Derivation and validation of a predictive scale to expedite endovascular intervention for acute stroke patients with an intervenable vessel occlusion.

BACKGROUND: Early endovascular intervention team mobilization may reduce reperfusion times and improve clinical outcomes for patients with acute ischemic stroke (AIS) with a possible intervenable vessel occlusion (IVO). In an emergency department or mobile stroke unit, incorporating rapidly available non-contrast CT (NCCT) information with examination findings may improve the accuracy of arterial occlusion prediction scales. For this purpose, we developed a rapid and straightforward IVO predictive instrument-the T3AM2PA1 scale. METHODS: The T3AM2PA1 scale was retrospectively derived from our 'Get with the Guidelines' database. We included all patients with acute stroke alert between January 2017 and August 2018 with a National Institutes of Health Stroke Scale (NIHSS) score between 5 and 25 inclusive. Different pre-intervention variables were collected, including itemized NIHSS and NCCT information. The T3AM2PA1 scale was also compared with other commonly used scales and was validated in a separate sequential retrospective cohort of patients with a full range of NIHSS scores. RESULTS: 574 eligible patients from 2115 acute stroke alerts were identified. The scale was established with five items (CT hyperdense sign, parenchymal hypodensity, lateralizing hemiparesis, gaze deviation, and language disturbance), with a total score of 9. To minimize unnecessary angiography, a cut-off of ≥5 for IVO detection yielded a sensitivity of 52%, a specificity of 90%, and a positive predictive value of 76%. CONCLUSIONS: The T3AM2PA1 scale accurately predicts the presence of clinical IVO in patients with AIS. Adopting the T3AM2PA1 scale could reduce revascularization times, improve treatment outcomes, and potentially reduce disability.

Randomised study of bailout intracranial angioplasty following thrombectomy for acute large vessel occlusion (ANGEL-REBOOT): protocol of a multicentre randomised controlled trial.

RATIONALE: Unsuccessful thrombectomy of acute large vessel occlusions (LVOs) has been associated with unfavourable outcomes. Multiple randomised controlled trials (RCTs) have reported a failure rate of 12%-41% for thrombectomy procedures. Various factors contribute to failed thrombectomy, including technical difficulties in accessing the occlusion, unsuccessful thrombus retrieval, thrombotic reocclusion and pre-existing intracranial atherosclerotic stenosis. Although some studies have explored balloon dilation or permanent stenting as rescue intracranial angioplasty for failed thrombectomy in individual cases, there is currently no evidence from RCTs on this specific topic. AIM: To evaluate the potential superiority of bailout angioplasty over standard treatment in cases of unsuccessful recanalisation (eTICI 0 to 2a) or residual severe stenosis (>70%) after thrombectomy in acute LVO patients within 24 hours of stroke onset. DESIGN: This study is a multicentre, prospective, randomised, controlled clinical trial designed by investigators. It compares bailout angioplasty with standard therapy and follows an open-label treatment approach while maintaining a blinded outcome assessment (PROBE design). Our objective is to allocate 348 patients in a 1:1 ratio to either receive bailout angioplasty as an intervention or standard therapy as a control, following unsuccessful thrombectomy. OUTCOME: The main measure of interest is the modified Rankin Scale (mRS) Score, which will be assessed in a blinded manner at 90 (±14) days following randomisation. The primary effect size will be determined using ordered logistic regression to calculate the common OR, representing the shift on the six-category mRS Scale at the 90-day mark. Additionally, the safety outcomes will be evaluated, including symptomatic intracranial haemorrhage within 18-36 hours, severe procedure-related complications and mortality within 90 (±14) days, among others. DISCUSSION: The ANGEL-REBOOT study aims to generate substantial evidence regarding the efficacy and safety of bailout intracranial angioplasty as a treatment option for patients with LVO who have experienced unsuccessful thrombectomy. TRIAL REGISTRATION NUMBER: NCT05122286.

Cost-effectiveness of endovascular therapy for acute ischemic stroke with large infarct in China.

