Thrombolysis In Cerebral Infarction 2b Research Articles

Outcomes of mechanical thrombectomy in octogenarians and nonagenarians patients with Acute ischemic Stroke: A systematic review and Network Meta-Analysis

PurposeAcute ischemic stroke (AIS) imposes a major healthcare burden, with the elderly population often underrepresented in clinical trials. This systematic review and network meta-analysis aims to evaluate the safety and efficacy of mechanical thrombectomy (MT) among octogenarians and nonagenarians with AIS due to large vessel occlusion (LVO). MethodsA systematic search was conducted using PubMed, Web of Science, and Scopus databases. Outcomes of interest were modified Rankin Scale (mRS) score of 0–2, thrombolysis in cerebral infarction (TICI) score of 2b-3, 90-day mortality, and symptomatic intracerebral hemorrhage (sICH). The study followed Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. ResultsThe analysis included 47 studies. Significantly lower rates of mRS score 0–2 were observed in nonagenarians (17.4 %) and octogenarians (21.3 %) compared to younger (40.2 %) patients (Odds Ratio (OR) = 3.30, 95 % Confidence Interval (CI):2.35–4.65 and OR = 2.47, 95 % CI: 2.07–2.94). 90-day mortality was significantly higher in nonagenarians (38.9 %) compared to octogenarians (25.4 %) and younger (14.0 %) patients (OR = 0.58, 95 % CI: 0.41–0.83 and OR = 0.31, 95 % CI: 0.21–0.44), and in octogenarians compared to younger patients (OR = 0.52, 95 % CI: 0.41–0.66). No significant differences were observed in TICI 2b-3 and sICH rates across groups. ConclusionsOur findings indicate that MT is a viable treatment option for AIS due to LVO among octogenarians and nonagenarians, albeit with nuanced differences. Specifically, octogenarians had lower 90-day mortality rates compared to nonagenarians. These insights support the need for individualized treatment plans for elderly patients with AIS due to LVO and highlight the importance of including this demographic in future clinical trials.

Stent-retriever characteristics and strategies associated with recanalization in thrombectomy for acute ischemic stroke

IntroductionPredictive factors for successful reperfusion in mechanical thrombectomy for acute ischemic stroke, and especially technical factors, remain controversial. We investigated various techniques for better angiographic outcomes. MethodsIn this retrospective study, acute ischemic stroke patients with large vessel occlusion treated with mechanical thrombectomy with combined technique were included. Scoring of the reperfusion grade for each attempt was conducted, and each attempt was divided into two groups based on successful reperfusion, which was defined using the presence or absence of modified thrombolysis in cerebral infarction 2b–3. The following characteristics were evaluated: the choice of stent-retriever, its length, occlusion site, thrombus position relative to deployed stent-retriever, methods of thrombectomy, and successful advancement of the distal access catheter to the proximal end of the thrombus. ResultsAmong 251 patients who underwent mechanical thrombectomy, 154 patients (255 attempts: mTICI 0-2a group, n = 119; mTICI 2b-3 group, n = 136) were included in the analysis. The thrombus position relative to the deployed stent-retriever was likely associated with successful reperfusion, although it was not statistically significant (proximal two-thirds 56.8%; distal one-third 44.3%, p = 0.09). Successful advancement of the distal access catheter was related to successful reperfusion both in univariate analysis (success 57.9%; fail 35.8%, p < 0.01) and in multivariate regression analysis (odds ratio 2.45; 95% confidence interval: 1.30–4.61, p < 0.01). ConclusionsSuccessful advancement of the distal access catheter to the proximal end of thrombus might be a key component for successful reperfusion in mechanical thrombectomy.

Is time really brain in stroke therapy?: A meta-analysis of mechanical thrombectomy up to 155h post ictus.

Mechanicalthrombectomy (MT) has been established as the gold standard of treatment for patients with Acute Ischemic Stroke (AIS) who present up to 6h after the onset of the stroke. Recently, the DEFUSE-3 and DAWN trials established the safety of starting the MT procedure up to 16 and 24h after the patient was last seen well, respectively. The purpose of this study is to assess the safety and functional effects of thrombectomy in individuals with AIS detected at a late stage (> 24h). PubMed, Web of Science, Embase, and Cochrane databases were thoroughly searched for research on MT in patients in the extremely late time window after AIS. The primary outcomes were symptomatic cerebral hemorrhage, 90-day mortality, Thrombolysis in Cerebral Infarction (TICI) 2b-3, and Modified Rankin Scale (mRS) 0-2. Our study included fifteen studies involving a total of 1,221 patients who presented with AIS and an extended time window. The primary outcome of interest was the favorable functional outcome, mRS 0-2 at 90days. The pooled proportion for this outcome was 45% (95% confidence interval 34-58%). Other outcomes included the TICI 2b or 3 (successful recanalization), which was reported in 12 studies and had a 79% incidence in the study population (95% CI 68-87%). Complications included: symptomatic intracranial hemorrhage (sICH), which revealed an incidence of 7% in the study population (95% CI 5-10%); and 90-day mortality, which reported a 27% incidence (95% CI 24-31%). In addition, we conducted a comparative analysis between endovascular treatment and standard medical therapy. Our meta-analysis provides evidence that supports the need of further randomized and prospective clinical trials to better assess the effectiveness and safety of MT in these patients.

