Decompressive craniectomy plus best medical treatment versus best medical treatment alone for spontaneous severe deep supratentorial intracerebral haemorrhage: a randomised controlled clinical trial.

BACKGROUND: It is unknown whether decompressive craniectomy improves clinical outcome for people with spontaneous severe deep intracerebral haemorrhage. The SWITCH trial aimed to assess whether decompressive craniectomy plus best medical treatment in these patients improves outcome at 6 months compared to best medical treatment alone. METHODS: In this multicentre, randomised, open-label, assessor-blinded trial conducted in 42 stroke centres in Austria, Belgium, Finland, France, Germany, the Netherlands, Spain, Sweden, and Switzerland, adults (18-75 years) with a severe intracerebral haemorrhage involving the basal ganglia or thalamus were randomly assigned to receive either decompressive craniectomy plus best medical treatment or best medical treatment alone. The primary outcome was a score of 5-6 on the modified Rankin Scale (mRS) at 180 days, analysed in the intention-to-treat population. This trial is registered with ClincalTrials.gov, NCT02258919, and is completed. FINDINGS: SWITCH had to be stopped early due to lack of funding. Between Oct 6, 2014, and April 4, 2023, 201 individuals were randomly assigned and 197 gave delayed informed consent (96 decompressive craniectomy plus best medical treatment, 101 best medical treatment). 63 (32%) were women and 134 (68%) men, the median age was 61 years (IQR 51-68), and the median haematoma volume 57 mL (IQR 44-74). 42 (44%) of 95 participants assigned to decompressive craniectomy plus best medical treatment and 55 (58%) assigned to best medical treatment alone had an mRS of 5-6 at 180 days (adjusted risk ratio [aRR] 0·77, 95% CI 0·59 to 1·01, adjusted risk difference [aRD] -13%, 95% CI -26 to 0, p=0·057). In the per-protocol analysis, 36 (47%) of 77 participants in the decompressive craniectomy plus best medical treatment group and 44 (60%) of 73 in the best medical treatment alone group had an mRS of 5-6 (aRR 0·76, 95% CI 0·58 to 1·00, aRD -15%, 95% CI -28 to 0). Severe adverse events occurred in 42 (41%) of 103 participants receiving decompressive craniectomy plus best medical treatment and 41 (44%) of 94 receiving best medical treatment. INTERPRETATION: SWITCH provides weak evidence that decompressive craniectomy plus best medical treatment might be superior to best medical treatment alone in people with severe deep intracerebral haemorrhage. The results do not apply to intracerebral haemorrhage in other locations, and survival is associated with severe disability in both groups. FUNDING: Swiss National Science Foundation, Swiss Heart Foundation, Inselspital Stiftung, and Boehringer Ingelheim.

Advances in Prehospital Management of Intracerebral Hemorrhage.

BACKGROUND: Spontaneous acute intracerebral hemorrhage (ICH) is associated with greater stroke-related disability and mortality. Hematoma expansion (HME), an important treatment target in acute ICH, is time-dependent, with a greater probability of hematoma growth occurring <3 hours from ICH onset. SUMMARY: Promising treatment options to reduce HME include early intensive blood pressure (BP) reduction and the administration of hemostatic or anticoagulant reversal agents, yet large phase III clinical trials have so far failed to show overwhelming benefit for these interventions in acute ICH. Post-hoc analyses provide evidence, however, that the therapeutic benefit of such treatments is enhanced by rapid and ultra-early intervention, likely driven in large part by attenuation of early HME. Clinical trials assessing ultra-rapid treatments (<2 hours from ICH onset), including study procedures in the ambulance setting are currently underway, and demonstrate that the prehospital phase is a critical window for ICH management and an indispensable area of ICH research. Mobile stroke units, specialized ambulances equipped with imaging capabilities can provide confirmatory diagnosis and expedite treatments, as in acute ischemic stroke. Nevertheless, multiple barriers (financial, organisational, geographical among others) hinder worldwide implementation. Emerging portable technologies as well as point-of-care measures of blood biomarkers show promise as feasible adjunct tools to discriminate ICH from AIS in the field and have the potential for widespread accessibility. KEY MESSAGES: Ultra-early interventions in acute ICH are likely necessary to mitigate the risk of HME, and as such, the prehospital setting is ideal to initiate time-sensitive ICH therapies. As such, reliable prehospital acute ICH detection is essential to provide disease-specific treatments. Overall, it is imperative that "Time is brain" become the mantra not only for ischemic stroke but for ICH as well, and that the promise of ultra-early therapies for ICH be translated into concrete benefits for patients with this devastating condition.

