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Background: A proportion of large vessel occlusion strokes demonstrate early recanalization, obviating the initial intention to proceed to endovascular thrombectomy. Neurological improvement is a possible surrogate marker for reperfusion. We aimed to determine the optimal threshold of neurological improvement, as defined by the National Institutes of Health Stroke Scale (NIHSS), which best associates with early recanalization., Methods: We retrospectively analyzed consecutive patients with large vessel occlusion transferred from primary stroke centers to a tertiary comprehensive stroke center in Melbourne, Australia, for possible endovascular thrombectomy from January 2018 to December 2022. Absolute and percentage changes in NIHSS between transfer, as well as other definitions of neurological improvement, were compared using receiver operating characteristic curve analysis for association with recanalization as defined by the absence of occlusion in the internal carotid artery, middle cerebral artery (M1 or M2 segments), or basilar artery on repeat vascular imaging., Results: Six hundred and fifty-four transferred patients with large vessel occlusion were included in the analysis: mean age was 68.8±14.0 years, 301 (46.0%) were women, and 338 (52%) received intravenous thrombolytics. The proportion of extracranial internal carotid artery, intracranial internal carotid artery, M1, proximal M2, and basilar artery occlusion was 18.8%, 13.6%, 48.3%, 15.0%, and 4.3%, respectively, on initial computed tomography angiogram. Median NIHSS primary stroke center and NIHSS comprehensive stroke center scores were 15 (interquartile range, 9-18) and 13 (interquartile range, 8-19), respectively. Early recanalization occurred in 82 (13%) patients. NIHSS reduction of ≥33% was the best tradeoff between sensitivity (64%) and specificity (83%) for identifying recanalization. NIHSS reduction of ≥33% had the highest discriminative ability to predict recanalization (area under the curve, 0.735) in comparison with other definitions of neurological improvement., Conclusions: One-third neurological improvement between the primary hospital and tertiary center was the best predictor of early recanalization., Competing Interests: Disclosures P. Mitchell reports research grants from Stryker Corporation and from Medtronic USA, Inc. Disclosures provided by B. Yan in compliance with the American Heart Association annual Journal Editor Disclosure Questionnaire are available at https://www.ahajournals.org/editor-coi-disclosures. The other authors report no conflicts.

Background: Following reperfusion treatment in ischemic stroke, computed tomography (CT) imaging at 24 h is widely used to assess radiological outcomes. Even without visible hyperattenuation, occult angiographic contrast may persist in the brain and confound Hounsfield unit-based imaging metrics, such as net water uptake (NWU)., Aims: We aimed to assess the presence and factors associated with retained contrast post-thrombectomy on 24-h imaging using dual-energy CT (DECT), and its impact on the accuracy of NWU as a measure of cerebral edema., Methods: Consecutive patients with anterior circulation large vessel occlusion who had post-thrombectomy DECT performed 24-h post-treatment from two thrombectomy stroke centers were retrospectively studied. NWU was calculated by interside comparison of HUs of the infarct lesion and its mirror homolog. Retained contrast was quantified by the difference in NWU values with and without adjustment for iodine. Patients with visible hyperdensities from hemorrhagic transformation or visible contrast retention and bilateral infarcts were excluded. Cerebral edema was measured by relative hemispheric volume (rHV) and midline shift (MLS)., Results: Of 125 patients analyzed (median age 71 (IQR = 61-80), baseline National Institutes of Health Stroke Scale (NIHSS) 16 (IQR = 9.75-21)), reperfusion (defined as extended-Thrombolysis-In-Cerebral-Infarction 2b-3) was achieved in 113 patients (90.4%). Iodine-subtracted NWU was significantly higher than unadjusted NWU (17.1% vs 10.8%, p < 0.001). In multivariable median regression analysis, increased age (p = 0.024), number of passes (p = 0.006), final infarct volume (p = 0.023), and study site (p = 0.021) were independently associated with amount of retained contrast. Iodine-subtracted NWU correlated with rHV (rho = 0.154, p = 0.043) and MLS (rho = 0.165, p = 0.033) but unadjusted NWU did not (rHV rho = -0.035, p = 0.35; MLS rho = 0.035, p = 0.347)., Conclusions: Angiographic iodine contrast is retained in brain parenchyma 24-h post-thrombectomy, even without visually obvious hyperdensities on CT, and significantly affects NWU measurements. Adjustment for retained iodine using DECT is required for accurate NWU measurements post-thrombectomy. Future quantitative studies analyzing CT after thrombectomy should consider occult contrast retention., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Vincent Thijs has received speaker and consulting fees from Bayer, Atricure, Bayer, Abbott, and Medtronic.

Introduction: Untreated basilar artery occlusion (BAO) carries 70% mortality. Guidelines recommend thrombectomy with or without thrombolysis., Aim: We compared Modified Rankin Scores (mRS) at 3 and 12 months post thrombectomy to determine benefit of long-term follow up., Methods: Retrospective, single centre analysis of BAO thrombectomies between 2015 and 2019. Inclusion criteria were symptomatic BAO on CT angiography, absent early ischemic changes, premorbid independence and intervention within 24 h. All received stroke ward care. Results were analysed with simple statistics and binary logistic regression as appropriate., Results: Of 82 patients: most were male (61%, 50/82) with median age 68 years (IQR 17 years) and median NIHSS 14 (IQR 15). Median door-to-puncture time was 42 min (IQR 72 min). Total deaths were 34.1% (28/82) at 3 months, and 37.8% (31/82) at 12 months. Of 51 patients alive at 12 months: 41% (21/51) had improved mRS, 16% (8/51) had worse mRS and 43% (22/51) had unchanged mRS, compared to 3 months. Improvements to mRS were: one point in 57.1% (14/21), two points in 28.9% (6/21) and three points in 4.8% (1/21). Nursing home admission was avoided in 11.8% (6/51) who improved from mRS4. Increased age was associated with decreased likelihood of reaching the primary outcome OR 0.87, 95% CI 0.76-0.99 (p value = 0.03)., Conclusion: Over a quarter of patients improved beyond 3 months. Future studies should adopt long-term follow up as primary outcome., (© 2023 The Authors. CNS Neuroscience & Therapeutics published by John Wiley & Sons Ltd.)

