Trial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct.

BACKGROUND: The role of endovascular therapy for acute stroke with a large infarction has not been extensively studied in differing populations. METHODS: We conducted a multicenter, prospective, open-label, randomized trial in China involving patients with acute large-vessel occlusion in the anterior circulation and an Alberta Stroke Program Early Computed Tomography Score of 3 to 5 (range, 0 to 10, with lower values indicating larger infarction) or an infarct-core volume of 70 to 100 ml. Patients were randomly assigned in a 1:1 ratio within 24 hours from the time they were last known to be well to undergo endovascular therapy and receive medical management or to receive medical management alone. The primary outcome was the score on the modified Rankin scale at 90 days (scores range from 0 to 6, with higher scores indicating greater disability), and the primary objective was to determine whether a shift in the distribution of the scores on the modified Rankin scale at 90 days had occurred between the two groups. Secondary outcomes included scores of 0 to 2 and 0 to 3 on the modified Rankin scale. The primary safety outcome was symptomatic intracranial hemorrhage within 48 hours after randomization. RESULTS: A total of 456 patients were enrolled; 231 were assigned to the endovascular-therapy group and 225 to the medical-management group. Approximately 28% of the patients in both groups received intravenous thrombolysis. The trial was stopped early owing to the efficacy of endovascular therapy after the second interim analysis. At 90 days, a shift in the distribution of scores on the modified Rankin scale toward better outcomes was observed in favor of endovascular therapy over medical management alone (generalized odds ratio, 1.37; 95% confidence interval, 1.11 to 1.69; P = 0.004). Symptomatic intracranial hemorrhage occurred in 14 of 230 patients (6.1%) in the endovascular-therapy group and in 6 of 225 patients (2.7%) in the medical-management group; any intracranial hemorrhage occurred in 113 (49.1%) and 39 (17.3%), respectively. Results for the secondary outcomes generally supported those of the primary analysis. CONCLUSIONS: In a trial conducted in China, patients with large cerebral infarctions had better outcomes with endovascular therapy administered within 24 hours than with medical management alone but had more intracranial hemorrhages. (Funded by Covidien Healthcare International Trading [Shanghai] and others; ANGEL-ASPECT ClinicalTrials.gov number, NCT04551664.).

Risk factors for decompressive craniectomy after endovascular treatment in acute ischemic stroke.

Endovascular treatment (EVT) is safe and effective for acute ischemic stroke (AIS) caused by large artery occlusion in the anterior circulation. However, some patients require decompressive craniectomy (DC), despite having undergone a timely EVT. This study aimed to evaluate the risk factors for subsequent DC after EVT. This retrospective cohort study comprised 138 patients who received EVT between April 2015 and June 2019 at our center. The need for subsequent DC was defined as cerebral edema or/and hemorrhagic transformation caused by large ischemic infarction, with a ≥ 5-mm midline shift and clinical deterioration after EVT. The relationship between risk factors and DC after EVT was assessed via univariate and multivariable logistic regression. Thirty (21.7%) patients required DC. These patients tended to have atrial fibrillation (P = 0.037), sedation (P = 0.049), mechanical ventilation (P = 0.008), poorer collateral circulation (P = 0.003), a higher baseline National Institutes of Health Stroke Scale (NIHSS) score (P < 0.001), heavier thrombus burden (P < 0.001), a lower baseline Alberta Stroke Program Early Computed Tomography Score (ASPECTS) (P < 0.001), and unsuccessful recanalization (P < 0.001). In the multivariate analysis, higher baseline NIHSS score [odds ratio (OR), 1.17; 95% confidence interval (CI), 1.03-1.32], heavier thrombus burden [OR, 1.35; 95% CI, 1.02-1.79], baseline ASPECTS ≤ 8 [OR, 7.41; 95% CI, 2.43-22.66], and unsuccessful recanalization [OR, 7.49; 95% CI, 2.13-26.36] were independent risk factors for DC after EVT. DC remains an essential treatment for some AIS patients after EVT, especially those with higher baseline NIHSS scores, heavier thrombus burden, baseline ASPECTS ≤ 8, and unsuccessful recanalization.

Aspiration Thrombectomy Versus Stent-Retriever Thrombectomy for the First-Pass Therapy of Intracranial Atherosclerosis-Related Large Vessel Occlusion: A Post Hoc Analysis of The Endovascular Treatment With Versus Without Tirofiban for Patients with Large Vessel Occlusion Stroke Trial.

