Therapy For Acute Stroke Research Articles

Endovascular Thrombectomy Versus Best Medical Therapy for Late Presentation Acute Ischemic Stroke With Proximal Large‐Vessel Occlusion Selected on the Basis of Noncontrast Computed Tomography: A Retrospective Analysis of 2 Prospectively Defined Cohorts

Background The efficacy and safety of endovascular thrombectomy (EVT) >6 hours from acute ischemic stroke (AIS) onset for patients selected without computed tomography (CT) perfusion or magnetic resonance imaging is undetermined in routine clinical practice. Methods In this single‐center study, we identified consecutive late‐presenting patients with AIS who were eligible for EVT on the basis of noncontrast CT/CT angiography (without CT perfusion or magnetic resonance imaging) using an Alberta Stroke Program Early CT Score of ≥6, >6 hours from stroke onset, between January 2018 and March 2022. During the study period, EVT capacity limitations meant EVT‐eligible patients presenting out of regular working hours, consistently received best medical management (BMM). Functional outcomes (modified Rankin Scale at 90 days), symptomatic intracranial hemorrhage, and mortality at 90 days were compared between patients receiving EVT or BMM following multivariable adjustment for age, sex, baseline stroke severity, Alberta Stroke Program Early CT Score, onset‐to‐neuroimaging time, intravenous thrombolysis, and clot location. Results Among 4802 patients with AIS, 150 patients (3.1%) presenting beyond 6 hours of onset were eligible for EVT: 74 (49%) treated with EVT and 76 (51%) with BMM. Compared with the BMM group, patients treated with EVT had significantly improved functional outcome (modified Rankin Scale) (adjusted common odds ratio, 2.23 [95% CI, 1.18–4.22]; P =0.013), and higher rates of functional independence (modified Rankin Scale ≤2; 39.2.% versus 9.2%; adjusted odds ratio, =4.73 [95% CI, 1.64–13.63]; P =0.004). No significant difference was observed between the EVT and BMM groups in the symptomatic intracranial hemorrhage (5.4% versus 2.6%; P =0.94) or mortality (20.2% versus 47.3%; P =0.16) rates, respectively. Conclusion In routine clinical practice, of the 3.1% of patients in our AIS population presenting after 6 hours from stroke onset who were deemed eligible for EVT by noncontrast CT/CT angiography alone, those treated with EVT achieved significantly improved functional outcome, compared with patients treated with BMM only. No significant differences were noted between the 2 groups with respect to symptomatic intracranial hemorrhage and mortality. While confirmatory randomized trials are awaited, these findings suggest that EVT is effective and safe when performed in patients with AIS selected without CT perfusion or magnetic resonance imaging >6 hours from stroke onset.

Revisiting Transcranial Light Stimulation as a Stroke Therapeutic-Hurdles and Opportunities.

Near-infrared laser therapy, a special form of transcranial light therapy, has been tested as an acute stroke therapy in three large clinical trials. While the NEST trials failed to show the efficacy of light therapy in human stroke patients, there are many lingering questions and lessons that can be learned. In this review, we summarize the putative mechanism of light stimulation in the setting of stroke, highlight barriers, and challenges during the translational process, and evaluate light stimulation parameters, dosages and safety issues, choice of outcomes, effect size, and patient selection criteria. In the end, we propose potential futureopportunities with transcranial light stimulation as a cerebroprotective or restorative tool for future stroke treatment.

Polymorphisms of the apolipoprotein E gene affect response to atorvastatin therapy in acute ischemic stroke.

Polymorphisms of the apolipoprotein E (APOE) gene are related to the efficacy of statin therapy. The biological functions of the APOE subtypes determine the metabolism of blood plasma lipids and the progression of atherosclerosis. This study aimed to explore the impact of APOE gene polymorphisms on the effect of atorvastatin on lipid regulation and plaque stabilization. The study was a prospective cohort study that consecutively included patients with acute ischemic stroke (AIS) in the Department of Neurology, Shanghai Tenth People's Hospital, from December 2018 to December 2019. The patients were divided into E2, E3, and E4 groups according to their APOE genotype. Atorvastatin (20 mg) was administrated to all patients. Changes in blood lipid levels over 3 months and plaque size and stability over 12 months were analyzed. We enrolled 253 consecutive patients with AIS, of whom, 136 had carotid atherosclerotic plaques. Two patients with genotype E2/E4 were excluded. There were 30 patients in the E2 group (12.0%), 191 patients in the E3 group (76.0%), and 30 patients in the E4 group (12.0%). The lowest percentage reduction in low-density lipoprotein cholesterol (LDL-C) was observed in the E4 group (41.2%), while the highest percentage reduction was observed in the E2 group (17.6%). The plaques in the E2 group showed slower progression, while those in the E4 group showed more rapid progression. APOE gene polymorphisms affect the biological functions of atorvastatin. Compared to the ε3 or ε4 allele, the ε2 allele exerted a greater lipid-lowering effect on LDL-C levels, enhanced the ability of atorvastatin to stabilize carotid artery plaques, and slowed carotid artery plaque progression.