Background: In patients with acute stroke who undergo endovascular thrombectomy, the relative prognostic power of computed tomography perfusion (CTP) parameters compared with multiphase CT angiogram (mCTA) is unknown. We aimed to compare the predictive accuracy of mCTA and CTP parameters on clinical outcomes., Methods: We included patients with acute ischemic stroke who had anterior circulation large vessel occlusion within 24 hours of onset in Melbourne Brain Centre at the Royal Melbourne Hospital. All patients underwent CTP for endovascular thrombectomy, and the mCTA collateral score was determined using CTP-reconstructed mCTA images. The primary outcome was 90-day functional outcomes defined by modified Rankin Scale. Multivariable logistic regression models analyzed associations between mCTA and CTP parameters and 90-day functional outcomes. The ability to discriminate 90 days-functional outcomes was compared between mCTA collateral score and CTP parameters using receiver operating curve analysis and C statistics., Results: One hundred and twenty patients were included. The median age was 69 years (interquartile range, 60-79), the median baseline National Institutes of Health Stroke Scale score was 14 (interquartile range, 9-19). The baseline ischemic core volume, defined by CTP-based relative cerebral blood flow <30%, was associated with excellent functional outcome (modified Rankin Scale score 0-1; odds ratio, 0.942 [-0.897 to -0.989]; P =0.015) and poor functional outcome (modified Rankin Scale score 5-6; odds ratio, 1.032 [1.007-1.056]; P =0.010) at 90 days in the analysis of multivariable regression. There was no significant association between the mCTA score and excellent functional outcome ( P =0.58) or poor functional outcome ( P =0.155). The relative cerebral blood flow <30%-based regression model best fit the data for the 90-day poor functional outcome (C statistic, 0.834)., Conclusions: The CTP-based ischemic core volume may provide better discrimination for 90-day functional outcomes for patients with acute stroke undergoing endovascular thrombectomy than the mCTA collateral score.

Background: The benefit of combined treatment with intravenous thrombolysis before endovascular thrombectomy in patients with acute ischaemic stroke caused by large vessel occlusion remains unclear. We hypothesised that the clinical outcomes of patients with stroke with large vessel occlusion treated with direct endovascular thrombectomy within 4·5 h would be non-inferior compared with the outcomes of those treated with standard bridging therapy (intravenous thrombolysis before endovascular thrombectomy)., Methods: DIRECT-SAFE was an international, multicentre, prospective, randomised, open-label, blinded-endpoint trial. Adult patients with stroke and large vessel occlusion in the intracranial internal carotid artery, middle cerebral artery (M1 or M2), or basilar artery, confirmed by non-contrast CT and vascular imaging, and who presented within 4·5 h of stroke onset were recruited from 25 acute-care hospitals in Australia, New Zealand, China, and Vietnam. Eligible patients were randomly assigned (1:1) via a web-based, computer-generated randomisation procedure stratified by site of baseline arterial occlusion and by geographic region to direct endovascular thrombectomy or bridging therapy. Patients assigned to bridging therapy received intravenous thrombolytic (alteplase or tenecteplase) as per standard care at each site; endovascular thrombectomy was also per standard of care, using the Trevo device (Stryker Neurovascular, Fremont, CA, USA) as first-line intervention. Personnel assessing outcomes were masked to group allocation; patients and treating physicians were not. The primary efficacy endpoint was functional independence defined as modified Rankin Scale score 0-2 or return to baseline at 90 days, with a non-inferiority margin of -0·1, analysed by intention to treat (including all randomly assigned and consenting patients) and per protocol. The intention-to-treat population was included in the safety analyses. The trial is registered with ClinicalTrials.gov, NCT03494920, and is closed to new participants., Findings: Between June 2, 2018, and July 8, 2021, 295 patients were randomly assigned to direct endovascular thrombectomy (n=148) or bridging therapy (n=147). Functional independence occurred in 80 (55%) of 146 patients in the direct thrombectomy group and 89 (61%) of 147 patients in the bridging therapy group (intention-to-treat risk difference -0·051, two-sided 95% CI -0·160 to 0·059; per-protocol risk difference -0·062, two-sided 95% CI -0·173 to 0·049). Safety outcomes were similar between groups, with symptomatic intracerebral haemorrhage occurring in two (1%) of 146 patients in the direct group and one (1%) of 147 patients in the bridging group (adjusted odds ratio 1·70, 95% CI 0·22-13·04) and death in 22 (15%) of 146 patients in the direct group and 24 (16%) of 147 patients in the bridging group (adjusted odds ratio 0·92, 95% CI 0·46-1·84)., Interpretation: We did not show non-inferiority of direct endovascular thrombectomy compared with bridging therapy. The additional information from our study should inform guidelines to recommend bridging therapy as standard treatment., Funding: Australian National Health and Medical Research Council and Stryker USA., Competing Interests: Declaration of interests AKC received webinar honoraria from Medtronic and educational honoraria from Stryker. BY received conference honoraria and institutional research grants from Medtronic and Stryker. BS was an unpaid member on the New South Wales Medical Board. GAD received grants from the Australian Medical Research Future Fund by the Australian National Health and Medical Research Council. GAD was on the advisory boards of Allergan and Argenica; received honoraria from Amgen; was on the data safety monitoring board of the STOP-MSU and EXTEND group of trials; was on the steering committee of DIRECT-SAFE; was shareholder in Argenica Therapeutics; and was on the board or committee of the Australian Stroke Alliance, Menzies Research Institute, Argenica Therapeutics, and the Colonial Foundation. MWP received payment to attend meetings by Boehringer Ingelheim. PJM received conference honoraria and institutional research grants from Medtronic and Stryker. SMD received grants from the Australian Medical Research Future Fund by the Australian National Health and Medical Research Council; received payment for participating on advisory boards of Boehringer Ingelheim, Medtronic, and CSL Behring; received speaker's honoraria from Amgen; was a member of the data safety monitoring board of the SELECT-2 trial; was on the steering committee of the DIRECT-SAFE trial and EXTEND group of trials; and was an unpaid cochair of the Australian Stroke Alliance and unpaid trustee of the RMH Neuroscience Foundation. TJK received honoraria from Boehringer Ingelheim. All other authors declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Intrinsic hospital factors leading to time delay to inter-hospital transfer for endovascular thrombectomy (EVT) have not been adequately investigated, leading to uncertainty in generalizability of hub and spoke EVT services. We investigated the contribution of intrinsic hospital factors to variations in time delay in a multicenter, retrospective study., Methods: The setting was a hub and spoke EVT state-wide system for a population of 6.3 million and 34 spoke hospitals. We collected data on acute large vessel occlusion strokes transferred from spoke to hub for consideration of EVT between January 2016 and December 2018. The primary endpoint was the proportion of variability in delay-time in transfer cases contributed to by intrinsic hospital factors estimated through variance component analysis implemented as a mixed-effect linear regression model with hospitals as random effects., Results: We included 434 patients. The median age was 72 years (IQR 62-79), 44% were female, and the median baseline National Institutes of Health Stroke Scale (NIHSS) was 16 (IQR 11-20). The median onset to CT time was 100 mins (IQR 69-157) at the spoke hospitals and CT acquisition at the spoke hospital to time of transfer was 93 min (IQR 70-132). 53% of the observed variability in time from CT acquisition at the spoke hospital to transfer to the EVT center was explained by intrinsic hospital factors, as opposed to patient-related factors., Conclusions: Intrinsic hospital factors explained more than half of the observed variability in time from CT acquisition at the spoke hospital to departure for transfer. We recommend that the design of hub and spoke EVT services should account for intrinsic hospital factors to minimize hospital transfer delay., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Polymorphisms in the CYP2C9 gene may be associated with adverse vascular events following endovascular procedures independent of antiplatelet therapy. We aimed to investigate the impact of CYP2C9 loss-of-function polymorphisms on adverse vascular events following neurointervention., Patients and Methods: Consecutive patients undergoing neurointervention were prospectively recruited between 2010 and 2016. Patients were genotyped for the CYP2C9*2 and *3 loss-of-function polymorphisms. On the basis of possible genetic influence on antiplatelet response, ex vivo clopidogrel response was measured using the VerifyNow® P2Y 12 Assay. The primary endpoint was the 90-day incidence of adverse vascular events including ischemic stroke., Results: A total of 229 patients were included. The median age was 57 years (IQR: 49-64), and 158 (69.00%) were female. Eighty-one (35.37%) patients carried at least one CYP2C9 loss-of-function (LOF) allele. After adjustment for stroke risk factors, the 90-day incidence of ischemic stroke was significantly lower in the LOF group compared to the wild type group (1.23% vs 10.14%; OR adj  = 0.16, 95% CI: 0.03-0.91; p = 0.04)., Conclusions: Our results suggest protection against ischemic stroke in carriers of CYP2C9*2 or *3 polymorphisms undergoing neurointervention. Our findings warrant further studies to investigate the mechanisms by which CYP2C9 may influence the risk of ischemic stroke., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Importance: Intravenous thrombolysis with tenecteplase improves reperfusion prior to endovascular thrombectomy for ischemic stroke compared with alteplase., Objective: To determine whether 0.40 mg/kg of tenecteplase safely improves reperfusion before endovascular thrombectomy vs 0.25 mg/kg of tenecteplase in patients with large vessel occlusion ischemic stroke., Design, Setting, and Participants: Randomized clinical trial at 27 hospitals in Australia and 1 in New Zealand using open-label treatment and blinded assessment of radiological and clinical outcomes. Patients were enrolled from December 2017 to July 2019 with follow-up until October 2019. Adult patients (N = 300) with ischemic stroke due to occlusion of the intracranial internal carotid, \basilar, or middle cerebral artery were included less than 4.5 hours after symptom onset using standard intravenous thrombolysis eligibility criteria., Interventions: Open-label tenecteplase at 0.40 mg/kg (maximum, 40 mg; n = 150) or 0.25 mg/kg (maximum, 25 mg; n = 150) given as a bolus before endovascular thrombectomy., Main Outcomes and Measures: The primary outcome was reperfusion of greater than 50% of the involved ischemic territory prior to thrombectomy, assessed by consensus of 2 blinded neuroradiologists. Prespecified secondary outcomes were level of disability at day 90 (modified Rankin Scale [mRS] score; range, 0-6); mRS score of 0 to 1 (freedom from disability) or no change from baseline at 90 days; mRS score of 0 to 2 (functional independence) or no change from baseline at 90 days; substantial neurological improvement at 3 days; symptomatic intracranial hemorrhage within 36 hours; and all-cause death., Results: All 300 patients who were randomized (mean age, 72.7 years; 141 [47%] women) completed the trial. The number of participants with greater than 50% reperfusion of the previously occluded vascular territory was 29 of 150 (19.3%) in the 0.40 mg/kg group vs 29 of 150 (19.3%) in the 0.25 mg/kg group (unadjusted risk difference, 0.0% [95% CI, -8.9% to -8.9%]; adjusted risk ratio, 1.03 [95% CI, 0.66-1.61]; P = .89). Among the 6 secondary outcomes, there were no significant differences in any of the 4 functional outcomes between the 0.40 mg/kg and 0.25 mg/kg groups nor in all-cause deaths (26 [17%] vs 22 [15%]; unadjusted risk difference, 2.7% [95% CI, -5.6% to 11.0%]) or symptomatic intracranial hemorrhage (7 [4.7%] vs 2 [1.3%]; unadjusted risk difference, 3.3% [95% CI, -0.5% to 7.2%])., Conclusions and Relevance: Among patients with large vessel occlusion ischemic stroke, a dose of 0.40 mg/kg, compared with 0.25 mg/kg, of tenecteplase did not significantly improve cerebral reperfusion prior to endovascular thrombectomy. The findings suggest that the 0.40-mg/kg dose of tenecteplase does not confer an advantage over the 0.25-mg/kg dose in patients with large vessel occlusion ischemic stroke in whom endovascular thrombectomy is planned., Trial Registration: ClinicalTrials.gov Identifier: NCT03340493.

