Rate Of sICH Research Articles

Stroke with large vessel occlusion in the posterior circulation: IV thrombolysis plus thrombectomy versus IV thrombolysis alone.

Efficacy and safety of mechanical thrombectomy (MT) for stroke with posterior circulation large vessel occlusion (LVO) is still under debate. We aimed to compare the outcomes of stroke patients with posterior circulation LVO treated with intravenous thrombolysis (IVT) (< 4.5h after symptom onset) plus MT < 6h after symptom onset with those treated with IVT alone (< 4.5h after symptom onset). Patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) and in the Italian centers included in the SITS-ISTR were analysed. We identified 409 IRETAS patients treated with IVT plus MT and 384 SITS-ISTR patients treated with IVT alone. IVT plus MT was significantly associated with higher rate of sICH (ECASS II) compared with IVT alone (3.1 vs 1.9%; OR 3.984, 95% CI 1.014-15.815), while the two treatments did not differ significantly in 3-month mRS score ≤ 3 (64.3 vs 74.1%; OR 0.829, 95% CI 0.524-1.311). In 389 patients with isolated basilar artery (BA) occlusion, IVT plus MT was significantly associated with higher rate of any ICH compared with IVT alone (9.4 vs 7.4%; OR 4.131, 95% CI 1.215-14.040), while two treatments did not differ significantly in 3-month mRS score ≤ 3 and sICH per ECASS II definition. IVT plus MT was significantly associated with higher rate mRS score ≤ 2 (69.1 vs 52.1%; OR 2.692, 95% CI 1.064-6.811) and lower rate of death (13.8 vs 27.1%; OR 0.299, 95% CI 0.095-0.942) in patients with distal-segment BA occlusion, while two treatments did not differ significantly in 3-month mRS score ≤ 3 and sICH per ECASS II definition. IVT plus MT was significantly associated with lower rate of mRS score ≤ 3 (37.1 vs 53.3%; OR 0.137, 0.009-0.987), mRS score ≤ 1 (22.9 vs 53.3%; OR 0.066, 95% CI 0.006-0.764), mRS score ≤ 2 (34.3 vs 53.3%; OR 0.102, 95% CI 0.011-0.935), and higher rate of death (51.4 vs 40%; OR 16.244, 1.395-89.209) in patients with proximal-segment BA occlusion. Compared with IVT alone, IVT plus MT was significantly associated with higher rate of sICH per ECASS II definition in patients with stroke and posterior circulation LVO, while two treatment groups did not differ significantly in 3-month mRS score ≤ 3. IVT plus MT was associated with lower rate of mRS score ≤ 3 compared with IVT alone in patients with proximal-segment BA occlusion, whereas no significant difference was found between the two treatments in primary endpoints in patients isolated BA occlusion and in the other subgroups based on site occlusion.

Safety and efficacy of intravenous thrombolysis in patients with acute ischemic stroke taking direct oral anticoagulants prior to stroke: a meta-analysis.

To assess the safety and efficacy of intravenous thrombolysis (IVT) in patients with acute ischemic stroke (AIS) taking direct oral anticoagulants (DOACs) prior to stroke. Literature was searched in PubMed, Cochrane Library, and Embase until March 13, 2023. The primary outcome was symptomatic intracranial hemorrhage (sICH). Secondary outcomes included excellent outcome (modified Rankin Scale [mRS] 0-1), functional independence (mRS 0-2), and mortality. Odds ratios (OR) with 95% confidence intervals (CI) were estimated using a random-effects model. Five non-randomized studies included 239,879 patients with AIS treated with IVT, with 3400 (1.42%) taking DOACs prior to stroke. The rates of sICH did not differ statistically between patients taking DOACs and those not taking anticoagulants (unadjusted OR 0.98; 95% CI 0.67-1.44; P = 0.92; adjusted OR 0.81; 95% CI 0.64-1.03; P = 0.09). Patients taking DOACs had significantly higher adjusted rates of excellent outcome (adjusted OR 1.22; 95% CI 1.06-1.40; P < 0.01) and functional independence (adjusted OR 1.25; 95% CI 1.10-1.42; P < 0.01) at discharge than those not taking anticoagulants. No significant difference was observed in mortality and other efficacy outcomes between groups after adjustment. The meta-analysis indicated that taking DOACs prior to stroke does not significantly increase the risk of sICH in selected patients with AIS treated with IVT. Furthermore, the benefits of IVT in selected patients taking DOACs appear to be comparable to those not taking anticoagulants. Further research is warranted to confirm the findings.

