Prior Thrombectomy Does Not Affect the Surgical Complication Rate of Decompressive Hemicraniectomy in Patients with Malignant Ischemic Stroke.

BACKGROUND: Even though mechanical recanalization techniques have dramatically improved acute stroke care since the pivotal trials of decompressive hemicraniectomy for malignant courses of ischemic stroke, decompressive hemicraniectomy remains a mainstay of malignant stroke treatment. However, it is still unclear whether prior thrombectomy, which in most cases is associated with application of antiplatelets and/or anticoagulants, affects the surgical complication rate of decompressive hemicraniectomy and whether conclusions derived from prior trials of decompressive hemicraniectomy are still valid in times of modern stroke care. METHODS: A total of 103 consecutive patients who received a decompressive hemicraniectomy for malignant middle cerebral artery infarction were evaluated in this retrospective cohort study. Surgical and functional outcomes of patients who had received mechanical recanalization before surgery (thrombectomy group, n = 49) and of patients who had not received mechanical recanalization (medical group, n = 54) were compared. RESULTS: The baseline characteristics of the two groups did significantly differ regarding preoperative systemic thrombolysis (63.3% in the thrombectomy group vs. 18.5% in the medical group, p < 0.001), the rate of hemorrhagic transformation (44.9% vs. 24.1%, p = 0.04) and the preoperative Glasgow Coma Score (median of 7 in the thrombectomy group vs. 12 in the medical group, p = 0.04) were similar to those of prior randomized controlled trials of decompressive hemicraniectomy. There was no significant difference in the rates of surgical complications (10.2% in the thrombectomy group vs. 11.1% in the medical group), revision surgery within the first 30 days after surgery (4.1% vs. 5.6%, respectively), and functional outcome (median modified Rankin Score of 4 at 5 and 14 months in both groups) between the two groups. CONCLUSIONS: A prior mechanical recanalization with possibly associated systemic thrombolysis does not affect the early surgical complication rate and the functional outcome after decompressive hemicraniectomy for malignant ischemic stroke. Patient characteristics have not changed significantly since the introduction of mechanical recanalization; therefore, the results from former large randomized controlled trials are still valid in the modern era of stroke care.

Automated detection and segmentation of intracranial hemorrhage suspect hyperdensities in non-contrast-enhanced CT scans of acute stroke patients.

OBJECTIVES: Artif icial intelligence (AI)-based image analysis is increasingly applied in the acute stroke field. Its implementation for the detection and quantification of hemorrhage suspect hyperdensities in non-contrast-enhanced head CT (NCCT) scans may facilitate clinical decision-making and accelerate stroke management. METHODS: NCCTs of 160 patients with suspected acute stroke were analyzed regarding the presence or absence of acute intracranial hemorrhages (ICH) using a novel AI-based algorithm. Read was performed by two blinded neuroradiology residents (R1 and R2). Ground truth was established by an expert neuroradiologist. Specificity, sensitivity, and area under the curve were calculated for ICH and intraparenchymal hemorrhage (IPH) detection. IPH-volumes were segmented and quantified automatically by the algorithm and semi-automatically. Intraclass correlation coefficient (ICC) and Dice coefficient (DC) were calculated. RESULTS: In total, 79 of 160 patients showed acute ICH, while 47 had IPH. Sensitivity and specificity for ICH detection were 0.91 and 0.89 for the algorithm; 0.99 and 0.98 for R1; and 1.00 and 0.98 for R2. Sensitivity and specificity for IPH detection were 0.98 and 0.89 for the algorithm; 0.83 and 0.99 for R1; and 0.91 and 0.99 for R2. Interreader reliability for ICH and IPH detection showed strong agreements for the algorithm (0.80 and 0.84), R1 (0.96 and 0.84), and R2 (0.98 and 0.92), respectively. ICC indicated an excellent (0.98) agreement between the algorithm and the reference standard of the IPH-volumes. The mean DC was 0.82. CONCLUSION: The AI-based algorithm reliably assessed the presence or absence of acute ICHs in this dataset and quantified IPH volumes precisely. KEY POINTS: • Artificial intelligence (AI) is able to detect hyperdense volumes on brain CTs reliably. • Sensitivity and specificity are highest for the detection of intraparenchymal hemorrhages. • Interreader reliability for hemorrhage detection shows strong agreement for AI and human readers.

Trimethylamine-N-oxide is elevated in the acute phase after ischaemic stroke and decreases within the first days.