BACKGROUND: Endovascular therapy administered within 24 hours has been shown to improve outcomes for patients with acute ischemic stroke with large infarction, but the data on its cost-effectiveness are limited. OBJECTIVE: To evaluate the cost-effectiveness of endovascular therapy for acute ischemic stroke with large infarction in China, the largest low- and middle-income country. METHODS: A short-term decision tree model and a long-term Markov model were used to analyze the cost-effectiveness of endovascular therapy for patients with acute ischemic stroke with large infarction. Outcomes, transition probability, and cost data were obtained from a recent clinical trial and published literature. The benefit of endovascular therapy was assessed by the cost per quality-adjusted life-years (QALYs) gained in the short and long term. Deterministic one-way and probabilistic sensitivity analyses were performed to assess the robustness of the results. RESULTS: Compared with medical management alone, endovascular therapy for acute ischemic stroke with large infarction was found to be cost-effective from the fourth year onward and during a lifetime. In the long term, endovascular therapy yielded a lifetime gain of 1.33 QALYs at an additional cost of ¥73 900 (US$ 11 400), resulting in an incremental cost of ¥55 500 (US$ 8530) per QALY gained. Probabilistic sensitivity analysis showed that endovascular therapy was cost-effective in 99.5% of the simulation runs at a willingness-to-pay threshold of ¥243 000 (3 × gross domestic product per capita of China in 2021) per QALY gained. CONCLUSIONS: Endovascular therapy for acute ischemic stroke with large infarction could be cost-effective in China.

Does MRI add value in selecting patients for thrombectomy beyond the 6 h window? A matched-control analysis.

Background: Controversy exists regarding the need of advanced imaging for patient selection in the extended window. Aims: To analyze the effect of initial imaging modalities on clinical outcomes of patients underwent MT in the extended window. Methods: This was a retrospective analysis of a prospective registry, the Endovascular Treatment Key Technique and Emergency Workflow Improvement of Acute Ischemic Stroke (ANGEL-ACT) registry which was conducted at 111 hospitals between November 2017 and March 2019 in China. Primary study cohort and Guideline like cohort were identified, in each cohort, two imaging modalities for patient selection in 6 to 24 h window were defined: (1) NCCT ± CTA, (2) MRI. Guideline-like cohort were further screened based on key features of the DAWN and DEFUSE 3 trials. The primary outcome was 90 day mRS. The safety outcomes were sICH, any ICH and 90-day mortality. Results: After adjusting for covariates, there were no significant differences in 90 day mRS or any safety outcomes between two imaging modalities groups in both cohorts. All outcome measures of mixed-effects logistic regression model were consistent with propensity score matching model. Conclusion: Our results indicate that patients presented with anterior large vessel occlusion in the extended time window can potentially benefit from MT even in the absence of MRI selection. This conclusion needs to be verified by the prospective randomized clinical trials.

Predictors of parenchymal hemorrhage after endovascular treatment in acute ischemic stroke: data from ANGEL-ACT Registry.

BACKGROUND: Parenchymal hemorrhage (PH) is a troublesome complication after endovascular treatment (EVT). OBJECTIVE: To investigate the incidence, independent predictors, and clinical impact of PH after EVT in patients with acute ischemic stroke (AIS) due to anterior circulation large vessel occlusion (LVO). METHODS: Subjects were selected from the ANGEL-ACT Registry. PH was diagnosed according to the European Collaborative Acute Stroke Study classification. Logistic regression analyses were performed to determine the independent predictors of PH, as well as the association between PH and 90-day functional outcome assessed by modified Rankin Scale (mRS) score. RESULTS: Of the 1227 enrolled patients, 147 (12.0%) were diagnosed with PH within 12-36 hours after EVT. On multivariable analysis, low admission Alberta Stroke Program Early CT score (ASPECTS)(adjusted OR (aOR)=1.13, 95% CI 1.02 to 1.26, p=0.020), serum glucose >7 mmol/L (aOR=1.82, 95% CI 1.16 to 2.84, p=0.009), and neutrophil-to-lymphocyte ratio (NLR; aOR=1.05, 95% CI 1.02 to 1.09, p=0.005) were associated with a high risk of PH, while underlying intracranial atherosclerotic stenosis (ICAS; aOR=0.42, 95% CI 0.22 to 0.81, p=0.009) and intracranial angioplasty/stenting (aOR=0.37, 95% CI 0.15 to 0.93, p=0.035) were associated with a low risk of PH. Furthermore, patients with PH were associated with a shift towards to worse functional outcome (mRS score 4 vs 3, adjusted common OR (acOR)=2.27, 95% CI 1.53 to 3.38, p<0.001). CONCLUSIONS: In Chinese patients with AIS caused by anterior circulation LVO, the risk of PH was positively associated with low admission ASPECTS, serum glucose >7 mmol/L, and NLR, but negatively related to underlying ICAS and intracranial angioplasty/stenting. TRIAL REGISTRATION NUMBER: NCT03370939.