Hyperglycemia Is Associated With Computed Tomography Perfusion Core Volume Underestimation in Patients With Acute Ischemic Stroke With Large‐Vessel Occlusion

BACKGROUND Computed tomography perfusion (CTP) predictions of infarct core play an important role in the determination of treatment eligibility in large‐vessel occlusion acute ischemic stroke. Prior studies have demonstrated that blood glucose can affect cerebral blood flow. Here, we examine the influence of acute and chronic hyperglycemia on CTP estimations of infarct core. METHODS From our prospectively collected multicenter observational cohort, we identified patients with large‐vessel occlusion acute ischemic stroke who underwent CTP with RAPID (IschemaView, Stanford, CA) postprocessing, followed by endovascular therapy with substantial reperfusion (Thrombolysis in Cerebral Infarction 2b–3) within 90 minutes, and final infarct volume determination by magnetic resonance imaging 48 to 72 hours posttreatment. Core volume overestimations and underestimations were defined as a difference of at least 20 mL between CTP‐RAPID predicted infarct core and Diffusion Weighted Imaging (DWI) final infarct volume. Primary outcome was the association of presentation glucose and hemoglobin A1c (HgbA1c) with underestimation of core volume and was measured using multivariable logistic regression adjusted for comorbidities and presentation characteristics. Secondary outcomes included frequency of overestimation of infarct core. RESULTS Among 256 patients meeting inclusion criteria, median age was 67 (interquartile range [IQR], 57–77) years, 51.6% were women, and 132 (51.6%) and 93 (36.3%) had elevated presentation glucose and elevated HgbA1c, respectively. Median CTP‐predicted core was 6 mL (IQR, 0–30 mL), median DWI final infarct volume was 14 mL (IQR, 6‐43 mL), and median difference was 12 mL (IQR, 5–35 mL). Twenty‐eight (10.9%) patients had infarct core overestimation and 68 (26.6%) had underestimation. Compared with those with no underestimation, patients with underestimation had elevated blood glucose (median, 119 [IQR, 103–155] versus 138 [IQR, 117–195] mg/dL; P = 0.002) and HgbA1c (median, 5.80% [IQR, 5.40–6.40] versus 6.40% [IQR, 5.50–7.90]; P = 0.009). In multivariable analysis, underestimation was independently associated with elevated glucose (adjusted odds ratio [OR], 2.10; P = 0.038) and HgbA1c (adjusted OR, 2.37; P = 0.012). Overestimation was associated with lower presentation blood glucose (median, 109 [IQR, 99–132] in overestimation versus 127 [IQR, 107–172] mg/dL in no overestimation; P = 0.003) and HgbA1c (5.6%[IQR 5.1–6.2] in overestimation versus 5.90%[IQR, 5.50–6.70] in no overestimation; P = 0.012). CONCLUSIONS Acute and chronic hyperglycemia were strongly associated with CTP underestimation in patients with large‐vessel occlusion acute ischemic stroke undergoing endovascular therapy. Glycemic state should be considered when interpreting CTP findings in patients with large‐vessel occlusion acute ischemic stroke.

Differences in outcome between left-sided and right-sided mechanical thrombectomy for acute ischemic stroke: A systematic review and meta-analysis.

