Thrombolysis In Cerebral Infarction Grade Research Articles

Characteristics and prognostic impact of unsuccessful recanalization after endovascular therapy for acute ischemic stroke

BackgroundEndovascular therapy (EVT) has shown high therapeutic efficacy for acute large vessel occlusion (LVO); however, recanalization is unsuccessful in some cases. This study aimed to examine the characteristics and prognostic impact of unsuccessful recanalization after EVT compared with medical treatment alone. MethodsWe conducted a post hoc analysis of RESCUE-Japan Registry 2, a nationwide registry of 2408 consecutive patients with acute LVO. Patients without successful recanalization after EVT (thrombolysis in cerebral infarction grade ≤ 2a) were classified into the Unsuccessful EVT group, and compared with the No-EVT group. To account for selection bias, the outcomes were compared in a propensity score-matched cohort. The outcomes included the modified Rankin Scale (mRS) score at 90 days and intracranial hemorrhage within 72 h after the LVO onset. ResultsAmong 188 (14.7 %) patients in the Unsuccessful EVT group out of 1281 who underwent EVT, 147 were matched with the No-EVT group, with comparable baseline characteristics. Patients in the Unsuccessful EVT group had a higher distribution of mRS score at 90 days and were less likely to achieve mRS 0–2 compared to those in the No-EVT group (23 % vs. 34 %, OR:0.58, 95 % CI:0.35–0.98). All-cause mortality was higher in the Unsuccessful EVT group (16 % vs. 6.8 %, OR: 2.54, 95 % CIs: 1.16–5.55). Symptomatic intracranial hemorrhage was more frequently observed in the Unsuccessful EVT group (5.4 % vs. 0.7 %, OR: 8.40, 95 % CIs: 1.04–68.1). ConclusionsThe clinical outcomes of patients without successful recanalization after EVT were worse than those who did not undergo EVT.

Age and Functional Outcomes in Patients With Large Ischemic Stroke Receiving Endovascular Thrombectomy

Randomized clinical trials have demonstrated the efficacy and safety of endovascular thrombectomy for acute ischemic stroke with large infarct. Patients older than 80 years with large infarct are commonly encountered in clinical practice but underrepresented in randomized clinical trials. To provide an age-based analysis of functional outcomes in endovascular thrombectomy for acute ischemic strokes with large infarct. This retrospective multicenter cohort study included patients from the German Stroke Registry who received endovascular thrombectomy for acute ischemic stroke with large infarct at 1 of 25 German stroke centers between May 2015 and December 2021. Patients with acute ischemic stroke due to anterior circulation large vessel occlusion and large infarct were included. Large infarct was defined as an Alberta Stroke Program Early Computed Tomography Score of 0 to 5. Patients were subdivided by age to evaluate its association with functional outcomes. Age. Primary outcomes were independent ambulation (90-day modified Rankin Scale score of 0-3) and mortality (90-day modified Rankin Scale score of 6). A total of 408 patients with large infarct were included (217 women [53.2%]; median [IQR] age, 75 [64-83] years). The rate of independent ambulation decreased from 56.4% in patients aged 60 years and younger (44 of 78 patients) to 15.1% in patients older than 80 years (19 of 126 patients) (P < .001), while mortality increased from 15.4% (12 patients) to 64.3% (81 patients) (P < .001). Being older than 80 years was associated with lower rates of independent ambulation (adjusted odds ratio [aOR], 0.44; 95% CI, 0.23-0.82; P = .01) and higher mortality (aOR, 2.75; 95% CI, 1.61-4.72; P < .001). A final modified Thrombolysis in Cerebral Infarction grade of 2b or 3 was associated with higher rates of independent ambulation (aOR, 4.95; 95% CI, 2.14-11.43; P < .001), independent of age and without significant interaction (aOR, 0.69; 95% CI, 0.35-1.34; P = .27). In this cohort study of patients with acute ischemic stroke and large infarct, age was associated with functional outcomes. Patients older than 80 years had poor prognosis with high mortality but with sizeable differences depending on additional baseline and treatment characteristics. While it does not seem justified to apply a fixed upper age limit for endovascular thrombectomy, these results could assist clinicians in making informed treatment decisions in older patients with large ischemic stroke.

Usefulness of Mechanical Thrombectomy in Patients with Cancer Who Developed Cerebral Infarction.