BACKGROUND AND PURPOSE: Trimethylamine-N-oxide (TMAO) is a biomarker of the gut microbiome and correlates with the risk of cardiovascular diseases. However, conflicting data exist on the specific role of TMAO in ischaemic stroke patients. We aimed to analyze the time course of TMAO levels in stroke patients compared with controls. METHODS: In this prospective, case-control study, patients suffering from ischaemic stroke (onset <24 h) and control patients with less than two cardiovascular risk factors were enrolled. Plasma TMAO levels were analyzed on admission, after 48 h and after 3 months. The primary endpoint was the difference in TMAO levels on admission between stroke patients and controls. RESULTS: A total of 196 patients with ischaemic stroke and 100 controls were included between February 2018 and April 2019. Plasma TMAO levels on admission were significantly higher in stroke patients than in controls [median value 4.09 (2.87-6.49) vs. 3.16 (2.08-5.16) µmol/L, P = 0.001]. There was a significant decrease in TMAO levels in stroke patients after 48 h [median at 48 h, 3.49 (2.30-5.39) µmol/L, P = 0.027]. TMAO levels increased again 3 months after stroke [median 4.23 (2.92-8.13) µmol/L, P = 0.047]. In controls, TMAO levels did not change between admission and after 48 h [median at 48 h, 3.14 (1.63-4.61) µmol/L, P = 0.11]. An inverse correlation between TMAO values and kidney function was found (Spearman rho -0.334, P < 0.001). CONCLUSIONS: Our study emphasizes the importance of the time course of TMAO levels after ischaemic stroke. Future studies should define the time point of TMAO analysis, preferably in the acute phase (<24 h).

Patient-centredness in acute stroke care - a qualitative study from the perspectives of patients, relatives and staff.

BACKGROUND AND PURPOSE: Although patient-centredness is considered a key component of high-quality neurological care, it is unclear to what extent it can or should be implemented during the acute phase. Using acute stroke as an example, the aim was to identify critical junctures for patient-centredness along the acute care pathway from the perspectives of patients, relatives and staff. METHODS: A qualitative multi-method study was conducted including 27 non-participant observations and 37 semi-structured interviews with patients, relatives and staff. Junctures were defined as critical when mentioned (as problematic) in two or three information sources (i.e. observations, staff interviews, or patient and relative interviews), as potentially critical when mentioned in one, and as uncritical when not mentioned. RESULTS: Post-procedure communication after thrombectomy, patients' stay at the stroke unit and decision-making around transfer, discharge and rehabilitation were identified as critical junctures for patient-centredness. Arrival at the emergency department and the (thrombectomy) treatment itself were identified as uncritical junctures, whilst history-taking and treatment preparation, the treatment decision and patients' stay at the intensive care unit were identified as potentially critical junctures. CONCLUSIONS: In acute stroke care, patients, relatives and staff prioritize fast over patient-centred decision-making in the most time-critical phases, especially before and during treatment. This is reversed after the procedure, when difficulties arise implementing a patient-centred approach in clinical practice. To improve patient-centredness where it is most needed, clear guidelines and accessible resources are recommended. Future research should investigate whether insights from acute phases of stroke care are applicable to other neurological conditions as well.

Stroke unit admission is associated with better outcome and lower mortality in patients with intracerebral hemorrhage.

BACKGROUND AND PURPOSE: There is no clear consensus among current guidelines on the preferred admission ward [i.e. intensive care unit (ICU) or stroke unit (SU)] for patients with intracerebral hemorrhage. Based on expert opinion, the American Heart Association and European Stroke Organization recommend treatment in neurological/neuroscience ICUs (NICUs) or SUs. The European Stroke Organization guideline states that there are no studies available directly comparing outcomes between ICUs and SUs. METHODS: We performed an observational study comparing outcomes of 10 811 consecutive non-comatose patients with intracerebral hemorrhage according to admission ward [ICUs, SUs and normal wards (NWs)]. Primary outcomes were the modified Rankin Scale score at discharge and intrahospital mortality. An additional analysis compared NICUs with SUs. RESULTS: Treatment outside an SU was associated with higher odds for an unfavorable outcome [ICU vs. SU: odds ratio (OR), 1.27; 95% confidence interval (CI), 1.09-1.46; NW vs. SU: OR, 1.28; 95% CI, 1.08-1.52] and higher odds for intrahospital mortality (ICU vs. SU: OR, 2.11; 95% CI, 1.75-2.55; NW vs. SU: OR, 1.52; 95% CI, 1.23-1.89). A subgroup analysis of severely affected patients treated in dedicated NICUs (vs. SUs) showed that they had a lower risk of a poor outcome (OR, 0.45; 95% CI, 0.26-0.79). CONCLUSIONS: Treatment in SUs was associated with better functional outcome and reduced mortality compared with ICUs and NWs. Our findings support the current guideline recommendations to treat patients with intracerebral hemorrhage in SUs or NICUs and suggest that some patients may further benefit from NICU treatment.

