Citations

Introduction: The benefits of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients with unsuccessful mechanical thrombectomy (MT) are not well established. Methods: This study included patients from the Stroke Thrombectomy and Aneurysm Registry (STAR) who underwent MT for ICA, M1, or M2 occlusions with unsuccessful MT (mTICI score ≤ 2a). Patients who received IVT prior to MT were compared to those who received MT alone. Propensity score (PS) matching was performed using age, sex, premorbid modified Rankin Scale (mRS), admission National Institute of Health Stroke Scale (NIHSS), occluded vessel, ASPECTS score, mTICI score, and symptom onset to groin puncture time. The primary outcome was favorable 90-day outcomes (mRS 0-2). Results: Of 610 patients with unsuccessful MT, 219 were matched in each group. Median ages were 70 [IQR: 61 - 80] and 73 [IQR: 62 - 81] in the IVT + MT and MT alone groups, respectively. In the IVT + MT group. Final TICI scores of 0, 1, and 2a were achieved in 92 (42.0%), 33 (15.1%), and 94 (42.9%) patients, respectively, compared to 76 (34.7%), 29 (13.2%), and 114 (52.1%) in the MT alone group. The IVT + MT group showed a significantly. higher 90-day mRS of 0-2 (aOR: 2.54, 95% CI: 1.53-4.32) and mRS of 0-3 (aOR: 2.05, 95% CI: 1.36-3.12). There were no significant differences between the groups in intracranial hemorrhage (ICH), symptomatic ICH, or 90-day mortality rates. Conclusions: IVT is associated with improved functional outcomes in patients with unsuccessful MT. Ensuring that IVT is provided to all eligible stroke patients should remain a priority.

Introduction: Up to 50% of acute ischemic stroke (AIS) patients who undergo successful mechanical thrombectomy (MT) fail to achieve favorable outcomes (futile recanalization). In this study we aim to develop a machine learning (ML) model to predict futile recanalization (FR) in AIS patients who undergo MT. Methods: We used data from an ongoing large, multicenter database from 2013 to 2023. We included AIS patients treated with MT for ICA, M1, or M2 occlusion with successful recanalization (modified Thrombolysis in Cerebral Infarction [mTICI] score ≥ 2C) and procedure durations under 60 minutes. FR was defined as successful recanalization with 90-day modified Rankin Scale (mRS) 3-6. The dataset was divided into 75% for training and 25% for external validation. Using the Caret Package in R, multiple models were tested, and their performances were evaluated by the area under the curve (AUC) of receiver operating. Both baseline and pre-interventional characteristics were incorporated into the model. The selected model was then externally validated on a 25% validation dataset. Results: Among 2,546 qualified patients, FR occurred in 1,342 (52.7%). In univariate analysis, baseline characteristics were significantly different between FR and non-FR groups. The M5P model demonstrated the highest performance (AUC: 0.833; 95% CI: 0.7989-0.852; PPV: 0.8101) in comparison to other tested models such as logistic regression (AUC: 0.74), RF (AUC: 0.78), J48 (AUC: 0.78), SVM (AUC: 0.79), and GB (AUC: 0.79). The external validation of the model showed satisfactory results (AUC: 75.25; 95% CI: 70-80; PPV: 76.87). Conclusion: Utilizing clinical, pre-procedural, and imaging parameters, the M5P model can efficiently predict F) in AIS patients before attempting MT. This tool can assist neurointerventionalists in adequately choosing their MT candidates.

Introduction: Collateral cerebrovasculature is important for the survival of penumbral tissue in patients with large vessel occlusive (LVO) stroke, and adequate collateralization is associated with favorable outcomes. The presence of cerebral microbleeds (CMB) have been implicated in vessel wall remodeling and impaired vasoreactivity. We investigated whether the presence of deep and/or lobar CMB predicts poor collateral recruitment in patients with LVO stroke who underwent thrombectomy (MT). Methods: We performed a retrospective, single-center study of adults who presented with LVO stroke and had MT between January 2012-June 2020. CT angiography of head prior to MT was used to assess collateral status with poor status defined as ≤50% filling and good status as >50% filling. CMBs were assessed using T2*-weighted gradient echo or susceptibility weighted magnetic resonance images. Location of CMB was further characterized as deep vs. lobar using consensus definitions. Poor stroke outcome was defined as modified Rankin Scale (mRS) ≥3 at 90 days. Multivariable logistic regressions were performed to evaluate the associations between CMB, CMB types (lobar, deep, lobar+deep) and poor collaterals after adjusting for vascular risk factors. Results: Consecutive 151 subjects were included (mean age 68±15 years, 47% women), with a median NIHSS of 18. CMB were identified in 57 subjects (37.4%). Of these, 20.5% had lobar CMB, 5.3% had deep CMB and 11.9% had combined lobar & deep CMB. Patients with CMB had higher odds of having poor collaterals compared to those without CMB (OR 1.56, 95% CI 1.09-2.23, P=0.015). The association of CMB with poor collaterals was strongest in patients with combined lobar & deep CMB (OR 4.78, 95% CI 1.43-15.93, P=0.011), compared with those with exclusively deep CMB (OR 2.78, 95% CI 0.44-17.62, P=0.278) or lobar CMB (OR 0.52, 95% CI 0.19-1.38, P=0.188). Patients with poor collaterals were more likely to have poor outcome compared with those with good collaterals (48.4% vs. 31.0%, P=0.03). Conclusion: Cerebral microbleeds are independently associated with poor collateral recruitment when adjusted for traditional vascular risk factors. Further study is warranted to elucidate the differential effects of CMB types on collateral recruitment.

