Tertiary Stroke Center Research Articles

Abstract 12: High HDL Cholesterol Is Associated With Reduced Reperfusion Injury And Favorable Functional Outcome Following Thrombectomy For Ischemic Stroke

Introduction: Animal research suggests that HDL cholesterol (HDL-C) ameliorates reperfusion injury, a phenomenon that worsens clinical outcome following recanalization therapy for ischemic stroke. Hypothesis: We hypothesized that higher HDL-C levels have a guarding effect against cerebral reperfusion injury in human stroke survivors treated with thrombectomy. Methods: We included patients with anterior circulation large vessel occlusion (acLVO) stroke who underwent thrombectomy from 01/2017 to 01/2023 at a tertiary stroke center in Germany into a prospective registry study with retrospective analysis. We assessed the association of HDL-C serum levels and imaging indices of post interventional reperfusion injury (any intracerebral or subarachnoid bleeding involving the ischemic brain region on CT or MRT), functional outcome quantified via modified Rankin scale (mRS) at 90 days and neurological outcome via National Institutes of Health Stroke Scale (NIHSS) score at discharge using multivariable lasso logistic and linear regression adjusted for demographic, clinical and imaging characteristics. We performed sensitivity analysis applying propensity score matching and shift analysis using ordered logistic regression. Results: In our study population of 811 acLVO patients treated with thrombectomy (420 females, median age 77 years [66-84, interquartile range]) reperfusion injury was associated with detrimental functional outcome (adjusted OR 2.87; 95% CI [1.86;4.41]; p=0.000). Higher HDL-C was associated with lower odds of reperfusion injury (adjusted OR 0.57; 95% CI [0.35;0.95]; p=0.03) and emerged as predictor of favorable functional outcome defined as 90-day mRS 0-2 (adjusted OR 0.57; 95% CI [0.34;0.99]; p=0.04) and alleviated neurological deficits with lower NIHSS score at discharge (ß=-2.51; 95CI% [-4.88; -1.30]; p=0.04). On propensity score analysis an HDL-C level exceeding the median (1.15 mmol/L) was associated with a 13.8 % decrease in the probability of reperfusion injury (ß=-0.14; 95CI% [-0.23; -0.05]; p=0.003). A significant shift of 90-day mRS distribution favoring high HDL is shown in the figure. Conclusions: In patients undergoing thrombectomy for acLVO a higher level of HDL-C reduced the odds of reperfusion injury, which translated into improved functional and neurological outcome, hence constituting a possible target of adjunctive neuroprotective treatment.

Precision in Stroke Care: A Novel Model for Predicting Functional Independence in Urgent Carotid Intervention Patients.

Stroke requires timely intervention, with carotid endarterectomy (CEA) and carotid artery stenting (CAS) increasingly used in select acute carotid-related stroke patients. We aimed to build a model to predict neurologic functional independence (modified Rankin scale, mRS ≤ 2) in this high-risk group. We analyzed data from 302 stroke patients undergoing urgent CEA or CAS between 2015 and 2023 at a tertiary Comprehensive Stroke Center. Predictors included: (1) stroke severity (NIH Stroke Scale, NIHSS), (2) time to intervention (≤48 hours), (3) thrombolysis use, and (4) frailty risk score. Two-way interactions were included to enhance generalizability without overfitting. Multiple models were constructed and selected based on the area under the ROC curve (AUC). The primary endpoint was discharge neurological functional independence (mRS ≤2). Presenting clinical factors and neurological outcomes data from 302 patients undergoing urgent CEA and CAS during the index hospitalization from 2015 to 2023 at a tertiary Comprehensive Stroke Center formed the model's foundation. Most patients (72.8%, 220/302) were discharged functionally independent (mRS ≤ 2). The combined 30-day rate of stroke, death, and MI was 8.3% (25/302); 6.5% (14/214) for CEA alone, and 12.5% (11/88) for CAS. The model, incorporating thrombolysis, time to intervention, stroke severity (NIHSS), and frailty risk, correctly predicted 93% of functional independence outcomes (AUC 0.808). We present a novel model using four clinical factors-stroke severity, time to intervention, thrombolysis use, and frailty risk-to predict functional neurologic independence with 93% accuracy in patients undergoing urgent carotid interventions for acute stroke. This high predictive capability can enhance clinical decision-making and improve patient outcomes by identifying those most likely to benefit from timely carotid revascularization.