Swiss trial of decompressive craniectomy versus best medical treatment of spontaneous supratentorial intracerebral haemorrhage (SWITCH): an international, multicentre, randomised-controlled, two-arm, assessor-blinded trial.

RATIONALE: Decompressive craniectomy (DC) is beneficial in people with malignant middle cerebral artery infarction. Whether DC improves outcome in spontaneous intracerebral haemorrhage (ICH) is unknown. AIM: To determine whether DC without haematoma evacuation plus best medical treatment (BMT) in people with ICH decreases the risk of death or dependence at 6 months compared to BMT alone. METHODS AND DESIGN: SWITCH is an international, multicentre, randomised (1:1), two-arm, open-label, assessor-blinded trial. Key inclusion criteria are age ⩽75 years, stroke due to basal ganglia or thalamic ICH that may extend into cerebral lobes, ventricles or subarachnoid space, Glasgow coma scale of 8-13, NIHSS score of 10-30 and ICH volume of 30-100 mL. Randomisation must be performed <66 h after onset and DC <6 h after randomisation. Both groups will receive BMT. Participants randomised to the treatment group will receive DC of at least 12 cm in diameter according to institutional standards. SAMPLE SIZE: A sample of 300 participants randomised 1:1 to DC plus BMT versus BMT alone provides over 85% power at a two-sided alpha-level of 0.05 to detect a relative risk reduction of 33% using a chi-squared test. OUTCOMES: The primary outcome is the composite of death or dependence, defined as modified Rankin scale score 5-6 at 6 months. Secondary outcomes include death, functional status, quality of life and complications at 180 days and 12 months. DISCUSSION: SWITCH will inform physicians about the outcomes of DC plus BMT in people with spontaneous deep ICH, compared to BMT alone. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02258919.

Characteristics of Ischemic Stroke Despite Oral Anticoagulant Use For Atrial Fibrillation.

Oral anticoagulation (OAC) prevents stroke in atrial fibrillation, yet a residual stroke risk remains. In this single-center retrospective analysis of acute ischemic stroke patients despite OAC, suboptimal OAC treatment is common (30%: inappropriate dosing (17%); patient non-adherence (13%)). Other causes of stroke included OAC interruption (14.5%), a competing stroke mechanism (11.0%), and undetermined breakthrough stroke in 44.5%. Overall, easily modifiable causes of ischemic stroke despite OAC are common. Accordingly, strategies to improve treatment compliance, including appropriate dosing along with guideline-based risk factor and periprocedural OAC management, should be emphasized to improve secondary stroke prevention in this patient population.

Screening for cognitive impairment in adults with sickle cell disease: A systematic review and meta-analysis.

Neurovascular disease such as symptomatic stroke, silent brain infarcts and vascular cognitive impairment are common complications of sickle cell disease (SCD) that can have devastating consequences on quality of life, employment, and social functioning.  Early recognition of neurovascular disease is a prerequisite for the timely optimization of medical care and to connect patients to adaptive resources. While cognitive impairment has been well described in children, currently available data are limited in adults. As a result, guidance on the optimal cognitive screening strategies in adults is scarce. We conducted a systematic review to identify the different screening tools that have been evaluated in SCD. A meta-analysis was performed to estimate the prevalence of suspected cognitive impairment in this population. In this qualitative synthesis, we present 8 studies that evaluated 6 different screening tools. Patient characteristics that impacted on cognitive screening performance included age, education level, and a prior history of stroke. We report a pooled prevalence of 38% [14-62%] of suspected cognitive impairment. We discuss the relative benefits and limitations of the different screening tools to help clinicians select an adapted approach tailored to their specific patients' needs. Further studies are needed to establish and validate cognitive screening strategies in patients with diverse cultural and educational backgrounds.

Infratentorial Brain Injury Among Patients Suspected of Death by Neurologic Criteria: A Systematic Review and Meta-analysis.

