Thrombolysis In Cerebral Ischemia Research Articles

Insights into Angiographic Recanalization of Large Arterial Occlusion: Institutional Experience with Mechanical Thrombectomy for Acute Ischemic Stroke.

Stroke is a leading cause of morbidity and mortality in humans. Most strokes are ischemic in nature and early recanalization of occluded vessels determines good outcomes. Recanalization of occluded vessels depends on many angiographic and demographic features. These factors need to be identified for better patient overall outcomes. Better preoperative knowledge of factors can help in customizing our treatment approach and explaining the prognosis to the guardians of the patients. We aim to share our institutional experience with mechanical thrombectomy (MT) for stroke and studied factors that affect an angiographic recanalization of vessels . A retrospective single-center study was conducted involving 104 patients who underwent MT at our institution between January 2016 and December 2019. Patient demographics, baseline characteristics, pre- and postprocedural imaging findings, and other clinical data were meticulously reviewed. We divided patients into successful recanalization (modified thrombolysis in cerebral ischemia [mTICI] 2b or 3) and unsuccessful recanalization (mTICI 2a or 1) groups and various factors were analyzed to evaluate their impact on recanalization rates. In the univariate analysis, a significant association was observed between successful recanalization and several factors: the absence of rheumatic heart disease (RHD) as a risk factor ( p = 0.035), the presence of a hyperdense vessel sign ( p = 0.003), and the use of treatment methods including aspiration ( p = 0.031), stent retriever ( p = 0.001), and Solumbra ( p = 0.019). However, in the multivariate analysis, none of these factors exhibited statistical significance. The presence of RHD is a risk factor associated with poor angiographic recanalization in all three MT treatment modalities. Based on the above variables we can guide the patients/relatives prior to MT procedure for their better outcome and risk-benefit ratio.

Abstract TP188: Diving MCA and First-Pass Reperfusion: A Subgroup Analysis of the Arise II Study

Introduction: Tortuosity of Internal carotid artery impact on achieving first pass in mechanical thrombectomy has been previously described. Here, we investigate the association of middle cerebral artery(MCA) tortuosity on radiographic and functional outcome. Methods: The Analysis of Revascularization in Ischemic Stroke with EmboTrap II was utilized to identify patients with anterior circulation stroke. MCA tortuosity was calculated using Inflection Count Metric(ICM) by two blinded readers to angiographical/clinical outcomes. The total cohort was trichotomized into 3 groups (A, B, C) based on M1 tortuosity tertiles. The primary efficacy end point was achievement of modified Thrombolysis in Cerebral Ischemia (mTICI) reperfusion scores of ≥2b on first pass. Good functional outcomes was defined as mRS0-2 on 90-day followup. Baseline and procedural data were compared between groups. Results: A total of 200 with known MCA tortuosity were identified. Patients within group A were significantly older (P<0.05) . Group C patient were more likely to have renal disease and atrial fibrillation (P<0.05). There was no differences in terms of NIHSS score at presentation nor ASPECT score between groups. Achieving first-pass success was more likely in group A (60.6%) vs 47% and 38.2%, P=0.033 for groups B and C, respectively. Likewise, the rate of mTICI≥2c was higher in group A (54.5%) vs 36.4% and 26.5%, p=0.003. Achieving mRS0-2 was more likely in group A (76.6%) vs 73.4% and 49.3%, p=0.001. There were no differences in distal emboli, or symptomatic intracranial hemorrhage. Findings of first-pass and angiographic outcomes were consistent with standard tortuosity scoring system. Conclusion: Patients with higher MCA tortuosity are less likely to have successful reperfusion and good functional outcome post mechanical thrombectomy for acute ischemic stroke.

Abstract TMP88: Impact of Tandem Vertebrobasilar Occlusion on Outcome of Mechanical Thrombectomy for Basilar Artery Occlusion

