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Background Mechanical thrombectomy has changed the landscape of acute ischemic stroke treatment, offering improved outcomes for patients with large vessel occlusions. The interplay between reperfusion techniques and occlusion sites remains a critical consideration in treatment decisions. This study investigates the impact of primary reperfusion techniques—stent retriever classic, stent retriever combination with aspiration, and direct aspiration—on procedural and clinical outcomes at different occlusion sites. Methods Using data from the ASSIST registry, a prospective multinational initiative, patients with anterior circulation acute ischemic stroke with large vessel occlusions (n = 1477) were included. Three primary occlusion sites—M1 segment of the middle cerebral artery, M2 segment of the middle cerebral artery, and the internal carotid artery—were studied. Univariate tests and multivariable logistic regression models were used to assess associations between reperfusion techniques and procedural and clinical outcomes, including the expanded thrombolysis in cerebral infarction score and the modified Rankin Scale, stratified by occlusion site. Results Achieving expanded thrombolysis in cerebral infarction ≥2c after first pass was lower in internal carotid artery occlusions (18.2%, P

Background Nerinetide treatment was associated with better clinical outcomes among patients with stroke undergoing endovascular treatment who were not treated with concurrent alteplase in the randomized ESCAPE‐NA1 (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischemic Stroke) trial. In patients receiving alteplase, no such effect was seen due to an inactivation of nerinetide by plasmin – the product of tissue plasminogen activation. We hypothesized that improved outcomes in the no‐alteplase patients were associated with reduced infarct growth, a radiological correlate of improved stroke outcomes. Methods Data are from the no‐alteplase stratum of the ESCAPE‐NA1 trial. Patients who underwent computer tomography perfusion (CTP) as part of routine clinical care were included. Admission CTP source data were processed using RAPID software. Infarct core at baseline was defined as areas of relative cerebral blood flow

Background First‐pass effect (FPE), that is, achieving reperfusion with a single thrombectomy device pass, is associated with better clinical outcomes in patients with acute stroke. FPE is therefore increasingly used as a marker of device and procedural efficacy. We aimed to evaluate the ability of thrombus‐based radiomics models to predict FPE in patients undergoing endovascular thrombectomy and compare performance with experts and nonradiomics thrombus characteristics. Methods Patients with thin‐slice noncontrast computed tomography and computed tomography angiography from the ESCAPE‐NA1 (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischemic Stroke) trial were included. Thrombi were manually segmented on all images. Data were randomly split into a derivation set that included a training and a validation subset and an independent test set. Radiomics features were extracted from the derivation set. The machine learning models were compared with 3 expert stroke physicians in predicting FPE in the test set using area under the receiver operating characteristic curves. Results Thin‐slice images of 554 patients were divided into a derivation set (training [n=388] and validation [n=55]) and a test set (n=111). A radiomics model using the combination of noncontrast computed tomography, computed tomography angiography, and noncontrast computed tomography–computed tomography angiography difference achieved the highest performance (area under the curve, 0.74 [95% CI, 0.64–0.84]) for prediction of FPE. This was higher than the mean area under the curve of the 3 experts (0.62 [95% CI, 0.53–0.71], P=0.01 for difference in area under the curves). The radiomics model also performed better than nonradiomics‐based thrombus features such as volume and permeability measurements in predicting FPE (P

Background Although the association between cortical venous opacification (VO) and clinical outcomes has been shown in previous studies, little is known about the relationship between parenchymal hemorrhage (PH) and VO in patients with acute stroke. We aimed to determine whether cortical VO assessed on computed tomography angiography correlates with the risk of PH following endovascular treatment. Methods This is a post hoc analysis of the ESCAPE NA‐1 (Efficacy and Safety of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke) trial. Control‐arm patients with adequate venous assessment on computed tomography angiography were included. Any PH and symptomatic intracranial hemorrhage were compared between patients with poor VO (cortical vein opacification score

