Symptomatic Intracranial Hemorrhage Research Articles

Tenecteplase versus alteplase in patients with acute ischemic stroke: An updated meta-analysis of randomized controlled trials.

Acute ischemic stroke (AIS) is a leading cause of morbidity and mortality worldwide. While alteplase has been widely used for acute management, recent clinical trials suggest that tenecteplase (TNK) may offer improved clinical outcomes. This study aims to compare the efficacy and safety of TNK compared with alteplase. A comprehensive literature search was conducted using PubMed, Embase and Cochrane Library from inception to October 2024 to identify randomized controlled trials that compared TNK at 0.25 mg/kg dosage with alteplase. Data about clinical outcomes was extracted from both groups and assessed by generating forest plots using the random-effects model and pooling odds ratios (ORs). A total of 11 RCTs with 7,546 patients were included in the analysis. TNK showed statistically significant improvement in excellent functional outcome (mRS 0-1) compared with alteplase (OR= 1.14, 95 % CI= 1.03-1.25). No statistically significant difference was observed for good functional outcome (mRS 0-2) (OR= 1.11, 95 % CI= 0.9-1.25), early neurological improvement (OR=1.08, 95 % CI= 0.93-1.26), all-cause death (OR=0.99, 95 % CI= 0.81-1.19), symptomatic intracranial hemorrhage (OR=1.11, 95 % CI=0.81-1.52) and poor functional outcome (mRS=4-6) (OR=0.95, 95 % CI=0.79-1.14). In patients with acute ischemic stroke, TNK demonstrated a significant advantage over alteplase in achieving excellent functional outcomes. The incidence of early neurological improvement, symptomatic intracranial hemorrhage, all-cause death, and poor functional outcome remained comparable across the two groups.

Risk of recurrence following acute cardioembolic stroke according to lesion size and NIHSS on admission.

Risk of recurrence following acute cardioembolic stroke according to lesion size and NIHSS on admission.

Endovascular thrombectomy for treatment of acute ischemic stroke: A double-edged sword?

Pakistan has a significant burden of stroke patients, with a recent study from KPK demonstrating a prevalence of 1.2%. Of the major risk factors obesity, hypertension, and smoking were identified in 38.8%, 21.9% and 6.6%, of patients respectively1. Strokes are the second leading cause of death in Pakistan, with the latest the World Health Organization WHO data showed that it caused 9.69% of total deaths2. Global trends indicate an increase in the incidence of stroke, along with disability adjusted life years from 1990 to 2020, with the incidence rate being predicted to further increase by the year 20303. Numerous techniques are emerging for management of patients with stroke, including endovascular thrombectomy, a procedure which involves the insertion of a catheter into an arterial vessel, which is then guided to the point of the blocked artery in the brain thereby removing the clot. Endovascular thrombectomy is associated with better functional independence compared to medical intervention, group according to Sarraj et al. Greater functional independence was seen at 20.3% in the thrombectomy group compared to 7.0% in the medical care group. Independent ambulation was reported as 37.9% in the thrombectomy group while the medical care group reported it by nearly half at 18.7%4. However, endovascular thrombectomy is not the magic bullet for stroke treatment as it seems, as the procedure poses significant risks. There is a considerable risk for symptomatic intracerebral haemorrhage which has shown a positive association with diabetes mellitus and high blood pressure, both of which are present at a very significant level in the Pakistani population5. Moreover, endovascular thrombectomy results in much greater early neurological worsening, with 44 patients from the thrombectomy group and 27 patients from the medical intervention group having experienced this event4. Early neurological worsening has been associated with worse functional outcomes by day 904. Therefore, caution is advised before providing endovascular thrombectomy as a treatment option, because of the greater risk of treatment-emergent adverse effects. Further trials are required specifically on the Pakistani population, to better assess the safety and efficacy of endovascular thrombectomy as a treatment option.

Hypoxemia after thrombectomy deteriorating functional prognosis and aggravates inflammatory response in acute ischemic stroke