Introduction: The efficacy of mechanical thrombectomy (MT) for tandem vertebrobasilar occlusion (tVBO) is not well established in patients with basilar artery occlusion (BAO). Objective: To investigate the treatment outcomes of MT in tVBO. Method: This international, multicenter, retrospective cohort included patients with MT for tVBO and isolated BAO from 2013 to 2023. The primary outcome was the 90-day modified Rankin Scale (mRS) score 0-2. Secondary outcomes included complete recanalization (modified Thrombolysis in Cerebral Ischemia [mTICI] ≥ 2C) and 90-day mortality rate. These outcomes were compared between tVBO and isolated BAO groups. Adjustment factors were age, sex, admission National Institutes of Health Stroke Scale (NIHSS), pre-morbid mRS, onset to groin duration, and intravenous tissue plasminogen activator. Results: Among 10,229 patients, 689 had BAO. Of those, 61 (9.7%) had a tVBO. Median age was 61 [IQR 53-74] years and 29 (47.5%) patients were female. Compared to isolated BAO, tVBO group had lower age (61 [53-74] versus 68 [58-79], P<0.001) and lower admission NIHSS (15 [7 - 22] versus 17 [9-26], P≤0.05). There was no significant difference in the rate of complete recanalization between the two groups (adjusted odds ratio [aOR]: 0.83; 95% CI: 0.39-1.79; P=0.60) However, the tVBO group had significantly lower odds of a favorable outcome compared to the isolated BAO group (aOR: 0.35; 95% CI: 0.13-0.83; P=0.023) and higher odds of 90-day mortality (aOR: 3.51; 95% CI: 1.59-7.85; P=0.002). Binary regression analysis revealed that age (OR 0.98; 95% CI 0.96 - 1.00; P=0.019), admission NIHSS (OR 0.90; 95% CI 0.87-0.93; P<0.001), premorbid mRS (OR 0.71; 95% CI 0.53-0.93; P=0.016), successful recanalization (OR 2.94; 95% CI 1.71-5.15; P<0.001), and tVBO (OR 0.33; 95% CI 0.11-0.86; P=0.031) were significant predictors of 90-day favorable outcome. Conclusion: tVBO was associated with poor outcomes. Further efforts should be aimed at improving outcomes for this subpopulation.

Abstract WP205: Development and Validation of a Prediction Model for Outcome in Mechanical Thrombectomy for Large-Vessel Occlusion Anterior Circulation Stroke With Low ASPECTS

Introduction: Recent randomized control trials suggested that mechanical thrombectomy (MT) was associated with good functional outcomes after acute ischemic stroke (AIS) due to large vessel occlusion (LVO) in patients presenting with low Alberta Stroke Program Early CT Score (ASPECTS) (defined as ASPECTS 2-5). The aim of this study is to develop and validate a stroke prediction tool for outcome in MT for AIS patients with low ASPECTS using data from an ongoing international multicenter registry, the Stroke Thrombectomy and Aneurysm Registry (STAR). Methods: 236 AIS patients with low ASPECTS caused by LVO who undertook MT between January 2010 and December 2022 were retrospectively investigated. Univariate and multivariate logistic regression results were used to screen model predictors and construct nomograms of 90-day modified Rankin Scale scores (mRS) 0-3. The performance of the model was detected by using receiver operating characteristic analysis. The bootstrap resampling method was considered internal validation of the model. Results: Age (< 70 years), premorbid status (mRS 0), National Institutes of Health Stroke Scale (NIHSS) (< 20), and recanalization status after the MT (modified Thrombolysis in Cerebral Ischemia [mTICU] ≥2b) were related to 90-day mRS 0-3. Predictive score was calculated by adding 1 point for age (< 70 years), premorbid status (mRS 0), and NIHSS < 20 and 3 points for a mTICI ≥2b (ranging 0-6). 90-day mRS 0-3 was observed in 0% of patients with a score of 0 or 1, 6.3% with a score of 2, 17.7% with a score of 3, 22.2% with a score of 4, 45.7% with a score of 5, and 73.7% with a score of 6. The score showed relatively high performance in predicting 90-day mRS0-3 (area under the curve: 0.79 [95% CI 0.73-0.79] and 0.78 [95% CI 0.78-0.78] for derivation and validation cohorts, respectively). Conclusions: This study indicates the STAR score can be calculated with baseline and periprocedural characteristics to predict the 90-day outcome after MT in AIS patients with low ASPECTS.

Abstract WP192: Impact of Second Line Thrombectomy Technique Following Failed First Pass Thrombectomy for Anterior Circulation Stroke: To Switch or Not to Switch?