Risk factors associated with progressive lacunar strokes and benefit from dual antiplatelet therapy.

BACKGROUND AND PURPOSE: Early neurological deterioration (END) occurs in 20%-30% of patients with lacunar stroke and challenges their clinical management. This retrospective cohort study analyzed clinical and neuroimaging risk factors predicting the occurrence of END, the functional outcome after END and potential benefit from dual antiplatelet therapy (DAPT) in patients with lacunar strokes. METHODS: Factors associated with END and benefit from DAPT were retrospectively analyzed in 308 patients with lacunar stroke symptoms and detected lacunar infarction by magnetic resonance imaging. END was defined by deterioration of ≥3 total National Institutes of Health Stroke Scale (NIHSS) points, ≥2 NIHSS points for limb paresis or documented deterioration within 5 days after admission. Patients were treated with DAPT according to in-house standards. The primary efficacy end-point for functional outcome was fulfilled if NIHSS at discharge improved after END at least to the score at admission. RESULTS: Male gender [odds ratio (OR) 2.08; 95% confidence interval (CI) 1.09-4.00], higher age (OR = 1.65 per 10 years; 95% CI 1.18-2.31), motor paresis (OR = 18.89, 95% CI 4.66-76.57) and infarction of the internal capsule or basal ganglia (OR = 3.58, 95% CI 1.26-10.14) were associated with an increased risk for END. A larger diameter of infarction (OR = 0.85, 95% CI 0.76-0.95), more microangiopathic lesions (OR = 0.75, 95% CI 0.57-0.99) and pontine localization (OR = 0.29, 95% CI 0.12-0.65) were factors associated with unfavorable functional outcome after END occurred. Localization in the internal capsule or basal ganglia was identified as a significant predictive factor for a benefit from DAPT after END. CONCLUSIONS: Identified clinical and neuroimaging factors predicting END occurrence, functional outcome after END and potential benefit from DAPT might improve the clinical management of patients with lacunar strokes.

The Influence of Angioarchitectural Features on the Success of Endovascular Embolization of Cranial Dural Arteriovenous Fistulas with Onyx.

BACKGROUND AND PURPOSE: Endovascular embolization can be an effective treatment for cranial dural arteriovenous fistulas. However, a considerable number of dural arteriovenous fistulas still cannot be treated sufficiently. The purpose of this study was to report our single-center experience of endovascular embolization of dural arteriovenous fistulas with Onyx, including the investigation of the influence of angioarchitectural features on the treatment success. MATERIALS AND METHODS: Clinical data, angioarchitectural features, complications, treatment success (defined as complete symptom remission for low-grade dural arteriovenous fistulas and complete occlusion for high-grade dural arteriovenous fistulas), and occlusion rates were assessed. The influence of various angioarchitectural features (including location, pattern of venous drainage, and quantity and origin of feeding arteries) was investigated using multivariable backward logistic regression. RESULTS: One hundred four patients with 110 dural arteriovenous fistulas were treated in 132 treatment procedures. Treatment success and complete occlusion rates were 81.8% and 90.9%, respectively. After a mean follow-up of 23.6 months, 95.5% of the patients showed complete symptom remission or symptom relief. The overall complication rate was 8.3% (4.5% asymptomatic, 2.3% transient, and 1.5% permanent complications). Logistic regression showed that ≥10 feeding arteries (P = .041) and involvement of the ascending pharyngeal artery (P = .039) significantly lowered the probability of treatment success. Treatment success tended to be lower for low-grade dural arteriovenous fistulas, Cognard type I dural arteriovenous fistulas, and dural arteriovenous fistulas with involvement of dural branches of the internal carotid artery, however without reaching statistical significance in the multivariable model. CONCLUSIONS: The presence of multiple feeding arteries and involvement of the pharyngeal artery negatively influence the treatment success of endovascular embolization of cranial dural arteriovenous fistulas with Onyx.

Angioplasty in asymptomatic carotid artery stenosis vs. endarterectomy compared to best medical treatment: One-year interim results of SPACE-2.