Endovascular therapy in acute anterior circulation large vessel occlusive patients with a large infarct core (ANGEL-ASPECT): protocol of a multicentre randomised trial.

BACKGROUND: The benefit of stroke thrombectomy for large infarct core still lacks robust randomised controlled studies. AIM: To demonstrate the design of a clinical trial on endovascular therapy for acute anterior circulation large vessel occlusion (LVO) patients with large infarct core volume. DESIGN: ANGEL-ASPECT is a multicentre, prospective, randomised, open-label, blinded End-point trial to evaluate whether best medical management (BMM) combined with endovascular therapy improves neurological functional outcomes as compared with BMM alone in acute LVO patients with Alberta Stroke Program Early CT Score (ASPECTS) of 3-5 on non-contrast CT or infarct core volume range of 70-100 mL (defined as rCBF <30% on CT perfusion or ADC <620 on MRI) up to 24 hours from symptom onset or last seen well. STUDY OUTCOMES: The primary efficacy outcome is 90 (±7) days modified Rankin Scale. Symptomatic intracranial haemorrhage within 48 hours from randomisation is the primary safety outcome. DISCUSSION: The ANGEL-ASPECT trial will screen patients with large infarct core (ASPECTS 3-5 or 70-100 mL) through image evaluation criteria within 24 hours and explore the efficacy and safety of endovascular therapy compared with BMM.

Time to Endovascular Reperfusion and Outcome in Acute Ischemic Stroke : A Nationwide Prospective Registry in China.

PURPOSE: The benefit of endovascular reperfusion therapy for acute ischemic stroke is highly time-dependent but the relation of delays in workflow with outcomes and the key determinants of delays remain uncertain. This study aimed to evaluate the association between faster endovascular therapy and outcomes in a Chinese population with acute ischemic stroke. METHODS: Patients treated with endovascular therapy within 7 h due to anterior large vessel occlusion were enrolled in the ANGEL-ACT registry. Time intervals from hospital arrival to arterial puncture (door-to-puncture), hospital arrival to reperfusion (door-to-reperfusion) and puncture-to-reperfusion were recorded. The outcomes included modified Rankin Scale (mRS) scores 0-1, 0-2, mortality at 3 months, substantial reperfusion, and symptomatic intracranial hemorrhage (sICH). RESULTS: Of 932 patients receiving endovascular therapy (mean age 65.1 years, 60.1% male), the median door-to-puncture, door-to-reperfusion, and puncture-to-perfusion times were 110min (interquartile range, IQR 72-155min), 200min (IQR, 149-260min), and 76min (IQR, 50-118min). Of the patients 87.4% achieved substantial reperfusion and 9.6% had sICH. The mRS 0-1, 0-2, and mortality at 3 months were 39.8%, 43.2%, and 16.4%. Faster door-to-reperfusion and puncture-to-reperfusion were associated with higher likelihood of mRS 0-1, mRS 0-2, and lower rate of sICH. There was a trend of improved mRS, lower mortality, and fewer ICH with shorter door-to-puncture time; however, most differences were not statistically significant. CONCLUSION: Among patients with acute ischemic stroke in routine clinical practice, shorter time to reperfusion was associated with better outcome after endovascular therapy. Standardized workflows and training in endovascular treatment techniques should be promoted nationally to reduce in-hospital delays.

Modern Appraisal of Patency and Complications in Cerebral Bypass Surgery: A Single Institution Experience.

BACKGROUND: Cerebral bypass is a valuable surgical technique in well-selected patient populations. Updated clinical guidelines and improved surgical techniques warrant a contemporary reevaluation of the complications and patency to inform clinical practice and enhance postoperative patient care. OBJECTIVE: To assess the complication rates and postoperative graft patency for the 3 most common indications for bypass surgery: moyamoya disease, intracranial atherosclerosis, and intracranial aneurysms. METHODS: Perioperative notes of 175 consecutive bypass patients at a single institution were retrospectively identified to evaluate the clinical course and complications of surgery. RESULTS: The rate of total postoperative complications between moyamoya disease (9 of 98, 9.2%), intracranial atherosclerotic disease (7 of 57, 12.3%), and intracranial aneurysm (4 of 20, 20%) was not statistically different (P = .33). Immediate postoperative bypass patency was significantly higher in moyamoya disease (90 of 96, 93.8%) and intracranial atherosclerotic disease (48 of 51, 94.1%) than in intracranial aneurysm (13 of 18, 72.2%; P = .02). Intravenous heparin administration during bypass suturing was negatively associated with immediate postoperative patency (87% heparin patency vs 99% no heparin patency; P = .02). Double-barrel bypass trended toward an increased risk of wound healing complications (2 of 13, 15.4%) compared with the single-barrel bypass technique (4 of 156, 2.6%; P = .07). CONCLUSION: Cerebral bypass surgery remains an excellent surgical treatment for moyamoya disease, intracranial atherosclerosis, and intracranial aneurysms. This study suggests bypass is safer in moyamoya disease and intracranial atherosclerosis. Additional studies to clarify the risk of single-barrel vs double-barrel bypass and intraoperative heparin-stratified complications may be beneficial.