Association of Lesion Topography with Functional Outcomes in Acute Ischemic Stroke Patients Considered for, or Receiving, Reperfusion Therapy: A Meta-Analysis.

The impact of lesion topography (LT), characterised by the Alberta Stroke Programme Early CT Score (ASPECTS), on outcomes after reperfusion therapy in acute ischemic stroke (AIS) is poorly elucidated. We investigated the prognostic accuracy of ASPECTS-based LT assessment and its association with clinical outcomes in AIS patients considered for reperfusion therapy or receiving intravenous thrombolysis (IVT), endovascular thrombectomy (EVT), or none or both. Studies were identified from PubMed with additional studies added from Google Scholar. The prevalence of individual ASPECTS regions will also be determined. The association of individual ASPECTS regions with the functional outcome at 90 days will be assessed using random-effects modelling for various cut-offs, such as 6, 7 and 8. The association of continuous ASPECTS with the functional outcome at 90 days will also be undertaken. Forest plots of odds ratios (ORs) will be generated. A total of 25 studies have been included in the final analysis, encompassing 11,404 patients. Pooled estimates indicate that the highest prevalence rates were in cases involving the insula and lentiform nucleus. Subgroup analysis for ASPECTS < 6 (OR 6.10; 95% CI 2.50-14.90; p < 0.0001), ASPECTS < 7 (OR 4.58; 95% CI 1.18-17.86; p < 0.0001) and ASPECTS < 8 (OR 2.26; 95% CI 1.32-3.89; p < 0.0001) revealed a significant association with poor functional outcome at 90 days. Decreasing ASPECTS significantly increased the odds of poor functional outcomes at 90 days (SMD -1.15; 95% CI -1.77--0.52; p < 0.0001). Our meta-analysis demonstrates that decreasing ASPECTS is significantly associated with poor functional outcomes. Individual ASPECTS regions associated with the highest odds of poor functional outcomes were identified. Future studies on the association of LT and clinical outcomes specific to EVT are required.

Admission Rates, Time Trends, Risk Factors, and Outcomes of Ischemic and Hemorrhagic Stroke From German Nationwide Data.

In the past decade, there have been major improvements in the control of risk factors, acute stroke therapies, and rehabilitation after the availability of high-quality evidence and guidelines on best practices in the acute phase. In this changing landscape, we aimed to investigate the stroke admission rates, time trends, risk factors, and outcomes during the period of 2014-2019 using German nationwide data. We obtained data of all acute stroke hospitalizations by the Federal Statistical Office. All hospitalized cases of adults (age 18 years or older) with acute stroke from the years 2014-2019 were analyzed regarding time trends, risk factors, treatments, morbidity, and in-hospital mortality according to stroke subtype (all-cause/ischemic/hemorrhagic). Between 2014 and 2019, overall stroke hospitalizations in adults (median age = 76 years, [IQR: 65-83 years]) initially increased from 306,425 in 2014 to peak at 318,849 in 2017 before falling to again to 312,692 in 2019, whereas percentage stroke hospitalizations that resulted in death remained stable during this period at 8.5% in 2014 and 8.6% in 2019. In a multivariate model of 1,882,930 cases, the strongest predictors of in-hospital stroke mortality were hemorrhagic subtype (adjusted OR [aOR] = 3.06, 95% CI 3.02-3.10; p < 0.001), cancer (aOR = 2.11, 2.06-2.16; p < 0.001), congestive heart failure (aOR = 1.70, 1.67-1.73; p < 0.001), and lower extremity arterial disease (aOR = 1.76, 1.67-1.84; p < 0.001). Despite recent advances in acute stroke care over the past decade, the percentage of stroke hospitalizations resulting in death remained unchanged. Further research is needed to determine how best to optimize stroke care pathways for multimorbid patients.