Impact of COVID-19 pandemic on acute stroke care in a tertiary stroke centre

The aim of this study was to evaluate how COVID-19 affected acute stroke care and outcome in patients with acute ischemic or hemorrhagic stroke. We performed a retrospective analysis on patients who were admitted with acute ischemic (AIS) or hemorrhagic (ICH) stroke from September 2020 to May 2021 with and without COVID-19. We recorded demographic and clinical data, imaging parameters, functional outcome and mortality at one year. Beside descriptive statistics we performed χ2-probe, Mann-Witney U-test, Student t-probe and multivariate testing. We found a 29%-reduction in the number of AIS cases during the pandemic. The number of the large vessel occlusions /LVOs/ (N = 83, 41.7%), from them 37 (17.7%) had mechanical thrombectomy (MT), was higher than before the COVID-19 period (p = 0.02 and p = 0.001, respectively). From all patients needing acute revascularization therapy (N = 137) 118 patients received it, among them 20 (16.9%) had COVID-19. Those positive for COVID-19 were more likely to have a higher median NIHSS score at baseline and at 24 h (p = 0.02 and p = 0.03, respectively). They also had a lower rate of favourable outcome at discharge (15% vs. 41.8%; p = 0.024) and at three months (25% vs. 52%, p = 0.02), longer median hospitalization (p < 0.0001), and a higher mortality rate (52% vs. 25%; p = 0.03). The incidence of symptomatic intracerebral hemorrhage (sICH) did not differ between the groups. Regarding the ICH patients, NIHSS score at 24 h (p = 0.036), mortality at 3 months (p = 0.004) and at one year (p = 0.00) were higher in the COVID-19 group. We concluded that the pandemic resulted fewer admission due to AIS with an increased number of LVOs and MTs. AIS patients with concomitant SARS-CoV-2 infection have more severe strokes and unfavorable long term outcome. The risk of sICH was not increased in COVID-19 positive patients therefore reperfusion therapies appear to be safe and beneficial for some individuals. Patients with ICH and comorbid COVID-19 have a very poor prognosis.

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.

An Audit of Best Medical Therapy Adherence Among Patients with Carotid Artery Stenosis Attending a Tertiary Stroke Centre

Abstract Background Carotid artery stenosis (CAS) is estimated to cause 11-28% of ischaemic strokes annually. The primary objective of this audit was to assess current adherence to best medical therapy (BMT) to patients with CAS in a tertiary stroke centre. Our secondary aim was to assess stability, regression or progression of CAS whilst on BMT. Methods A retrospective chart review was conducted in a tertiary stroke centre over a six-week period. Patients were included if they were aged over 18 years, presenting to an outpatient stroke clinic, and had a known diagnosis of either symptomatic or asymptomatic CAS. The European Stroke Organisation Guidelines were used to define BMT. Results A total of 56 charts were reviewed at three weekly outpatient clinics. Of the 27 patients meeting our inclusion criteria 66% (n=18) were male, median degree of CAS was 50-70% and 78% (n=20) had symptomatic CAS. 89% were on BMT but only 56% achieved a low-density lipoprotein cholesterol (LDL-C) target of &amp;lt;1.8 (median 1.6 (range: 0.7-4.2) and only 66% (n=18) had a documented smoking status. 81% of patients with symptomatic CAS on BMT had stable stenosis, 5% had regression and 14% had progression of stenosis. 50% of asymptomatic patients had progression of the degree of their stenosis. Conclusion Overall adherence to BMT was good at 89% but there is room for improvement particularly in terms of lipid target level and documentation of risk factor status. BMT resulted in stable stenosis and low progression rates particularly in patients with symptomatic CAS. BMT and early detection are essential for management to control progression of CAS, but we have highlighted the opportunity to improve LDL-C targets. Further research is needed to evaluate if the results of this study are translatable to the stroke population in general.

Telemedicine-Enabled Ambulances for Prehospital Acute Stroke Management: A Pilot Study