ABSTRACT Background Following endovascular therapy (EVT) in acute ischemic stroke (AIS), there is a discrepancy between vessel reperfusion and favorable prognosis. Hypoxemia commonly occurs during the acute phase of AIS and may exacerbate damage to the ischemic penumbra. This study aims to investigate the correlation between hypoxemia and functional prognosis after EVT, and its influence on inflammatory response. Method A retrospective study was conducted involving patients who underwent EVT for anterior circulation AIS. Hypoxemia was defined as arterial blood oxygen pressure <80 mmHg. The propensity score matching (PSM) method was performed to match the Hypoxemia and non-Hypoxemia groups at 1:1 ratio. The primary outcome was the difference in the mRS score at 90 days. Secondary outcomes included functional independence, NIHSS, infarct volume, mortality, symptomatic intracranial hemorrhage (sICH), pneumonia, urinary infection, and seizures. Inflammatory cytokines and cell data were also collected and analyzed. Results A total of 116 patients were analyzed. Patients with hypoxemia had worse outcomes at 90 days, evidenced by higher modified Rankin Scale (mRS) scores (3 vs. 2), lower rates of functional independence (43.1 vs. 63.7%), and larger infarct volumes. Additionally, the hypoxemia group had lower lymphocyte but higher neutrophil and monocyte counts. Inflammatory cytokine levels were significantly elevated in the hypoxemia group, includingIL22, IL-1β, IL-6, and IL-8. Logistic regression analysis identified six factors associated with functional prognosis, including ASPECTS score, age, hypoxemia, neutrophil count, lymphocyte count, and IL-1β level. Conclusion Hypoxemia during early phases may worsen functional prognosis of AIS patients after EVT and exacerbate inflammatory response.

Comparison of thrombectomy alone versus bridging thrombolysis in a US population using regression discontinuity analysis

The role of intravenous thrombolysis (IVT) in combination with endovascular thrombectomy (EVT) for the treatment of large vessel occlusion acute ischemic stroke has been evaluated exclusively outside the US, in randomized clinical trials which failed to demonstrate non-inferiority of skipping IVT. Because practice patterns and IVT dosing differ within the US, and prior observational US-based cohorts suggested improved clinical outcomes in patients who received IVT before EVT, a US-based evaluation is needed. This is a quasi-experimental study of a large US cohort using a regression discontinuity design (RDD) that enables the estimation of causal effects when randomization is not feasible. In this multi-center prospective cohort of patients undergoing EVT, we observed a sharp drop (65%) in the probability of receiving IVT at the cutoff of IVT eligibility time window while there were no significant differences in potential confounders including age, NIHSS, and ASPECTS at the cutoff. We found no association between IVT treatment and functional independence (mRS 0–2) at 90-days in patients undergoing EVT, nor in the secondary outcomes of excellent outcomes (mRS 0–1) at 90 days, mortality, symptomatic intracranial hemorrhage, first pass reperfusion, or final reperfusion.

Transarterial embolization for infants under 3 months of age with refractory seizures due to hemimegalencephaly: complication analysis and evolution of treatment strategy.

Hemimegalencephaly (HME) is a rare, congenital brain malformation associated with drug-resistant seizures that are challenging to manage in young infants. Hemispheric surgery in infants <3 months of age carries increased risks of blood loss and complications due to the fragility of the immature brain parenchyma and cerebral vasculature. Transarterial embolization (TAE) has emerged from an adjunct to surgery to a potential alternative to hemispherectomy in a subset of HME patients. To review the safety, efficacy, and evolution of TAE performed in infants <3 months of age with medically refractory seizures due to HME. We retrospectively reviewed patient demographics, intraprocedural events, procedure-related complications, and epilepsy characteristics for all infants who underwent TAE between 2013 and 2024 at a single quaternary institution. Thirteen patients underwent a total of 41 embolizations, with a mean age of 45.5±26.8 (range 10-99) days at first embolization. Procedure-related complications included femoral arterial occlusion (n=2), symptomatic intracranial hemorrhage resulting in progressive hydrocephalus requiring cerebrospinal fluid shunting (n=1), and non-target embolization (n=2). One mortality occurred from multifocal intraparenchymal hemorrhages due to post-procedure coagulopathy. Two patients developed delayed contralateral ischemic injury. Engel Class I (free of disabling seizures) was achieved in 72.7% (8/11) of patients, with a mean follow-up age of 4.4±3.6 (range 1.3-11.0) years. TAE is a potential alternative to hemispherectomy for refractory epilepsy due to HME in infants <3 months of age; however, technical and perioperative challenges remain important considerations. Optimizing patient selection and periprocedure care are critical factors to improve patient outcomes.