Mechanical thrombectomy (MT) is a safe and effective treatment option for acute ischemic stroke due to large vessel occlusion. To investigate differences in outcomes between patients receiving left-sided and right-sided MT, we performed a systematic review and meta-analysis. A systematic literature review was performed using Embase, PubMed, Scopus, and Web of Science databases. Additional literature was searched for manually. Studies reporting safety and efficacy metrics for MT were included. Data regarding the modified Rankin scale (mRS), thrombolysis in cerebral infarction (TICI), symptomatic intracranial hemorrhage (sICH), and 90-day mortality were included. A random-effects model was used to calculate pooled odds ratios (ORs), mean differences (MDs), and 95% confidence intervals (CIs). The literature search yielded 13 reports consisting of 19 studies ranging from 98 to 5590 patients. Patients presenting with left-sided stroke had a National Institutes of health stroke scale score 2.89 greater than patients presenting with right-sided stroke (MD = 2.89; 95% CI = 2.09-3.68; P-value < 0.001). There were no differences between left-sided and right-sided MT patients for mRS 0-2 (OR = 0.94; 95% CI = 0.85-1.04; P-value = 0.224), TICI 2b-3 (OR = 1.05; 95% CI = 0.88-1.25; P-value = 0.598), sICH (OR = 0.83; 95% CI = 0.61-1.14; P-value = 0.255), or 90-day mortality (OR = 1.06; 95% CI = 0.84-1.33; P-value = 0.610). There does not appear to be a difference in outcomes for patients undergoing left-sided or right-sided thrombectomy.

Variation in Vessel Size and Angiographic Outcomes Following Stent‐Retriever Thrombectomy in Acute Ischemic Stroke: STRATIS Registry

Background Mechanical thrombectomy is established for large‐vessel occlusions in acute ischemic stroke, but the potential role in distal vessel occlusions of medium arteries is less well established. Such medium or distal arterial segments have not been assessed with respect to thrombectomy devices used during endovascular therapy. We conducted an analysis of arterial size, segmental anatomy, and stent‐retriever device performance with respect to vessel size during thrombectomy. Methods The STRATIS registry angiography core laboratory adjudicated the exact location of the occlusion, proximal, and distal device deployment, relationship to arterial bifurcations, and anatomic nomenclature. Arterial diameters were measured at all these sites. Statistical analyses examined the relationship between vessel and stent size, and arterial recanalization using expanded Thrombolysis in Cerebral Infarction reperfusion score. Results Overall, 665 patients with stroke were included following thrombectomy using various Solitaire device sizes, including Solitaire 4×40, Solitaire 6×30, Solitaire 4×20, Solitaire 6×20, and Solitaire 4×15. Arterial diameter at the occlusion site was a median of 2.17 mm (interquartile range [IQR], 1.88–2.60 mm) in the distal M1, 1.67 mm (IQR, 1.47–2.06 mm) in the proximal M2 middle cerebral artery, 1.50 mm (IQR, 1.15–1.61 mm) in the distal M2 middle cerebral artery, 1.24 mm (IQR, 1.11–1.24 mm) in the M3 middle cerebral artery, and 1.88 mm (IQR, 1.49–1.94 mm) in the P1 posterior cerebral artery. Expanded Thrombolysis in Cerebral Infarction 2b to 3 reperfusion was achieved in all M3 or P1 segment occlusions. The rate of first‐pass recanalization was significantly higher in patients with medium (0.75–2 mm) versus large (&gt;2 mm) vessel occlusion (69.5% versus 57.1%; P = 0.003). Conclusion Considerable overlap was noted between arterial sizes at occlusion sites carrying different segmental arterial nomenclature or vessel names. Substantial reperfusion may be achieved with currently available mechanical thrombectomy devices in medium arteries.

Safety and Efficacy of Aspiration Catheter CAT6 and 5 Fr Navien in the Endovascular Treatment of Acute Ischemic Stroke.

Mechanical thrombectomy has become a key treatment option for acute ischemic stroke. This study compared the safety and efficacy of aspiration catheter CAT6 and 5 Fr Navien. Thrombectomy was performed in103 patients with the acute internal carotid artery, middle cerebral artery M1 or M2 occlusions, including the CAT6 group (n=53 with stent retriever and CAT6 aspiration) and the 5 Fr Navien group (n=50 with stent retriever and 5 Fr Navien aspiration) at the Advanced Stroke Center. Overall, an aspiration catheter placement success rate was achieved in 93.2% of cases, 52 (98.11%) for CAT6, and 44 (88.00%) for 5 Fr Navien ( P =0.042). Overall, 17 cases (16.51%) required additional guidewire rates, 5.66% for CAT6, and 13.592% for 5 Fr Navien ( P =0.002). First-pass success rate (FPSR) was achieved in 38.84% of cases overall, a rate that did not differ significantly between catheters: 45.28% for CAT6; 32.00% for 5 Fr Navien ( P =0.167). Final thrombolysis in cerebral infarction 2b or 3 reperfusion was achieved in 91.26% of cases overall, 51 (96.23%) for CAT6, and 43 (86%) for 5 Fr Navien ( P =0.066). The participants had a mean number of passes for the index thrombus of 1.956 and a median procedure time of 65.82±21.8 minutes. There was no significant difference found in 90-day good outcome (mean 42.7%, modified Rankin Score 0 to 2) and 90-day mortality (17%) between CAT6 and 5 Fr Navien. Aspiration catheter placement success rate and first-pass success rate seemed to be higher for CAT6 and, moreover, the rate of additional guidewires was lower.

