Search

Purpose: The outcomes of patients with large ischemic core who fail to recanalize with endovascular therapy (EVT) compared to medical management (MM) are uncertain. The objective was to evaluate the clinical and safety outcomes of patients who underwent EVT in patients with large ischemic core and unsuccessful recanalization., Methods: This was a post hoc analysis of the ANGEL-ASPECT randomized trial. Unsuccessful recanalization was defined as patients who underwent EVT with eTICI 0-2a. The primary endpoint was 90-day very poor outcome (mRS 5-6). Multivariable logistic regression was conducted controlling for ASPECTS, occlusion location, intravenous thrombolysis, and time to treatment., Results: Of 455 patients 225 were treated with MM. Of 230 treated with EVT, 43 (19%) patients had unsuccessful recanalization. There was no difference in 90-day very poor outcomes (39.5% vs. 40%, aOR 0.93, 95% confidence interval, CI 0.47-1.85, p = 0.95), sICH (7.0% vs. 2.7%, aOR 2.81, 95% CI 0.6-13.29, p = 0.19), or mortality (30% vs. 20%, aOR 1.65, 95% CI 0.89-3.06, p = 0.11) between the unsuccessful EVT and MM groups, respectively. There were higher rates of ICH (55.8% vs. 17.3%, p < 0.001), infarct core volume growth (142.7 ml vs. 90.5 ml, β = 47.77, 95% CI 20.97-74.57 ml, p < 0.001), and decompressive craniectomy (18.6% vs. 3.6%, p < 0.001) in the unsuccessful EVT versus MM groups., Conclusion: In a randomized trial of patients with large ischemic core undergoing EVT with unsuccessful recanalization, there was no difference in very poor outcomes, sICH or death versus medically managed patients. In the unsuccessful EVT group, there were higher rates of any ICH, volume of infarct core growth, and decompressive craniectomy., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background and Purpose: Intracranial atherosclerotic disease (ICAD) is a common etiology of acute vertebrobasilar artery occlusion (VBAO) in Asia, which complicated endovascular treatment (EVT). We aimed to investigate the incidence, impacts, and predictors of ICAD in VBAO., Methods: Subjects were selected from the Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke registry and divided into two groups based on whether underlying ICAD existed. Underlying ICAD was determined when the following situations arise in the occlusion site during EVT: (1) fixed stenosis degree >70% or (2) stenosis >50% with distal blood flow impairment or evidence of repeated reocclusion. Multivariable regression models were used to investigate the effect of underlying ICAD on outcomes measured by modified Rankin Scale (mRS) score at 90 days and to identify baseline characteristics associated with underlying ICAD., Results: Among the 315 patients enrolled, 171 (54.3%) had underlying ICAD. Favorable functional outcomes (mRS 0-3) occurred in 79 of 163 patients (48.5%) with ICAD and 69 of 137 patients (50.4%) without ICAD ( p  = 0.743). Outcomes were similar between the two groups and remained similar after adjusting for the confounders. History of hypertension and elevated admission neutrophil to lymphocyte ratio were strong predictors of underlying ICAD, whereas history of atrial fibrillation and distal basilar artery occlusion were negative predictors., Conclusions: In our study, underlying ICAD was recognized in approximately half of the VBAO patients, leading to comparable outcomes after more complex EVT strategies. Some baseline characteristics were identified to be predictors for underlying ICAD, which were helpful to guide the EVT strategies before the procedure.

Background: The role of endovascular therapy for acute stroke with a large infarction has not been extensively studied in differing populations., Methods: We conducted a multicenter, prospective, open-label, randomized trial in China involving patients with acute large-vessel occlusion in the anterior circulation and an Alberta Stroke Program Early Computed Tomography Score of 3 to 5 (range, 0 to 10, with lower values indicating larger infarction) or an infarct-core volume of 70 to 100 ml. Patients were randomly assigned in a 1:1 ratio within 24 hours from the time they were last known to be well to undergo endovascular therapy and receive medical management or to receive medical management alone. The primary outcome was the score on the modified Rankin scale at 90 days (scores range from 0 to 6, with higher scores indicating greater disability), and the primary objective was to determine whether a shift in the distribution of the scores on the modified Rankin scale at 90 days had occurred between the two groups. Secondary outcomes included scores of 0 to 2 and 0 to 3 on the modified Rankin scale. The primary safety outcome was symptomatic intracranial hemorrhage within 48 hours after randomization., Results: A total of 456 patients were enrolled; 231 were assigned to the endovascular-therapy group and 225 to the medical-management group. Approximately 28% of the patients in both groups received intravenous thrombolysis. The trial was stopped early owing to the efficacy of endovascular therapy after the second interim analysis. At 90 days, a shift in the distribution of scores on the modified Rankin scale toward better outcomes was observed in favor of endovascular therapy over medical management alone (generalized odds ratio, 1.37; 95% confidence interval, 1.11 to 1.69; P = 0.004). Symptomatic intracranial hemorrhage occurred in 14 of 230 patients (6.1%) in the endovascular-therapy group and in 6 of 225 patients (2.7%) in the medical-management group; any intracranial hemorrhage occurred in 113 (49.1%) and 39 (17.3%), respectively. Results for the secondary outcomes generally supported those of the primary analysis., Conclusions: In a trial conducted in China, patients with large cerebral infarctions had better outcomes with endovascular therapy administered within 24 hours than with medical management alone but had more intracranial hemorrhages. (Funded by Covidien Healthcare International Trading [Shanghai] and others; ANGEL-ASPECT ClinicalTrials.gov number, NCT04551664.)., (Copyright © 2023 Massachusetts Medical Society.)