A telemedicine tool for acute stroke management in Malaysia: a smartphone application

BackgroundAccurate assessment of stroke severity, precise neuroimaging diagnosis, and seamless coordination among stakeholders are crucial in ensuring prompt diagnosis and treatment during acute stroke activation. The study aimed to assess how the telestroke tool JOIN enhances time metrics in acute stroke care, specifically by improving decision-making speed and thereby enhancing patients’ clinical outcomes.MethodsThis prospective cohort study was conducted at Seberang Jaya Hospital and Umum Sarawak Hospital in Malaysia. It included adult ischaemic stroke patients who arrived within 4.5 h of stroke onset at one of the two locations. Patients were divided into two groups: the pre-JOIN period using conventional communication versus the JOIN period using JOIN. Time metrics were collected from medical records and/or social networking services (pre-JOIN), and timestamp data (JOIN). Analysis was performed using the Statistical Package for the Social Sciences, with a total sample size of 120 patients.ResultsWith 60 patients in each group (pre-JOIN and JOIN), the mean (SD) ages were 57 (12.6) and 60 (14.1) respectively. Patients in both groups were similar at baseline, showing comparable stroke subtypes, events, and severity, primarily Lacunar Anterior Circulation Infarct with mild stroke as their initial occurrence. Both median door-to-imaging time and door-to-decision time were reduced by 6 min with JOIN, although the difference was not statistically significant. Thrombolysis rates and symptomatic intracranial haemorrhages were similar between groups, but door-to-needle time was significantly shorter with JOIN (78 [28.0] minutes versus 45 [42.0] minutes, p = 0.008). Most patients were discharged alive with similar modified Rankin Scale scores between the groups.ConclusionsDoor-to-needle time was shorter in the post-JOIN period than in the pre-JOIN period, suggesting that the implementation of JOIN may contribute to improved time metrics in acute stroke care. Its safety, affordability, ease of use, and additional features make it a promising telestroke tool, crucial for handling high patient volumes with limited resources.Trial registrationThis study was registered with the Malaysian National Medical Research Register and received ethical approval (NMRR ID-21-02363-XFT) from the Medical Research and Ethics Committee, Ministry of Health Malaysia dated 30-March-2023.

Development and validation of a nomogram to predict symptomatic intracranial hemorrhage following endovascular treatment in acute ischemic stroke: A single center retrospective, observational study.

Symptomatic intracranial hemorrhage (SICH) is a severe post-endovascular treatment (EVT) complication of acute ischemic stroke, leading to high morbidity, mortality, and neurological deficits. However, despite these risk factors, there is currently no clinically accepted predictive model to predict SICH risk in EVT patients. This study aimed to identify independent perioperative risk factors for SICH and to provide a new nomogram-based predictive model for large vessel occlusion patients. This study retrospectively examined 127 acute ischemic stroke patients receiving EVT from the First Affiliated Hospital of Wenzhou Medical University. Inclusion criteria included the National Institutes of Health Stroke Scale (NIHSS), Alberta Stroke Program Early CT Score (ASPECTS), and American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) collateral scores. Using these predictors, a logistic regression model was used to generate the NIHSS/ASPECTS/ASITN (NAA) nomogram. The predictive ability was measured with the area under the receiver operating characteristic curve and calibration plots. Our data demonstrated that SICH patients had significantly higher baseline NIHSS scores (median: 22.38 vs 15.03; P < .001), ASPECTS (median: 5.89 vs 7.69; P < .001), and ASITN/SIR scores (median: 1.62 vs 2.69; P < .001). The NAA nomogram exhibited an area under the receiver operating characteristic curve value of 0.845 (95% confidence interval: 0.763-0.928), which is superior to the predictive performance. Calibration plots were robust in predicting and observing values. The NAA nomogram is a robust predictor of SICH after EVT that is more accurate than any scoring system. More external validation is needed to make it generalizable to diverse clinical settings.

SUMMIT MAX: A randomized trial of the super large bore HiPoint Reperfusion System versus Vecta System for aspiration thrombectomy.

Background: Rapid and complete recanalization is a primary goal in the endovascular treatment of large vessel occlusion stroke. The effectiveness and safety of super large bore aspiration catheters (.088" inner diameter) for the treatment of large vessel occlusion stroke have not been demonstrated in a randomized trial. Methods: SUMMIT MAX was a prospective, randomized, controlled, open label clinical trial of patients with ICA and MCA M1 occlusions, comparing the super large bore HiPoint Reperfusion system (Route 92 Medical) to the Vecta Aspiration system (Stryker Neurovascular) (NCT05018650). We hypothesized that the effectiveness and safety of the HiPoint reperfusion system was non-inferior (12.5% non-inferiority margin) to the Vecta Aspiration system. The primary effectiveness endpoint was successful reperfusion, defined as mTICI ≥ 2b as adjudicated by an independent core lab, using only the assigned study device, with any use of a non-study device prior to or following use of study device defined as failure. The primary safety endpoint was symptomatic intracranial hemorrhage (sICH) within 24h (-8/+24) post-procedure. Results: There were 250 patients enrolled of whom 166 met criteria for the modified intent-to-treat population: 89 in HiPoint and 77 in Vecta. The median age was 69; 54.2% were female. Successful reperfusion with any adjunctive therapy counted as a failure was 77.5% (69/89) in the HiPoint group versus 50.6% (39/77) in the Vecta group (p<0.0001 for non-inferiority). SICH within 24h (-8/+24h) post procedure was similar between groups (3.6% vs. 2.7%, respectively). At 90 days, good clinical outcome (mRS<2) was achieved in 50.6% in the HiPoint group and 53.3% in the Vecta group (absolute difference -2.8%, 95% CI -18.2%, 12.7%, p=0.75). Conclusion: In this randomized trial of patients with anterior large vessel occlusion, the super large bore HiPoint system was non-inferior to the Vecta system in achieving successful reperfusion, with a similar safety profile. This study supports the super large bore HiPoint system for mechanical thrombectomy. Registration: NCT05018650.