Background and Purpose- Mobile stroke units (MSUs) are increasingly used worldwide to provide prehospital triage and treatment. The benefits of MSUs in giving earlier thrombolysis have been well established, but the impacts of MSUs on endovascular thrombectomy (EVT) and effect on disability avoidance are largely unknown. We aimed to determine the clinical impact and disability reduction for reperfusion therapies in the first operational year of the Melbourne MSU. Methods- Treatment time metrics for MSU patients receiving reperfusion therapy were compared with control patients presenting to metropolitan Melbourne stroke units via standard ambulance within MSU operating hours. The primary outcome was median time difference in first ambulance dispatch to treatment modeled using quantile regression analysis. Time savings were subsequently converted to disability-adjusted life years avoided using published estimates. Results- In the first 365-day operation of the Melbourne MSU, prehospital thrombolysis was administered to 100 patients (mean age, 73.8 years; 62% men). The median time savings per MSU patient, compared with the control cohort, was 26 minutes ( P <0.001) for dispatch to hospital arrival and 15 minutes ( P <0.001) for hospital arrival to thrombolysis. The calculated overall time saving from dispatch to thrombolysis was 42.5 minutes (95% CI, 36.0-49.0). In the same period, 41 MSU patients received EVT (mean age, 76 years; 61% men) with median dispatch-to-treatment time saving of 51 minutes ([95% CI, 30.1-71.9], P <0.001). This included a median time saving of 17 minutes ([95% CI, 7.6-26.4], P =0.001) for EVT hospital arrival to arterial puncture for MSU patients. Estimated median disability-adjusted life years saved through earlier provision of reperfusion therapies were 20.9 for thrombolysis and 24.6 for EVT. Conclusions- The Melbourne MSU substantially reduced time to reperfusion therapies, with the greatest estimated disability avoidance driven by the more powerful impact of earlier EVT. These findings highlight the benefits of prehospital notification and direct triage to EVT centers with facilitated workflow on arrival by the MSU.