Background: Parenchymal hemorrhage (PH) is a troublesome complication after endovascular treatment (EVT)., Objective: To investigate the incidence, independent predictors, and clinical impact of PH after EVT in patients with acute ischemic stroke (AIS) due to anterior circulation large vessel occlusion (LVO)., Methods: Subjects were selected from the ANGEL-ACT Registry. PH was diagnosed according to the European Collaborative Acute Stroke Study classification. Logistic regression analyses were performed to determine the independent predictors of PH, as well as the association between PH and 90-day functional outcome assessed by modified Rankin Scale (mRS) score., Results: Of the 1227 enrolled patients, 147 (12.0%) were diagnosed with PH within 12-36 hours after EVT. On multivariable analysis, low admission Alberta Stroke Program Early CT score (ASPECTS)(adjusted OR (aOR)=1.13, 95% CI 1.02 to 1.26, p=0.020), serum glucose >7 mmol/L (aOR=1.82, 95% CI 1.16 to 2.84, p=0.009), and neutrophil-to-lymphocyte ratio (NLR; aOR=1.05, 95% CI 1.02 to 1.09, p=0.005) were associated with a high risk of PH, while underlying intracranial atherosclerotic stenosis (ICAS; aOR=0.42, 95% CI 0.22 to 0.81, p=0.009) and intracranial angioplasty/stenting (aOR=0.37, 95% CI 0.15 to 0.93, p=0.035) were associated with a low risk of PH. Furthermore, patients with PH were associated with a shift towards to worse functional outcome (mRS score 4 vs 3, adjusted common OR (acOR)=2.27, 95% CI 1.53 to 3.38, p<0.001)., Conclusions: In Chinese patients with AIS caused by anterior circulation LVO, the risk of PH was positively associated with low admission ASPECTS, serum glucose >7 mmol/L, and NLR, but negatively related to underlying ICAS and intracranial angioplasty/stenting., Trial Registration Number: NCT03370939., Competing Interests: Competing interests: ZR: consultant to Penumbra Company, USA., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Early neurological deterioration (END) may occur in some patients with acute large vessel occlusion (LVO) undergoing endovascular treatment (EVT). Despite several clear causes of END, such as symptomatic intracranial hemorrhage, failure of recanalization, and intraprocedure complications, a particular END, termed unexplained END (END unexplained ), exists. We aimed to investigate the incidence, independent predictors, and clinical impact of END unexplained after EVT in patients with acute LVO., Methods: Subjects were selected from the ANGEL-ACT registry. END unexplained was defined as ≥4-point increase in the National Institutes of Health Stroke Scale (NIHSS) score between baseline and 24 hours after EVT, without the causes listed above. Logistic regression analyses were performed to determine the independent predictors of END unexplained , as well as the association between END unexplained and 90-day outcomes assessed by modified Rankin Scale (mRS) score., Results: Among the 1557 enrolled patients, the incidence of END unexplained was 4.3% (67/1557). Admission NIHSS ≤8 (OR=6.88, 95% CI 3.86 to 12.26, p<0.001), general anesthesia (OR=3.15, 95% CI 1.81 to 5.48, p<0.001), admission neutrophil to lymphocyte ratio >5 (OR=2.82, 95% CI 1.61 to 4.94, p<0.001), and number of EVT attempts >3 (OR=2.11, 95% CI 1.14 to 3.89, p=0.018) were associated independently with a high risk of END unexplained . Furthermore, patients with END unexplained were associated with a shift toward worse 90-day outcomes (mRS 5 vs 3, common OR=5.24, 95% CI 3.22 to 8.52, p<0.001)., Conclusions: END unexplained associated with poor 90day outcomes occurred in 4.3% of patients with acute LVO undergoing EVT. Several independent predictors of END unexplained were identified in this study, which should be considered in daily practice to improve acute LVO management., Clinical Trial Registration: http://wwwclinicaltrialsgov NCT03370939., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Purpose: Endovascular treatment (EVT) has shown an overwhelming benefit for