Blood Pressure Trajectory Groups and Outcome After Endovascular Thrombectomy: A Multicenter Study.

BACKGROUND: Elevated blood pressure after endovascular thrombectomy (EVT) has been associated with an increased risk of hemorrhagic transformation and poor functional outcomes. However, the optimal hemodynamic management after EVT remains unknown, and the blood pressure course in the acute phase of ischemic stroke has not been well characterized. This study aimed to identify patient subgroups with distinct blood pressure trajectories after EVT and study their association with radiographic and functional outcomes. METHODS: This multicenter retrospective cohort study included consecutive patients with anterior circulation large-vessel occlusion ischemic stroke who underwent EVT. Repeated time-stamped blood pressure data were recorded for the first 72 hours after thrombectomy. Latent variable mixture modeling was used to separate subjects into five groups with distinct postprocedural systolic blood pressure (SBP) trajectories. The primary outcome was functional status, measured on the modified Rankin Scale 90 days after stroke. Secondary outcomes included hemorrhagic transformation, symptomatic intracranial hemorrhage, and death. RESULTS: Two thousand two hundred sixty-eight patients (mean age [±SD] 69±15, mean National Institutes of Health Stroke Scale 15±7) were included in the analysis. Five distinct SBP trajectories were observed: low (18%), moderate (37%), moderate-to-high (20%), high-to-moderate (18%), and high (6%). SBP trajectory group was independently associated with functional outcome at 90 days (P<0.0001) after adjusting for potential confounders. Patients with high and high-to-moderate SBP trajectories had significantly greater odds of an unfavorable outcome (adjusted odds ratio, 3.5 [95% CI, 1.8-6.7], P=0.0003 and adjusted odds ratio, 2.2 [95% CI, 1.5-3.2], P<0.0001, respectively). Subjects in the high-to-moderate group had an increased risk of symptomatic intracranial hemorrhage (adjusted odds ratio, 1.82 [95% CI, 1-3.2]; P=0.04). No significant association was found between trajectory group and hemorrhagic transformation. CONCLUSIONS: Patients with acute ischemic stroke demonstrate distinct SBP trajectories during the first 72 hours after EVT that have differing associations with functional outcome. These findings may help identify potential candidates for future blood pressure modulation trials.

What is the added value of CT-angiography in patients with transient ischemic attack?

BACKGROUND: Transient ischemic attack (TIA) is an important predictor for a pending stroke. Guidelines recommend a workup for TIA-patients similar to that of stroke patients, including an assessment of the extra- and intracranial arteries for vascular pathologies with direct therapeutic implications via computed tomography angiography (CTA). Aim of our study was a systematic analysis of TIA-patients receiving early CTA-imaging and to evaluate the predictive value of TIA-scores and clinical characteristics for ipsilateral vascular pathologies and the need of an invasive treatment. METHODS: We analysed clinical and imaging data from TIA patients being admitted to a tertiary university hospital between September 2015 and March 2018. Following subgroups were identified: 1) no- or low-grade vascular pathology 2) ipsilateral high-risk vascular pathology and 3) high-risk findings that needed invasive, surgical or interventional treatment. We investigated established TIA-scores (ABCD2-, the ABCD3- and the SPI-II score) and various clinical characteristics as predictive factors for ipsilateral vascular pathologies and the need for invasive treatment. RESULTS: Of 812 patients, 531 (65.4%) underwent initial CTA in the emergency department. In 121 (22.8%) patients, ipsilateral vascular pathologies were identified, of which 36 (6.7%) needed invasive treatment. The ABCD2-, ABCD3- and SPI-II-scores were not predictive for ipsilateral vascular pathologies or the need for invasive treatment. We identified male sex (OR 1.579, 95%CI 1.049-2.377, p = 0.029), a short duration of symptoms (OR 0.692, 95% CI 0.542-0.884, p = 0.003), arterial hypertension (OR 1.718, 95%CI 0.951-3.104, p = 0.073) and coronary heart disease (OR 1.916, 95%CI 1.184-3.101, p = 0.008) as predictors for ipsilateral vascular pathologies. As predictors for the need of invasive treatment, a short duration of symptoms (OR 0.565, 95%CI 0.378-0.846, p = 0.006), arterial hypertension (OR 2.612, 95%OR 0.895-7.621, p = 0.079) and hyperlipidaemia (OR 5.681, 95%CI 0.766-42.117, p = 0.089) as well as the absence of atrial fibrillation (OR 0.274, OR 0.082-0.917, p = 0.036) were identified. CONCLUSION: More than every fifth TIA-patient had relevant vascular findings revealed by acute CTA. TIA-scores were not predictive for these findings. Patients with a short duration of symptoms and a vascular risk profile including coronary heart disease, arterial hypertension and hyperlipidaemia most likely might benefit from early CTA to streamline further diagnostics and therapy.

