Hospital Implementation of Endovascular Thrombectomy and Health Equity in Acute Stroke Outcomes.

Background: The introduction of novel therapeutics into clinical practice could impact equity in health outcomes.

Methods: This was a retrospective, observational cohort study based on the Get With The Guidelines-Stroke program of the American Heart Association. Two epochs were considered: January 2010 to December 2014 and January 2016 to December 2019.

Should We Stop Endovascular Treatment of M2 Occlusions?: A Critical Look at Recent Evidence.

Medium vessel occlusions represent a substantial proportion of patients with acute ischemic stroke. Recently presented randomized controlled trials, ESCAPE-MeVO (Endovascular Treatment to Improve Outcomes for Medium Vessel Occlusions), DISTAL (Endovascular Therapy Plus Best Medical Treatment [BMT] Versus BMT Alone for Medium Distal Vessel Occlusion Stroke), and DISCOUNT (Evaluation of Mechanical Thrombectomy in Acute Ischemic Stroke Related to a Distal Arterial Occlusion), did not demonstrate a clinical benefit of endovascular thrombectomy in distal and medium vessel occlusions, potentially generating uncertainty about optimal treatment strategies for medium vessel occlusions. Specifically, these results may lead clinicians to hesitate in performing endovascular thrombectomy for M2 occlusions, despite prior evidence indicating benefit in this subgroup.

Device-Detected Atrial Fibrillation in Patients With and Without Cryptogenic Ischemia: The ANTARCTICA Pooled Analysis.

Background: Insertable cardiac monitoring (ICM) detects atrial fibrillation (AF) in substantial proportions of cryptogenic stroke, noncryptogenic ischemic stroke without known AF, and nonstroke patients who are at risk of underlying AF. Given differences in patient characteristics across studies, there may be differences in AF detection rates on ICM across these subgroups that have not been identified. We investigate whether AF detection rates on ICM are higher in cryptogenic stroke or transient ischemic attack (C-IS/TIA) patients compared with individuals with noncryptogenic stroke or without stroke, when accounting for differences in study populations.

Trajectory of hematoma growth and functional recovery after intracerebral hemorrhage: a latent class analysis of BASC data.

Background: Moderate blood pressure (BP) reduction reduces hematoma growth but this has not been shown to translate into improved functional recovery after intracerebral hemorrhage (ICH). This study aims to define patient profiles according to hematoma growth and functional recovery patterns, and explore the prognostic factors of the patterns.

Methods: Analysis of the Blood pressure in Acute Stroke Collaboration (BASC) dataset involving randomized controlled trials of early BP lowering in acute ICH.

Oxygen Extraction Fraction on Baseline MRI Predicts Infarction Growth in Successfully Reperfused Patients.

Background: In patients with acute ischemic stroke, infarct growth occurs despite successful reperfusion. Oxygen extraction fraction (OEF) has shown promising results in evaluating ischemic tissue viability and can now be quantified from routinely performed dynamic susceptibility contrast perfusion. We aimed to determine the association of OEF alterations within the ischemic tissue on pretreatment magnetic resonance imaging and infarct growth in patients who underwent successful reperfusion.

A pilot comparison of the retention rates of FAST and BEFAST stroke warning-sign mnemonics.

Background: Several pre-hospital delays prevent stroke patients from arriving within the optimal 4.5-h therapeutic window, including failure to recognize stroke symptoms and lack of urgency in perceiving them as requiring immediate medical attention. Community stroke education is critical in reducing pre-hospital delays.

Intra-Arterial Tenecteplase After Successful Reperfusion in Large Vessel Occlusion Stroke: A Randomized Clinical Trial.

Importance: The optimal dose, safety, and efficacy of intra-arterial tenecteplase after successful reperfusion by endovascular thrombectomy for large vessel occlusion (LVO) is unknown.

Objective: To evaluate the dose-dependent adverse events and signals of efficacy of intra-arterial tenecteplase in LVO after successful reperfusion with thrombectomy, defined as an Extended Treatment in Cerebral Infarction score of 2b-3.

Design, Setting, And Participants: This open-label, blinded-outcome assessment trial, incorporating a 14 + 8 dose-escalation (phase 1b, nonrandomized) and dose-expansion (phase 2a, randomized) design, was conducted in China between 2023 and 2024, with follow-up continuing through November 2024.

Early Tirofiban Infusion after Intravenous Thrombolysis for Stroke.

Background: Intravenous thrombolysis remains a standard treatment for acute ischemic stroke within 4.5 hours after onset. Vascular reocclusion may occur after intravenous thrombolysis and may be preventable with an antiplatelet agent within the first 24 hours after thrombolysis.

More than half of patients with wake-up stroke have slept through their stroke onset.

Background: Conventional time-from-onset decision-making for use of reperfusion therapies in acute ischemic stroke is challenged by patients with wake-up strokes (WUS) in whom onset time is uncertain. Management of these patients, including use of advanced imaging to make "tissue-clock" rather than "time-clock" treatment decisions, and development of wearable technologies to detect stroke onset during sleep, would be aided by delineation of how often WUS patients had onset long before or shortly before awakening.

