Angiography­based quantitative flow ratio for functional assessment of intracranial atherosclerotic disease.

BACKGROUND: Intracranial atherosclerotic stenosis (ICAS), an important cause of stroke, is associated with a considerable stroke recurrence rate despite optimal medical treatment. Further assessment of the functional significance of ICAS is urgently needed to enable individualised treatment and, thus, improve patient outcomes. AIMS: We aimed to evaluate the haemodynamic significance of ICAS using the quantitative flow ratio (QFR) technique and to develop a risk stratification model for ICAS patients. METHODS: Patients with moderate to severe stenosis of the middle cerebral artery, as shown on angiography, were retrospectively enrolled. For haemodynamic assessment, the Murray law-based QFR (µQFR) was performed on eligible patients. Multivariate logistic regression models composed of µQFR and other risk factors were developed and compared for the identification of symptomatic lesions. Based on the superior model, a nomogram was established and validated by calibration. RESULTS: Among 412 eligible patients, symptomatic lesions were found in 313 (76.0%) patients. The µQFR outperformed the degree of stenosis in discriminating culprit lesions (area under the curve [AUC]: 0.726 vs 0.631; DeLong test p-value=0.001), and the model incorporating µQFR and conventional risk factors also performed better than that containing conventional risk factors only (AUC: 0.850 vs 0.827; DeLong test p-value=0.034; continuous net reclassification index=0.620, integrated discrimination improvement=0.057; both p<0.001). The final nomogram showed good calibration (p for Hosmer-Lemeshow test=0.102) and discrimination (C-statistic 0.850, 95% confidence interval: 0.812-0.883). CONCLUSIONS: The µQFR was significantly associated with symptomatic ICAS and outperformed the angiographic stenosis severity. The final nomogram effectively discriminated symptomatic lesions and may provide a useful tool for risk stratification in ICAS patients.

Angiography-based hemodynamic features predict recurrent ischemic events after angioplasty and stenting of intracranial vertebrobasilar atherosclerotic stenosis.

OBJECTIVES: To assess the predictive value of hemodynamic features for stroke relapse in patients with intracranial vertebrobasilar atherosclerotic stenosis treated with percutaneous transluminal angioplasty and stenting (PTAS) using quantitative digital subtraction angiography (q-DSA). METHODS: In this retrospective longitudinal study, patients with intracranial vertebrobasilar atherosclerotic stenosis and who underwent PTAS treatment between January 2012 and May 2020 were enrolled. The q-DSA assessment was performed before and after PTAS. ROIs 1-4 were placed along the vertebral artery, proximal and distal basilar artery, and posterior cerebral artery; ROIs 5-8 were in 5 mm and 10 mm proximal and distal to the lesion, respectively. Relative time to peak (rTTP) was defined as the difference in TTP between ROIs. Cox regression analyses were performed to determine risk factors for recurrent stroke. RESULTS: A total of 137 patients (mean age, 62 years ± 10 [standard deviation], 83.2% males) were included, and 26 (19.0%) patients had stroke relapse during follow-up (median time of 42.6 months [interquartile range, 19.7-60.7]). Preprocedural rTTP4-1 (adjusted hazard ratio (HR) = 2.270; 95% CI 1.371-3.758; p = 0.001) and preprocedural rTTP8-5 (adjusted HR = 0.240; 95% CI 0.088-0.658; p = 0.006) were independently associated with the recurrent stroke. These hemodynamic parameters provided an incremental prognostic value for stroke relapse (AUC, 0.817 [0.704-0.931]; the net reclassification index, 0.431 [0.057-0.625]; and the integrated discrimination index, 0.140 [0.035-0.292]). CONCLUSIONS: In patients with intracranial vertebrobasilar atherosclerosis treated with PTAS, preprocedural prolonged TTP of the target vessel and shortened trans-stenotic TTP difference were associated with stroke relapse. Q-DSA-defined hemodynamic parameters provided incremental predictive value over conventional parameters for stroke recurrence. CLINICAL RELEVANCE STATEMENT: Quantitative DSA analysis enables intuitive observation and semi-quantitative evaluation of peri-therapeutic cerebral blood flow. More importantly, quantitative DSA-defined hemodynamic parameters have the potential for risk stratification of patients with intracranial atherosclerotic stenosis. KEY POINTS: Semi-quantitative angiography-based parameters can reflect pre- and postprocedural subtle changes in blood flow in patients with intracranial atherosclerotic stenosis. Although angioplasty procedures can significantly improve blood flow status, patients with more restricted baseline blood flow still show a higher risk of stroke recurrence. Angiography-based hemodynamic features possess prognostic value and can serve as clinical markers to assess stroke risk of patients with intracranial atherosclerotic stenosis.