Safety of Recanalization Therapy in Acute Ischemic Stroke Patients on Direct Oral Anticoagulant Therapy: An Updated Systematic Review and Meta-Analysis.

This review provides an updated assessment of the safety of recanalization therapy for Acute Ischemic Stroke (AIS) patients receiving direct oral anticoagulants (DOAC) therapy. We checked the literature for published observational from 1st January 1950 to 31st March 2021. The rate of symptomatic intracerebral hemorrhage (sICH), arterial recanalization rate, good functional recovery, and mortality at 3 months were investigated, and data were expressed as Risk ratio (RR) with a 95% confidence interval (CI). Publication bias, sensitivity analysis, and meta-regression analyses were conducted utilizing STATA software. 17 articles [14 for endovascular therapy (EVT) and 3 intravenous thrombolysis for (IVT)] were finally included in the review. AIS patients with DOAC therapy showed a decreased rate of sICH (RR = 0.85, 95% CI = 0.72 to 1.00, P = 0.04), and lower probability of good functional recovery at three months (RR = 0.79, 95% CI = 0.73 to 0.85, P < 0.001) than patients without anticoagulation therapy post EVT. However, no significant differences in sICH rates in AIS patients with DOAC therapy after IVT (RR = 0.87, 95% CI = 0.48 to 1.58, P = 0.64) were observed. AIS patients not prescribed DOAC after EVT had a higher mortality risk (RR = 1.29, 95% CI = 1.15-1.44, P < 0.001). Patients with AIS on DOAC therapy were found to have a lower incidence of sICH following EVT. However, no evidence of an increased bleeding risk in patients previously treated with DOAC after IVT was observed. Therefore, more detailed studies with biological data to monitor compliance and details on the size and etiology/severity of the incident ischemic lesion is needed.

Pharmacological Inhibition of Class III Alcohol Dehydrogenase 5: Turning Remote Ischemic Conditioning Effective in a Diabetic Stroke Model.

The restoration of cerebral blood flow (CBF) to achieve brain tissue oxygenation (PbtO2) is the primary treatment for ischemic stroke, a significant cause of adult mortality and disability worldwide. Nitric oxide (NO) and its bioactive s-nitrosylated (SNO) reservoirs, such as s-nitrosoglutathione (GSNO), induce hypoxic vasodilation to enhance CBF during ischemia. The endogenous pool of SNOs/GSNO is enhanced via the activation of endothelial NO synthase (eNOS/NOS3) and by the suppression of class III alcohol dehydrogenase 5 (ADH5), also known as GSNO reductase (GSNOR). Remote ischemic conditioning (RIC), which augments NOS3 activity and SNO, is an emerging therapy in acute stroke. However, RIC has so far shown neutral effects in stroke clinical trials. As the majority of stroke patients are presented with endothelial dysfunctions and comorbidities, we tested the hypothesis that NOS3 dysfunction and diabetes will abolish the protective effects of RIC therapy in stroke, and the prior inhibition of GSNOR will turn RIC protective. Our data demonstrate that RIC during thrombotic stroke failed to enhance the CBF and the benefits of thrombolysis in NOS3 mutant (NOS3+/−) mice, a genetic model of NOS3 dysfunction. Interestingly, thrombotic stroke in diabetic mice enhanced the activity of GSNOR as early as 3 h post-stroke without decreasing the plasma nitrite (NO2−). In thrombotic stroke, neither a pharmacological inhibitor of GSNOR (GRI) nor RIC therapy alone was protective in diabetic mice. However, prior treatment with GRI followed by RIC enhanced the CBF and improved recovery. In a reperfused stroke model, the GRI–RIC combination therapy in diabetic mice augmented PbtO2, a translatory signature of successful microvascular reflow. In addition, RIC therapy unexpectedly increased the inflammatory markers at 6 h post-stroke in diabetic stroke that were downregulated in combination with GRI while improving the outcomes. Thus, we conclude that preexisting NOS3 dysfunctions due to comorbidities may neutralize the benefits of RIC in stroke, which can be turned protective in combination with GRI. Our findings may support the future clinical trial of RIC in comorbid stroke. Further studies are warranted to test and develop SNO reservoirs as the blood-associated biomarker to monitor the response and efficacy of RIC therapy in stroke.

