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Background Competitive leptomeningeal flow (CLF) can be observed immediately after mechanical thrombectomy (MT) reperfusion with retrograde contrast clearing of the distal leptomeningeal branches from non-contrast opacified flow through different vascular territories. We aim to evaluate the frequency of the CLF phenomenon, to determine if it has an association with the degree of leptomeningeal collateral status, and to understand the potentia impact it may have on the final expanded Treatment in Cerebral Ischemia (eTICI) score rating. Methods Retrospective analysis of a prospective MT database spanning November 2020 to December 2021. Consecutive cases of intracranial internal carotid (i-ICA) or middle cerebral artery (MCA) M1 occlusions were included. CLF was defined by the observation of retrograde clearing of distal MCA branches that were previously opacified by antegrade reperfusion. The clearance of the distal branches is presumed to occur due to CLF via non-contrast opacified posterior cerebral artery or anterior cerebral artery flow. The washout was considered CLF if it cleared abruptly with or without forward reconstitution of antegrade opacification. Results A total of 125 patients met the inclusion criteria. The median age was 64 years (IQR 52.5-75) and 64 (51%) were men. The baseline median National Institutes of Health Stroke Scale score was 17 (IQR 12-22) and the Alberta Stroke Program Early CT Score was 9 (IQR 8-10). Median last known well time to puncture was 7 hours (IQR 4-13.1) and 30.4% received tissue plasminogen activator. Final eTICI 2c-3 was achieved in 80%. CLF was present in 32 (25.6%) patients, who had comparable baseline characteristics to patients without CLF. Twelve (37.5%) patients had regional CLF and 20 (62.5%) had focal CLF. The CLF arm had better leptomeningeal single-phase CTA collaterals than the non-CLF arm (P=0.01). The inter-rater agreement for the eTICI score was moderate when CLF was present and strong in its absence (Krippendorf's alpha=0.65 and 0.81, respectively). There was minimal agreement (Kappa=0.3) for the presence versus absence of CLF between the two operators, possibly related to reader experience. Conclusion CLF was observed in 32% of patients, was associated with better collateral flow, and impacted the reported procedural eTICI rating. [ABSTRACT FROM AUTHOR]

We aimed to explore if anatomical and technical features could interact and favor the chances of reperfusion according to the treatment strategy: combined technique (CoT) of mechanical thrombectomy (MT) with contact aspiration and stent-retriever (SR) versus SR alone.Retrospective analysis of a prospective MT database for carotid terminus or MCA-M1 occlusion, first-line SR alone or CoT, and angiographic run with SR deployed on the first pass. The primary analysis involved the interaction between clinical and angiographic characteristics and first-line MT modality on first-pass effect (FPE; first pass eTICI2c-3).A total of 300 consecutive patients were included (SR alone, n = 210 vs CoT, n = 90). Baseline characteristics as well as baseline ASPECTS, CTA collateral score, clot burden score, FPE were similar amongst groups. Anatomical and technical variables (presence of reperfusion channel, frequency of SR position in dominant MCA division, angle of device-clot interaction, and clot length) were comparable between groups, with exception of SR opening (diameter across the occlusion) and length of SR purchase beyond the clot being more pronounced in the SR group. None of the clinical, anatomical, and technical factors were found to have an interaction with the MT strategy on the chances of FPE (P-interaction ≥ 0.001). Multivariable logistic regression showed that clot burden score ≥8 (aOR 3.02, P = 0.003), angle of interaction (aOR 1.01, P = 0.015) but not the MT modality were associated with FPE.No specific anatomical or technical features were observed to predispose to benefit when combining contact aspiration and SR thrombectomy. Clot burden score ≥ 8 and angle of interaction were independent factors associated with FPE. Additional studies are warranted. [ABSTRACT FROM AUTHOR]