acute anterior circulation artery occlusion (ACO). Whether it can achieve the same outcomes in posterior circulation artery occlusion (PCO) has not been well explained. We aimed to evaluate the characteristics and prognosis of ACO and PCO after EVT in a nationwide registry., Method: The present analysis was based on the prospective ANGEL-ACT Registry in China between November 2017 and March 2019. Demographic data, periprocedural times, recanalisation rate, intracranial haemorrhage (ICH) and 90-day functional outcomes were compared between the ACO and PCO groups., Results: A total of 1793 patients were analysed including 397 (22.1%) consecutive patients with PCO and 1396 (77.9%) patients with ACO treated with EVT. A larger proportion of patients with PCO had intracranial atherosclerotic disease and received extra angioplasty during EVT. Successful recanalisation and 90-day favourable functional outcomes did not differ significantly between the two groups. Patients with PCO showed lower 24-hour ICH and symptomatic ICH rates. There was a trend towards higher mortality rate in the PCO group (22.09% vs 14.44%; adjusted OR 1.286 (95% CI 0.820 to 2.017), p=0.2731), especially when the onset to puncture time was over 6 hours (30.77% vs 11.13%; adjusted OR 2.673 (95% CI 1.280 to 5.583), p=0.0089, interactive p=0.0002)., Conclusions: In this large prospective multicentre registry, there was a significant difference in the characteristics and periprocedural features between patients with PCO and ACO. However, successful recanalisation and 90-day favourable functional outcomes in PCO were equivalent to those in ACO., Competing Interests: Competing interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The role of stroke etiology subtype in patients with acute large vessel occlusion on the occurrence of hemorrhagic transformation (HT) after endovascular treatment is poorly studied, and which factors mediate their relationship remains largely unknown. We utilized nationwide registry data to explore the association of stroke subtype (cardioembolism versus large artery atherosclerosis) with HT and to identify the possible mediators., Methods: A total of 1015 subjects were selected from the ANGEL-ACT registry (Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke)-a prospective consecutive cohort of acute large vessel occlusion patients undergoing endovascular treatment at 111 hospitals in China between November 2017 and March 2019-and divided into large artery atherosclerosis (n=538) and cardioembolism (n=477) according to the Trial of ORG 10172 in Acute Stroke Treatment criteria. The types of HT included any intracerebral hemorrhage (ICH), parenchymal hematoma, and symptomatic ICH within 24 hours after endovascular treatment. The association between stroke subtype and HT was analyzed using a logistic regression model. Mediation analysis was done to assess how much of the effect of stroke subtype on HT was mediated through the identified mediators., Results: Stroke subtype (cardioembolism versus large artery atherosclerosis) was associated with increased risk of any ICH (29.8% versus 16.5%; odds ratio, 2.03 [95% CI, 1.22-3.36]), parenchymal hematoma (14.3% versus 5.4%; odds ratio, 2.90 [95% CI, 1.38-6.13]), and symptomatic ICH (9.9% versus 4.7%; odds ratio, 2.59 [95% CI, 1.09-6.16]) after adjustment for potential confounders. The more thrombectomy passes in cardioembolism patients had a significant mediation effect on the association of stroke subtype with increased risk of HT (any ICH, 15.9%; parenchymal hematoma, 13.4%; symptomatic ICH, 14.2%, respectively)., Conclusions: Stroke subtype is an independent risk factor for HT within 24 hours following endovascular treatment among acute large vessel occlusion patients. Mediation analyses propose that stroke subtype contributes to HT partly through thrombectomy pass, suggesting a possible pathomechanistic link., Registration: URL: https://www., Clinicaltrials: gov; Unique identifier: NCT03370939.