Blood Pressure Goals and Clinical Outcomes after Successful Endovascular Therapy: A Multicenter Study.

OBJECTIVE: Elevated systolic blood pressure (SBP) after successful revascularization (SR) via endovascular therapy (EVT) is a known predictor of poor outcome. However, the optimal SBP goal following EVT is still unknown. Our objective was to compare functional and safety outcomes between different SBP goals after EVT with SR. METHODS: This international multicenter study included 8 comprehensive stroke centers and patients with anterior circulation large vessel occlusion who were treated with EVT and achieved SR. SR was defined as modified thrombolysis in cerebral ischemia 2b to 3. Patients were divided into 3 groups based on SBP goal in the first 24 hours after EVT. Inverse probability of treatment weighting (IPTW) propensity analysis was used to assess the effect of different SBP goals on clinical outcomes. RESULTS: A total of 1,019 patients were included. On IPTW analysis, the SBP goal of <140mmHg was associated with a higher likelihood of good functional outcome and lower odds of hemicraniectomy compared to SBP goal of <180mmHg. Similarly, SBP goal of <160mmHg was associated with lower odds of mortality compared to SBP goal of <180mmHg. In subgroup analysis including only patients with pre-EVT SBP of ≥140mmHg, an SBP of <140mmHg was associated with a higher likelihood of good functional outcome, lower odds of symptomatic intracranial hemorrhage, and lower odds of requirement for hemicraniectomy compared to SBP goal of <180mmHg. INTERPRETATION: SBP goals of <140 and < 160mmHg following SR with EVT appear to be associated with better clinical outcomes than SBP of <180mmHg. ANN NEUROL 2020;87:830-839.

Blood Pressure and Outcome After Mechanical Thrombectomy With Successful Revascularization.

Background and Purpose- Successful reperfusion can be achieved in more than two-thirds of patients treated with mechanical thrombectomy. Therefore, it is important to understand the effect of blood pressure (BP) on clinical outcomes after successful reperfusion. In this study, we investigated the relationship between BP on admission and during the first 24 hours after successful reperfusion with clinical outcomes. Methods- This was a multicenter study from 10 comprehensive stroke centers. To ensure homogeneity of the studied cohort, we included only patients with anterior circulation who achieved successful recanalization at the end of procedure. Clinical outcomes included 90-day modified Rankin Scale, symptomatic intracerebral hemorrhage (sICH), mortality, and hemicraniectomy. Results- A total of 1245 patients were included in the study. Mean age was 69±14 years, and 51% of patients were female. Forty-nine percent of patients had good functional outcome at 90-days, and 4.7% suffered sICH. Admission systolic BP (SBP), mean SBP, maximum SBP, SBP SD, and SBP range were associated with higher risk of sICH. In addition, patients in the higher mean SBP groups had higher rates of sICH. Similar results were found for hemicraniectomy. With respect to functional outcome, mean SBP, maximum SBP, and SBP range were inversely associated with the good outcome (modified Rankin Scale score, 0-2). However, the difference in SBP parameters between the poor and good outcome groups was modest. Conclusions- Higher BP within the first 24 hours after successful mechanical thrombectomy was associated with a higher likelihood of sICH, mortality, and requiring hemicraniectomy.

High Systolic Blood Pressure after Successful Endovascular Treatment Affects Early Functional Outcome in Acute Ischemic Stroke.

BACKGROUND: Endovascular treatment (EVT) has been shown to significantly improve functional outcome in patients with acute large cerebral vessel occlusions. To date, no evidence-based recommendations on blood pressure management after successful EVT exist. Previous studies showed an association between high pre-EVT systolic blood pressure (SBP) and functional outcome, but do not answer the question on how to manage blood pressure after successful recanalization. The purpose of this study was to determine the role of blood pressure measurements as a predictor for early functional outcome in patients with successful EVT. METHODS: Prospectively derived data from patients with acute large vessel occlusion within the anterior circulation and EVT was analyzed in this monocentric study. Mean systolic- and maximum SBP as well as SBP-peaks have been obtained for the first 24 h after successful EVT. Predictive value of SBP for discharge modified Rankin Scale (mRS) ≤2 has been investigated using logistic regression models. RESULTS: From 168 patients with successful EVT, 74 (44%) had a favorable outcome with an mRS ≤2. Mean- (127 vs. 131 mm Hg, p = 0.035) and maximum SBP (157 vs. 169 mm Hg, p < 0.001) as well as the number of SBP-peaks (0 vs. 1.5, p = 0.004) were lower in patients with favorable outcomes. Multivariable logistic regression showed high mean- and maximum SBP to predict unfavorable outcomes. Cutoff mean SBP was 141 mm Hg and maximum SBP 159 mm Hg. CONCLUSIONS: High SBP in the first 24 h after recanalization of acute anterior cerebral vessel occlusions is associated with unfavorable functional outcome. Interventional studies are needed to determine the role of SBP management as a modifiable parameter in the early phase after successful EVT.