Predicting futile recanalization risk in acute basilar artery occlusion: Combination of collateral status and pre-procedural systemic inflammation response index

Acute basilar artery occlusion (ABAO) is a rare form of acute ischemic stroke (AIS). Endovascular treatment (EVT) has emerged as a primary therapeutic approach for achieving early reperfusion of the ischemic area. However, a favorable prognosis remains elusive for a considerable number of patient post-recanalization. The assessment of disparities in hematological and radiological indicators is of notable significance for predicting the prognosis of AIS patients. Our study aimed to predict futile recanalization (FR) by analyzing inflammation levels and collateral status in ABAO patients treated with EVT. Clinical data were collected from January 2019 to March 2023. The angiographic collateral grading system for basilar artery occlusion (ACGS-BAO) and the systemic inflammation response index (SIRI) was employed to assess the collateral status and inflammation levels, respectively. FR was defined as patients experiencing an unfavorable functional outcome (modified Rankin Scale &gt;2) at 3-month post-EVT, despite successful recanalization (modified Thrombolysis in Cerebral Infarction 2b or 3). Logistic regression models were utilized to analyze the association of ACGS-BAO and SIRI with FR. A total of 72 (65.5%) patients developed FR. Multivariate logistic analysis revealed that ACGS-BAO (odds ratio [OR]: 0.343, 95% confidence interval [CI]: 0.179 &amp;ndash; 0.658, P = 0.001), procedure time (OR: 1.028, 95% CI: 1.007 &amp;ndash; 1.050, P = 0.01), and natural logarithm-transformed of the SIRI (Ln[SIRI]) (OR: 2.857, 95% CI: 1.518 &amp;ndash; 5.380, P = 0.001) were independently associated with FR. In receiver operating characteristic analysis, the area under the curve for ACGS-BAO combined SIRI was 0.789 (95% CI: 0.699 &amp;ndash; 0.878; P &lt; 0.001). The effects of ACGS-BAO and Ln(SIRI) on FR were similar in all subgroups (P &gt; 0.10 for all interactions). In conclusion, poor collateral status and high inflammatory levels are independent predictors of FR after EVT in patients with ABAO.

Endovascular re-canalization for symptomatic non-acute intracranial large artery occlusion: a single-center retrospective study.

Managing patients with symptomatic non-acute intracranial large artery occlusion (SNA-ILAO) poses a significant challenge due to the high morbidity and risk of recurrent critical ischemic events, even with standard medical therapy. This unique subgroup of patients requires specialized attention. The aim of this study is to evaluate the feasibility and safety of endovascular interventional recanalization for SNA-ILAO. We retrospectively collected data of patients with SNA-ILAO who underwent endovascular interventional therapy at the Fourth Affiliated Hospital of Xinjiang Medical University from 2018 to 2021. The collected data included clinical demography, imaging data, treatment details, and prognosis. Follow-up imaging assessments were conducted for the patients, and descriptive statistics were performed. A total of 24 patients were enrolled, with a majority being male (58.3%) and a mean age of 62.0±9.3 years. The pre-treatment median modified Rankin scale (mRS) and the National Institutes of Health Stroke Scale (NIHSS) scores at baseline were 3 and 1, respectively. The most common occlusion location was the middle cerebral artery (MCA), including M1 (70.8%), M2 (20.8%), and M3 (4.7%). Successful recanalization was achieved in all 24 patients, with 21 cases (87.5%) achieving thrombolysis in cerebral infarction (TICI) 3 reperfusion and the remaining 3 cases (12.5%) achieving TICI 2b reperfusion. Asymptomatic intracranial hemorrhage (ICH) occurred in 2 patients (8.3%). During the first 30-day clinical follow-up, none of these patients experienced any recurrent cerebral ischemic events. During the 29.5-month follow-up period for vessel imaging, only 12.5% (3/24) of patients who had follow-up imaging experienced re-stenosis. Endovascular recanalization is a potentially safe and effective procedure for patients with SNA-ILAO. However, it is important to note that there is still a non-negligible rate of complications associated with this treatment. Therefore, exercising caution and implementing strict controls when administering this procedure is crucial.