Systemic THrombolysis Randomization IN Endovascular Stroke Therapy (SHRINE) Collaboration: a patient-level pooled analysis of the SKIP and DEVT Trials

ObjectiveTo evaluate the non-inferiority of endovascular treatment (EVT) alone versus intravenous thrombolysis (IVT) followed by EVT and to assess its heterogeneity across prespecified subgroups.MethodsWe pooled data from two trials (SKIP...

Effects of intravenous thrombolysis on stent retriever and aspiration thrombectomy outcomes: a systematic review and meta-analysis of the randomized controlled trials

BackgroundRisks and benefits of intravenous thrombolysis (IVT) in patients undergoing mechanical thrombectomy (MT) have been a topic of interest. However, IVT’s specific effects on stent retriever (SR) and aspiration thrombectomy...

Safety of Mechanical Thrombectomy in Patients on Antiplatelet/Anticoagulation

Mechanical thrombectomy (MT) is performed in patients who are already on anticoagulation (AC)/antiplatelet therapy (AP). However, data are insufficient regarding MT's safety and efficacy profiles in these patients. Investigate the outcome of stroke patients already on anticoagulation/antiplatelet receiving MT. We included consecutive acute ischemic stroke patients treated with MT for 10years (2012-2022) in a comprehensive stroke center. Baseline variables, efficacy (recanalization [Thrombolysis in Cerebral Infraction]≥2b), good functional outcome (modified Ranking Scale ≤ 2 at 3months), and safety (symptomatic intracranial hemorrhage [sICH], mortality rates) were evaluated. Additionally, we conducted a subgroup analysis of patients with prior single-AP versus DAPT. Six hundred forty-six patients were included (54.5% women, median age 71years), 84 (13%) were on AC, 196 (30.3%) on AP, and 366 (56.7%) in the control group. The AC and AP groups were older and had more comorbidities. sICH occurred in 7.3% of cases. There was no significant difference in sICH incidence across the groups. The AC group had a lower rate of intravenous thrombolysis (15.9%; P < 0.001), a higher rate of sICH (11.9% vs. AP 7.7% and control 6%; P= 0.172), and higher mortality at discharge (17.9% vs. AP 8.7% and control 10.4%; P= 0.07). However, the groups had similar functional outcomes and mortality rates at 3months. Successful recanalization was achieved in 92.7% and was similar across groups. Multivariable logistic regression and the subgroup analysis (single-AP vs. dual AP) did not reveal statistically significant associations. MT in patients with prior anticoagulation and AP presenting with acute ischemic strokeis feasible, effective, and safe.

Endovascular Versus Medical Management of Posterior Cerebral Artery Occlusion Stroke: The PLATO Study.

The optimal management of patients with isolated posterior cerebral artery occlusion is uncertain. We compared clinical outcomes for endovascular therapy (EVT) versus medical management (MM) in patients with isolated posterior cerebral artery occlusion. This multinational case-control study conducted at 27 sites in Europe and North America included consecutive patients with isolated posterior cerebral artery occlusion presenting within 24 hours of time last well from January 2015 to August 2022. Patients treated with EVT or MM were compared with multivariable logistic regression and inverse probability of treatment weighting. The coprimary outcomes were the 90-day modified Rankin Scale ordinal shift and ≥2-point decrease in the National Institutes of Health Stroke Scale. Of 1023 patients, 589 (57.6%) were male with median (interquartile range) age of 74 (64-82) years. The median (interquartile range) National Institutes of Health Stroke Scale was 6 (3-10). The occlusion segments were P1 (41.2%), P2 (49.2%), and P3 (7.1%). Overall, intravenous thrombolysis was administered in 43% and EVT in 37%. There was no difference between the EVT and MM groups in the 90-day modified Rankin Scale shift (aOR, 1.13 [95% CI, 0.85-1.50]; P=0.41). There were higher odds of a decrease in the National Institutes of Health Stroke Scale by ≥2 points with EVT (aOR, 1.84 [95% CI, 1.35-2.52]; P=0.0001). Compared with MM, EVT was associated with a higher likelihood of excellent outcome (aOR, 1.50 [95% CI, 1.07-2.09]; P=0.018), complete vision recovery, and similar rates of functional independence (modified Rankin Scale score, 0-2), despite a higher rate of SICH and mortality (symptomatic intracranial hemorrhage, 6.2% versus 1.7%; P=0.0001; mortality, 10.1% versus 5.0%; P=0.002). In patients with isolated posterior cerebral artery occlusion, EVT was associated with similar odds of disability by ordinal modified Rankin Scale, higher odds of early National Institutes of Health stroke scale improvement, and complete vision recovery compared with MM. There was a higher likelihood of excellent outcome in the EVT group despite a higher rate of symptomatic intracranial hemorrhage and mortality. Continued enrollment into ongoing distal vessel occlusion randomized trials is warranted.