Mechanical thrombectomy (MT) is an established treatment for large vessel occlusion in the acute phase of stroke. However, its efficacy and safety in patients with cancer remain unclear. This study aimed to evaluate the therapeutic effect of MT against large vessel occlusion between patients with and without cancer. A total of 71 patients who underwent MT from August 2014 to November 2021 were included in this study. Patients with cancer and/or a history of cancer (n = 16) were included in the with cancer group and the remaining patients in the without cancer group (n = 55). The frequency of preoperative tissue plasminogen activator administration was significantly lower in the with cancer group (n = 2 [12.5%]) than in the without cancer group (n = 24 [43.6%]). However, there were no significant differences between the two groups in terms of treatment time, pass frequency, thrombolysis in cerebral infarction grade, modified Rankin scale score at 1 week after treatment [mRS (1w) ], modified Rankin scale score at discharge [mRS (ENT) ], modified Rankin scale score at 90 days after treatment [mRS (90 days) ], and length of hospital stay (days). In the multivariate analysis, if the objective variables were mRS (1w) and mRS (90 days), the National Institutes of Health Stroke Scale (NIHSS) and preonset mRS scores were considered significant variables. The presence or absence of cancer was not considered an independent factor of mRS (1w), mRS (ENT), or mRS (90 days). Aggressive treatment may be recommended to patients with cancer and/or a history of cancer who present with a systemic condition that can be managed with MT.

Difference between arterial and venous peak optical density after thrombectomy is associated with functional outcomes.

The density of contrast medium in digital subtraction angiography (DSA) have been used to evaluate the cerebral circulation function. Our aim was to study the effect of difference in arteriovenous peak optical density (POD) after thrombectomy on functional outcomes. Consecutive patients with acute ischemic stroke due to large vessel occlusion who underwent thrombectomy were reviewed. We processed DSA images with ImageJ software to measure the POD of internal carotid artery (ICA) and cortical veins. The average POD of cortical veins (PODVA) and the POD difference between ICA and cortical veins (PODICA-CV) were calculated. Primary outcome was good functional outcome (modified Rankin scale score of 0-2 at 90 days). One hundred sixty-six patients were finally included in the study. Patients with good functional outcome had lower ipsilateral PODVA (median [interquartile range (IQR)], 257.198 [216.623-296.631] vs. 290.944 [248.647-338.819], p < 0.001) and lower ipsilateral PODICA-CV (median [IQR], 128.463 [110.233-153.624] vs. 182.01 [146.621-211.331], p < 0.001). Multivariable logistic regression analyses showed that ipsilateral PODVA (odds ratio [OR] 0.991, 95% confidence interval [CI] 0.984-0.999, p = 0.019) and ipsilateral PODICA-CV (OR 0.975, 95% CI 0.963-0.986, p < 0.001) were associated with good functional outcome. The predictive ability was significantly enhanced in the model including ipsilateral PODICA-CV (0.893 vs. 0.842, p = 0.027). No correlation was found between ipsilateral PODICA-CV and expanded Thrombolysis in Cerebral Infarction grades (r = -0.133, p = 0.099). Ipsilateral PODICA-CV is an additional indicator of cerebral reperfusion status and predicts functional outcomes after thrombectomy.

Acute Vertebrobasilar Artery Occlusion with Underlying Atherosclerosis: Balloon Angioplasty Combined with Tirofiban as Initial Salvage Therapy

The optimal rescue endovascular treatment for patients with intracranial atherosclerotic stenosis in acute vertebrobasilar artery occlusion is not well established. We investigated the safety and efficacy of balloon angioplasty combined with tirofiban as the initial rescue strategy in these patients. We retrospectively analyzed the records of 41 patients admitted between January 2014 and September 2022, with vertebrobasilar artery atherosclerotic occlusion. Balloon angioplasty in combination with tirofiban was used as the first-line salvage therapy after the failure of mechanical thrombectomy. The technical success rate, recanalization outcome, procedure-related complications, symptomatic intracranial hemorrhage, and functional outcome at 90days were reviewed. Recanalization with a modified Thrombolysis in Cerebral Infarction grade of 2b-3 was achieved in 38 of the 41 patients (92.7%). Acute stents were deployed in 5 patients who did not achieve successful reperfusion after balloon angioplasty. Six patients (14.6%, 6/41) underwent stent angioplasty in the stable stage for severe residual stenosis detected on follow-up imaging. There was no procedure-related complication. Hemorrhagic transformation was detected on follow-up imaging in 11 patients (26.8%), while no symptomatic intracranial hemorrhage was recorded. Good functional outcome rate was 31.7% (13/41). Balloon angioplasty combined with intravenous tirofiban administration is a safe and effective salvage therapy in patients with acute atherosclerotic occlusion of the vertebrobasilar artery.