Introduction: Despite comparable outcomes for different frontline techniques in mechanical thrombectomy (MT) for acute ischemic stroke (AIS), there are sparse data regarding if and when to switch techniques if the first pass is unsuccessful. We aimed to investigate the impact of converting from one MT technique to another on the second MT attempt for AIS among patients with large vessel occlusion (LVO). Methods: This was a retrospective observational study using data from the large multicenter international Stroke Thrombectomy and Aneurysm Registry (STAR). Data from 29 stroke centers for 10,229 AIS patients treated with MT for LVO between January 2010 and December 2022 was investigated. The primary outcome measure was successful recanalization defined as modified Thrombolysis in Cerebral Ischemia (mTICI) score of 2b or higher. 90-day modified Rankin score (mRS) 0-2, mortality and symptomatic hemorrhage were used as secondary outcomes. Clinical and technical outcomes after the second MT attempt were compared between those with or without technique conversion. Results: Among 10,229 AIS patients, 1,797 AIS patients with LVO failed first pass recanalization and were included in this retrospective analysis. 927 patients were female (52%) and median (interquartile range) age was 72 (61-81) years. Converting to alternative techniques following a first failed attempt was more likely to be associated with successful recanalization at the second attempt (adjusted odds ratio 2.30, 95% CI: 1.37-3.86, P = 0.002) and 90-day good clinical outcome (adjusted odds ratio 2.10, 95% CI: 1.15-3.85, P = 0.02) after multivariate adjustment. Conclusions: This study demonstrates better clinical and technical outcomes with conversion of MT technique for the second attempt in AIS patients with LVO who failed first pass recanalization.

Balloon angioplasty as first-choice recanalization strategy for intracranial atherosclerosis-related emergent large vessel occlusion with small clot burden.

The optimal primary recanalization strategy for intracranial atherosclerosis-related emergent large vessel occlusion (ICAS-ELVO) remains controversial. We aimed to explore the safety and efficacy of balloon angioplasty as the first-choice recanalization strategy for ICAS-ELVO with small clot burden. Consecutive ICAS-ELVO patients presenting with microcatheter "first-pass effect" during endovascular treatment (EVT) were retrospectively analyzed. Patients were divided into preferred balloon angioplasty (PBA) and preferred mechanical thrombectomy (PMT) groups based on the first-choice recanalization strategy. The reperfusion and clinical outcomes between the two groups were compared. Seventy-six patients with ICAS-ELVO involving the microcatheter "first-pass effect" during EVT were enrolled. Compared with patients in the PMT group, those in the PBA group were associated with (i) a higher rate of first-pass recanalization (54.0% vs. 28.9%, p = .010) and complete reperfusion (expanded thrombolysis in cerebral ischemia ≥ 2c; 76.0% vs. 53.8%, p = .049), (ii) shorter puncture-to-recanalization time (49.5min vs. 89.0min, p < .001), (iii) lower operation costs (¥48,499.5 vs. ¥ 99,086.0, p < .001), and (iv) better 90-day functional outcomes (modified Rankin scale:0-1; 44.0% vs. 19.2%, p = .032). Logistic regression analysis revealed that balloon angioplasty as the first-choice recanalization strategy was an independent predictor of 90-day excellent functional outcomes for ICAS-ELVO patients with microcatheter "first-pass effect" (adjusted odds ratio = 6.01, 95% confidence interval: 1.15-31.51, p = .034). Direct balloon angioplasty potentially improves 90-day functional outcomes for ICAS-ELVO patients with small clot burden, and may be a more appropriate first-choice recanalization strategy than mechanical thrombectomy for these patients.

Intravenous Thrombolysis Before Endovascular Treatment in Posterior Circulation Occlusions: A MR CLEAN Registry Study.

The effectiveness of intravenous thrombolysis (IVT) before endovascular treatment (EVT) has been investigated in randomized trials and meta-analyses. These studies mainly concerned anterior circulation occlusions. We aimed to investigate clinical, technical, and safety outcomes of IVT before EVT in posterior circulation occlusions in a nationwide registry. Patients were included from the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), a nationwide, prospective, multicenter registry of patients with acute ischemic stroke due to a large intracranial vessel occlusion receiving EVT between 2014 and 2019. All patients with a posterior circulation occlusion were included. Primary outcome was a shift toward better functional outcome on the modified Rankin Scale at 90 days. Secondary outcomes were favorable functional outcome (modified Rankin Scale scores, 0-3), occurrence of symptomatic intracranial hemorrhages, successful reperfusion (extended Thrombolysis in Cerebral Ischemia ≥2B), first-attempt successful reperfusion, and mortality at 90 days. Regression analyses with adjustments based on univariable analyses and literature were applied. A total of 248 patients were included, who received either IVT (n=125) or no IVT (n=123) before EVT. Results show no differences in a shift on the modified Rankin Scale (adjusted common odds ratio, 1.04 [95% CI, 0.61-1.76]). Although symptomatic intracranial hemorrhages occurred more often in the IVT group (4.8% versus 2.4%), regression analysis did not show a significant difference (adjusted odds ratio, 1.65 [95% CI, 0.33-8.35]). Successful reperfusion, favorable functional outcome, first-attempt successful reperfusion, and mortality did not differ between patients treated with and without IVT. We found no significant differences in clinical, technical, and safety outcomes between patients with a large vessel occlusion in the posterior circulation treated with or without IVT before EVT. Our results are in line with the literature on the anterior circulation.