Comparison of the Tigertriever and Self-expanding Stent Retrievers for Mechanical Thrombectomy of Acute Ischemic Stroke: A Single-center Experience.

Stent retrievers, including the novel Tigertriever, are important in mechanical thrombectomy for acute ischemic stroke due to a proximal large-vessel occlusion within the anterior circulation. We aimed to assess the efficacy and safety of the Tigertriever compared to self-expanding stent retrievers like EmboTrap, Solitaire, Trevo, or Tron. Patients treated at a stroke center for intracranial vessel occlusion in the anterior circulation between August 2022 and August 2024 were evaluated. The primary outcome was a modified first-pass effect, defined as a modified thrombolysis in cerebral infarction grade of 2b-3 after the first pass. Secondary outcomes included the first-pass effect, device-related serious adverse events, embolization in new territory, and hemorrhagic complications within 24 hours post-procedure. Data from 104 hemispheres in 103 patients were analyzed (24 in the Tigertriever group and 80 in the stent-retriever group). The Tigertriever group demonstrated a higher modified first-pass effect (70.8% vs. 52.5%; adjusted odds ratio 3.17; 95% confidence interval 1.06-9.47; p = 0.02). Although not statistically significant, vessel dissection (0% vs. 3.8%), subarachnoid hemorrhage (20.8% vs. 32.5%), and symptomatic intracranial hemorrhage (4.2% vs. 12.5%) within 24 hours post-procedure were lower in the Tigertriever group. No significant differences were observed in the first-pass effect or embolization in the new territory between the 2 groups. The Tigertriever might be effective for anterior circulation intracranial vessel occlusion, achieving a higher rate of modified first-pass effect. It might also be associated with minimal serious procedural complications, indicating its safety profile.

Comparison of the Aperio Hybrid® and Solitaire FR/X® stents for anterior circulation stroke thrombectomy across different time periods: A propensity score-matched analysis of recanalization and symptomatic hemorrhage.

IntroductionThrombectomy has become the standard treatment for acute ischemic stroke (AIS) caused by large vessel occlusions (LVOs). The Aperio Hybrid (Acandis, Pforzheim, Germany) is a new stent retriever designed to enhance the effectiveness of this treatment. However, this new stent has not yet been compared to other thrombectomy devices in a clinical setting. The aim of this study was to compare the Aperio Hybrid® with the Solitaire™ FR/X (Medtronic, Minneapolis, USA) during thrombectomy in patients with AIS due to anterior circulation LVO.Materials and methodsWe analyzed data from a multicenter registry of thrombectomy for anterior circulation LVO. Patients with carotid/M1 or proximal M2 occlusions who underwent thrombectomy with either the Aperio Hybrid® or Solitaire™ FR/X® were compared using propensity-score matching (PSM). The primary outcome was the recanalization rate, measured by the Treatment in Cerebral Ischemia (TICI) score of 2b-3, while the secondary outcome was the rate of symptomatic intracranial hemorrhage (sICH).ResultsAmong 455 patients treated, after PSM, 258 patients (129 per group) were analyzed. The adjusted recanalization rates (TICI 2b-3) for the Aperio Hybrid and Solitaire FR/X were 79.8% and 75.9%, respectively (p = .08), while the adjusted sICH rates were 6.9% and 6.2%, respectively (p = .80).ConclusionsIn this observational study on thrombectomy for AIS, the Aperio Hybrid and Solitaire FR/X demonstrated similar rates of recanalization and symptomatic intracranial hemorrhage. However, due to significant selection bias, these results should be interpreted with caution.