One-Stop Management of Acute Stroke Patients: Minimizing Door-to-Reperfusion Times.

BACKGROUND AND PURPOSE: Intrahospital time delays significantly affect the neurological outcome of stroke patients with large-vessel occlusion. This study was conducted to determine whether a one-stop management can reduce intrahospital times of patients with acute large-vessel occlusion. METHODS: In this observational study, we report the first 30 consecutive stroke patients imaged and treated in the same room. As part of our protocol, we transported patients with a National Institutes of Health Stroke Scale score of ≥10 directly to the angio suite, bypassing multidetector computed tomography (CT). Preinterventional imaging consisted of noncontrast flat detector CT and flat detector CT angiography, acquired with an angiography system. Patients with large-vessel occlusions remained on the angio table and were treated with mechanical thrombectomy; patients with small artery occlusions were treated with intravenous thrombolysis, whereas patients with an intracranial hemorrhage and stroke mimics were treated as per guidelines. Door-to-groin puncture times were recorded and compared with our past results. RESULTS: Thirty patients were transferred directly to our angio suite from June to December 2016. The time from symptom onset to admission was 105 minutes. Ischemic stroke was diagnosed in 22 of 30 (73%) patients, 4 of 30 (13.5%) had an intracranial hemorrhage, and 4 of 30 (13.5) were diagnosed with a Todd's paresis. Time from admission to groin puncture was 20.5 minutes. Compared with 44 patients imaged with multidetector CT in the first 6 months of 2016, door-to-groin times were significantly reduced (54.5 minutes [95% confidence interval, 47-61] versus 20.5 minutes [95% confidence interval, 17-26]). CONCLUSIONS: In this small series, a one-stop management protocol of selected stroke patients using latest generation flat detector CT led to a significant reduction of intrahospital times.

The effect of inadvertent systemic hypothermia after mechanical thrombectomy in patients with large-vessel occlusion stroke.

Background and aims: Postinterventional hypothermia is a frequent complication in patients with large-vessel occlusion strokes (LVOS) after mechanical thrombectomy (MT). This inadvertent hypothermia might potentially have neuroprotective but also adverse effects on patients' outcomes. The aim of the study was to determine the rate of hypothermia in patients with LVOS receiving MT and its influence on functional outcome. Methods: We performed a monocentric, retrospective study using a prospectively derived databank, including all LVOS patients receiving MT between 2015 and 2021. Predictive values of postinterventional body temperature and body temperature categories (hyperthermia (≥38°C), normothermia (35°C-37.9°C), and hypothermia (<35°C)) on functional outcome were analyzed using multivariable Bayesian logistic regression models. Favorable outcome was defined as modified Rankin Scale (mRS) ≤3. Results: Of the 480 included LVOS patients with MT (46.0% men; mean ± SD age 73 ± 12.9 years), 5 (1.0%) were hyperthermic, 382 (79.6%) normothermic, and 93 (19.4%) hypothermic. Postinterventional hypothermia was significantly associated with unfavorable functional outcome (mRS > 3) after 90 days (OR 2.06, 95% CI 1.01-4.18, p = 0.045). For short-term functional outcome, patients with hypothermia had a higher discharge NIHSS (OR 1.38, 95% CI 1.06 to 1.79, p = 0.015) and a higher change of NIHSS from admission to discharge (OR 1.35, 95% CI 1.03 to 1.76, p = 0.029). Conclusion: Approximately a fifth of LVOS patients in this cohort were hypothermic after MT. Hypothermia was an independent predictor of unfavorable functional outcomes. Our findings warrant a prospective trial investigating active warming during MT.

Peri-hematomal edema shape features related to 3-month outcome in acute supratentorial intracerebral hemorrhage.

INTRODUCTION: Perihematomal edema (PHE) represents secondary brain injury and a potential treatment target in intracerebral hemorrhage (ICH). However, studies differ on optimal PHE volume metrics as prognostic factor(s) after spontaneous, non-traumatic ICH. This study examines associations of baseline and 24-h PHE shape features with 3-month outcomes. PATIENTS AND METHODS: We included 796 patients from a multicentric trial dataset and manually segmented ICH and PHE on baseline and follow-up CTs, extracting 14 shape features. We explored the association of baseline, follow-up, difference (baseline/follow-up) and temporal rate (difference/time gap) of PHE shape changes with 3-month modified Rankin Score (mRS) - using Spearman correlation. Then, using multivariable analysis, we determined if PHE shape features independently predict outcome adjusting for patients' age, sex, NIH stroke scale (NIHSS), Glasgow Coma Scale (GCS), and hematoma volume. RESULTS: Baseline PHE maximum diameters across various planes, main axes, volume, surface, and sphericity correlated with 3-month mRS adjusting for multiple comparisons. The 24-h difference and temporal change rates of these features had significant association with outcome - but not the 24-h absolute values. In multivariable regression, baseline PHE shape sphericity (OR = 2.04, CI = 1.71-2.43) and volume (OR = 0.99, CI = 0. 98-1.0), alongside admission NIHSS (OR = 0.86, CI = 0.83-0.88), hematoma volume (OR = 0.99, CI = 0. 99-1.0), and age (OR = 0.96, CI = 0.95-0.97) were independent predictors of favorable outcomes. CONCLUSION: In acute ICH patients, PHE shape sphericity at baseline emerged as an independent prognostic factor, with a less spherical (more irregular) shape associated with worse outcome. The PHE shape features absolute values over the first 24 h provide no added prognostic value to baseline metrics.