Vascular endothelium deploys caveolin-1 to regulate oligodendrogenesis after chronic cerebral ischemia in mice.

Oligovascular coupling contributes to white matter vascular homeostasis. However, little is known about the effects of oligovascular interaction on oligodendrocyte precursor cell (OPC) changes in chronic cerebral ischemia. Here, using a mouse of bilateral carotid artery stenosis, we show a gradual accumulation of OPCs on vasculature with impaired oligodendrogenesis. Mechanistically, chronic ischemia induces a substantial loss of endothelial caveolin-1 (Cav-1), leading to vascular secretion of heat shock protein 90α (HSP90α). Endothelial-specific over-expression of Cav-1 or genetic knockdown of vascular HSP90α restores normal vascular-OPC interaction, promotes oligodendrogenesis and attenuates ischemic myelin damage. miR-3074(-1)-3p is identified as a direct inducer of Cav-1 reduction in mice and humans. Endothelial uptake of nanoparticle-antagomir improves myelin damage and cognitive deficits dependent on Cav-1. In summary, our findings demonstrate that vascular abnormality may compromise oligodendrogenesis and myelin regeneration through endothelial Cav-1, which may provide an intercellular mechanism in ischemic demyelination.

The MRI enhancement ratio and plaque steepness may be more accurate for predicting recurrent ischemic cerebrovascular events in patients with intracranial atherosclerosis.

OBJECTIVES: To assess the complementary value of high-resolution multi-contrast MRI (hrMRI) in identifying symptomatic patients with intracranial atherosclerosis (ICAS) who are likely to experience recurrent ischemic cerebrovascular events. METHODS: In this retrospective cohort study, eighty patients with acute ischemic events attributed to ICAS who underwent hrMRI examination between January 2015 and January 2019 were included. Median follow-up for all patients was 30 months (range: 1 to 52 months) and recurrent ischemic cerebrovascular events were recorded. Cox regression analysis and time-dependent ROC were performed to quantify the association between the plaque characteristics and recurrent events. RESULTS: During the follow-up, 14 patients experienced recurrent ischemic cerebrovascular events. Young males and those with diabetes and poor medication persistence were more likely to experience recurrent events. ICAS in patients with recurrence had significantly higher enhancement ratio and steepness which is defined as the ratio between the plaque height and length than those without (p < 0.001 and p = 0.015, respectively). After adjustment of clinical factors, enhancement ratio (HR, 13.13 [95% CI, 3.58-48.20], p < 0.001) and plaque steepness (HR, 110.27 [95% CI, 4.75-2560.91], p = 0.003) were independent imaging biomarkers associated with recurrent events. Time-dependent ROC indicated that integrated high enhancement ratio and steepness into clinical risk factors improved discrimination power with the ROC increased from 0.79 to 0.94 (p = 0.008). CONCLUSIONS: The enhancement ratio and plaque steepness improved the accuracy over traditional clinical risk factors in predicting recurrent ischemic cerebrovascular events for patients with ICAS. KEY POINTS: • High-resolution magnetic resonance imaging helps clinicians to evaluate high-risk Intracranial plaque. • The higher enhancement ratio and plaque steepness (= height/length) were the primary biomarkers associated with future ischemic cerebrovascular events. • High-resolution magnetic resonance imaging combined with clinical characteristics showed a higher accuracy for the prediction of recurrent events in patients with intracranial atherosclerosis.