Background: CT perfusion may improve diagnostic accuracy in posterior circulation stroke. The posterior circulation Acute Stroke Prognosis Early CT score (pc-ASPECTS) on Computed Tomography Angiography source images (CTA-SI) predicts functional outcome in patients with basilar artery occlusion., Aims: We assessed the prognostic value of pc-ASPECTS on CT perfusion in patients with vertebral and basilar artery occlusion (VBAO) in comparison with CTA-SI., Methods: Whole-brain CT perfusion from consecutive stroke patients with VBAO at four stroke centers was retrospectively analyzed. pc-ASPECTS - a 10-point score assessing hypoattenuation on CTA-SI - was calculated from CT perfusion parameters as focally reduced cerebral blood flow or cerebral blood volume, focally increased time to peak of the deconvolved tissue residue function (Tmax) or mean transit time. Two investigators independently reviewed the images. Reliability was assessed with intraclass correlation coefficient. Good outcome was defined as modified Rankin scale ≤3 at three months., Results: We included 60 patients with VBAO. After assessment of four CT perfusion maps simultaneously, area-under-ROC curve (AROC) was 0.83 (95%CI 0.72-0.93) for cerebral blood volume, 0.76 (95%CI 0.64-0.89) for cerebral blood flow, 0.77 (95%CI 0.64-0.89) for Tmax, 0.70 (95%CI 0.56-0.84) for mean transit time versus area-under-ROC curve 0.64 (95%CI 0.50-0.79) for CTA-SI. Cerebral blood volume had greater accuracy compared with CTA-SI for poor outcome (p = 0.04). In logistic regression analysis, cerebral blood volume pc-ASPECTS≤8 was independently associated with poor outcome (OR 9.3 95%CI 2.2-41; p = 0.003, adjusted for age and clinical severity). Inter-rater agreement was substantial for cerebral blood volume pc-ASPECTS (intraclass correlation coefficient 0.82 95%CI 0.71-0.90 versus 0.67 for CTA-SI 95%CI 0.43-0.81)., Conclusions: Cerebral blood volume pc-ASPECTS may identify VBAO patients at higher risk of disability.

Background: The benefits of endovascular clot retrieval (ECR) for anterior circulation stroke with large ischaemic cores remain uncertain. In spite of recent pooled analysis of randomised controlled studies, conclusions regarding the fate of large ischaemic cores cannot be reached given the small number of included patients., Aim: To evaluate outcomes of ECR in acute stroke with large ischaemic core., Methods: This was a single centre retrospective study of patients treated with ECR in the period 2012-2017. The inclusion criteria were anterior circulation stroke with symptom onset less than 6 h, baseline computed tomography perfusion and a 90-day clinical follow up defined by the modified Rankin score., Results: Two hundred and sixty-one patients were included. Median age of 72 (interquartile range: 61-78) and 59% were male. The mean ischaemic core volume was 27.6 mL (SD: 34.9 mL). There were 235 patients with an ischaemic core volume of <70 mL and 26 patients with an ischaemic core volume of ≥70 mL. There was no statistically significant difference; however, in a 90-day functional independence with 66% (154/235) in the <70 mL core group and 54% (14/26) in the ≥70 mL core group reaching a 90-day modified Rankin score ≤2., Conclusions: We found that patients selected for ECR with ischaemic core size ≥70 mL had clinical outcomes not significantly different compared with those with smaller ischaemic cores. We recommend that large ischaemic core size alone does not necessarily constitute an absolute contraindication for ECR. Randomised controlled studies are needed to define better the benefits for this group of patients., (© 2018 Royal Australasian College of Physicians.)

Importance: The positive treatment effect of endovascular therapy (EVT) is assumed to be caused by the preservation of brain tissue. It remains unclear to what extent the treatment-related reduction in follow-up infarct volume (FIV) explains the improved functional outcome after EVT in patients with acute ischemic stroke., Objective: To study whether FIV mediates the relationship between EVT and functional outcome in patients with acute ischemic stroke., Design, Setting, and Participants: Patient data from 7 randomized multicenter trials were pooled. These trials were conducted between December 2010 and April 2015 and included 1764 patients randomly assigned to receive either EVT or standard care (control). Follow-up infarct volume was assessed on computed tomography or magnetic resonance imaging after stroke onset. Mediation analysis was performed to examine the potential causal chain in which FIV may mediate the relationship between EVT and functional outcome. A total of 1690 patients met the inclusion criteria. Twenty-five additional patients were excluded, resulting in a total of 1665 patients, including 821 (49.3%) in the EVT group and 844 (50.7%) in the control group. Data were analyzed from January to June 2017., Main Outcome and Measure: The 90-day functional outcome via the modified Rankin Scale (mRS)., Results: Among 1665 patients, the median (interquartile range [IQR]) age was 68 (57-76) years, and 781 (46.9%) were female. The median (IQR) time to FIV measurement was 30 (24-237) hours. The median (IQR) FIV was 41 (14-120) mL. Patients in the EVT group had significantly smaller FIVs compared with patients in the control group (median [IQR] FIV, 33 [11-99] vs 51 [18-134] mL; P = .007) and lower mRS scores at 90 days (median [IQR] score, 3 [1-4] vs 4 [2-5]). Follow-up infarct volume was a predictor of functional outcome (adjusted common odds ratio, 0.46; 95% CI, 0.39-0.54; P < .001). Follow-up infarct volume partially mediated the relationship between treatment type with mRS score, as EVT was still significantly associated with functional outcome after adjustment for FIV (adjusted common odds ratio, 2.22; 95% CI, 1.52-3.21; P < .001). Treatment-reduced FIV explained 12% (95% CI, 1-19) of the relationship between EVT and functional outcome., Conclusions and Relevance: In this analysis, follow-up infarct volume predicted functional outcome; however, a reduced infarct volume after treatment with EVT only explained 12% of the treatment benefit. Follow-up infarct volume as measured on computed tomography and magnetic resonance imaging is not a valid proxy for estimating treatment effect in phase II and III trials of acute ischemic stroke.

