Endovascular thrombectomy with or without intravenous thrombolysis in acute basilar artery occlusion ischemic stroke: A meta-analysis

IntroductionIt is poorly understood if endovascular thrombectomy (EVT) with or without intravenous thrombolysis (IVT) better facilitates clinical outcomes in patients with acute basilar artery occlusion (BAO) ischemic stroke.MethodsA systematic literature review and meta-analysis was completed to investigate the outcomes of EVT with IVT versus direct EVT alone in acute BAO. Data was collected from the literature and pooled with the authors’ institutional experience. The primary outcome measure was 90-day modified Rankin sale (mRS) of 0-2. Secondary measures were successful post-thrombectomy recanalization defined as mTICI ≥2b, 90-day mortality, and rate of symptomatic ICH.ResultsOur institutional experience combined with three multicenter studies resulted in a total of 1,127 patients included in the meta-analysis. 756 patients underwent EVT alone, while 371 were treated with EVT+IVT. Patients receiving EVT+IVT had a higher odds of achieving a 90-day mRS of ≤ 2 compared to EVT alone (OR: 1.50, 95% CI 1.15 to 1.95, P =0.002, I² =0%). EVT+IVT also had a lower odds of 90-day mortality (OR: 0.57, 95% CI 0.37 to 0.89, P=0.01, I²=24%). There was no difference in sICH between the two groups (OR: 1.0, 95% CI: 0.56 to 1.79, P=0.99, I²=0%). There was also no difference in post-thrombectomy recanalization rates defined as mTICI ≥2b (OR: 1.11, 95% CI 0.70 to 1.75, P = 0.65, I²=37%).ConclusionsOn meta-analysis, EVT with bridging IVT results in superior 90-day functional outcomes and lower 90-day mortality without increase in symptomatic ICH. These findings likely deserve further validation in a randomized controlled setting.     

Racial and Ethnic Disparities in Functional Outcome after Thrombectomy: A Cohort Study of an Integrated Stroke Network

ObjectivesPrevious studies have shown racial disparities in access to treatment and outcomes in ischemic stroke patients. We sought to define racial disparities in functional outcomes among ischemic stroke patients receiving endovascular thrombectomy (EVT).Materials and MethodsWe performed a retrospective review of patients in our institution's prospectively collected stroke patient registry from 08/2015 to 06/2019 at 1 comprehensive and 2 thrombectomy-ready stroke centers. We reviewed patients aged ≥ 18 who received mechanical thrombectomy including only patients with race/ethnicity data belonging to the 3 largest race/ethnic groups: Non-Hispanic White (NHW), Non-Hispanic Black (NHB), and Hispanic (HIS). We compared baseline characteristics and performed multivariable logistic regression to evaluate differences in good functional outcome defined as 90-day modified Rankin score (90 day mRS 0–2) as the primary outcome. Secondary outcomes were discharge disposition, length of stay, and excellent functional outcome (90 day mRS 0-1). Results are given as OR [95% CI].ResultsAmong 666 patients that met inclusion criteria, 45% were NHW, 30% were NHB, and 19% were HIS. NHB and HIS patients were younger than NHW (average age NHB 62; HIS 64; and NHW 70; p < 0.001). Diabetes was more prevalent in NHB (32%, p = 0.02) and HIS (47%, p < 0.001) compared to NHW (23%). There were no significant racial differences in pre-morbid mRS, arrival NIHSS, tPA treatment rates. There was no difference in primary outcome by race comparing NHW to the other racial groups (OR 1.08 [0.68–1.72]) but compared to HIS patients, NHW had a higher likelihood of the secondary outcome of excellent functional outcome (aOR 2.23 [1.01–4.93]) defined as mRS 0-1.ConclusionsIn this study of over 600 patients treated with EVT, we did not find significant racial disparities in functional outcome except for less excellent functional outcome in HIS compared to NHW. Further study on disparities in post-acute stroke care is needed.     