The proximal balloon occlusion together with direct thrombus aspiration (protect plus) technique: Experience at a tertiary comprehensive stroke center.

Timely restoration of cerebral blood flow using reperfusion therapy is the most effective maneuver for salvaging penumbra. We re-evaluated the previously described PROTECT (PRoximal balloon Occlusion TogEther with direCt Thrombus aspiration during stent retriever thrombectomy) Plus technique at a tertiary comprehensive stroke center. We retrospectively analyzed all patients who underwent mechanical thrombectomy with stentrievers between May 2011 and April 2020. Patients were divided between those who underwent PROTECT Plus and those who did not (proximal balloon occlusion with stent retriever only). We compared the groups in terms of reperfusion, groin to reperfusion time, symptomatic intracranial hemorrhage (sICH), modified Rankin Scale (mRS) score at discharge. Within the study period, 167 (71.4%) PROTECT Plus and 67 (28.6%) non-PROTECT patients which met our inclusion criteria. There was no statistically significant difference in the number of patients with successful reperfusion (mTICI >2b) between the techniques (85.0% vs 82.1%; p = 0.58). The PROTECT Plus group had lower rates of mRS ≤2 at discharge (40.1% vs 57.6%; p = 0.016). The rate of sICH was comparable (p = 0.35) between the PROTECT Plus group (7.2%) and the non-PROTECT group (3.0%). The PROTECT Plus technique using a BGC, a distal reperfusion catheter and stent retriever is feasible for recanalization of large vessel occlusions. Successful recanalization, first-pass recanalization and complication rates are similar between PROTECT Plus and non-PROTECT stent retriever techniques. This study adds to an existing body of literature detailing techniques that use both a stent retriever and a distal reperfusion catheter to maximize recanalization for patients with large vessel occlusions.

Low-dose vs. standard-dose intravenous alteplase for acute ischemic stroke with unknown time of onset.

Standard-dose intravenous alteplase for acute ischemic stroke (AIS) in the unknown or extended time window beyond 4.5 h after symptom onset is both effective and safe for certain patients who were selected based on multimodal neuroimaging. However, uncertainty exists regarding the potential benefit of using low-dose alteplase among the Asian population outside the 4.5-h time window. Consecutive AIS patients who received intravenous alteplase between 4.5 and 9 h after symptom onset or with an unknown time of onset guided by multimodal computed tomography (CT) imaging were identified from our prospectively maintained database. The primary outcome was excellent functional recovery, defined as having a modified Rankin scale (mRS) score of 0-1 at 90 days. Secondary outcomes included functional independence (an mRS score of 0-2 at 90 days), early major neurologic improvement (ENI), early neurologic deterioration (END), any intracranial hemorrhage (ICH), symptomatic ICH (sICH), and 90-day mortality. Propensity score matching (PSM) and multivariable logistic regression models were used to adjust for confounding factors and compare the clinical outcomes between the low- and standard-dose groups. From June 2019 to June 2022, a total of 206 patients were included in the final analysis, of which 143 were treated with low-dose alteplase and 63 were treated with standard-dose alteplase. After accounting for confounding factors, we observed that there were no statistically significant differences between the standard- and low-dose groups with respect to excellent functional recovery [adjusted odds ratio = 1.22 (aOR), 95% confidence interval (CI): 0.62-2.39; adjusted rate difference (aRD) = 4.6%, and 95% CI: -11.2 to 20.3%]. Patients of both groups had similar rates of functional independence, ENI, END, any ICH, sICH, and 90-day mortality. In the subgroup analysis, patients aged ≥70 years were more likely to achieve excellent functional recovery when receiving standard-dose rather than low-dose alteplase. The effectiveness of low-dose alteplase might be comparable to that of standard-dose alteplase in AIS patients aged <70 years with favorable perfusion-imaging profiles in the unknown or extended time window but not in those aged ≥70 years. Furthermore, low-dose alteplase did not significantly reduce the risk of sICH compared to standard-dose alteplase.

