Stroke Center Research Articles

Lipid-Lowering Therapy Use When Indicated and Subsequent Ischemic Stroke Severity.

Elevated low-density lipoprotein cholesterol is a risk factor for atherosclerotic cardiovascular disease, including acute ischemic stroke (AIS), due to large- and small-vessel disease. Cholesterol management guidelines recommend lipid-lowering therapy (LLT) to prevent atherosclerotic cardiovascular disease events. This study assessed use of LLT at the time of AIS according to guideline recommendations and determined the association of prestroke LLT use with stroke severity. We conducted a retrospective study of patients hospitalized with AIS from 2015 to 2020 at a large academic comprehensive stroke center. Patients with AIS secondary to either small-vessel disease or large-artery atherosclerosis recorded in the institutional Get With The Guidelines-Stroke registry and with a prestroke indication for LLT were included. Using propensity score subclassification, adjusted logistic regression models were built to explore the associations between LLT use before AIS when indicated and presenting National Institutes of Health Stroke Scale score >4. There were 384 patients with AIS who met guideline-recommended criteria for prestroke LLT (median age 70 years, 57% men), of whom only 207 patients (54%) were prescribed LLT before AIS. Not being prescribed LLT when indicated was associated with a significantly higher likelihood of a presenting with National Institutes of Health Stroke Scale score >4, even when adjusted for specific stroke cause (odds ratio, 1.13 [95% CI, 1.03-1.20]; P=0.006). LLT is underused in patients who present with atherosclerosis-related AIS. Lack of prestroke LLT use was associated with more severe stroke symptoms upon presentation. These findings emphasize the need to prescribe LLT when indicated, because its use may mitigate poststroke disability.

Infarct Growth in Patients with Emergent Large Vessel Occlusion Stroke Transferred for Endovascular Thrombectomy.

Patients with a large vessel occlusion (LVO) stroke who are transferred to a comprehensive stroke center (CSC) for endovascular thrombectomy (EVT) often experience infarct growth. We aimed to investigate the clinical predictors of fast infarct growth and its effect on clinical outcomes. We retrospectively collected EVT data of patients with LVO transferred to our center between March 14, 2019, and June 28, 2022. The absolute rate of Alberta Stroke Program Early Computed Tomography Score (ASPECTS) decay was defined as (ASPECTS primary CT - ASPECTS repeat CT)/elapsed hours. The ratio of relative ASPECTS deterioration was defined as (ASPECTS primary CT - ASPECTS repeat CT)/ASPECTS primary CT. In the primary analysis, the study population was dichotomized into absolute slow progressors and absolute fast progressors using the median absolute rate of ASPECTS decay. Secondary analysis was also conducted using the median relative ASPECTS deterioration ratio, and the study population was categorized into relative fast progressors and relative slow progressors. Favorable outcome was defined as a 90-day modified Rankin Scale (mRS) score ≤ 2. We included 309 patients: median age 72years (IQR 65-77); median National Institutes of Health Stroke Scale (NIHSS) 14 (IQR 11-18). The median absolute rate of ASPECTS decay was 0.42 points/hour and the median relative ASPECTS deterioration ratio was 11.1%. Overall, fast infarct growth was independently associated with worse 90-day outcome (absolute rate of ASPECTS decay: OR = 3.395; 95% CI 1.844-6.250; P < 0.001; relative ASPECTS deterioration ratio: OR = 3.754; 95% CI 2.050-6.873; P < 0.001). In multivariable analysis, fast infarct growth was independently associated with high admission NIHSS, proximal occlusions, and poor collateral status, while intravenous thrombolysis before transfer was negative with fast inter-hospital infarct growth. For patients with LVO stroke who are transferred from a PSC to CSC for EVT, the infarct growth rate is highly variable and is strongly associated with 90-day outcomes. Initiation of intravenous bridging therapy before transfer may limit the infarct growth during inter-hospital transfer.

Effectiveness of oral health care intervention for stroke patients following the introduction of Oral Health Assessment Tool.