Outcomes of mechanical thrombectomy in stroke patients with extreme large infarction core

BackgroundRecent clinical trials have demonstrated that patients with large vessel occlusion (LVO) and large infarction core may still benefit from mechanical thrombectomy (MT). In this study, we evaluate outcomes of...

Abstract 221: EARLY EXPERIENCE OF EMBOGUARD BALLOON GUIDE CATHETER IN LARGE VESSEL OCCLUSION THROMBECTOMY

Introduction Endovascular thrombectomy (EVT) is the standard of care in acute ischemic stroke secondary to large vessel occlusion in selective patients within the first 24 hours. With the evolving technology and newer generation of catheters and devices, the interest in improving the technical and procedural factors that can help better the recanalization success, clinical outcomes, and efficiency is ever‐growing. Proximal flow arrest with balloon guide catheters (BGC) has been shown to optimize revascularization success and functional outcome in stroke EVT. We aim to evaluate the performance of the Emboguard BGC (Cerenovus, Irvine, CA, USA) in anterior circulation large vessel occlusion (LVO) acute ischemic strokes. Methods A prospectively maintained EVT database was reviewed for 12 months between May 2022 to May 2023 to identify all patients at our institution with intracranial vessel occlusion who underwent EVT using Emboguard BGC. Included patients were ≥18 years with large‐vessel occlusion who presented within 24 hours of time from last‐known‐well and had baseline National Institutes of Health Stroke Scale (NIHSS) score ≥ 6. Non‐dominant M2, M3, and A2 occlusions were excluded. We collected baseline demographic, clinical, and radiographic characteristics including age, sex, co‐morbidities, baseline NIHSS score, baseline modified Rankin Score (mRS), ASPECTS score, site of occlusion, imaging at our site, and use of intravenous and/or intra‐arterial thrombolytics. Outcomes included complications, NIHSS at discharge, final modified TICI (thrombolysis in cerebral ischemia) scores including the first‐pass effect (FPE, defined as mTICI 2c/3 after first pass), modified‐FPE (defined as, mTICI 2b‐3 after first pass), symptomatic intracranial hemorrhage (SITS‐MOST definition), and death at discharge. Data were analyzed using descriptive statistics, with frequency/percent for qualitative data and median/ interquartile range (IQR) for quantitative data. Results A total of 57 patients underwent EVT using Emboguard BGC. Among them, 54.4% were female and the median age was 72 years [IQR 66‐80]. Most of the patients had MCA occlusion (68.4% with 50.9% M1 and dominant/co‐dominant M2s 17.5%) with median ASPECTS 9 [IQR 8‐10]). About one‐third of our patients received intravenous thrombolytics. Following EVT, successful recanalization defined as modified TICI (thrombolysis in cerebral ischemia) scores of 2b/3 was achieved in 56 cases (98.2%) with 1 being the median number of passes (IQR 1‐2). The first pass effect (defined as one pass with mTICI of 2c/3) was achieved in 45.6% of cases. The median National Institutes of Health Stroke Scale (NIHSS) reduced significantly from 16 (IQR 12‐22) at baseline to 4 (IQR 1.5–12) at discharge (Table). Symptomatic intracranial hemorrhage was reported in 6 cases (10.5%), death at discharge was reported in 9 cases (15.8%), and access site complications were reported in 3 cases (5.3%). Conclusion Emboguard BGC showed promising results evident by a high rate of FPE, smaller number of EVT passes and improved recanalization rates with reasonable safety profile. Comparative prospective studies are needed to confirm these results.

ASPECTS evolution after endovascular successful reperfusion in the early and extended time window.

