Shorter Reperfusion Time in Stroke is Associated with Better Cognition.

BACKGROUND: Cognitive changes that result from cerebrovascular disease contribute to a poor functional outcome with reduced quality of life. Among patients undergoing endovascular therapy (EVT), we aim to assess cognitive function and evaluate the impact of reperfusion time in cognitive performance. METHODS: Patients with acute right anterior circulation strokes that underwent EVT between January 2018 and August 2020 at Centro Hospitalar de Vila Nova de Gaia/Espinho, participated in the study. Modified treatment in cerebral infarction (mTICI) assessed the level of recanalization. Cognitive evaluation was assessed with Addenbrooke's Cognitive Examination revised (ACE-R). Multiple linear regression analyses were used to determine the association between time for recanalization and ACE-R. The level of significance adopted was 0.05. RESULTS: The mean age of participants was 71.5 (interquartile range [IQR] 62.0-78.2) years, and 50% (22) were women. The median time after stroke was 28.6 months (IQR 18.94-31.55). All patients in our sample had a successful level of recanalization with EVT (mTICI ≥ 2b). Time for recanalization showed an inverse association with the ACE-R (b = -0.0207, P = 0.0203). Also the mRS at 3 months had an inverse association with cognition (b = -5.2803, p = 0.0095). Level of education had a strong and direct relationship with ACE-R results (b = 3.0869, p < 0.0001). CONCLUSIONS: Longer time between stroke symptoms and recanalization with EVT in patients with right hemisphere ischemic stroke lead to lower ACE-R scores. Measures to improve door-to-recanalization time are also important for cognitive performance after ischemic stroke.

Ultra-early improvement after endovascular thrombectomy and long-term outcome in anterior circulation acute ischemic stroke.

BACKGROUND: The use of post-treatment measures after acute ischemic stroke is important to predict good functional outcome. The most studied is 24 h National Institutes of Health Stroke Scale (NIHSS) score and existing literature is scarce regarding the use of earlier indicators, namely NIHSS immediately after endovascular thrombectomy (EVT). We hypothesized that an immediate neurological improvement after EVT, that we called ultra-early neurological improvement (UENI), would be a reliable functional independence predictor in anterior circulation acute ischemic stroke patients. METHODS: We included 296 anterior circulation stroke patients who received EVT at our institution between January 2015 and December 2017. We obtained post-EVT NIHSS score in the angiography room. UUENI was defined as a ≥ 4 point decrease in post-EVT NIHSS score relatively to baseline or post-EVT NIHSS score of 0-1. Patients' functional outcome was assessed using the modified Rankin Scale at 3 months. The ability of UENI to predict good functional outcome was assessed using logistic regression analysis. RESULTS: A total of 155 (52.4%) patients presented UENI. This group of patients achieved a statistically significant higher rate of functional independence (70.3% vs 46.8%, OR crude 2.69, 95% CI 1.67-4.34). After adjusting for potential confounders, the UENI showed to be an independent predictor of good outcome, with UENI patients having 4.61 times the probability of obtaining good outcome compared to patients without UENI. CONCLUSIONS: UENI is useful in outcome prediction in patients with anterior circulation stroke treated with EVT, with the advantage that it can be assessed at an ultra-early stage.

NCCT and CTA-based imaging protocol for endovascular treatment selection in late presenting or wake-up strokes.

INTRODUCTION: Recently, the benefit of selecting patients for endovascular treatment (EVT) beyond the 6-hour time window using a tissue-based approach was demonstrated in two randomized trials. The optimal imaging protocol for selecting patients is under debate, and it is still unknown if a simpler and faster protocol may adequately select patients with wake-up stroke (WUS) and late-presenting stroke (LPS) for EVT. OBJECTIVE: To compare outcomes of patients submitted to EVT presenting within 6 hours of symptom onset or 6-24 hours after last seen well, selected using non-contrast computed tomography (NCCT) and CT angiography (CTA). METHODS: An observational study was performed, which included consecutive patients with anterior circulation ischemic stroke with large vessel occlusion treated with EVT. Patients presenting within 6 hours were treated if their NIH Stroke Scale (NIHSS) score was ≥6 and Alberta Stroke Program Early CT score (ASPECTS) was ≥6, while patients presenting with WUS or 6-24 hours after last seen well (WUS/LPS) were treated if their NIHSSscore was ≥12 and ASPECTS was ≥7. RESULTS: 249 patients were included, 63 of whom were in the WUS/LPS group. Baseline characteristics were similar between groups, except for longer symptom-recanalization time, lower admission NIHSS (16 vs 17, P=0.038), more frequent tandem occlusions (25.4% vs 11.8%, P=0.010), and large artery atherosclerosis etiology (22.2% vs 11.8%, P=0.043) in the WUS/LPS group. No differences in symptomatic intracranial hemorrhage, peri-procedural complications or mortality were found between groups. Three-month functional independence was similar in both groups (65.1% in WUS/LPS vs 57.0% in ≤6 hours, P=0.259) and no differences were found after adjustment for confounders. CONCLUSIONS: This real-world observational study suggests that EVT may be safe and effective in patients with WUS and LPS selected using clinical-core mismatch (high NIHSS/high ASPECTS in NCCT).