ObjectiveTo assess the feasibility and potential scalability of telemedicine-enabled ambulances for the prehospital evaluation of patients with suspected acute stroke symptoms. Patients and MethodsA pilot study of telemedicine-enabled ambulances for evaluating patients with suspected acute stroke symptoms en route at 2 tertiary academic comprehensive stroke centers from January 1, 2018, to February 5, 2024. Charts of included patients were reviewed for demographic data, vascular risk factors, final diagnosis, time from arrival to neuroimaging, door-to–needle and door-to-puncture times in patients eligible for acute treatment, and any reported technical challenges during audio-video consultations. ResultsForty-seven patients (mean age, 68.0 years; 62% men) were evaluated via telemedicine-enabled ambulances, of which 35 (74%) where for hospital-to-hospital transferred patients. Mean time from arrival to neuroimaging was 11.8 minutes. Twenty-nine patients (62%) were diagnosed with acute ischemic stroke, and the remainder were diagnosed with intracranial hemorrhage (n=13), seizure (n=2), brain mass (n=1), or other diagnoses (n=3). Four patients (9%) received intravenous thrombolysis with alteplase (mean door to needle, 30.3 minutes), and 15 patients (32%) underwent mechanical thrombectomy (mean door to puncture, 72 minutes). Technical challenges were reported in 15 of the 42 (36%) cases, of which 10 (67%) were related to poor internet connectivity. ConclusionTelemedicine-enabled ambulances in emergency medical services systems are novel, feasible, and potentially scalable options for evaluating patients with suspected acute stroke in the prehospital setting. However, optimization of infrastructure, staffing models, and internet connectivity is necessary, and larger studies evaluating the clinical and cost effectiveness of this approach are needed before widespread implementation.

A predictive score for atrial fibrillation in poststroke patients.

Atrial fibrillation (AF) is a risk factor for cerebral ischemia. Identifying the presence of AF, especially in paroxysmal cases, may take time and lacks clear support in the literature regarding the optimal investigative approach; in resource-limited settings, identifying a higher-risk group for AF can assist in planning further investigation. To develop a scoring tool to predict the risk of incident AF in the poststroke follow-up. A retrospective longitudinal study with data collected from electronic medical records of patients hospitalized and followed up for cerebral ischemia from 2014 to 2021 at a tertiary stroke center. Demographic, clinical, laboratory, electrocardiogram, and echocardiogram data, as well as neuroimaging data, were collected. Stepwise logistic regression was employed to identify associated variables. A score with integer numbers was created based on beta coefficients. Calibration and validation were performed to evaluate accuracy. We included 872 patients in the final analysis. The score was created with left atrial diameter ≥ 42 mm (2 points), age ≥ 70 years (1 point), presence of septal aneurysm (2 points), and score ≥ 6 points at admission on the National Institutes of Health Stroke Scale (NIHSS; 1 point). The score ranges from 0 to 6. Patients with a score ≥ 2 points had a fivefold increased risk of having AF detected in the follow-up. The area under the curve (AUC) was of 0.77 (0.72-0.85). We were able structure an accurate risk score tool for incident AF, which could be validated in multicenter samples in future studies.

The relationship between intracranial atherosclerosis and white matter hyperintensity in ischemic stroke patients: a retrospective cross-sectional study using high-resolution magnetic resonance vessel wall imaging.

Both intracranial atherosclerosis and white matter hyperintensity (WMH) are prevalent among the stroke population. However, the relationship between intracranial atherosclerosis and WMH has not been fully elucidated. Therefore, the aim of this study was to investigate the relationship between the characteristics of intracranial atherosclerotic plaques and the severity of WMH in patients with ischemic stroke using high-resolution magnetic resonance vessel wall imaging. Patients hospitalized with ischemic stroke and concurrent intracranial atherosclerosis at Beijing Tsinghua Changgung Hospital, a tertiary comprehensive stroke center, who underwent high-resolution magnetic resonance vessel wall imaging and conventional brain magnetic resonance imaging were continuously recruited from January 2018 to December 2018. Both intracranial plaque characteristics (plaque number, maximum wall thickness, luminal stenosis, T1 hyperintensity, and plaque length) and WMH severity (Fazekas score and volume) were evaluated. Spearman correlation or point-biserial correlation analysis was used to determine the association between clinical characteristics and WMH volume. The independent association between intracranial plaque characteristics and the severity as well as WMH score was analyzed using logistic regression. The associations of intracranial plaque characteristics with total white matter hyperintensity (TWMH) volume, periventricular white matter hyperintensity (PWMH) volume and deep white matter hyperintensity (DWMH) volume were determined using multilevel mixed-effects linear regression. A total of 159 subjects (mean age: 64.0±12.5 years; 103 males) were included into analysis. Spearman correlation analysis indicated that age was associated with TWMH volume (r=0.529, P<0.001), PWMH volume (r=0.523, P<0.001) and DWMH volume (r=0.515, P<0.001). Point-biserial correlation analysis indicated that smoking (r=-0.183, P=0.021) and hypertension (r=0.159, P=0.045) were associated with DWMH volume. After adjusting for confounding factors, logistic regression analysis showed plaque number was significantly associated with the presence of severe WMH [odds ratio (OR), 1.590; 95% CI, 1.241-2.035, P<0.001], PWMH score of 3 (OR, 1.726; 95% CI, 1.074-2.775, P=0.024), and DWMH score of 2 (OR, 1.561; 95% CI, 1.150-2.118, P=0.004). Intracranial artery luminal stenosis was associated with presence of severe WMH (OR, 1.032; 95% CI, 1.002-1.064, P=0.039) and PWMH score of 2 (OR, 1.057; 95% CI, 1.008-1.109, P=0.023). Multilevel mixed-effects linear regression analysis showed that plaque number was associated with DWMH volume (β=0.128; 95% CI, 0.016-0.240; P=0.026) after adjusted for age and sex. In ischemic stroke patients, intracranial atherosclerotic plaque characteristics as measured by plaque number and luminal stenosis were associated with WMH burden.