BACKGROUND: This study sought to scrutinize the clinical outcomes associated with first-pass mechanical thrombectomy strategies in the management of intracranial atherosclerosis (ICAS)-related large vessel occlusion (LVO). METHODS: Within this post-hoc analysis of the The Endovascular Treatment With vs Without Tirofiban for Patients with Large Vessel Occlusion Stroke (RESCUE BT) trial, we compared data pertaining to patients with ICAS-LVO situated in the anterior circulation who underwent initial therapeutic interventions utilizing either aspiration thrombectomy or stent-retriever thrombectomy. The analysis encompassed the assessment of intraprocedural recanalization, rescue procedures involving balloon angioplasty or stenting, 48-hour reocclusion rates, occurrences of cerebral hemorrhagic complications, and 90-day Modified Rankin Scale scores. RESULTS: Among the 948 patients encompassed in the RESCUE BT trial, a total of 230 patients with ICAS-LVO in the anterior circulation were enrolled in the study. Of these, 111 underwent aspiration thrombectomy as the first-pass therapy, while 119 patients underwent stent-retriever thrombectomy as the initial intervention. The difference in first pass recanalization rates between aspiration thrombectomy and stent-retriever thrombectomy was not statistically significant (17.1% vs. 14.3%, P = 0.555), and mechanical thrombectomy success rates (90.1% vs. 90.8%, P = 0.864), the use of balloon angioplasty or stenting for rescue therapy (54.6% vs. 45.9%, P = 0.189; 23.4% vs. 25.2%, P = 0.752), and favorable 90-day Modified Rankin Scale outcomes (53.2% vs. 40.3%, P = 0.051) showed no statistically significant differences. CONCLUSIONS: Both aspiration thrombectomy and stent-retriever thrombectomy can be considered as primary therapeutic options for patients presenting with ICAS-LVO in the anterior circulation.

Clinical use of a neuronavigation system in hemangioblastoma resection of posterior cranial fossa.

The aim of this study was to retrospectively evaluate the effectiveness of the Stryker Leibinger neuronavigation system in surgical resection of hemangioblastomas of the posterior fossa. The study included 16 cases of solid hemangioblastoma of posterior cranial fossa treated since we began using Stryker Leibinger neuronavigation system-assisted microneurosurgery in 2003. These cases were compared on the basis of time, blood loss, and complications to 19 similar cases of solid hemangioblastoma that underwent conventional microneurosurgical resection prior to 2003. All patients in the experimental (neuronavigation-assisted) group underwent surgical resection without complications while the control groups' resections all involved blood loss related to the longer operation time. Neuronavigation also resulted in a clear field of surgical vision and clear lesion boundaries, making it easier to remove lesions and reduce accidental injury of adjacent normal structures. The application of navigation technology is very valuable for solid hemangioblastoma operations not only by shortening operative time, thereby significantly reducing operative blood loss, but also by making surgical excision easier, reducing damage to adjacent normal structures, and decreasing surgical complications and mortality.

Predictors of unfavorable outcome in stent-assisted coiling for symptomatic unruptured intracranial spontaneous vertebral artery dissecting aneurysms (uis-VADAs): results from a multicenter study.

OBJECTIVE: To evaluate predictors of unfavorable outcome in stent-assisted coiling for symptomatic unruptured intracranial spontaneous vertebral artery dissecting aneurysms (uis-VADAs) based on 608 reconstructed lesions in 30 medical centres. METHODS: A total of 608 patients (male:female=479:129; mean age, 53.26±10.26 years) with 608 symptomatic uis-VADAs underwent reconstructive treatments using stent(s) with coils between January 2009 and December 2015. Treatments and predictors of unfavorable outcomes were retrospectively analyzed. RESULTS: Mainly, three methods were used to treat patients with uis-VADAs, including routine single-stent in 208 patients (such as Enterprise and others), new low-profile LVIS single stent in 107 patients, and multiple stents in 293 patients. During the median 66 months of clinical follow-up, 14 patients died, and 16 of the remaining 594 survivors had unfavorable outcomes (modified Rankin Scale score 3-5). The overall mortality rate was 2.3% (14/608), and the unfavorable outcome (mRS score 3-6) rate was 4.9% (30/608). Multivariate logistic regression analysis indicated that preprocedural ischemic infarctions (OR=3.78; 95% CI 1.52 to 9.40; p<0.01), diabetes mellitus (OR=3.74; 95% CI 1.31 to 10.68; p=0.01), and procedural complications (OR=14.18; 95% CI 5.47 to 36.80; p<0.01) were predictors of unfavorable outcome in the reconstructed VADAs. CONCLUSIONS: This multicenter study indicated that preprocedural ischemic infarctions, diabetes mellitus, and procedural complications were related to unfavorable clinical outcomes in the reconstructed uis-VADAs.