BACKGROUND AND OBJECTIVES: There is a paucity of data on the frequency and prognosis of infratentorial brain injury among patients suspected of death by neurologic criteria (DNC), which likely contributes to scientific uncertainty regarding the role of isolated brainstem death in DNC determination. Our aim was to synthesize the prevalence, characteristics, and evolution of infratentorial brain injury, including isolated brainstem death, among patients suspected of DNC. METHODS: We conducted a systematic review by searching Medline, Embase, EBM Reviews, CINAHL Complete, and the gray literature from inception to March 26, 2021. We selected cohort and cross-sectional studies, case reports, and case series that included patients suspected of DNC. Two study investigators independently performed study selection, data collection, and risk of bias assessment. Our primary outcomes were the respective prevalence of infratentorial brain injury and isolated brainstem death, which we meta-analyzed using mixed-effects Bayesian hierarchical models with diffuse priors. Our secondary outcomes were the characteristics and evolution of patients with infratentorial brain injury and isolated brainstem death. RESULTS: Twenty-one studies met the selection criteria, most of which were of moderate to high risk of bias. Among patients suspected of DNC, the prevalence of infratentorial brain injury ranged from 2% to 16% (n = 3,602, mean prevalence: 6.3%, 95% highest density interval [2.4%-14.2%]), whereas the prevalence of isolated brainstem death ranged from 1% to 4% (n = 3,692, mean prevalence: 1.5%, 95% highest density interval [0.5%-3.9%]). A total of 38 isolated brainstem death cases with data on clinical characteristics and/or evolution were included. All had infratentorial strokes. Twenty patients had EEG background activity in the α or θ frequencies, 19 had preserved cerebral blood flow, 2 had preserved supratentorial cerebral perfusion, 2 had cortical responses to visual evoked potentials, and 1 had cortical responses to somatosensory evoked potentials. At the latest follow-up, 28 had progressed to whole-brain death. DISCUSSION: Studies with moderate to high risk of bias suggest that infratentorial brain injury is relatively uncommon among patients suspected of DNC. Isolated brainstem death is rarer and seems to carry a high risk of progression to whole-brain death. These findings require further high-quality investigation.

Successful thrombectomy is beneficial in patients with pre-stroke disability: Results from an international multicenter cohort study.

BACKGROUND: Patients with pre-stroke disability, defined as a modified Rankin Scale (mRS) ≥3, were excluded from most trials of endovascular thrombectomy (EVT) for acute stroke. We sought to evaluate the prognostic factors associated with favorable outcome in stroke patients with known disability undergoing EVT, and the impact of successful reperfusion. METHODS: Consecutive acute stroke patients with pre-stroke disability, undergoing EVT, were retrospectively collected between 2016 to 2019 from a Canadian cohort and a multicenter French cohort (Endovascular Treatment in Ischemic Stroke registry-ETIS). Favorable outcome was defined as an mRS equal to pre-stroke mRS. Patients achieving successful reperfusion (defined as a modified Thrombolysis in Cerebral Infarction score of 2b/3) were compared with patients without successful reperfusion to determine if successful EVT was associated with better functional outcomes. RESULTS: Among 6220 patients treated with EVT, 280 (4.5%) patients with a pre-stroke mRS ≥3 were included. Sixty-one patients (21.8%) had a favorable outcome and 146 (52.1%) died at 3 months. Patients with successful reperfusion had a higher proportion of favorable 90-day mRS (27.6% versus 19.6%, p = 0.025) and a lower mortality (48.3% versus 69.6%, p = 0.008) than patients without successful reperfusion. After adjusting for baseline prognostic factors, successful reperfusion defined by TICI ≥2b was associated with favorable functional outcome (OR 3.16 CI95% [1.11-11.5]; p 0.048). CONCLUSION: In patients with pre-stroke disability, successful reperfusion is associated with a greater proportion of favorable outcome and lower mortality.

Three-month functional outcomes following endovascular thrombectomy during the first wave of the COVID-19 pandemic: a Canadian single-center cohort study.

BACKGROUND: The COVID-19 pandemic has disrupted acute stroke care logistics, including delays in hyperacute management and decreased monitoring following endovascular therapy (EVT). We aimed to assess the impact of the pandemic on 90-day functional outcome among patients treated with EVT. METHODS: This is an observational cohort study including all patients evaluated for an acute stroke between March 30, 2020 and September 30, 2020 (pandemic cohort) and 2019 (reference cohort) in a high-volume Canadian academic stroke center. We collected baseline characteristics, acute reperfusion treatment and management metrics. For EVT-treated patients, we assessed the modified Rankin score (mRS) at 90 days. We evaluated the impact of the pandemic on a 90-day favourable functional status (defined as mRS 0-2) and death using multivariable logistic regressions. RESULTS: Among 383 and 339 patients included in the pandemic and reference cohorts, baseline characteristics were similar. Delays from symptom onset to evaluation and in-house treatment were longer during the early first wave, but returned to reference values in the subsequent months. Among the 127 and 136 EVT-treated patients in each respective cohort, favourable 90-day outcome occurred in 53/99 (53%) vs 52/109 (48%, p=0.40), whereas 22/99 (22%) and 28/109 (26%, p=0.56) patients died. In multivariable regressions, the pandemic period was not associated with 90-day favourable functional status (aOR 1.27, 95% CI 0.60 to 2.56) or death (aOR 0.74, 95% CI 0.33 to 1.63). CONCLUSION: In this single-center cohort study conducted in a Canadian pandemic epicenter, the first 6 months of the COVID-19 pandemic did not impact 90-day functional outcomes or death among EVT-treated patients.