BACKGROUND: Treatment of individuals with asymptomatic carotid artery stenosis is still handled controversially. Recommendations for treatment of asymptomatic carotid stenosis with carotid endarterectomy (CEA) are based on trials having recruited patients more than 15 years ago. Registry data indicate that advances in best medical treatment (BMT) may lead to a markedly decreasing risk of stroke in asymptomatic carotid stenosis. The aim of the SPACE-2 trial (ISRCTN78592017) was to compare the stroke preventive effects of BMT alone with that of BMT in combination with CEA or carotid artery stenting (CAS), respectively, in patients with asymptomatic carotid artery stenosis of ≥70% European Carotid Surgery Trial (ECST) criteria. METHODS: SPACE-2 is a randomized, controlled, multicenter, open study. A major secondary endpoint was the cumulative rate of any stroke (ischemic or hemorrhagic) or death from any cause within 30 days plus an ipsilateral ischemic stroke within one year of follow-up. Safety was assessed as the rate of any stroke and death from any cause within 30 days after CEA or CAS. Protocol changes had to be implemented. The results on the one-year period after treatment are reported. FINDINGS: It was planned to enroll 3550 patients. Due to low recruitment, the enrollment of patients was stopped prematurely after randomization of 513 patients in 36 centers to CEA (n = 203), CAS (n = 197), or BMT (n = 113). The one-year rate of the major secondary endpoint did not significantly differ between groups (CEA 2.5%, CAS 3.0%, BMT 0.9%; p = 0.530) as well as rates of any stroke (CEA 3.9%, CAS 4.1%, BMT 0.9%; p = 0.256) and all-cause mortality (CEA 2.5%, CAS 1.0%, BMT 3.5%; p = 0.304). About half of all strokes occurred in the peri-interventional period. Higher albeit statistically non-significant rates of restenosis occurred in the stenting group (CEA 2.0% vs. CAS 5.6%; p = 0.068) without evidence of increased stroke rates. INTERPRETATION: The low sample size of this prematurely stopped trial of 513 patients implies that its power is not sufficient to show that CEA or CAS is superior to a modern medical therapy (BMT) in the primary prevention of ischemic stroke in patients with an asymptomatic carotid stenosis up to one year after treatment. Also, no evidence for differences in safety between CAS and CEA during the first year after treatment could be derived. Follow-up will be performed up to five years. Data may be used for pooled analysis with ongoing trials.

Clinical Outcome after Thrombectomy in Patients with Stroke with Premorbid Modified Rankin Scale Scores of 3 and 4: A Cohort Study with 136 Patients.

BACKGROUND AND PURPOSE: We aimed to analyze the clinical outcome after mechanical thrombectomy in patients with premorbid mRS 3 and 4 because there are currently no data on this patient group. MATERIALS AND METHODS: Between January 2009 and November 2017, all patients with premorbid mRS 3 or 4 undergoing mechanical thrombectomy due to anterior circulation stroke were selected. Good outcome was defined as a clinical recovery to the status before stroke onset (ie, equal premorbid mRS and mRS at 90 days). In addition, mortality at discharge and at 90 days was analyzed. RESULTS: One hundred thirty-six patients were included, of whom 81.6% presented with premorbid mRS 3; and 18.4%, with premorbid mRS 4; 24.0% of patients with premorbid mRS 4 achieved clinical recovery compared with 20.7% of patients with premorbid mRS 3 (P = .788). However, the proportion of hospital mortality and mortality at 90 days was nonsignificant, but markedly higher in patients with premorbid mRS 4. Multivariate analysis identified low NIHSS scores (OR, 0.92; 95% CI, 0.85-0.99; P = .040), high ASPECTS (OR, 1.45; 95% CI, 1.02-2.16; P = .049), and TICI 2b-3 (OR, 7.11; 95% CI, 1.73-49.90; P = .017) as independent predictors of good outcome. CONCLUSIONS: Good outcome in patients with premorbid mRS 3 and 4 is less frequent compared with premorbid mRS 0-2. Nevertheless, about 20% of the patients return to their premorbid mRS, which may justify endovascular treatment. The most important predictor of good outcome is successful recanalization.

Predictors of symptomatic intracranial haemorrhage in off-label thrombolysis: an analysis of the Safe Implementation of Treatments in Stroke registry.