Simulated Quantum Mechanics-Based Joint Learning Network for Stroke Lesion Segmentation and TICI Grading.

Segmenting stroke lesions and assessing the thrombolysis in cerebral infarction (TICI) grade are two important but challenging prerequisites for an auxiliary diagnosis of the stroke. However, most previous studies have focused only on a single one of two tasks, without considering the relation between them. In our study, we propose a simulated quantum mechanics-based joint learning network (SQMLP-net) that simultaneously segments a stroke lesion and assesses the TICI grade. The correlation and heterogeneity between the two tasks are tackled with a single-input double-output hybrid network. SQMLP-net has a segmentation branch and a classification branch. These two branches share an encoder, which extracts and shares the spatial and global semantic information for the segmentation and classification tasks. Both tasks are optimized by a novel joint loss function that learns the intra- and inter-task weights between these two tasks. Finally, we evaluate SQMLP-net with a public stroke dataset (ATLAS R2.0). SQMLP-net obtains state-of-the-art metrics (Dice:70.98% and accuracy:86.78%) and outperforms single-task and existing advanced methods. An analysis found a negative correlation between the severity of TICI grading and the accuracy of stroke lesion segmentation.

Subcortical infarcts on admission CTP predict poor outcome despite excellent reperfusion in delayed time windows.

The effect of pretreatment infarct location on clinical outcome after successful mechanical thrombectomy is not understood. Our aim was to evaluate the association between computed tomography perfusion (CTP)-based ischemic core location and clinical outcome following excellent reperfusion in late time windows. We retrospectively reviewed patients who underwent thrombectomy for acute anterior circulation large vessel occlusion in late time windows from October 2019 to June 2021 and enrolled 65 patients with visible ischemic core on admission CTP who had received excellent reperfusion (modified thrombolysis in cerebral infarction grade 2c/3). Poor outcome was defined as a modified Rankin scale score of 3-6 at 90 days. The ischemic core infarct territories were classified into the cortical and subcortical areas. Multivariate logistic regression and receiver operating characteristic (ROC) curve analyses were used in this study. Of the 65 patients analyzed, 38 (58.5%) had a poor outcome. Multivariable logistic analysis showed that the subcortical infarcts (OR 11.75; 95% CI 1.79-77.32; P = 0.010) and their volume (OR 1.17; 95% CI 1.04-1.32; P = 0.011) were independently associated with poor outcome. The ROC curve indicated the capacity of the subcortical infarct involvement (areas under the curve (AUC) = 0.65; 95% CI, 0.53-0.77, P < 0.001) and subcortical infarct volume (AUC = 0.72; 95% CI, 0.60-0.83, P < 0.001) in predicting poor outcome accurately. Subcortical infarcts and their volume on admission CTP are associated with poor outcome after excellent reperfusion in late time windows, rather than cortical infarcts.

Balloon-Assisted Catheterization of Occluded Carotid Artery (BOCA) Technique in Acute Stroke.

Acute ischemic stroke from tandem occlusion of internal carotid artery (ICA) poses a technical challenge to neurointerventionalists. To present a novel balloon-assisted catheterization of occluded carotid artery (BOCA) technique used for rapid and effective catheterization of occluded/critically stenosed ICA in tandem occlusion. A retrospective review of 10 patients with tandem carotid occlusion, treated with BOCA technique for revascularization between July 2020 and June 2021, was performed. Clinical, radiographic, and procedural data; details of BOCA technique; complications; and outcomes were reviewed. Of the 10 patients, 8 (80%) had complete occlusion of the cervical ICA and the remaining 2 had high-grade stenosis with poor intracranial flow. The mean age was 63.2 years. The mean presenting NIH Stroke Scale was 13.4. The BOCA technique resulted in recanalization of ICA in all patients and allowed mechanical thrombectomy of middle cerebral artery. Thrombolysis in cerebral infarction grade 2b/3 was achieved in all 10 patients. The mean groin-to-reperfusion time was 41.4 minutes. The mean internal carotid artery stenosis was 99.7% preoperatively and 41.1% postoperatively. Only one patient needed stent at the end of the procedure because of dissection. The BOCA technique can be used in distal first approach for acute stroke from tandem ICA occlusion. This technique allows direct guide catheterization of occluded ICA by tracking over a partially inflated balloon.