Predictors of Outcome After Mechanical Thrombectomy in Stroke Patients Aged ≥85 Years.

BACKGROUND: The effectiveness of mechanical thrombectomy (MT) in elderly stroke patients remains debated. We aimed to describe outcomes and their predictors in a cohort of patients aged ≥ 85 years treated with MT. METHODS: Data from consecutive patients aged ≥ 85 years undergoing MT at two stroke centers between January 2016 and November 2019 were reviewed. Admission National Institutes of Health Stroke Scale (NIHSS), pre-stroke, and 3-month modified Rankin scale (mRS) were collected. Successful recanalization was defined as modified thrombolysis in cerebral ischemia score ≥ 2b. Good outcome was defined as mRS 0-3 or equal to pre-stroke mRS at 3 months. RESULTS: Of 151 included patients, successful recanalization was achieved in 74.2%. At 3 months, 44.7% of patients had a good outcome and 39% had died. Any intracranial hemorrhage (ICH) and symptomatic ICH occurred in 20.3% and 3.6%, respectively. Logistic regression analysis identified lower pre-stroke mRS score (adjusted odds ratio [aOR], 0.52; 95% CI, 0.36-0.76), lower admission NIHSS score (aOR, 0.90; 95% CI, 0.83-0.97), successful recanalization (aOR, 3.65; 95% CI, 1.32-10.09), and absence of ICH on follow-up imaging (aOR, 0.42; 95% CI, 0.08-0.75), to be independent predictors of good outcome. Patients with successful recanalization had a higher proportion of good outcome (45.3% vs 34.3%, p = 0.013) and lower mortality at 3 months (35.8% vs 48.6%, p = 0.006) compared to patients with unsuccessful recanalization. CONCLUSIONS: Among patients aged ≥ 85 years, successful recanalization with MT is relatively common and associated with better 3-month outcome and lower mortality than failed recanalization. Attempting to achieve recanalization in elderly patients using MT appears reasonable.

Prospective Evaluation of a Two-Scale Protocol for Prehospital Large Vessel Occlusion Detection.

Background and purposes: Stroke severity scales may expedite prehospital large vessel occlusion (LVO) stroke detection, but few are validated for paramedic use. We evaluated the feasibility of introducing the Cincinnati Stroke Triage Assessment Tool (C-STAT) in the field and its capacity to detect LVO stroke.Methods: We performed a prospective paramedic-based study assessing C-STAT in the field on patients currently redirected to two comprehensive stroke centers (CSC), based on a Cincinnati Prehospital Stroke Scale (CPSS) score of 3/3. C-STAT was administered by on-site paramedics with telephone guidance from trained centralized clinical support paramedics.Results: Between October 2018 and November 2019, C-STAT scores were obtained in 188/218 (86.2%) patients, among which 118/188 (62.8%) were positive. Paramedics reported performing the C-STAT in less than 5 minutes on 170/188 (90.4%) patients and noted no difficulties administering the scale in 151/188 (80.3%). A positive C-STAT identified 51/68 (75%) LVO strokes in the cohort, demonstrating a 43% (95% CI: 38%-48%) positive and 76% (95% CI: 66%-83%) negative predictive value for LVO stroke diagnosis. In a cohort of 100 patients with CPSS 3/3, requiring a positive C-STAT for redirection would decrease CSC patient volume by 37 but miss 9 of 36 LVO strokes.Conclusion: Prehospital administration of the C-STAT was feasible, using a model of minimal paramedic training and real-time telephone guidance. A protocol based on both a CPSS 3/3 and a positive C-STAT would decrease CSC redirected patient volume by one-third but would miss one-quarter of LVO strokes when compared to a CPSS-based protocol.

Early Impact of the COVID-19 Pandemic on Acute Stroke Treatment Delays.