BACKGROUND AND PURPOSE: Intravenous thrombolysis (IVT) is the only approved pharmacological treatment for acute ischemic stroke. Off-label IVT for ischemic stroke is common. We aimed to analyse its safety in a large database. METHODS: This was a retrospective analysis of the safe implementation of treatments in stroke (SITS) thrombolysis registry with regard to 11 off-label criteria according to the European licence for alteplase. Symptomatic intracranial haemorrhage (SICH) according to SITS was defined as primary safety endpoint and SICH according to the European Cooperative Acute Stroke Study (ECASS II) definition and the National Institute of Neurological Disorders and Stroke definition as secondary safety endpoints. Multivariable logistic regression analyses after replacing missing values using multiple imputations were performed. RESULTS: Patients from 793 centres in 44 countries were included, mainly (95%) in Europe. A total of 56 258 patients who were treated with intravenous alteplase were included. Median age was 71 (IQR 61-78) years and median National Institutes of Health Stroke Scale score was 12 (IQR 7-17). A total of 16 740 (30%) patients received off-label IVT and 1037 (1.8%) patients suffered from SICH according to the SITS definition (SICH SITS). Median percentage of missing values per variable was 0.4%. The only two off-label criteria constituting independent positive and negative predictors for SICH SITS were high blood pressure (odds ratio, 1.39; 95% confidence interval, 1.08-1.80; P = 0.012) and minor stroke (odds ratio, 0.51; 95% confidence interval, 0.33-0.78; P = 0.002). Very severe stroke, previous stroke and diabetes, age and high glucose levels were additional independent predictors of SICH according to the ECASS II and National Institute of Neurological Disorders and Stroke definitions. CONCLUSIONS: Thrombolysis appears to be safe with regard to SICH for most of the off-label criteria, especially for minor stroke, but is risky in patients with high blood pressure. Individual risk-benefit evaluation should be performed.

[Diagnostic and treatment standards for cerebral sinus venous thrombosis : Results of an online survey of German stroke units]. / Diagnose- und Behandlungsstandards der zerebralen Sinus­/Venenthrombose : Ergebnisse einer Onlineumfrage an deutschen Stroke-Units.

BACKGROUND AND PURPOSE: The aim of this survey was to characterize the current diagnostic and therapeutic strategies for thrombosis of the cerebral sinus and veins (CVT) performed in German stroke units (SU). METHODS: Between September 2015 and January 2016 all clinical heads of certified SUs in Germany were invited to participate in a standardized online survey. The survey concentrated on the basic characteristics of SUs, diagnostic and therapeutic procedures and was made anonymous if so desired. Frequencies were expressed as percentages and differences between regional stroke units (RSU) and supraregional (i. e. comprehensive) SUs (SRSU) were compared with the χ2-test or Fisher's test RESULTS: A total of 107 SU heads participated (response rate 42.8%) and 55.1% of these were RSUs. In 77.2% the diagnosis is made by magnetic resonance imaging angiography (MR-A, RSU 81.1% vs. SRSU 72.3%; p = 0.29). Of the SUs 79.1% determined d­dimer if CVT is suspected (79.3% vs. 78.7%; p = 0.94) and 88.5% carried out screening for thrombophilia (89.5% vs. 87.2%; p = 0.72). Intravenous unfractionated heparin (67.2% vs. 70.2%; p = 0.74) or subcutaneous low molecular weight heparin (32.8% vs. 29.8%; p = 0.74) are first line therapy in all SUs. Invasive procedures, such as hypothermia (3.7% vs. 10.6%; p = 0.25), hemicraniectomy (26% vs. 63.9%; p = 0.0001), endovascular techniques (11.1% vs. 40.4%; p = 0.0007) and systemic thrombolysis (5.5% vs. 10.6%; p = 0.47) are performed more frequently in SRSUs. Of the SUs 18.5% already use new oral anticoagulants (10.7% vs. 27.7%; p = 0.027). Most of the SUs organize a follow-up visit (70.9% vs. 76.6%; p = 0.52) with a MRI (94.2% vs. 91.1%; p = 0.7) within the first 6 months. CONCLUSION: The survey revealed substantial homogeneity between RSUs and SRSUs and standards are mostly in line with the guidelines. Non-established procedures, such as invasive therapeutic procedures and the administration of new oral anticoagulants were used significantly more often in SRSUs.

The Impact of Conscious Sedation versus General Anesthesia for Stroke Thrombectomy on the Predictive Value of Collateral Status: A Post Hoc Analysis of the SIESTA Trial.