Association Between Intravenous Thrombolysis and Clinical Outcomes Among Patients With Ischemic Stroke and Unsuccessful Mechanical Reperfusion

Clinical evidence of the potential treatment benefit of intravenous thrombolysis preceding unsuccessful mechanical thrombectomy (MT) is scarce. To determine whether intravenous thrombolysis (IVT) prior to unsuccessful MT improves functional outcomes in patients with acute ischemic stroke. Patients were enrolled in this retrospective cohort study from the prospective, observational, multicenter German Stroke Registry-Endovascular Treatment between May 1, 2015, and December 31, 2021. This study compared IVT plus MT vs MT alone in patients with acute ischemic stroke due to anterior circulation large-vessel occlusion in whom mechanical reperfusion was unsuccessful. Unsuccessful mechanical reperfusion was defined as failed (final modified Thrombolysis in Cerebral Infarction grade of 0 or 1) or partial (grade 2a). Patients meeting the inclusion criteria were matched by treatment group using 1:1 propensity score matching. Mechanical thrombectomy with or without IVT. Primary outcome was functional independence at 90 days, defined as a modified Rankin Scale score of 0 to 2. Safety outcomes were the occurrence of symptomatic intracranial hemorrhage and death. After matching, 746 patients were compared by treatment arms (median age, 78 [IQR, 68-84] years; 438 women [58.7%]). The proportion of patients who were functionally independent at 90 days was 68 of 373 (18.2%) in the IVT plus MT and 42 of 373 (11.3%) in the MT alone group (adjusted odds ratio [AOR], 2.63 [95% CI, 1.41-5.11]; P = .003). There was a shift toward better functional outcomes on the modified Rankin Scale favoring IVT plus MT (adjusted common OR, 1.98 [95% CI, 1.35-2.92]; P < .001). The treatment benefit of IVT was greater in patients with partial reperfusion compared with failed reperfusion. There was no difference in symptomatic intracranial hemorrhages between treatment groups (AOR, 0.71 [95% CI, 0.29-1.81]; P = .45), while the death rate was lower after IVT plus MT (AOR, 0.54 [95% CI, 0.34-0.86]; P = .01). These findings suggest that prior IVT was safe and improved functional outcomes at 90 days. Partial reperfusion was associated with a greater treatment benefit of IVT, indicating a positive interaction between IVT and MT. These results support current guidelines that all eligible patients with stroke should receive IVT before MT and add a new perspective to the debate on noninferiority of combined stroke treatment.

Impact of width of susceptibility vessel sign on recanalization following endovascular therapy

Background and purposeWe aimed to investigate the relationship between arterial recanalization following endovascular therapy and the susceptibility vessel sign (SVS) length and width on susceptibility-weighted imaging. MethodsWe retrospectively evaluated consecutive patients with anterior circulation ischemic stroke who underwent magnetic resonance imaging preceded endovascular therapy, and measured the SVS length and width. Successful recanalization was defined as expanded thrombolysis in cerebral infarction grade of 2b to 3. Logistic regression analysis was executed to determine the independent predictors of successful recanalization and first-pass reperfusion (FPR) after endovascular therapy. ResultsAmong 100 patients, successful recanalization and FPR were observed in 77 and 34 patients, respectively. The median SVS length and width were 10.3 mm (interquartile range, 6.8–14.1 mm) and 4.2 mm (interquartile range, 3.1–5.2 mm), respectively. In multivariate logistic regression analysis, SVS width was associated with successful recanalization (odds ratio, 1.88; 95% confidence interval, 1.14–3.07; p = 0.005) and FPR (odds ratio, 1.38; 95% confidence interval, 1.01–1.89; p = 0.039). The optimal cutoff value for the SVS width to predict successful recanalization and FPR were 4.2 mm and 4.0 mm, respectively. ConclusionsLarger SVS width may predict successful recanalization and FPR following endovascular therapy.