Association between blood pressure variability and outcomes after endovascular thrombectomy for acute ischemic stroke: An individual patient data meta-analysis.

INTRODUCTION: Data on the association between blood pressure variability (BPV) after endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) and outcomes are limited. We sought to identify whether BPV within the first 24 hours post EVT was associated with key stroke outcomes. METHODS: We combined individual patient-data from five studies among AIS-patients who underwent EVT, that provided individual BP measurements after the end of the procedure. BPV was estimated as either systolic-BP (SBP) standard deviation (SD) or coefficient of variation (CV) over 24 h post-EVT. We used a logistic mixed-effects model to estimate the association [expressed as adjusted odds ratios (aOR)] between tertiles of BPV and outcomes of 90-day mortality, 90-day death or disability [modified Rankin Scale-score (mRS) > 2], 90-day functional impairment (⩾1-point increase across all mRS-scores), and symptomatic intracranial hemorrhage (sICH), adjusting for age, sex, stroke severity, co-morbidities, pretreatment with intravenous thrombolysis, successful recanalization, and mean SBP and diastolic-BP levels within the first 24 hours post EVT. RESULTS: There were 2640 AIS-patients included in the analysis. The highest tertile of SBP-SD was associated with higher 90-day mortality (aOR:1.44;95% CI:1.08-1.92), 90-day death or disability (aOR:1.49;95% CI:1.18-1.89), and 90-day functional impairment (adjusted common OR:1.42;95% CI:1.18-1.72), but not with sICH (aOR:1.22;95% CI:0.76-1.98). Similarly, the highest tertile of SBP-CV was associated with higher 90-day mortality (aOR:1.33;95% CI:1.01-1.74), 90-day death or disability (aOR:1.50;95% CI:1.19-1.89), and 90-day functional impairment (adjusted common OR:1.38;95% CI:1.15-1.65), but not with sICH (aOR:1.33;95% CI:0.83-2.14). CONCLUSIONS: BPV after EVT appears to be associated with higher mortality and disability, independently of mean BP levels within the first 24 h post EVT. BPV in the first 24 h may be a novel target to improve outcomes after EVT for AIS.

Blood Pressure Trajectories and Outcomes After Endovascular Thrombectomy for Acute Ischemic Stroke.

BACKGROUND: Data on systolic blood pressure (SBP) trajectories in the first 24 hours after endovascular thrombectomy (EVT) in acute ischemic stroke are limited. We sought to identify these trajectories and their relationship to outcomes. METHODS: We combined individual-level data from 5 studies of patients with acute ischemic stroke who underwent EVT and had individual blood pressure values after the end of the procedure. We used group-based trajectory analysis to identify the number and shape of SBP trajectories post-EVT. We used mixed effects regression models to identify associations between trajectory groups and outcomes adjusting for potential confounders and reported the respective adjusted odds ratios (aORs) and common odds ratios. RESULTS: There were 2640 total patients with acute ischemic stroke included in the analysis. The most parsimonious model identified 4 distinct SBP trajectories, that is, general directional patterns after repeated SBP measurements: high, moderate-high, moderate, and low. Patients in the higher blood pressure trajectory groups were older, had a higher prevalence of vascular risk factors, presented with more severe stroke syndromes, and were less likely to achieve successful recanalization after the EVT. In the adjusted analyses, only patients in the high-SBP trajectory were found to have significantly higher odds of early neurological deterioration (aOR, 1.84 [95% CI, 1.20-2.82]), intracranial hemorrhage (aOR, 1.84 [95% CI, 1.31-2.59]), mortality (aOR, 1.75 [95% CI, 1.21-2.53), death or disability (aOR, 1.63 [95% CI, 1.15-2.31]), and worse functional outcomes (adjusted common odds ratio,1.92 [95% CI, 1.47-2.50]). CONCLUSIONS: Patients follow distinct SBP trajectories in the first 24 hours after an EVT. Persistently elevated SBP after the procedure is associated with unfavorable short-term and long-term outcomes.