Functional Assessment of Cerebral Artery Stenosis by Angiography-Based Quantitative Flow Ratio: A Pilot Study.

BACKGROUND: Increasing attention has been paid to the hemodynamic evaluation of cerebral arterial stenosis. We aimed to demonstrate the performance of angiography-based quantitative flow ratio (QFR) to assess hemodynamic alterations caused by luminal stenoses, using invasive fractional pressure ratios (FPRs) as a reference standard. METHODS: Between March 2013 and December 2019, 29 patients undergoing the pressure gradient measurement of cerebral atherosclerosis were retrospectively enrolled. Wire-based FPR was defined by the arterial pressure distal to the stenotic lesion (Pd) to proximal (Pa) pressure ratios (Pd/Pa). FPR < 0.70 or FPR < 0.75 was assumed as hemodynamically significant stenosis. The new method of computing QFR from a single angiographic view, i.e., the Murray law-based QFR, was applied to the interrogated vessel. An artificial intelligence algorithm was developed to realize the automatic delineation of vascular contour. RESULTS: Fractional pressure ratio and QFR were assessed in 38 vessels from 29 patients. Excellent correlation and agreement were observed between QFR and FPR [r = 0.879, P < 0.001; mean difference (bias): -0.006, 95% limits of agreement: -0.198 to 0.209, respectively). Intra-observer and inter-observer reliability in QFR were excellent (intra-class correlation coefficients, 0.996 and 0.973, respectively). For predicting FPR < 0.70, the area under the receiver-operating characteristic curves (AUC) of QFR was 0.946 (95% CI, 0.820 to 0.993%). The sensitivity and specificity of QFR < 0.70 for identifying FPR < 0.70 was 88.9% (95% CI, 65.3 to 98.6%) and 85.0% (95% CI, 62.1 to 96.8%). For predicting FPR < 0.75, QFR showed similar performance with an AUC equal to 0.926. CONCLUSION: Computational QFR from a single angiographic view achieved comparable results to the wire-based FPR. The excellent diagnostic performance and repeatability empower QFR with high feasibility in the functional assessment of cerebral arterial stenosis.

Off-hour effect on time metrics and clinical outcomes in endovascular treatment for large vessel occlusion: A systematic review and meta-analysis.

BACKGROUND: There is an ongoing debate on the off-hour effect on endovascular treatment (EVT) for acute large vessel occlusion (LVO). AIM: This meta-analysis aimed to compare time metrics and clinical outcomes of acute LVO patients who presented/were treated during off-hour with those during working hours. SUMMARY OF REVIEW: Structured searches on the PubMed, Embase, Web of Science, and Cochrane Library databases were conducted through 23 February 2021. The primary outcomes were onset to door (OTD), door to imaging, door to puncture (DTP), puncture to recanalization, procedural time, successful recanalization, symptomatic intracranial hemorrhage (SICH), mortality in hospital, good prognosis (90-day modified Rankin Scale (mRS) score 0-2), and 90-day mortality. The secondary outcomes were imaging to puncture (ITP), onset to puncture (OTP), onset to recanalization (OTR), door to recanalization (DTR) time, mRS 0-2 at discharge, and consecutive 90-day mRS score. The odds ratio (OR) and weighted mean difference (WMD) with 95% confidence interval (CI) of the outcomes were calculated using random-effect models. Heterogenicity and publication bias were analyzed. Subgroup and sensitivity analyses were conducted as appropriate. Nineteen studies published between 2014 and 2021 with a total of 14,185 patients were eligible for quantitative synthesis. Patients in the off-hour group were significantly younger than those in the on-hour group and with comparable stroke severity and intravenous thrombolysis rate. The off-hour group had longer OTD (WMD [95% CI], 12.83 [1.84-23.82] min), DTP (WMD [95% CI], 11.45 [5.93-16.97] min), ITP (WMD [95% CI], 10.39 [4.61-16.17] min), OTP (WMD [95% CI], 25.30 [13.11-37.50] min), OTR (WMD [95% CI], 25.16 [10.28-40.04] min), and DTR (WMD [95% CI], 18.02 [10.01-26.03] min) time. Significantly lower successful recanalization rate (OR [95% CI], 0.85 [0.76-0.95]; p = 0.004; I2 = 0%) was detected in the off-hour group. No significant difference was noted regarding SICH and prognosis. But a trend toward lower OR of good prognosis was witnessed in the off-hour group (OR [95% CI], 0.92 [0.84-1.01]; p = 0.084; I2 = 0%). CONCLUSIONS: Patients who presented/were treated during off-hour were associated with excessive delays before the initiation of EVT, lower successful reperfusion rate, and a trend toward worse prognosis when compared with working hours. Optimizing the workflows of EVT during off-hour is needed.

