Late-Onset Vaccine-Induced Immune Thombotic Thrombocytopenia (VITT) with Cerebral Venous Sinus Thrombosis.

OBJECTIVES: Vaccine-induced thrombotic thrombocytopenia (VITT) is a rare complication after adenoviral vector vaccination against COVID-19 reported up to 24 days after ChAdOx1 nCOV-19 (AZD1222) vaccination. This report describes a case with a significantly later onset of VITT with cerebral venous sinus thrombosis. CASE DESCRIPTION: We report a 42-year-old woman presenting to the emergency department 53 days after AZD1222 vaccination with sudden onset sensory aphasia and an 18-day history of headache. Cranial computed tomography (CT) showed acute intracranial hemorrhage and CT venogram demonstrated thrombosis of the left vein of Labbé and transverse and sigmoid sinus. D-dimers were elevated and despite a normal platelet count, platelet-activating anti-PF4 antibody testing was positive, confirming the diagnosis of VITT. The patient was treated with intravenous immunoglobulins and argatroban, and was discharged without any neurological deficit on day 12. CONCLUSION: Our report of VITT with symptom onset on day 35 and diagnosis of cerebral sinuous thrombosis on day 53 after AZD1222 vaccination significantly enhances the time window during which VITT may occur.

Endovascular Treatment for Acute Stroke in Cerebral Amyloid Angiopathy.

Background and Purpose: We aimed to compare outcome of endovascular thrombectomy in acute ischemic stroke in patients with and without cerebral amyloid angiopathy (CAA). Methods: We included patients with and without possible or probable CAA based on the modified Boston criteria from an observational multicenter cohort of patients with acute ischemic stroke and endovascular thrombectomy, the German Stroke Registry Endovascular Treatment trial. We analyzed baseline characteristics, procedural parameters, and functional outcome after 90 days. Results: Twenty-eight (17.3%) of 162 acute ischemic stroke patients were diagnosed with CAA based on iron-sensitive magnetic resonance imaging performed before endovascular thrombectomy. CAA patients were less likely to have a good 90-day outcome (14.3 versus 37.8%). National Institutes of Health Stroke Scale score (adjusted odds ratio, 0.88; P<0.001), successful recanalization (adjusted odds ratio 6.82; P=0.005), and CAA (adjusted odds ratio 0.28; P=0.049) were independent outcome predictors. Intravenous thrombolysis was associated with an increased rate of good outcome (36.3% versus 0%, P=0.031) in CAA. Conclusions: Endovascular thrombectomy with or without thrombolysis appears beneficial in acute ischemic stroke patients with possible or probable CAA, but is associated with a worse functional outcome. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03356392.

PDGRFB mutation-associated myofibromatosis: Response to targeted therapy with imatinib.

Heterozygous activating mutations in platelet-derived growth factor receptor B (PDGFRB) have been recently identified as a cause of autosomal-dominant infantile myofibromatosis. We describe a 36-year-old man with PDGFRB c.1681C>T (p.R561C) mutation. Upon progressive disease, the patient received treatment with imatinib and showed a remarkable response with remission of multiple lesions after 12 months. This is the first report of an adult patient with PDGFRB c.1681C>T mutation treated with imatinib.

Successful mechanical thrombectomy in stroke with thrombolysis-associated intracerebral hemorrhage-a case report.

BACKGROUND: Intravenous thrombolysis and mechanical thrombectomy are the standard of care for patients with acute ischemic stroke with large vessel occlusion. Intracerebral hemorrhage is a main complication of intravenous thrombolysis, however, no data are available on the efficacy and safety of mechanical thrombectomy in patients with thrombolysis-associated intracerebral hemorrhage. This constellation is expected to become more frequent as increasing numbers of patients are treated under the drip-and-ship paradigm. CASE REPORT: A 75-year-old male patient was admitted to an emergency department with acute onset dysarthria and left side hemiparesis due to right middle cerebral artery occlusion. Intravenous thrombolysis was initiated and the patient transferred to our center for mechanical thrombectomy. Upon arrival, cerebral imaging showed persistent right middle cerebral artery occlusion and new onset left frontal, temporal, and parietal intracerebral hemorrhage. Thrombectomy was performed and perfusion completely re-established with excellent neurological outcome. Follow-up imaging revealed probable cerebral amyloid angiopathy. CONCLUSION: Mechanical thrombectomy may be safe and effective in ischemic stroke with large vessel occlusion and thrombolysis-associatied intracerebral hemorrhage.

Home and workforce reintegration one year after thrombectomy in acute stroke patients.