Methods: We performed a meta-analysis of studies comparing diffusion weighted imaging-fluid-attenuated inversion recovery (DWI-FLAIR) mismatch frequencies in patients with WUS compared with patients with clear onset time stroke (COS).

The Large Core Paradox.

Recently, 6 randomized controlled trials of endovascular treatment (EVT) versus medical management in anterior circulation large vessel occlusion with large-core documented significant benefit of EVT on functional outcome. Moreover, one trial reported the benefit of EVT in the very large-core category (Alberta Stroke Program Early CT Score, 0-2). These results are considered paradoxical by some as they contradict the prevailing view that the presence of a large core precludes the possibility of good outcomes following reperfusion.

Intravenous Glyburide in Medical and Endovascular-Treated Large-Core Stroke: A Subgroup Analysis of the CHARM Randomized Clinical Trial.

Objective: The Glibenclamide for Large Hemispheric Infarction Analyzing mRS and Mortality (CHARM) trial enrolled participants with large hemispheric infarction, randomized to a placebo or intravenous glyburide. Our objective in this post-hoc study was to evaluate the relationship between baseline stroke volume and the potential efficacy of i.v.

PFO Device Closure in Patients >60 Years of Age With Ischemic Stroke: Results From U.S. Medicare Beneficiaries.

Background: Transcatheter closure of patent foramen ovale (PFO) is a recommended stroke reduction option in patients ≤60 years of age with cryptogenic ischemic stroke, but data on clinical outcomes following PFO closure in patients >60 years of age are scarce.

Objectives: The aim of this real-world evidence study was to evaluate the clinical outcomes of PFO closure in patients >60 years of age in the United States.

Methods: Medicare fee-for-service data from 2016 to 2022 were used to identify patients >60 years of age who were hospitalized with ischemic stroke and diagnosed with PFO or atrial septal defect and also had ≥6 months of prior fee-for-service coverage.

Intravenous Tenecteplase before Thrombectomy in Stroke.

Background: The safety and efficacy of treatment with intravenous tenecteplase before endovascular thrombectomy in patients with acute ischemic stroke due to large-vessel occlusion remain uncertain.

Methods: In this open-label trial conducted in China, we randomly assigned patients with acute ischemic stroke due to large-vessel occlusion who had presented within 4.5 hours after onset and were eligible for thrombolysis to receive either intravenous tenecteplase followed by endovascular thrombectomy or endovascular thrombectomy alone.

Effectiveness of intravenous thrombolysis in patients with large-vessel occlusion receiving endovascular treatment in Korea.

Background: The effectiveness of intravenous tissue plasminogen activator (IV tPA) in patients with large-vessel occlusion (LVO) receiving endovascular treatment (EVT) for acute ischemic stroke (AIS) has been questioned. We investigated IV tPA effectiveness in real-world AIS patients, including those with intracranial LVO receiving EVT.

Methods: We identified patients with AIS who presented to hospital with National Institutes of Health Stroke Scale ≥4 within 8 hours of symptom onset from the institutional stroke registry.

Endovascular thrombectomy in acute stroke with a large ischemic core: A systematic review and meta-analysis of randomized controlled trials.

Background: Endovascular thrombectomy (EVT) is the standard treatment for acute ischemic stroke due to internal carotid artery (ICA) or middle cerebral artery (MCA) M1 occlusion with a small ischemic core. However, the effect of EVT on acute stroke with a large ischemic core remains unclear. This study aimed to evaluate the association of EVT plus medical care versus medical care alone with outcomes in patients with acute stroke and a large ischemic core due to ICA or MCA M1 occlusion.

Quantification of patent foramen ovale shunt severity by transesophageal echocardiogram and transcranial doppler in routine clinical practice.

Background: The presence of a large physiologic shunt, defined as >20 left atrial microbubbles within 3 cardiac cycles on transesophageal echocardiography (TEE), is a randomized trial-validated indication for patent foramen ovale (PFO) closure in patients with otherwise cryptogenic ischemic stroke. The frequency with which this information is available to treating physicians from clinical TEE reports has not been well-delineated.

Methods: Among consecutive ischemic stroke patients, clinical TEE report shunt size characterizations were abstracted and compared to transcranial Doppler (TCD) formal shunt grades in the same patients and to central Core Lab TEE quantified assessments.

Association Between Collateral Status, Blood Pressure During Thrombectomy, and Clinical Outcomes in Patients With Basilar Artery Occlusion.

Background And Objectives: We investigated the relationship between intraprocedural blood pressure (BP) and clinical outcomes in patients with basilar artery occlusion (BAO) undergoing endovascular treatment (EVT), exploring whether it is modifiable by collateral status.

Methods: Patient data from the Endovascular Treatment for Acute Basilar Artery Occlusion (ATTENTION) randomized trial were analyzed for those with BAO who received EVT. Intraprocedural BP data were extracted, with collateral status assessed using the Basilar Artery on CT Angiography (BATMAN) score (BATMAN score ≥7 favorable collateral status, <7 unfavorable).