Delayed neurological improvement is predictive to long-term clinical outcome on endovascular thrombectomy patients.

OBJECTIVES: This study aims at exploring the 3-month outcome predicting ability of delayed neurological improvement and the cause of delayed neurological improvement. MATERIALS AND METHODS: Early neurological improvement and delayed neurological improvement were calculated to represent the neurological improvements. Good functional outcome was defined as a 90-day modified Rankin Scale score 0-2. We used multivariant logistic regression to explore the influential factors of good functional outcome as well as delayed neurological improvement. We applied net reclassification improvement and integrated discrimination improvement to assess the quantitative improvement of the predictive model. RESULTS: Early neurological improvement was observed in 50 (23%) patients and delayed neurological improvement exhibited in 67 (30%) patients. Early neurological improvement and delayed neurological improvement were both independent predictive factors to good functional outcome. In the basic model (adjusted for age, admission glucose level, baseline National Institute of Health Stroke Scale, and complications and number of retrieval attempts), early neurological improvement and delayed neurological improvement statistically improved the predictive ability (early neurological improvement: net reclassification improvement = 0.34, 95% confidence interval, 95% confidential interval (0.06, 0.69); integrated discrimination improvement = 0.05, p < 0.001; delayed neurological improvement: net reclassification improvement = 0.79, 95% confidential interval (0.47, 1.12); integrated discrimination improvement = 0.14, p < 0.001) delayed neurological improvement could predict clinical outcomes more accurately than early neurological improvement (early neurological improvement vs. delayed neurological improvement: integrated discrimination improvement = 0.09, p < 0.001). Moreover, delayed neurological improvement was affected by hypertension (odds ratio = 0.40, 95% CI (0.18, 0.88), p = 0.02), early neurological improvement (odds ratio = 20.10, 95% confidential interval (8.24, 19.02), p < 0.001), number of retrieval attempts (odds ratio = 0.39, 95% confidential interval (0.24, 0.66), p < 0.001), and complication (odds ratio = 0.25, 95% confidential interval (0.12, 0.54), p < 0.001). CONCLUSIONS: Delayed neurological improvement could predict clinical outcomes more accurately than early neurological improvement. Hypertension, early neurological improvement, numbers of retrieval attempts, and complications were all predicting factors to delayed neurological improvement.

A Score of Low-Grade Inflammation for Predicting Stroke Recurrence in Patients with Ischemic Stroke.