BACKGROUND AND PURPOSE: Radiologic selection criteria to identify patients likely to benefit from endovascular stroke treatment are still controversial. In this post hoc analysis of the recent randomized Sedation versus Intubation for Endovascular Stroke TreAtment (SIESTA) trial, we aimed to investigate the impact of sedation mode (conscious sedation versus general anesthesia) on the predictive value of collateral status. MATERIALS AND METHODS: Using imaging data from SIESTA, we assessed collateral status with the collateral score of Tan et al and graded it from absent to good collaterals (0-3). We examined the association of collateral status with 24-hour improvement of the NIHSS score, infarct volume, and mRS at 3 months according to the sedation regimen. RESULTS: In a cohort of 104 patients, the NIHSS score improved significantly in patients with moderate or good collaterals (2-3) compared with patients with no or poor collaterals (0-1) (P = .011; mean, -5.8 ± 7.6 versus -1.1 ± 10.7). Tan 2-3 was also associated with significantly higher ASPECTS before endovascular stroke treatment (median, 9 versus 7; P < .001) and smaller mean infarct size after endovascular stroke treatment (median, 35.0 versus 107.4; P < .001). When we differentiated the population according to collateral status (0.1 versus 2.3), the sedation modes conscious sedation and general anesthesia were not associated with significant differences in the predictive value of collateral status regarding infarction size or functional outcome. CONCLUSIONS: The sedation mode, conscious sedation or general anesthesia, did not influence the predictive value of collaterals in patients with large-vessel occlusion anterior circulation stroke undergoing thrombectomy in the SIESTA trial.

e-ASPECTS Correlates with and Is Predictive of Outcome after Mechanical Thrombectomy.

BACKGROUND AND PURPOSE: The e-ASPECTS software is a tool for the automated use of ASPECTS. Our aim was to analyze whether baseline e-ASPECT scores correlate with outcome after mechanical thrombectomy. MATERIALS AND METHODS: Patients with ischemic strokes in the anterior circulation who were admitted between 2010 and 2015, diagnosed by CT, and received mechanical thrombectomy were included. The ASPECTS on baseline CT was scored by e-ASPECTS and 3 expert raters, and interclass correlation coefficients were calculated. The e-ASPECTS was correlated with functional outcome (modified Rankin Scale) at 3 months by using the Spearman rank correlation coefficient. Unfavorable outcome was defined as mRS 4-6 at 3 months, and a poor scan was defined as e-ASPECTS 0-5. RESULTS: Two hundred twenty patients were included, and 147 (67%) were treated with bridging protocols. The median e-ASPECTS was 9 (interquartile range, 8-10). Intraclass correlation coefficients between e-ASPECTS and raters were 0.72, 0.74, and 0.76 (all, P < .001). e-ASPECTS (Spearman rank correlation coefficient = -0.15, P = .027) correlated with mRS at 3 months. Patients with unfavorable outcome had lower e-ASPECTS (median, 8; interquartile range, 7-10 versus median, 9; interquartile range, 8-10; P = .014). Sixteen patients (7.4%) had a poor scan, which was associated with unfavorable outcome (OR, 13.6; 95% CI, 1.8-104). Independent predictors of unfavorable outcome were e-ASPECTS (OR, 0.79; 95% CI, 0.63-0.99), blood sugar (OR, 1.01; 95% CI, 1.004-1.02), atrial fibrillation (OR, 2.64; 95% CI, 1.22-5.69), premorbid mRS (OR, 1.77; 95% CI, 1.21-2.58), NIHSS (OR, 1.11; 95% CI, 1.04-1.19), general anesthesia (OR, 0.24; 95% CI, 0.07-0.84), failed recanalization (OR, 8.47; 95% CI, 3.5-20.2), and symptomatic intracerebral hemorrhage (OR, 25.8; 95% CI, 2.5-268). CONCLUSIONS: The e-ASPECTS correlated with mRS at 3 months and was predictive of unfavorable outcome after mechanical thrombectomy, but further studies in patients with poor scan are needed.

Correlation of Thrombectomy Maneuver Count with Recanalization Success and Clinical Outcome in Patients with Ischemic Stroke.

BACKGROUND AND PURPOSE: In the treatment of acute thromboembolic stroke, the effectiveness and success of thrombus removal when using stent retrievers is variable. In this study, we analyzed the correlation of thrombectomy maneuver count with a good clinical outcome and recanalization success. MATERIALS AND METHODS: One hundred and four patients with acute occlusion of the middle cerebral artery or the terminal internal carotid artery who were treated with thrombectomy were included in this retrospective study. A good clinical outcome was defined as a 90-day mRS of ≤2, and successful recanalization was defined as TICI 2b-3. RESULTS: The maneuver count ranged between 1-10, with a median of 2. Multivariate logistic regression analyses identified an increasing number of thrombectomy maneuvers as an independent predictor of poor outcome (adjusted OR, 0.59; 95% CI, 0.38-0.87; P = .011) and unsuccessful recanalization (adjusted OR, 0.48; 95% CI, 0.32-0.66; P < .001). A good outcome was significantly more likely if finished within 2 maneuvers compared with 3 or 4 maneuvers, or even more than 4 maneuvers (P < .001). CONCLUSIONS: An increasing maneuver count correlates strongly with a decreasing probability of both good outcome and recanalization. The probability of successful recanalization decreases below 50% if not achieved within 5 thrombectomy maneuvers. Patients who are recanalized within 2 maneuvers have the best chance of achieving a good clinical outcome.