Endovascular thrombectomy is beneficial for functional nonagenarians – a multicenter cohort analysis

IntroductionThe use of endovascular thrombectomy (EVT) has dramatically increased in recent years. However, most existing studies used an upper age limit of 80 and data regarding the safety and efficacy of EVT among nonagenarians is still lacking.Methods767 consecutive patients undergoing EVT for large vessel occlusion (LVO) in three participating centers were recruited into a prospective ongoing database. Demographic, clinical and imaging characteristics were documented. Statistical analysis was done to evaluate EVT outcome among nonagenarians compared to younger patients.ResultsThe current analysis included 41 (5.4%) patients older than 90 years. Compared to younger patients, nonagenarians were more often female (78% versus 50.3%, p ≤ 0.001), had worse baseline mRS scores (2 [0–3] versus 0 [0–2], p < 0.001), higher rates of hypertension and hyperlipidemia and a higher admission NIHSS (20 [14–23] versus 16 [11–20], p < 0.001). No differences were found between groups regarding the involved vessel, stroke etiology, time from symptoms to door or symptoms to EVT, successful recanalization rates and hemorrhagic transformation rates. Nonagenarians had worse mRS at 90 days (5 [3–6] versus 3 [2–5], p = 0.001), similar discharge NIHSS (5 [1–11] versus 4 [1–11], p = 0.78) and higher mortality rates (36.6% versus 15.8%, p < 0.001). All nonagenarians with baseline mRS 4 have died within 90 days. 36.4% of nonagenarian patients with baseline MRS of 3 or less had favorable outcome.DiscussionThis study demonstrates that nonagenarian stroke patients with baseline mRS of 3 or less benefit from EVT with no significant difference in the rate of favorable outcome compared to octogenarians.     

Successful thrombectomy is beneficial in patients with pre-stroke disability: Results from an international multicenter cohort study

BackgroundPatients with pre-stroke disability, defined as a modified Rankin Scale (mRS) ≥3, were excluded from most trials of endovascular thrombectomy (EVT) for acute stroke. We sought to evaluate the prognostic factors associated with favorable outcome in stroke patients with known disability undergoing EVT, and the impact of successful reperfusion.MethodsConsecutive acute stroke patients with pre-stroke disability, undergoing EVT, were retrospectively collected between 2016 to 2019 from a Canadian cohort and a multicenter French cohort (Endovascular Treatment in Ischemic Stroke registry-ETIS). Favorable outcome was defined as an mRS equal to pre-stroke mRS. Patients achieving successful reperfusion (defined as a modified Thrombolysis in Cerebral Infarction score of 2b/3) were compared with patients without successful reperfusion to determine if successful EVT was associated with better functional outcomes.ResultsAmong 6220 patients treated with EVT, 280 (4.5%) patients with a pre-stroke mRS ≥3 were included. Sixty-one patients (21.8%) had a favorable outcome and 146 (52.1%) died at 3 months. Patients with successful reperfusion had a higher proportion of favorable 90-day mRS (27.6% versus 19.6%, p = 0.025) and a lower mortality (48.3% versus 69.6%, p = 0.008) than patients without successful reperfusion. After adjusting for baseline prognostic factors, successful reperfusion defined by TICI ≥2b was associated with favorable functional outcome (OR 3.16 CI95% [1.11–11.5]; p 0.048).ConclusionIn patients with pre-stroke disability, successful reperfusion is associated with a greater proportion of favorable outcome and lower mortality.     

Factors affecting the outcomes of tirofiban after endovascular treatment in acute ischemic stroke: Experience from a single center

Aims

To investigate the predicted factors influencing the outcomes in acute ischemic stroke (AIS) patients who received tirofiban after endovascular treatment (EVT) and the optimal administration of tirofiban.

Methods

In this retrospective study, AIS patients who received EVT followed by tirofiban between January 2017 and October 2021 were enrolled. The dose and duration of tirofiban were adjusted by trained clinicians according to the patient's clinical status. A reduction of at least four points on the National Institutes of Health Stroke Scale (NIHSS) after tirofiban compared with that before tirofiban was defined as an effective response. A modified ranking scale (mRS) of 0–2 was defined as a favorable outcome at a 90-day follow-up.

Results

A total of 260 consecutive patients were enrolled, and 36.5% of patients achieved a favorable outcome. The modified thrombolysis in cerebral infarction (mTICI) 2b-3 occurred in 93.5% of patients. Symptomatic intracerebral hemorrhage (sICH) occurred in 6.2% of patients, and the mortality at 90-day follow-up was 16.9%. Duration of tirofiban >24 h (adjusted OR: 2.545; 95% CI: 1.008–6.423; p = 0.048) and effective response to tirofiban (adjusted OR: 25.562; 95% CI: 9.794–66.715; p < 0.001) were related to the favorable outcome (mRS 0–2). Higher NIHSS (adjusted OR: 0.855; 95% CI: 0.809–0.904; p < 0.001) and glucose level on admission (adjusted OR: 0.843; 95% CI: 0.731–0.971; p = 0.018) were predictive for the unfavorable outcome (mRS 3–6).