This study aimed to evaluate the effectiveness of oral health assessment tools in facilitating oral health care interventions by dental care providers for acute stroke patients within 48 h of admission, following a reform of the nursing system. Data were gathered from a retrospective cohort study conducted at a stroke center, comparing 10 months before and after the implementation of the reformed system, with a 2-month interval. Parameters assessed included stroke type, severity measured using the National Institutes of Health Stroke Scale, stroke history, stroke-related factors, number of teeth, hospitalization cost and duration, occurrence of fever and pneumonia, stroke treatment, days from admission to dental intervention, and intervention frequency. Implementation of the new system significantly reduced the time before dental intervention (P < 0.001), increased the frequency of interventions (P < 0.001), and allowed for the management of more severe cases (P = 0.007). However, there was a slight increase in the occurrence of fevers and the days of fever (P = 0.039 and P = 0.015, respectively). Multiple regression analysis showed that fever days were positively correlated with stroke severity and the number of days from admission to dental intervention (P < 0.001 and P = 0.013, respectively). Even after propensity score matching adjusting for stroke severity, these associations persisted. Additional multiple regression analysis was performed after this, but fever days were positively correlated with stroke severity and sex (P < 0.001 and P = 0.008, respectively), as well as with the presence of other factors affecting the occurrence of fever. Although the frequency and duration of fevers increased slightly, this approach, incorporating oral health assessment tools, made it possible to provide early dental intervention, particularly for patients with severe strokes. Geriatr Gerontol Int 2024; ••: ••-••.

Extending the Time Window for Tenecteplase by Effective Reperfusion of Penumbral Tissue in Patients with Large Vessel Occlusion (ETERNAL-LVO): Rationale and design of a multicenter, prospective, randomized, open-label, blinded-endpoint, controlled phase 3 trial.

The benefit of tenecteplase in the treatment of large vessel occlusion (LVO) patients presenting within 24 hours of symptom onset remains unclear. To assess the effectiveness and safety of tenecteplase, compared to standard of care, in patients presenting within the first 24 hours of symptom onset with a LVO and target mismatch on perfusion CT. The "Extending the time window for Tenecteplase by Effective Reperfusion of peNumbrAL tissue in patients with Large Vessel Occlusion" (ETERNAL-LVO) trial is a prospective, randomized, open-label, blinded endpoint, phase 3, parallel-group, superiority trial with covariate-adjusted 1:1 randomization, and adaptive sample size re-estimation. Patients with an anterior circulation LVO stroke, who present within 24 hours of stroke onset or last known well with a target mismatch on CTP or MRI, will be randomized to tenecteplase (0.25 mg/kg) or standard of care (alteplase 0.90 mg/kg or conservative management at clinician discretion) prior to undergoing endovascular therapy. The primary outcome is the proportion of patients with a modified Rankin Scale (mRS) of 0-1 (no disability) or return to baseline mRS at 3 months. Secondary and safety outcomes include the proportion of patients with a mRS of 0-2 at 3 months, an ordinal analysis of the mRS at 3 months, the proportion of patients with symptomatic intracerebral haemorrhage (sICH), the proportion of patients with death due to any cause, and the proportion of patients with mRS 5-6 at 3 months (severe disability or death). The ETERNAL-LVO trial will build upon the current evidence for tenecteplase in the >4.5-hour window. Specifically, this trial will evaluate tenecteplase in a patient population who have access to endovascular therapy but may incur delays to endovascular therapy commencement or require transfer from a primary to a comprehensive stroke center. ClincialTrials.gov: NCT04454788.

Impact of tortuosity of the V1-segment vertebral artery on mechanical thrombectomy

Tortuosity of the vasculature poses challenges to mechanical thrombectomy (MT); however, only a few studies have reported the impact of vertebral artery (VA) tortuosity on MT. The present study aimed to investigate the impact of tortuosity of the V1-segment VA on MT in patients with acute vertebrobasilar artery occlusion (AVBAO). The patients diagnosed with AVBAO and treated with MT in the Stroke Center of Xijing Hospital from November 2019 to March 2022 were analyzed retrospectively. According to the tortuosity of V1-segment VA, patients were divided into tortuous (coiling and kinking) and non-tortuous groups (straight, single-arc, and multi-arc). A binary logistic regression model was established to analyze the association between the tortuosity of V1-segment VA and successful reperfusion (mTICI ≥ 2b), neurological improvement at 7 days, favorable and poor outcome at 90 days, and symptomatic intracranial hemorrhage (ICH) within 24 h. After adjustment for age, baseline National Institute of health stroke scale (NIHSS) score and puncture-to-recanalization time, the impact of tortuosity of the V1-segment VA on outcomes was analyzed. After screening, 35 patients were enrolled in this study. The overall rate of successful reperfusion was 74.3% (26/35), and 40% (14/34) patients achieved favorable outcomes at 90 days. Subsequently, 15/35 (42.9%) patients were included in the tortuous group, and the remaining 20 patients comprised the non-tortuous group. After adjustment for age, baseline NIHSS score, and puncture-to-recanalization time, the rate of 90-day favorable outcome in the tortuous group was significantly lower than that of the non-tortuous group (20% vs. 57.9%, P = 0.034), while the rates of reperfusion (80% vs. 73.7%) and 7-day neurological improvement (33.3% vs. 36.8%) were similar between the two groups. The incidence of 24-h symptomatic ICH in the tortuous group was higher than that in the non-tortuous group (26.7% vs. 15.8%), albeit not significantly. In patients with AVBAO, tortuosity of the V1-segment VA was negatively associated with favorable outcomes 90 days after MT.