Background: There remains major uncertainty regarding the optimal therapy for symptomatic nonacute extracranial vertebral artery occlusion (EVAO). Endovascular recanalization for EVAO is technically challenging, and limited data are available. This research aimed to report a multicenter clinical experience of endovascular recanalization for symptomatic nonacute EVAO and establish a novel angiographic classification., Methods: From June 2011 to December 2019, 50 symptomatic nonacute EVAO patients treated with endovascular recanalization in three regional referral stroke centers were retrospectively analyzed. All patients were categorized into four groups based on the angiographic classification. The rates of technical success, periprocedural complications, any stroke or death within 1 month, and follow-up data were assessed., Results: The rates of technical success, periprocedural complications, and any stroke or death within 1 month were 86.0% (43/50), 12.0% (6/50), and 4.0% (2/50), respectively. The recanalization rates gradually decreased from Type A to Type D (100%, 94.7%, 80%, and 63.6%, respectively; P=0.007). The EVAO patients in the Type A group with tapered stump and short-segment occlusions showed excellent recanalization effects, with 100% technical success rates and no complications. Conversely, the lowest recanalization rate of 63.6% (7/11) and the highest periprocedural complication rate of 27.3% (3/11) were observed for the Type D group., Conclusions: Endovascular recanalization for symptomatic nonacute EVAO is technically feasible, especially Type A EVAO patients, which can provide an alternative treatment option for recurrent vertebrobasilar ischemia despite optimal medical therapy. The angiographic categorization established in this study is conducive to the selection of suitable patients prior to treatment decision., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: The epidemic of COVID-19 has greatly affect the world health care system, particular measures have been taken not only to provide safety for health care providers but also to maintain the treatment quality. We evaluate the effect of COVID-19 epidemic to acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) received endovascular treatment (EVT) in our institution., Methods: AIS patients with LVO who underwent EVT in the period of January 1st to April 30th between 2015 and 2020 from our stroke center. The baseline characteristics, working flow time, safety and efficacy outcome and the hospitalization status were retrospectively reviewed, compared and analyzed., Results: There is significant decline in the number of AIS patients with LVO treated compared with the previous year (36 Vs 72 patients) during the epidemic period. The door to puncture time was significantly prolong (225 minutes versus 115 minutes) as well as the length of hospital stay with increase of the hospitalization costs ( P  < 0.05 for all). There is no significant difference on the safety and efficacy outcome, such recanalization rate, incidence of intracranial hemorrhage, functional independence and mortality during the epidemic ( P  > 0.05 for all)., Conclusions: Prolongation of the working time flow during the COVID-19 epidemic did not influence the safety and efficacy of EVT in AIS patients with LVO. However, special policy and particular measures in this circumstances is still need to evolve to improve the treatment quality.

Background: There is no consensus on the optimal treatment of non-acute basilar artery occlusion (BAO), and endovascular recanalization still poses a therapeutic challenge for these patients. We report a multicenter clinical experience of endovascular recanalization for symptomatic non-acute BAO and propose an angiographic grouping to determine which patient subgroup most benefits from this treatment., Methods: Forty-two patients with non-acute BAO with progressive or recurrent vertebrobasilar ischemic symptoms who underwent endovascular recanalization were retrospectively analyzed from January 2015 to December 2019. These patients were classified into three subtypes based on their occlusion length and distal collateral reconstruction on angiograms. The rates of technical success, periprocedural complications and outcome, any stroke or death within 1 month, and follow-up data were examined., Results: The success rate of endovascular recanalization was 76.2% (32/42). The rate of periprocedural complications was 14.3% (6/42). In the three subgroups (types I-III) the success rates of endovascular recanalization were reduced (90.0%, 71.4% and 50%, respectively, p=0.023), while the overall rates of periprocedural complications were increased (5.0%, 14.3% and 37.5%, respectively, p=0.034). Type I lesions, with short-segment occlusions and good distal BA collateral reconstruction, showed favorable responses to endovascular recanalization. The median follow-up time was 1 year (IQR 11.0-19.5 months), with any stroke or death during follow-up at a rate of 7.9%., Conclusion: Endovascular recanalization can be safe and feasible for reasonably selected patients with non-acute BAO, especially type I lesions, and offers an alternative choice for those with progressive or recurrent vertebrobasilar ischemic symptoms despite aggressive medical therapy., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The optimal treatment for medically refractory non-acute intracranial artery occlusion is uncertain, and endovascular recanalization remains a technical challenge. Here, a multicenter clinical experience of dual-roadmap guidance for endovascular recanalization of non-acute intracranial artery occlusion is reported, focusing on the technical feasibility and safety., Methods: From January 2014 to December 2019, 52 consecutive patients with medically refractory atherosclerotic non-acute intracranial artery occlusion who underwent endovascular recanalization under dual-roadmap guidance in three large regional referral stroke centers were analyzed retrospectively. Four types of dual-roadmap technical schemes were applied during endovascular recanalization. The rates of technical success, periprocedural complications, any stroke or death within 30 days, and follow-up results were evaluated., Results: The technical success rate was 92.3% (48/52). The perioperative complication rate was 7.7% (4/52), and the rate of any stroke or death within 30 days was 3.8% (2/52). Asymptomatic dissection occurred in two patients, acute in-stent thrombosis followed by postoperative mild stroke (National Institutes of Health Stroke Scale (NIHSS) 3) in one patient, and