Association of Aortic Arch Calcification with Acute Ischemic Stroke Subtypes and Endovascular Thrombectomy Outcomes

PurposeTo analyze the aortic arch calcification (AAC) on computed tomography (CT) scans, with the goal of predicting the subtypes of patients with ischemic stroke and endovascular thrombectomy (EVT) outcomes. Materials and MethodsAutomated analysis was used to quantify AAC on CT scans. From January 2020 to March 2021, 119 patients diagnosed with ischemic stroke were analyzed, and the feasibility of EVT was assessed; 43 underwent the procedure. ResultsAAC was present in 117 (98.3%) of 119 patients. There was a significant difference (P <.001) in AAC severity among all patients with ischemic stroke according to the Trial of ORG 10172 in Acute Stroke Treatment classification. In patients who underwent EVT, AAC severity was significantly related to the thrombolysis in cerebral infarction grade, thrombectomy procedure time, and modified Rankin scale at discharge (P =.002, P =.035 and P =.015, respectively). Multivariate logistic regression analysis also showed that severe AAC (volume, ≥1,000 mm3) (adjusted odds ratio [OR], 12.1; adjusted 95% confidence interval [CI]), 2.1–36.4; P =.001) and intracranial atherosclerotic disease (adjusted OR, 9.5; adjusted 95% CI, 2.3–33.7; P =.001) were both independently associated with poor thrombolysis reperfusion rate. ConclusionsA high proportion of patients with ischemic stroke have AAC, the severity of which is a potential imaging marker of ischemic stroke subtypes and the outcome of EVT.

On-Table Catheter-Based Neurosalvage Performed by Cardiologists for Embolic Complication during an Endovascular Procedure.

To report our experience and clinical results of neurosalvage techniques, performed by interventional cardiologists without moving the patient, to manage cerebral thromboembolic complications. Iatrogenic emboli may be released during an endovascular procedure, causing permanent neurological complications and catastrophic outcomes. Between July 2013 and December 2017, a total of eight patients suffered from embolic complications during endovascular procedures (two radiofrequency catheter ablation, five coronary angiogram/angioplasty, and one subclavian artery angioplasty). Catheter-based neurosalvage was attempted by experienced interventional cardiologists promptly in the same catheterization room. The embolized locations were the M1 segment of the middle cerebral artery in four patients, the M2/M3 segments in three, and the basilar artery in one. Access to the supra-aortic vessels was achieved. Local intra-arterial thrombolysis was given in five patients (63%) and balloon angioplasty in three (38%). Intra-arterial thrombectomy with a stent retriever was attempted in three patients but failed in one. A combination of different techniques was used in three patients (38%). Final thrombolysis in cerebral infarction grade 3 flow was achieved in seven patients (88%). Favorable clinical outcomes at 1-month follow-up (modified Rankin scale of 0-2) were observed in seven patients (88%), and none of the patients had died at 12 months. Our experience demonstrated that acute embolic complications during an endovascular procedure can be salvaged by interventional cardiologists with acceptable angiographic and clinical results.

Status of neurological deficits after mechanical thrombectomy in elderly patients with ischemia

BackgroundNumerous studies report poorer outcomes after mechanical thrombectomy (MT) in elderly patients than in non-elderly patients. We aimed to investigate the changes in neurological symptoms after MT in elderly patients. MethodsWe included 151 patients with acute stroke who independently performed activities of daily living before admission, underwent MT at our hospital between January 1, 2019 and December 31, 2021, and had successful recanalization (thrombolysis in cerebral infarction grade >2b). The subjects were divided into two groups according to whether they were aged ≥80 years (elderly group) or <80 years (non-elderly group), and the National Institutes of Health Stroke Scale (NIHSS) scores and deep and subcortical white matter hyperintensity (DSWMH) grades were compared between both groups. ResultsThere were 57 (38 %) and 94 (62 %) patients in the elderly and non-elderly groups, respectively. After propensity score matching, the median (interquartile range) NIHSS scores were significantly higher in the elderly group than in the non-elderly group at both 24 h (12 [5.5–19] vs 8; [2–14] P = 0.040) and 1 week (8 [3–12] vs 2.5 [0–13.5]; P = 0.041) after MT but not before MT (18 [13.5–22.5] vs 20 [14.5–24]; P = 0.549). DSWMH grades were significantly higher in the elderly group than in the non-elderly group (2 [1–3] vs 1 [0–2]; P = 0.018). ConclusionsMT in the elderly group was associated with poorer improvement in neurological symptoms from the early period after MT than in the non-elderly group, even when successful recanalization was achieved. White matter lesions may contribute to the poor neurological improvement after recanalization in the elderly group.