Endovascular Thrombectomy for Large Ischemic Core Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

The optimal management of acute ischemic stroke (AIS) patients with large vessel occlusion and large ischemic core is uncertain. We aimed to evaluate the safety and efficacy of endovascular thrombectomy (EVT) compared with best medical treatment (BMT) for AIS through a study-level meta-analysis and meta-regression of 6 randomized controlled trials (RCTs). PubMed, Embase, and the Cochrane databases were searched from January 1, 1980, to June 30, 2024. We limited search results to RCTs which compared EVT vs BMT among large-core AIS. The Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline was used for abstracting and assessing data quality and validity. The risk ratio (RR) with 95% CI was used to measure the association of EVT vs BMT with outcomes. Univariable meta-regression analyses were conducted to evaluate possible moderating effects of onset to randomization time (OTR) on outcomes when comparing EVT with BMT. The primary outcome was the 90-day ordinal modified Rankin Scale (mRS). Secondary outcomes were independent ambulation (mRS 0-3) at 90 days, and symptomatic intracranial hemorrhage (sICH) and mortality at 90 days. Six RCTs comprising 1,887 patients with large core AIS were included. Pooled results showed that EVT compared with BMT was associated with improved mRS score at 90 days (generalized OR, 1.6, 95% CI 1.4-1.8) and higher odds of independent ambulation (RR 1.9; 95% CI 1.5-2.5). Although the risk of sICH was higher in the EVT group (RR 1.7; 95% CI 1.1-2.7), there was a reduction in mortality in the EVT group (RR 0.9; 95% CI 0.8-1.0). Meta-regression showed that the benefit of EVT decreased with the extension of OTR (mRS 0-3, regression slope, -0.11, 95% CI -0.12 to -0.10; mRS 0-2, regression slope, -0.15, 95% CI -0.16 to -0.14). For patients with Alberta Stroke Program Early CT Score (ASPECTS) 0-2, EVT was associated with increased 90-day mRS 0-3 (RR 2.1, 95% CI 1.4-3.3) and mRS 0-2 (RR 2.8, 95% CI 1.2-6.7). EVT improved clinical outcomes among patients with large-core AIS assessed by ASPECTS of 3-5 or volumetric methods. Patients with ASPECTS 0-2 also had benefit from EVT and require further study. These results support expansion of the routine application of EVT.

Clinical outcomes of endovascular therapy in acute basilar artery occlusion with low pc-ASPECTS : Outcomes in ABAO with low pc-ASPECTS.

The effectiveness and safety of endovascular therapy (EVT) in patients with Acute Basilar Artery Occlusion (ABAO) with low pc-ASPECTS is unclear. To evaluate the effectiveness and safety of EVT in ABAO patients with low pc-ASPECTS. We analyzed 199 ABAO patients with pc-ASPECTS ≤ 6 who were prospectively registered in the BASILAR study. The patients were divided into the standard medical treatment group (SMT group) and the endovascular therapy group (EVT group). We compared the differences between the two groups in terms of primary outcomes (mRS scores of 0-3, 0-2 and 0-1 at 1year), secondary outcomes (mRS scores of 0-3, 0-2 and 0-1 at 90days), primary safety outcomes (symptomatic intracranial haemorrhage at 48h, mortality at 90days). Among the 199 patients, 134 (67.34%) were in the EVT group. Compared with the SMT group, the EVT group showed a significantly higher likelihood of achieving mRS score of 0-3 [adjusted OR [aOR] 21.17, 95% CI (2.08-215.43), P = 0.010] and mRS score of 0-2 [aOR 16.34, 95% CI (1.64-163.32), P = 0.017] at 1year. There was no significant difference in safety outcomes at 90days between the two groups. EVT improves long-term clinical outcomes in ABAO patients with pc-ASPECTS ≤ 6, patients undergoing EVT demonstrated significantly better functional outcomes at 1year compared to those receiving SMT, with no significant difference in mortality at 90days. Overall, ABAO patients treated with EVT achieve both effective and safe outcomes.

Effect of stereo-EEG versus subdural EEG on functional and seizure outcome in pediatric and adult epilepsy surgery: A 21-year single-center experience.