High prevalence of intracranial arterial stenosis among acute ischemic stroke patients in a Brazilian center: a transcranial color-coded duplex sonography study.

There is limited data available regarding the prevalence of intracranial arterial stenosis (ICAS) among acute ischemic stroke (AIS) patients in Brazil and Latin America. The present study sought to investigate the frequency and predictors of ICAS among patients with AIS or transient ischemic attack (TIA) in a Brazilian center, with transcranial color-coded duplex sonography (TCCS) technique. Consecutive AIS and TIA patients, admitted to an academic public comprehensive stroke center in Brazil from February to December 2014, evaluated by TCCS were prospectively selected. Vascular narrowings > 50% were considered as ICAS, based on ultrasound criteria previously defined in the literature. We assessed 170 consecutive patients with AIS or TIA, of whom 27 (15.9%) were excluded due to an inadequate transtemporal acoustic bone window. We confirmed ICAS in 55 patients (38.5%). The most common location was the proximal segment of the middle cerebral artery (28.2%), followed by the vertebral (15.4%), posterior cerebral (13.6%), terminal internal carotid (9.1%) and basilar (8.2%) arteries. On multivariate models adjusting for potential confounders, systolic blood pressure (OR: 1.03, 95%CI: 1.01-1.04; p = 0.008) was independently associated with ICAS. We found significant ICAS in approximately ⅓ of patients admitted with symptoms of AIS or TIA in a public tertiary academic stroke center in Brazil. The TCCS is an accessible and noninvasive technique that can be used to investigate the presence of moderate and severe ICAS, especially in patients who cannot be exposed to more invasive exams, such as the use of intravenous contrast agents.

External Validation of Vision, Aphasia and Neglect, Ventura Emergent Large Vessel Occlusion and Large Artery Intracranial Occlusion Screening Tools for Emergent Large Vessel Occlusion Stroke: A Multicenter, Prospective, Cross-Sectional Study

BackgroundVision, Aphasia, and Neglect (VAN), Ventura Emergent Large Vessel Occlusion (VES), and Large Artery Intracranial Occlusion (LARIO) are promising stroke screening tools that were shown to have high diagnostic performance to detect Emergent Large Vessel Occlusion (ELVO) in their derivation studies. ObjectivesThis study aimed to assess the validation of VAN, VES, and LARIO in predicting ELVO among patients presenting at emergency department (ED) triage with suspected acute ischemic stroke. MethodsThis is a prospective multicenter study conducted in five EDs of tertiary stroke centers between June and October 2023. Patients with suspected stroke admitted to ED for triage were evaluated using the VAN, VES, and LARIO stroke screening tools. Diagnostic performances of these tools for predicting ELVO were determined and compared with the National Institute of Health Stroke Scale (NIHSS). ResultsA total of 614 patients were included. The prevalence of ELVO was found to be 23.5% in the study population. VAN exhibited a sensitivity of 70.1% and specificity of 78.7%, VES showed a higher sensitivity (79.1%) with lower specificity (63.4%), while LARIO displayed high specificity (86%) with lower sensitivity (56.3%). Receiver operating characteristic curve analysis showed that LARIO and NIHSS had similar diagnostic performance (areas under the curve [AUC] 0.801 and 0.805, p = 0.7, respectively), while VES showed a modestly poorer performance (AUC 0.746, p < 0.001 and p = 0.003). ConclusionThe comparable diagnostic performance of VAN, VES, and LARIO to the NIHSS, in addition to their straightforwardness and rapid evaluation time, can facilitate optimal care for patients with ELVO in prehospital or ED triage settings.

Impact of demographic and clinical factors on in-hospital delays in acute ischemic stroke treatment.