death due to reperfusion hemorrhage after successful recanalization in one patient. The rate of stroke or death beyond 30 days was 6.5% (3/46). The median clinical follow-up period was 19 months, and the median imaging follow-up period was 12 months. The restenosis rate was 13.2% (5/38)., Conclusions: Endovascular recanalization of non-acute intracranial occlusions can be performed with a high rate of technical success and few complications with assistance of the dual-roadmap technique for navigation. Four types of dual-roadmap schemes provide technical references., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Endovascular recanalization for medically refractory non-acute middle cerebral artery (MCA) occlusion remains a clinical dilemma, and limited data are available. We report the multicenter clinical results of endovascular recanalization for symptomatic non-acute MCA occlusion and propose a new angiographic classification to explore which subgroups of patients are most suitable for this treatment., Methods: From January 2015 to December 2019, 50 consecutive patients who underwent endovascular recanalization for recurrent symptomatic non-acute MCA occlusion were analyzed retrospectively. All patients were divided into three types according to the angiographic classification. The technical success rate, periprocedural complications, rate of stroke or death within 30 days, and follow-up results were evaluated., Results: The overall technical success rate was 84.0% (42/50). The perioperative complication rate was 14.0% (7/50), and the rate of stroke or death within 30 days was 12.0% (6/50). The revascularization success rate was higher in patients with type I occlusion than in those with type II or type III occlusion (95.5%, 83.3%, and 60%, respectively; p=0.014), and the opposite was true for the perioperative complication rate (4.5%, 11.1%, and 40.0%, respectively; p=0.013). The median clinical follow-up period was 13.4 months (IQR 12.5-15.6), and the rate of stroke or death beyond 30 days was 8.3%., Conclusions: Endovascular recanalization for non-acute MCA occlusion is technically feasible in reasonably selected patients, especially type I patients, and has potential as an alternative option for patients with recurrent stroke or transient ischemic attack in the short term despite optimal medical therapy., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Poor clinical outcomes despite endovascular therapy (EVT) are common in patients with acute basilar artery occlusion (BAO). We aimed to develop a new angiographic collateral grading system for predicting 90-day functional outcomes of acute BAO after EVT. A prospectively registered consecutive cohort of acute BAO patients treated with EVT in our center during a 6-year period was reviewed. The angiographic collateral grading system for BAO (ACGS-BAO) included 4 grades for poor (grade 1-2), intermediate (grade 3), and good (grade 4) collateral statuses. First, the independent association of ACGS-BAO with 90-day functional independence (mRS ≤ 2), favorable outcome (mRS ≤ 3), and death was evaluated by multivariable logistic regression model; then, the heterogeneity in the effects of ACGS-BAO on 90-day outcomes was explored among the subgroups stratified by age, time window, stroke severity, and etiology. Finally, the interobserver agreement of ACGS-BAO was assessed by weighted kappa statistic. Of 173 patients included in this study, 62 (35.8%), 83 (48.0%), and 36 (20.8%) achieved 90-day functional independence, favorable outcome, and death, respectively. Multivariable logistic analyses showed that ACGS-BAO was independently associated with functional independence (OR = 2.07, 95% CI = 1.05-4.07) and favorable outcome (OR = 1.84, 95% CI = 1.02-3.43) but not related to death (OR = 0.78, 95% CI = 0.37-1.64). Similar effects of ACGS-BAO on 90-day outcomes were seen across all subgroups (P > 0.10 for all interactions). The interobserver agreement of ACGS-BAO was very high (weighted kappa = 0.96, 95% CI = 0.93-0.99). The ACGS-BAO is an angiographic tool with excellent interobserver reliability that can be used to predict the 90-day outcome of acute BAO treated by EVT. Nevertheless, our findings are still needed to be confirmed in a prospective multicenter study before clinical application.

Background and Purpose: The benefit of endovascular treatment (EVT) for large vessel occlusion in clinical practice in developing countries like China needs to be confirmed. The aim of the study was to determine whether the benefit of EVT for acute ischemic stroke in randomized trials could be generalized to clinical practice in Chinese population., Methods: We conducted a prospective registry of EVT at 111 centers in China. Patients with acute ischemic stroke caused by imaging-confirmed intracranial large vessel occlusion and receiving EVT were included. The primary outcome was functional independence at 90 days defined as a modified Rankin Scale score of 0 to 2. Outcomes of specific subgroups in the anterior circulation were reported and logistic regression was performed to predict the primary outcome., Results: Among the 1793 enrolled patients, 1396 (77.9%) had anterior circulation large vessel occlusion (median age, 66 [56-73] years) and 397 (22.1%) had posterior circulation large vessel occlusion (median age, 64 [55-72] years). Functional independence at 90 days was reached in 45% and 44% in anterior and posterior circulation groups, respectively. For anterior circulation population, underlying intracranial atherosclerotic disease was identified in 29% of patients, with higher functional independence at 90 days (52% versus 44%; P =0.0122) than patients without intracranial atherosclerotic disease. In the anterior circulation population, after adjusting for baseline characteristics, procedure details, and early outcomes, the independent predictors for functional independence at 90 days were age <66 years (odds ratio [OR], 1.733 [95% CI, 1.213-2.476]), time from onset to puncture >6 hours (OR, 1.536 [95% CI, 1.065-2.216]), local anesthesia (OR, 2.194 [95% CI, 1.325-3.633]), final modified Thrombolysis in Cerebral Infarction 2b/3 (OR, 2.052 [95% CI, 1.085-3.878]), puncture-to-reperfusion time ≤1.5 hours (OR, 1.628 [95% CI, 1.098-2.413]), and National Institutes of Health Stroke Scale score 24 hours after the procedure <11 (OR, 9.126 [95% CI, 6.222-13.385])., Conclusions: Despite distinct characteristics in the Chinese population, favorable outcome of EVT can be achieved in clinical practice in China. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03370939.