Primary Thrombectomy Versus Combined Mechanical Thrombectomy and Intravenous Thrombolysis in Large Vessel Occlusion Acute Ischemic Stroke.

Mechanical thrombectomy (MT) in combination with intravenous thrombolysis (IVT) is the standard of care for patients with acute ischemic stroke with anterior circulation large vessel occlusion. The particular benefit of IVT in these patients is unknown. We performed a retrospective analysis of patients submitted to MT at our center between January 2015 and June 2017. Functional outcome was prospectively assessed using modified Rankin scale (mRS) at 3 months. A total of 234 patients were enrolled, 152 (65%) in the combined treatment group and 82 (35%) in the direct MT group. Patients receiving combined treatment had a higher frequency of intracranial internal carotid artery occlusion (48 [31.6%] versus 16 [19.5%], P = .048) and significantly less strokes of cardioembolic etiology (72 [47.4%] versus 57 [69.5%], P = .01). Other baseline characteristics did not differ between the 2 groups. Good functional outcome at 3 months (mRS 0-2) was trending toward being higher in patients in the combined treatment group (98 [64.9%] versus 42 [52.5%], P = .066). Rates of symptomatic intracranial hemorrhage (5 [3.3%] versus 4 [4.9%], P = .723) and mortality (15 [9.9%] versus 14 [17.5%], P = .099) did not differ between groups. In multivariate logistic regression analysis, we did not find a statistically significant association between the use of IVT and any of the outcomes studied. Our results suggest that combined treatment carries similar effectiveness and safety than direct MT. Randomized controlled trials regarding this subject are warranted.

Is the Efficacy of Endovascular Treatment for Acute Ischemic Stroke Sex-Related.

BACKGROUND: Several reports refer to differences in stroke between females and males, namely in incidence and clinical outcome, but also in response to treatments. Driven by a recent analysis of the MR CLEAN trial, which showed a higher benefit from acute stroke endovascular treatment (EVT) in males, we intended to determine if clinical outcomes after EVT differ between sexes, in a real-world setting. METHODS: We analyzed 145 consecutive patients submitted to EVT for anterior circulation large-vessel occlusion, between January 2015 and September 2016, and compared the outcomes between sexes. RESULTS: Our population was represented by 81 (55.9%) females, with similar baseline characteristics (pre-stroke disability, baseline NIHSS, and ASPECTS), rate of previous intravenous thrombolysis, time from onset to recanalization, and rate of revascularization; with the exception that women were on average 4 years older and had more hypertension, and men in turn had more tandem occlusions and atherosclerotic etiology (all p < 0.05). Even after adjusting for these statistically significant variables and for intravenous thrombolysis (as some studies advocate a different response to this treatment between sexes), there were no differences in intracranial hemorrhage, functional independence (mRS ≤2 in 60.9% males vs. 66.7% in females, p = 0.48; adjusted p = 0.36), or mortality at 3 months. CONCLUSION: In a real-world setting, we found no sex differences in clinical and safety outcomes after acute stroke EVT. Our results support the idea that women are equally likely to achieve good outcomes as men after acute stroke EVT.

Emergent carotid artery stenting in atherosclerotic disease of the internal carotid artery with tandem intracranial occlusion.

BACKGROUND: Several randomized clinical trials have proven the safety and efficacy of mechanical thrombectomy (MT) in large vessel occlusions; nonetheless, there is still no consensus concerning hyperacute management of tandem occlusions. Recent studies have suggested that emergent carotid artery stenting (eCAS), along with mechanical thrombectomy, is an effective and safe treatment option. AIMS: To characterize the safety and short-term outcome of patients treated with eCAS during endovascular treatment of acute ischaemic stroke. METHODS: Review of the prospective patient registry submitted to MT for anterior circulation acute ischaemic stroke in a single referral centre and selection of patients treated with eCAS for atherosclerotic occlusion or near-occlusion of cervical internal carotid artery during 22 consecutive months. Clinical data was collected, and assessment of procedure safety and 3-month-outcome were performed. RESULTS: Among 156 patients submitted to MT, 16 patients (10.3%) underwent eCAS. Most patients were male (15/16), median age was 64.5 years (interquartile range [IQR] = 57-75), median admission NIHSS was 14 (IQR = 11.5-19) and 10/16 patients had been submitted to intravenous thrombolysis. Successful recanalization was obtained in 93.8% of the patients. One patient (6.3%) experienced symptomatic intracranial haemorrhage, one patient experienced early intra-stent thrombosis and one patient developed cerebral hyperperfusion syndrome. At 3-month follow-up, 11 patients were independent (68.8%) and 1 patient had died (6.3%). CONCLUSIONS: In this study, positive results were obtained using eCAS. Although an optimal intervention for this type of occlusions has not yet been formally established, eCAS has been surging has a feasible and safe treatment option.