Conclusions

An effective response to tirofiban is an independent factor in predicting the long-term efficacy outcome, and extending the duration of tirofiban is beneficial for neurological improvement.     

Red Cell Distribution Width as a Predictor of One-Year Prognosis and Mortality of Endovascular Therapy for Acute Anterior Circulation Ischemic Stroke

ObjectivesTo investigate if Red cell distribution width (RDW) can predict long-term prognosis in patients with acute ischemic stroke (AIS) receiving endovascular therapy (EVT).MethodsIn this study, 102 AIS patients treated with EVT were retrospectively recruited. Clinical profiles and prognoses were collected for all patients. The patients were grouped following the modified ranking scale (MRS) scoring system as given below: a group of favorable functional outcome: 0–2; and a group of unfavorable functional outcome: 3–6.ResultsIn multivariate logistic regression, RDW (odds ratio [OR] = 2.799, 95 % confidence interval [CI] = 1.425–5.489; p = 0.003) was an independent predictor of unfavorable functional outcome, and it (OR, 1.929; 95% CI, 1.075–3.458; p = 0.028) was also an independent biomarker for all-cause mortality. The best predictive RDW cut-off value was 13.05% (sensitivity: 93.1%, specificity: 60.3%, AUC: 0.806, p < 0.001).ConclusionsThe results imply that pre-RDW is a reliable predictor of one-year prognosis and mortality after EVT in acute anterior circulation stroke patients.     

Risk Factors and Outcomes of Stroke-Associated Pneumonia in Patients with Stroke and Acute Large Artery Occlusion Treated with Endovascular Thrombectomy

Background and PurposeStroke-associated pneumonia (SAP) often increases high hospital mortality, prolongs length of hospital stay, and has considerable economic impact on healthcare costs. We aimed to explore independent predictors of SAP in acute anterior large artery occlusion patients who treated with endovascular treatment (EVT).MethodsConsecutive patients with acute anterior large artery occlusion stroke who underwent EVT from the Nanjing Stroke Registry from January 2019 to January 2020 were identified retrospectively. Patients were divided into SAP group and Non-SAP group. In the univariate analysis, variables including demographics, clinical factors, labs, and EVT features were compared between the two groups. Then a multivariable logistic regression analysis was conducted to determine independent predictors of SAP.ResultsOne hundred and twelve patients were enrolled. Patients with SAP, compared to those without SAP, had lower modified treatment in cerebral infarction (mTICI) score 2b-3 rate (54.8% vs 85.2%; P = 0.001), higher asymptomatic intracerebral hemorrhage rate (48.4% vs 28.4%; P = 0.046), lower modified Rankin Scale (mRS) score 0–2 rate at 90days rate (9.7% vs 60.5%; P < 0.001), and higher mortality at 90days (38.7% vs 11.1%; P = 0.001). The independent predictors of SAP were dysphagia (Unadjusted Odds ratio[OR] 6.49, 95% Confidence interval[CI] 2.49–16.92; P = 0.02; Adjusted OR 3.59, 95% CI 1.19–10.83; P = 0.02), neutrophil-lymphocyte ratio (Unadjusted OR 1.19, 95% CI 1.1–1.3; P = 0.001; Adjusted OR 1.15, 95% CI 1.06–1.25; P = 0.001), and mTICI 2b-3 (Unadjusted OR 0.21, 95% CI 0.08–0.54; P = 0.001; Adjusted OR 0.3, 95% CI 0.1–0.92; P = 0.04).ConclusionDysphagia, higher neutrophil-lymphocyte ratio, and failed recanalization were associated with SAP in acute ischemic stroke patients underwent endovascular therapy. Identification and prevention of SAP was necessary and important.     

A randomized pilot study of patients with tandem carotid lesions undergoing thrombectomy