Impact of smoking on outcomes following endovascular therapy for acute ischemic stroke: A systematic review and meta-analysis.

Smoking represents a leading risk factor for acute ischemic stroke (AIS). Previous literature has described a "smoking paradox", wherein smokers experience better outcomes following intravenous thrombolysis for AIS. It is unclear whether such a phenomenon exists in smokers undergoing endovascular therapy (EVT) for AIS. To assess outcomes in smokers following EVT for AIS, we conducted a systematic review and meta-analysis. Following the PRISMA guidelines, a systematic literature review of the English language literature was conducted using PubMed, Embase Web of Science, and Scopus. Outcomes of interest included 90-day modified Rankin Scale (mRS) 0-2, thrombolysis in cerebral infarction (TICI) score 2b-3, symptomatic intracranial hemorrhage (sICH), and mortality. We calculated mean difference (MD), pooled odds ratios (ORs) and their corresponding 95% confidence intervals (CI). Eight studies with 2633 patients comprised our analysis. On average, smokers were 10.14 years (MD = 10.14, [95% CI = -14.49 to -5.79], P-value < 0.001) younger than non-smokers. Smokers achieved mRS 0-2 (OR = 1.82, [95% CI, 1.34-2.48], P-value < 0.001) and TICI 2b-3 (OR = 1.61, [95% CI, 1.19-2.19], P-value = 0.002) at a higher rate than non-smokers. sICH rates were comparable between smokers and non-smokers (OR = 1.07, [95% CI, 0.62-1.85], P-value = 0.81). Smokers had a lower rate of 90-day mortality than non-smokers (OR = 0.54, [95% CI, 0.41-0.71], P-value < 0.001). In this meta-analysis of eight studies, we found that smokers with AIS undergoing EVT experienced better 90-day outcomes and higher rates of TICI 2b-3. This may be due to baseline differences between smokers and non-smokers, but future studies should explore alternative reasons that could explain this relationship between smoking and AIS treated with EVT.

Matched-pair analysis of patients with ischemic stroke undergoing thrombectomy using next-generation balloon guide catheters

BackgroundBalloon guide catheters (BGCs) have not been widely adopted, possibly due to the incompatibility of past-generation BGCs with large-bore intermediate catheters. The next-generation BGC is compatible with large-bore catheters. We...

Predictors of tissue infarction from distal emboli after mechanical thrombectomy.

Distal embolization after endovascular thrombectomy (EVT) is common. We aimed to determine factors associated with tissue infarction in the territories of distal emboli. This is a retrospective cohort study of consecutive patients with anterior circulation large vessel occlusions who underwent EVT from 2015 to 2021. Patients with Thrombolysis In Cerebral Infarction (TICI) 2b reperfusion and follow-up imaging were identified. Baseline characteristics, procedural details, and imaging findings were reviewed. Primary outcome was categorized according to the occurrence of infarction at the territory of distal embolus on follow-up diffusion-weighted imaging MRI. Of 156 subjects, 97 (62%) had at least one infarction in the territories at risk. Hypertension was significantly more prevalent in the infarct group (83% vs 53%, P=0.001). General anesthesia was more commonly used in the infarct group (60% vs 43%, P=0.037). The median number of distal emboli and diameter of the occluded vessel were similar. After adjusting for confounders, hypertension (aOR 4.73, 95% CI 1.81 to 13.25, P=0.002), higher blood glucose (aOR 1.01, 95% CI 1.00 to 1.03, P=0.023), and general anesthesia (aOR 2.75, 95% CI 1.15 to 6.84, P=0.025) were independently associated with infarction. The presence of angiographic leptomeningeal collaterals predicted tissue survival (aOR 0.13, 95% CI 0.05 to 0.33, P<0.001). 90-day modified Rankin scale (mRS) scores were worse for the infarction patients (mRS 0-2: infarct, 39% vs 55%, P=0.046). Nearly 40% of patients with TICI 2b had no tissue infarction in the territory of a distal embolus. The association of infarction with hypertension and general anesthesia suggests late or post-procedural blood pressure management could be a modifiable factor. Patients with poor leptomeningeal collaterals or hyperglycemia may benefit from further attempts at revascularization.