Association of Stroke Subtype With Hemorrhagic Transformation Mediated by Thrombectomy Pass: Data From the ANGEL-ACT Registry.

BACKGROUND: The role of stroke etiology subtype in patients with acute large vessel occlusion on the occurrence of hemorrhagic transformation (HT) after endovascular treatment is poorly studied, and which factors mediate their relationship remains largely unknown. We utilized nationwide registry data to explore the association of stroke subtype (cardioembolism versus large artery atherosclerosis) with HT and to identify the possible mediators. METHODS: A total of 1015 subjects were selected from the ANGEL-ACT registry (Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke)-a prospective consecutive cohort of acute large vessel occlusion patients undergoing endovascular treatment at 111 hospitals in China between November 2017 and March 2019-and divided into large artery atherosclerosis (n=538) and cardioembolism (n=477) according to the Trial of ORG 10172 in Acute Stroke Treatment criteria. The types of HT included any intracerebral hemorrhage (ICH), parenchymal hematoma, and symptomatic ICH within 24 hours after endovascular treatment. The association between stroke subtype and HT was analyzed using a logistic regression model. Mediation analysis was done to assess how much of the effect of stroke subtype on HT was mediated through the identified mediators. RESULTS: Stroke subtype (cardioembolism versus large artery atherosclerosis) was associated with increased risk of any ICH (29.8% versus 16.5%; odds ratio, 2.03 [95% CI, 1.22-3.36]), parenchymal hematoma (14.3% versus 5.4%; odds ratio, 2.90 [95% CI, 1.38-6.13]), and symptomatic ICH (9.9% versus 4.7%; odds ratio, 2.59 [95% CI, 1.09-6.16]) after adjustment for potential confounders. The more thrombectomy passes in cardioembolism patients had a significant mediation effect on the association of stroke subtype with increased risk of HT (any ICH, 15.9%; parenchymal hematoma, 13.4%; symptomatic ICH, 14.2%, respectively). CONCLUSIONS: Stroke subtype is an independent risk factor for HT within 24 hours following endovascular treatment among acute large vessel occlusion patients. Mediation analyses propose that stroke subtype contributes to HT partly through thrombectomy pass, suggesting a possible pathomechanistic link. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03370939.

The Safety and Efficacy of Endovascular Treatment in Acute Ischemic Stroke Patients Caused by Large-Vessel Occlusion with Different Etiologies of Stroke: Data from ANGEL-ACT Registry.

This study aimed to investigate the safety and efficacy of endovascular treatment (EVT) in acute ischemic stroke (AIS) patients caused by large-vessel occlusion (LVO) with different etiologies of stroke. A total of 928 AIS patients were assigned into intracranial atherosclerotic stenosis (ICAS)-LVO, cardioembolic (CE)-LVO, and artery to artery embolism (ATA)-LVO groups. The safety and efficacy endpoints were symptomatic intracranial hemorrhage (SICH) at 24 h after EVT, 90-day favorable outcomes (modified Rankin Scale (mRS) of 0-2), successful recanalization (modified thrombolysis in cerebral infarct (mTICI) 2b/3), and complete recanalization (mTICI 3). The logistic regression analysis was used to determine the associations between the safety and efficacy endpoints. There were 305 (32.9%), 535 (57.6%), and 88 (9.5%) patients in ICAS-LVO, CE-LVO, and ATA-LVO groups, respectively. No significant difference was found in the 90-day mRS and successful recanalization among the three groups. However, compared with the ICAS-LVO group, complete recanalization rate was higher in the CE-LVO (adjusted odds ratio, 4.50; 95% confidence interval (CI), 2.37-8.56) and ATA-LVO groups (aOR, 2.43; 95% CI, 1.16-5.10). The results of subgroup analysis showed a significant association between CE-LVO stroke etiology and complete recanalization in the age population < 65 years old (aOR, 14.33; 95% CI, 4.39-46.79, P = 0.019). Functional outcomes were similar among different etiologies of stroke. CE-LVO and ATA-LVO could be related to a higher rate of complete recanalization, and there was a trend of the increased risk of parenchymal hemorrhage in the CE-LVO group.