Background: Despite decades long adoption as the standard-of-care for ischemic stroke, the majority of eligible patients do not receive intravenous thrombolysis (IVT), with underutilization especially pronounced in rural areas. Telestroke, however, may help alleviate this geographical healthcare disparity. The current study aims to identify the impact of implementing a mature telestroke network within a rural setting. Methods: Retrospective review of a prospectively maintained telestroke database from a large rural tertiary care comprehensive stroke center covering 31 spoke hospitals spanning critical access hospitals to primary stroke centers between 10/2021-02/2023. Data was compared to a previous review period (01/2016-12/2018; comprised of 8 spokes) and the statewide IVT rates recorded in GWTG. Data analysis conducted via descriptive statistics and Fisher’s (two-tailed) exact test. Results: 1801 telestroke consults were performed; 41.4% (746/1801) were ineligible for acute stroke intervention. 39% (410/1055) of eligible patients were treated with IVT (vs. 33% [317/959] previously, p = 0.068), representing 58% (410/708; vs 24% [107/448] previously, p < 0.001) of statewide total IVT administration. Symptomatic hemorrhage (sICH) was 3.0%, overall 30-day mortality was 5.6%, and sICH mortality was 1.0%. IVT deferred most commonly: low NIH (44%), mimics (21%), coagulopathy (8%), followed by other. 22% (396/1801) of total consults were transferred from the originating site (vs. 34% [305/890] previously, p < 0.0001) of which 10% (42/396) underwent EVT. Discussion: The impact of expanding a rural telestroke network continued to produce high IVT rates (nearly double the national average) with safety outcomes (sICH, mortality) at or below national standards. Additionally, a large network has significantly increased the proportion of patients remaining at originating sites, optimizing both tertiary and local centers’ resources. The value of a regional telestroke hub is further underscored by the significant increase in statewide IVT attributed to network consults. However, further strategies are needed to better educate rural providers on acute stroke to reduce the rate of ineligible consults and streamline use of telestroke services.

Introduction: Impact of race on outcomes in the treatment of intracranial aneurysm (IA) remains unclear. We aimed to investigate the relationship between race classified into White, Black, Hispanic, and other ("other" includes Native American or Alaska Native, Asian or Pacific Islander, and other race) and treatment outcomes in patients with ruptured and unruptured IAs. Methods: Stroke Thrombectomy and Aneurysm Registry (STAR) was a retrospective observational study. Data from 9 centers in the United States, Europe, and Asia for IA patients who undertook endovascular treatment (EVT) or microsurgical treatment (MST) between January 2016 and December 2020 were included for analysis. The primary outcome was 90-day mRS 0-2. Secondary outcomes included periprocedural cerebral infarction and intracranial hemorrhage, perioperative symptomatic cerebral vasospasm in ruptured IA and mortality, and all causes of mortality within 90 days. Results: 2,836 IA patients treated with EVT or MST were included. Among these 2,836 patients, 1,053 patients were White, 350 were Black, 264 were Hispanic, and 1,169 were other. The primary outcome in Hispanic patients was significantly lower than White patients (adjusted odds ratio [aOR] 0.36, 95% CI, 0.23-0.56, P < .001). The periprocedural cerebral infarction, perioperative mortality, and all causes of mortality in Hispanic patients were significantly higher than White patients (aOR 2.53, 95% CI, 1.40-4.58, P = .002, aOR 1.84, 95% CI, 1.00-3.38, P = .049, aOR 1.83, 95% CI, 1.06-3.17, P = .03, respectively). However, these outcomes were not significantly different in Black and other patients compared to White patients. Conclusions: This study demonstrates Hispanic IA patients are more likely to have a poor outcome at 90 days following EVT or MST than White patients.