The Alberta Stroke Program Early CT scan Score (ASPECTS) is a reliable imaging biomarker of infarct extent on admission but the value of 24-hour ASPECTS evolution in day-to-day practice is not well studied, especially after successful reperfusion. We aimed to assess the association between ASPECTS evolution after successful reperfusion with functional and safety outcomes, as well as to identify the predictors of ASPECTS evolution. We used data from an ongoing prospective multicenter registry. Stroke patients with anterior circulation large vessel occlusion treated with endovascular therapy (EVT) and achieved successful reperfusion (modified thrombolysis in cerebral ischemia (mTICI) 2b-3) were included. ASPECTS evolution was defined as one or more point decrease in ASPECTS at 24 hours. A total of 2366 patients were enrolled. In a fully adjusted model, ASPECTS evolution was associated with lower odds of favorable outcome (modified Rankin Scale (mRS) score 0-2) at 90 days (adjusted odds ratio (aOR) = 0.46; 95% confidence interval (CI) = 0.37-0.57). In addition, ASPECTS evolution was a predictor of excellent outcome (90-day mRS 0-1) (aOR = 0.52; 95% CI = 0.49-0.57), early neurological improvement (aOR = 0.42; 95% CI = 0.35-0.51), and parenchymal hemorrhage (aOR = 2.64; 95% CI, 2.03-3.44). Stroke severity, admission ASPECTS, total number of passes, complete reperfusion (mTICI 3 vs. mTICI 2b-2c) and good collaterals emerged as predictors of ASPECTS evolution. ASPECTS evolution is a strong predictor of functional and safety outcomes after successful endovascular therapy. Higher number of EVT attempts and incomplete reperfusion are associated with ASPECTS evolution at day 1.

Continued Infarction Growth and Penumbral Consumption After Reperfusion in Vaccine-Naïve Patients With COVID-19: A Case-Control Study.

Background: Neurologic sequelae of SARS-CoV-2 include potentially malignant cerebrovascular events arising from complex hemodynamic, hematologic, and inflammatory processes occurring in concert. Objective: This study concerns the hypothesis that, despite angiographic reperfusion, COVID-19 promotes continued consumption of at-risk tissue volumes after acute ischemic stroke (AIS) unlike what is seen with COVID-negative individuals, yielding critical insights into prognostication and monitoring paradigms in vaccine-naïve patients experiencing AIS. Methods: This retrospective study compared 100 consecutively presenting patients with COVID-19 and AIS between March 2020 and April 2021 with a contemporaneous cohort of 282 patients with AIS who did not have COVID-19. Reperfusion classes were dichotomized into positive (extended thrombolysis in cerebral ischemia [eTICI] score = 2c-3) and negative (eTICI score < 2c) groups. All patients underwent endovascular therapy following initial CT perfusion imaging (CTP) to document infarction core and total hypoperfusion volumes. Results: Ten COVID-positive (mean age ± SD, 67 ± 6 years; seven men, three women) and 144 COVID-negative patients (mean age, 71 ± 10 years; 76 men, 68 women) undergoing endovascular reperfusion with antecedent CTP and follow-up imaging comprised the final dataset. Initial infarction core and total hypoperfusion volumes were 1.5 ± 18 mL and 85 ± 100 mL in COVID-negative patients and 30.5 ± 34 mL and 117 ± 80.5 mL in COVID-positive patients, respectively. Final infarction volumes were significantly larger in patients with COVID-19, with median volumes of 77.8 mL versus 18.2 mL among control patients (p = .01), as were normalized measures of infarction growth relative to baseline infarction volume (p = .05). In adjusted logistic parametric regression models, COVID positivity emerged as a significant predictor for continued infarct growth (OR, 5.1 [95% CI, 1.0-25.95]; p = .05). Conclusion: These findings support the potentially aggressive clinical course of cerebrovascular events in patients with COVID-19, suggesting greater infarction growth and ongoing consumption of at-risk tissues, even following angiographic reperfusion. Clinical Impact: SARS-CoV-2 infection may promote continued infarction progression, despite angiographic reperfusion, in vaccine-naïve patients with large-vessel occlusion AIS. The findings carry potential implications for prognostication, treatment selection, and surveillance for infarction growth among revascularized patients in future waves of infection by novel viral strains.

