retrospective observational studies. We searched MEDLINE, the Cochrane Central Register of Controlled Trials, Embase, Web of Science and the ClinicalTrials.gov registry from inception through June 3 rd 2022. The primary endpoint was symptomatic intracranial hemorrhage (sICH) and secondary endpoints included any ICH, mortality, angioedema, gastrointestinal hemorrhage and other extracranial hemorrhage. We performed separate random effects meta analyses for each endpoint. Evidence was synthesized as relative risks, comparing subjects exposed to TNK versus alteplase as well as absolute risks in those treated with TNK. Results: Of 2,226 records identified, 26 were eligible for inclusion including 7,921 patients. Seventeen studies included alteplase as a comparator group and 10 were non-comparative. The relative risk of sICH in patients treated with TNK compared with alteplase was 0.93 (95% CI: 0.68-1.28). Across those treated with low, medium and high doses of TNK, the relative risks were 0.78 (95% CI: 0.22-2.82), 0.84 (95% CI: 0.58-1.20) and 2.31 (0.69-7.75) respectively. The unadjusted rate of sICH, including comparative and non-comparative studies, was 1%, 2% and 4% within the low, medium and high dose groups. Discussion: To-date, this is the most comprehensive systematic review examining relative complications of TNK and alteplase. The rate of treatment harms is broadly comparable between those treated with the two agents. We present evidence that the rate of sICH may be increased in those treated with higher doses of TNK.

Abstract 25: Safety And Outcomes Of Endovascular Thrombectomy In Acute Ischemic Stroke Patients With Recent Use Of Non-vitamin K Antagonist Oral Anticoagulants

Introduction: An increasing number of patients with acute ischemic stroke (AIS) have recently used non-vitamin K antagonist oral anticoagulants (NOACs). However, there are limited data on safety of endovascular therapy (EVT) in these patients. Methods: We performed a retrospective, observational, cohort study of patients treated with EVT within 6 hours of symptom onset in the American Heart Association’s “Get With The Guideline-Stroke Program” between October 2015 and March 2020 to compare safety and functional outcomes in patients who were or were not taking NOACs in the 7 days prior to stroke. Results: Of 33,355 patients (median age 72 years (60,81); 50.8% female), 3,727 (11.2%) were taking NOACs, and 29,628 (88.8%) were not taking any oral anticoagulants (OAC) prior to stroke. Compared with those not on OAC, patients taking NOACs were older (median age 75 vs. 71 years) and had a higher prevalence of comorbidities including cardiovascular risk factors, although stroke severity was similar between the groups (median NIHSS 18 vs. 17). After adjusting for baseline clinical factors including intravenous alteplase, patients taking NOACs were not at a significantly higher risk of sICH compared with patients not taking anticoagulants (4.9% vs 6.4%; aOR, 0.93 [95% CI, 0.75-1.14]) or in-hospital mortality (14.1% vs 13.1%; aOR, 0.90 [95% CI, 0.78-1.02]). Of the secondary discharge outcomes, 3 of 7 showed significant differences in favor of the NOAC group including ambulating independently (33.7% vs 38.7%; aOR, 1.15 [95% CI, 1.02-1.30]) and freedom from disability (modified Rankin Scale [mRS] 0-1, 13.0% vs 16.2%; aOR, 1.23 [95% CI, 1.04-1.46]) at discharge. In a subset of patients with documented time of last NOACs dose (n=213), sICH rate was 3.1% (6/196) with last dose ≤2 days and 0% (0/17) with &gt;2 days. Conclusions: Among patients with acute ischemic stroke treated with EVT within 6 hours, use of NOACs within the preceding 7 days, compared with no use of anticoagulants, was not associated with a significantly increased risk of adverse events and was associated with better functional outcomes at discharge.