Safety and efficacy of intensive systolic blood pressure lowering after successful endovascular therapy: a post hoc analysis of the BP TARGET trial

BackgroundThe Safety and Efficacy of Intensive Blood Pressure Lowering after Successful Endovascular Therapy in Acute Ischaemic Stroke (BP TARGET) trial demonstrated no benefit from intensive systolic blood pressure (SBP) treatment...

What You Always Wanted to Know about Endovascular Therapy in Acute Ischemic Stroke but Never Dared to Ask: A Comprehensive Review.

In 2015, mechanical thrombectomy (MT) in combination with intravenous thrombolysis was demonstrated to be superior to best medical treatment alone in patients with anterior circulation stroke. This finding resulted in an unprecedented boost in endovascular stroke therapy, and MT became widely available. MT was initially approved for patients presenting with large vessel occlusion in the anterior circulation (intracranial internal carotid artery or proximal middle cerebral artery) within a 6-hour time window. Eventually, it was shown to be beneficial in a broader group of patients, including those without known symptom-onset, wake-up stroke, or patients with posterior circulation stroke. Technical developments and the implementation of novel thrombectomy devices further facilitated endovascular recanalization for acute ischemic stroke. However, some aspects remain controversial. Is MT suitable for medium or very distal vessel occlusions? Should emergency stenting be performed for symptomatic stenosis or recurrent occlusion? How should patients with large vessel occlusion without disabling symptoms be treated? Do certain patients benefit from MT without intravenous thrombolysis? In the era of personalized decision-making, some of these questions require an individualized approach based on comorbidities, imaging criteria, and the severity or duration of symptoms. Despite its successful development in the past decade, endovascular stroke therapy will remain a challenging and fascinating field in the years to come. This review aims to provide an overview of patient selection, and the indications for and execution of MT in patients with acute ischemic stroke.

Endovascular thrombectomy with or without intravenous alteplase in acute stroke: a systematic review and meta-analysis of randomized clinical trials.

This study investigated clinical outcomes after direct endovascular thrombectomy (EVT) compared to bridging therapy (EVT with prior intravenous alteplase) in acute stroke within 4.5h after onset. PubMed and Embase were searched for eligible randomized controlled trials. The primary outcome was the rates of neurological functional independence defined as modified Rankin scale score 0-2 at 90days, whose non-inferiority margin was set at - 15%, - 10%, - 6.5%, - 5%, and - 1.3% for its risk difference (RD). We included six studies enrolling 2334 participants. The crude cumulative rates of functional independence were 49.0% with direct EVT vs 50.9% with bridging therapy, without significant difference (Odd ratio [OR] = 0.93, 95% confidence interval [CI] 0.79-1.09) between two groups, where the pooled RD was - 2% (95% CI - 6 to 2%) whose lower 95% CI bound fell within non-inferiority margins of - 15%, - 10%, -6.5%, but not - 5% and - 1.3%. Between the two groups, no significant difference was found in excellent function rate (30.2% vs 30.6%, OR = 0.99, 95% CI 0.82-1.18) with RD of 0% (95% CI - 3 to 4%), mortality rate (16.0% vs 15.0%, OR = 1.08, 95% CI 0.86-1.35) with RD of 1% (95% CI - 2 to 4%), and symptomatic intracranial hemorrhage rate (4.3% vs 5.0%, OR = 0.86, 95% CI 0.58-1.27) with RD of 0% (95% CI - 2 to 1%). No statistical difference was found in functional and safety outcomes between direct EVT and bridging therapy groups in acute stroke within 4.5h after symptom onset. EVT alone was non-inferior to bridging therapy for several, but not the more stringent, non-inferiority margins.

Early Versus Delayed Non-Vitamin K Antagonist Oral Anticoagulant Therapy After Acute Ischemic Stroke in Atrial Fibrillation (TIMING): A Registry-Based Randomized Controlled Noninferiority Study.