First-pass effect in posterior acute ischemic stroke undergoing endovascular thrombectomy: A systematic review and meta-analysis

ObjectivesFirst-pass effect (FPE) has been shown to be a predictor of favorable clinical outcomes following endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) in the anterior circulation. Literature regarding FPE for posterior circulation AIS is sparse; we conducted a systematic review and meta-analysis to explore FPE in posterior circulation stroke undergoing EVT. Materials and MethodsWe conducted a systematic review of the English literature in PubMed, Embase, Scopus, and Web of Science. FPE was defined as thrombolysis in cerebral infarction (TICI) 2c-3 and modified FPE (mFPE) was defined as TICI 2b-3 in one pass. Definitions of non-FPE and non-mFPE varied among studies. The primary outcome of interest was modified Rankin Scale (mRS) 0-2. Secondary outcomes of interest were mRS 0-3, symptomatic intracranial hemorrhage (sICH), and mortality. We calculated odds ratios (OR) and corresponding 95% confidence intervals (CI). Heterogeneity was assessed with Q statistic and I2 test. ResultsSeven studies with 417 patients in the mFPE group, 942 in the non-mFPE group, 545 in the FPE group, and 1023 in the non-FPE group were included. Overall, FPE was associated with greater rates of 90-day mRS 0-2 (OR= 2.78, 95% CI= 2.11-3.65; P-value< 0.001) and mRS 0-3 (OR= 2.67, 95% CI= 1.98-3.60; P-value< 0.001); however, there was significant heterogeneity among studies for both mRS 0-2 (I2= 69%; P-value< 0.001) and mRS 0-3 (I2= 69%; P-value< 0.001). FPE and non-FPE were associated with similar rates of sICH (OR= 0.65, 95% CI= 0.40-1.07; P-value= 0.09), and no heterogeneity was observed (I2= 0%; P-value= 0.95). FPE was associated with lower rates of mortality (OR= 0.44, 95% CI= 0.33-0.58; P-value< 0.001), although heterogeneity was observed (I2= 58%; P-value= 0.01). ConclusionsFPE is associated with favorable clinical outcomes in patients undergoing EVT for posterior circulation AIS. Future studies should work to further quantify the impact of FPE on outcomes in the posterior circulation.

2b Or 2c-3? A meta-analysis of first pass thrombolysis in cerebral infarction 2b vs multiple pass thrombolysis in cerebral infarction 2c-3 following mechanical thrombectomy for stroke.

Procedural success following mechanical thrombectomy for acute ischemic stroke is assessed using the thrombolysis in cerebral infarction scale. We conducted a systematic review and meta-analysis to determine whether outcomes differed between first pass thrombolysis in cerebral infarction 2b and multiple pass thrombolysis in cerebral infarction 2c-3. We conducted a systematic review of the literature using PubMed, Embase, Scopus, and Web of Science. We included original studies in which outcomes were stratified based on first pass thrombolysis in cerebral infarction 2b and multiple pass thrombolysis in cerebral infarction 2c-3. The primary outcome of interest was the rate of modified Rankin Scale 0-2. Secondary outcomes of interest were rates of modified Rankin Scale 0-1, symptomatic intracranial hemorrhage, and mortality. We calculated odds ratios and corresponding 95% confidence intervals. Four studies with 1554 patients were included in the quantitative analysis. Rate of modified Rankin Scale 0-2 (odds ratio = 0.91, 95% confidence interval = 0.70-1.18; P-value = 0.49), modified Rankin Scale 0-1 (odds ratio = 1.21, 95% confidence interval = 0.86-1.71; P-value = 0.27), symptomatic intracranial hemorrhage (odds ratio = 1.36, 95% confidence interval = 0.47-3.98; P-value = 0.57), and mortality (odds ratio = 0.91, 95% confidence interval = 0.67-1.25; P-value = 0.56) did not differ between first pass thrombolysis in cerebral infarction 2b and multiple pass thrombolysis in cerebral infarction 2c-3. There was no heterogeneity among included studies for modified Rankin Scale 0-2, modified Rankin Scale 0-1, or mortality; however, there was moderate heterogeneity among studies for symptomatic intracranial hemorrhage (I2 = 53%, P-value = 0.12). Clinical and safety outcomes did not differ between first pass thrombolysis in cerebral infarction 2b and multiple pass thrombolysis in cerebral infarction 2c-3. Future prospective studies and clinical trials should determine whether first pass thrombolysis in cerebral infarction 2b is a viable endpoint to thrombolysis in cerebral infarction 2c-3.

Effect of Needle-To-Puncture Time on Reperfusion Outcome in Acute Ischemic Stroke.