Background: White matter hyperintensities (WMH) are associated with risk of dementia and stroke, so are an important therapeutic target for clinical trials. The cost of broad MRI screening to identify those individuals with significant WMH, however, limits the feasibility of designing clinical trials which target WMH presence and which test treatments that slow progression. Hypothesis: A low-cost retinal or clinical screening measure prior to an MRI screening stage reduces the cost of recruiting persons with significant WMH burden in a hypothetical clinical trial vs an MRI-only screening design. Method: Data were from participants in the Atherosclerosis Risk in Communities-Neurocognitive study with clinical, retinal and WMH measurements ( N = 1311) at ages 53-70 years. Significant WMH burden was defined as a Cardiovascular Health Study score >2. Three low-cost pre-screening measures were assessed: (1) retinal: a score incorporating multiple markers of abnormal retinal vasculature, (2) clinical: a score incorporating hypertension, diabetes, and age, (3) combined retinal-clinical: a score incorporating retinal and clinical factors. Given a prior published target sample for a WMH clinical trial (N= 646), we calculated a theoretical screening sample size based on the proportion of each pre-screening measure in the population multiplied by the proportion of significant WMH burden among those with a prevalent pre-screening feature. Total recruitment cost was calculated using standard retinal ($32.50) and MRI ($650) cost estimates. Results: Compared to the estimated cost of MRI-only screening (>$4.24M, requiring MRI screening 6,526 participants), pre-screening for a high clinical score reduced total cost to $2.47M, but increased the initial screening group to 52,778 participants, of whom 3,801 would be screened by MRI). A high retinal-clinical score cutoff reduced costs to $2.9M while only requiring 13,572 screened participants (of these only 3,801 would require MRI). Conclusion: A 2-stage recruitment design with a low-cost pre-screening retinal and clinical measure is a promising approach, resulting in a reduction of theoretical recruitment costs for recruiting persons with significant WMH burden compared to an MRI-only design.

Background and Objectives: Acute small subcortical infarcts (SSI) result in high rates of early neurological deterioration (END) despite best medical management. Those with SSI-related END have worse functional outcomes after stroke leading to increased morbidity. Presently, it is unknown in a robust manner the incidence or risk factors for END within this demographic. The aim of this study was to perform a systematic review and meta-analysis to understand the incidence and risk factors of SSI-related END. Methods: We searched PubMed, Cochrane Library, and Google Scholar between January 1, 2000, and June 1, 2022, including both retrospective cross-sectional and prospective observational studies. The primary outcome was development of END based on publishing authors’ definition. Abstracted data included age, sex, cohort size, diagnoses of hypertension, hyperlipidemia, diabetes mellitus, study definition of END and SSI, and presence of branch atheromatous disease (BAD) and lesion diameter. Results: We identified 31 studies enrolling 6376 patients. Most studies were conducted in East Asia (27/31, 87%) and had a least some concern for risk of bias. Funnel plot illustrated a high level of publication bias favoring high incidence studies. END was commonly defined as ≥ 2 overall NIHSS change or ≥ 1 motor change within 3 to 7 days from admission (average: 5 days). A pooled proportion of END was 22% (95%CI 0.19 - 0.25, I2 = 91.2%, 31 studies). Meta-regression identified that female sex [risk ratio (RR) 1.23, 95%CI 1.09-1.39, I2=30.8%, 31 studies], diabetes mellitus (RR 1.16 95%CI 1.01-1.33, I2=38.4%, 30 studies), and BAD (RR 1.99 95%CI 1.61-2.46, I2=50.7%, 17 studies) as risk factors for END. Discussion: Our data identified primarily within an East Asian cohort that risk factors for SSI-related END include diabetes mellitus and branch atheromatous disease with a pooled prevalence of END occurring in 1 in 4 patients. Future studies are needed to understand treatment and preventative strategies for this patient population.

Introduction: The vascular contribution to Alzheimer’s disease (AD) and AD-related dementias is increasingly recognized. Scanning laser ophthalmoscopy (SLO) visualizes two important markers of cognitive dysfunction in the retina, vascular changes and amyloid plaque deposition. The relationship between retinal vascular changes and peri-vascular amyloid deposition in the continuum of neurodegeneration is imperfectly understood. In this exploratory topographic analysis of a cohort of subjects with normal and impaired cognition that underwent SLO, we investigated the retinal vascular-adjacent (para-vascular) amyloid plaque distribution and its correlation with cognitive measures. Methods: 34 subjects with cognitive decline underwent retinal SLO, brain magnetic resonance imaging and standard neuropsychometric testing. Retinal para-arteriolar and para-venular curcumin positive amyloid plaques were quantified in the supero-temporal retinal quadrant, in the first-, second- and third-order retinal vascular branches. The para-venous and para-arteriolar amyloid count were compared between patients with normal and impaired cognition, and their correlation with brain volumes and white matter hyperintensities was determined. Results: We analyzed retinal para-venous and para-arteriolar amyloid and vascular-structural parameters derived from 29 subjects, mean (SD) age 65(7), 48% female. Para-arteriolar plaque was higher than para-venular plaque in the entire cohort (p<0.0001). Secondary branch para-venular amyloid plaque count was higher in patients with impaired cognition, CDR ≥1 and MOCA ≤26. The para-arterial plaque count in the secondary branches significantly correlated with hippocampal volume and white matter hyperintensities scores. Conclusion: Our topographic analysis of the amyloid plaque distribution in retinal para-vascular regions shows higher amyloid accumulation in the para-arteriolar regions overall, and specifically in the secondary para-venular branches in patients with impaired cognition. Larger longitudinal studies are needed to study the temporal and spatial relationship between vascular dysfunction and para-vascular amyloid deposition in AD.