Abstract WP153: Tirofiban Increase Symptomatic Intracranial Hemorrhage After Endovascular Therapy In Cardio-embolized Stroke Patients: Insight From Rescue Bt Trial

Introduction: Efficacy and safety of tirofiban in endovascular therapy among cardio-embolized ischemic stroke patients remains controversial. We aimed to assess effects of tirofiban before endovascular therapy in cardio-embolized stroke patients. Methods: This is a post hoc analysis of Endovascular Treatment With vs Without Tirofiban for Patients with Large Vessel Occlusion Stroke (RESCUE BT) trial. Before endovascular therapy, participants were randomized to tirofiban or placebo group in ratio of 1:1. Tirofiban was administrated as a bolus dose of 10 ug/kg, followed by continuous infusion of 0.15 ug/kg /min for up to 24-hour. We collected cardio-embolized stroke patients according to Trial of Org 10172 in Acute Stroke Treatment classification. The efficacy outcome was global disability at 90-day assed by modified Rankin Scale (mRS). The primary safety outcome was symptomatic intracranial hemorrhage (sICH) assessed by Heidelberg bleeding classification within 48-hour. Secondary safety outcome was any radiologic intracranial hemorrhage and death at 90-day. Results: 406 cardio-embolized stroke patients were collected. Tirofiban did not correlated to favorable shift to lower 90-day mRS (adjusted odds ratio [aOR], 0.91; 95% CI, 0.64-1.3; P = 0.617). However, tirofiban subgroup had a significantly higher risk of sICH within 48-hour (aOR, 3.26; 95% CI, 1.4-7.57; P = 0.006) compared with placebo group. The aOR was 1.44 (95% CI, 0.94-2.19; P = 0.094) for any intracranial hemorrhage and 1.48 (95% CI, 0.88-2.52; P = 0.143) for death at 90-day. Conclusions: Tirofiban increased symptomatic intracranial hemorrhage after endovascular therapy in cardio-embolized stroke patients. Figure 1 . Outcomes of endovascular therapy in cardio-embolic stroke participants in tirofiban vs placebo group.

Risk factors and predictors of intracranial hemorrhage after mechanical thrombectomy in acute ischemic stroke: insights from the Stroke Thrombectomy and Aneurysm Registry (STAR)

BackgroundReducing intracranial hemorrhage (ICH) can improve patient outcome in acute ischemic stroke (AIS) intervention. We sought to identify ICH risk factors after AIS thrombectomy.MethodsThis is a retrospective review of the...

Endovascular Treatment of Basilar Artery Occlusion: What Can We Learn from the Results?

Background and Objectives: Current guidelines lack specific endovascular treatment (EVT) recommendations for posterior circulation stroke (PCS). The results of earlier studies are controversial. We aimed to compare early hospital outcomes of stroke caused by large-vessel occlusion (LVO) treated with EVT or bridging therapy (BT) in anterior circulation stroke (ACS) versus PCS (middle cerebral artery occlusion (MCAO) and basilar artery occlusion (BAO), and establish the risk factors for poor outcome. Materials and Methods: we analyzed the data of 279 subjects treated with EVT due to LVO-caused stroke in a comprehensive stroke centre in 2015−2021. The primary outcome was hospital mortality, secondary outcomes were National Institutes of Health Stroke Scale (NIHSS) after 24 h, early neurological deterioration, futile recanalization (FR), the ambulatory outcome at discharge, and complications. Results: BAO presented with higher baseline NIHSS scores (19 vs. 14, p < 0.001), and longer door-to-puncture time (93 vs. 82 min, p = 0.034), compared to MCAO. Hospital mortality and the percentage of FR were the same in BAO and almost two times higher than in MCAO (20.0% vs. 10.3%, p = 0.048), other outcomes did not differ. In BAO, unsuccessful recanalization was the only significant predictor of the lethal outcome, though there were trends for PAD and RF predicting lethal outcome. A trend for higher risk of symptomatic intracranial hemorrhage (sICH) was observed in the BAO group when BT was applied. Nevertheless, neither BT nor sICH predicted lethal outcomes in the BAO group. Conclusions: Compared to the modern gold standard of EVT in the ACS, early outcomes in BAO remain poor, there is a substantial amount of FR. Nevertheless, unsuccessful recanalization remains the strongest predictor of lethal outcomes. BT in PCS might pose a higher risk for sICH, but not the lethal outcome, although this finding requires further investigation in larger trials.

