Association of critical hypoperfusion biomarkers on CT with futile recanalization and poor outcome after mechanical thrombectomy in acute ischemic stroke.

BACKGROUND AND PURPOSE: We aimed to investigate the association between critical perfusion delay and poor outcome among recanalized stroke patients with anterior large-vessel occlusion, and to use pretreatment hypoperfusion biomarkers on CT to predict futile recanalization even after successful thrombectomy. METHODS: An ischemic region with time-to-maximum (Tmax) > 12s-10s was defined as critical hypoperfusion, Tmax > 8s as moderate hypoperfusion, and hypoperfusion intensity ratio (HIR, volumetric ratio of Tmax > 10s / Tmax > 6s) represented for severity of critical hypoperfusion and rCBF < 30% for ischemic core. The associations between these CT perfusion characteristics and favorable or unfavorable outcome (mRS 0-2 versus 3-6) were analyzed in univariable regression, and a multivariable model was then used to predict futile recanalization. RESULTS: Seventy-nine stroke patients were included and had good grades of instant recanalization. Forty-two patients (53%) had poor outcomes, and they had a significantly larger volume of critical hypoperfusion as seen with Tmax > 10s and > 12s (P = 0.032 and 0.008, respectively), a larger volume of ischemic core (P = 0.011) and a higher HIR (P = 0.002) than those patients achieving good outcomes. In the univariable analysis, a lower HIR (OR, 0.008; 95%CI, 0.001-0.254, P = 0.006) was associated with favorable outcome. The volume size of Tmax > 12s was significantly and positively correlated with the size of ischemic core. A HIR value higher than 0.491 might predict a futile recanalization and poor outcome (AUC = 0.701). CONCLUSIONS: The critical hypoperfusion biomarkers on CTP could be useful in triaging endovascular treatment and identifying stroke patients at risk of futile recanalization.

Association of Intravenous Tirofiban with Functional Outcomes in Acute Ischemic Stroke Patients with Acute Basilar Artery Occlusion Receiving Endovascular Thrombectomy.

INTRODUCTION: The aim of this study was to test the hypothesis that intravenous tirofiban improves functional outcomes without promoting the risk of intracranial hemorrhage (ICH) in stroke secondary to basilar artery occlusion (BAO) receiving endovascular thrombectomy. METHODS: Patients with acute BAO stroke who were treated with endovascular thrombectomy and had tirofiban treatment information were derived from "BASILAR": a nationwide, prospective registry. All eligible patients were divided into tirofiban and no-tirofiban groups according to whether tirofiban was used intravenously. The primary endpoint was the 90-day severity of disability as assessed by the modified Rankin scale score. Safety outcomes were the frequency of ICH and mortality. RESULTS: Of 645 patients included in this cohort, 363 were in the tirofiban group and 282 were in the no-tirofiban group. Thrombectomy with intravenous tirofiban reduced the 90-day disability level over the range of the modified Rankin scale (adjusted common odds ratio, 2.08; 95% confidence interval (CI), 1.45-2.97; p < 0.001). The 90-day mortality of patients in the tirofiban group was lower than that in the no-tirofiban group (41.6% vs. 52.1%; adjusted hazard ratio, 0.60; 95% CI, 0.47-0.77; p < 0.001). The frequency of any ICH (6.7% vs. 13.7%; p = 0.004) and symptomatic ICH (4.8% vs. 10.1%; p = 0.01) in the tirofiban group was significantly lower than that in the no-tirofiban group. CONCLUSIONS: In patients with acute BAO stroke who underwent endovascular treatment, intravenous tirofiban might be associated with favorable outcome, reduced mortality, and a decreased frequency of ICH.

Cranial midline shift is a predictor of the clinical prognosis of acute cerebral infarction patients undergoing emergency endovascular treatment.