Impact of Procedure Time on First Pass Effect in Mechanical Thrombectomy for Anterior Circulation Acute Ischemic Stroke.

BACKGROUND AND OBJECTIVES: First pass effect (FPE) is a metric increasingly used to determine the success of mechanical thrombectomy (MT) procedures. However, few studies have investigated whether the duration of the procedure can modify the clinical benefit of FPE. We sought to determine whether FPE after MT for anterior circulation large vessel occlusion acute ischemic stroke is modified by procedural time (PT). METHODS: A multicenter, international data set was retrospectively analyzed for anterior circulation large vessel occlusion acute ischemic stroke treated by MT who achieved excellent reperfusion (thrombolysis in cerebral infarction 2c/3). The primary outcome was good functional outcome defined by 90-day modified Rankin scale scores of 0-2. The primary study exposure was first pass success (FPS, 1 pass vs ≥2 passes) and the secondary exposure was PT. We fit-adjusted logistic regression models and used marginal effects to assess the interaction between PT (≤30 vs >30 minutes) and FPS, adjusting for potential confounders including time from stroke presentation. RESULTS: A total of 1310 patients had excellent reperfusion. These patients were divided into 2 cohorts based on PT: ≤30 minutes (777 patients, 59.3%) and >30 minutes (533 patients, 40.7%). Good functional outcome was observed in 658 patients (50.2%). The interaction term between FPS and PT was significant ( P = .018). Individuals with FPS in ≤30 minutes had 11.5% higher adjusted predicted probability of good outcome compared with those who required ≥2 passes (58.2% vs 46.7%, P = .001). However, there was no significant difference in the adjusted predicted probability of good outcome in individuals with PT >30 minutes. This relationship appeared identical in models with PT treated as a continuous variable. CONCLUSION: FPE is modified by PT, with the added clinical benefit lost in longer procedures greater than 30 minutes. A comprehensive metric for MT procedures, namely, FPE 30 , may better represent the ideal of fast, complete reperfusion with a single pass of a thrombectomy device.

Doppler flow morphology characteristics of epiaortic arteries in aortic valve pathologies: a retrospective study on a cohort of patients with ischemic stroke.

BACKGROUND AND AIMS: Neurovascular ultrasound (nvUS) of the epiaortic arteries is an integral part of the etiologic workup in patients with ischemic stroke. Aortic valve disease shares similar vascular risk profiles and therefore not only presents a common comorbidity, but also an etiologic entity. The aim of this study is to investigate the predictive value of specific Doppler curve flow characteristics in epiaortic arteries and the presence of aortic valve disease. METHODS: Retrospective, single-center analysis of ischemic stroke patients, both receiving full nvUS of the extracranial common- (CCA), internal- (ICA) and external carotid artery (ECA) and echocardiography (TTE/TEE) during their inpatient stay. A rater blinded for the TTE/TEE results investigated Doppler flow curves for the following characteristics: 'pulsus tardus et parvus' for aortic valve stenosis (AS) and 'bisferious pulse', 'diastolic reversal', 'zero diastole' and 'no dicrotic notch' for aortic valve regurgitation (AR). Predictive value of these Doppler flow characteristics was investigated using multivariate logistic regression models. RESULTS: Of 1320 patients with complete examination of Doppler flow curves and TTE/TEE, 75 (5.7%) showed an AS and 482 (36.5%) showed an AR. Sixty-one (4.6%) patients at least showed a moderate-to-severe AS and 100 (7.6%) at least showed a moderate-to-severe AR. After adjustment for age, coronary artery disease, arterial hypertension, diabetes mellitus, smoking, peripheral arterial disease, renal failure and atrial fibrillation, the following flow pattern predicted aortic valve disease: 'pulsus tardus et parvus' in the CCA and ICA was highly predictive for a moderate-to-severe AS (OR 1158.5, 95% CI 364.2-3684.8, p < 0.001). 'No dicrotic notch' (OR 102.1, 95% CI 12.4-839.4, p < 0.001), a 'bisferious pulse' (OR 10.8, 95% CI 3.2-33.9, p < 0.001) and a 'diastolic reversal' (OR 15.4, 95% CI 3.2-74.6, p < 0.001) in the CCA and ICA predicted a moderate-to-severe AR. The inclusion of Doppler flow characteristics of the ECA did not increase predictive value. CONCLUSIONS: Well defined, qualitative Doppler flow characteristics detectable in the CCA and ICA are highly predictive for aortic valve disease. The consideration of these flow characteristics can be useful to streamline diagnostic and therapeutic measures, especially in the outpatient setting.

The effect of occlusion location and technique in mechanical thrombectomy for minor stroke.