Safety and efficacy of early versus delayed acetylsalicylic acid after surgery for spontaneous intracerebral haemorrhage in China (E-start): a prospective, multicentre, open-label, blinded-endpoint, randomised trial

Patients with non-traumatic intracerebral haemorrhage have a substantial risk of major adverse cardiovascular and cerebrovascular events, including ischaemic stroke, after surgery. The optimal timing of antiplatelet therapy after surgery for spontaneous intracerebral haemorrhage in patients at high risk of postoperative ischaemic events has not been characterised. We aimed to investigate the safety and efficacy of early versus late initiation of antiplatelet therapy after surgery for spontaneous intracerebral haemorrhage. This prospective, open-label, blinded-endpoint, randomised trial was done at eight stroke centres in China. Eligible patients were aged 18-70 years, undergoing surgery for the evacuation of spontaneous intracerebral haemorrhage, and had a high risk of postoperative ischaemic events. Using the minimisation method in an online randomisation system, patients were randomly assigned (1:1) to receive 100 mg acetylsalicylic acid once per day in either the early-start group (starting on the third day after surgery until the 90th day after surgery) or the late-start group (starting on the 30th day after surgery until the 90th day after surgery). Medication was taken orally or delivered via a feeding tube. The primary efficacy outcome was a composite of new major ischaemic cardiovascular, cerebrovascular, or peripheral vascular events within 90 days and the primary safety outcome was any intracranial bleeding within 90 days, both measured in the intention-to-treat population. The trial is registered at ClinicalTrials.gov, NCT04820972, and is complete. From May 1, 2021, to May 1, 2023, 7323 patients were screened, of whom 269 (4%) were enrolled and randomly assigned: 134 to the early-start group and 135 to the late-start group. 195 (72%) patients were male, 74 (28%) were female, and the median age was 60·2 years (IQR 52·0-66·5). Haematomas were supratentorial and deep in most (170 [63%] of 269) patients. Ischaemic major cardiovascular, cerebrovascular, or peripheral vascular events occurred within 90 days after surgery in 27 (20%) of 134 patients in the early-start group and 42 (31%) of 135 patients in the late-start group (odds ratio 0·56 [95% CI 0·32-0·98]; p=0·041). Intracranial bleeding occurred in one (1%) of 134 patients in the early-start group and four (3%) of 135 patients in the late-start group. Non-bleeding serious adverse events occurred in 57 (42%) of 134 patients in the early-start group and 57 (42%) of 135 patients in the late-start group. Starting acetylsalicylic acid on the third day after surgery for spontaneous intracerebral haemorrhage in Chinese patients at high risk of postoperative ischaemic events resulted in fewer postoperative ischaemic major cardiovascular, cerebrovascular, or peripheral vascular events than starting acetylsalicylic acid therapy at 30 days, with no increased risk of intracranial bleeding. Whether early initiation of acetylsalicylic acid therapy is safe and improves clinical outcomes for broader populations of patients with spontaneous intracerebral haemorrhage requires further research. The National Key Research and Development Program of China.

Enhancing mortality prediction in patients with spontaneous intracerebral hemorrhage: Radiomics and supervised machine learning on non-contrast computed tomography

PurposeThis study aims to develop a Radiomics-based Supervised Machine-Learning model to predict mortality in patients with spontaneous intracerebral hemorrhage (sICH). MethodsRetrospective analysis of a prospectively collected clinical registry of patients with sICH consecutively admitted at a single academic comprehensive stroke center between January-2016 and April-2018. We conducted an in-depth analysis of 105 radiomic features extracted from 105 patients. Following the identification and handling of missing values, radiomics values were scaled to 0-1 to train different classifiers. The sample was split into 80-20% training-test and validation cohort in a stratified fashion. Random Forest(RF), K-Nearest Neighbor(KNN), and Support Vector Machine(SVM) classifiers were evaluated, along with several feature selection methods and hyperparameter optimization strategies, to classify the binary outcome of mortality or survival during hospital admission. A tenfold stratified cross-validation method was used to train the models, and average metrics were calculated. ResultsRF, KNN, and SVM, with the "DropOut+SelectKBest" feature selection strategy and no hyperparameter optimization, demonstrated the best performances with the least number of radiomic features and the most simplified models, achieving a sensitivity range between 0.90 and 0.95 and AUC range from 0.97 to 1 on the validation dataset. Regarding the confusion matrix, the SVM model did not predict any false negative test (negative predicted value 1). ConclusionRadiomics-based Supervised Machine Learning models can predictmortality during admission in patients with sICH. SVM with the "DropOut+SelectKBest"feature selection strategy and no hyperparameter optimization was the best simplifiedmodel to detect mortality during admission in patients with sICH.