Background and purposeThe optimal management of patients with tandem lesions (TL), or cervical internal carotid artery (c-ICA) steno-occlusive pathology and ipsilateral intracranial occlusion, who are undergoing endovascular thrombectomy (EVT) remains unknown. We sought to establish the feasibility of a trial designed to address this question.Materials and methodsThe Endovascular Acute Stroke Intervention (EASI) study was a single-centre randomized trial comparing EVT to medical therapy for large-vessel occlusion stroke. Patients with TL receiving EVT were randomly allocated to acute c-ICA stenting or no stenting. The primary outcome was the proportion of patients with a modified Rankin Scale (mRS) score of 0–2 at 90 days. Safety outcomes were symptomatic intracranial hemorrhage (sICH) at 24 hours and mortality at 90 days.ResultsOf 301 patients included in EASI between 2013 and 2018, 24 (8.0%) with TL were randomly allocated to acute stenting (n = 13) or no stenting (n = 11). Baseline characteristics were balanced. Eight (61.5%; 95% CI 35.5%–82.3%) and 7 (63.6%; 95% CI 35.4%–84.9%) patients, respectively, had a favorable outcome (mRS 0–2; P = 1.0). One non-stented patient had a symptomatic intracerebral hemorrhage.ConclusionsThis pilot trial of patients with TL undergoing EVT suggests that a sufficiently powered larger TL trial comparing acute c-ICA stenting to no stenting is feasible.Clinical Trial RegistrationURL: http://www.clinicaltrials.gov. Unique identifier: NCT02157532.     

Elevated pulsatility index is associated with poor functional outcome in stroke patients treated with thrombectomy: A retrospective cohort study

AimsTo evaluate pulsatility index (PI) in patients with acute ischemic stroke (AIS) who underwent endovascular thrombectomy (EVT).MethodsPatients were retrospectively recruited if their stroke were secondary to middle cerebral artery (MCA) occlusion and achieved full recanalization after EVT. Transcranial Doppler was performed within 24‐hour post‐EVT. The primary outcome was correlation between the MCA‐PI on the affected side and 3‐month functional outcome, with modified Rankin scale (mRS) ≥5 indicated extremely poor functional outcomes.ResultsTotally, 170 patients were included. High MCA‐PI was positively related to the 3‐month mRS score (r = 0.288, p < 0.001). The highest quartile of the MCA‐PI was associated with a high incidence of extremely poor functional outcomes (adjusted OR, 13.33; 95% CI, 2.65–67.17; adjusted p = 0.002) after adjusting for confounding factors. The predictive capacity of the MCA‐PI for extremely poor functional outcomes was good (area under the curve, 0.755; 95% CI, 0.655–0.854; p < 0.001), and its cutoff value for predicting extremely poor outcomes was 1.04, with a sensitivity of 65.6% and specificity of 78.3%.ConclusionThe MCA‐PI on the affected side is a prognostic biomarker in patients who have undergone stroke thrombectomy. An elevated MCA‐PI may be prognostically valuable for predicting extremely poor functional outcomes.     

Outcomes in patients with ischaemic stroke undergoing endovascular thrombectomy: Impact of atrial fibrillation

ObjectivesEndovascular thrombectomy (EVT) is associated with good clinical outcomes in ischaemic stroke, but the risk of intracerebral haemorrhage (ICH) and mortality remains common following ischaemic stroke. The effect of concomitant atrial fibrillation (AF) on clinical outcomes following acute ischaemic stroke in patients receiving EVT remains unclear. The aim is to investigate associations between AF and intracerebral haemorrhage and all-cause mortality at 90 days in patients with ischaemic stroke undergoing EVT.Materials and MethodsA retrospective cohort was conducted using TriNetX, a global health research network. The network was searched for people aged ≥18 years with ischaemic stroke, EVT and AF recorded in electronic medical records between 01/09/2018 and 01/09/2021. These patients were compared to controls with ischaemic stroke, EVT and no AF. Propensity score matching for age, sex, race, comorbidities, National Institutes of Health Stroke Scale (NIHSS) scores, and prior use of anticoagulation was used to balance the cohorts with and without AF.ResultsIn total 3,106 patients were identified with history of ischaemic stroke treated by EVT. After propensity-score matching, 832 patients (mean age 68 ± 13; 47% female) with ischaemic stroke, EVT and AF, were compared to 832 patients (mean age 67 ± 12; 47% female) with ischaemic stroke, EVT and no history of AF. In the cohort with AF, 11.5% (n = 96) experienced ICH within 90 days following EVT, compared with 12.3% (n = 103) in patients without AF (Odds Ratio (OR) 0.92, 95% confidence interval (CI) 0.68-1.24; p = 0.59). In the patients with AF, mortality within 90 days following EVT was 18.7% (n = 156), compared with 22.5% in patients without AF (n = 187) (OR 0.79, 95% CI 0.63-1.01; p = 0.06).ConclusionIn patients with ischaemic stroke undergoing EVT, AF was not significantly associated with intracerebral haemorrhage or all‐cause mortality at 90‐day follow‐up.     