Endovascular treatment is widely used in acute cerebral infarction (ACI), but patient prognosis varies greatly. We aimed to investigate the predictive value of midline shift (MLS) threshold for the clinical prognosis of patients with ACI who undergo emergency endovascular treatment. We prospectively enrolled patients with ACI who received endovascular treatment within 24 h of onset. Cranial images were collected within 24 h after endovascular treatment. We assessed MLS at the level of the midbrain, pineal calcification, septum pellucida, and falx cerebri and noted the maximum MLS (MLS[max]) among these locations. Functional outcomes were assessed at 90 days using the modified Rankin Scale. Receiver operating characteristic curves and optimal cutoff points were used to analyze the predictive value of MLS. We enrolled 82 patients, including 46 with poor outcomes. Although the MLS values at all levels were significantly different between the poor and favorable outcome groups (p < 0.01), the MLS(max) tended to be a better marker for 90-day poor outcome. To predict poor outcome, the optimal cutoff values for MLS(max) within 24 and 48 h after intervention were 0.45 and 2.35 mm, respectively. MLS(max) has predictive value for patient prognosis.

Association of tirofiban treatment with outcomes following endovascular therapy in cardioembolic stroke: insights from the RESCUE BT randomized trial.

BACKGROUND AND PURPOSE: The efficacy and safety of tirofiban in endovascular therapy for cardioembolic ischemic stroke patients remain controversial. This study aimed to evaluate the role of intravenous tirofiban before endovascular therapy in cardioembolic stroke. METHODS: This post hoc analysis utilized data from the RESCUE BT (Endovascular Treatment With versus Without Tirofiban for Patients with Large Vessel Occlusion Stroke) trial, which was an investigator-initiated, randomized, double-blind, placebo-controlled trial. Participants were randomized to receive either tirofiban or a placebo in a 1:1 ratio before undergoing endovascular therapy. The study included patients aged 18 years or older, presenting with occlusion of the internal carotid artery or middle cerebral artery (MCA) M1/M2 within 24 h of the last known well time, and with a stroke etiology of cardioembolism. The primary efficacy outcome was global disability at 90 days, assessed using the modified Rankin Scale (mRS). The safety outcome included symptomatic intracranial hemorrhage (sICH) within 48 h and mortality within 90 days. RESULTS: A total of 406 cardioembolic stroke patients were included in this study, with 212 assigned to the tirofiban group and 194 assigned to the placebo group. Tirofiban treatment did not correlate with a favorable shift towards a lower 90-day mRS score (adjusted common odds ratio [OR], 0.91; 95% CI 0.64-1.3; p = 0.617). However, the tirofiban group had a significantly higher risk of symptomatic intracranial hemorrhage (sICH) within 48 h (adjusted OR, 3.26; 95% CI 1.4-7.57; p = 0.006) compared to the placebo group. The adjusted odds ratio (aOR) for mortality within 90 days was 1.48 (95% CI 0.88-2.52; p = 0.143). CONCLUSIONS: Tirofiban treatment was not associated with a lower level of disability and increased the incidence of sICH after endovascular therapy in cardioembolic stroke patients.

Effect of vertebrobasilar dolichoectasia on endovascular therapy in acute posterior circulation infarction.

Background and purpose: This study aimed to analyze the feasibility and safety of endovascular therapy (EVT) in patients with acute posterior circulation stroke and vertebrobasilar dolichoectasia (VBD). Materials and methods: BASILAR was a national prospective registry of consecutive patients with symptomatic and imaging-confirmed acute stroke in the posterior circulation within 24 h of symptom onset. We evaluated EVT feasibility and safety in patients with VBD. Primary outcomes included improvement in modified Rankin Scale scores (mRS) at 90 days and mortality within 90 days. The secondary outcome was the rate of favorable functional outcome, defined as mRS ≤ 3 (indicating independent ambulation) at 90 days. Safety outcomes included surgery-related complications and other serious adverse events. Results: A total of 534 cases were included: 159 with VBD and 375 controls. No significant difference in mRS at 90 days was found between groups, but patients with VBD had a higher baseline National Institutes of Health Stroke Scale (NIHSS) score [30 (19-33) vs. 25 (15-32)] and were older [65 (59-74) vs. 63 (55-72) year]. After propensity score matching, there were no significant differences in baseline NIHSS score between the two groups, and the efficacy and safety of EVT were similar between patients with or without VBD. Furthermore, the prognostic effect of puncture-to-recanalization time on the probability of mortality within 90 days in EVT-treated patients with VBD was significant {adjusted odds ratio, 1.008 [95% confidence interval (1.001-1.015)]}. Conclusion: Endovascular therapy is safe and feasible in patients with acute posterior circulation stroke and VBD. The puncture-to-recanalization time is important for predicting the prognosis of EVT-treated patients with VBD.