This is an observational cohort study comparing 156 patients evaluated for acute stroke between March 30 and May 31, 2020 at a comprehensive stroke center with 138 patients evaluated during the corresponding time period in 2019. During the pandemic, the proportion of COVID-19 positive patients was low (3%), the time from symptom onset to hospital presentation was significantly longer, and a smaller proportion of patients underwent reperfusion therapy. Among patients directly evaluated at our institution, door-to-needle and door-to-recanalization metrics were significantly longer. Our findings support concerns that the current pandemic may have a negative impact on the management of acute stroke.

Acute carotid stenting in patients undergoing thrombectomy: a systematic review and meta-analysis.

BACKGROUND: The benefit of acute carotid stenting compared with no acute stenting on clinical outcomes among patients with tandem lesions (TL) undergoing endovascular thrombectomy (EVT) remains unknown. METHODS: We conducted a a systematic review and meta-analysis of studies comparing acute carotid stenting versus no stenting among TL patients undergoing EVT with regards to 90 day modified Rankin Scale (mRS) score, symptomatic intracerebral hemorrhage (sICH), and mortality. Four reviewers screened citations for eligibility and two assessed retained studies for risk of bias and data extraction. A random effects model was used for the synthesis of aggregated data. RESULTS: 21 studies (n=1635 patients) were identified for the systematic review; 19 were cohort studies, 1 was a post-hoc analysis of an EVT trial, and 1 was a pilot randomized controlled trial. 16 studies were included in the meta-analysis. Acute stenting was associated with a favorable 90 day mRS score: OR 1.43 (95% CI 1.07, 1.91). No significant heterogeneity between studies was found for this outcome (I2=17.0%; χ2=18.07, p=0.26). There were no statistically significant differences for 3 month mortality (OR 0.80 (95% CI 0.50, 1.28)) or sICH (OR 1.41 (95% CI 0.91, 2.19)). CONCLUSIONS: This meta-analysis suggests that among TL patients undergoing EVT, acute carotid stenting is associated with a greater likelihood of favorable outcome at 90 days compared with no stenting.

Streamlined Poststroke Treatment Order Sets During the SARS-CoV-2 Pandemic: Simplifying While Not Compromising Care.

BACKGROUND AND PURPOSE: Standard poststroke treatment monitoring protocols are made problematic during the coronavirus disease 2019 (COVID-19) pandemic by the frequency of patient assessments, requiring repeated donning and doffing procedures in a short interval of time. METHODS: A streamlined poststroke treatment protocol was developed to limit frequency of patient encounters while maximizing the yield of each encounter by grouping together different components of poststroke care into single bedside visits. RESULTS: Streamlined order sets were developed late March 2020. During the first 6 weeks following implementation, 70 patients were admitted to a geographically defined designated warm COVID-19 unit with modified poststroke care order sets. Of these, 33 (47.1%) patients received acute reperfusion therapy. All but 3 patients evolved favorably with either stable or improving National Institutes of Health Stroke Scale at 24 hours. In the 3 patients who experienced early neurological deterioration, none were found to be attributable to insufficient patient monitoring. CONCLUSIONS: Adapting preexisting poststroke care protocols may be necessary while the risk of COVID-19 infection remains high. We propose a streamlined approach to facilitate poststroke monitoring in patients with stroke with unknown COVID status.

Medical management with interventional therapy versus medical management alone for unruptured brain arteriovenous malformations (ARUBA): final follow-up of a multicentre, non-blinded, randomised controlled trial.