INTRODUCTION: Endovascular mechanical thrombectomy (MT) is an established treatment for large vessel occlusion strokes with a National Institutes of Health Stroke Scale (NIHSS) score of 6 or higher. Data pertaining to minor strokes, medium, or distal vessel occlusions, and most effective MT technique is limited and controversial. METHODS: A multicenter retrospective study of all patients treated with MT presenting with NIHSS score of 5 or less at 29 comprehensive stroke centers. The cohort was dichotomized based on location of occlusion (proximal vs. distal) and divided based on MT technique (direct aspiration first-pass technique [ADAPT], stent retriever [SR], and primary combined [PC]). Outcomes at discharge and 90 days were compared between proximal and distal occlusion groups, and across MT techniques. RESULTS: The cohort included 759 patients, 34% presented with distal occlusion. Distal occlusions were more likely to present with atrial fibrillation (p = 0.008) and receive IV tPA (p = 0.001). Clinical outcomes at discharge and 90 days were comparable between proximal and distal groups. Compared to SR, patients managed with ADAPT were more likely to have a modified Rankin Scale of 0-2 at discharge and at 90 days (p = 0.024 and p = 0.013). Primary combined compared to ADAPT, prior stroke, multiple passes, older age, and longer procedure time were independently associated with worse clinical outcome, while successful recanalization was positively associated with good clinical outcomes. CONCLUSIONS: Proximal and distal occlusions with low NIHSS have comparable outcomes and safety profiles. While all MT techniques have a similar safety profile, ADAPT was associated with better clinical outcomes at discharge and 90 days.

Predictors of Angiographic Outcome After Failed Thrombectomy for Large Vessel Occlusion: Insights from the Stroke Thrombectomy and Aneurysm Registry.

BACKGROUND: Mechanical thrombectomy failure (MTF) occurs in approximately 15% of cases. OBJECTIVE: To investigate factors that predict MTF. METHODS: This was a retrospective review of prospectively collected data from the Stroke Thrombectomy and Aneurysm Registry. Patients who underwent mechanical thrombectomy (MT) for large vessel occlusion (LVO) were included. Patients were categorized by mechanical thrombectomy success (MTS) (≥mTICI 2b) or MTF (

Outcomes after endovascular mechanical thrombectomy for low compared to high National Institutes of Health Stroke Scale (NIHSS): A multicenter study.

OBJECTIVE: The role of endovascular mechanical thrombectomy (MT) in patients presenting with "minor" stroke is uncertain. We aimed to compare outcomes after MT for ischemic stroke patients presenting with National Institutes of Health Stroke Scale (NIHSS) 5 and - within the low NIHSS cohort - identify predictors of a favorable outcome, mortality, and symptomatic intracranial hemorrhage (ICH). METHODS: We retrospectively analyzed a prospectively maintained, international, multicenter database. RESULTS: The study cohort comprised a total of 7568 patients from 29 centers. NIHSS was low (<5) in 604 patients (8%), and > 5 in 6964 (92%). Patients with low NIHSS were younger (67 + 14.8 versus 69.6 + 14.7 years, p < 0.001), more likely to have diabetes (31.5% versus 26.9%, p = 0.016), and less likely to have atrial fibrillation (26.6% versus 37.6%, p < 0.001) compared to those with higher NIHSS. Radiographic outcomes (TICI > 2B 84.6% and 84.3%, p = 0.412) and complication rates (8.1% and 7.2%, p = 0.463) were similar between the low and high NIHSS groups, respectively. Clinical outcomes at every follow up interval, including NIHSS at 24 h and discharge, and mRS at discharge and 90 days, were better in the low NIHSS group, however patients in the low NIHSS group experienced a relative decline in NIHSS from admit to discharge. Mortality was lower in the low NIHSS group (10.4% versus 24.5%, p < 0.001). CONCLUSIONS: Relative to patients with high NIHSS, MT is safe and effective for stroke patients with low NIHSS, and it is reasonable to offer it to appropriately selected patients presenting with minor stroke symptoms. Our findings justify efforts towards a randomized trial comparing MT versus medical management for patients with low NIHSS.

High Periventricular T1 Relaxation Times Predict Gait Improvement After Spinal Tap in Patients with Idiopathic Normal Pressure Hydrocephalus.