INTRODUCTION: Endovascular thrombectomy (EVT) combined with intravenous thrombolysis is the current standard treatment for acute large-vessel occlusion stroke. Beyond clear clinical benefits in the acute and post-acute phases, comprehensive evaluations of long-term outcomes, including home and workforce reintegration, remain limited. This study aimed to assess home and workforce reintegration 1 year post-EVT in a cohort of acute stroke patients and explore their association with health-related quality of life (HRQoL). PATIENTS AND METHODS: We conducted a prospective observational study of 404 patients undergoing EVT at a tertiary university medical center between October 2019 and December 2021. Patients' functional outcomes were evaluated using the modified Rankin Scale (mRS), and HRQoL was assessed via the European Quality of Life Five Dimension Scale (EQ-5D). Data on occupational and living status were collected through standardized telephone interviews at 3- and 12-months post-treatment. RESULTS: Of 357 patients with 12-month follow-up data, 33.6% had a favorable outcome (mRS 0-2). Among stroke survivors, the rate of home reintegration without nursing care was 42.1%, and workforce reintegration among previously employed patients was 43.3% at 12 months. Both outcomes were significantly associated with improved HRQoL. Lower neurological deficits and younger age were predictive of successful home and workforce reintegration. DISCUSSION AND CONCLUSION: One year post-EVT, approximately 40%-50% of acute stroke patients successfully reintegrate into home and work settings. These findings underscore the need for ongoing support tailored to improving long-term reintegration and quality of life for stroke survivors. DATA ACCESS STATEMENT: The data supporting the findings of the study are available from the corresponding author upon reasonable request and in accordance to European data privacy obligations.

Machine learning models for outcome prediction in thrombectomy for large anterior vessel occlusion.

OBJECTIVE: Predicting long-term functional outcomes shortly after a stroke is challenging, even for experienced neurologists. Therefore, we aimed to evaluate multiple machine learning models and the importance of clinical/radiological parameters to develop a model that balances minimal input data with reliable predictions of long-term functional independency. METHODS: Our study utilized data from the German Stroke Registry on patients with large anterior vessel occlusion who underwent endovascular treatment. We trained seven machine learning models using 30 parameters from the first day postadmission to predict a modified Ranking Scale of 0-2 at 90 days poststroke. Model performance was assessed using a 20-fold cross-validation and one-sided Wilcoxon rank-sum tests. Key features were identified through backward feature selection. RESULTS: We included 7485 individuals with a median age of 75 years and a median NIHSS score at admission of 14 in our analysis. Our Deep Neural Network model demonstrated the best performance among all models including data from 24 h postadmission. Backward feature selection identified the seven most important features to be NIHSS after 24 h, age, modified Ranking Scale after 24 h, premorbid modified Ranking Scale, intracranial hemorrhage within 24 h, intravenous thrombolysis, and NIHSS at admission. Narrowing the Deep Neural Network model's input data to these features preserved the high performance with an AUC of 0.9 (CI: 0.89-0.91). INTERPRETATION: Our Deep Neural Network model, trained on over 7000 patients, predicts 90-day functional independence using only seven clinical/radiological features from the first day postadmission, demonstrating both high accuracy and practicality for clinical implementation on stroke units.

Endovascular treatment of primary M3 occlusion stroke in clinical practice: analysis of the German Stroke Registry.

BACKGROUND: Endovascular treatment (ET) options for acute stroke due to distal middle cerebral artery occlusions are rapidly evolving, but data on outcome and safety are sparse. We therefore performed an analysis of patients undergoing ET for primary M3 occlusions in routine clinical practice in a nationwide registry. METHODS: Patients enrolled between 01/20 and 12/21 in the prospective, multicenter German Stroke Registry-Endovascular Treatment (GSR-ET) were screened for mechanical thrombectomy performed for primary M3 occlusion. We analyzed neurological deficit as measured by the National Institute of Health Stroke Scale (NIHSS), symptomatic intracranial hemorrhage (sICH), thrombectomy technique, successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score of 2b-3) and functional outcome as measured by the modified Rankin Scale (mRS) at discharge and 90 days. RESULTS: Out of 5574 patients, 11 patients (0.2%, median age 80 years, 54.5% female) underwent ET for primary M3 occlusion. All patients had pre-admission mRS ≤ 1, median NIHSS on admission was 8, and successful reperfusion was achieved in 6/11 patients (54.5%). While no vasospasm, dissection or perforation was reported, symptomatic intracranial hemorrhage occurred in 2 patients (18.2%). Favorable outcome (mRS ≤ 2) was achieved in 6/11 patients (54.5%) at 90-day follow-up. CONCLUSIONS: ET for primary M3 occlusions is rarely performed. While technically feasible, the procedure's potential benefits must be carefully weighed against its associated risks, including clinically relevant complications. Caution and further research is needed to optimize patient selection for this intervention. TRIAL REGISTRATION: GSR-ET; ClinicalTrials.gov Identifier: NCT03356392; Trial Registration Date: 11/29/2017.

Intravenous thrombolysis upon flow restoration improves outcome in endovascular thrombectomy.