The current study aimed to evaluate whether patients with different pathologic subtypes of basilar artery occlusion (BAO) stroke could affect the clinical outcome after receiving endovascular treatment (EVT). A total of 187 consecutive patients with acute BAO receiving endovascular treatment (EVT) from January 2012 to July 2018 at the Beijing Tiantan Hospital were recruited in this study. The patients were categorized into three groups: embolism without vertebral artery (VA) steno-occlusion (group 1), in situ atherosclerotic thrombosis (group 2), and embolism from tandem VA steno-occlusion (group 3). Among the 187 patients, 4 patients with embolic combined with ICAS and 1 patient with tandem VA steno-occlusion combined with ICAS were excluded. Of the remaining 182 patients (153 men and 29 women; mean age, 60 years), 43 (23.6%) had embolism without vertebral artery (VA) steno-occlusion (group 1), 116 (63.7%) showed in situ atherosclerotic thrombosis (group 2), and 23 (12.6%) had embolism from tandem VA steno-occlusion (group 3). Overall, successful recanalization (modified thrombolysis in cerebral infarction grade 2b or 3) was achieved in 95.3%, 86.2%, and 60.9% in groups 1, 2, and 3, respectively. The favorable outcome (90-day modified Rankin scale score, 0-3) in the three groups was 51.2%, 52.6%, and 30.4%, respectively. Mortality was higher in group 3 (47.8%) as compared with groups 1 (16.3%) (p = 0.009) and 2 (17.2%) (p = 0.004). Embolism from tandem VA steno-occlusion (group 3) seems to be associated with a lower rate of recanalization and significantly higher rate of mortality as compared with another pathological mechanism of BAO.

Aim: Optimal blood pressure (BP) management in vertebrobasilar circulation stroke patients undergoing thrombectomy remains undetermined. We aimed to evaluate the impact of perioperative BP on clinical outcome after MT in acute basilar artery occlusion (BAO) patients., Methods: We retrospectively analyzed all consecutive patients hospitalized with acute basilar artery occlusion administered endovascular treatment within 24 h from January 2012 to July 2018 in Beijing Tiantan Hospital. BP was measured at regular intervals during the first 24 h after stroke onset, during and after thrombectomy. The clinical outcomes assessed at 3-month follow up were functional independence (mRS score of 0-2) and mortality (mRS score of 6)., Results: Of the 187 treated patients, 157 were male; patient ages were 60±10 years. The median NIHSS on admission was 22. Totally in 179 patients had complete BP level assessment. In these individuals, univariate analysis revealed significant associations of postoperative Max SBP and Max MAP with mortality (all P < 0.05). Multivariate regression analysis also demonstrated that postoperative Max SBP (OR=0.964, 95% CI 0.941 to 0.987, P < 0.003) and Max MAP (OR=0.942, 95% CI 0.907 to 0.979, P < 0.002) were independent predictors of mortality., Conclusions: In acute BAO patients administered thrombectomy, Max SBP between 120 and 160 mmHg may be associated with better outcome, with a trend of reduced risk of mortality., Competing Interests: Declaration of Competing Interests The authors declare that they have no conflict of interest., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The perioperative optimal blood pressure targets during mechanical thrombectomy for acute ischemic stroke are uncertain, and randomized controlled trials addressing this issue are lacking. There is still no consensus on the optimal target for perioperative blood pressure in acute ischemic stroke patients with large vessel occlusion. In addition, there are many confounding factors that can influence the outcome including the patient's clinical history and stroke characteristics. We review the factors that have an impact on perioperative blood pressure change and discuss the influence of perioperative blood pressure on functional outcome after mechanical thrombectomy. In conclusion, we suggest that blood pressure should be carefully and flexibly managed perioperatively in patient-received mechanical thrombectomy. Blood pressure changes during mechanical thrombectomy were independently correlated with poor prognosis, and blood pressure should be maintained in a normal range perioperatively. Postoperative blood pressure control is associated with recanalization status in which successful recanalization requires normal range blood pressure (systolic blood pressure 120-140 mmHg), while non-recanalization requires higher blood pressure (systolic blood pressure 160-180 mmHg). The preoperative blood pressure targets for mechanical thrombectomy should be tailored based on the patient's clinical history (systolic blood pressure ≤185 mmHg). Blood pressure should be carefully and flexibly managed intraoperatively (systolic blood pressure 140-180 mmHg) in patient-received endovascular therapy.