A tool to improve stroke outcome prediction: The charlotte large artery occlusion endovascular therapy outcome score

ObjectivesWe sought to optimize functional outcome prediction for large artery occlusion (LAO) patients treated with endovascular thrombectomy (EVT).Materials and MethodsPatients presenting with an anterior circulation LAO treated with EVT from November 2016-July 2020 were included from a health system's code stroke registry. Data were separated into training and validation cohorts using a simple random sampling method. Logistic regression analysis was used to identify pre-intervention prognostic factors independently associated with 90-day modified Rankin score 4–6 in the training cohort. The model was tested in the validation cohort and compared to previously reported scales using Area Under Curve (AUC) analyses.Results646 total patients were included. The Charlotte Large artery occlusion Endovascular therapy Outcome Score, CLEOS = (5 x Age) + (10 x NIHSS) + Glucose – (150 x Cerebral Blood Volume Index). CLEOS was associated with an increased odds of poor 90-day outcome (per 1-point increase, OR 1.008, 95% CI 1.006–1.010, p < 0.0001) and performed better than Stroke Prognostication using Age and National Institute of Health Stroke Scale – 100 (AUC 0.62, p < 0.0001) and Houston Intra-Arterial Therapy 2 (AUC 0.70, p < 0.0063), with a trend observed versus Pittsburgh Response to Endovascular therapy (AUC 0.72, p = 0.0884), in the combined analysis of the derivation and validation cohorts. CLEOS ≥ 700 was not associated with a lower risk of poor outcome despite excellent endovascular reperfusion.ConclusionsCLEOS can predict poor 90-day outcomes after thrombectomy and help risk stratify patients based on the degree of revascularization after EVT.     

Endovascular Therapy of Acute Ischemic Stroke in Patients with Large-Vessel Occlusion Associated with Active Malignancy

PurposeThere is limited data on the effectiveness of endovascular therapy (EVT) in stroke patients with active malignancy. In this study, we investigated the outcome of EVT for acute ischemic stroke for patients with active malignancy compared to those without malignancy.MethodsWe selected patients who underwent EVT for acute ischemic stroke between January 2015 and July 2019. Patients were divided into two groups, those with active malignancy (oncology group - OG) and those without (non-oncology group, NOG).Results300 patients were included in this study. There were 19 EVT procedures (18 patients) in the OG and 285 procedures (282 patients) in the NOG. There was no difference in recanalization success rate (mTICI 2b & 3) between the groups: 94.7% versus 80.9% in OG and NOG respectively (p = 0.13). Success rate using the direct aspiration (ADAPT) technique of EVT was not different between compared groups (42.9% versus 67.7%; p = 0.18). However, when using smaller-caliber aspiration devices, ADAPT was less successful in OG (0.0% versus 64.7%, p < 0.05). There was no difference in recanalization success rate of EVT when using a stent-retriever or combined technique. Patients in the OG had a less favorable functional outcome than in the NOG group (mRS 0-2 at 90-days post event: 22.2% versus 48.2%, p < 0.05)ConclusionThe technical success rate of EVT in patients with active malignancy is similar to the general population of stroke patients. Interestingly, the success rate of EVT using the ADAPT technique was lower in the OG when using smaller caliber aspiration devices.     

Does thrombus imaging characteristics predict the degree of recanalisation after endovascular thrombectomy in acute ischaemic stroke?

BackgroundIdentification of computed tomography (CT) thrombus imaging characteristics can predict the degree of recanalization and outcome after endovascular thrombectomy (EVT) in patients with acute ischaemic stroke and large vessel occlusion.AimWe analyzed the thrombus imaging characteristics and procedural factors and correlated with the degree of recanalization and functional outcome after EVT.MethodsWe evaluated the thrombus imaging characteristics (hyperdense MCA sign, thrombus location, length and thrombus permeability) from thin slice CT and CT angiogram. In addition, groin to recanalization time, number of passes, and EVT technique were documented. The primary outcome was degree of recanalization (mTICI score) and secondary outcome was modified Rankin scale (mRS) at 3 months.ResultsThe mean age of 102 patients was 60.5±11.8 years. Patients with hyperdense MCA sign (90 % vs 75%, p=0.07) and permeable thrombus (86 % vs 70 %, p=0.09) had good recanalization (mTICI grade 2b,2c or 3). The requirement of <3 passes (90 % vs 62 %, p= 0.001) was associated with good recanalization. Multiple logistic regression analysis showed thrombus permeability (OR 5.9; 95% CI 1.3-26.6, p=0.02), use of stent retreiver alone (without aspiration) (OR 5.4; 95% CI 1.3-22.5, p=0.02) and a puncture to recanalization ≤60 minutes (OR 7.9; 95% CI 1.7-36.8; p=0.008) were associated with good recanalization. The requirement of ≥3 passes was associated with poor functional outcome (OR 3.4;95% CI 1.2-9.8; p=0.02).ConclusionsThrombus permeability was a predictor of successful recanalization after EVT. The requirement of three or more passes during EVT was associated with poor recanalization and poor functional outcome.     