Effect of Solitaire FR Stent Thrombectomy Combined with the Suction Thrombus on the Clinical Effect and Prognosis of Acute Middle Cerebral Artery Occlusion.

To determine the curative effect and prognosis of Solitaire FR stent thrombectomy integrated with the suction thrombus on the treatment of acute middle cerebral artery occlusion (AMCAO). Based on the treatment, patients suffering from AMCAO were separated into the Solitaire FR group (Solitaire FR stent + suction thrombus) and suction group (suction thrombus). Modified thrombolysis in cerebral infarction grading, National Institutes of Health Stroke Scale (NIHSS) score, modified Rankin Scale score, and safety performance were compared between the two groups. The operation time in the suction group was obviously shorter than the Solitaire FR group (P < 0.05). Significant differences were observed in the NIHSS scores 1 week and 4 weeks after the operation between the Solitaire FR group and the suction group (P < 0.05). The NIHSS scores 1 week and 4 weeks after operation were significantly lower than those before operation (P < 0.05). NIHSS scores 1 week after operation did not show obvious difference (P > 0.05). The Solitaire FR group showed obvious lower NIHSS scores than the suction group 4 weeks after surgery (P < 0.05). Statistically obvious difference in cerebral infarction grading of modified thrombolysis between the Solitaire FR group and the suction group were observed (P < 0.05). The recanalization rate of the Solitaire FR group was obviously higher than the suction group (P < 0.05). The difference in the monthly modified Rankin Scale score was obvious (P < 0.05). The good prognosis rate of the Solitaire FR group was obviously higher than the suction group (P < 0.05). No obvious differences in the incidence of internal bleeding, reocclusion, and 3-month postoperative mortality were observed (P > 0.05). These results showed that the treatment of the Solitaire FR stent + suction thrombus in AMCAO patients has a good thrombus recanalization rate and is helpful in improving the prognosis and safety performance.

Failed recanalization mediates the association of women with poor outcomes after thrombectomy: a single-center experience

Background: Whether thrombectomy benefits differ according to sex remains debatable. We aimed to investigate whether there was a difference in stroke outcomes between men and women treated with thrombectomy.Methods: We studied 173 patients with anterior circulation strokes. Failed recanalization was defined as thrombolysis in cerebral infarction grade 0-2a. Scores &gt;2 on the modified Rankin Scale at 3 months were regarded as poor outcomes. To prove that failed recanalization mediated the association between sex differences and functional outcome, the four steps of the reasoning process adapted from Baron and Kenny’s causal-steps approach were tested. The adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated. Results: This study included 76 women and 97 men. Women were older and presented with atrial fibrillation more frequently than men. Female sex was independently associated with failed recanalization (aOR, 2.729; 95% CI, 1.334–5.582), which was an independent predictor of poor outcomes (aOR, 4.630; 95% CI, 1.882–11.389). Women were associated with poor outcomes in the analysis adjusted for confounders, except for failed recanalization (aOR, 2.285; 95% CI, 1.064–4.906). However, the association became insignificant in the additional analysis adjusted for failed recanalization (aOR, 1.670; 95% CI, 0.738–3.784). The indirect effect between female sex and poor outcomes via failed recanalization was statistically significant (aOR, 1.038; 95% CI, 1.010–1.127). Conclusion: Our study showed that failed recanalization mediated the association between women and poor outcomes after thrombectomy. Nonetheless, this might be explained by chance given our limited study population.

Balloon Angioplasty Combined with Tirofiban as a First-Line Rescue Treatment After Failed Mechanical Thrombectomy for Middle Cerebral Artery Occlusion with Underlying Atherosclerosis