E.2 Predictors of successful endovascular thrombectomy for M2 occlusion in acute ischemic stroke

Background: There remains lack of data in regards to factors influencing successful endovascular reperfusion of isolated occlusion of the M2 segment of the middle cerebral artery (MCA). In this study, we set out to investigate the variables that affect the successful endovascular reperfusion of isolated M2 segment occlusion. Methods: M2 segment occlusion was defined as isolated clot anywhere within the M2 segment of the MCA. A prediction model of successful endovascular reperfusion defined as modified Thrombolysis in Cerebral Ischemia (mTICI) score of 2b, 2c and 3 and unsuccessful endovascular reperfusion defined as mTICI score of 0, 1 and 2a was developed from demographics (age, sex) , clinical factors (NIHSS at the time of presentation to hospital), imaging characteristics (ASPECTS, ICA occlusion, presence of Intracranial arterial disease (ICAD), computed tomography perfusion (CTP)-based ischemic core and mismatch volume estimation), and treatment (alteplase/tenecteplase use and periprocedural complications) variables from 64 patients who underwent endovascular thrombectomy (EVT) at Kingston Health Science Centre between December 24, 2018 and October 18, 2022. Results: The only statistical significant predictor of successful endovascular reperfusion was CTP-based ischemic core volume (smaller core volume) (p&lt;0.05). Conclusions: The CTP-based ischemic core volume is the most important predictor of successful endovascular reperfusion for M2 occlusion.

Improved catheter delivery for aspiration thrombectomy using Tenzing 7 ledge reducing catheter and FreeClimb 70.

Previous comparative mechanical thrombectomy device trials reported a substantial crossover rate from first-line aspiration to stent-retriever thrombectomy. A specialized delivery catheter may help track large-bore aspiration catheters to target occlusions. We report our multicenter experience of aspiration thrombectomy of intracranial large vessel occlusions using the FreeClimbTM 70 and Tenzing® 7 delivery catheter (Route 92, San Mateo, CA). After local Institutional Review Board approval, we retrospectively reviewed the clinical, procedural, and imaging data of patients who underwent mechanical thrombectomy with the FreeClimb 70 and Tenzing 7. FreeClimb 70 was successfully delivered using Tenzing 7 to target occlusion in 30/30 (100%) patients (18 M1, 6 M2, 4 ICA-terminus, and 2 basilar artery occlusions), without the use of a stent-retriever for anchoring. In 21/30 (70%) cases, a leading microwire was not needed to advance the Tenzing 7 to the target. Median (interquartile range) time from groin puncture to first pass was 12 (interquartile range 8-15) minutes. Overall first pass effect, or first pass effect (modified thrombolysis in cerebral ischemia 2C-3), was achieved 16/30 (53%). For M1 occlusions, first pass effect was 11/18 (61%). Successful reperfusion (modified thrombolysis in cerebral ischemia ≥ 2B) was achieved in 29/30 (97%) cases after a median of 1 pass (interquartile range 1-3). Median groin puncture to reperfusion time was 16 (interquartile range 12-26) minutes. There were no procedural complications or symptomatic intracranial hemorrhage. Average improvement in National Institutes of Health Stroke Scale at discharge was 6.6 ± 7.1. There were three patient deaths (renal failure, respiratory failure, and comfort care). Initial data support the use of Tenzing 7 with FreeClimb 70 catheter for reliable access to rapid, effective, and safe aspiration thrombectomy of large vessel occlusions.

Visualization of both proximal M2-MCA segments in patients (the Tilted-V Sign) with acute M1-MCA occlusion stroke is associated with better procedural and prognostic outcomes.

We aimed to assess the clinical significance of M1-MCA occlusion with visualization of both MCA-M2 segments ["Tilted-V sign" (TVS)] on initial CT angiography (CTA) in patients with acute ischemic stroke (AIS) undergoing endovascular thrombectomy (EVT). Data for patients with consecutive AIS undergoing EVT for large vessel occlusion (LVO) in two academic centers are recorded in ongoing databases. Patients who underwent EVT for M1-MCA occlusions ≤ 6 h from symptom onset were included in this retrospective analysis. A total of 346 patients met the inclusion criteria; 189 (55%) had positive TVS. Patients with positive TVS were younger (68 ± 14 vs. 71 ± 14 years, P = 0.028), with similar rates of vascular risk factors and baseline modified Rankin scores (mRS) 0-2. The rates of achieving thrombolysis in cerebral ischemia (TICI) 2b-3 were similar to the two groups (79%), although successful first-pass recanalization was more common with TVS (64 vs. 36%, p = 0.01). On multivariate analysis, higher collateral score [odds ratio (OR) 1.38 per unit increase, p = 0.008] and lower age (OR 0.98 per year increase, p = 0.046) were significant predictors of TVS. Patients with positive TVS had higher post-procedural Alberta Stroke Program Early CT Score (ASPECTS; 6.9 ± 2.2 vs. 5.2 ± 2.3, p = 0.001), were discharged with lower National Institutes of Health Stroke Score (NIHSS; 6±6 vs. 9±7, p = 0.003) and higher rates of mRS 0-2 (29.5 vs. 12%, p = 0.001), and had lower rates of 90-day mortality (13.2 vs. 21.6%, p = 0.038). However, TVS was not an independent predictor of functional independence (OR 2.51; 95% CI 0.7-8.3). Tilted-V Sign, an easily identifiable radiological marker, is associated with fewer recanalization attempts, better functional outcomes, and reduced mortality.