There are no evidence-based recommendations on the optimal time point to initiate non-vitamin K antagonist oral anticoagulants (NOACs) after acute ischemic stroke in patients with atrial fibrillation. We aimed to investigate the efficacy and safety of early versus delayed initiation of NOAC in these patients. TIMING (Timing of Oral Anticoagulant Therapy in Acute Ischemic Stroke With Atrial Fibrillation) was a registry-based, randomized, noninferiority, open-label, blinded end-point study at 34 stroke units using the Swedish Stroke Register for enrollment and follow-up. Within 72 hours from stroke onset, patients were randomized to early (≤4 days) or delayed (5-10 days) NOAC initiation, with choice of NOAC at the investigators' discretion. The primary outcome was the composite of recurrent ischemic stroke, symptomatic intracerebral hemorrhage, or all-cause mortality at 90 days. The prespecified noninferiority margin was 3%. Secondary outcomes included the individual components of the primary outcome. Between April 2, 2017, and December 30, 2020, 888 patients were randomized to either early (n=450) or delayed (n=438) initiation of NOAC. No patient was lost to 90-day follow-up. Mean age was 78.3 years (SD, 9.9 years); 46.2% were women; 49.1% had previously known atrial fibrillation; and 17.5% prior stroke. The primary outcome occurred in 31 patients (6.89%) assigned to early initiation and in 38 patients (8.68%) assigned to delayed NOAC initiation (absolute risk difference, -1.79% [95% CI, -5.31% to 1.74%]; Pnoninferiority=0.004). Ischemic stroke rates were 3.11% and 4.57% (risk difference, -1.46% [95% CI, -3.98% to 1.07%]) and all-cause mortality rates were 4.67% and 5.71% (risk difference, -1.04% [95% CI, -3.96% to 1.88%]) in the early and delayed groups, respectively. No patient in either group experienced symptomatic intracerebral hemorrhage. Early initiation was noninferior to delayed start of NOAC after acute ischemic stroke in patients with atrial fibrillation. Numerically lower rates of ischemic stroke and death and the absence of symptomatic intracerebral hemorrhages implied that the early start of NOAC was safe and should be considered for acute secondary stroke prevention in patients eligible for NOAC treatment. URL: http://www. gov; Unique identifier: NCT02961348.

Stent-retriever induces more endothelial damage than direct aspiration in endovascular therapy for acute ischemic stroke

Abstract Background Mechanical arterial recanalization is increasingly used to treat acute ischemic stroke. Known to inflict vascular injury, it might affect pro-thrombotic character and healing patterns. Stent-retriever thrombectomy (SR) and direct aspiration (DA) are both used for acute recanalization and not only lead to endothelial denudation, but also to platelet activation and local formation of microthrombi, potentially adding to the risk of distal embolization. Purpose We aimed to quantify and characterize endovascular damage, microthrombus formation, and vascular healing following SR and DA in a swine model of arterial thrombo-embolic occlusion. Methods Aged autologous thrombi, created under flow, were used to occlude swine extracranial arteries for two hours to mimic a thrombo-embolic occlusion. Arteries were randomized to SR, DA, or control (C). Injury was assessed acutely (SR n=8; DA n=7; C n=4), and at 3 days follow-up (SR n=8; DA n=7; C n=4) using Evans Blue (EB) dye-exclusion-testing to quantify injury, expressed as %EB-area in the treated area. Scanning electron microscopy (SEM) was used to characterize vascular injury and presence of microthrombi (&amp;lt;100 μm). Data are given as mean±SD or median (min-max). Results Regression analysis for EB-area (ANOVA p&amp;lt;0.001; Adj. R2=0.5) showed that SR induced more damage than DA (p=0.001). Both showed partial healing at 3 days (p&amp;lt;0.01) (Table 1). Only for DA, did more attempts lead to an increased EB-area (p=0.016), as for SR one attempt already resulted in almost complete denudation. For both SR and DA, SEM of acute injury showed endothelial denudation, microthrombi, and adhesion of leukocytes and activated platelets (Fig. 1A–C). At three days, SEM showed partial re-endothelialization with increased surface folds as a sign of endothelial activation (Fig. 1D). Microthrombi/cm2 decreased significantly from 7 (2–17) acutely to 1 (0–4) at 3 days (p&amp;lt;0.001). Conclusions Stent-retrievers induce more endothelial damage than direct aspiration. Both treatments yield microthrombi, platelet activation and leukocyte adhesion. After three days, the endothelium is significantly, but only partially recovered. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): We acknowledge the support of the Netherlands Cardiovascular Research Initiative which is supported by the Dutch Heart Foundation (CVON2015-01: CONTRAST), the support of the Brain Foundation Netherlands (HA2015.01.06), and the support of Health∼Holland, Top Sector Life Sciences &amp; Health (LSHM17016), Stryker, Medtronic and Cerenovus. The collaboration project is additionally financed by the Ministry of Economic Affairs by means of the PPP Allowance made available by the Top Sector Life Sciences &amp; Health to stimulate public-private partnerships.