The standard rescue modality for patients with intracranial atherosclerotic stenosis after failed mechanical thrombectomy (MT) is not well established. We evaluated the safety and efficacy of balloon dilation in combination with tirofiban as the first-line salvage therapy when MT failed in these patients. We retrospectively analyzed the records of 47 patients admitted between January 2018 and June 2021, with middle cerebral artery atherosclerotic occlusion, who underwent balloon angioplasty in combination with tirofiban as the first-line salvage therapy after the failure of MT. The recanalization outcome, procedure-related complications, symptomatic intracranial hemorrhage, and functional outcome at 90days were reviewed. Recanalization with a modified Thrombolysis in Cerebral Infarction grade of 2b-3 was achieved in 41 (87.2%) of the 47 patients. Acute stents were deployed in another 6 patients who did not achieve successful re-perfusion after balloon angioplasty. Successful recanalization was achieved in 3 of them. One patient (2.1%, 1/47) experienced re-occlusion several days later due to the withdrawal of antiplatelet therapy for parenchymal hematoma. Seven patients (14.9%, 7/47) underwent stent angioplasty in the stable stage (range: 1-2months) because severe residual stenosis was detected on follow-up imaging. There was only one event of periprocedural complication, namely ectopic migration of emboli. The good functional outcome rate was 55.3% (26/47), without the events of symptomatic intracranial hemorrhage and mortality. Balloon angioplasty in combination with tirofiban is safe and effective for middle cerebral artery atherosclerotic occlusion after the failure of MT.

An Initial High National Institutes of Health Stroke Scale Score and Any Intracranial Hemorrhage Are Independent Factors for a Poor Outcome in Nonagenarians Treated with Thrombectomy for Acute Large Vessel Occlusion: The Tokyo/Tama-REgistry of Acute Endovascular Thrombectomy (TREAT) Study

Mechanical thrombectomy (MT) is effective in acute ischemic stroke patients ≥80years old with large vessel occlusion (LVO). However, data for patients ≥90years old remain very limited, and factors influencing functional outcomes are unclear. This study aimed to investigate factors influencing functional outcomes in patients ≥90years old treated with MT for acute LVO. This retrospective observational study used prospectively collected data from the Tokyo/tama-REgistry of Acute endovascular Thrombectomy (TREAT) study. Inclusion criteria were as follows: 1) patients ≥90years old treated with MT for LVO and 2) prestroke modified Rankin Scale (mRS) score, 0-3. The functional outcome was defined based on the mRS score at 90days after the procedure: good functional outcome, mRS score 0-3 and poor functional outcome, mRS score 4-6. Data were analyzed for 104 patients ≥90years old. The good functional outcome was observed in 25 patients (24.0%), and the poor functional outcome was observed in the remaining 79 patients. Significant differences were identified in initial National Institutes of Health Stroke Scale (NIHSS) score, modified Thrombolysis in Cerebral Infarction grade 2b-3, modified Thrombolysis in Cerebral Infarction grade 3, and any intracranial hemorrhage and hemorrhagic infarction in univariate analyses. Multivariable analysis confirmed the initial NIHSS score (odds ratio, 1.08; 95% confidence interval, 1.01-1.17; P=0.045) and any intracranial hemorrhage (odds ratio, 11.6; 95% confidence interval, 1.43-95.0; P= 0.022) as independent factors for the functional outcome. An initial high NIHSS score and any intracranial hemorrhage are independent factors for the poor functional outcome in acute ischemic stroke patients ≥90years old treated with MT.

Outcomes After Endovascular Thrombectomy With or Without Alteplase in Routine Clinical Practice