Introduction: The outcomes of mechanical thrombectomy (MT) for patients with acute ischemic stroke (AIS) caused by medium vessel occlusions (MeVOs) in different vessels remains unknown. The aim of this study is to investigate MT outcomes in AIS patients with isolated MeVOs in different occluded vessel segments using the data from an ongoing international multicenter registry, the Stroke Thrombectomy and Aneurysm Registry (STAR). The aim of this study is to investigate MT outcomes in AIS patients with isolated MeVOs in different occluded vessel segments using the data from an ongoing international multicenter registry, the Stroke Thrombectomy and Aneurysm Registry (STAR). Methods: 110 AIS patients with MeVO who undertook MT between January 2010 and December 2022 were retrospectively investigated. MeVO was defined as isolated occlusion of the A2 or A3 (A23O) segment of the anterior cerebral artery, M3 segment of the middle cerebral artery (M3O), and P2 or P3 segment of the posterior cerebral artery (P23O). The primary outcome measure was a 90-day modified Rankin score (mRS) 0-2. The 90-day mRS 0-1, any intracranial hemorrhage, symptomatic intracranial hemorrhage, and 90-day mortality were used as secondary outcomes. Outcomes were compared between A23O, M3O, and P23O. Results: Median (interquartile range) age was 68.3 (58.4-76.0) years and 49 patients were female (46.7%). MeVO included 17 A23O (15.5%), 60 M3O (54.5%), and 33 P23O (30.0%).Compared to patients with A23O (17.7%), those with M3O (56.7%) and P23O (45.5%) had a higher proportion of 90-day mRS 0-2 (M3O, adjusted odds ratio 10.3, 95% confidence interval 1.71-62.2, p = 0.01; P23O adjusted odds ratio 8.86, 95% confidence interval 1.32-59.3, p =0.02). Other outcomes showed no significant differences. Conclusions: This study indicates A2O might be related to poorer outcomes compared to M3O and P23 in MT treatment for AIS patients due to isolated MeVO. Efforts should be aimed at improving outcomes following A23O to match those at other MeVO locations.

Background: Mechanical thrombectomy (MT) has significantly reduced morbidity and mortality in acute ischemic stroke (AIS). This study aims to analyze the outcomes and factors associated with decompressive hemicraniectomy (DHC) in AIS patients who underwent MT. Methods: We retrospectively analyzed data from an ongoing, multicenter database to investigate AIS patients who underwent MT for ICA, M1, or M2 occlusion. We compared clinical and procedural variables between patients who underwent DHC and those who did not. Propensity score (PS) matching between the two groups was conducted using age, sex, admission NIHSS, occluded vessel, ASPECTS, time from symptoms onset to arterial puncture, intracranial hemorrhage (ICH), and symptomatic ICH (sICH). Results: Among the 3,135 MT patients who met our inclusion criteria, 113 underwent DHC. A 1:3 propensity matching yielded a well-matched cohort of 113 in the DHC group versus 339 in the non-DHC group. The DHC group had a significantly higher rate of successful recanalization (mTICI ≥ 2C) (175 [51.6%] versus 36 [31.9%], P < 0.001) and a longer procedure duration, with a median of 30 minutes (IQR: 17-54) compared to 44 minutes (IQR: 25-78) in the non-DHC group (P = <0.001). Further comparison of patients with low ASPECTS (≤ 5) who underwent DHC (n = 36) with those who did not (n = 99) showed no significant difference in successful recanalization rates (15 [41.7%] versus 43 [43.4%], P > 0.90). However, procedure duration was significantly longer in the DHC group with a median of 29 minutes (IQR: 13-52), compared to 39 minutes (IQR: 27-86) in the non-DHC group (P = 0.02). Conclusions: Successful recanalization can help in preventing DHC in AIS patients with high ASPECTS, but not those with low ASPECTS. Procedure duration is independently related to DHC following MT, especially in low ASPECTS patients.