Outcomes in patients with acute stroke treated at a comprehensive stroke center using telemedicine versus in-person assessments.

Telemedicine has been shown to be a safe and effective modality to assess and treat patients with acute stroke who present to a community hospital. There are no previous reports on using telemedicine to treat patients with acute stroke who present to a comprehensive stroke center. We report here the outcomes of patients with acute stroke treated in 2021 at our comprehensive stroke center using telemedicine versus an in-person assessment. Patients with acute ischemic stroke who were treated after either a telemedicine or in-person assessment at our hospital in 2021 were identified by a retrospective chart review. The primary outcomes collected were door-to-needle (DTN) time for alteplase (tPA) administration, door-to-puncture (DTP) time for endovascular thrombectomy, symptomatic intracranial hemorrhage (sICH) rates and 3-month mortality. There were 302 patients with acute stroke treated at our hospital in 2021. Of these, 18.2% (n = 55/302) were treated using telemedicine. There were no differences in any of the outcomes between patients treated using telemedicine versus an in-person assessment: DTN (35.5 min (n = 42) vs 33 min (n = 182), p < 0.76), DTP (86.5 min (n = 30) vs 85 min (n = 134), p < 0.97), sICH (0% (n = 0/55) vs 1.6% (n = 4/245, p < 0.59) or 3-month mortality (20.6% (n = 7/34) vs 22.1% (n = 40/181), p < 0.29). To the best of our knowledge, this is the first study to report on outcomes for acute stroke patients treated using telemedicine at a comprehensive stroke center. In this study, there were no differences in outcomes between patients treated using telemedicine versus an in-person assessment.

Endovascular Thrombectomy Beyond 24 Hours from Stroke Onset: A Systematic Review and Meta-Analysis (S24.001)

<h3>Objective:</h3> To assess the safety and efficacy of endovascular thrombectomy (EVT) &gt;24-h and compare clinical outcomes with patients treated &lt;24-h. <h3>Background:</h3> Trials have demonstrated the benefit of EVT up to 24-hours after acute ischemic stroke (AIS) onset. Recently, real-world observational studies reported that EVT was effective and safe beyond 24-h from AIS onset with comparable outcomes to EVT within 24-h. <h3>Design/Methods:</h3> A systematic search was performed in MEDLINE and EMBASE for studies published from inception to July 2022. Studies including patients with AIS who received EVT beyond 24-h from stroke onset were selected. We also included patients treated with EVT (&gt;24-h and &lt;24-h) from our institutional retrospective data. Outcomes of interest included functional independence (90-day mRS 0–2), successful recanalization (mTICI 2b-3), symptomatic intracerebral hemorrhage (sICH), and all-cause mortality at 90 days. First, a single-arm meta-analysis (MA) of proportions was conducted for studies with EVT &gt;24-h. Then, we performed a comparative MA between the &lt;24-h and &gt;24-h groups to calculate pooled odds ratios (OR) for each outcome. Statistical heterogeneity across studies was assessed with I² statistics. <h3>Results:</h3> Five studies with 298 patients treated &gt;24-h were included. Functional independence rate was 39% (95%CI 27–54%; I²=68%) and successful recanalization rate was 79% (95%CI 75–83%; I²=0%). Mortality and sICH rates were 25% (95%CI 20–30%; I²=0%) and 6% (95%CI 4–9%; I²=0%), respectively. We included 3272 patients (&gt;24-h = 179; &lt;24-h = 3093) in the comparative analysis. There was no significant difference in functional independence (OR 0.76; 95%CI 0.41–1.32), successful recanalization (OR 0.6; 95%CI 0.44–1.0), and mortality (OR 1.18; 95%CI 0.7–1.9) rates between patients who underwent EVT &lt;24-h versus &gt;24-h. <h3>Conclusions:</h3> Our findings prove that EVT beyond 24-h is safe and effective. Also, this MA did not demonstrate a significant difference between EVT beyond and within 24-h from stroke onset regarding functional independence, successful recanalization, and mortality. <b>Disclosure:</b> Dr. Rodriguez-Calienes has nothing to disclose. Mr. Vivanco-Suarez has nothing to disclose. Dr. Galecio-Castillo has nothing to disclose. Cynthia Zevallos has nothing to disclose. Mr. Malaga has nothing to disclose. Dr. Farooqui has nothing to disclose. Dr. Ortega Gutierrez has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for stryker. Dr. Ortega Gutierrez has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for medtronic. Dr. Ortega Gutierrez has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for microvention. Dr. Ortega Gutierrez has received personal compensation in the range of $0-$499 for serving as an officer or member of the Board of Directors for SVIN. The institution of Dr. Ortega Gutierrez has received research support from stryker. The institution of Dr. Ortega Gutierrez has received research support from Siemens. The institution of Dr. Ortega Gutierrez has received research support from IschemiaView. The institution of Dr. Ortega Gutierrez has received research support from Medtronic.