Feasibility of rescue stenting technique in patients with acute ischemic stroke due to middle cerebral artery occlusion after failed thrombectomy: A single-center retrospective experience.

BackgroundDespite remarkable advancements in intra-arterial mechanical thrombectomy (IAT), recanalization failure rates up to 24% have been reported. Recently, permanent stent placement (rescue stent, RS) during IAT has been suggested as an optional modality for better reperfusion and outcomes in these patients. However, previous studies were limited owing to non-standardized procedure protocols and small sample sizes. Here, we aimed to determine the efficacy and safety of RS in patients with acute ischemic stroke (AIS) with middle cerebral artery (MCA) occlusion.MethodsOf the 243 patients in our IAT database (2015–2021), 183 were identified as having MCA occlusion alone. Among them, we extracted 53 patients in whom the IAT failed to show thrombolysis in cerebral ischemia (TICI) scores of 2A or worse. Intraoperatively, RS was deployed in 22 patients (RS group), whereas 31 patients (no-stent group) received IAT without stenting. The baseline characteristics and radiologic and clinical outcomes were reviewed. Comparisons between the groups and multivariate logistic analyses for recanalization and good functional outcomes (modified Rankin Scale 0–2) were performed.ResultsNo baseline differences were noted (RS vs. no-stent); however, the recanalization outcomes (59.1% vs. 25.8%, p = 0.15) and proportion of good modified Rankin Scale scores (45.5% vs. 19.4%, p = 0.041) were better in the RS group. The parameters of symptomatic ICH (9.7% vs. 9.4%) and mortality (6.5% vs. 5.7%) showed no significant difference. In the multivariate analyses, ‘hypertension’ and ‘RS deployment’ were identified as significantly associated factors with recanalization and good prognosis.ConclusionIn select patients with MCA occlusion AIS after failed IAT, the RS technique can be an optional rescue treatment modality for acquiring better functional outcomes and delayed recanalization.

Post-ASPECTS based on hyperdensity in NCCT immediately after thrombectomy is an ultra-early predictor of hemorrhagic transformation and prognosis.

Background and PurposeAlmost half of the patients exhibit futile recanalization after thrombectomy; however, the early postoperative predictors of futile recanalization remain unclear. We analyzed the relationship of post-thrombectomy ASPECTS (Post-ASPECTS) with 90-day prognosis and hemorrhagic transformation (HT).MethodsWe collected data from patients with acute ischemic stroke (AIS) with anterior-circulation large vessel occlusion (ACLVO) who were treated via thrombectomy within 10 h in 3 hospitals. Successful endovascular recanalization was achieved (modified thrombolysis in cerebral ischemia [mTICI] 2b/3). Non-contrast computed tomography (NCCT) examination was performed immediately (within 1 h) after thrombectomy. Post-ASPECTS were scored based on the brain parenchymal hyperdensity in NCCT according to the ASPECTS scoring method. HT was defined according to the ECASS II classification criteria. Linear correlation, logistic regression, and receiver operating characteristic curve analyses were used to determine the influencing factors and best predictive value of 90-day prognosis, 90-day death, and HT.ResultsA total of 231 patients were enrolled. The good prognosis rate, mortality rate, and HT rate were 57.1, 9.5, and 38.3%, respectively. The Post-ASPECTS affected poor prognosis, death, and HT. The best predictive value of Post-ASPECTS for poor prognosis, death, and HT was 7. The specificities of Post-ASPECTS for predicting HT, poor prognosis, and death were 87.6% (AUC, 0.811; P < 0.001), 87.1% (AUC, 0.768; P < 0.001), and 73.7% (AUC, 0.748; P < 0.001), with positive predictive values of 74.2, 75.7, and 21.4%, respectively.ConclusionPost-ASPECTS predicted 90-day prognosis, death, and HT with high specificity and high positive predictive value in patients with AIS with ACLVO. Post-ASPECTS may be an ultra-early predictor of prognosis after thrombectomy.