(1) To compare use, benefits, and complications of stereo-EEG (SEEG) and subdural EEG (SD) in presurgical epilepsy candidates. (2) To evaluate the effectiveness of both methods in delineation of the epileptogenic zone (EZ) and guiding tailored resective surgery. We included patients with SEEG or SD evaluations in children and adults at the Bethel Epilepsy Centre, Germany, between 2000 and 2020. We retrospectively assessed epilepsy related parameters, main indication of iEEG (intracranial EEG, for identification of the EZ and functional mapping), complications, seizure, and functional outcome. The second objective was addressed by a subgroup analysis in patients with focal cortical dysplasia (FCD) and mild malformation of cortical development with oligodendroglial hyperplasia (MOGHE) for delineation of the EZ. Two hundred and nineteen iEEG explorations in 215 patients (age range: 1.3-64.6 years) were assessed (SEEG, n = 78; SD, n = 141). We observed a change in iEEG usage away from SD towards SEEG. In the SEEG group, the decision rate against surgery was higher (SEEG: 23.1% vs. SE: 3.5%, p < .001) and more patients achieved seizure freedom 2 years after surgery (SEEG: 67.8% vs. SD: 46.5%, p = .008). For all iEEG, complications were rare; symptomatic intracranial bleeding only occurred in the SD group (n = 6, 4.3%). In patients with FCD/MOGHE for delineation of the EZ, all patients were operated with favorable seizure freedom after SEEG, but with acceptance of planned neurological deficits (SEEG n = 8, SD n = 20, seizure freedom rate SEEG 87.5% vs. SD 30%, p = .011; neurological deficits: SEEG n = 3 planned motor deficits vs. SD n = 1 unplanned motor deficit due to ischemia). SEEG has largely replaced SD in iEEG for the identification of the EZ. It is better tolerated and allows more freedom of choice with respect to resective surgery, resulting in the better identification of surgical candidates and delineation of the EZ with favorable seizure outcomes.

Leukoaraiosis severity and outcomes of endovascular thrombectomy for acute ischemic stroke: a systematic review and meta-analysis.

Endovascular thrombectomy (EVT) is the standard of care for eligible patients with large vessel occlusion (LVO). Yet, little is known regarding the impact of leukoaraiosis (LA) on outcomes following EVT for LVO. We conducted a systematic review and meta-analysis to investigate the impact of LA on outcomes following EVT. A literature search was performed in PubMed, Embase, Scopus, and Web of Science, from inception until January 7, 2024. Patients were categorized into two groups based on the level of LA: one with absent to mild LA (AMLA) and the other with moderate to severe LA (MSLA). The primary outcome of interest was 90-day modified Rankin Scale (mRS) 0-2. Secondary outcomes included symptomatic intracranial hemorrhage (sICH), thrombolysis in cerebral infarction (TICI) score 2b-3, and mortality. Using R software, we calculated pooled odds ratios (ORs) and their corresponding 95% confidence intervals (CI). We included 18 studies with 7022 patients. MSLA was associated with lower rates of mRS 0-2 (OR, 0.32 [95% CI: 0.26-0.41]; p < 0.001), similar rates of TICI 2b-3 (OR, 0.91 [95% CI: 0.77-1.07]; p = 0.235) and sICH (OR, 1.18 [95% CI: 0.92-1.51]; p = 0.202), and greater rates of mortality (OR, 2.89 [95% CI: 2.38-3.52]; p < 0.001) compared to AMLA. MSLA is associated with lower rates of mRS 0-2 and worse safety outcomes following EVT for LVO, despite similar rates of TICI 2b-3. Future prospective studies should further study MSLA as a prognosticator following EVT. Question Does the severity of LA impact functional and safety outcomes following EVT for acute ischemic stroke due to LVO? Findings Moderate-to-severe LA was associated with lower rates of good functional outcome and higher mortality following EVT, despite similar rates of successful reperfusion and sICH. Clinical relevance LA severity is an independent prognostic factor in EVT outcomes. Identifying patients with moderate-to-severe LA can aid in risk stratification and post-procedural management, optimizing individualized stroke treatment and follow-up strategies.

Influence of Asymptomatic Hemorrhagic Transformation After Endovascular Treatment on Stroke Outcome: A Population-Based Study.