Delays in reperfusion treatment, both intravenous thrombolysis (IVT) and endovascular treatment (EVT), adversely affect outcomes in patients with acute ischemic stroke (AIS). To alleviate these delays, it is essential to comprehend how patients' baseline and stroke characteristics impact in-hospital reperfusion delays. While demographic and socioeconomic factors affect stroke outcomes, their impact on in-hospital delays remains unclear. This is retrospective analysis at a tertiary stroke center, encompassing AIS patients receiving IVT and / or EVT between 2019 and 2022 (re-canalization cohort). Outcomes of interest were time intervals of admission to CT and admission to recanalization. Univariable analyses explored age, gender, baseline functional status, socioeconomic status (SES), ethnicity, vascular risk factors, and stroke characteristics. Subsequently, multivariable logistic regression analyses were performed. Altogether, 313 patients treated with IVT and 293 with EVT were included in the re-canalization cohort. No demographic variables were found to be associated with stroke treatment time intervals. Following multivariable analysis, stroke severity (low NIHSS, p < 0.01), arrival to the hospital by other means than ambulance (p < 0.01), and atypical stroke symptoms (p < 0.01), were associated with in-hospital delays, both in the EVT and the IVT groups. Our findings indicate that patients with a more severe ischemic stroke, typical stroke symptoms, and arrival by ambulance have shorter stroke treatment time intervals. These results emphasize that, in atypical cases, even a lower suspicion of stroke should promote urgent workup for stroke diagnosis. Our findings do not indicate any influence of demographic or SES on in-hospital reperfusion delays.

Resuscitation orders demonstrate differences by gender, stroke type and intervention

Background and purposeResuscitation orders describe individual preferences and types of intervention, such as suitability for cardiopulmonary resuscitation (CPR), that may provide benefit in the event of critical deterioration. The purpose of this study was to examine stroke inpatient resuscitation order completion and content. MethodsThis retrospective cohort study examined resuscitation orders in consecutive individuals admitted to a tertiary stroke centre over a 21-month period. Multivariable logistic regression was used to identify factors associated with resuscitation order completion and content. Results1924 individuals were included in the study. The proportion of individuals who had resuscitation orders completed was 37.4%. Several factors were associated with an increased likelihood of resuscitation order completion including having received endovascular thrombectomy (p=0.013) and having intracerebral haemorrhage (p=0.001). Females were more likely to have a resuscitation order that is not for CPR (p=0.021, OR 95%CI 1.080-2.542). Patients with intracerebral haemorrhage were also more likely to be not for CPR (p=0.037, OR 95%CI 1.039-3.353). ConclusionsDisparities exist in resuscitation order completion and content based on demographic and stroke characteristics. Further research is required to identify the reasons for these differences and to optimise resuscitation order completion.

Clinical Characteristics, Functional Outcome, and Socioeconomic Impact of Ischemic Stroke among Young Egyptian Adults.

Stroke in young patients results in disproportionately high societal cost given the productive life-years lost. Little is known about stroke in young Egyptian patients. We aimed to analyze clinicodemographic characteristics, functional outcome, and socioeconomic impact of ischemic stroke among young Egyptian adults. This is a prospective, observational cohort study of consecutively recruited patients with acute ischemic stroke (AIS), 18-50 years, between September 2022 and September 2023 at a tertiary stroke center in the south of Egypt. We recorded baseline demographic and cardiovascular risk factors, stroke severity, stroke subtype according to the TOAST classification, intravenous thrombolysis, employment, and ambulation status pre- and post-stroke, post-stroke complications, and 90-day functional outcome measured by the modified Rankin Scale (mRS). Our cohort comprised 210 patients, 38.0 (±7.8) years, 89 (42%) females. Mean NIHSS score was 11.2 (±4.8); in-hospital case fatality was 9% (19 patients). Dyslipidemia (n = 105, 50%), smoking (n = 105, 50%), and hypertension (n = 67, 32%) were the most prevalent cardiovascular risk factors. At 90 days, 58 (29%) patients had a 90-day mRS 0-1 and 53 (26%) met criteria for depression diagnosis. Sixty-nine of the 116 employed individuals (59%) remained out of work after 90 days of stroke, 61 of whom were single earners in their household. 36/60 (60%) thrombolysis-eligible patients received it; an additional 98 otherwise thrombolysis-eligible patients presented &gt;4.5 h from symptom onset. Patients receiving IV thrombolysis were significantly more likely to have resumed full-time work at 90 days (32% vs. 11%, p = 0.006) but with no significant difference in 90-day mRS. Young adult AIS patients in Egypt experience high rates of post-stroke depression and face challenges in their ability to work and provide for their families. Since most patients have treatable cardiovascular risk factors and only about two-thirds of eligible patients receive thrombolysis, reinforcing primary prevention, education about early stroke signs, and benefits of acute can improve outcomes and have significant potential societal benefit.