Predictive Value of Plasma D-Dimer for Cerebral Herniation Post-Thrombectomy in Acute Ischemic Stroke Patients.

Cerebral hernia is a serious complication after thrombectomy in patients with acute ischemic stroke (AIS). This study aims to explore the predictive value of emergency preoperative plasma D-dimer levels in cerebral herniation after successful thrombectomy. Between January 2019 and December 2023, patients with AIS who received a successful thrombectomy in our single comprehensive stroke center were retrospectively enrolled. We conducted a statistical analysis on the data using SPSS 26.0. Receiver operating characteristic curve (ROC) was used to evaluate the predictive value of D-dimer level for cerebral herniation. Among 278 enrolled patients, 20 cases (7.19%) experienced cerebral herniation. In patients with cerebral hernia, the score of the National Institutes of Health Stroke Scale was higher (16.5 vs 12.0, P < 0.001), the Alberta Stroke Plan early CT score was lower (6.5 vs 8.0, P < 0.001), the score of collateral circulation was lower (2.0 vs 3.0, P < 0.001), the proportion of eTICI blood flow grading of 3 of the occluded vessel was less (35% vs 75.19%), the proportion of pathogenesis of large atherosclerosis was less (5.00% vs 46.51%, P < 0.001), and the level of plasma D-dimer was higher (2.61 vs 0.82). After adjusting for potential confounders, the level of D-dimer (adjusted OR = 1.131, 95% CI 1.022-1.250, P = 0.017) was significantly correlated with cerebral hernia. Based on the ROC curve, the sensitivity and specificity of D-dimer in predicting cerebral herniation were 75.0% and 73.3%, respectively, and the area under the curve was 0.766. Although our study had certain limitations, we found that elevated emergency preoperative plasma D-dimer level is an independent predictive factor for the cerebral herniation after successful thrombectomy in patients with AIS, which is of great clinical significance.

Hematoma surface irregularity predicts postoperative rebleeding and poor drainage in patients with spontaneous intracerebral hemorrhage following minimally invasive surgery: a retrospective cohort study at a high-volume stroke center.

The surface regularity index (SRI) reflects hematoma surface regularity in patients with intracerebral hemorrhage (ICH). Studies had reported an association between hematoma surface irregularity and hematoma expansion (HE). However, research on the correlation between the SRI and clinical outcomes in ICH patients following minimally invasive surgery (MIS) is limited. This study aimed to investigate the ability of the SRI to predict rebleeding and poor drainage in patients with spontaneous ICH following MIS. The data of patients with ICH who underwent MIS between January 2021 to September 2022 at Beijing Tiantan Hospital, a high-volume stroke center, were retrospectively analyzed. The clinical, radiological, and surgical characteristics of the patients were systematically reviewed. The hematoma were segmented and constructed, and the SRI scores were estimated using image-processing software [three-dimensional (3D) Slicer] based on preoperative computed tomography (CT) scans. Univariate and logistic regression analyses were conducted to identify potential predictors for post-MIS rebleeding and poor drainage (defined as a residual hematoma >15 mL). A total of 151 ICH patients were included in the study, of whom 28 (18.5%) experienced post-MIS rebleeding, and 75 (49.7%) had poor drainage. The SRI was found to be independently associated with rebleeding [odds ratio (OR): 0.926, 95% confidence interval (CI): 0.891-0.963; P<0.001] and poor drainage (OR: 0.912, 95% CI: 0.882-0.944; P<0.001) after adjusting for confounders in the logistic regression. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve of the SRI in predicting postoperative rebleeding was 0.765 (the cut-off point, sensitivity, and specificity were 44.980, 66.7%, and 82.1%, respectively), and that for poor drainage was 0.809 (the cut-off point, sensitivity, and specificity were 53.462, 61.8%, and 89.3%, respectively). The hematoma SRI is an independent indicator of postoperative rebleeding and poor drainage in ICH patients following MIS.

Geographic Access to High-Volume Mechanical Thrombectomy Centers in Florida, 2019.