In patients with acute ischemic stroke (AIS), the impact of hemorrhagic transformation (HT) after endovascular treatment (EVT) on poorer stroke outcome is well established when associated with clinical deterioration. However, the influence of asymptomatic HT remains unclear. We aimed to examine the impact of asymptomatic HT after EVT on functional outcome and mortality. Drawing on Catalan (Spain) population-based prospective stroke registry data, we included patients from 10 comprehensive stroke centers with anterior circulation AIS (2017-2023) who underwent EVT, excluding patients without data on the presence of HT or functional outcome at 3 months of follow-up. HT was categorized as parenchymal hemorrhage (PH), hemorrhagic infarct (HI) types 1 and 2, and remote PH (rPH). Asymptomatic HT was defined as any HT not causing death or the NIH Stroke Scale (NIHSS) score to increase by ≥ 4 points. Functional outcome was centrally assessed using the modified Rankin Scale (mRS). The primary end point was a shift in the 3-month mRS score. After excluding symptomatic intracerebral hemorrhage (sICH), multivariable ordinal regression analyses (adjusted by age, mRS, baseline NIHSS score, baseline Alberta Stroke Program Early CT Score, and modified Thrombolysis In Cerebral Infarction score ≥2b) were performed to test for asymptomatic HT association with the primary end point. We included 3,067 patients (72.0 ± 13.6 years, 50.7% women), 179 (5.8%) with sICH and 612 (20.0%) with asymptomatic HT. HT category frequencies were 8.9% HI1, 7.2% HI2, 4.4% PH1, 3.8% PH2, and 1.5% rPH. The percentage of asymptomatic patients showed a hierarchical distribution, ranging from 93.4% in HI1 to 25.0% in PH2. In the multivariable analysis, asymptomatic HT was associated with poorer outcomes (common odds ratio [cOR] 2.24, 95% CI 1.89-2.66) and higher mortality (adjusted odds ratio 1.50, 95% CI 1.17-1.91). In the sensitivity analyses, the association with functional outcome remained significant for each HT category, with asymptomatic PH2 showing the highest odds of poorer outcomes (cOR 3.15, 95% CI 1.46-6.83). In patients with AIS undergoing EVT, asymptomatic HT was associated with poorer functional outcomes and higher mortality, suggesting that any HT, regardless of its clinical impact or radiologic category, should be considered as an additional EVT safety measure.

Intravenous tirofiban in acute ischemic stroke patients not receiving reperfusion treatments: a systematic review and meta-analysis of randomized controlled trials.

Reperfusion treatments with intravenous thrombolysis and endovascular thrombectomy after acute ischemic stroke (AIS) can improve patients' outcomes significantly. Yet, a substantial portion of patients miss the opportunity to receive reperfusion treatments. In this study, we aimed to assess the role of intravenous tirofiban in this specific population. A search was performed in Embase, Cochrane Central Register of Controlled Trials, Medline, and Web of Science databases from inception until August 2024. The random-effects model was used to calculate odds ratios (ORs) with their corresponding 95% confidence intervals (CIs). Efficacy endpoints included excellent (modified Rankin scale of 0-1) and good (modified Rankin scale of 0-2) functional outcomes at 90 days. Safety outcomes included symptomatic intracerebral hemorrhage (sICH), any ICH, and 90-day mortality. Four randomized clinical trials, including a total of 1,199 patients, were included. Of these, 599 patients (50%) received tirofiban. The meta-analysis demonstrated that tirofiban was associated with significantly higher rates of both excellent (OR 1.63 [95% CI, 1.24-2.13]; I2 = 0) and good (OR 1.65 [95% CI, 1.19-2.29]; I2 = 0) functional outcomes at 90 days. No significant differences were observed in sICH, any ICH, or 90-days mortality. Treatment with intravenous tirofiban can be beneficial without increased risk in patients with AIS who are not eligible for reperfusion treatment. Further studies are still needed to validate the generalizability of these findings. https://www.crd.york.ac.uk/PROSPERO/view/CRD42024590097, CRD42024590097.

Sex-Related Differences in Endovascular Treatment Outcomes for Acute Large Infarcts: The ANGEL-ASPECT Subanalysis.

The outcomes of endovascular therapy (EVT) across sexes for large infarcts remain unclear. This study aimed to evaluate the impact of sex on the outcomes of EVT or medical management for patients with large infarcts. In this secondary analysis of the ANGEL-ASPECT (Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients With a Large Infarct Core) randomized controlled trial conducted at 46 stroke centers across China between October 2, 2020, and May 18, 2022, we compared baseline characteristics and clinical outcomes between males and females, and each cohort further divided into EVT and medical management groups. The primary outcome was the 90-day modified Rankin Scale score distribution. Safety outcomes included symptomatic intracranial hemorrhage within 48 hours and mortality within 90 days. There were 176 of 455 patients enrolled in the ANGEL-ASPECT trial who were female. There were 54.0% (95/176) of females and 48.4% (135/279) of males who underwent EVT. The treatment effect of EVT did not vary in both sexes with large infarcts (all P>0.05 for interaction). Compared with medical management, EVT improved 90-day functional outcomes for both males (3 [2-5] versus 4 [3-5]; common odds ratio, 1.94 [95% CI, 1.27-2.97]; P=0.002) and females (4 [3-6] versus 5 [4-6]; common odds ratio, 2.50 [95% CI, 1.41-4.45]; P=0.002). The symptomatic intracranial hemorrhage rate was not different in both treatment groups across both sexes (males, 5.2% versus 2.8%; odds ratio, 2.05 [95% CI, 0.56-7.50]; P=0.278; females, 7.4% versus 2.5%; odds ratio, 2.89 [95% CI, 0.55-15.14]; P=0.210). In patients with large ischemic core, the treatment effect of EVT did not differ between females and males, with better outcomes with EVT versus medical management, without an increased risk of symptomatic intracranial hemorrhage. These findings emphasize the need for equal attention and care for both sexes with large infarcts in clinical practice. URL: https://www.clinicaltrials.gov; Unique identifier: NCT04551664.