PURPOSE: The diagnosis of idiopathic normal pressure hydrocephalus (iNPH) can be challenging. Aim of this study was to use a novel T1 mapping method to enrich the diagnostic work-up of patients with suspected iNPH. METHODS: Using 3T magnetic resonance imaging (MRI) we prospectively evaluated rapid high-resolution T1 mapping at 0.5 mm resolution and 4 s acquisition time in 15 patients with suspected iNPH and 8 age-matched, healthy controls. T1 mapping in axial sections of the cerebrum, clinical and neuropsychological testing were performed prior to and after cerebrospinal fluid tap test (CSF-TT). T1 relaxation times were measured in 5 predefined periventricular regions. RESULTS: All 15 patients with suspected iNPH showed gait impairment, 13 (86.6%) showed signs of cognitive impairment and 8 (53.3%) patients had urinary incontinence. Gait improvement was noted in 12 patients (80%) after CSF-TT. T1 relaxation times in all periventricular regions were elevated in patients with iNPH compared to controls with the most pronounced differences in the anterior (1006 ± 93 ms vs. 911 ± 77 ms; p = 0.023) and posterior horns (983 ± 103 ms vs. 893 ± 68 ms; p = 0.037) of the lateral ventricles. Montreal cognitive assessment (MoCA) scores at baseline were negatively correlated with T1 relaxation times (r < -0.5, p < 0.02). Higher T1 relaxation times were significantly correlated with an improvement of the 3­m timed up and go test (r > 0.6 and p < 0.03) after CSF-TT. CONCLUSION: In iNPH-patients, periventricular T1 relaxation times are increased compared to age-matched controls and predict gait improvement after CSF-TT. T1 mapping might enrich iNPH work-up and might be useful to indicate permanent shunting.

Temporal profiles of systolic blood pressure variability and neurologic outcomes after endovascular thrombectomy.

Introduction: Observational studies have found an increased risk of hemorrhagic transformation and worse functional outcomes in patients with higher systolic blood pressure variability (BPV). However, the time-varying behavior of BPV after endovascular thrombectomy (EVT) and its effects on functional outcome have not been well characterized. Patients and methods: We analyzed data from an international cohort of patients with large-vessel occlusion stroke who underwent EVT at 11 centers across North America, Europe, and Asia. Repeated time-stamped blood pressure data were recorded for the first 72 h after thrombectomy. Parameters of BPV were calculated in 12-h epochs using five established methodologies. Systolic BPV trajectories were generated using group-based trajectory modeling, which separates heterogeneous longitudinal data into groups with similar patterns. Results: Of the 2041 patients (age 69 ± 14, 51.4% male, NIHSS 15 ± 7, mean number of BP measurements 50 ± 28) included in our analysis, 1293 (63.4%) had a poor 90-day outcome (mRS ⩾ 3) or a poor discharge outcome (mRS ⩾ 3). We identified three distinct SBP trajectories: low (25%), moderate (64%), and high (11%). Compared to patients with low BPV, those in the highest trajectory group had a significantly greater risk of a poor functional outcome after adjusting for relevant confounders (OR 2.2; 95% CI 1.2-3.9; p = 0.008). In addition, patients with poor outcomes had significantly higher systolic BPV during the epochs that define the first 24 h after EVT (p < 0.001). Discussion and conclusions: Acute ischemic stroke patients demonstrate three unique systolic BPV trajectories that differ in their association with functional outcome. Further research is needed to rapidly identify individuals with high-risk BPV trajectories and to develop treatment strategies for targeting high BPV.

Predictive Factors for the Need of Tracheostomy in Patients With Large Vessel Occlusion Stroke Being Treated With Mechanical Thrombectomy.

Background: Patients with large vessel occlusion stroke (LVOS) eligible for mechanical thrombectomy (MT) are at risk for stroke- and non-stroke-related complications resulting in the need for tracheostomy (TS). Risk factors for TS have not yet been systematically investigated in this subgroup of stroke patients. Methods: Prospectively derived data from patients with LVOS and MT being treated in a large, academic neurological ICU (neuro-ICU) between 2014 and 2019 were analyzed in this single-center study. Predictive value of peri- and post-interventional factors, stroke imaging, and pre-stroke medical history were investigated for their potential to predict tracheostomy during ICU stay using logistic regression models. Results: From 635 LVOS-patients treated with MT, 40 (6.3%) underwent tracheostomy during their neuro-ICU stay. Patients receiving tracheostomy were younger [71 (62-75) vs. 77 (66-83), p < 0.001], had a higher National Institute of Health Stroke Scale (NIHSS) at baseline [18 (15-20) vs. 15 (10-19), p = 0.009] as well as higher rates of hospital acquired pneumonia (HAP) [39 (97.5%) vs. 224 (37.6%), p < 0.001], failed extubation [15 (37.5%) vs. 19 (3.2%), p < 0.001], sepsis [11 (27.5%) vs. 16 (2.7%), p < 0.001], symptomatic intracerebral hemorrhage [5 (12.5%) vs. 22 (3.9%), p = 0.026] and decompressive hemicraniectomy (DH) [19 (51.4%) vs. 21 (3.8%), p < 0.001]. In multivariate logistic regression analysis, HAP (OR 21.26 (CI 2.76-163.56), p = 0.003], Sepsis [OR 5.39 (1.71-16.91), p = 0.004], failed extubation [OR 8.41 (3.09-22.93), p < 0.001] and DH [OR 9.94 (3.92-25.21), p < 0.001] remained as strongest predictors for TS. Patients with longer periods from admission to TS had longer ICU length of stay (r = 0.384, p = 0.03). There was no association between the time from admission to TS and clinical outcome (NIHSS at discharge: r = 0.125, p = 0.461; mRS at 90 days: r = -0.179, p = 0.403). Conclusions: Patients with LVOS undergoing MT are at high risk to require TS if extubation after the intervention fails, DH is needed, and severe infectious complications occur in the acute phase after ischemic stroke. These factors are likely to be useful for the indication and timing of TS to reduce overall sedation and shorten ICU length of stay.