The aim of the study was to investigate the impact of time interval between start of intravenous thrombolysis (IVT) to start of endovascular thrombectomy (EVT) on stroke outcomes. Data from the Quality Improvement and Clinical Research (QuICR) provincial stroke registry from Alberta, Canada, were used to identify stroke patients who received IVT and EVT from January 2015 to December 2019. We assessed the impact of the time interval between IVT bolus to EVT puncture (needle-to-puncture times [NPT]) on outcomes. Radiological outcomes included successful initial recanalization (revised Arterial Occlusive Lesion 2b-3), successful initial and final reperfusion (modified thrombolysis in cerebral infarction 2b-3). Clinical outcomes were 90-day modified Rankin Scale (mRS) and mortality. Of the 680 patients, 233 patients (median age: 73, 41% females) received IVT + EVT. Median NPT was 38 min (IQR, 24-60). Arrival during working hours was independently associated with shorter NPT (p &lt; 0.001). Successful initial recanalization and initial and final reperfusion were observed in 12%, 10%, and 83% of patients, respectively. NPT was not associated with initial successful recanalization (OR 0.97 for every 10-min increase of NPT, 95% CI: 0.91-1.04), initial successful reperfusion (OR 1.01, 95% CI: 0.96-1.07), or final successful reperfusion (OR: 1.03, 95% CI: 0.97-1.08). Every 10-min delay in NPT was associated with lower odds of functional independence at 90 days (mRS ≤2; OR: 0.93; 95% CI, 0.88-0.97). Patients with shorter NPT (≤38 min) had lower 90-day mRS scores (median 1 vs. 3; OR: 0.54 [0.31-0.91]) and had lower mortality (6.1% vs. 21.2%; OR, 0.23 [0.10-0.57]) than the longer NPT group. Shorter NPT did not impact reperfusion outcomes but was associated with better clinical outcome.

Real world data in mechanical thrombectomy: who are we losing to follow-up?

BackgroundMissing outcome data (MOD) is a common problem in clinical trials and registries, and a potential bias when drawing conclusions from these data. Identifying factors associated with MOD may help...

Critical evaluation of the modified Rankin Scale for assessment of the efficacy of mechanical thrombectomy: A retrospective comparison between the modified Rankin Scale and functional independence measure.

The primary outcome measure used in mechanical thrombectomy (MT) trials is the modified Rankin Scale (mRS). However, the accuracy of mRS might be limited. On the other hand, the functional independence measure (FIM) is a widely used tool to quantify the extent to which patients require assistance during their activities of daily living. The current study aimed to reveal different clinical backgrounds that affect the efficacy of MT measured either by mRS or FIM. Patients who underwent MT at our institution from January 2019 to July 2022 were included and divided into groups based on mRS scores of 0-2 and ≥ 3. Patients were also divided into two groups based on a cut-off value of FIM of ≥ 108, as patients with FIM ≥ 108 are capable of living an independent life. The mRS score was 0-2 in 33% of the patients, while the FIM score was ≥ 108 in only 15% of the patients. In the mRS groups, there were significant differences in terms of duration of hospitalization, National Institutes of Health Stroke Scale (NIHSS) scores, achievement of thrombolysis in cerebral infarction (TICI) reperfusion grade of 2b or 3, and postoperative bleeding. Multivariate logistic regression analysis revealed that NIHSS score and achievement of TICI 2b or 3 were significant factors related to mRS 0-2 at discharge. The FIM groups differed significantly in terms of age and, duration of hospitalization, NIHSS score, although multivariate logistic regression analysis revealed that only the NIHSS score was significantly associated with an FIM score of ≥ 108. The study showed that the percentage of independent patients is significantly reduced when we evaluated the patients by the FIM. In addition, there are some differences in the clinical background that led to a good outcome between that evaluated by mRS and FIM.

Effect of atrial fibrillation on outcomes in patients with anterior circulation occlusion stroke receiving endovascular therapy.

Atrial fibrillation is one of the major risk factors of ischemic stroke. Endovascular thrombectomy (EVT) has become the standard treatment for acute ischemic stroke with large vessel occlusion. However, data regarding the impact of AF on the outcome of patients with acute ischemic stroke treated with mechanical thrombectomy are controversial. The aim of our study was to determine whether atrial fibrillation modifies the functional outcome of patients with anterior circulation acute ischemic stroke receiving EVT. We reviewed 273 eligible patients receiving EVT from January 2019 to January 2022 from 3 comprehensive Chinese stroke centers, of whom 221 patients were recruited. Demographics, clinical, radiological and treatment characteristics, safety outcomes, and functional outcomes were collected. Modified Rankin scale (mRS) score ≤ 2 at 90 days was defined as a good functional outcome. In our cohort, 79 patients (35.74%) were eventually found to have AF. Patients with AF were elder (70.08 ± 11.72 vs. 61.82 ± 13.48 years, p = 0.000) and less likely to be males (54.43 vs. 73.94%, p = 0.03). The significant reperfusion rate (modified thrombolysis in cerebral infarction 2b-3) was 73.42 and 83.80% in patients with and without AF, respectively (p = 0.064). The good functional outcome (90-day modified Rankin scale: 0 to 2) rate was 39.24 and 44.37% in patients with and without AF, respectively (p = 0.460) after adjusting multiple confounding factors. There was no difference in the presence of symptomatic intracerebral hemorrhage between the two groups (10.13 vs. 12.68%, p = 0.573). Despite their older age, AF patients achieved similar outcomes as non-AF patients with anterior circulation occlusion treated with endovascular therapy.