BACKGROUND AND PURPOSE: The impact of low-grade inflammation (LGI) on stroke recurrence has not been well studied yet. We aimed to evaluate the association between LGI and stroke recurrence in patients with ischemic stroke. METHODS: Patients with first-ever ischemic stroke diagnosed within 72 hours of symptoms onset were consecutively recruited from the Nanjing Stroke Registry Program. C-reactive protein (CRP) level, white blood cell (WBC) count, platelet (PLT) count, and neutrophil-to-lymphocyte ratio (NLR) were conceived as low-grade inflammation biomarkers and combined into a standardized LGI score. The association of LGI score with the risk of stroke recurrence was analyzed with multivariate Cox regression models. Analyses accounting for the competing risk of stroke recurrence and death were also performed. RESULTS: Of the 1214 patients studied (median age, 61 years; male, 71.6%), 177 (14.6%) patients experienced a recurrent stroke with a median follow-up of 23.0 (interquartile ranges, 14.5-34.0) months. Patients with stroke recurrence had a higher LGI score (median, 3 versus -2; P < 0.001) than those without recurrence. The univariate analysis indicated that patients with LGI scores in the fourth quartile were more likely to have a stroke recurrence (hazard ratios [HR], 4.312; 95% confidence interval [CI], 2.675-6.952; P < 0.001). After adjusting for potential confounders, the association remained significant in the multivariate Cox regression model (HR, 4.080; 95% CI, 2.420-6.879; P < 0.001). Competing risks model and sensitivity analysis further confirmed this conclusion. CONCLUSION: This study showed that an elevated LGI score was associated with a higher risk of stroke recurrence, independent of other vascular risk factors.

Prognostic Value of Abnormal Liver Function Tests After Mechanical Thrombectomy for Acute Ischemic Stroke.

Objective: To determine the clinical significance of post-procedural abnormal liver function test (ALFT) on the functional outcomes at 90 days in acute ischemic stroke (AIS) treated with mechanical thrombectomy (MT). Methods: In this retrospective observational study, patients with AIS undergoing MT were enrolled from the Nanjing Stroke Registry Program and the multicenter Captor trial. A favorable outcome was defined as a modified Rankin Scale score 0-2 at 90 days. Predictive models were established by multivariable logistic regression. Improved predictive value of models was assessed by continuous net reclassification improvement (NRI) and integrated discrimination improvement (IDI). In addition, multivariable logistic regression and restricted cubic spline were used to analyze dose-response correlations between the severity of ALFT and prognosis. Results: Among 420 patients enrolled, 234 (55.7%) patients were diagnosed as post-procedural ALFT after MT. Patients with post-procedural ALFT had higher National Institute of Health Stroke Scale score on admission (median, 18 vs. 15, p < 0.001) and more pneumonia (65.4 vs. 38.2%, p < 0.001) than those without post-procedural ALFT. Post-procedural ALFT, rather than preprocedural ALFT, was independently associated with favorable outcome (adjusted odds ratio, 0.48; 95% CI 0.28-0.81; p = 0.006). The improvement of predictive model after adding post-procedural ALFT was significant [continuous NRI (value, 0.401; p < 0.001), IDI (value, 0.013; p < 0.001)]. However, the restricted cubic spline indicated no evidence of a dose-response relationship between the severity of post-procedural ALFT and prognosis. Conclusions: In AIS patients treated by MT, post-procedural ALFT was associated with more severe stroke and served as an independent predictor of worse prognosis at 90 days.

Off-hour effect is not significant in endovascular treatment for anterior circulation large vessel occlusion in a multicentre registry.