Impact of aspiration catheter size on clinical outcomes in aspiration thrombectomy

BackgroundDirect aspiration thrombectomy is a well-established method for mechanical thrombectomy in acute ischemic stroke. Yet, the influence of aspiration catheter internal diameter (ID) on aspiration thrombectomy efficacy is incompletely understood.MethodsA...

Thrombus radiomics in patients with anterior circulation acute ischemic stroke undergoing endovascular treatment

BackgroundThrombus radiomics (TR) describe complex shape and textural thrombus imaging features. We aimed to study the relationship of TR extracted from non-contrast CT with procedural and functional outcome in endovascular-treated...

BOBBY balloon guide catheter thrombectomy in large-vessel occlusion stroke: Initial experience.

Nonrandomized studies have found Balloon Guide Catheter (BGC) use to improve technical and functional outcomes in patients undergoing mechanical thrombectomy (MT). We performed a retrospective analysis on prospectively collected data of consecutive ischemic stroke patients undergoing MT at our institution (December 2020-October 2021). Interventions where BOBBY BGC (BBGC, MicroVentionTM, Aliso Viejo, CA) was used were identified. Baseline demographics and clinico-radiographic characteristics were retrospectively collected and analysed using descriptive statistics. A total of 43 patients received BBGC-MT (male: female = 26:17, median age 72 years [IQR 62-82]). The most common occlusion site was the middle cerebral artery (MCA) (60.4%). Over half (51.2%) received intravenous thrombolytics. The BBGC tracked well over tortuous aortic arches (type II 34.8%, type III 16.3%), with median arteriotomy-to-perfusion time of 29 min (IQR 20-46). Thromboaspiration was used as first-line MT technique in 69.7% cases, with 1 (IQR 1-2) median MT pass achieving modified TICI (thrombolysis in cerebral ischemia) scores of 3 and 2b/3 in 74.4% and 95.3% respectively. Our overall first pass effect (FPE, defined as mTICI 3 after firs-pass) and modified FPE (defined as, mTICI 2b/3 after first-pass) rates were 51.1% and 79.1% respectively, with rates of 92.3% and 100% respectively when stentretriever and thromboaspiration were combined. The median reduction in National Institutes of Health Stroke Scale (NIHSS) was 9 (IQR 4-15, p < 0.0001), with a median 90-day modified Rankin Score (mRS) of 1.5 (IQR 0-2). BOBBY BGC use resulted in a high first-pass effect rate and may contribute towards improved functional outcomes.

Stroke Severity and Early Ischemic Changes Predict Infarct Growth Rate and Clinical Outcomes in Patients With Large‐Vessel Occlusion

Background The infarct growth rate (IGR) measures ischemic stroke progression and varies among patients. Clinicoradiological phenotypes of IGR are poorly understood. We evaluated the association of presentation stroke severity and early ischemic changes with infarct progression in patients who underwent successful thrombectomy. Methods This is a retrospective cohort observational study of consecutive endovascular therapy patients with anterior circulation large‐vessel occlusion strokes and successful reperfusion (modified Thrombolysis in Cerebral Ischemia≥2b) from 2 comprehensive stroke centers. National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT [Computed Tomography] Score (ASPECTS) were scored at admission. IGR was defined as the final infarct volume after endovascular therapy divided by the time from stroke onset to successful reperfusion. We used the Youden J index to identify the optimal IGR cutoff to stratify fast and slow progressors. A multivariate logistic regression was used to identify variables associated with a fast IGR and clinical outcomes. Results A total of 212 patients were included in the study. The optimal IGR threshold was 3.2 mL/h, and 135 patients (63.6%) were classified as fast progressors. Presentation National Institutes of Health Stroke Scale score (odds ratio [OR], 1.12; 95% CI, 1.06–1.19) and ASPECTS (OR, 0.56; 95% CI, 0.41–0.73) were accurate predictors of a fast IGR after adjusting for significant confounders. For each 1‐point increase in National Institutes of Health Stroke Scale score at admission, the likelihood of being a fast progressor increased by 12%; for each 1‐point increase in ASPECTS, the likelihood of being a fast progressor decreased by 44%. In the early window (≤6 hours), all patients with ASPECTS &lt;7 were identified as fast progressors. Conclusions This study shows that National Institutes of Health Stroke Scale score and ASPECTS at presentation could predict fast versus slow IGR in patients receiving endovascular therapy.