BACKGROUND: In A Randomized trial of Unruptured Brain Arteriovenous malformations (ARUBA), randomisation was halted at a mean follow-up of 33·3 months after a prespecified interim analysis showed that medical management alone was superior to the combination of medical management and interventional therapy in preventing symptomatic stroke or death. We aimed to study whether these differences persisted through 5-years' follow-up. METHODS: ARUBA was a non-blinded, randomised trial done at 39 clinical centres in nine countries. Adults (age ≥18 years) diagnosed with an unruptured brain arteriovenous malformation, who had never undergone interventional therapy, and were considered by participating clinical centres to be suitable for intervention to eradicate the lesion, were eligible for inclusion. Patients were randomly assigned (1:1) by a web-based data collection system, stratified by clinical centre in a random permuted block design with block sizes of two, four, and six, to medical management alone or with interventional therapy (neurosurgery, embolisation, or stereotactic radiotherapy, alone or in any combination, sequence, or number). Although patients and investigators at a given centre were not masked to treatment assignment, investigators at other centres and those in the clinical coordinating centre were not informed of assignment or outcomes at any of the centres. The primary outcome was time to death or symptomatic stroke confirmed by imaging, assessed by a neurologist at each centre not involved in the management of participants' care, and monitored by an independent committee using an adaptive approach with interim analyses. Enrolment began on April 4, 2007, and was halted on April 15, 2013, after which follow-up continued until July 15, 2015. All analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, NCT00389181. FINDINGS: Of 1740 patients screened, 226 were randomly assigned to medical management alone (n=110) or medical management plus interventional therapy (n=116). During a mean follow-up of 50·4 months (SD 22·9), the incidence of death or symptomatic stroke was lower with medical management alone (15 of 110, 3·39 per 100 patient-years) than with medical management with interventional therapy (41 of 116, 12·32 per 100 patient-years; hazard ratio 0·31, 95% CI 0·17 to 0·56). Two patients in the medical management group and four in the interventional therapy group (two attributed to intervention) died during follow-up. Adverse events were observed less often in patients allocated to medical management compared with interventional therapy (283 vs 369; 58·97 vs 78·73 per 100 patient-years; risk difference -19·76, 95% CI -30·33 to -9·19). INTERPRETATION: After extended follow-up, ARUBA showed that medical management alone remained superior to interventional therapy for the prevention of death or symptomatic stroke in patients with an unruptured brain arteriovenous malformation. The data concerning the disparity in outcomes should affect standard specialist practice and the information presented to patients. The even longer-term risks and differences between the two therapeutic approaches remains uncertain. FUNDING: National Institute of Neurological Disorders and Stroke for the randomisation phase and Vital Projects Fund for the follow-up phase.

Non-Contrast CT and CT-Angiogram for Late Window Ischemic Stroke Treatment Selection.

INTRODUCTION: The benefit of late window endovascular treatment (EVT) for anterior circulation ischemic stroke has been demonstrated using perfusion-based neuroimaging. We evaluated whether non-contrast CT (NCCT) and CT-angiogram (CTA) alone can select late-presenting patients for EVT. METHODS: We performed a retrospective comparison of all patients undergoing EVT at a single comprehensive stroke center from January 2016 to April 2017. Patients planned for EVT were divided into early (<6 hours from onset) and late (≥6 hours from onset or last time seen normal) window groups. Incidence of symptomatic hemorrhagic transformations (sHTs) at 24 hours and 3-month modified Rankin scores (mRSs) were compared. RESULTS: During the study period, 204 (82%) patients underwent EVT in the early and 44 (18%) in the late window. Median (interquartile range) NIH Stroke Scale Score was similar between groups (early: 18 [15-23] vs. late: 17 [13-21]), as were median ASPECT scores (early: 9 [8-10] vs. late: 9 [7-9]). In the late window, 42 (95%) strokes were of unknown onset. Similar proportions of sHT occurred at 24 hours (early: 12 [6%] vs. late: 4 [9%], p = 0.43). At 3 months, the proportion of patients achieving functional independence (mRS 0-2) were comparable in the early (80/192 [42%]) and late (16/41 [39%]) windows (p = 0.76). CONCLUSION: NCCT- and CTA-based patient selection led to similar functional independence outcomes and low proportions of sHT in the early and late windows. In centers without access to perfusion-based neuroimaging, this pragmatic approach could be safe, particularly for strokes of unknown onset.

Sex differences in treatment, radiological features and outcome after intracerebral haemorrhage: Pooled analysis of Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials 1 and 2.

INTRODUCTION: Reports vary on how sex influences the management and outcome from acute intracerebral haemorrhage. We aimed to quantify sex disparities in clinical characteristics, management, including response to blood pressure lowering treatment, and outcomes in patients with acute intracerebral haemorrhage, through interrogation of two large clinical trial databases. PATIENTS AND METHODS: Post-hoc pooled analysis of the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials 1 and 2, where patients with a hypertensive response (systolic, 150-220 mmHg) after spontaneous intracerebral haemorrhage (<6 h) were randomised to intensive (target <140 mmHg <1 h) or guideline-recommended (<180 mmHg) blood pressure lowering treatment. The interaction of sex on early haematoma growth (24 h), death or major disability (modified Rankin scale scores 3-6 at 90 days), and effect of randomised treatment were determined in multivariable logistic regression models adjusted for baseline confounding variables. RESULTS: In 3233 participants, 1191 (37%) were women who were significantly older, had higher baseline National Institutes of Health Stroke Scale scores and smaller haematoma volumes compared to men. Men had higher three-month mortality (odds ratio 1.48, 95% confidence interval 1.10-2.00); however, there was no difference between women and men in the combined endpoint of death or major disability. There were no significant sex differences on mean haematoma growth or effect of randomised blood pressure lowering treatment. DISCUSSION: Men included in the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials had more comorbidities, larger baseline haematoma volumes and higher mortality after adjustment for age, as compared with women. CONCLUSION: Men included in the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials had a greater odds of dying after intracerebral haemorrhage than women, which could not be readily explained by differing casemix or patterns of blood pressure management. CLINICAL TRIAL REGISTRATION: The Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage trials studies are registered with ClinicalTrials.gov (NCT00226096 and NCT00716079).