Alberta Stroke Program Early CT Score applied to hyperdense lesion on noncontrast CT immediately post-thrombectomy is a predictor of poor outcome in acute ischemic stroke: A case-control study.

We aimed to evaluate whether Alberta Stroke Program Early CT Score (ASPECTS) applied to hyperdense lesion on noncontrast CT obtained immediately post-thrombectomy (post-ASPECTS) is useful for predicting poor outcome. We retrospectively reviewed patients who underwent noncontrast CT (NCCT) immediately after mechanical thrombectomy between January 2017 and July 2020 in our comprehensive stroke center. We collected baseline NCCT and post-ASPECTS score. The sensitivity, specificity, and positive and negative predictive values of the post-ASPECTS in predicting clinical outcome were calculated. A total of 223 patients were included. The hyperdense lesion on NCCT immediately after endovascular thrombectomy presented in 85.7% (191/223) patients, poor clinical outcome was in 56.1% (112/191) of hyperdense lesion patients. Low post-ASPECTS was associated with poor outcome (OR 0.390; 95% CI 0.258-0.589; P = .001), with an AUCROC curve of 0.753 (95% CI 0.684-0.822), while baseline NCCT-ASPECTS was not (OR 0. 754; 95% CI 0. 497-1.144; P = .185). A score ≤ 7 in post-ASPECTS was the best cut-off to poor clinical outcome (sensitivity 84.8%; specificity 52.7%; positive predictive value 68.4%; negative predictive value 73.8%). Our results point to the proportion of patients who present hyperdense lesion on NCCT is very high, post-ASPECTS could predict poor clinical outcomes in patients with stroke treated with endovascular mechanical thrombectomy, and post-ASPECTS may achieved better predictive value than baseline ASPECTS.

Risk score for symptomatic intracranial haemorrhage in patients with acute ischaemic stroke receiving endovascular treatment.

BACKGROUND AND PURPOSE: This study aimed to develop a score to predict the risk for symptomatic intracranial haemorrhage (sICH) associated with endovascular treatment (EVT) in patients with acute ischaemic stroke caused by large vessel occlusions (LVOs) in the anterior circulation. METHODS: Between January 2017 and December 2019, acute stroke patients with anterior circulation occlusion and EVT were retrospectively enroled from 11 comprehensive stroke centres in China. Univariate analyses were performed to compare the factors in patients with or without sICH. The predictive value of parameters associated with sICH was evaluated with multivariate logistic regression, and the score was developed according to the magnitude of regression coefficients. We performed external validation in a retrospective stroke registry of EVT for acute anterior circulation ischaemic stroke in 21 comprehensive stroke centres across 10 provinces in China (ACTUAL). RESULTS: Of the 433 patients, 70 (16.2%) patients had sICH. The preoperative predictive factors of sICH were poor collateral circulation, low baseline ASPECTS, cardioembolic stroke and high serum glucose. Using the OR of preoperative predictive factors (collateral circulation status, baseline ASPECTS, TOAST type and serum glucose) in the multivariable model, we derived the ACTS score. In the derivation cohort, the area under the ROC curve (AUC) was 0.797; in the validation cohort, it was 0.727. CONCLUSION: The ACTS score provides a quick and easy-to-perform scale to predict the risk of sICH in acute anterior circulation stroke patients treated with EVT. This score should be further examined and improved in future prospective studies to increase its precision and applicability before it can be recommended to make clinical decisions regarding the performance of EVT.