Melatonin Offers Dual-Phase Protection to Brain Vessel Endothelial Cells in Prolonged Cerebral Ischemia-Recanalization Through Ameliorating ER Stress and Resolving Refractory Stress Granule.

Ischemic-reperfusion injury limits the time window of recanalization therapy in cerebral acute ischemic stroke (AIS). Brain vessel endothelial cells (BVECs) form the first layer of the blood-brain barrier (BBB) and are thus the first sufferer of ischemic-reperfusion disorder. The current study demonstrates that melatonin can reduce infarct volume, alleviate brain edema, ameliorate neurological deficits, and protect BBB integrity in prolonged-stroke mice. Here, we demonstrate that endoplasmic reticulum (ER)-associated injury contributes to BVEC death in the dural phase of reperfusion after prolonged ischemia. When encountering ischemia, ER stress arises, specifically activating PERK-EIF2α signaling and the subsequent programmed cell death. Prolonged ischemia leads stress granules (SGs) to be refractory, which remain unresolved and accumulate in ER during recanalization. During reperfusion, refractory SGs activate PKR-EIF2α and further exacerbate BVEC injury. We report that melatonin treatment downregulates ER stress in the ischemic period and enhances dissociation of the refractory SGs during reperfusion, thus offering dual-phase protection to BVECs in prolonged cerebral stroke. Mechanistically, melatonin enhances autophagy in BVECs, which preserves ER function and resolves refractory SGs. We, therefore, propose that melatonin is a potential treatment to extend the time window of delayed recanalization therapy in AIS.

Clinical value of automated volumetric quantification of early ischemic tissue changes on non-contrast CT

BackgroundQuantitative and automated volumetric evaluation of early ischemic changes on non-contrast CT (NCCT) has recently been proposed as a new tool to improve prognostic performance in patients undergoing endovascular therapy...

Endovascular therapy for acute ischemic stroke in patients with active malignancy: a meta-analysis with trial sequential analysis

BackgroundActive malignancy has a poorer prognosis and more deaths in patients with acute ischemic stroke (AIS). The outcomes of endovascular therapy (EVT) remain controversial in patients with AIS and active...

Endovascular thrombectomy or bridging therapy in minor ischemic stroke with large vessel occlusion

BackgroundWhether direct endovascular thrombectomy (EVT) is non-inferior to bridging therapy (intravenous thrombolysis [IVT] followed by EVT) in minor acute ischemic stroke due to large vessel occlusions (AIS-LVO) is not clear. Therefore, this study aimed to assess whether direct EVT is non-inferior to bridging therapy in minor AIS-LVO. Methods903 patients with acute ischemic stroke due to large vessel occlusion and National Institutes of Health Stroke Scale (NIHSS) score <6 receiving EVT treatment were enrolled at Bigdata Observatory Platform for Stroke of China in China from January 1, 2019, to December 31, 2020, with final follow-up on March 31, 2021. The primary efficacy endpoint was a favorable outcome defined as a modified Rankin Scale score of 0 to 2 at three months. In addition, there were three prespecified secondary efficacy endpoints, including symptomatic intracerebral hemorrhage (ICH), in-hospital mortality, and mortality by month 3. ResultsA total of 662 patients treated with direct EVT (age 65.9 ± 10.5 years, 71.5 % male, NIHSS score 2.4 [standard deviation {SD}. 1.8]) were compared to 241 bridging-treated patients (age 65.7 ± 10.8, 75.9 % female, NIHSS score 2.5 [1.8]). The rate of symptomatic ICH in the EVT group was lower than in the bridging group (4.2 % vs. 8.3 %; P = 0.02). The in-hospital mortality was not different between the two groups (EVT vs. bridging group: adjusted hazard ratio {HR}, 0.9 [95 % confidence interval {CI}, 0.5 to 1.9]; P = 0.93). There was no significant difference in 3-month poor functional outcome rate (EVT vs. bridging group: 17.1 % vs. 16.2 % [absolute difference, 0.9 % {95 % CI, −0.8 % to 2.4 %}, P = 0.75; adjusted hazard ratio {HR}, 1.0 {95 % CI, 0.6 to 1.7}, P = 0.83]) and mortality rate (13.0 % vs. 11.2 % [absolute difference, 1.5 % {95 % CI, −3.9 % to 6.8 %}, P = 0.47; adjusted HR, 1.1 {95 % CI, 0.8 to 1.9}, P = 0.55]) between those two groups. ConclusionAmong patients with minor AIS-LVO, direct EVT, compared with bridging therapy, met the prespecified statistical threshold for noninferiority for the 3-month prognosis.