Inhouse Bridging Thrombolysis Is Associated With Improved Functional Outcome in Patients With Large Vessel Occlusion Stroke: Findings From the German Stroke Registry.

Background: Endovascular treatment (EVT) for large vessel occlusion stroke (LVOS) is highly effective. To date, it remains controversial if intravenous thrombolysis (IVT) prior to EVT is superior compared with EVT alone. The aim of our study was to specifically address the question, whether bridging IVT directly prior to EVT has additional positive effects on reperfusion times, successful reperfusion, and functional outcomes compared with EVT alone. Methods: Patients with LVOS in the anterior circulation eligible for EVT with and without prior IVT and direct admission to endovascular centers (mothership) were included in this multicentric, retrospective study. Patient data was derived from the German Stroke Registry (an open, multicenter, and prospective observational study). Outcome parameters included groin-to-reperfusion time, successful reperfusion [defined as a Thrombolysis in Cerebral Infarction (TICI) scale 2b-3], change in National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), and mortality at 90 days. Results: Of the 881 included mothership patients with anterior circulation LVOS, 486 (55.2%) received bridging therapy with i.v.-rtPA prior to EVT, and 395 (44.8%) received EVT alone. Adjusted, multivariate linear mixed effect models revealed no difference in groin-to-reperfusion time between the groups (48 ± 36 vs. 49 ± 34 min; p = 0.299). Rates of successful reperfusion (TICI ≥ 2b) were higher in patients with bridging IVT (fixed effects estimate 0.410, 95% CI, 0.070; 0.750, p = 0.018). There was a trend toward a higher improvement in the NIHSS during hospitalization [ΔNIHSS: bridging-IVT group 8 (IQR, 9.8) vs. 4 (IQR 11) points in the EVT alone group; fixed effects estimate 1.370, 95% CI, -0.490; 3.240, p = 0.149]. mRS at 90 days follow-up was lower in the bridging IVT group [3 (IQR, 4) vs. 4 (IQR, 4); fixed effects estimate -0.350, 95% CI, -0.680; -0.010, p = 0.041]. There was a non-significantly lower 90 day mortality in the bridging IVT group compared with the EVT alone group (22.4% vs. 33.6%; fixed effects estimate 0.980, 95% CI -0.610; 2.580, p = 0.351). Rates of any intracerebral hemorrhage did not differ between both groups (4.1% vs. 3.8%, p = 0.864). Conclusions: This study provides evidence that bridging IVT might improve rates of successful reperfusion and long-term functional outcome in mothership patients with anterior circulation LVOS eligible for EVT.

Bridging therapy is associated with improved cognitive function after large vessel occlusion stroke - an analysis of the German Stroke Registry.

BACKGROUND: The targeted use of endovascular therapy (EVT), with or without intravenous thrombolysis (IVT) in acute large cerebral vessel occlusion stroke (LVOS) has been proven to be superior compared to IVT alone. Despite favorable functional outcome, many patients complain about cognitive decline after EVT. If IVT in addition to EVT has positive effects on cognitive function is unclear. METHODS: We analyzed data from the German Stroke Registry (GSR, an open, multicenter and prospective observational study) and compared cognitive function 90 days after index ischemic stroke using MoCA in patients with independent (mRS ≤ 2 pts) and excellent (mRS = 0 pts) functional outcome receiving combined EVT and IVT (EVT + IVT) vs. EVT alone (EVT-IVT). RESULTS: Of the 2636 GSR patients, we included 166 patients with mRS ≤ 2 at 90 days in our analysis. Of these, 103 patients (62%) received EVT + IVT, 63 patients (38%) were treated with EVT alone. There was no difference in reperfusion status between groups (mTICI ≥ 2b in both groups at 95%, p = 0.65). Median MoCA score in the EVT + IVT group was 20 pts. (18-25 IQR) vs. 18 pts. (16-21 IQR) in the EVT-IVT group (p = 0.014). There were more patients with cognitive impairment (defined as MoCA < 26 pts) in the EVT-IVT group (54 patients (86%)) compared to the EVT + IVT group (78 patients (76%)). EVT + IVT was associated with a higher MoCA score at 90 days (mRS ≤ 2: p = 0.033, B = 2.39; mRS = 0: p = 0.021, B = 4.38). CONCLUSIONS: In Patients with good functional outcome after LVOS, rates of cognitive impairment are lower with combined EVT and IVT compared to EVT alone. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03356392.