A randomized pilot study of patients with tandem carotid lesions undergoing thrombectomy.

BACKGROUND AND PURPOSE: The optimal management of patients with tandem lesions (TL), or cervical internal carotid artery (c-ICA) steno-occlusive pathology and ipsilateral intracranial occlusion, who are undergoing endovascular thrombectomy (EVT) remains unknown. We sought to establish the feasibility of a trial designed to address this question. MATERIALS AND METHODS: The Endovascular Acute Stroke Intervention (EASI) study was a single-centre randomized trial comparing EVT to medical therapy for large-vessel occlusion stroke. Patients with TL receiving EVT were randomly allocated to acute c-ICA stenting or no stenting. The primary outcome was the proportion of patients with a modified Rankin Scale (mRS) score of 0-2 at 90 days. Safety outcomes were symptomatic intracranial hemorrhage (sICH) at 24hours and mortality at 90 days. RESULTS: Of 301 patients included in EASI between 2013 and 2018, 24 (8.0%) with TL were randomly allocated to acute stenting (n=13) or no stenting (n=11). Baseline characteristics were balanced. Eight (61.5%; 95% CI 35.5%-82.3%) and 7 (63.6%; 95% CI 35.4%-84.9%) patients, respectively, had a favorable outcome (mRS 0-2; P=1.0). One non-stented patient had a symptomatic intracerebral hemorrhage. CONCLUSIONS: This pilot trial of patients with TL undergoing EVT suggests that a sufficiently powered larger TL trial comparing acute c-ICA stenting to no stenting is feasible. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02157532.

Cincinnati Prehospital Stroke Scale for EMS Redirection of Large Vessel Occlusion Stroke.

INTRODUCTION: Prehospital identification of large vessel occlusion (LVO) stroke may expedite treatment by direct transport to comprehensive stroke centers (CSCs) with endovascular capabilities. The Cincinnati Prehospital Stroke Scale (CPSS) is commonly used for prehospital stroke detection. We aimed to assess whether (1) a high CPSS score can identify LVO and (2) an Emergency Medical Service (EMS) redirection protocol based on high CPSS accelerated endovascular treatment (EVT). METHODS: A retrospective comparison of patients transported by EMSs for suspected stroke to a high-volume CSC over a 16-month period, before and after implementation of an EMS redirection protocol based on high CPSS score (3/3). Charts were reviewed to determine the presence of LVO. Time to EVT and 3-month outcomes were compared before and after implementation. RESULTS: A prehospital CPSS 3/3 score was found in 223 (59%) patients, demonstrating positive and negative predictive values for LVO of 29% and 94%, respectively. CPSS-based EMS redirection increased the proportion of EVT performed after direct transport to CSC [before: 21 (36%), after: 45 (63%), p < 0.01] and decreased median first door-to-groin puncture time by 28 minutes [109 (interquartile range (IQR) 64-116) versus 81 (IQR 56-130), p = 0.03]. At 3 months, the proportion of patients achieving functional independence (modified Rankin score 0-2) went from 20/57 (35%) to 29/68 (43%) (p = 0.39) following implementation. CONCLUSIONS: CPSS-based EMS redirection accelerated identification of LVO strokes in the out-of-hospital setting and decreased time to EVT. Nevertheless, this protocol was also associated with high rates of non-LVO stroke. Impact on clinical outcomes should be evaluated in a larger cohort.