Short‐Term Outcomes of Acute Stroke During COVID‐19 by Race and Ethnicity in the United States: The Society of Vascular and Interventional Neurology Multicenter Collaboration

Background The COVID‐19 pandemic has disproportionately affected Black and Hispanic communities, whose stroke care has been previously shown to experience existing disparities. We sought to evaluate how these disparities in stroke care and in‐hospital mortality have been affected by the COVID‐19 pandemic. Methods In this retrospective observational cohort study, we evaluated stroke hospitalizations in the Society of Vascular and Interventional Neurology COVID‐19 registry. We compared stroke characteristics between non‐Hispanic White, non‐Hispanic Black, and Hispanic patients pre–COVID‐19 and post–COVID‐19 (March–July 2019 versus March–July 2020) and evaluated whether racial and ethnic differences present before the pandemic were exacerbated during the pandemic. Our primary outcome was in‐hospital mortality/discharge to hospice, and secondary outcomes were acute treatment use. Results Of the 4908 included patients, numerically fewer non‐Hispanic White and Hispanic patients were evaluated during COVID‐19. Non‐Hispanic White and non‐Hispanic Black patients with large‐vessel occlusion were more likely to undergo thrombectomy ( P &lt;0.01 for both) when compared with the pre–COVID‐19 epoch. In‐hospital mortality/hospice rates were higher during COVID‐19 (12.8% versus 9.9%; P &lt;0.01), with higher rates observed across all race and ethnic groups, although the odds of death/hospice during the pandemic period became nonsignificant after multivariable adjustment (adjusted odds ratio, 1.23 [95% CI, 0.95–1.62]; P =0.12). Conclusions There was an increase in mortality/hospice discharges among all races during the COVID‐19 period. There were no noted racial or ethnic differences in rates of thrombolytic use, thrombectomy, or mortality within racial groups prepandemic compared with during the pandemic. Although other studies have demonstrated deepening disparities in these outcomes during COVID‐19, our data suggest that declines in stroke presentations and use of acute stroke therapies were not a uniform phenomenon. Disparities in stroke care were differentially affected in thrombolytic versus endovascular therapies and among non‐Hispanic Black and Hispanic patients.

Endovascular treatment for M3 occlusions.

Endovascular treatment (ET) is a beneficial treatment for M1-2 occlusions of the middle cerebral artery. Mortality and disability rates are high if large vessel occlusions are not treated. While these rates are lower in M3 occlusions, important branch blockages can lead to disability. Endovascular treatment of small vessel occlusions is difficult, and there are no studies on the effectiveness of endovascular treatment for M3 occlusions. Accordingly, in this study, our aim was to assess the feasibility, safety, and preliminary efficacy of endovascular therapy for M3 occlusions. This study involved a retrospective analysis of a prospectively collected from two centres for acute ischemic stroke of the anterior system between July 2015 and April 2020. Demographic, radiologic, procedural and outcome variables were collected for patients who underwent endovascular therapy for acute ischemic stroke of the anterior system. Complete or near complete reperfusion (mTICI 2b-3) of the M3 occlusion was achieved in 15 cases (38.5%). Complete (mTICI 3) reperfusion was achieved in 24 cases (61.5%). Twenty-six patients were treated for primary M3 occlusion, while 13 patients with M3 occlusion were treated as a rescue strategy after successful treatment of a proximal greater vascular occlusion. Complete or near complete reperfusion (mTICI 2b-3) of primary occlusion was achieved in eight cases (30.8%), and complete (mTICI 3) reperfusion was achieved in 18 cases (69.2%). In addition, complete or near complete reperfusion (mTICI 2b-3) of rescue M3 occlusion was achieved in seven cases (%53.8), while complete (mTICI 3) reperfusion was achieved in six cases (46.2%). Only one patient with primary M3 occlusion had ICH due to extravasation. The patient's neurological examination one month later was normal. This retrospective study demonstrates that endovascular treatment of M3 occlusions is safe, effective and reliable.