Background: Early identification of intracranial atherosclerotic disease (ICAD) may impact the management of patients undergoing mechanical thrombectomy (MT). We sought to develop and validate a scoring system for pre-thrombectomy diagnosis of ICAD in anterior circulation large vessel/distal medium vessel occlusion strokes (LVOs/DMVOs)., Methods: Retrospective analysis of two prospectively maintained comprehensive stroke center databases including patients with anterior circulation occlusions spanning 2010-22 (development cohort) and 2018-22 (validation cohort). ICAD cases were matched for age and sex (1:1) to non-ICAD controls., Results: Of 2870 MTs within the study period, 348 patients were included in the development cohort: 174 anterior circulation ICAD (6% of 2870 MTs) and 174 controls. Multivariable analysis β coefficients led to a 20 point scale: absence of atrial fibrillation (5); vascular risk factor burden (1) for each of hypertension, diabetes, smoking, and hyperlipidemia; multifocal single artery stenoses on CT angiography (3); absence of territorial cortical infarct (3); presence of borderzone infarct (3); or ipsilateral carotid siphon calcification (2). The validation cohort comprised 56 ICAD patients (4.1% of 1359 MTs): 56 controls. Area under the receiver operating characteristic curve was 0.88 (0.84-0.91) and 0.82 (0.73-0.89) in the development and validation cohorts, respectively. Calibration slope and intercept showed a good fit for the development cohort although with overestimated risk for the validation cohort. After intercept adjustment, the overestimation was corrected (intercept 0, 95% CI -0.5 to -0.5; slope 0.8, 95% CI 0.5 to 1.1). In the full cohort (n=414), ≥11 points showed the best performance for distinguishing ICAD from non-ICAD, with 0.71 (95% CI 0.65 to 0.78) sensitivity and 0.82 (95% CI 0.77 to 0.87) specificity, and 3.92 (95% CI 2.92 to 5.28) positive and 0.35 (95% CI 0.28 to 0.44) negative likelihood ratio. Scores ≥12 showed 90% specificity and 63% sensitivity., Conclusion: The proposed scoring system for preprocedural diagnosis of ICAD LVOs and DMVOs presented satisfactory discrimination and calibration based on clinical and non-invasive radiological data., Competing Interests: Competing interests: RGN: consultant for Anaconda, Biogen, Cerenovus, Genentech, Philips, Hybernia, Imperative Care, Medtronic, Phenox, Philips, Prolong Pharmaceuticals, Stryker Neurovascular, Shanghai Wallaby, and Synchron; stock options in Astrocyte, Brainomix, Cerebrotech, Ceretrieve, Corindus Vascular Robotics, Vesalio, Viz-AI, RapidPulse, and Perfuze; principal investigator of the ENDOLOW trial and DUSK trial; stock options in Viz-AI, Perfuze, Cerebrotech, Reist/Q’Apel Medical, Truvic, Tulavi Therapeutics, Vastrax, Piraeus Medical, Brain4Care, Quantanosis AI, and Viseon. SAS: grant from National Institutes of Health (R01NS121154); consultant for Penumbra and Imperative Care; ownership of Motif Neurosciences. DCH: consultant for Stryker Neurovascular, Cerenovus, Chiesi USA, Brainomix, Poseydon Medical; consulting/DSMB for Jacobs Institute/Medtronic, Vesalio, Rapid Pulse; stock options in VizAI and Motif Neurotech., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Fast and complete reperfusion in endovascular therapy (EVT) for ischemic stroke leads to superior clinical outcomes. The effect of changing the technical approach following initially unsuccessful passes remains undetermined., Objective: To evaluate the association between early changes to the EVT approach and reperfusion., Methods: Multicenter retrospective analysis of prospectively collected data for patients who underwent EVT for intracranial internal carotid artery, middle cerebral artery (M1/M2), or basilar artery occlusions. Changes in EVT technique after one or two failed passes with stent retriever (SR), contact aspiration (CA), or a combined technique (CT) were compared with repeating the previous strategy. The primary outcome was complete/near-complete