Mechanical thrombectomy (MT) improves outcomes for acute ischemic stroke (AIS) due to large vessel occlusion, but is time sensitive and requires specialized infrastructure. Professional organizations and certification bodies have promulgated minimum procedural volume standards for centers and for individual proceduralists but it is unclear whether enforcing these requirements would decrease geographic access to MT. Therefore, we sought to evaluate the potential impact of applying a minimum procedural volume threshold on geographic access to MT. We identified all hospital discharges for stroke where an MT procedure was performed at any nonfederal hospital in Florida in 2019 using statewide hospital discharge data. We then generated geographic service area maps based on prespecified ground transport distances for the subset of hospitals that performed at least 1 MT and for those that performed at least 15 MTs that year, the minimum volume threshold required for thrombectomy capable and comprehensive stroke centers by the Joint Commission. Then, using zip code centroids and patient-level discharge hospital data, we computed the proportion of patients with AIS who lived within each of the generated service areas. A total of 105 of 297 hospitals performed MT; of those, 51 (17%) were low-volume centers (1-14 MTs/year) and 54 (18%) were high-volume centers (≥15 MTs/year). High-volume centers accounted for nearly 95% of all MTs performed in the state. Most patients hospitalized with AIS (87%) lived within 20 miles (or an estimated as a 1-hour driving time) of a hospital that performed at least 1 MT, and all (100%) lived within 115 miles (or estimated as 3-hour driving time). Setting a minimum MT volume threshold of 15 would decrease the proportion of stroke patients living within 1-hour driving time of an MT center from 87% to 77%. In 2019, most Florida stroke patients lived within a 1-hour ground transport time to a center that performed at least 1 MT and all lived within 3-hour driving time of an MT center, irrespective of whether a minimum procedural volume threshold of 15 cases per year was applied or not.

Presentation, Treatment and Outcomes of Acute Basilar Artery Occlusion: A Retrospective Analysis

IntroductionWe aim to assess the clinical presentation, treatment, and outcomes in patients with acute basilar artery occlusion (BAO) after receiving medical management (MM) (including IV thrombolysis, antiplatelet, anticoagulation) and endovascular therapy (EVT) (including intra-arterial thrombolysis, stent placement, mechanical thrombectomy). MethodsThis is a retrospective cohort study including all adult patients treated at three Mayo Clinic stroke centers with acute BAO from 2008 to 2021. Chart review was conducted to extract details of presentation, treatment, and outcome. Comparisons of treatment outcomes between patients treated with MM and EVT were analyzed and include changes of modified Rankin Scale (mRS) and NIHSS score change from admission to discharge. ResultsA total of 182 patients were included in our final analysis: 95 in the MM group and 87 in the EVT group. There was a statistically significant difference in favorable functional outcome at discharge (mRS 0-3) favoring the MM group compared to EVT group (56.0% vs 34.9%; OR 0.42, p=0.005) and the difference remained significant in multivariate analysis (OR 0.38, p=0.048). There were significantly increased odds of having NIHSS improvement of more than 5 points (OR 3.94 p<0.001), and 10 points (OR 3.92 p<0.001) in patients treated with EVT compared to MM. ConclusionOur data demonstrates that although in general patients who received EVT had lower odds of having favorable outcomes at discharge, they were also more likely to have NIHSS score improvement of more than 5 and 10 points from presentation to discharge compared to MM, suggesting EVT could be beneficial in some patients.

One in six patients exhibit changes in reperfusion on 10-minute repeat cerebral angiography during mechanical thrombectomy for stroke

BackgroundPost-recanalization target vessel re-occlusion (TVR) following endovascular thrombectomy (EVT) is a known complication of the procedure, and it is associated with worse long-term functional outcomes. The incidence and factors that...

Prehospital telemedicine support for urban stroke care: Analysis of current state of care and conceptualization

BackgroundThe reduction of processing times in the treatment of acute ischemic stroke is of outstanding importance. Our objective is to analyze the acute stroke care chain from onset to treatment in a city in Germany comprising three stroke units. Additionally, we discuss solutions for detected treatment delays.MethodsWe conducted an in-depth analysis of acute stroke care processing times across three local stroke centers in Düsseldorf among all emergency services transportations for suspected stroke. Isochrone mapping was performed to identify areas with prolonged transportation times.ResultsAmong the 1,714 transportations, 943 patients had confirmed strokes. Prehospital care constituted 58% of total emergency care time until imaging. Patients with confirmed stroke had reduced in-hospital times while patients receiving treatment experienced faster in-hospital times. Isochrone mapping revealed disparities in transportation times within the city.ConclusionsIn conclusion, we identified confirmation of stroke symptoms as pre- and in-hospital and treatment eligibility as in-hospital process accelerators in stroke care. We propose the introduction of an in-ambulance video consulting model to accelerate contact to stroke-experts and accelerate processing times for patients eligible for treatment. Furthermore, we discuss the combination of in-ambulance video consulting with imaging and starting treatment outside traditional stroke centers, followed by transportation to a stroke center during thrombolysis, which might further accelerate treatment in specific cases.