Acute Basilar Artery Occlusion Thrombectomy Performed in Early (&lt;6 hours) and Late Time Window (&gt;6 hours) from the PC-SEARCH Registry (S24.002)

Acute Basilar Artery Occlusion Thrombectomy Performed in Early (&lt;6 hours) and Late Time Window (&gt;6 hours) from the PC-SEARCH Registry (S24.002)

A propensity score-matched comparative study of balloon guide catheters versus conventional guide catheters for concurrent mechanical thrombectomy with carotid stenting in tandem strokes: comparison of first pass effect, symptomatic intracranial hemorrhage, and 90-day functional outcomes

BackgroundExtensive clot burden in tandem strokes accounts for poor mechanical thrombectomy (MT) outcomes. Several studies have shown the benefit of balloon guide catheters (BGCs) in MT and carotid artery stenting.ObjectiveIn...

The relationship between antiplatelet therapies and the outcome of endovascular treatment for acute ischemic stroke

PurposeWe conducted this study to investigate the safety and efficacy of antiplatelet therapies (APT) for acute ischemic patients received endovascular treatment (EVT). MethodsThe population of our study was derived from a nationwide multicentered registry conducted by 111 centers in China. Patients were divided to groups of no APT, single APT (SAPT) or dual APT (DAPT) according to the APT received at 24 h after EVT. The primary outcome was 90-day functional independence, and the safety outcomes included the symptomatic intracranial hemorrhage (sICH), any type of intracranial hemorrhage, and all-caused death within 90 days. Patient characteristics, procedural data, and outcomes were analyzed. ResultsA total of 1679 patients were included in this study, 71.42% of whom received oral APT at 24 h after EVT, and the initial time was 20.53(13.94–27.17) hours after recanalization or the end of procedure. 90-day functional independence was significantly more observed in patients with DAPT (54.02% vs. 33.64%; adjusted odds ratio [OR] 1.940, 95% CI 1.444–2.606), but not in SAPT (40.75% vs. 33.64%; adjusted OR 1.280, 95% CI 0.907–1.804) compared with patients without APT. APT increased the risk of sICH (1.14% vs. 0, p = 0.036). Both the application of DAPT (adjusted OR 0.264, 95% CI 0.178–0.392, p < 0.001) and SAPT (adjusted OR 0.341, 95% CI 0.213–0.545, p < 0.001) could reduce the 90-day mortality. ConclusionsIn this uncontrolled series of patients APT at 24 h after EVT showed improvement of the patients' functional independence and reduction of mortality, even though the rate of sICH was increased, especially in the DAPT-group.

Outcome after endovascular treatment for acute ischemic stroke by underlying etiology: Tertiary experience and meta-analysis.