Prevalence of right-to-left shunt in stroke patients with cancer.

Cancer is associated with an increased risk of acute ischemic stroke (AIS) and venous thromboembolism. The role of a cardiac right-to-left shunt (RLS) as a surrogate parameter for paradoxical embolism in cancer-related strokes is uncertain. We sought to investigate the relationship between the presence of an RLS and cancer in AIS patients. We included consecutive AIS patients hospitalized at our tertiary stroke center between January 2015 and December 2020 with available RLS status as detected on transesophageal echocardiography (TEE). Active cancers were retrospectively identified and the association with RLS was assessed with multivariable logistic regression and inverse probability of treatment weighting to minimize the ascertainment bias of having a TEE obtained. Of the 2236 AIS patients included, 103 (4.6%) had active cancer, of whom 24 (23%) were diagnosed with RLS. An RLS was present in 774 out of the 2133 AIS patients without active cancer (36%). After adjustment and weighting, the absence of RLS was associated with active cancer (adjusted odds ratio (aOR) 2.29; 95% confidence interval (CI), 1.14-4.58). When analysis was restricted to patients younger than 60 years of age or those with a high-risk RLS (Risk of Paradoxical Embolism Score ⩾ 6), there was no association between RLS and cancer (aOR, 3.07; 95% CI, 0.79-11.88 and aOR, 0.56; 95% CI, 0.10-3.10, respectively). RLS was diagnosed less frequently in AIS patients with cancer than in cancer-free patients, suggesting that arterial sources may play a larger role in cancer-related strokes than paradoxical venous embolization. Future studies are needed to validate these findings and evaluate potential therapeutic implications, such as the general indication, or lack thereof, for patent foramen ovale (PFO) closure in this patient population.

Sex Differences in Outcomes after Endovascular Thrombectomy for Patients with Acute Ischemic Stroke

Introduction: Endovascular thrombectomy (EVT) is the standard of care for patients with large-vessel occlusion acute ischemic stroke (AIS). There may be differing recanalization effectiveness based on patients’ sex, and understanding such variations can improve patient outcomes by adjusting for differences. We aimed to assess the sex differences in outcome after EVT for patients with AIS. Methods: We retrospectively analyzed 250 consecutive AIS patients who underwent EVT from July 2019 to February 2022 across two large comprehensive tertiary care stroke centers in China. Outcomes of male patients were compared to females, where poor outcome was defined as a modified Rankin score (mRS) of 3–6 at 90 days. Results: Male patients had higher rates of symptomatic intracranial hemorrhage (sICH) (12.50% vs. 4.05%, p = 0.042) and higher hospitalization costs (114,541.08 vs. 105,790.27 RMB, p = 0.024). Male patients also had a longer median onset-to-needle time (ONT) (146.00 [104.00, 202.00] versus 120.00 [99.25, 144.75], p = 0.026). However, there were no differences in hospitalization length (p = 0.251), 90-day favorable outcome (p = 0.952), and 90-day mortality (p = 0.931) between the sexes. Conclusion: Female patients had lower hospitalization costs and sICH rates than males after EVT for AIS. Identifying such differences and implementing measures, including adaptations to workflow optimization, would help to reduce the ONT and last known normal-to-puncture time seen in males to improve patient outcomes. Despite such variations, favorable outcomes and mortality are similar in female and male AIS patients.

How much of the variance in functional outcome related to intracerebral hemorrhage volume is already apparent in neurological status at admission?

BackgroundHematoma volume is a major pathophysiological hallmark of acute intracerebral hemorrhage (ICH). We investigated how the variance in functional outcome induced by the ICH volume is explained by neurological deficits at admission using a mediation model.MethodsPatients with acute ICH treated in three tertiary stroke centers between January 2010 and April 2019 were retrospectively analyzed. Mediation analysis was performed to investigate the effect of ICH volume (0.8 ml (5% quantile) versus 130.6 ml (95% quantile)) on the risk of unfavorable functional outcome at discharge defined as modified Rankin Score (mRS) ≥ 3 with mediation through National Institutes of Health Stroke Scale (NIHSS) at admission. Multivariable regression was conducted to identify factors related to neurological improvement and deterioration.ResultsThree hundred thirty-eight patients were analyzed. One hundred twenty-one patients (36%) achieved mRS ≤ 3 at discharge. Mediation analysis showed that NIHSS on admission explained 30% [13%; 58%] of the ICH volume-induced variance in functional outcome at smaller ICH volume levels, and 14% [4%; 46%] at larger ICH volume levels. Higher ICH volume at admission and brainstem or intraventricular location of ICH were associated with neurological deterioration, while younger age, normotension, lower ICH volumes, and lobar location of ICH were predictors for neurological improvement.ConclusionNIHSS at admission reflects 14% of the functional outcome at discharge for larger hematoma volumes and 30% for smaller hematoma volumes. These results underscore the importance of effects not reflected in NIHSS admission for the outcome of ICH patients such as secondary brain injury and early rehabilitation.