Combined Approach to Eptifibatide and Thrombectomy in Acute Ischemic Stroke Because of Large Vessel Occlusion: A Matched-Control Analysis.

BACKGROUND: In patients undergoing mechanical thrombectomy (MT), adjunctive antithrombotic might improve angiographic reperfusion, reduce the risk of distal emboli and reocclusion but possibly expose patients to a higher intracranial hemorrhage risk. This study evaluated the safety and efficacy of combined MT plus eptifibatide for acute ischemic stroke. METHODS: This was a propensity-matched analysis of data from 2 prospective trials in Chinese populations: the ANGEL-ACT trial (Endovascular Treatment Key Technique and Emergency Workflow Improvement of Acute Ischemic Stroke) in 111 hospitals between November 2017 and March 2019, and the EPOCH trial (Eptifibatide in Endovascular Treatment of Acute Ischemic Stroke) in 15 hospitals between April 2019 and March 2020. The primary efficacy outcome was good outcome (modified Rankin Scale score 0-2) at 3 months. Secondary efficacy outcomes included the distribution of 3-month modified Rankin Scale scores and poor outcome (modified Rankin Scale score 5-6) and successful recanalization. The safety outcomes included any intracranial hemorrhage, symptomatic intracranial hemorrhage, and 3-month mortality. Mixed-effects logistic regression models were used to account for within-hospital clustering in adjusted analyses. RESULTS: Eighty-one combination arm EPOCH subjects were matched with 81 ANGEL-ACT noneptifibatide patients. Compared with the no eptifibatide group, the eptifibatide group had significantly higher rates of successful recanalization (91.3% versus 81.5%; P=0.043) and 3-month good outcomes (53.1% versus 33.3%; P=0.016). No significant difference was found in the remaining outcome measures between the 2 groups. All outcome measures of propensity score matching were consistent with mixed-effects logistic regression models in the total population. CONCLUSIONS: This matched-control study demonstrated that MT combined with eptifibatide did not raise major safety concerns and showed a trend of better efficacy outcomes compared with MT alone. Overall, eptifibatide shows potential as a periprocedural adjunctive antithrombotic therapy when combined with MT. Further randomized controlled trials of MT plus eptifibatide should be prioritized. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03844594 (EPOCH), NCT03370939 (ANGEL-ACT).

Factors associated with in-stent stenosis after cerebral aneurysm embolization using a Pipeline embolization device.

BACKGROUND: Flow-diverting (FD) stents, with or without coiling, are a mainstay in endovascular treatment of intracranial aneurysms (IAs). One observed complication from flow diverter stent (FDS) insertion has been in-stent stenosis. Though previously studied in the short-term period, the long-term history of this complication has yet to be described. METHODS: We performed a retrospective cohort study of consecutive IAs treated with Pipeline Embolization Device (PED), with or without coiling, at our centre between September 2014 and December 2018 that had at least one digital subtraction angiogram (DSA) during follow-up. In-stent stenosis was measured from DSA images, and associated patient and procedural characteristics were analysed. RESULTS: 94 patients treated with PED for IA were identified. On initial DSA during follow-up, 52 patients (55.3%) had in-stent stenosis within the PED. Of these 52 patients, 17 had a second DSA during follow-up. In this 2nd DSA, improvement and/or stable in-stent stenosis was seen 16 patients (94.1%). One patient in this group had worsening in-stent stenosis had a vertebrobasilar junction FD stent. Of the patients without in-stent stenosis on initial DSA, 15 had a second DSA during follow-up. Only one of these patients (6.7%) had new appearance of in-stent stenosis (measuring 5%). Multivariate analysis found statin use to be predictive of in-stent stenosis (p = 0.020, Odds ratio = 0.279 and 95% confidence interval = 0.095-0.821). CONCLUSIONS: In-stent stenosis after FDS placement was seen in 53.2% of cases, which had between 1-50% of stenosis. 82.4% had resolution/improvement of their stenosis. Statin use was protective of in-stent stenosis.