Background and Purpose: Endovascular recanalization for patients with nonacute intracranial vertebral artery occlusion remains clinically challenging. We aim to evaluate the feasibility and safety of endovascular recanalization for nonacute intracranial vertebral artery occlusion and propose a new angiographic classification., Methods: Fifty patients with symptomatic atherosclerotic nonacute intracranial vertebral artery occlusion from January 2015 to December 2019 were analyzed, retrospectively. The rate of recanalization, peri-procedural complications, and follow-up results were evaluated. All patients were divided into 4 groups according to an angiographic classification., Results: Among the 50 patients, 38 (76%) achieved successful recanalization. Any stroke or death within 30 days was 4% (2/50). From type I to type IV, the recanalization rate gradually decreased (94.1%, 76.9%, 70%, and 50%, respectively, P =0.012), while the perioperative complication rate gradually increased (0.0%, 7.7%, 20%, and 50%, respectively, P =0.001)., Conclusions: Endovascular recanalization may be feasible and safe for carefully selected patients with symptomatic atherosclerotic nonacute intracranial vertebral artery occlusion and, therefore, represents an alternative treatment, especially for type I and type II patients.

Background and Objective: The research on the effect of anesthesia on endovascular therapy (EVT) of acute ischemic stroke is mainly focused on the anterior circulation, and little is known about the data of basilar artery occlusion (BAO). This study aims to investigate the association of anesthesia strategy with 90-day clinical outcomes of patients with acute BAO treated with EVT., Methods: We reviewed our prospectively collected data from the endovascular treatment database at the Beijing Tiantan Hospital. This included patients with acute BAO who had a documented 90-day modified Rankin Scale (mRS) score from January 2012 to July 2018. Options for EVT included general anesthesia (GA) and conscious sedation (CS) performed by an anesthesia care team in the institution. The recommendation of anesthesia for patients was a joint decision between anesthesiologist and neurointerventionalist according to a pre-designed scheme. Patients who required tracheal intubation for airway protection prior to EVT were excluded. The clinical outcomes we observed were functional independence (mRS ≤2), favorable outcome (mRS ≤3), and mortality at 90 days after the procedure. Univariate and multivariable logistic regression analyses were used to explore the relationship between anesthesia methods and 90-day outcomes., Results: A total of 187 patients with BAO were treated by EVT in this study. Nine cases requiring emergent intubation prior to EVT were excluded. 139 patients (78.1%) underwent GA and 39 patients (21.9%) underwent CS. In univariate analysis, GA was associated with less functional independence [odds ratio (OR), 0.28; 95% confidence interval (CI), 0.13-0.59] and less favorable outcome (OR, 0.23; 95% CI, 0.10-0.52) than was CS. After adjusting for potential confounders, multivariable analysis showed that there were still significant differences between GA and CS in functional independence (OR, 0.31; 95%CI, 0.10-0.97) and favorable outcome (OR, 0.24; 95%CI, 0.07-0.75)., Conclusion: Our retrospective analysis suggested that the anesthesia strategy may affect outcome, in which general anesthesia may result in less favorable outcomes. Nevertheless, future multicenter randomized controlled trials are needed to confirm our findings.

There were limited studies comparing the anterior (AC) and posterior (PC) circulation acute ischemic strokes (AIS). Our study aimed to evaluate distinct features of AC and PC strokes regarding clinical, vascular risk, pathogenesis and outcome factors after endovascular procedures. This multicenter prospective study registered 873 patients with acute large occlusion of anterior circulation stroke (ACS) and posterior circulation stroke (PCS). Patients who underwent endovascular procedures were included in this study. The differences in ACS and PCS regarding baseline characteristics, post-operative intracranial hemorrhage and outcomes were evaluated. A total of 741 patients were included in the data analysis. Intravenous thrombolysis (31.5%), atrial fibrillation (22.7%) and stent thrombectomy (82.4%) were more frequently observed in ACS patients. While higher NIHSS score, hypertension (67.6%) and balloon angioplasty (20.7%) were more prevalent in PCS patients. Symptomatic intracranial hemorrhage was more common in ACS (7.4% vs 2.8%). However, a 3-month follow-up outcomes were better in ACS with higher functional independence and low mortality rate than PCS (46.8% vs 30.3% and 16.4% vs 33.8%, respectively, P < 0.01). In this large prospective study, there were significant differences in the pathogenesis of stroke and treatment procedure between ACS and PCS which influence the clinical outcome. These findings could lead to a tailored clinical procedures and treatment strategies to improve the prognosis in both groups.