Minor Stroke Syndromes in Large-Vessel Occlusions: Mechanical Thrombectomy or Thrombolysis Only?

While mechanical thrombectomy for large-vessel occlusions is now an evidence-based treatment, its efficacy and safety in minor stroke syndromes (NIHSS ≤ 5) is not proved. We identified, in our prospective data base, 378 patients with minor strokes in the anterior circulation; 54 (14.2%) of these had proved large-vessel occlusions. Eight of 54 (14.8%) were immediately treated with mechanical thrombectomy, 6/54 (11.1%) after early neurologic deterioration, and the rest were treated with standard thrombolysis only. Rates of successful recanalization were similar between the 2 mechanical thrombectomy groups (75% versus 100%). Rates of excellent outcome (modified Rankin Scale 0-1) were higher in patients with immediate thrombectomy (75%) compared with patients with delayed thrombectomy (33.3%) and thrombolysis only (55%). No symptomatic intracranial hemorrhage occurred in either group. These descriptive data are encouraging, and further analysis of large registries or even randomized controlled trials in this patient subgroup should be performed.

Restenosis after Carotid Interventions and Its Relationship with Recurrent Ipsilateral Stroke: A Systematic Review and Meta-analysis.

OBJECTIVE: Do asymptomatic restenoses > 70% after carotid endarterectomy (CEA) and carotid stenting (CAS) increase the risk of late ipsilateral stroke? METHODS: Systematic review identified 11 randomised controlled trials (RCTs) reporting rates of restenosis > 70% (and/or occlusion) in patients who had undergone CEA/CAS for the treatment of primary atherosclerotic disease, and nine RCTs reported late ipsilateral stroke rates. Proportional meta-analyses and odds ratios (OR) at end of follow-up were performed. RESULTS: The weighted incidence of restenosis > 70% was 5.8% after "any" CEA, median 47 months (11 RCTs; 4249 patients); 4.1% after patched CEA, median 32 months (5 RCTs; 1078 patients), and 10% after CAS, median 62 months (5 RCTs; 2716 patients). In four RCTs (1964 patients), one of 125 (0.8%) with restenosis > 70% (or occlusion) after CAS suffered late ipsilateral stroke over a median 50 months, compared with 37 of 1839 (2.0%) in CAS patients with no significant restenosis (OR 0.87; 95% CI 0.24-3.21; p = .8339). In seven RCTs (2810 patients), 13 out of 141 (9.2%) with restenosis > 70% (or occlusion) after CEA suffered late ipsilateral stroke over a median 37 months, compared with 33 out of 2669 (1.2%) in patients with no significant restenoses (OR 9.02; 95% CI 4.70-17.28; p < .0001). Following data correction to exclude patients whose surveillance scan showed no evidence of restenosis > 70% before stroke onset, the prevalence of stroke ipsilateral to an untreated asymptomatic > 70% restenosis was seven out of 135 (5.2%) versus 40 out of 2704 (1.5%) in CEA patients with no significant restenosis (OR 4.77; 95% CI 2.29-9.92). CONCLUSIONS: CAS patients with untreated asymptomatic > 70% restenosis had an extremely low rate of late ipsilateral stroke (0.8% over 50 months). CEA patients with untreated, asymptomatic > 70% restenosis had a significantly higher risk of late ipsilateral stroke (compared with patients with no restenosis), but this was only 5% at 37 months. Overall, 97% of all late ipsilateral strokes after CAS and 85% after CEA occurred in patients without evidence of significant restenosis or occlusion.

Clinical Outcome After Mechanical Thrombectomy in Non-elderly Patients with Acute Ischemic Stroke in the Anterior Circulation: Primary Admission Versus Patients Referred from Remote Hospitals.