Mechanical thrombectomy for middle cerebral artery M2 occlusions.

The safety and efficacy of mechanical thrombectomy (MT) for proximal large vessel occlusion after acute ischemic stroke (AIS) have been demonstrated. Clinical investigations of endovascular approaches for treating AIS due to M2 occlusions have been ongoing. To assess the outcomes of M2 occlusions according to treatment modality and anatomical division. A total of 113 consecutive M2 occlusions treated with endovascular treatment (EVT) at our tertiary stroke center between January 2019 and December 2022 were retrospectively analyzed. Patients were divided into three groups: mechanical thrombectomy (MT); intravenous thrombolysis plus MT (IVT + MT); and IVT alone. The primary outcomes were good prognosis (mRS = 0-2) and mortality (mRS = 6) on day 90. The secondary outcome was to determine the differences in outcomes between lesions in the superior and inferior branches of M2. In total, 55 (48.7%) patients underwent MT. In 42 (37.2%) patients, bridging IVT was performed with MT, and IVT alone was applied in 16 (14.2%) patients. Neither the prognosis at 90 days nor the mortality rate significantly differed among the groups. The outcomes did not significantly differ between occlusions in the superior and inferior branches of M2. MT was found to be safe and effective for treating M2 occlusions in this series.

Thrombus discrimination with electron density: potential implications for non-contrast computed tomography imaging.

The potential clinical usefulness of electron density (ED) imaging, that can be directly estimated using dual-layer spectral computed tomography (CT), has been poorly investigated. We explored whether ED imaging might improve thrombus identification compared to conventional imaging in vitro. We evaluated mechanical thrombectomy material obtained from patients with acute ischemic stroke (AIS) treated in a tertiary level stroke center and immediately fixed in 10% neutral buffered formalin and stored in polystyrene test tubes. The test tubes were immersed in a bucket of water for evaluation by spectral CT, along with scattered control tubes. All images were obtained using a dual-layer detector CT scanner. Each tube was assessed using multiparametric side-by-side view of conventional CT (120 kVp), low monoenergetic imaging (40 keV), and ED images. Fifty-eight polystyrene tubes were analyzed, comprising 52 tubes with thrombectomy material of at least 1 mm2 size obtained from 52 AIS patients, and six control tubes filled with formalin. ED imaging identified accurately the presence of material in all tubes, whereas 2 (3%) of the tubes containing thrombus were not identified by conventional CT, leading to a very good agreement between observers for the presence of material using conventional CT and ED imaging (kappa =0.84, P<0.001). Using ED imaging, thrombus material showed a mean density of 108.8±2.9 percent ED relative to water (%EDW), water had a mean density of 100.0±0.3 %EDW, and formalin a mean density of 103.5±1.2 %EDW. Compared to conventional imaging and 40 keV monoenergetic, ED imaging had a significantly higher signal-to-noise ratio (conventional 10.4±7.0, vs. 40 keV 11.5±8.4, vs. ED 490.0±304.5, P<0.001) and contrast-to-noise ratio (CNR) (conventional 4.3±4.3, vs. 40 keV 5.7±11.2, vs. ED 37.8±29.1, P<0.001). In this in-vitro study, we demonstrated improved visualization of thrombus with ED imaging compared to conventional imaging and low monoenergetic imaging, with a significant increase in CNR.

Intravenous Thrombolysis Before Thrombectomy Improves Functional Outcome After Stroke Independent of Reperfusion Grade.