Background: Endovascular treatment (EVT) is now considered the gold standard for select patient populations with anterior circulation stroke; however, data on the treatment of posterior circulation stroke are less clear. This study aims to determine the characteristics and treatment outcomes of patients with acute basilar artery occlusion (BAO) and to evaluate the effectiveness and safety of EVT for patients with acute BAO in a high-volume stroke center., Methods: This study included 187 consecutive patients with acute BAO who underwent EVT from January 2012 to July 2018 in the Beijing Tiantan Hospital. The baseline characteristics, procedure parameters, and functional outcome were assessed., Results: Among the 187 patients, 138 (73.8%) underwent mechanical thrombectomy with a stent retriever, 33 (17.6%) underwent direct intracranial angioplasty (balloon dilation and/or stent implantation) for underlying severe intracranial atherosclerotic disease, and 91 (48.7%) underwent combined mechanical thrombectomy and angioplasty. Successful recanalization [modified Thrombolysis in Cerebral Infarction (mTICI) grade 2b-3] was achieved in 158 patients (84.5%). Overall, the rates of functional independence [modified Rankin Scale (mRS) 0-2] and favorable outcome (mRS 0-3) at 90 days were 36.4 and 49.2%, respectively, and 90-day all-cause mortality was 20.3%., Conclusion: EVT was effective and safe for treating patients with acute BAO.

Objective: To determine the safety and efficacy of endovascular treatment with the Solitaire device for acute basilar artery occlusion (ABAO) and identify factors affecting clinical outcomes., Methods: We enrolled 36 consecutive ABAO patients (aged 58.6 ± 8.10 years) who underwent mechanical thrombectomy with the Solitaire device. We analyzed baseline characteristics, mechanical thrombectomy results, and factors predicting clinical outcomes, which were assessed at 90 days., Results: The median prethrombectomy National Institutes of Health Stroke Scale (NIHSS) score was 25.50 (interquartile range: 21.00-29.00); the median prethrombectomy Glasgow Coma Scale (GCS) score was 8.00 (5.00-9.75). Thirty patients (83.3%) had atherosclerotic stenosis of the occluded artery, and 25 underwent angioplasty (69.4%). Recanalization was successful (Thrombolysis in Cerebral Infarction grade: 2b-3) in 34 patients (94.4%). Six symptomatic intracranial hemorrhages (16.67%) occurred. Favorable outcomes (modified Rankin scale [mRS] score: 0-2) were achieved in 27.8% patients (10/36). The overall mortality rate was 30.6% (11/36) at 90 days. On univariate analysis, low prethrombectomy GCS and high post-thrombectomy NIHSS scores were associated with poor outcomes (mRS score >2) and mortality. Prethrombectomy unconsciousness, onset-to-recanalization time > 10.5 hours, and severe stenosis were associated with poor outcomes. Age ≥ 60 years was associated with mortality., Conclusions: Endovascular treatment with the Solitaire device yielded high recanalization rates in ABAO patients and favorable clinical outcomes in approximately one third of patients. Intracranial stenosis was the main cause of occlusion. Angioplasty was commonly performed during mechanical thrombectomy to improve recanalization and prognosis. Early recanalization and better prethrombectomy status predicted better outcomes., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background and Purpose: The long term results of vertebral artery ostium (VAO) stenting remain uncertain. We sought to evaluate the incidence and risk factors for recurrent ischemic events on long term follow-up in patients who have undergone VAO stenting., Methods: 190 consecutive patients who had undergone a total of 202 stenting procedures for symptomatic atherosclerotic VAO stenosis between January 2011 and December 2012 were screened. Baseline demographics of the patients and morphological features of VAO were recorded. The primary outcome events analyzed included recurrent transient ischemic attack (TIA), stroke, and vascular related mortality. Risk factors for these recurrent events were identified. Other outcome events analyzed included in-stent restenosis (ISR) ≥50% and stent fracture noted on follow-up., Results: Of the 188 patients with available follow-up data (mean follow-up period 16.7 months), 34 patients suffered recurrent TIAs (18.1%); none had stroke or death. 40 patients were found to have ISR (21.2%) and nine patients had stent fracture (4.7%). Patients with recurrent events were significantly more likely to have ISR, stent fracture, vessel tortuosity, and hyperlipidemia than patients without recurrent events., Conclusions: Stenting for VAO stenosis seems to be safe and efficacious. The majority of recurrent events were TIAs, which may be related to ISR, stent fracture, vessel tortuosity, and hyperlipidemia., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)