The effectiveness and safety of intravenous alteplase given before or concurrently with endovascular thrombectomy (EVT) is uncertain. Randomized clinical trials suggest there is little difference in outcomes but with only modest precision and insufficient power to analyze uncommon outcomes including symptomatic intracranial hemorrhage (sICH). To determine whether 8 prespecified outcomes are different in patients with acute ischemic stroke treated in routine clinical practice with EVT with alteplase compared with patients treated with EVT alone without alteplase. It was hypothesized that alteplase would be associated with higher risk of sICH. This was an observational cohort study conducted from February 1, 2019, to June 30, 2020, that included adult patients with acute ischemic stroke treated with EVT within 6 hours of time last known well, after excluding patients without information on discharge destination and patients with in-hospital stroke. Participants were recruited from Get With The Guidelines-Stroke, a large nationwide registry of patients with acute ischemic stroke from 555 hospitals in the US. Intravenous alteplase or no alteplase. Prespecified outcomes were discharge destination, independent ambulation at discharge, modified Rankin score at discharge, discharge mortality, cerebral reperfusion according to modified Thrombolysis in Cerebral Infarction grade, and sICH. There were 15 832 patients treated with EVT (median [IQR] age, 72.0 [61.0-82.0] years; 7932 women [50.1%]); 10 548 (66.7%) received alteplase and 5284 (33.4%) did not. Patients treated with alteplase were younger, arrived via Emergency Medical Services sooner, were less likely to have certain comorbidities, including atrial fibrillation, hypertension, and diabetes, but had similar National Institutes of Health Stroke Severity (NIHSS) scores. Compared with patients who did not receive alteplase treatment, patients treated with alteplase were less likely to die (11.1% [1173 of 10 548 patients] vs 13.9% [734 of 5284 patients]; adjusted odds ratio [aOR] 0.83; 95% CI, 0.77-0.89; P < .001), more likely to have no major disability based on modified Rankin scale of 2 or less at discharge (28.5% [2415 of 8490 patients] vs 20.7% [894 of 4322 patients]; aOR, 1.36; 95% CI, 1.28-1.45; P < .001), and to have better reperfusion based on modified Thrombolysis in Cerebral Infarction grade 2b or greater (90.9% [8474 of 9318 patients] vs 88.0% [4140 of 4705 patients]; aOR, 1.39; 95% CI, 1.28-1.50; P < .001). However, alteplase treatment was associated with higher risk of sICH (6.5% [685 of 10 530 patients] vs 5.3% [279 of 5249 patients]; OR, 1.28; 95% CI, 1.16-1.42; P < .001). In this observational cohort study of patients treated with EVT, intravenous alteplase treatment was associated with better in-hospital survival and functional outcomes but higher sICH risk after adjusting for other covariates.

Predicting Role of Prestroke Glycemic Variability Estimated by Glycated Albumin for Reperfusion and Prognosis after Endovascular Treatment

Introduction: Glycated hemoglobin is widely used for the diagnosis of diabetes, but it is not accurately correlated with blood glucose fluctuations. We evaluated the impact of prestroke glycemic variability, measured by glycated albumin (GA) on reperfusion rate and stroke outcomes after endovascular treatment (EVT). Methods: We consecutively collected 310 EVT-treated patients for 60 months using a multicenter registry database. Primary outcome was unsuccessful reperfusion defined by modified Thrombolysis in Cerebral Infarction grade 0 to 2a. Secondary outcomes were occurrence of early neurologic deterioration (END), symptomatic hemorrhagic transformation (SHT) and a 3-month poor outcome (modified Rankin Scale >2). GA was measured in the morning after hospital admission with overnight fasting and determined to reflect high prestroke glycemic variability (GA ≥16.0%). Results: Over the median follow-up of 60 months of 310 patients, there were 64 (20.6%) events of unsuccessful reperfusion, 66 (21.3%) of END, 21 (6.8%) of SHT, and 180 (58.1%) of 3-month poor outcome. In the higher GA group (130, 41.9%), proportion of unsuccessful reperfusion, END, SHT, and poor outcome were higher than lower GA group. The multivariate analysis showed that higher GA was associated with unsuccessful reperfusion after EVT (adjusted odds ratio 4.13; 95% confidence interval [CI], 1.93–8.85). The area under the receiver operating characteristic of GA (0.644; 95% CI: 0.634–0.740) for predicting poor outcome was better than that of glycated hemoglobin (0.586; 95% CI: 0.529–0.642, p for DeLong’s pairwise comparison = 0.005). Conclusion: GA, reflecting prestroke glycemic variability, could be a reliable parameter for predicting reperfusion rate and acute ischemic stroke outcome in this study.

Endovascular mechanical thrombectomy in a child with COVID-19: Clot analysis reveals a novel pathway in the neuroinflammatory cascade resulting in large-vessel occlusion.

Large-vessel occlusion is rare in children, but its results can be devastating and may lead to recurrent strokes, persistent neurological deficits, and decreased quality of life. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has yielded extrapulmonary effects and multiorgan diseases, many of which are neurological manifestations. There is a paucity of literature in pediatric patients about large-vessel occlusion in the setting of COVID-19 infection. We discuss a nine-year-old child who presented with a left middle cerebral artery occlusion and underwent revascularization with a Thrombolysis in Cerebral Infarction grade 3 reperfusion approximately three weeks after COVID-19 diagnosis. The patient harbored concerning signs and symptoms of multisystem inflammatory syndrome in children. This case emphasizes the importance of recognizing SARS-CoV-2 and the propensity for thrombosis in a delayed fashion, which can lead to severe stroke in young people.