Comparison of prehospital stroke assessment scales for acute ischemic stroke with large vessel occlusion within six hours of onset: A single-center study in Eastern Taiwan

ABSTRACT Objectives: In Taiwan, acute ischemic stroke (AIS) with large vessel occlusion (LVO) remains a significant health concern. Reperfusion therapy is more effective if the patient arrives at the medical center within the early time window, emphasizing the importance of prehospital stroke assessment to identify LVO and rapid transfer. This study focused on Eastern Taiwan, where the Hualien Tzu Chi Hospital is the sole comprehensive stroke center. We compared different prehospital stroke assessment scales in identifying LVO. Materials and Methods: We reviewed 598 patients with acute stroke admitted to our hospital’s emergency department between April 1, 2021, and March 31, 2022. Of these, 110 AIS cases presenting within 6 h of symptom onset were retrospectively analyzed using the medical records and National Institute of Health Stroke Scale (NIHSS) scores to evaluate the efficacies of prehospital stroke scales, including our institution’s Tzu Chi Stroke Severity Scale and its modified version. LVO was defined as occlusion of the anterior cerebral artery, middle cerebral artery, and its main branches, intracranial carotid arteries, and vertebrobasilar arteries. Results: Among 110 patients, 39.1% had LVO, which showed a higher mortality rate and prevalence of atrial fibrillation. LVO had higher NIHSS scores and longer hospital stays. The Vision Aphasia Neglect (VAN) Scale and Modified Tzu Chi Stroke Severity Scale showed the highest sensitivity, with the latter also exhibiting the highest sensitivity for posterior circulation LVO. Conclusion: The VAN and the modified Tzu Chi Stroke Severity Scale offer comparable sensitivity for detecting LVO in the prehospital setting. Our study supports the adoption of the modified Tzu Chi scale in the regional emergency medical service transfer algorithm for LVO detection for timely intervention.

Stress hyperglycemia is associated with early neurologic deterioration in patients with acute ischemic stroke after intravenous thrombolysis without hemorrhagic transformation.

This aimed to elucidate the impact of stress hyperglycemia on early neurological deterioration (END) in patients with acute non-cardiogenic cerebral infarction who did not experience hemorrhagic transformation following intravenous thrombolysis to identify risk factors associated with END. This retrospective case-control study analyzed data from consecutive patients who received intravenous thrombolysis for acute ischemic stroke (AIS) without hemorrhagic transformation at the Stroke Center of The Fifth Affiliated Hospital of Sun Yat-sen University from January 2018 to February 2023. END was defined as an increase of more than 2 points on the National Institutes of Health Stroke Scale (NIHSS) within 7 days of admission. A total of 250 patients (56 males, 22.4%) were included, with a mean age of 63.34 ± 12.90 years. Of them, 41 were classified into the END group and 209 into the non-END group. Stress hyperglycemia ratio (SHR) demonstrated a significant correlation with END (r=-0.003, P = 0.003). HbA1c (OR = 0.68, 95% CI: 0.481-0.921) and SHR (OR = 0.00, 95% CI: 0.0-0.051) were independently associated with END. Receiver-operating characteristic (ROC) curve analysis indicated that SHR had a sensitivity of 79.9%, specificity of 88.8%, and an area under the curve (AUC) of 0.857 for predicting END. SHR was significantly associated with END in patients with acute non-cardioembolic cerebral infarction who did not undergo hemorrhagic transformation after intravenous thrombolysis.

Soft partial release of non-aggressive stent retriever technique for very distal arterial occlusion stroke.