Background: Follow-up infarct volume (FIV) has been recommended as an early indicator of treatment efficacy in patients with acute ischemic stroke. Questions remain about the optimal imaging approach for FIV measurement., Objective: To examine the association of FIV with 90-day modified Rankin Scale (mRS) score and investigate its dependency on acquisition time and modality., Methods: Data of seven trials were pooled. FIV was assessed on follow-up (12 hours to 2 weeks) CT or MRI. Infarct location was defined as laterality and involvement of the Alberta Stroke Program Early CT Score regions. Relative quality and strength of multivariable regression models of the association between FIV and functional outcome were assessed. Dependency of imaging modality and acquisition time (≤48 hours vs >48 hours) was evaluated., Results: Of 1665 included patients, 83% were imaged with CT. Median FIV was 41 mL (IQR 14-120). A large FIV was associated with worse functional outcome (OR=0.88(95% CI 0.87 to 0.89) per 10 mL) in adjusted analysis. A model including FIV, location, and hemorrhage type best predicted mRS score. FIV of ≥133 mL was highly specific for unfavorable outcome. FIV was equally strongly associated with mRS score for assessment on CT and MRI, even though large differences in volume were present (48 mL (IQR 15-131) vs 22 mL (IQR 8-71), respectively). Associations of both early and late FIV assessments with outcome were similar in strength (ρ=0.60(95% CI 0.56 to 0.64) and ρ=0.55(95% CI 0.50 to 0.60), respectively)., Conclusions: In patients with an acute ischemic stroke due to a proximal intracranial occlusion of the anterior circulation, FIV is a strong independent predictor of functional outcome and can be assessed before 48 hours, oneither CT or MRI., Competing Interests: Competing interests: MG reports grants from Covidien, personal fees from Covidien, during the conduct of the study; MG has a patent for diagnosing strokes (PCT/ CA2013/000761) licensed to GE Healthcare. BKM reports membership of the Steering and Executive Committee, ESCAPE trial that received support from Covidien Inc., Site Principal Investigator, SOCRATES Trial, sponsored by Astra Zeneca, honoraria from Penumbra Inc., a provisional patent 62/086077 for triaging systems in ischemic stroke, research funding from CIHR, HSFC, AIHS, HBI and the Faculty of Medicine, University of Calgary and board membership of QuikFlo Health Inc. WHvZ reports Honoraria; Modest; Stryker (paid to Institution). DWJD reports honoraria; Modest; Stryker (paid to Institution). PJM reports unrestricted grant funding for the EXTEND-IA trial to the Florey Institute of Neuroscience and Mental Health from Covidien (Medtronic), has served as an unpaid consultant to Codman Johnson and Johnson, his organization has received unrestricted research funding and grants from Codman Johnson and Johnson, Medtronic, and Stryker. AMD reports grant support and personal fees from Covidien (Medtronic). AD reports consultant/Advisory Board; Modest; Medtronic Neurovascular (Steering Committee STAR). CBLMM reports speakers' Bureau; Modest; Stryker (paid to institution). GAD reports grants from the Australian National Health & Medical Research Council, non-financial support from, and has served on advisory boards for Boehringer Ingelheim, Astra Zeneca, Bristol Meyers-Squibb, Merck Sharp & Dohme outside the submitted work. BCVC reports research support from the National Health and Medical Research Council of Australia (GNT1043242, GNT1035688), Royal Australasian College of Physicians, Royal Melbourne Hospital Foundation, National Heart Foundation, National Stroke Foundation of Australia and unrestricted grant funding for the EXTEND-IA trial to the Florey Institute of Neuroscience and Mental Health from Covidien (Medtronic). MDH reports unrestricted grant funding for the ESCAPE trial to University of Calgary from Covidien (Medtronic), and active/in-kind support consortium of public/charitable sources (Heart & Stroke Foundation, Alberta Innovates Health Solutions, Alberta Health Services) and the University of Calgary (Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, and Calgary Stroke Program); personal fees from Merck, non-financial support from Hoffmann-La Roche Canada Ltd, outside the submitted work; MDH has a patent Systems and Methods for Assisting in Decision-Making and Triaging for Acute Stroke Patients pending to US Patent office Number: 62/086,077 and owns stock in Calgary Scientific Incorporated, a company that focuses on medical imaging software. AMMB and HAM own stock in Nico.lab, a company that focuses on medical imaging software. TGJ has consulted for Codman Neurovascular and Neuravi, holds stock in Silk Road and Blockade; has acted as an unpaid consultant to Stryker as PI of the DAWN trial and served as an unpaid member of a Medtronic Advisory Board. SMD reports lecture fees from Covidien (Medtronic). ScB acts as consultant for Medtronic. GWA reports equity and consulting for iSchemaView (imaging software) and consulting for Medtronic., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background and Purpose- Clot migration to distal intracranial arterial segments was observed in patients presented with acute large vessel occlusions. It is postulated that the exposure of patients to intravenous thrombolysis (IVT) increases the risk of clot migration and associated with inaccessibility of the clot by endovascular thrombectomy (EVT). In this study, we aimed to investigate the incidence of clot migration and its association with IVT before EVT. Methods- We conducted a single-center retrospective analysis of patients who had EVT during the period 2009 to 2016. Patients who fulfilled clinical criteria were treated with bridging IVT and those who did not were treated with direct EVT. Clot position was assessed by pretreatment computed tomography angiogram or magnetic resonance angiogram and was compared with clot position identified by digital subtraction angiography before planned endovascular thrombectomy. Results- Of 314 included patients, clot migration occurred in 43 patients (13.7%). The proportion of clot migration was 18.7% (39 of 209) in patients who had bridging IVT with EVT compared with 3.8% (4 of 105) in direct EVT ( P=0.001). Of the 39 patients who had clot migration in the bridging IVT with EVT, 59.0% (23 of 39) demonstrated clot inaccessibility compared with 25.0% (1 of 4) in clot migration cases in the direct EVT group ( P=0.011). Conclusions- The incidence of clot migration was significantly increased in the setting of bridging IVT before EVT, leading to increased proportion of clot inaccessibility by EVT.

Background: Endovascular thrombectomy (ET) is safe, effective, and cost-effective for large artery occlusion ischemic stroke, even if under different selection criteria., Purpose: To study the preferences for ET selection criteria by surveying clinicians and consumers, where number needed to treat to achieve functional independence is the only factor being considered., Methods: A survey providing visual representation of the proportion of patients treated and expected functional outcomes, based on the selection criteria in each of the recent randomized trials of ET, was distributed nationwide in Australia and New Zealand to clinicians and consumers. The preferred selection criteria were identified by the frequency of first choice and using decision-analysis techniques to assess consensus by treating respondents as a panel of experts and aggregating their preferences on selection criteria., Results: 104 clinicians and 107 consumer respondents (43/107 (40%) stroke survivors) took part in the study. Selection criteria of EXTEND-IA were ranked as the most preferred by the consensus process analysis and were the first choice of 64 individual clinicians (61.5%; 95% CI 52% to 71%). ESCAPE trial selection criteria were ranked as the most preferred option and chosen by 42 individual consumers (39%; 95% CI 29% to 48%). Most clinicians based their choice on the ratio of patients benefiting from ET, while consumers considered the absolute number of patients benefiting., Conclusions: Consumers favor maximization of the absolute number achieving good outcome in comparison with clinicians. This finding suggests that less restrictive criteria may be favored in clinical practice., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Introduction: Endovascular clot retrieval (ECR) following intravenous thrombolysis is superior to intravenous thrombolysis alone for acute stroke with large vessel occlusion. However, trial selection criteria may exclude potentially salvageable patients. We investigated the impact of published selection criteria on the different proportions of patients excluded and clinical outcome., Methods: We included patients with anterior circulation stroke treated with ECR from a single centre. Selection criteria from five trials (REVASCAT, EXTEND IA, MR CLEAN, SWIFT PRIME, ESCAPE) and American Stroke Association (ASA) guidelines were applied. We calculated the proportion of patient's ineligible for ECR according to different selection criteria. Clinical benefit and harm were quantified as the number of patients benefiting per 1 patient harmed (NB1H) for each of the 6 applied selection criteria., Results: One hundred and seventy-eight patients were included. Mean age was 74 (SD 14) years, 60.1% were male, median baseline NIHSS was 17 (IQR 13-21). Patients were hypothetically excluded from ECR: REVASCAT 35.4%, EXTENDA IA 86%, SWIFT PRIME 86%, MR CLEAN 2.3%, ESCAPE 93.3% and ASA 29.2%. The NB1H for included and excluded patients respectively in decreasing order of magnitude: EXTEND IA >100 vs 3, ESCAPE >100 vs 3.4, SWIFT PRIME 10 vs 3.3, REVASCAT 4.4 vs 2.9, MR CLEAN 3.7 vs >100, and ASA 3.7 vs 3.9., Conclusion: We found that criteria from MR CLEAN, ASA and REVASCAT excluded the lowest proportion of patients with comparable NB1H. We believe that these criteria would be reasonable to be utilised for ECR selection., (© 2018 The Royal Australian and New Zealand College of Radiologists.)