reperfusion, defined as an expanded Thrombolysis in Cerebral Infarction (eTICI) of 2c-3, following the second and third passes., Results: Among 2968 included patients, median age was 66 years and 52% were men. Changing from SR to CA on the second or third pass was not observed to influence the rates of eTICI 2c-3, whereas changing from SR to CT after two failed passes was associated with higher chances of eTICI 2c-3 (OR=5.3, 95% CI 1.9 to 14.6). Changing from CA to CT was associated with higher eTICI 2c-3 chances after one (OR=2.9, 95% CI 1.6 to 5.5) or two (OR=2.7, 95% CI 1.0 to 7.4) failed CA passes, while switching to SR was not significantly associated with reperfusion. Following one or two failed CT passes, switching to SR was not associated with different reperfusion rates, but changing to CA after two failed CT passes was associated with lower chances of eTICI 2c-3 (OR=0.3, 95% CI 0.1 to 0.9). Rates of functional independence were similar., Conclusions: Early changes in EVT strategies were associated with higher reperfusion and should be contemplated following failed attempts with stand-alone CA or SR., Competing Interests: Competing interests: RN: consultant: Anaconda, Biogen, Cerenovus, Genentech, Hybernia, Imperative Care, Medtronic, Phenox, Philips, Prolong Pharmaceuticals, Stryker Neurovascular, Shanghai Wallaby, and Synchron; stock options: Astrocyte, Brainomix, Cerebrotech, Ceretrieve, Corindus Vascular Robotics, Vesalio, Viz-AI, RapidPulse, Perfuze; principal investigator: ENDOLOW and DUSK trials; stock options: Viz-AI, Perfuze, Cerebrotech, Reist/Q’Apel Medical, Truvic, Tulavi Therapeutics, Vastrax, Piraeus Medical, Brain4Care, Quantanosis AI, Viseon. SAS: NIH grant (R01NS121154); consultant: Penumbra and Imperative Care; ownership: Motif Neurosciences. SO-G: grants: Medtronic, Stryker, NINDS, Methinks. personal fees: Medtronic and Stryker outside the submitted work. DCH: consultant: Stryker Neurovascular, Cerenovus, Chiesi USA, Brainomix, Poseydon Medical. Consulting/DSMB: Jacobs Institute/Medtronic, Vesalio, Rapid Pulse. Stock options: VizAI, Motif Neurotech. Other authors: none., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Mechanical thrombectomy (MT) is the standard of care for eligible acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) since 2015., Aim: Our aim was to determine the key challenges for MT implementation and access worldwide., Methods: We conducted an international online survey consisting of 37 questions, distributed through the World Stroke Organization network, and as invited by co-authors between December 2022 and March 2023. The survey included a preamble outlining its purpose, questions on respondent demographics, imaging availability, MT service availability, MT selection criteria, barriers to MT, and training status in each country., Results: We received 526 responses from 89 countries distributed across 7 continents. One hundred and sixteen (22.1%) respondents did not have available MT service, 43(8.2%) had available MT only during working hours, 362(68.8%) had 24/7 MT availability. Regarding neuroimaging protocols, 13.5% used Non-contrast Computed Tomography (NCCT) only, 40.1% used NCCT/CT angiography, 37.5% used NCCT/CT angiography /CT perfusion), 0.4% used Magnetic Resonance Imaging (MRI) only, and 7.8% used MRI/MR angiography. The most common reasons for not receiving MT were cost, late presentation, and lack of availability of qualified neuro-interventional services within reasonable distance. There were 59.1% of respondents who reported having a well-structured MT training program. Lack of qualified trainers, financial support, support from higher authorities and lack of collaboration between departments were the most common obstacles against developing a training program., Conclusion: Our study highlights significant variations in MT availability, accessibility, patient selection criteria and MT service training programs worldwide. Financial costs and a shortage of trained neurointerventionalists were the main challenges in low- and middle-income countries.