Thirty-Day Outcomes of the Enterprise Stent in Treating Hypoperfusion of Symptomatic Intracranial Stenosis.

OBJECTIVE: To evaluate the 30-day outcomes of using the Enterprise stent to treat patients with hypoperfusion of symptomatic severe intracranial stenosis. METHODS: Patients with symptomatic severe intracranial stenosis (70%-99%) who underwent Enterprise stent intervention between August 2014 and November 2018 were retrospectively analyzed. The 30-day primary outcomes included the success rate of stenting and the incidence of complications, including ischemic stroke, cerebral hemorrhage, and death. The 30-day complication rates of patients with different lesion locations and classifications of Mori morphology were compared. RESULTS: Sixty-eight patients were treated using 70 Enterprise stents. The success rate was 100%. The 30-day complication rate was 4.4%. The rates of ischemic stroke, cerebral hemorrhage, and death were 1.5%, 2.9%, and 0%, respectively. No significant difference was found in the 30-day complication rate between patients with different lesion locations and classifications of Mori morphology (P > 0.05). CONCLUSION: Enterprise stents were relatively safe in treating patients with hypoperfusion of symptomatic severe intracranial stenosis.

Paradoxical Herniation after Unilateral Decompressive Craniectomy: A Retrospective Analysis of Clinical Characteristics and Effectiveness of Therapeutic Measures.

AIM: We aimed to investigate the importance of early diagnosis and proper management of paradoxical herniation based on the data of 13 patients who had 14 occurrences of paradoxical herniation. MATERIAL AND METHODS: The characteristics and the effectiveness of treatments of 13 patients with paradoxical herniation were reviewed and analyzed retrospectively. RESULTS: Paradoxical herniation occurred in eight patients (61.54%) during the postoperative 2 weeks and they presented with typical symptoms of brain herniation and a tense skin flap without sinking at the region of decompressive craniectomy. On the other hand, six patients developed paradoxical herniation in the postoperative period of 2 weeks to 2 months and presented with sinking skin flaps and delayed neurological deficits. Furthermore, all patients received emergency treatments, including sufficient hydration, clamping cerebrospinal fluid (CSF) drainage, and being placed in the Trendelenburg position. Six patients achieved full neurologic recovery after successful cranioplasty. CONCLUSION: Intracranial hypotension causing paradoxical herniation can rapidly progress, especially along with CSF depletion. It is important for neurosurgeons to suspect paradoxical herniation in a subset of patients with large cranium defects and tense skin flap without sinking during the postoperative 2 weeks. Paradoxical herniation is rapidly reverted by improving CSF hydration, and performing early cranioplasty referred as the definitive treatment.

Paradoxical Herniation After Unilateral Decompressive Craniectomy Predicts Better Patient Survival: A Retrospective Analysis of 429 Cases.

Paradoxical herniation (PH) is a life-threatening emergency after decompressive craniectomy. In the current study, we examined patient survival in patients who developed PH after decompressive craniectomy versus those who did not. Risk factors for, and management of, PH were also analyzed. This retrospective analysis included 429 consecutive patients receiving decompressive craniectomy during a period from January 2007 to December 2012. Mortality rate and Glasgow Outcome Scale (GOS) were compared between those who developed PH (n = 13) versus those who did not (n = 416). A stepwise multivariate logistic regression analysis was carried out to examine the risk factors for PH. The overall mortality in the entire sample was 22.8%, with a median follow-up of 6 months. Oddly enough, all 13 patients who developed PH survived beyond 6 months. Glasgow Coma Scale did not differ between the 2 groups upon admission, but GOS was significantly higher in subjects who developed PH. Both the disease type and coma degree were comparable between the 13 PH patients and the remaining 416 patients. In all PH episodes, patients responded to emergency treatments that included intravenous hydration, cerebral spinal fluid drainage discontinuation, and Trendelenburg position. A regression analysis indicated the following independent risk factors for PH: external ventriculostomy, lumbar puncture, and continuous external lumbar drainage. The rate of PH is approximately 3% after decompressive craniectomy. The most intriguing findings of the current study were the 0% mortality in those who developed PH versus 23.6% mortality in those who did not develop PH and significant difference of GOS score at 6-month follow-up between the 2 groups, suggesting that PH after decompressive craniectomy should be managed aggressively. The risk factors for PH include external ventriculostomy, ventriculoperitoneal shunt, lumbar puncture, and continuous external lumbar drainage.