Background: Intravenous infusion of alteplase is used for thrombolysis before endovascular thrombectomy for ischemic stroke. Tenecteplase, which is more fibrin-specific and has longer activity than alteplase, is given as a bolus and may increase the incidence of vascular reperfusion., Methods: We randomly assigned patients with ischemic stroke who had occlusion of the internal carotid, basilar, or middle cerebral artery and who were eligible to undergo thrombectomy to receive tenecteplase (at a dose of 0.25 mg per kilogram of body weight; maximum dose, 25 mg) or alteplase (at a dose of 0.9 mg per kilogram; maximum dose, 90 mg) within 4.5 hours after symptom onset. The primary outcome was reperfusion of greater than 50% of the involved ischemic territory or an absence of retrievable thrombus at the time of the initial angiographic assessment. Noninferiority of tenecteplase was tested, followed by superiority. Secondary outcomes included the modified Rankin scale score (on a scale from 0 [no neurologic deficit] to 6 [death]) at 90 days. Safety outcomes were death and symptomatic intracerebral hemorrhage., Results: Of 202 patients enrolled, 101 were assigned to receive tenecteplase and 101 to receive alteplase. The primary outcome occurred in 22% of the patients treated with tenecteplase versus 10% of those treated with alteplase (incidence difference, 12 percentage points; 95% confidence interval [CI], 2 to 21; incidence ratio, 2.2; 95% CI, 1.1 to 4.4; P=0.002 for noninferiority; P=0.03 for superiority). Tenecteplase resulted in a better 90-day functional outcome than alteplase (median modified Rankin scale score, 2 vs. 3; common odds ratio, 1.7; 95% CI, 1.0 to 2.8; P=0.04). Symptomatic intracerebral hemorrhage occurred in 1% of the patients in each group., Conclusions: Tenecteplase before thrombectomy was associated with a higher incidence of reperfusion and better functional outcome than alteplase among patients with ischemic stroke treated within 4.5 hours after symptom onset. (Funded by the National Health and Medical Research Council of Australia and others; EXTEND-IA TNK ClinicalTrials.gov number, NCT02388061 .).

Background and hypothesis Intravenous thrombolysis with alteplase remains standard care prior to thrombectomy for eligible patients within 4.5 h of ischemic stroke onset. However, alteplase only succeeds in reperfusing large vessel arterial occlusion prior to thrombectomy in a minority of patients. We hypothesized that tenecteplase is non-inferior to alteplase in achieving reperfusion at initial angiogram, when administered within 4.5 h of ischemic stroke onset, in patients planned to undergo endovascular therapy. Study design EXTEND-IA TNK is an investigator-initiated, phase II, multicenter, prospective, randomized, open-label, blinded-endpoint non-inferiority study. Eligibility requires a diagnosis of ischemic stroke within 4.5 h of stroke onset, pre-stroke modified Rankin Scale≤3 (no upper age limit), large vessel occlusion (internal carotid, basilar, or middle cerebral artery) on multimodal computed tomography and absence of contraindications to intravenous thrombolysis. Patients are randomized to either IV alteplase (0.9 mg/kg, max 90 mg) or tenecteplase (0.25 mg/kg, max 25 mg) prior to thrombectomy. Study outcomes The primary outcome measure is reperfusion on the initial catheter angiogram, assessed as modified treatment in cerebral infarction 2 b/3 or the absence of retrievable thrombus. Secondary outcomes include modified Rankin Scale at day 90 and favorable clinical response (reduction in National Institutes of Health Stroke Scale by ≥8 points or reaching 0-1) at day 3. Safety outcomes are death and symptomatic intracerebral hemorrhage. Trial registration ClinicalTrials.gov NCT02388061.

Objective: Endovascular therapy has recently become standard therapy for select patients with acute ischemic stroke. Infarcted brain tissue may undergo hemorrhagic transformation (HT) after endovascular therapy. We investigated the association between HT and occurrence of poststroke seizures in patients treated with endovascular therapy., Methods: Consecutive patients treated with endovascular therapy for acute anterior circulation ischemic stroke were included. HT was assessed with computed tomography/magnetic resonance imaging (CT/MRI) at 24 h after stroke onset. Patients were followed for up to 2 years for seizure occurrence., Results: A total of 205 (57.1% male) patients were analyzed. Median age was 69 years (interquartile range [IQR] 57-78). Among patients with HT, 17.9% (10/56) developed poststroke seizures compared with 4.0% (6/149) among those without HT (hazard ratio [HR] 5.52; 95% confidence interval [CI] 2.00-15.22; P = .001). The association remained significant after adjustment for cortical involvement, baseline National Institutes of Health Stroke Scale score, age and use of intravenous tissue plasminogen activator and clot retrieval (HR 4.85; 95% CI 1.60-14.76; P = .005). In patients who developed seizures within the follow-up period, median time to first seizure was 111 days (IQR 28-369) in patients with HT and 36 days (IQR 0.5-183) in patients without HT., Significance: A patient who develops HT following endovascular therapy for acute ischemic stroke had a nearly 5 times higher rate of developing poststroke seizures within 2 years. HT may be used as an imaging biomarker for poststroke seizures., (Wiley Periodicals, Inc. © 2017 International League Against Epilepsy.)