Differences between males and females following endovascular therapy for stroke: A systematic review and meta-analysis

BackgroundEndovascular therapy (EVT) represents the standard of care for eligible patients with acute ischemic stroke (AIS) and large vessel occlusion. To better understand differences in baseline characteristics and outcomes between males and females following EVT, we conducted a systematic review and meta-analysis.MethodsWe identified, using the Nested Knowledge AutoLit platform, prospective studies that reported 90-day outcomes in males and females treated with EVT for AIS. The primary outcome of interest was 90-day modified Rankin Scale (mRS) 0-2. Secondary outcome variables included mRS 0-1, symptomatic intracranial hemorrhage (sICH), thrombolysis in cerebral infarction (TICI) score 2b-3, and mortality. Using R software version 4.1.2, we calculated pooled odds ratios (ORs) and their corresponding 95% confidence intervals (CI).ResultsWe included 10 studies with 10,209 patients. There was no difference between males and females in rate of mRS 0-2 (OR= 1.16; 95% CI= 0.87-1.56; P-value= 0.316); however, after removing outliers, males had higher rates of mRS 0-2 (OR= 1.40; 95% CI= 1.19-1.66; P-value< 0.001). Similar results were reported for mRS 0-1 (OR= 1.21; 95% CI= 0.93-1.56; P-value= 0.15), after removing outliers (OR= 1.32; 95% CI= 1.17-1.50; P-value< 0.001). There was no difference between males and females in rate of sICH (OR= 0.89; 95% CI= 0.74-1.08; P-value= 0.246), mortality (OR= 0.88; 95% CI= 0.74-1.05; P-value= 0.15), or TICI 2b-3 (OR= 1.19; 95% CI= 0.85-1.67; P-value= 0.309).ConclusionsMales tend to experience better outcomes following EVT for AIS, even in the setting of similar reperfusion. The mechanisms underlying this phenomenon remain unclear, and further research is warranted. EVT remains a safe and effective option for both males and females with AIS.     

The clinical utility of dual-energy CT in post-thrombectomy care: Part 1, predictors and outcomes of subarachnoid and intraparenchymal hemorrhage

ObjectivesDual-energy CT allows differentiation between blood and iodinated contrast. We aimed to determine predictors of subarachnoid and intraparenchymal hemorrhage on dual-energy CT performed immediately post-thrombectomy and the impact of these hemorrhages on 90-day outcomes.Materials and MethodsA retrospective analysis was performed on patients who underwent thrombectomy for anterior circulation large-vessel occlusion and subsequent dual-energy CT at a comprehensive stroke center from 2018-2021. The presence of contrast, subarachnoid hemorrhage, or intraparenchymal hemorrhage immediately post-thrombectomy was assessed by dual-energy CT. Univariable and multivariable analyses were performed to identify predictors of post-thrombectomy hemorrhages and 90-day outcomes. Patients with unknown 90-day mRS were excluded.ResultsOf 196 patients, subarachnoid hemorrhage was seen in 17, and intraparenchymal hemorrhage in 23 on dual-energy CT performed immediately post-thrombectomy. On multivariable analysis, subarachnoid hemorrhage was predicted by stent retriever use in the M2 segment of MCA (OR,4.64;p=0.017;95%CI,1.49-14.35) and the number of thrombectomy passes (OR,1.79;p=0.019;95%CI,1.09-2.94;per an additional pass), while intraparenchymal hemorrhage was predicted by preprocedural non-contrast CT-based ASPECTS (OR,8.66;p=0.049;95%CI,0.92-81.55;per 1 score decrease) and preprocedural systolic blood pressure (OR,5.10;p=0.037;95%CI,1.04-24.93;per 10 mmHg increase). After adjusting for potential confounders, intraparenchymal hemorrhage was associated with worse functional outcomes (OR,0.25;p=0.021;95%CI,0.07-0.82) and mortality (OR,4.30;p=0.023,95%CI,1.20-15.36), while subarachnoid hemorrhage was associated with neither.ConclusionsIntraparenchymal hemorrhage immediately post-thrombectomy was associated with worse functional outcomes and mortality and can be predicted by low ASPECTS and elevated preprocedural systolic blood pressure. Future studies focusing on management strategies for patients presenting with low ASPECTS or elevated blood pressure to prevent post-thrombectomy intraparenchymal hemorrhage are warranted.     