BACKGROUND AND PURPOSE: Whether the off-hour effect has an impact on workflow and outcomes of endovascular treatment (EVT) for anterior circulation large vessel occlusion (AC-LVO) remains uncertain. This study aimed to compare the characteristics and outcomes of patients who presented or were treated during off-hour versus on-hour in a multi-center registry. METHODS: AC-LVO patients from 21 centres were categorised into the off-hour group and the on-hour group. Off-hour (weekends, holidays, and 18:00-7:59 on weekdays) and on-hour (8:00-17:59 on weekdays except for holidays) were defined according to arrival and groin-puncture time points, respectively. Subgroup comparisons between patients both arrived and treated during off-hour (true off-hour) and on-hour (true on-hour) were performed. The primary outcome was the 90-day modified Rankin Scale (mRS) score. Secondary outcomes included favourable outcome (mRS 0-2 at 90 days), EVT-related time metrics, and other clinical outcomes. Ordinary and binary logistic regression and linear regression were taken to adjust for confounding factors. RESULTS: Of all 698 patients enrolled, 435 (62.3%) and 456 (65.3%) patients were categorised into the off-hour arrival and off-hour puncture group, respectively. Shorter onset to door time (adjusted ß coefficient: -21.56; 95% CI -39.96 to -3.16; p=0.022) was noted in the off-hour arrival group. Ordinal and dichotomous mRS scores at 90 days were comparable between the off-hour group and the on-hour group regardless of off-hour definitions. Other time metrics and outcomes were comparable between the two groups. Of 595 patients both presented and were treated during off-hour or on-hour, 394 patients were categorised into the true off-hour group and 201 into the true on-hour group. Time metrics and clinical outcomes were similar between the true off-hour and the true on-hour group. CONCLUSIONS: The off-hour effect was not significant regarding clinical outcomes and in-hospital workflow in AC-LVO patients receiving EVT in this Chinese multicentre registry.

Predictors of mortality for acute vertebrobasilar artery occlusion receiving endovascular treatment.

OBJECTIVES: Acute vertebrobasilar artery occlusion (VBAO) is a devastating type of stroke with a high mortality rate. This study aimed to investigate the predictors of 3-month and 1-year mortality in VBAO patients receiving endovascular treatment (EVT). MATERIALS & METHODS: Consecutive acute VBAO patients undergoing EVT between January 2014 and December 2019 were retrospectively analyzed in a prospectively maintained database. Multivariate logistical regression models were used to explore the potential predictors of mortality at 3 months and 1 year, respectively. The discrimination of the final model was assessed with the area under the receiver operating characteristic curve. RESULTS: A total of 100 patients were enrolled in this study (mean age 62 years; 77.0% male). After excluding patients lost to follow-up, the overall mortality rate was 34.3% (34/99) at 3 months and 45.4% (44/97) at 1 year. The Glasgow Coma Scale (GCS) score at 24 h (Odds ratio [OR], 0.676; 95% confidence interval [CI], 0.540-0.846; p = .001) and mechanical ventilation (MV) (OR, 7.356; 95% CI, 2.200-24.593; p = .001) were predictors of 3-month mortality after adjusting for potential confounders in multivariable analysis. Furthermore, the GCS score at 24 h (OR, 0.714; 95% CI, 0.590-0.864; p = .001), intracranial hemorrhage (OR, 7.330; 95% CI, 1.772-30.318; p = .006), and MV (OR, 5.804; 95% CI, 1.841-18.294; p = .003) were independently associated with mortality at 1 year. Sensitivity analyses showed similar results. CONCLUSION: The 24-h GCS score and MV were common predictors of 3-month and 1-year mortality, and ICH was an additional predictor of 1-year mortality.

A Pre-Interventional Scale to Predict in situ Atherosclerotic Thrombosis in Acute Vertebrobasilar Artery Occlusion Patients.

Background and Purpose: Determining the occlusion mechanism before endovascular treatment (EVT) is of great significance for acute large vessel occlusion patients. We aimed to develop and validate a simple pre-EVT scale with readily available variables for predicting in situ atherosclerotic thrombosis (ISAT) in acute vertebrobasilar artery occlusion (VBAO) patients. Materials and Methods: Consecutive patients were retrieved from Nanjing Stroke Registry Program between January 2014 and December 2019 as a derivation cohort. Anonymous data of consecutive patients between January 2014 and December 2019 were collected from another comprehensive stroke center as an external validation cohort. Demographics, medical histories, and clinical characteristics were collected. ISAT was defined according to the following criteria: (a) detection of moderate to severe (≥50%) stenosis or stenosis with significant distal flow impairment at the occluded segment when successful reperfusion was achieved; (b) transient visualization of eccentric plaque contour or a recurrent re-occlusion tendency when reperfusion was unsuccessful. Logistic regression was taken to develop a predictive scale. The performance of the scale was assessed by area under the receiver operating characteristic curve (AUC) and Hosmer-Lemeshow test. Results: ISAT was observed in 41 of 95 (43.2%) patients included in the derivation cohort. The ISAT predictive scale consisted of three pre-interventional predictors, including the history of hypertension, atrial fibrillation rhythm, and baseline serum glucose level ≥7.55 mmol/L. The model depicted acceptable calibration (Hosmer-Lemeshow test, P = 0.554) and good discrimination (AUC, 0.853; 95% confidence interval, 0.775-0.930). The optimal cutoff value of the ISAT scale was 1 point with 95.1% sensitivity, 64.8% specificity, and 77.9% accuracy. In the validation cohort, the discrimination ability was still promising with an AUC value of 0.800 (0.682-0.918). Conclusion: The three-item scale comprised of the history of hypertension, atrial fibrillation rhythm, and dichotomous serum glucose level had a promising predictive value for ISAT before EVT in acute VBAO patients.