Navigating an Internal Carotid Artery Anatomic Variant During Endovascular Therapy for Acute Ischemic Stroke.

HomeStrokeVol. 53, No. 12Navigating an Internal Carotid Artery Anatomic Variant During Endovascular Therapy for Acute Ischemic Stroke No AccessCase ReportRequest AccessFull TextAboutView Full TextView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsNo AccessCase ReportRequest AccessFull TextNavigating an Internal Carotid Artery Anatomic Variant During Endovascular Therapy for Acute Ischemic Stroke Teng J. Peng, MD, Richa Sharma, MD, Joseph P. Antonios, MD, PhD, Ryan Hebert, MD and Adam S. Jasne, MD Teng J. PengTeng J. Peng https://orcid.org/0000-0002-0576-1402 Department of Neurology (T.J.P., R.S., A.S.J.), Yale University School of Medicine. Search for more papers by this author , Richa SharmaRicha Sharma Department of Neurology (T.J.P., R.S., A.S.J.), Yale University School of Medicine. Search for more papers by this author , Joseph P. AntoniosJoseph P. Antonios https://orcid.org/0000-0002-5147-1377 Department of Neurosurgery (J.P.A., R.H.), Yale University School of Medicine. Search for more papers by this author , Ryan HebertRyan Hebert Department of Neurosurgery (J.P.A., R.H.), Yale University School of Medicine. Search for more papers by this author and Adam S. JasneAdam S. Jasne Correspondence to: Adam S. Jasne, MD, Department of Neurology, Division of Stroke, Yale Medical School, 15 York St, LCI 1002, New Haven, CT 06510. Email E-mail Address: [email protected] https://orcid.org/0000-0001-9092-3607 Department of Neurology (T.J.P., R.S., A.S.J.), Yale University School of Medicine. Search for more papers by this author Originally published15 Sep 2022https://doi.org/10.1161/STROKEAHA.122.040501Stroke. 2022;53:e517–e518"Navigating an Internal Carotid Artery Anatomic Variant During Endovascular Therapy for Acute Ischemic Stroke." Stroke, 53(12), pp. e517–e518FootnotesSupplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.122.040501.For Sources of Funding and Disclosures, see page e518.Correspondence to: Adam S. Jasne, MD, Department of Neurology, Division of Stroke, Yale Medical School, 15 York St, LCI 1002, New Haven, CT 06510. Email adam.[email protected]edu

Study on the Guidance of Platelet Inhibition Rate Detected with Thrombelastogram in Antiplatelet Therapy for Acute Non-Cardiogenic Stroke

Objective: To investigate the application value of thrombelastogram (TEG) in the detection of platelet inhibition rate for antiplatelet therapy for acute non-cardiogenic stroke. Methods: A total of 100 patients with ischemic non-cardiogenic stroke were selected for this study from September 2020 to October 2021. Patients were randomly divided into experimental group and control group, with 50 cases for each group. Before and after 1 week of antiplatelet drug treatment, the platelet inhibition rate in the experimental group was measured with arachidonic acid (AA) and adenosine diphosphate (ADP) by TEG; no platelet inhibition rates detection was conducted for the control group. The dose and type of drugs were adjusted for the experimental group according to the platelet functions and medication based on the clinical experience conducted for the control group. The neurological deficits of the discharged patients were scored with NIHSS score, mRS score, stroke recurrence, hemorrhage, and other events were followed up at the 3rd month of discharge. Results: In the experimental group, the inhibition rates of AA and ADP were significantly higher than those before treatment (both P &lt; 0.05). After treatment, the inhibition rates of AA and ADP in dual antiplatelet patients were higher than those of monoclonal antiplatelets (both P &lt; 0.05). The NIHSS score at discharge and the mRS score at the 3rd-month-follow-up in the experimental group were lower than those in the control group (both P &lt; 0.05). The incidences of stroke recurrence and hemorrhage events in the experimental group were lower than those in the control group (P &lt; 0.05). Conclusion: The application of a thrombelastogram in the detection of platelet inhibition rate to guide antiplatelet therapy in patients with acute non-cardiogenic stroke reduces the recurrences of cerebral infarction and the risk of hemorrhage and improves patients’ clinical prognosis.