Underlying intracranial atherosclerotic disease is associated with worse outcomes in acute large vessel occlusion undergoing endovascular thrombectomy

BackgroundData on large vessel occlusion (LVO) management due to intracranial atherosclerotic disease (ICAD) are scarce.ObjectiveTo compare clinical outcomes between patients with ICAD and those without ICAD following mechanical thrombectomy (MT).MethodsWe performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center, and compared in-hospital mortality, 90-day mortality, favorable functional outcome at 90 days, and symptomatic intracranial hemorrhage (ICH) using chi-squared tests and multivariate logistic regression analyses. We defined ICAD as observable plaque at occlusion site post-thrombectomy.ResultsAmong 215 patients (mean age 67.1 ± 16.0 years; 60.5% female; 83.6% Black, median NIHSS score 16), ICAD was present in 38 patients (17.7%). Diabetes and dyslipidemia were more common in those with ICAD (57.9% vs. 38.4%, p = 0.027 and 29.0% vs. 14.7%, p = 0.035, respectively). Substantial reperfusion (TICI ≥2b) was achieved less often (84.2% vs. 94.4%, p = 0.031) but symptomatic ICH was also less common in ICAD patients (0% vs. 9.0%, p = 0.081). In-hospital and 90-day mortality were more common (36.8% vs. 15.8%, p = 0.003 and 52.6% vs. 26.6%, p = 0.002, respectively) and favorable functional outcome (mRS 0-2) at 90 days was less common (7.9% vs. 33.9%, p = 0.001) in ICAD patients. After adjusting for prognostic variables, ICAD was independently associated with in-hospital mortality (OR=4.1, 95% CI 1.7-9.7), 90-day mortality (OR=3.7, 95% CI 1.6-8.6), and poor functional outcome at 90 days (OR=5.5, 95% CI 1.6-19.4).ConclusionSymptomatic ICAD in a predominantly African American cohort is associated with increased odds of mortality and poor functional outcome at 90 days in patients with LVO undergoing MT.     

Care-needs Certification in the National Long-Term Care Insurance is Useful for Assessment of Premorbid Function in Older Japanese Patients with Stroke

ObjectiveTo investigate the effects of premorbid long-term care insurance (LTCI) care-need certification on functional improvement during acute hospitalization in older patients with stroke.MethodsIn this single-center prospective cohort study, we assessed LTCI care-needs certification and the modified Rankin Scale (mRS) at the premorbid stage, on admission, and at hospital discharge in older patients with stroke. We also assessed adverse events during hospitalization. The main outcome was the presence of functional improvement during hospitalization (mRS on admission < mRS at discharge). Multivariate analysis was performed to investigate the relationship between functional improvement and premorbid LTCI care-need certification.ResultsIn total, 246 older patients with stroke were enrolled in this study. There was a significant independent association between premorbid LTCI care-needs certification (care level 1 = odds ratio [OR]: 0.26, 95% CI: 0.10–0.72, p = 0.01; Care level 2 = OR: 0.27, 95% CI: 0.10–0.73, p = 0.01; care level 3–5 = OR: 0.21, 95% CI: 0.08–0.56, p = 0.002; Not applicable = reference) and functional improvement.ConclusionsPremorbid LTCI care-need certification is associated with short-term functional improvement in older patients with stroke. Assessment of premorbid LTCI care-needs certification is valid for predicting functional improvement in older patients with stroke.     

Associations of Neutrophil-Lymphocyte Ratios with Reperfusion and Functional Outcomes in Ischemic Stroke after Endovascular Therapy