BACKGROUND: We hypothesized that ongoing IV thrombolysis (IVT) at flow restoration in patients with acute ischemic stroke (AIS) treated with IVT and endovascular thrombectomy (ET) is associated with improved outcome. METHODS: We included patients with IVT and successful recanalization (modified Thrombolysis in Cerebral Infarction score ≥2b) after ET from an observational multicenter cohort, the German Stroke Registry - Endovascular Treatment trial. Procedural characteristics and functional outcome at discharge and 90 days were compared between patients with and without ongoing IVT at flow restoration. To determine associations with functional outcome, adjusted ORs were calculated using ordinal multivariable logistic regression models adjusted for potential baseline confounder variables. RESULTS: Among 1303 patients treated with IVT and ET who achieved successful recanalization, IVT was ongoing in 13.8% (n=180) at flow restoration. Ongoing IVT was associated with better functional outcome at discharge (adjusted OR 1.61; 95% CI 1.13 to 2.30) and at 90 days (adjusted OR 1.52; 95% CI 1.06 to 2.18). CONCLUSION: These results provide preliminary evidence for a benefit of ongoing IVT at flow restoration in patients with AIS treated with ET.

Clinical significance and prevalence of subarachnoid hyperdensities on flat detector CT after mechanical thrombectomy: does it really matter?

BACKGROUND: Subarachnoid hyperdensities after mechanical thrombectomy (MT) are a common finding. However, it is often regarded as clinically insignificant. OBJECTIVE: With this single-center investigation, to identify the prevalence of subarachnoid hyperdensities following MT, associated predictors, and the impact on the clinical outcome of the patients. METHODS: 383 patients from the stroke registry were analyzed for the presence of subarachnoid hyperdensities on flat detector CT (FDCT) directly after the completion of MT, and on follow-up dual-energy CT, then classified according to a visual grading scale. 178 patients were included with anterior circulation occlusions. Regression analysis was performed to identify significant predictors, and Kruskal-Wallis analysis and Χ2 test were performed to test the variables among the different groups. The primary outcome was the modified Rankin Scale (mRS) score at 90 days and was analyzed with the Wilcoxon-Mann-Whitney rank-sum test. RESULTS: The prevalence of subarachnoid hyperdensities on FDCT was (66/178, 37.1%) with patients experiencing a significant unfavorable outcome (P=0.035). Significantly fewer patients with subarachnoid hyperdensities achieved a mRS score of ≤3 at 90 days 25/66 (37.9%) vs 60/112 (53.6%), P=0.043). In addition, mortality was significantly higher in the subarachnoid hyperdensities group (34.8% vs 19.6%, P=0.024). Distal occlusions and a higher number of device passes were significantly associated with subarachnoid hyperdensities (P=0.026) and (P=0.001), respectively. Patients who received intravenous tissue plasminogen activator had significantly fewer subarachnoid hyperdensities (P=0.029). CONCLUSIONS: Postinterventional subarachnoid hyperdensities are a frequent finding after MT and are associated with neurological decline and worse functional outcome. They are more common with distal occlusions and multiple device passes.

Endovascular thrombectomy in young patients with stroke.

BACKGROUND: Endovascular treatment (ET) is standard of care in patients with acute ischemic stroke due to large vessel occlusion, but data on ET in young patients remain limited. AIM: We aim to compare outcomes for young stroke patients undergoing ET in a matched cohort. METHODS: We analyzed patients from an observational multicenter cohort with acute ischemic stroke and ET, the German Stroke Registry-Endovascular Treatment trial. Baseline characteristics, procedural parameters, and functional outcome at 90 days were compared between young (<50 years) and older (⩾50 years) patients with and without nearest-neighbor 1:1 propensity score matching. RESULTS: Out of 6628 acute ischemic stroke patients treated with ET, 363 (5.5%) were young. Young patients differed with regard to prognostic outcome characteristics. Specifically, National Institutes of Health Stroke Scale (NIHSS) at admission was lower (median 13, interquartile range (IQR) 8-17 vs. 15, IQR 9-19, p < 0.001), and prestroke dependence was less frequent (2.9% vs. 12.2%, p < 0.001) than in older patients. Compared to a matched cohort of older patients, ET was faster (time from groin puncture to flow restoration, 35 vs. 45 min, p < 0.001) and intracranial hemorrhage was less frequent in young patients (10.0% vs. 25.9%, p < 0.001). Good functional outcome (modified Rankin Scale (mRS) 0-2) at 3 months was achieved more frequently in young patients (71.6% vs. 44.1%, p < 0.001), and overall mortality was lower (6.7% vs. 25.4%, p < 0.001). Among previously employed young patients (n = 177), 37.9% returned to work at 3-month follow-up, while 74.1% of the remaining patients were still undergoing rehabilitation. CONCLUSION: Young stroke patients undergoing ET have better outcomes compared to older patients, even when matched for prestroke condition, comorbidities, and stroke severity. Hence, more liberal guidelines to perform ET for younger patients may have to be established by future studies.