To investigate the effect of two major etiologies [intracranial atherosclerotic stenosis (ICAS) and cardioembolism (CE])] on outcomes of acute ischemic stroke (AIS) patients due to large vessel occlusion (LVO) after endovascular thrombectomy (EVT). Anterior circulation AIS patients receiving EVT were retrospectively analyzed. Clinical and laboratory data were collected. Clinical outcomes including favorable outcome (90-day modified Rankin Scale 0-2), mortality, intracranial hemorrhage (ICH) and symptomatic ICH (sICH) were compared. A systematic review and meta-analysis was also performed. A total of 302 AIS patients were included and divided into the ICAS group (86 patients) and the CE group (216 patients). Patients in the ICAS group were younger (62[18.0] vs. 68[19.0] years, p < 0.001), more likely to have smoking (52.3% vs. 26.9%, p < 0.001) and drinking (52.3% vs. 23.1%, p < 0.001) history, and more frequently required rescue therapy (80.2% vs. 4.6%, p < 0.001) compared to the CE group. However, favorable outcome (aOR 0.722, 95%CI 0.372-1.402, p = 0.336) and mortality (aOR 1.522, 95%CI 0.606-3.831, p = 0.371) were not significantly different between the two groups before and after adjustment. The incidence of sICH and ICH were comparable between the two groups before and after adjustment. Systematic review and meta-analysis consisted of 8 eligible studies (7 previous studies and this current study), incorporating 552 ICAS patients and 1,402 CE patients. Favorable outcome was slightly more likely in the ICAS group compared to the CE group (54.2% vs. 46.3%, OR 1.40, 95%CI 1.00-1.96, I 2 = 53.2%). Moreover, the ICAS group had a lower rate of mortality (14.3% vs. 22.2%, OR 0.63, 95%CI 0.46-0.87, I 2 = 0.0%) and ICH (19.5% vs. 31.9%, OR 0.60, 95%CI 0.42-0.84, I 2 = 0.0%) than the CE group, while the two groups were similar in sICH rate (5.9% vs. 6.7%, OR 0.94, 95%CI 0.55-1.60, I 2 = 6.3%). Etiology was not considered as an important factor in functional outcome, despite the differences in baseline characteristics and technical EVT approach. The current study of anterior circulation AIS-LVO patients supports that outcomes for those with ICAS are not significantly different from those with CE.

Differences between males and females following endovascular therapy for stroke: A systematic review and meta-analysis

BackgroundEndovascular therapy (EVT) represents the standard of care for eligible patients with acute ischemic stroke (AIS) and large vessel occlusion. To better understand differences in baseline characteristics and outcomes between males and females following EVT, we conducted a systematic review and meta-analysis. MethodsWe identified, using the Nested Knowledge AutoLit platform, prospective studies that reported 90-day outcomes in males and females treated with EVT for AIS. The primary outcome of interest was 90-day modified Rankin Scale (mRS) 0-2. Secondary outcome variables included mRS 0-1, symptomatic intracranial hemorrhage (sICH), thrombolysis in cerebral infarction (TICI) score 2b-3, and mortality. Using R software version 4.1.2, we calculated pooled odds ratios (ORs) and their corresponding 95% confidence intervals (CI). ResultsWe included 10 studies with 10,209 patients. There was no difference between males and females in rate of mRS 0-2 (OR= 1.16; 95% CI= 0.87-1.56; P-value= 0.316); however, after removing outliers, males had higher rates of mRS 0-2 (OR= 1.40; 95% CI= 1.19-1.66; P-value< 0.001). Similar results were reported for mRS 0-1 (OR= 1.21; 95% CI= 0.93-1.56; P-value= 0.15), after removing outliers (OR= 1.32; 95% CI= 1.17-1.50; P-value< 0.001). There was no difference between males and females in rate of sICH (OR= 0.89; 95% CI= 0.74-1.08; P-value= 0.246), mortality (OR= 0.88; 95% CI= 0.74-1.05; P-value= 0.15), or TICI 2b-3 (OR= 1.19; 95% CI= 0.85-1.67; P-value= 0.309). ConclusionsMales tend to experience better outcomes following EVT for AIS, even in the setting of similar reperfusion. The mechanisms underlying this phenomenon remain unclear, and further research is warranted. EVT remains a safe and effective option for both males and females with AIS.