We studied the association of bridging intravenous thrombolysis (IVT) before thrombectomy for anterior circulation large-vessel occlusion and functional outcome and scrutinized its dependence on grade of reperfusion and distal thrombus migration. We included consecutive patients withanterior circulation large-vessel occlusion from our prospective registry of thrombectomy-eligible patients treated from January 1, 2017 to January 1, 2023 at a tertiary stroke center in Germany in this retrospective cohort study. To evaluate the association of bridging IVT and functional outcome quantified via modified Rankin Scale score at 90 days we used multivariable logistic and lasso regression including interaction terms with grade of reperfusion quantified via modified Thrombolysis in Cerebral Infarction (mTICI) scale and distal thrombus migration adjusted for demographic and cardiovascular risk profiles, clinical and imaging stroke characteristics, onset-to-recanalization time and distal thrombus migration. We performed sensitivity analysis using propensity score matching. In our study population of 1000 thrombectomy-eligible patients (513 women; median age, 77 years [interquartile range, 67-84]), IVT emerged as a predictor of favorable functional outcome (modified Rankin Scale score, 0-2) independent of modified mTICI score(adjusted odds ratio, 0.49 [95% CI, 0.32-0.75]; P=0.001). In those who underwent thrombectomy (n=812), the association of IVT and favorable functional outcome was reproduced (adjusted odds ratio, 0.49 [95% CI, 0.31-0.74]; P=0.001) and was further confirmed on propensity score analysis, where IVT led to a 0.35-point decrease in 90-day modified Rankin Scale score (ß=-0.35 [95 CI%, -0.68 to 0.01]; P=0.04). The additive benefit of IVT remained independent of modified mTICI score (ß=-1.79 [95% CI, -3.43 to -0.15]; P=0.03) and distal thrombus migration (ß=-0.41 [95% CI, -0.69 to -0.13]; P=0.004) on interaction analysis. Consequently, IVT showed an additive association with functional outcome in the subpopulation of patients undergoing thrombectomy who achieved successful reperfusion (mTICI ≥2b; ß=-0.46 [95% CI, -0.74 to -0.17]; P=0.002) and remained beneficial in those with unsuccessful reperfusion (mTICI ≤2a; ß=-0.47 [95% CI, -0.96 to 0.01]; P=0.05). In thrombectomy-eligible patients with anterior circulation large-vessel occlusion, IVT improves functional outcome independent of grade of reperfusion and distal thrombus migration.

Functional Outcomes in Conservatively vs Surgically Treated Cerebellar Infarcts

According to the current American Heart Association/American Stroke Association guidelines, decompressive surgery is indicated in patients with cerebellar infarcts that demonstrate severe cerebellar swelling. However, there is no universal definition of swelling and/or infarct volume(s) available to support a decision for surgery. To evaluate functional outcomes in surgically compared with conservatively managed patients with cerebellar infarcts. In this retrospective multicenter cohort study, patients with cerebellar infarcts treated at 5 tertiary referral hospitals or stroke centers within Germany between 2008 and 2021 were included. Data were analyzed from November 2020 to November 2023. Surgical treatment (ie, posterior fossa decompression plus standard of care) vs conservative management (ie, medical standard of care). The primary outcome examined was functional status evaluated by the modified Rankin Scale (mRS) at discharge and 1-year follow-up. Secondary outcomes included the predicted probabilities for favorable outcome (mRS score of 0 to 3) stratified by infarct volumes or Glasgow Coma Scale score at admission and treatment modality. Analyses included propensity score matching, with adjustments for age, sex, Glasgow Coma Scale score at admission, brainstem involvement, and infarct volume. Of 531 included patients with cerebellar infarcts, 301 (57%) were male, and the mean (SD) age was 68 (14.4) years. After propensity score matching, a total of 71 patients received surgical treatment and 71 patients conservative treatment. There was no significant difference in favorable outcomes (ie, mRS score of 0 to 3) at discharge for those treated surgically vs conservatively (47 [66%] vs 45 [65%]; odds ratio, 1.1; 95% CI, 0.5-2.2; P > .99) or at follow-up (35 [73%] vs 33 [61%]; odds ratio, 1.8; 95% CI, 0.7-4.2; P > .99). In patients with cerebellar infarct volumes of 35 mL or greater, surgical treatment was associated with a significant improvement in favorable outcomes at 1-year follow-up (38 [61%] vs 3 [25%]; odds ratio, 4.8; 95% CI, 1.2-19.3; P = .03), while conservative treatment was associated with favorable outcomes at 1-year follow-up in patients with infarct volumes of less than 25 mL (2 [34%] vs 218 [74%]; odds ratio, 0.2; 95% CI, 0-1.0; P = .047). Overall, surgery was not associated with improved outcomes compared with conservative management in patients with cerebellar infarcts. However, when stratifying based on infarct volume, surgical treatment appeared to be beneficial in patients with larger infarct volumes, while conservative management appeared favorable in patients with smaller infarct volumes.