The Society of Vascular and Interventional Neurology (SVIN) Mechanical Thrombectomy Registry: Outcomes in Patients With Acute Ischemic Stroke and COVID‐19

Background Clinical and radiographic outcomes after mechanical thrombectomy in the setting of COVID‐19 infection remain poorly characterized. We sought to determine how COVID‐19 status affects mechanical thrombectomy outcomes in the real‐world setting in the United States. Methods The prospectively maintained multicenter mechanical thrombectomy registry from the Society of Vascular and Interventional Neurology was queried for baseline clinical characteristics among patients with and without COVID‐19 who underwent mechanical thrombectomy between March 1 and December 31, 2020 at 12 sites. Primary outcome was the likelihood of good neurological outcomes (90 day modified Rankin scale 0–2) among patients with COVID‐19 treated with endovascular thrombectomy, which was assessed using multivariable logistic regression adjusted for age, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and substantial reperfusion (modified Thrombolysis in Cerebral Infarction 2b, 2c, and 3). Secondary outcomes included National Institutes of Health Stroke Scale at 24 hours. Results Among 915 patients who underwent mechanical thrombectomy during the study period, 51 patients were positive for COVID‐19 (5.6%). Univariate analysis revealed that compared with patients who were COVID‐19 negative, patients who were positive for COVID‐19 were more likely to be male, nonsmokers, have lower Alberta Stroke Program Early CT Score, and present with intracranial internal carotid artery occlusions (Table 1). They were also less likely to achieve successful reperfusion. Multivariable analysis, however, failed to identify any independent associations with COVID‐19 positive status. Conclusion In our cohort, patients postive for COVID‐19 with acute ischemic stroke who undergo mechanical thrombectomy have similar baseline characteristics, imaging features, procedural, and clinical outcomes compared to patients who are negative for COVID‐19 in multivariate analysis. Further analyses are warranted.

Rescue Stenting for Failed Mechanical Thrombectomy in Acute Ischemic Stroke: Systematic Review and Meta‐analysis

Background When mechanical thrombectomy (MT) fails to achieve successful reperfusion, rescue stenting (RS) has proven to be a feasible rescue therapy. However, the available evidence remains underpowered to assess clinical outcomes. We aimed to compare the safety and efficacy of RS versus routine medical management in patients with failed MT using an aggregated meta‐analysis. Methods A systematic review was performed from inception to July 2022 of all studies using RS after failed MT. Outcomes of interest included a modified Rankin scale score of 0–2 at 90 days, successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b–3) after RS and symptomatic intracranial hemorrhage. A random‐effects meta‐analysis between the RS and medical treatment arms was performed to calculate pooled odds ratios (OR) for each outcome. We assessed the certainty of evidence using the Grading of Recommendation, Assessment, Development, and Evaluation approach. Statistical heterogeneity across studies was assessed with I2 statistics. Results A total of 12 studies included 1855 participants, 729 in the RS arm and 1126 in the medical treatment arm. The pooled results indicated that RS was associated with a significantly higher proportion of patients with a modified Rankin scale score of 0–2 at 90 days (RS: 41% versus 21%; OR,3.27; [95% CI 2.08–5.16]; I2=64%; moderate‐certainty evidence) and a decreased risk of mortality at 90 days (RS: 22.5% versus 33.8%; OR, 0.47; [95% CI 0.32–0.69]; I2=45%; low‐certainty evidence), compared with medical treatment after failed MT. The pooled rate of successful reperfusion after RS was 87% (95% CI 82–91; I2=57%; low‐certainty evidence). The rate of symptomatic intracranial hemorrhage did not differ between groups (RS: 8.5% versus 11.7%; OR, 0.85; [95% CI 0.59–1.20]; I2=7%; low‐certainty evidence). Conclusion RS is a promising strategy for maximizing recovery in acute stroke patients after first line MT fails to achieve meaningful reperfusion. However, randomized trials using a standardized approach/technique and MT failure definition are warranted to confirm these results.