558 Use Of Balloon-Guide Catheters For Concomitant Mechanical Thrombectomy And Carotid Revascularization With Flow-Arrest Results In Significantly Lower sICH And Better 90-Day Outcomes In Tandem Stroke Patients: A Propensity Score-Matched Study

INTRODUCTION: A larger than normal clot burden accounts for worse presentation and poorer thrombectomy outcomes in tandem stroke cases. METHODS: A prospectively maintained database was retrospectively searched for patients who presented with a tandem stroke. Patients were dichotomized into two groups; those treated with BGCs and those treated without BGCs. A one-to-one matched propensity score analysis was performed to adjust for treatment selection bias using the nearest-neighbor matching technique for covariates (baseline comorbidities and stroke severity). Patient demographics, presentation characteristics, and procedural details were recorded. Outcomes were assessed as periprocedural sICH, in-hospital mortality, and 90-day mRS. Mann-whitney U test, and multivariate logistic regression was performed to compare the procedural parameters and the clinical outcomes between groups. RESULTS: We included 125 patients (BGC: 85 [40 after PSM]; No BGC: 40 [40 after PSM]). Concomitant carotid revascularization (stenting or angioplasty) was performed in all cases. After PSM, no difference was seen between the two groups in terms of comorbidities, and initial stroke severity. BGC group had significantly lower procedure duration (61.5% vs. 77.9% (OR = 0.996; P = 0.006)), lower NIHSS at discharge (8.0% vs. 11.0% (OR = 0.987; P = 0.042)), and higher odds of good outcomes (mRS 0-2 at 90-day) (52.3% vs. 27.5% (OR = 0.34; P = 0.040)). On multivariate regression analysis, BGC group had significantly higher rate of first-pass effect (mTICI 2B-3) (OR = 0.660, 95% CI = 0.480-0.908;P = 0.013), and a lower periprocedural sICH rate (OR = 0.615, 95% CI = 0.406-0.932; P = 0.025). No difference in in-hospital mortality was observed (OR = 1.591; 95% CI = 0.976-2.593; P = 0.067). CONCLUSIONS: Use of BGCs for concomitant mechanical thrombectomy and carotid revascularization with flow-arrest is safe and results in superior clinical and angiographic outcomes in tandem stroke patients.

CT Perfusion vs Noncontrast CT for Late Window Stroke Thrombectomy: A Systematic Review and Meta-analysis.

Patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT) in the late window (6-24 hours) can be evaluated with CT perfusion (CTP) or with noncontrast CT (NCCT) only. Whether outcomes differ depending on the type of imaging selection is unknown. We conducted a systematic review and meta-analysis comparing outcomes between CTP and NCCT for EVT selection in the late therapeutic window. This study is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 guidelines. A systematic literature review of the English language literature was conducted using Web of Science, Embase, Scopus, and PubMed databases. Studies focusing on late-window AIS undergoing EVT imaged through CTP and NCCT were included. Data were pooled using a random-effects model. The primary outcome of interest was rate of functional independence, defined as modified Rankin scale 0-2. The secondary outcomes of interest included rates of successful reperfusion, defined as thrombolysis in cerebral infarction 2b-3, mortality, and symptomatic intracranial hemorrhage (sICH). Five studies with 3,384 patients were included in our analysis. There were comparable rates of functional independence (odds ratio [OR] 1.03, 95% CI 0.87-1.22; p = 0.71) and sICH (OR 1.09, 95% CI 0.58-2.04; p = 0.80) between the 2 groups. Patients imaged with CTP had higher rates of successful reperfusion (OR 1.31, 95% CI 1.05-1.64; p = 0.015) and lower rates of mortality (OR 0.79, 95% CI 0.65-0.96; p = 0.017). Although recovery of functional independence after late-window EVT was not more common in patients selected by CTP when compared with patients selected by NCCT only, patients selected by CTP had lower mortality.

Prior anticoagulation and bridging thrombolysis improve outcomes in patients with atrial fibrillation undergoing endovascular thrombectomy for anterior circulation stroke

BackgroundWhere stroke occurs with pre-existing atrial fibrillation (AF)studies validating the safety and efficacy of bridging thrombolysis, and the use of endovascular thrombectomy (EVT) in the setting of prior anticoagulation, are...

Endovascular treatment achieves better outcomes than best medical management in patients with M2 occlusion and high stroke severity: a meta-analysis.