Endovascular thrombectomy (EVT) for very distal vessel occlusion (DVO) stroke is increasingly performed but there is insufficient evidence on the efficacy and safety of distal EVT techniques. We hypothesized that the technique of soft partial release of non-aggressive stent retrievers (SPORNS) reduces friction on the perforating vessels during thrombectomy and thereby reduces bleeding complications. Retrospective study including consecutive DVO patients who were treated with the SPORNS technique between 1 January 2022 and 31 December 2022 at two tertiary stroke centers. DVOs were defined as isolated occlusions of the M3 and M4 segments of the middle cerebral artery, occlusions of the A2 and A3 segments of the anterior cerebral artery, and occlusions of the P2 and P3 segments of the posterior cerebral artery or of the superior cerebellar artery. The technique is described in detail and procedural and clinical outcomes are given. Twenty-four patients were treated with the SPORNS technique of whom 22 (92%) had complete or near complete recanalization (eTICI 2c/3). National Institutes of Health Stroke Scale (NIHSS) decreased from a median of nine (IQR 7-13) at admission to three (1-5) at discharge and 18 patients (75%) achieved a good outcome (modified Rankin scale 0-2) at day 90 post-stroke. Two patients (8%) had a small subarachnoid hemorrhage and two patients (8%) had a symptomatic intracerebral hemorrhage on follow-up imaging. For the treatment of very distal arterial occlusions, the SPORNS technique employing a soft partial release of a non-aggressive stent retriever is safe and effective for the thrombectomy of small clots. The technique potentially yields a lower rate of subarachnoid hemorrhages while achieving an excellent rate of complete and first-pass recanalization.

Mechanical thrombectomy failure in anterior and posterior circulation stroke: current results from a high-volume comprehensive center.

Mechanical thrombectomy (MT) is an established therapy for acute ischemic stroke (AIS), but recanalization is not always achieved. Common reasons are inadequate removal at the thrombus site and difficulties with the access route. In order to identify risk factors for MT failure we conducted a retrospective study on a high-volume comprehensive stroke center. Evaluation of 552 thrombectomies (2019-23; anterior and posterior circulation, direct aspiration +/- stent retriever [SR]). MT failures (= modified Thrombolysis in Cerebral Infarction score 0 or 1) were analyzed for age, sex, pre- and post-MT modified Rankin Scale, bridging intravenous thrombolysis (IVT), occlusion site (anterior / posterior circulation, proximal / distal), the Kaesmacher classification and time trend results. MT failure occurred in 56 patients (10.1%; median age 76; 53.6% female). Nineteen (33.9%) patients received IVT (p = 0.326). Logistic regression analysis did not show a significant association of age, sex or occlusion site with MT failure (p = 0.165, p = 0.738, p = 0.838). Distal MT generally demonstrated lower success rates (p < 0.01). According to the Kaesmacher classification SR failure was the most frequent cause of MT failure (category 2B: 48%, p < 0.001). Time trend analysis suggests improving recanalization rates in the further course (4 times in year-on-year comparison; p < 0.01). MT failure occurs in AIS treatment, even in high-volume centers and occurs more frequently in distal occlusions. Improvements in device technology, particularly SR, and ongoing refinements in access route selection offer the prospect of better outcomes in the future.

Postoperative time-of-flight magnetic resonance angiography classification is a predictor of postoperative recanalization of unruptured cerebral aneurysms

Endovascular treatment has become the preferred approach for managing unruptured cerebral aneurysms, with simple and balloon-assisted coil embolization as the standard first-line therapy. However, recanalization after coil embolization remains a major clinical concern. This study aimed to evaluate the predictive factors for recanalization using time-of-flight magnetic resonance (TOF-MR) angiography. This retrospective multicenter study analyzed data from 241 patients with unruptured cerebral aneurysms who underwent coil embolization at five stroke centers. Aneurysms were evaluated using TOF-MR angiography within 7 days post-procedure and at follow-up. The study investigated the role of aneurysm characteristics and the Postoperative TOF-MR Angiography (PTMA) classification in predicting recanalization. Of the 241 aneurysms analyzed, 79 (32.7%) exhibited recanalization, and 15 (6.2%) required retreatment. Aneurysms with a maximum diameter of ≥10 mm were associated with a higher risk of recanalization (odds ratio (OR), 3.27; 95% confidence interval (CI), 1.38-7.75; p<0.01). The PTMA classification, which indicated incomplete occlusion (SN/RN/PO), also showed a significant association with recanalization (OR, 4.82; 95% CI, 2.17-10.7; p<0.01). The modified Raymond-Roy classification (Class IIIb) also contributed to the prediction of recanalization (OR, 3.09; 95% CI, 1.50-6.38; p<0.01). Aneurysm size, the modified Raymond-Roy classification, and PTMA classification within 7 days of coil embolization were significant predictors of recanalization. This study suggests that TOF-MR angiography may be accurate, and that PTMA classification may serve as an appropriate predictor of aneurysm recanalization. Further prospective studies with larger cohorts are required to validate our findings.