Endovascular treatment in acute intracranial distal medium vessel occlusion stroke: Study protocol and rationale.

Background: Distal medium vessel occlusions (MeVOs) account for an estimated 25% to 40% of all acute ischemic strokes. Emerging evidence from non-randomized trials suggest that endovascular thrombectomy (EVT) can achieve high rates of successful reperfusion in MeVO strokes, with a safety profile comparable to EVT for proximal arterial occlusions. These findings underscore the need for a prospective randomized clinical trial to evaluate the safety and efficacy of EVT for MeVO stroke.

Short-Term Safety and Effectiveness for Tenecteplase and Alteplase in Acute Ischemic Stroke.

Importance: Tenecteplase is an alternative to alteplase for emergency treatment of acute ischemic stroke. However, limited data are available comparing their clinical effectiveness in routine clinical practice.

Objective: To compare short-term effectiveness and safety outcomes for patients with ischemic stroke treated with intravenous tenecteplase vs alteplase.

Is there diurnal variation in neuroprotective and thrombolytic therapy effect upon acute cerebral ischemia outcome?

Background: Preclinical studies have found marked diurnal/circadian variation in the effect of neuroprotective agents in acute ischemic stroke. However, the presence of diurnal variation in treatment outcomes after neuroprotective therapy has not been analyzed in human clinical trials and variation after thrombolytic therapy has been under-studied.

Methods: We analyzed patients with acute cerebral ischemia enrolled in the Field Administration of Stroke Therapy - Magnesium (FAST-MAG) randomized trial of magnesium sulfate started in the ambulance within two hours of stroke onset (last known well time).

A new taxonomy of neuroprotective agents for stroke appropriate for the reperfusion era.

The advent of the era of highly effective reperfusion therapy for acute ischemic stroke has reawakened interest in neuroprotective treatments as they are far more likely to be efficacious as synergistic complements to reperfusion rather than standalone interventions. However, testing neuroprotective agents combined with reperfusion mandates not only renewed conduct of trials but also a fundamental reconceptualization of the subclasses of neuroprotection therapies. We propose a new taxonomy of neuroprotective treatment agents appropriate for the reperfusion era that recognizes six broad classes of agents, each targeting a distinct process and time epoch of injury: (1) Bridging neuroprotectives slow infarct expansion in the pre-reperfusion period, (2) Blood-brain barrier stabilizers restore the integrity of BBB before and early after reperfusion, (3) Microcirculation lumen preservers protect arteriolar and capillary endothelial cell integrity deterring the no-reflow phenomenon, (4) Reperfusion injury preventors block inflammatory, oxidative, and other processes that start immediately after reperfusion, (5) Edema reducers avert cerebral swelling and secondary injury due to brain tissue compression and herniation, and (6) Delayed neuroprotectives mitigate injury due to apoptosis and mitochondrial dysfunction in the late post-reperfusion period.

Trends in Ischemic Stroke Hospitalization and Outcomes in the United States Pre- and Peri-COVID-19 Pandemic: A National Inpatient Sample Study.

The COVID-19 pandemic impacted healthcare systems globally, disrupting the management and treatment of acute ischemic stroke (AIS). Understanding how AIS admissions, treatments, and outcomes were affected is critical for improving stroke care in future crises. The objective of this work was to assess the COVID-19 pandemic's impact on AIS admissions, treatment patterns, complications, and patient outcomes in the U.

A Nationwide Prospective Registry of Endovascular Thrombectomy for Extra-Large Ischemic Stroke with Large Vessel Occlusion (XL STROKE): Rationale and Design.

Introduction: The role of endovascular thrombectomy (EVT) for acute extra-large ischemic stroke patients with large vessel occlusion (LVO) is uncertain. We aimed to explore the clinical and safety outcomes of medical management (MM) plus EVT (EVT group) versus MM alone (MM group) among acute extra-large ischemic stroke patients with LVO within 24 h of last known well.

Methods: XL STROKE (EVT for extra-large ischemic stroke) is an investigator-initiated, nationwide, prospective registry with blinded end point assessment performed at approximately 60 sites in China and will enroll up to 990 acute ischemic stroke patients within 24 h of last known well.

Modified Rankin Scale at 90 Days Versus National Institutes of Health Stroke Scale at 24 Hours as Primary Outcome in Acute Stroke Trials.

Background: We investigate whether the National Institutes of Health Stroke Scale (NIHSS) at 24 hours could serve as a primary outcome in acute ischemic stroke trials, and whether combining 90-day modified Rankin Scale (mRS) and 24-hour NIHSS in a hierarchical outcome could enhance detection of treatment effect, using endovascular treatment (EVT) as an exemplary study intervention.

Methods: This was a post hoc analysis of pooled data from 7 randomized EVT trials. Twenty-four-hour NIHSS as a surrogate outcome for 90-day mRS was assessed in a causal mediation model.