The lack of randomized evidence makes it difficult to establish reliable treatment recommendations for patients with M2 occlusion. This study aims to compare the efficacy and safety of endovascular treatment (EVT) with best medical management (BMM) in patients with M2 occlusion, and to investigate whether the optimal treatment varies according to stroke severity. Comprehensive literature retrieval was conducted to identify studies that directly compared the outcomes of EVT and BMM. According to stroke severity, the study population were classified into those with moderate-severe stroke and those with mild stroke. National Institute of Health Stroke Scale (NIHSS) scores ≥ 6 was defined as moderate-severe stroke, and NIHSS scores 0-5 as mild stroke. Random-effects meta-analyses were performed to measure the symptomatic intracranial hemorrhage (sICH) within 72h, and the modified Rankin Scale (mRS) scores 0-2 and the mortality at 90 days. Totally, 20 studies were identified, including 4358 patients. In the moderate-severe stroke population, the EVT had 82% higher odds for mRS scores 0-2 (OR 1.82, 95% CI 1.34-2.49) and a 43% lower odds for mortality (OR 0.57, 95% CI 0.39-0.82) compared with the BMM. However, no difference was found in the sICH rate (OR 0.88, 95% CI 0.44-1.77). In the mild stroke population, no differences were observed in the mRS scores 0-2 (OR 0.81, 95% CI 0.59-1.10) or mortality (OR 1.23, 95% CI 0.72-2.10) between EVT and BMM, whereas EVT was associated with higher sICH rate (OR 4.21, 95% CI 1.86-9.49). EVT may be only beneficial for patients with M2 occlusion and high stroke severity, but not for those with NIHSS scores 0-5.

Abstract Number ‐ 27: VARIANCE: Variability of Assessed BP Readings In Acute Neuro‐intervention Cases and its Effect on outcomes

Introduction Blood pressure variability (BPV) following endovascular thrombectomy (EVT) in acute ischemic strokes is associated with poor functional outcomes both in the short and long term. Patient variables which may predict high BPV must be examined to improve outcomes. The purpose of this study is to analyze the affect of BPV on outcomes in patients with good recanalization with EVT and examine potential predictors of BPV. Methods We conducted a retrospective analysis of prospectively collected data from an IRB approved Stroke Registry of two academic Comprehensive Stroke Centers in Southern California between 2017 and 2022. Patients were included if they had 1) anterior circulation ischemic stroke due to large vessel occlusions (LVO) and 2) successful EVT with TICI 2b‐3. All BPs were recorded as immediate pre‐op SBP and DBP (one minute prior to procedure start time), immediate post‐op SBP and DBP (at time of recanalization), and 24 hours post revascularization. Variables examined include age, sex, Hispanic ethnicity, initial NIHSS, history of HTN, current antihypertensive use, symptom onset to groin puncture time, door to groin puncture time, and symptomatic ICH (sICH). Outcome was assessed via hospital discharge disposition and modified Rankin Scale at 90 days. Good short‐term outcome was disposition to home or rehab. Good long‐term outcome was mRS of 0–2. BPV was defined by the average real variability (ARV) calculated as the absolute value of the average of the differences between consecutive BP measurements divided by the number of measurements. A correlation matrix was used to identify both continuous and categorical variables with a significant correlation with ARV (p≤0.10). A stepwise logistic regression model for good versus poor outcome was created by including all significant variable from the correlation matrix. A significance level of p≤0.05 was included for all non‐correlational analysis. Results We identified 253 patients (mean age 70±14 years, 51.4% female). 49% were white, 6.3% asian, 5.5% black, 1.6% native Hawaiian pacific islander, and 37.5% are unspecified. 30.4% were Hispanic. The median NIHSS was 17±8. Mean BMI was 27±8. Mean symptom onset to groin puncture time was 478±326 mins. Mean door to groin puncture time was 86±110 mins. 34.8% of patients received tPA (100% of those eligible as our population included patients in the extended window who qualified per DAWN/DEFUSE‐3). 57.2% had cardioembolic etiology. 4.7% had sICH. 58.9% of patients had a good discharge disposition. ARVAB as defined as the average SBP variability as an absolute value was 30.6±25.6. ARVAB was associated with sex, home antihypertensive use, and immediate pre‐op and post‐op SBPs. ARVAB was not associated with age, initial NIHSS, Hispanic ethnicity, HTN, rate of sICH, or short or long term outcome. Conclusions There was a significant correlation with female sex and home use of antihypertensives and higher BPV. These variables can potentially be used as predictors of BPV. BPV was not correlated with discharge disposition or 90 day mRS in our population. While our study did not show a positive correlation between BPV and outcome, our ARVAB was lower than prior populations likely due to more accurate BP monitoring and control.