Tirofiban for Acute Ischemic Stroke Patients Receiving Intravenous Thrombolysis: A Systematic Review and Meta-Analysis

Introduction: Tirofiban has been used as a rescue when thrombectomy is not successful in endovascular therapy (EVT) for acute ischemic stroke (AIS), but the use of tirofiban after intravenous thrombolysis (IVT) is controversial. The purpose of this meta-analysis was to evaluate the safety and efficacy of tirofiban combined with IVT in AIS compared with not receiving tirofiban. Methods: The PubMed and Embase databases were searched for all relevant studies published up to August 31, 2021. The safety endpoints included symptomatic intracranial hemorrhage (sICH), any intracranial hemorrhage (ICH), and mortality. The efficacy endpoint was the modified Rankin Scale (mRS) score at the 3-month follow-up. Results: Seven articles (1,036 patients) were included. Of these, 444 patients received tirofiban, and 592 patients did not. Meta-analysis showed that tirofiban did not increase the risk of sICH (OR 0.98; 95% CI 0.50–1.93; p = 0.96), any ICH (OR 0.94; 95% CI 0.63–1.39; p = 0.75) or mortality (OR 0.67; 95% CI 0.39–1.15; p = 0.15) and tended to be associated with a favorable functional outcome (OR 1.33; 95% CI 0.99–1.78; p = 0.06) in patients with AIS. Subgroup analysis showed that bridging therapy combined with tirofiban could reduce mortality (OR 0.47; 95% CI 0.23–0.98; p = 0.04). Tirofiban significantly improved the favorable functional outcome in patients with IVT only (non-EVT) (OR 1.98; 95% CI 1.30–3.02; p = 0.002). Conclusion: Intravenous tirofiban could be safe for patients with AIS undergoing IVT, regardless of receiving EVT. Intravenous tirofiban may reduce mortality rates for patients undergoing bridging therapy. It also could increase the likelihood of a favorable functional outcome, especially for patients receiving IVT only.

Efficacy of endovascular therapy for basilar and vertebral artery occlusion: A systematic review and meta-analysis of randomized controlled trials

BackgroundThe best management for acute basilar artery occlusion (BAO) has increasingly been clarified by recent randomized controlled trials (RCTs). We conducted a systematic review and meta-analysis of RCTs comparing endovascular therapy (EVT) vs best medical management (BMM). MethodsWe searched PubMed, Embase, the CENTRAL, and ClinicalTrials.gov from January 1, 2000, to November 20, 2022. We included RCTs comparing EVT vs BMM in BAO or bilateral vertebral artery occlusion (VAO). Primary outcome was ambulation (modified Rankin Scale score [mRS] 0–3) at 90 days. Secondary outcomes were independence (mRS 0–2) at 90 days, death by 90 days, and symptomatic intracranial hemorrhage (sICH). Risk ratio (RR) with 95% CI was used as a measure of the association of EVT vs BMM with outcomes. ResultsFinal analyses included 4 RCTs with 988 patients with BAO or VAO. Pooled results showed that EVT vs BMM was associated with an increased rate of 90-day ambulation (RR 1.54, 95% CI 1.16–2.05), independence (RR 1.83, 1.08–3.08) and a reduced risk of mortality (RR 0.76, 0.65–0.89), but an increased risk of sICH (RR 7.48, 2.27–24.62) and the benefits might be confined to patients with BAO but not patients with VAO. EVT effect was modified by occlusion location with the basilar artery, with greatest benefit for proximal, intermediate benefit for middle, and least benefit for distal occlusions. ConclusionEVT compared with BMM might be associated with an increased rate of ambulation, independence and survival but with an increased risk of sICH in patients with acute BAO.

Acidosis in arterial blood gas testing is associated with clinical outcomes after endovascular thrombectomy.

Despite recanalization, some of the patients undergoing endovascular thrombectomy (EVT) still suffer from unfavorable outcomes. Patients with poor prognoses are often accompanied by acidosis in arterial blood gas (ABG) testing. We, therefore, explored the ABG testing results in the early phase of recanalization and analyzed their association with poor prognosis. We identified all patients with ischemic stroke and successful endovascular recanalization for anterior circulation vessel occlusion between June 2019 and May 2022. ABG testing was performed in all patients within 0-30 min and 8 h after endovascular therapy. We investigated the relationship between the ABG testing results with symptomatic intracerebral hemorrhage (sICH), hemicraniectomy, and mortality. A total of 123 patients with stroke after endovascular thrombectomy were analyzed. Of those, eight (6.5%) patients had postinterventional sICH. Acidosis was associated with sICH. Decreased levels and levels at 8 h after EVT were independently related to a higher risk of sICH. Twelve (9.8%) patients underwent hemicraniectomy for postischemic malignant edema and similar results were found for hemicraniectomy. Increased lactate at 8 h after EVT and decreased levels at 8 h after EVT were closely associated with hemicraniectomy. Twenty-two (17.9%) patients died within 3 months. Decreased levels were independently related to mortality, as were decreased pH levels at 8 h after EVT and decreased levels at 8 h after EVT. Acidosis is associated with clinical outcomes after endovascular therapy and may help to select patients with poor prognosis in the acute early phase of recanalization.