Professional and public views about early return of patients from Comprehensive Stroke Centers to local Acute Stroke Centers in England following displacement by emergency care pathways

BackgroundMechanical thrombectomy is a highly effective emergency treatment for selected cases of ischemic stroke but can only be provided at hospitals with appropriate facilities and interventionists. Many patients require transfers for treatment, including some who are subsequently considered ineligible. To maintain capacity at thrombectomy centers, displaced patients should soon be returned to their local hospital following assessment and treatment, but return processes vary. We sought the views of stroke and ambulance services, clinicians, and public representatives about the timing, planning and implementation of acceptable processes to inform recommendations about the early return of patients (&amp;lt; 24 h) displaced as a result of thrombectomy pathways.MethodsThree workstreams were undertaken between 01/05/2023 and 31/10/2023: 1. An online survey of hospital stroke services supplemented by a convenience poll of stroke clinicians. 2. An online survey of ambulance services. 3. Focus groups with stroke patients and carers using a topic guide describing typical early return scenarios. The surveys used multiple choice answers supplemented by free text boxes for additional comments. Data were reported descriptively without statistical comparison. Focus group data were analyzed thematically using emergent coding.ResultsResponses were obtained from 32 stroke services, 44 stroke clinicians, and 11 ambulance services. Stroke service and clinician respondents generally supported early return for most clinical scenarios but advised caution regarding transfers &amp;lt; 4 h after thrombectomy and &amp;lt; 24 h for hemorrhagic stroke due to the higher risk of complications. Ambulance respondents highlighted travel time, immediate service pressures and crew type as influences upon providing early returns, but supported 24/7 provision. Twenty-nine patients and four carers participated in three focus groups. There was general acceptance of early return processes but these participants emphasized the need for clear communication and individualized decisions based upon clinical status, age, journey length, patient preferences and individual contextual factors.ConclusionsAll contributors were generally supportive of early patient returns to maintain thrombectomy center capacity, but the results suggest important organizational, clinical, and patient-focused considerations for successful implementation.

CTP-Derived venous outflow profiles correlate with tissue-level collaterals regardless of arterial collateral status

Background and PurposeTissue-level collaterals (TLC), which quantify the state of arterial blood flow transiting through cerebral ischemic tissue, have been shown to be related to the clinical outcomes of acute ischemic stroke (AIS), regardless of the arterial collateral status on computed tomography angiography(CTA). Herein, we investigated whether venous outflow (VO) profiles on computed tomographic perfusion (CTP) were linked to TLC, regardless of the arterial collateral status. MethodsConsecutive anterior circulation AIS patients with large vessel occlusion(LVO) undergoing thrombectomy in a retrospective cohort were evaluated between January 2021 and August 2023 at two comprehensive stroke centers. All patients underwent pretreatment noncontrast computed tomography (NCCT), computed tomography perfusion (CTP) and follow-up NCCT or head magnetic resonance imaging (MRI) within 72 h of endovascular treatment (EVT). The VO profile parameters were recorded based on time–density curve derived from the CTP, including the peak time of VO (PTV) and total VO time (TVT). As the quantitative index of TLC, hypoperfusion intensity ratio (HIR) ≦0.4 was considered favorable for TLC. The primary outcome was tissue-level collaterals (TLC), defined by the HIR. Logistic regression analysis was used to assess the association between VO characteristics and TLC, whereas receiver operating characteristic (ROC) analysis was used to evaluate the value of VO parameters in predicting favorable TLC. ResultsThis study enrolled 221 eligible patients, among whom patients with favorable TLC were found to have a shorter PTV than patients with unfavorable TLC (12 s vs.16.5 s, P < 0.001) in univariable analysis. A shorter PTV was significantly associated with a favorable TLC (odds ratio [OR], 0.811; 95% confidence interval [CI], 0.709 to 0.927; P=0.002). Multivariable binary logistic stepwise regression analysis revealed that PTV was negatively correlated with TLC, regardless of the arterial collateral status was good (Good: OR, 0.777; 95%CI, 0.660–0.914; P=0.002; Poor: OR,0.729; 95%CI, 0.569–0.932; P=0.012). ROC analysis revealed that the PTV threshold for predicting favorable TLC was ≤13s, with an area under the curve (AUC), sensitivity, and specificity of 0.754, 0.728, and 0.699, respectively. The comprehensive predictor combined with PTV had an optimal predictive ability for TLC with an AUC of 0.894 (sensitivity=0.839, specificity=0.864). ConclusionCerebral VO profiles in patients with anterior circulation AIS with LVO were related to TLC regardless of arterial collateral status, while PTV≤13s was a good predictor of favorable TLC.