Utilité de l'échelle de Cincinnati pour la redirection des occlusions artérielles cérébrales proximales par les services médicaux d'urgence. Introduction : Dans un contexte pré-hospitalier, le fait de pouvoir identifier l'occlusion de vaisseaux sanguins cérébraux proximaux peut accélérer l'amorce d'un traitement en favorisant un transfert direct vers un centre complet de prise en charge des AVC (comprehensive stroke centers) doté de moyens d'intervention endovasculaire. L'échelle de Cincinnati (Cincinnati Prehospital Stroke Scale ou CPSS) est couramment utilisée afin de détecter les signes d'un AVC dans un contexte pré-hospitalier. Notre intention est double ici : 1) évaluer dans quelle mesure un score élevé à la CPSS peut permettre d'identifier l'occlusion de vaisseaux sanguins cérébraux proximaux ; 2) évaluer dans quelle mesure un protocole des services médicaux d'urgence consistant à rediriger des patients en fonction d'un score élevé à la CPSS a permis d'accélérer l'offre d'un traitement endovasculaire. Méthodes : Au cours d'une période de 16 mois, soit avant et après la mise sur pied de ce protocole en fonction d'un score élevé à la CPSS (3/3), nous avons effectué une comparaison rétrospective des dossiers de patients transportés vers des centres complets de prise en charge des AVC en raison de soupçons d'AVC. Ces dossiers ont été analysés afin de pouvoir identifier les cas d'occlusion proximales. Enfin, les délais permettant d'obtenir un traitement endovasculaire et l'évolution de l'état de santé des patients au bout de 3 mois ont été comparés avant et après la mise sur pied de ce protocole. Résultats : En fonction d'un score de 3/3 à la CPSS obtenu en contexte pré-hospitalier a été observé chez 223 patients (59 %), la valeur prédictive positive et négative pour des cas d'occlusion de vaisseaux sanguins cérébraux proximaux étant respectivement de 29 % et de 94 %. Le fait que les services médicaux d'urgence redirigent des patients en fonction d'un certain score à la CPSS a fini par augmenter le nombre de traitements endovasculaires prodigués à la suite d'un transfert direct vers un centre complet de prise en charge des AVC (avant le protocole : 21 (36 %) ; après le protocole : 45 (63 %) ; p < 0,01) et par diminuer de 28 minutes les délais entre la prise en charge à l'arrivée et la ponction artérielle (109 [intervalle interquartile de 64-116] contre 81 [intervalle interquartile de 56-130] ; p = 0,03). Au bout de 3 mois, à la suite de la mise sur pied du protocole, la proportion de patients autonomes sur le plan fonctionnel (échelle de Rankin modifiée : 0-2) est passée de 20/57 (35 %) à 29/68 (43 %) (p = 0,39). Conclusion : Le fait de rediriger des patients en fonction d'un certain score à la CPSS a permis d'accélérer la détection de cas d'AVC survenus à la suite de l'occlusion de vaisseaux sanguins cérébraux proximaux et donc de réduire les temps d'intervention. Cela dit, ce protocole a aussi été associé à un taux élevé de détection d'AVC non produits par l'occlusion de vaisseaux sanguins cérébraux proximaux. L'impact de cette constatation en ce qui regarde l'évolution de l'état de santé des patients devrait être évalué dans une plus vaste cohorte.

Lack of Consensus Among Stroke Experts on the Optimal Management of Patients With Acute Tandem Occlusion.

Background and Purpose- In patients with acute stroke caused by tandem occlusion, the benefit of immediate revascularization (stenting) of the cervical internal carotid artery lesion during endovascular thrombectomy is uncertain. We sought to determine current practice patterns and whether consensus existed among physicians with stroke expertise. Methods- We distributed an online survey to stroke experts affiliated with the Canadian Stroke Consortium, the Canadian Interventional Neuro Group, the Society of Vascular and Interventional Neurology, and international ESCAPE trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times) collaborators. Questions were based on clinical scenarios, and multiple choice responses across a Likert-type scale were provided. The survey was sent out in September 2017. After 2 months, data were extracted and then analyzed using descriptive statistics. Results- Responses from 162 stroke experts were analyzed; most were stroke physicians (n=65, 40.1%) and neurointerventionalists (n=74, 45.7%), from Canada (n=95, 58.6%), the United States (n=42, 25.9%), and other countries (n=25, 15.4%). Over half (n=96, 59.3%) of respondents consider acute stenting of the cervical internal carotid artery as a treatment option, whereas 40.7% (n=66) would never use it. Most respondents (n=113, 69.8%) agree that there exists uncertainty about the optimal acute management of patients with tandem occlusion. A majority (n=88, 54.3%) of physicians surveyed would include patients in a randomized trial addressing this question. Conclusions- This survey shows high variability in practice about acute management of tandem occlusion. The existence of community equipoise underscores the importance of a randomized trial evaluating the benefit of acute internal carotid artery stenting in patients with tandem occlusion undergoing endovascular thrombectomy.