Endovascular Treatment in Acute Ischemic Stroke with Large Vessel Occlusion According to Different Stroke Subtypes: Data from ANGEL-ACT Registry.

INTRODUCTION: Endovascular treatment's (EVT) safety and efficacy have been proven in treating acute ischemic stroke (AIS) due to large vessel occlusion (LVO). However, limited data exist in different stroke subtypes. We aimed to investigate the differences in efficacy and safety of EVT for acute LVO according to different stroke subtypes. METHODS: A total of 1635 AIS patients with LVO undergoing EVT from a prospective cohort of the Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke (ANGEL-ACT) registry were classified into three types according to the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria. We compared the primary outcome: 90-day modified Rankin Scale (mRS) score, the secondary outcomes: 90-day mRS (0-1, 0-2, and 0-3), successful recanalization (mTICI 2b/3), and complete recanalization (mTICI 3), and the safety outcomes: death within 90 days, parenchymal hemorrhage (PH), and symptomatic intracranial hemorrhage (SICH) among the three subtypes of stroke patients. Then, multivariable logistic regression models adjusting for potential baseline-confounding variables to determine the associations between stroke subtypes and safety and efficacy endpoints were performed. Finally, we performed subgroup analyses to explore discrepancies in the relationships. RESULTS: EVT of cardioembolic LVO (CE-LVO) had a higher rate of mTICI 3 (71.7% vs. 65.9% and 63.2%; P = 0.024) and a higher rate of PH (13.8% vs. 5.4% and 6.7%; P < 0.001) when compared to other stroke subtypes. Even multivariable analysis demonstrated that CE-LVO was associated with mTICI 3 [adjusted odds ratio (OR), 1.50 (95% CI 1.04-2.17)] and PH [adjusted OR, 1.97 (95% CI 1.09-3.55)]. However, the 90-day mRS distribution and 90-day mRS (0-1, 0-2, and 0-3) did not differ among the stroke subtypes, and nor did the SICH (P > 0.05). CONCLUSIONS: Functional outcomes were similar among different stroke subtypes. Despite a higher rate of complete recanalization, there is an increased risk of parenchymal hemorrhage in CE-LVO. TRIAL REGISTRATION: Clinical trial registration number: NCT03370939.

Non-contrast head CT alone for thrombectomy in acute ischemic stroke: analysis of the ANGEL-ACT registry.

BACKGROUD: The goal of this study was to determine if the choice of imaging paradigm performed in the emergency department influences the procedural or clinical outcomes after mechanical thrombectomy (MT). METHODS: This is a retrospective comparative outcome study which was conducted from the ANGEL-ACT registry. Comparisons were made between baseline characteristics and clinical outcomes of patients with acute ischemic stroke undergoing MT with non-contrast head computed tomography (NCHCT) alone versus patients undergoing NCHCT plus non-invasive vessel imaging (NVI) (including CT angiography (with or without CT perfusion) and magnetic resonance angiography). The primary outcome was the modified Rankin Scale (mRS) score at 90 days. Secondary outcomes included change in mRS score from baseline to 90 days, the proportions of mRS 0-1, 0-2, and 0-3, and dramatic clinical improvement at 24 hours. The safety outcomes were any intracranial hemorrhage (ICH), symptomatic ICH, and mortality within 90 days. RESULTS: A total of 894 patients met the inclusion criteria; 476 (53%) underwent NCHCT alone and 418 (47%) underwent NCHCT + NVI. In the NCHCT alone group, the door-to-reperfusion time was shorter by 47 min compared with the NCHCT + NVI group (219 vs 266 min, P<0.001). Patients in the NCHCT alone group showed a smaller increase in baseline mRS score at 90 days (median 3 vs 2 points; P=0.004) after adjustment. There were no significant differences between groups in the remaining clinical outcomes. CONCLUSIONS: In patients selected for MT using NCHCT alone versus NCHCT + NVI, there were improved procedural outcomes and smaller increases in baseline mRS scores at 90 days.

Clot imaging characteristics predict first pass effect of aspiration-first approach to thrombectomy.