Endovascular Treatment of Acute Large Vessel Occlusion in the Anterior and Posterior Circulation.

Endovascular treatment (EVT) has been strongly recommended as a first-line treatment for acute ischemic strokes (AIS) caused by large vessel occlusion (LVO). To evaluate the efficacy, safety, and predictors of favorable outcomes of EVT for LVO-caused AIS in both the anterior and posterior circulations, consecutive patients who had undergone EVT for AISs caused by LVO were retrospectively enrolled, and the clinical data, symptomatic intracranial hemorrhage (sICH), modified Rankin Scale (mRS) score, and mortality at 90 days were analyzed. In total, 231 patients were enrolled with a mean age of 63.25 ± 11.48 years, including 167 (72.29%) patients with anterior circulation occlusion (ACO) and 64 (27.71%) patients with posterior circulation occlusion (PCO) treated with EVT. The median baseline National Institutes of Health Stroke Scale (NIHSS) Score on admission was 17 (12-20). The median time from symptom onset to recanalization (OTR) was 380 (307.5-461) minutes. Successful recanalization was achieved in 90.04% of patients. At 3-month follow-up, 118 (51.08%) patients had favorable clinical outcomes (mRS 0-2), with a mortality rate of 18.61% (43/231). Younger age (p = 0.001), a lower baseline NIHSS score (p < 0.001), a higher recanalization rate (p = 0.018), and shorter OTR time (p = 0.026) were significant independent risk factors for favorable outcomes. Compared to patients with ACO, PCO patients had a lower favorable outcome rate (p = 0.049) and a higher mortality rate (p < 0.001). In conclusion, EVT is safe and effective for patients with LVO-caused AIS, and younger age, lower baseline NIHSS scores, a higher recanalization rate, and shorter OTR time are independent risk factors for favorable outcomes. PCO patients may have worse clinical outcomes and a higher mortality rate than ACO patients.

Feasibility of emergent single-step intracranial self-expanding stent deployment using over-the-wire coronary balloons in intracranial atherosclerosis-related large vessel occlusion thrombectomy.

The currently US Food and Drug Administration approved intracranial stent delivery system involves a multistep deployment process that requires the use of an exchange length microwire (ELW). In this study, we describe a single-step approach to deploy the Neuroform Atlas stent without the need for ELW or lesion re-access, using the MINI TREK II over-the-wire (OTW) semi-compliant coronary balloon. We performed a retrospective review of prospectively maintained mechanical thrombectomy databases from two comprehensive stroke centers. The study included consecutive large vessel occlusion (LVO) stroke patients who underwent single-step angioplasty with the MINI TREK II OTW balloon followed by deployment of the Neuroform Atlas intracranial stent, without the use of an ELW. A total of 12 patients met the inclusion criteria. Among them, the median age was 67 years (IQR: 58-73) and 50% were female. Most patients had middle cerebral artery (MCA) M1 occlusion (75%). One-third of the patients received intravenous thrombolysis. All patients achieved successful reperfusion (modified Treatment in Cerebral Ischemia (mTICI) 2b/3) with a median of two passes. The median National Institutes of Health Stroke Scale (NIHSS) score decreased from 14 (IQR: 10-19) at baseline to 4 (IQR: 1-9) at discharge, and the median modified Rankin Scale (mRS) score was 1 (IQR: 1-4) at discharge and 3 (IQR: 2-4) at 90 days. None of the patients in this series experienced symptomatic intracranial hemorrhage, though two patients (16.7%) were dead at 90 days but there was no procedural-related mortality. This preliminary experience demonstrates the technical feasibility and success of single-step deployment of the Neuroform Atlas stent following angioplasty with the MINI TREK II OTW balloon, without the need for an ELW or lesion re-access. Larger prospective studies with extended clinical follow-up are needed to validate these findings.