Background/aim: Endovascular thrombectomy may be performed in anticoagulated patients taking vitamin-K antagonists (VKA) or direct-acting oral anticoagulants (DOAC) in whom the use of intravenous tissue plasminogen activator (tPA) is contraindicated. We aimed to investigate the efficacy and safety of mechanical thrombectomy specifically in anticoagulated patients ineligible for thrombolysis., Methods: We performed a retrospective analysis of a prospectively collected database of consecutive ischaemic stroke patients undergoing mechanical thrombectomy from January 2008 to June 2017. Patients receiving any dose of intravenous or intra-arterial thrombolysis were excluded. Patients taking oral anticoagulants (VKAs or DOACs) were compared with non-anticoagulated patients. Outcomes compared between groups included the rate of intracerebral haemorrhage (ICH) on follow-up imaging (ICHany), symptomatic ICH, functional independence at 90 days (modified Rankin scale score, 0-2), mortality, and post-treatment recanalization (Thrombolysis in Cerebral Infarction score ≥2b)., Results: In all, 102 patients undergoing mechanical thrombectomy without prior thrombolysis were included in the study. Sixty-six (64.7%) patients were not anticoagulated, 23 (22.5%) patients were taking VKAs, and 13 (12.7%) patients were taking DOACs. There were no significant differences in the rate of ICHany (11.1 vs. 13.6%, p = 0.93) or sICH (2.8 vs. 1.5%, p = 0.14) in anticoagulated patients compared to non-anticoagulated patients. No cases of sICH were observed among patients taking DOACs. After 90 days of follow-up, the rates of functional independence (50.0 vs. 43.1%) and mortality (27.8 vs. 25.8%) were also similar between the anticoagulation and the non-anticoagulation groups., Conclusion: Mechanical thrombectomy appears to be safe and effective in anticoagulated patients ineligible for thrombolysis, with observed haemorrhage rates similar to those of patients not on anticoagulant therapy. However, further multicentre prospective studies are needed, due to the rising number of patients on warfarin and DOACs worldwide., (© 2018 S. Karger AG, Basel.)

Background: Endovascular clot retrieval (ECR) improves outcomes for acute ischaemic stroke with large artery occlusion. However, the provision of ECR requires resource-intensive comprehensive stroke centres (CSC), which are impractical to establish in regional hospitals. An alternative is a "hub-and-spoke" model, whereby ischaemic strokes are triaged at the regional primary centres and where eligible, transferred to a CSC. We aimed to compare the outcomes of patients directly admitted to a CSC with patients treated in the "hub-and-spoke" model. We hypothesize that there are no significant differences in clinical outcomes between the 2 systems., Methods: We included patients undergoing ECR at a CSC. Patients were categorised into 2 groups; the first group included patients directly admitted to the CSC and the second group included patients in the "hub-and-spoke" model. Good clinical outcome was defined as modified Rankin Scale 0-2 and the difference between the 2 groups was tested by logistic regression., Results: Of 178 patients, 50 (28%) presented directly to CSC and 128 (72%) were transferred from a referring hospital. The median age was 70 (interquartile range 58-77) and 61% were male. Thrombolysis in ischaemic cerebral-infarction 2b/3 recanalisation was achieved in 79% of patients. Of the direct group, 63% (95% CI 48-77%) achieved good clinical outcomes compared to 52% (95% CI 43-61%) in the "hub-and-spoke" group (p = 0.233)., Conclusion: This state-wide service model demonstrates comparable clinical outcomes to that described in clinical trials. We found no significant difference in outcome between patients directly admitted to CSC and those with "hub-and-spoke" service delivery., (© 2018 S. Karger AG, Basel.)

Background: Recently, 5 randomized controlled trials confirmed the superiority of endovascular mechanical thrombectomy (EMT) to intravenous thrombolysis in acute ischemic stroke with large-vessel occlusion. The implication is that our health systems would witness an increasing number of patients treated with EMT. However, in-hospital delays, leading to increased time to reperfusion, are associated with poor clinical outcomes. This review outlines the in-hospital workflow of the treatment of acute ischemic stroke at a comprehensive stroke center and the lessons learned in reduction of in-hospital delays., Methods: The in-hospital workflow for acute ischemic stroke was described from prehospital notification to femoral arterial puncture in preparation for EMT. Systematic review of literature was also performed with PubMed., Results: The implementation of workflow streamlining could result in reduction of in-hospital time delays for patients who were eligible for EMT. In particular, time-critical measures, including prehospital notification, the transfer of patients from door to computed tomography (CT) room, initiation of intravenous thrombolysis in the CT room, and the mobilization of neurointervention team in parallel with thrombolysis, all contributed to reduction in time delays., Conclusions: We have identified issues resulting in in-hospital time delays and have reported possible solutions to improve workflow efficiencies. We believe that these measures may help stroke centers initiate an EMT service for eligible patients., (Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Basilar artery occlusion is associated with high risk of disability and mortality. This study aimed to assess the prognostic value of a new radiological score: the Basilar Artery on Computed Tomography Angiography (BATMAN) score., Methods: A retrospective analysis of consecutive stroke patients with basilar artery occlusion diagnosed on computed tomographic angiography was performed. BATMAN score is a 10-point computed tomographic angiography-based grading system which incorporates thrombus burden and the presence of collaterals. Reliability was assessed with intraclass coefficient correlation. Good outcome was defined as modified Rankin Scale score of ≤3 at 3 months and successful reperfusion as thrombolysis in cerebral infarction 2b-3. BATMAN score was externally validated and compared with the Posterior Circulation Collateral score., Results: The derivation cohort included 83 patients with 41 in the validation cohort. In receiver operating characteristic (ROC) analysis, BATMAN score had an area under receiver operating characteristic curve of 0.81 (95% confidence interval [CI], 0.7-0.9) in derivation cohort and an area under receiver operating characteristic curve of 0.74 (95% CI, 0.6-0.9) in validation cohort. In logistic regression adjusted for age and clinical severity, BATMAN score of <7 was associated with poor outcome in derivation cohort (odds ratio, 5.5; 95% CI, 1.4-21; P =0.01), in validation cohort (odds ratio, 6.9; 95% CI, 1.4-33; P =0.01), and in endovascular patients, after adjustment for recanalization and time to treatment (odds ratio, 4.8; 95% CI, 1.2-18; P =0.01). BATMAN score of <7 was not associated with recanalization. Interrater agreement was substantial (intraclass coefficient correlation, 0.85; 95% CI, 0.8-0.9). BATMAN score had greater accuracy compared with Posterior Circulation Collateral score ( P =0.04)., Conclusions: The addition of collateral quality to clot burden in BATMAN score seems to improve prognostic accuracy in basilar artery occlusion patients., (© 2017 American Heart Association, Inc.)

Aims: We aimed to evaluate early recanalization postintravenous (i.v.) tissue plasminogen activator (t-PA) by digital subtraction angiography (DSA) in acute ischemic stroke (AIS) with large vessel occlusion (LVO)., Methods: We performed baseline CT angiography to identify LVO in AIS. Recanalization pre- and post-intra-arterial therapy (IAT) was categorized to none, partial, and global recanalization (GR). Modified Rankin Scale score ≤2 at 3 months was considered a favorable outcome., Results: Among 1610 patients with AIS, 286 received IV t-PA. Of these, 55 patients with LVO were included. The median time from IV t-PA to DSA was 120 min (interquartile range, 79-152). Recanalization post-IV t-PA was observed in seven patients (12.7%). By occlusion sites, the recanalization rates were as follows: extracranial internal carotid artery 2 of 14 (14.3%); intracranial internal carotid artery 3 of 24 (12.5%); M1 of middle cerebral artery 3 of 39 (7.7%); M2 of middle cerebral artery 1 of 40 (2.5%); vertebral artery 0 of 4; and basilar artery 0 of 7. GR post-IAT was associated with favorable outcomes (odds ratio: 8.6; 95% confidence interval, 1.5-48.0; P = 0.014)., Conclusion: Early recanalization assessed by DSA post-IV t-PA is rarely observed in acute ischemic stroke patients with LVO., (© 2016 John Wiley & Sons Ltd.)