ObjectivesTreatment of ischemic stroke with endovascular thrombectomy (EVT) leads to improved outcomes compared to IV tPA. The neutrophil-lymphocyte ratio (NLR), a marker of inflammation, has been proposed to predict outcomes in ischemic stroke patients and may be used to identify patients at risk for poor outcomes after EVT.Materials and MethodsThis was a retrospective study of adult ischemic stroke patients undergoing EVT between 1/1/2018 and 12/31/2020. Outcomes were successful reperfusion (TICI score ≥2B), favorable discharge NIHSS (≤4), favorable discharge and 3-month mRS (≤2), and symptomatic intracranial hemorrhage (sICH). The primary exposure was NLR, measured pre- and post-EVT. Other variables collected included demographics and timing of stroke onset, arrival, groin puncture, tPA, and recanalization.ResultsA total of 592 patients were included. The most common vessel involved was the middle cerebral artery (73%). Lower admission NLR was associated with favorable discharge NIHSS and favorable discharge and 3-month mRS (all P < 0.01). NLRs measured after EVT were associated with all the primary outcomes. Improvements in NLR after EVT were associated with favorable discharge (P = 0.02) and 3-month mRS (P = 0.02) and lower incidence of sICH (P = 0.01).ConclusionsBecause of the long-term functional deficits that can persist after ischemic stroke, it is vital to identify patients with higher probability for these outcomes. The results from this study showed that favorable NLR measures, as well as favorable trends in NLR over time, are associated with improved outcomes, indicating that NLR is a useful marker to identify patients at risk for poor functional outcomes.     

Endovascular Therapy for Acute Ischemic Stroke in Patients with Large-Vessel Occlusion due to Atherosclerotic Stenosis

ObjectivesEndovascular therapy (EVT) is safe and effective for acute ischemic stroke (AIS) due to large-vessel occlusion (LVO). However, the influence of the AIS subtype (large-artery atherosclerosis [LAA] or cardioembolism [CE]) on clinical outcome in patients treated with EVT remains unclear. This study aimed to evaluate the differences in clinical results between the two subtypes using data from a multicenter prospective registry (RESCUE-Japan Registry 2).Materials and MethodsAmong 2420 patients in RESCUE-Japan Registry, 682 patients who were diagnosed with LAA or CE were enrolled. The primary outcome was a modified Rankin Scale (mRS) score of 0–2 at 90 days. The secondary outcomes were 90-day mRS 0–1, 0–3, and 6. The relationship between time from onset and clinical outcome was also analyzed.ResultsAmong the 682 patients, 124 were classified into the LAA group and 558 into the CE group. The baseline National Institutes of Health Stroke Scale score was significantly lower (median 15 vs. 18, p < 0.001). At 90 days, mRS 0–2 was observed in 54 of 124 patients (44%) in the LAA group and 232 of 558 patients (42%) in the CE group (p = 0.69). The proportion of patients with mRS 0–2 tended to decrease according to onset-to-puncture time in the CE group but not in the LAA group (p_trend=0.0007).ConclusionsThe rate of good outcome was similar between LVO due to LAA and CE. However, the rate of favorable outcome did not decrease according to onset-to-puncture time in the LAA group.     

Long-term outcomes,including the survival rate and period to death,in patients over 80 years old after ruptured cerebral aneurysm clipping

ObjectiveThis study aimed to identify the long-term outcomes, including the survival rate, period to death, causes of death, and predictors of poor outcomes, in patients aged over 80 years who underwent surgical clipping for a ruptured anterior circulation aneurysm.Materials and MethodsIn this retrospective observational study, the medical records of patients from April 1, 1994, to June 30, 2019, were evaluated. All patients underwent surgical clipping within 72 h of subarachnoid hemorrhage (SAH) onset. Information on the patient, SAH, and outcomes were collected.ResultsThe mean hospitalization and long-term follow-up periods for all patients were 54.5 days and 53.3 months, respectively. The period to death was significantly shorter in patients with modified Rankin scale (mRS) of 4–5 than for those with an mRS of 0–3 at discharge (p=0.001). The Kaplan–Meier method using the log-rank test demonstrated that patients with an mRS of 4–5 at discharge had a significantly lower survival rate compared to those with an mRS of 0–3 at discharge (p<0.05). Univariate analysis revealed that the proportion of patients with Hunt and Hess grade and presence of surgical complications were significantly larger in the group with an mRS of 4–5 than in that with an mRS of 0–3 at discharge (p=0.0013 and 0.011, respectively). Multivariate analysis demonstrated that presence of surgical complications was the only independent predictor of poor outcomes (p=0.043, odds ratio [OR] 7.937, 95% confidence interval [CI] 1.061–59.38). The Kaplan-Meier method using the log-rank test demonstrated that patients with surgical complications had a significantly lower survival rate compared to those with no surgical complications (p<0.05).ConclusionsEspecially in patients aged over 80 years, those with H-H grade 2 and a good clinical condition can be candidates for surgical clipping, whereas avoiding surgical complications is essential for achieving good outcomes.