BACKGROUND AND PURPOSE: Stroke networks have been installed to increase access to advanced stroke specific treatments like mechanical thrombectomy (MT). This concept often requires patients to be transferred to a comprehensive stroke center (CSC) offering MT. Do patient referral, transportation, and logistic effort translate into clinical outcomes comparable to patients admitted primarily to the CSC? MATERIAL AND METHODS: We categorized 112 patients with acute ischemic stroke in the anterior circulation, who received MT at our institution, into primary admissions (A) and referrals from either local (B) or regional (C) hospitals, assessed the clinical outcome, and tested the impact of distance and delay of transportation from the referring remote hospital. RESULTS: The median time from symptom onset to initial CT was similar in all groups (p = 0,939). Patients who were transferred to the CSC had significantly increasing median time between initial CT and MT (in minutes (interquartile range [IQR]); A: 83 [68-120]; B: 174 [159-208]; C: 220 [181-235]; p < 0.001) and median time between onset to MT (in minutes [IQR]; A: 178 [150-210]; B: 274 [238-349]; C: 293 [256-329]; p < 0.001). After 90 days of MT there was no significant difference in clinical outcome (modified Rankin Scale ≤ 2) between primary admitted and referred patients (p = 0.502). CONCLUSION: Clinical outcome in patients who received MT after transfer from either local or regional remote hospitals was not significantly worse than in patients primarily admitted to the CSC. In the event of an acute ischemic stroke patients living in urban or rural areas should, despite a possible delay, have access to MT.

Endovascular Stroke Treatment of Nonagenarians.

BACKGROUND AND PURPOSE: Although endovascular treatment has become a standard therapy in patients with acute stroke, the benefit for very old patients remains uncertain. The purpose of this study was the evaluation of procedural and outcome data of patients ≥90 years undergoing endovascular stroke treatment. MATERIALS AND METHODS: We retrospectively analyzed prospectively collected data of patients ≥90 years in whom endovascular stroke treatment was performed between January 2011 and January 2016. Recanalization was assessed according to the TICI score. The clinical condition was evaluated on admission (NIHSS, prestroke mRS), at discharge (NIHSS), and after 3 months (mRS). RESULTS: Twenty-nine patients met the inclusion criteria for this analysis. The median prestroke mRS was 2. Successful recanalization (TICI ≥ 2b) was achieved in 22 patients (75.9%). In 9 patients, an NIHSS improvement ≥ 10 points was noted between admission and discharge. After 3 months, 17.2% of the patients had an mRS of 0-2 or exhibited prestroke mRS, and 24.1% achieved mRS 0-3. Mortality rate was 44.8%. There was only 1 minor procedure-related complication (small SAH without clinical sequelae). CONCLUSIONS: Despite high mortality rates and only moderate overall outcome, 17.2% of the patients achieved mRS 0-2 or prestroke mRS, and no serious procedure-related complications occurred. Therefore, very high age should not per se be an exclusion criterion for endovascular stroke treatment.

Mechanical Thrombectomy in Patients with Acute Ischemic Stroke and Lower NIHSS Scores: Recanalization Rates, Periprocedural Complications, and Clinical Outcome.

BACKGROUND AND PURPOSE: Mechanical thrombectomy, in addition to intravenous thrombolysis, has become standard in acute ischemic stroke treatment in patients with large-vessel occlusion in the anterior circulation. However, previous randomized controlled stroke trials were not focused on patients with mild-to-moderate symptoms. Thus, there are limited data for patient selection, prediction of clinical outcome, and occurrence of complications in this patient population. The purpose of this analysis was to assess clinical and interventional data in patients treated with mechanical thrombectomy in case of ischemic stroke with mild-to-moderate symptoms. MATERIALS AND METHODS: We performed a retrospective analysis of a prospectively collected stroke data base. Inclusion criteria were anterior circulation ischemic stroke treated with mechanical thrombectomy at our institution between September 2010 and October 2015 with an NIHSS score of ≤8. RESULTS: Of 484 patients, we identified 33 (6.8%) with the following characteristics: median NIHSS = 5 (interquartile range, 4-7), median onset-to-groin puncture time = 320 minutes (interquartile range, 237-528 minutes). Recanalization (TICI = 2b-3) was achieved in 26 (78.7%) patients. Two cases of symptomatic intracranial hemorrhage were observed. Favorable (mRS 0-2) and moderate (mRS 0-3) clinical outcome at 90 days was achieved in 21 (63.6%) and 30 (90.9%) patients, respectively. CONCLUSIONS: The clinical outcome of patients undergoing mechanical thrombectomy for acute ischemic stroke with mild stroke due to large-vessel occlusion appears to be predominately favorable, even in a prolonged time window. However, although infrequent, angiographic complications could impair clinical outcome. Future randomized controlled trials should assess the benefit compared with the best medical treatment.