Need for refining successful revascularization in endovascular treatment of acute ischemic stroke: Data from real-world.

INTRODUCTION: Modified TICI (mTICI) score≥2b has been largely used as a definition of successful revascularization in acute stroke endovascular treatment (EVT). However, mTICI 2b encompasses a broad range of different revascularization states and its clinical relevance, comparing to mTICI 3, has been questioned. We aimed to compare clinical outcomes between these two reperfusion groups, in patients submitted to EVT for anterior circulation large-vessel occlusion, in a real-world setting. MATERIALS AND METHODS: Retrospective statistical analysis of our database of consecutive EVTs. RESULTS: Our study population of 178 patients has a mean age of 71years, 46.6% males, median baseline NIHSS of 17 and ASPECTS of 8. There were no statistically significant differences in baseline characteristics and interventional procedure data between groups. A significantly higher rate of mRS≤1 at 3months (OR=2.33, 95%CI 1.03-5.25) and lower rate of total (OR=0.18, 95%CI 0.06-0.53) and symptomatic intracranial hemorrhage (OR=0.08, 95%CI 0.01-0.74) was seen in mTICI 3 group. This group also showed non-significant trend (adjusted p=0.071) toward higher percentages of mRS≤2 (71.8% versus 51.5%) and lower mortality at 3months (6.4% versus 19.1%). CONCLUSIONS: In accordance with previous reports from clinical trials, these real-world data suggest that is probably time to refine the definition of successful revascularization in acute stroke EVT.

Endovascular Stroke Treatment of Patients Over 80 Years Old: Cumulative Evidence from the "Real World".

BACKGROUND: Evidence on stent retriever-based thrombectomy (SRT) efficacy in elderly patients is controversial. This study aimed to analyze safety and efficacy outcomes in octogenarians submitted to SRT. METHODS: Analysis was based on a prospective observational registry of patients with stroke because of anterior circulation large-vessel occlusion treated with SRT at our center between January 2015 and September 2016. Patients were dichotomized into 2 age groups: ≤80 and >80 years old. Outcomes at 90 days were assessed: "excellent outcome" (a modified Rankin scale [mRs] score of 0-1) and "good outcome" (a mRs score of 0-2). RESULTS: A total of 141 patients were included: 35 (24.8%) >80 years old and 106 (71.2%) ≤80 years old; 43.4% of patients in the younger group and 25.7% of patients in the older group achieved an "excellent outcome." A "good outcome" was achieved in 65.1% of patients in the younger group, and 60% of patients in the older group; crude odds ratio (OR) for "excellent outcome" was 0.452 (P = .067). Crude OR for "good outcome" was 0.804 (P = .587). After adjusting for gender, National Institutes of Health Stroke Scale score at admission, Alberta Stroke Program Early CT Score, and thrombolysis, the OR was 0.450 (P = .100) and 1.217 (P = .686) for "excellent" and "good" outcomes, respectively. CONCLUSIONS: In this cohort, 60% of elderly patients regained functional independence at 3 months after SRT. Although age may be a prognostic factor, patients should not be excluded from SRT based on age criteria.

Mechanical Thrombectomy in Acute Ischemic Stroke: Initial Single-Center Experience and Comparison with Randomized Controlled Trials.

BACKGROUND: Until recently, intravenous thrombolysis was the only reperfusion therapy with proven efficacy in patients with acute ischemic stroke. However, this treatment option has low recanalization rates in large-vessel occlusions. The search for additional treatments continued until 5 randomized trials (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, and REVASCAT) revealed the superiority of mechanical thrombectomy for anterior circulation large-vessel occlusion. After 1 year of performing thrombectomy with stent retrievers in our tertiary hospital, we intended to answer the question: is it possible to achieve similar results in a "real-world" setting? METHODS: We analyzed data from our prospective observational registry, compared it with the trials aforementioned, and concluded that the answer is affirmative. RESULTS: Our study population of 77 patients, with a mean age of 68,2 years and 48,1% men, is comparable with these trials in much of selection criteria, baseline characteristics, and rate of previous intravenous thrombolysis (72,7%). Recovery of functional independence at 90 days was achieved in almost two thirds of patients, similarly to the referred trials. We devoted special emphasis on fast recanalization, keeping a simple image selection protocol (based on non-enhanced and computed tomography angiography) and not waiting for clinical response to thrombolysis in patients eligible for mechanical thrombectomy. We emphasize a successful recanalization rate of 87% and only 2,6% symptomatic intracranial hemorrhage. CONCLUSION: In summary, mechanical thrombectomy seems to be a safe and effective treatment option in a "real-world" scenario, with results similar to those of the recent randomized controlled trials.