Predictors of Symptomatic Intracranial Hemorrhage after Endovascular Thrombectomy in Acute Ischemic Stroke Patients with Anterior Large Vessel Occlusion-Procedure Time and Reperfusion Quality Determine.

We aimed to evaluate predictors of symptomatic intracranial hemorrhage (sICH) in acute ischemic stroke (AIS) patients following thrombectomy due to anterior large vessel occlusion (LVO). Data on stroke patients from January 2018 to December 2020 in a tertiary care centre were retrospectively analysed. sICH was defined as intracranial hemorrhage associated with a deterioration of at least four points in the National Institutes of Health Stroke Scale (NIHSS) score or hemorrhage leading to death. A smoothed ridge regression model was run to analyse the impact of 15 variables on their association with sICH. Of the 174 patients (median age 77, 41.4% male), sICH was present in 18 patients. Short procedure time from groin puncture to reperfusion (per 10 min OR 1.24; 95% CI 1.071-1.435; p = 0.004) and complete reperfusion (TICI 3) (OR 0.035; 95% CI 0.003-0.378; p = 0.005) were significantly associated with a lower risk of sICH. On the contrary, successful reperfusion (TICI 3 and TICI 2b) was not associated with a lower risk of sICH (OR 0.508; 95% CI 0.131-1.975, p = 0.325). Neither the total time from symptom onset to reperfusion nor the intravenous thrombolysis was a predictor of sICH (per 10 min OR 1.0; 95% CI 0.998-1.001, p = 0.745) (OR 1.305; 95% CI 0.338-5.041, p = 0.697). Our findings addressed the paramount importance of short procedure time and complete reperfusion to minimize sICH risk. The total ischemic time from onset to reperfusion was not a predictor of sICH.

Imaging mismatch between Alberta Stroke Program Early CT Score and perfusion imaging may be a good variable for endovascular treatment.

Some patients with acute large vessel occlusion (LVO) presented imaging mismatch, low Alberta Stroke Program Early CT Score (ASPECTS) with small ischemic core, or high ASPECTS with large ischemic core. The study was designed to explore whether patients with imaging mismatch could benefit from endovascular treatment (EVT). We retrospectively reviewed patients with LVO treated with EVT in our center from March 2018 to Jul 2020. Patients were divided into three groups, imaging mismatch, small ischemic core, and large ischemic core groups. Pooled analyses based on stroke onset to treatment time were done. Multivariate regression analysis was performed to explore the factors for good outcomes. Sixty-eight of 419 patients with LVO presented with imaging mismatch, and 35 of those (51%) achieved good outcomes after EVT at 90-day. No significant differences were noted in good outcomes and symptomatic intracranial hemorrhage (sICH) between patients with imaging mismatch and small ischemic core. Compared with large ischemic core, patients with imaging mismatch presented lower risk of sICH (95% confidence interval (CI) 0.04-0.75, p = 0.011) within 6 h and higher proportion of good outcomes (95% CI 0.37-0.82, p = 0.002) at 6 to 24 h. Baseline NIHSS (odds ratio (OR) = 0.91, 95% CI 0.88-0.95)), ASPECTS (OR = 1.14, 95% CI 1.01-1.29), ischemic core (OR = 0.99, 95% CI 0.98-1.00), and sICH (OR = 61.61, 95% CI 8.09-461.32) were associated with good outcomes. Patients with imaging mismatch treated within 24 h could benefit from EVT and without increasing the risk of sICH. • Patients with imaging mismatch between ASPECTS and ischemic core could achieve good outcomes after endovascular treatment. • Compared with large ischemic core, patients with imaging mismatch presented lower risk of symptomatic hemorrhage within 6 h and higher proportion of good outcomes within 6-24 h. • Baseline NIHSS score, ASPECTS, ischemic core, and symptomatic intracranial hemorrhage were associated with good outcomes.