BACKGROUND: The value of clot imaging in patients with emergent large vessel occlusion (ELVO) treated with thrombectomy is unknown. METHODS: We performed retrospective analysis of clot imaging (clot density, perviousness, length, diameter, distance to the internal carotid artery (ICA) terminus and angle of interaction (AOI) between clot and the aspiration catheter) of consecutive cases of middle cerebral artery (MCA) occlusion and its association with first pass effect (FPE, TICI 2c-3 after a first attempt). RESULTS: Patients (n = 90 total) with FPE had shorter clot length (9.9 ± 4.5 mm vs. 11.7 ± 4.6 mm, P = 0.07), shorter distance from ICA terminus (11.0 ± 7.1 mm vs. 14.7 ± 9.8 mm, P = 0.048), higher perviousness (39.39 ± 29.5 vs 25.43 ± 17.6, P = 0.006) and larger AOI (153.6 ± 17.6 vs 140.3 ± 23.5, P = 0.004) compared to no-FPE patients. In multivariate analysis, distance from ICA terminus to clot ≤13.5 mm (odds ratio (OR) 11.05, 95% confidence interval (CI) 2.65-46.15, P = 0.001), clot length ≤9.9 mm (OR 7.34; 95% CI 1.8-29.96, P = 0.005), perviousness ≥ 19.9 (OR 2.54, 95% CI 0.84-7.6, P = 0.09) and AOI ≥ 137°^ (OR 6.8, 95% CI 1.55-29.8, P = 0.011) were independent predictors of FPE. The optimal cut off derived using Youden's index was 6.5. The area under the curve of a score predictive of FPE success was 0.816 (0.728-0.904, P < 0.001). In a validation cohort (n = 30), sensitivity, specificity, positive and negative predictive value of a score of 6-10 were 72.7%, 73.6%, 61.5% and 82.3%. CONCLUSIONS: Clot imaging predicts the likelihood of achieving FPE in patients with MCA ELVO treated with the aspiration-first approach.

Comparative study of intracranial access in thrombectomy using next generation 0.088 inch guide catheter technology.

BACKGROUND: Most conventional 0.088 inch guide catheters cannot safely navigate intracranial vasculature. The objective of this study is to evaluate the safety of stroke thrombectomy using a novel 0.088 inch guide catheter designed for intracranial navigation. METHODS: This is a multicenter retrospective study, which included patients over 18 years old who underwent thrombectomy for anterior circulation large vessel occlusions. Technical outcomes for patients treated using the TracStar Large Distal Platform (TracStar LDP) or earlier generation TRX LDP were compared with a matched cohort of patients treated with other commonly used guide catheters. The primary outcome measure was device-related complications. Secondary outcome measures included guide catheter failure and time between groin puncture and clot engagement. RESULTS: Each study arm included 45 patients. The TracStar group was non-inferior to the control group with regard to device-related complications (6.8% vs 8.9%), and the average time to clot engagement was 8.89 min shorter (14.29 vs 23.18 min; p=0.0017). There were no statistically significant differences with regard to other technical outcomes, including time to recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2B). The TracStar was successfully advanced into the intracranial internal carotid artery in 33 cases (73.33%); in three cases (6.67%), it was swapped for an alternate catheter. Successful reperfusion (mTICI 2B-3) was achieved in 95.56% of cases. Ninety-day follow-up data were available for 86.67% of patients, among whom 46.15% had an modified Rankin Score of 0-2%, and 10.26% were deceased. CONCLUSIONS: Tracstar LDP is safe for use during stroke thrombectomy and was associated with decreased time to clot engagement. Intracranial access was regularly achieved.

MRS SOFIA: a multicenter retrospective study for use of Sofia for revascularization of acute ischemic stroke.

BACKGROUND: Over the past several years there has been increased interest in the use of the Sofia aspiration system (MicroVention, Tustin, California) as a primary aspiration catheter. OBJECTIVE: To perform a multicenter retrospective study examining the efficacy of the Sofia aspiration catheter as a standalone aspiration treatment for large vessel occlusion. METHODS: Consecutive cases in which the Sofia catheter was used for aspiration thrombectomy for large vessel occlusion were included. Exclusion criteria were the following: (1) Sofia not used for first pass, and (2) a stent retriever used as an adjunct on the first pass. The primary outcome of the study was first pass recanalization (Thrombolysis in Cerebral Infarction (TICI) 2c/3). Secondary outcomes included first pass TICI 2b/3, crossover to other thrombectomy devices, number of passes, time from puncture to recanalization, and complications. RESULTS: 323 patients were included. First pass TICI 2c/3 was achieved in 49.8% of cases (161/323). First pass TICI 2b/3 was achieved in 69.7% (225/323) of cases. 74.8% had TICI 2b/3 with the Sofia alone. Crossover to other thrombectomy devices occurred in 29.1% of cases (94/323). The median number of passes was 1 (IQR=1-3). Median time from puncture to recanalization was 26 min (IQR=17-45). Procedure related complications occurred in 3.1% (10/323) of cases. CONCLUSION: Our study highlights the potential advantage of the Sofia aspiration catheter for primary aspiration thrombectomy in acute ischemic stroke. High rates of first pass recanalization with low crossover rates to other thrombectomy devices were achieved. Median procedure time was low, as were procedural complications.