Background Statistical models to predict outcomes after endovascular therapy for acute ischemic stroke often incorporate baseline (pretreatment) variables only. We assessed the performance of stroke outcome prediction models for endovascular therapy in stroke in an iterative fashion using baseline, treatment‐related, and posttreatment variables. Methods Data from the ESCAPE‐NA1 (Safety and Efficacy of Nerinetide [NA‐1] in Subjects Undergoing Endovascular Thrombectomy for Stroke) trial were used to build 4 outcome prediction models using multivariable logistic regression: model 1 included baseline variables available before treatment decision making, model 2 included additional treatment‐related variables, model 3 additional posttreatment variables that become available early (within 24–48 hours), and model 4 later (beyond 48 hours) after endovascular therapy. The primary outcome was functional independence (90‐day Modified Rankin Scale score 0–2). Model performance was compared using the area under the receiver operating characteristic curve (AUC). Shapley values were used to determine marginal contributions of variables to outcome variance in the regression models. Results Among 1105 patients, functional independence was achieved by 666 (60.3%). When using baseline variables only (model 1), the AUC was 0.74 (95% CI, 0.71–0.77); this iteratively improved when treatment and posttreatment variables were added to the models (model 2: AUC, 0.77; 95% CI, 0.74–0.80; model 3: AUC, 0.80; 95% CI, 0.77–0.83; model 4: AUC, 0.82; 95% CI, 0.79–0.85). With baseline variables alone, 26% of patients who achieved functional independence were erroneously classified as not achieving functional independence. Even with the most comprehensive model, 19.8% of patients were misclassified as such. Patient age contributed most to outcome variance (Shapley value, 0.28), followed by severe adverse events including pneumonia (0.16) and intracranial hemorrhage at 24‐hours imaging (0.13). Conclusions A substantial contribution to outcomes after endovascular therapy comes from factors unrelated to currently collected baseline patient variables. One‐fifth of patients achieving functional independence were misclassified as not achieving independence, even with the most comprehensive model. Our findings suggest that the achievable accuracy of current outcome prediction models is limited, and caution should be used when applying them in clinical practice.

Abstract Background Primary intraventricular hemorrhage is an uncommon cause of stroke and is often associated with longstanding, uncontrolled hypertension. Reversible cerebral vasoconstriction is also an uncommon condition characterized by reversible constriction of intracerebral vessels, which can lead to ischemic or hemorrhagic strokes. Case presentation We describe a case of isolated primary intraventricular hemorrhage secondary to reversible cerebral vasoconstriction syndrome triggered by pseudoephedrine. Conclusions Reversible cerebral vasoconstriction syndrome is a rare cause of primary intraventricular hemorrhage and should be considered in the differential in angiography-negative IVH when there is a history of vasoactive substance use.

Endovascular treatment of anterior circulation large vessel occlusion in the elderly population presents special challenges and opportunities. In this review, we discuss the published literature regarding thrombectomy in elderly patients and also discuss specific issues related to treatment in this patient population. In summary, while the overall outcomes following thrombectomy in elderly patients are worse than following thrombectomy in younger patients, there appears to be a similar benefit as in young patients. While there are challenges with successfully delivering thrombectomy in older patients, age alone should not be an independent exclusion from thrombectomy.

Intracranial atherosclerotic disease (ICAD) is likely the most common cause of stroke worldwide and remains highly morbid even with highly monitored medical therapy. Recent results of the SAMMPRIS trial which randomized patients to stenting plus aggressive medical management versus aggressive medical management alone have shown that additional treatment of intracranial atherosclerotic lesions with the Wingspan stent is inferior to aggressive medical management alone. In light of these results there has been renewed interest in angioplasty alone to treat symptomatic ICAD. This article will briefly review the natural history of intracranial atherosclerotic disease (ICAD) and discuss the possible future for endovascular treatment of ICAD with primary intracranial angioplasty in appropriately selected patients.

One of the enigmas in tumor biology is that different types of cancers are prevalent in different age groups. One possible explanation is that the ability of a specific oncogene to cause tumorigenesis in a particular cell type depends on epigenetic parameters such as the developmental context. To address this hypothesis, we have used the tetracycline regulatory system to generate transgenic mice in which the expression of a c-MYC human transgene can be conditionally regulated in murine hepatocytes. MYC's ability to induce tumorigenesis was dependent upon developmental context. In embryonic and neonatal mice, MYC overexpression in the liver induced marked cell proliferation and immediate onset of neoplasia. In contrast, in adult mice MYC overexpression induced cell growth and DNA replication without mitotic cell division, and mice succumbed to neoplasia only after a prolonged latency. In adult hepatocytes, MYC activation failed to induce cell division, which was at least in part mediated through the activation of p53. Surprisingly, apoptosis is not a barrier to MYC inducing tumorigenesis. The ability of oncogenes to induce tumorigenesis may be generally restrained by developmentally specific mechanisms. Adult somatic cells have evolved mechanisms to prevent individual oncogenes from initiating cellular growth, DNA replication, and mitotic cellular division alone, thereby preventing any single genetic event from inducing tumorigenesis.