Increased intracranial hemorrhage of mechanical thrombectomy in acute ischemic stroke patients with atrial fibrillation.

The impact of atrial fibrillation (AF) on outcomes of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) is controversial, and with a paucity of evidence base. This study aimed to investigate the potential association between AF and outcomes after MT in AIS patients. A post-hoc analysis of a multi-center prospective clinical trial was conducted. Before and after propensity score matching (PSM), the clinical features were compared between patients with and without AF. Multivariable logistic regression and mediation analyses were performed to assess the relationship between AF and ICH. Of the total 245 patients, 123 patients were included in the AF group. After PSM, the AF group showed more retrieval attempts (P = 0.004), comparable favorable outcome (P = 0.493), and mortality (P = 0.362) at 90 days. Multivariate analysis revealed that AF was significantly associated with increased risk for ICH (OR 2.198; 95%CI 1.099-4.395; P = 0.026). INR and retrieval attempts were found to act as partial mediations. In the subgroup with lower INR, AF still had a significant association with ICH (OR 2.496; 95%CI 1.331-4.679; P = 0.004). In AIS patients undergoing MT, AF was associated with more retrieval attempts and higher risk of any ICH. Of note, the effect of AF on the increased risk of ICH was partly attributable to the adjusted anticoagulation status and more retrieval attempts. It is crucial to elaborately prevent ICH after thrombectomy for stroke patients with AF.

Bridge mechanical thrombectomy may be a better choice for acute large vessel occlusions.

Direct mechanical thrombectomy (DMT) was confirmed non-inferior to bridge mechanical thrombectomy (BMT, MT preceded by intravenous alteplase within 4.5 h after symptom onset) for acute ischemic stroke with large vessel occlusions (AIS-LVO) in mothership patients. However, the noninferiority of DMT in the general population (including drip and ship mode) is controversial, and the impact of thrombolysis on retrieval attempts remains uncertain. This was a post-hoc analysis of a multi-center, prospective enrolled study. Patients were divided into the BMT group and the DMT group. Baseline characteristics and clinical outcomes were compared by using univariate analysis, multivariable analysis, and propensity score matching analysis, respectively. Of all 245 patients enrolled in this study, 79 (32.2%) patients underwent BMT. In the multivariable analysis, the ratio of excellent prognosis (defined as modified Rankin Scale [mRS] score 0-1 at 90 days) was significantly higher in the BMT group compared with the DMT group (odds ratio, 2.731; 95% confidence interval, 1.238-6.023; P = 0.013). The ratio of good prognosis (mRS score 0-2 at 90 days), successful recanalization rate [modified Thrombolysis In Cerebral Ischemia (mTICI) score 2b-3] and mortality rate were similar between the two groups. The excellent prognosis rate was significantly higher in the BMT group after propensity score matching (P = 0.023). BMT was associated with a higher ratio of excellent prognosis (mRS 0-1) and a similar successful recanalization rate without increasing peri-operation complications compared with DMT in AIS-LVO patients. It is prudent to continue BMT until further data is available.