Eloquence-based reperfusion scoring and its ability to predict post-thrombectomy disability and functional status.

BACKGROUND: Angiographic reperfusion after endovascular thrombectomy in acute ischemic stroke is commonly graded using volume-based reperfusion scores such as the modified thrombolysis in cerebral infarct score. The location of non-reperfused regions is not included in modified thrombolysis in cerebral infarct score. We studied the predictive ability of an eloquence-based reperfusion score. METHODS: Consecutive cases of endovascular thrombectomy for anterior circulation strokes performed between January 2018 and April 2020 were included. Digital subtraction angiograms were reviewed by two blinded neurointerventionalist operators. Incomplete reperfusion was further classified by lobar regions lacking reperfusion to create various cohorts. Outcomes were graded four to seven days post-procedure with the National Institute of Health Stroke Scale (NIHSS) and 90 days post-procedure with the modified Rankin Scale. RESULTS: One hundred patients were identified. Via multivariate analysis, we found that frontal lobe non-reperfusion (mean difference (MD) = -1.60, p = 0.002) and occipital lobe non-reperfusion (MD = -1.68, p = 0.001) were associated with worse mental status improvement while left-sided stroke (MD = 2.02, p < 0.001) featured better improvement post-thrombectomy. Occipital lobe non-reperfusion (MD = -0.734, p = 0.009) was associated with the worse improvement of visual fields. The non-reperfusion of the frontal lobe was associated with a 1.732-worse NIHSS hemibody strength score (95% confidence interval (95%CI) = -3.39 to -0.072, p = 0.041). Worse improvement in NIHSS scores was found to be associated with frontal lobe non-reperfusion (MD = -5.34, 95%CI = -9.52 to -1.18, p = 0.013) and occipital lobe non-reperfusion (MD = -6.35, 95%CI = -10.4 to -2.31, p = 0.002). Odds of achieving modified Rankin Scale of 0-2 at 90 days were decreased with frontal lobe non-reperfusion (odds ratio (OR) = 0.279, 95%CI = 0.090-0.869, p = 0.028) and left laterality (OR = 0.376, 95%CI = 0.153-0.922, p = 0.033). CONCLUSIONS: Eloquence-based reperfusion assessment is an important predictor for functional outcomes after thrombectomy.

Direct Transfer to Angiosuite in Acute Stroke: Why, When, and How?

Time to reperfusion is one of the strongest predictors of functional outcome in acute stroke due to a large vessel occlusion (LVO). Direct transfer to angiography suite (DTAS) protocols have shown encouraging results in reducing in-hospital delays. DTAS allows bypassing of conventional imaging in the emergency room by ruling out an intracranial hemorrhage or a large established infarct with imaging performed before transfer to the thrombectomy-capable center in the angiography suite using flat-panel CT (FP-CT). The rate of patients with stroke code primarily admitted to a comprehensive stroke center with a large ischemic established lesion is <10% within 6 hours from onset and remains <20% among patients with LVO or transferred from a primary stroke center. At the same time, stroke severity is an acceptable predictor of LVO. Therefore, ideal DTAS candidates are patients admitted in the early window with severe symptoms. The main difference between protocols adopted in different centers is the inclusion of FP-CT angiography to confirm an LVO before femoral puncture. While some centers advocate for FP-CT angiography, others favor additional time saving by directly assessing the presence of LVO with an angiogram. The latter, however, leads to unnecessary arterial punctures in patients with no LVO (3%-22% depending on selection criteria). Independently of these different imaging protocols, DTAS has been shown to be effective and safe in improving in-hospital workflow, achieving a reduction of door-to-puncture time as low as 16 minutes without safety concerns. The impact of DTAS on long-term functional outcomes varies between published studies, and randomized controlled trials are warranted to examine the benefit of DTAS.