Background: The risks of intracranial haemorrhage (ICH) post intra-arterial therapy (IAT) for stroke are not well understood. We aimed to study the influence of recanalization status post IAT for anterior circulation stroke and posterior circulation stroke on ICH development., Methods: Retrospective analysis of 193 patients in a prospectively collected database of IAT stroke patients was performed. Successful recanalization was defined as a Thrombolysis in Cerebral Infarction Score of 2b or 3 and symptomatic ICH (SICH) as parenchymal hematoma type 2 (PH2) with neurological deterioration. The association between the recanalization status and ICH/SICH was investigated using logistic regression models adjusted for baseline characteristics selected by univariate analyses., Results: One hundred and thirty-six patients had successful recanalization post procedure, 41 patients developed ICH and 10 patients SICH. There was a statistically significant baseline imbalance between the groups with and without successful recanalization on gender, baseline National Institute of Health Stroke Scale (NIHSS) score, the use of intravenous tPA and intra-arterial urokinase (p < 0.05). Logistic regression analysis adjusted for the above variables and the time to digital subtraction angiography demonstrated a statistically significant association between successful recanalization and ICH (odds ratio 0.42; 95% CI 0.19, 0.95; p = 0.04)., Conclusion: Successful recanalization post endovascular therapy is statistically significantly and negatively associated with ICH.

Background: Intra-arterial therapy has improved recanalization rates compared with intravenous thrombolysis for acute ischemic stroke; however, superior clinical efficacy has not been convincingly demonstrated. Time to recanalization is postulated as a mechanism hindering the efficacy of intra-arterial therapy., Aim: To investigate the effects of time to recanalization on clinical outcome postintra-arterial therapy for acute ischemic stroke., Methods: Clinical data were collected prospectively for consecutive patients undergoing intra-arterial therapy for acute ischemic stroke at a single center between 2009 and 2013. Ninety-day functional outcome was assessed by the modified Rankin scale. Univariate analyses identified candidate clinical variables for inclusion in the multivariable model; multivariable logistic regression analyses identified variables independently associated with good outcome, defined as modified Rankin scale 0-2., Results: One hundred and seven patients were included in the analysis. Median (interquartile range) age was 67 (54-77) years, 41 (38%) were female, and median (interquartile range) baseline National Institute of Health Stroke Severity score was 18 (13-22). Median time from symptom onset to recanalization was 330 min (interquartile range 277-397). Fifty-four (50%) patients achieved a favorable modified Rankin scale at 90 days. Age, successful recanalization, and time to recanalization were independently associated with good outcome at 90 days in multivariable logistic regression analysis. For every 15 min delay in recanalization, the odds of good outcome decreased by 10%., Conclusions: Longer time to recanalization was associated with poorer functional outcome post intra-arterial therapy. We recommend that a systematic approach to minimize time delay to treatment is warranted in intra-arterial therapy for acute ischemic stroke., (© 2015 World Stroke Organization.)

Background: The hyperdense artery sign (HAS) on CT brain scan is an assumed radiological marker of acute intra-arterial thrombotic occlusion. However, the relationship between HAS between time of stroke onset has not been adequately investigated, leading to uncertainty regarding its validity as a marker of acute ischaemia. We attempted to determine if the presence of the hyperdense artery sign is associated with time from stroke onset., Methods: Retrospective cross-sectional study conducted in a tertiary referral centre. Consecutive patients with acute ischaemic stroke and confirmed middle cerebral arterial occlusion on initial CT angiogram from 2007-2011 were included. Visual estimation and manual measurement of Hounsfield units of affected and corresponding non-affected artery on non-contrast CT was completed and mean density was calculated from four separate readings. Primary outcome measures were Time from stroke onset and HAS on both visual estimation and the ratio of mean value in Hounsfield Units (HU) of affected to non-affected artery., Results: One hundred and fifty-four subjects with confirmed arterial occlusion on CT Angiogram were included in the study. There were no significant differences in age distribution or vascular risk factor presence between subjects with or without HAS. Subjects with HAS were less likely to be male (50.9% vs 70.8%, p = 0.02).) HAS was found in 106 (68.8%) of all subjects. Median NIHSS score at presentation was significantly higher in the HAS group (17 vs 12, p = 0.02). No statistically significant association between HAS and stroke onset time or density ratio between affected and non-affected artery was detected overall within either the first 24-h or on subgroup analysis of those in the first 4.5-h. A small subgroup of three patients with stroke onset greater than 24-h all had absent HAS., Conclusions: No evidence of a correlation between time of stroke onset and presence of a HAS within the first 24-h post acute ischaemic stroke was identified. The HAS was associated with a higher NIHSS score at presentation.

Background and Purpose: The composition of occlusive thrombus in acute ischemic stroke may affect treatment success. Neuroimaging characteristics may correlate with thrombus composition. In this study we aimed to investigate the relationship between the hyperdense artery sign (HAS) on imaging and thrombus composition., Materials and Methods: Acute ischemic stroke patients who underwent endovascular thrombus retrieval from 2010-2012 were prospectively recruited. One blinded pathologist prepared the histology sections of retrieved thrombi whereby staining with haematoxylin and eosin and CD34 immunostain were performed. Histology sections were categorised into 4 phases of thrombus formation: red blood cell (RBC) dominant, RBC proportion equal to fibrin, fibrin dominant and organised fibrin. Computed tomography (CT) brain scans were assessed for HAS. Fisher's exact test was performed to identify an association between HAS and thrombus composition., Results: Forty patients were included. The mean age was 65.6±12.9 years and 67.5% were male. Atrial fibrillation was detected in 19 (47.5%) patients, diabetes mellitus in 6 (15.0%), hypercholesterolaemia in 11 (27.5%), hypertension in 20 (50.0%) and previous stroke or transient ischemic attack in 8 (20.0%) patients. Of the retrieved thrombi, 11 (27.5%) were RBC dominant, 11 (27.5%) RBC proportion was equal to fibrin, 7 (17.5%) fibrin dominant and 11 (27.5%) organised fibrin pathology. HAS was present in 29 (72.5%) patients and was significantly associated with thrombus early phase pathology (P<0.05)., Conclusion: HAS was significantly associated with early phase thrombus composition. This may enable the prediction of thrombus composition and allow for targeted selection of therapeutic modality., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Background: Trials of endovascular therapy for ischemic stroke have produced variable results. We conducted this study to test whether more advanced imaging selection, recently developed devices, and earlier intervention improve outcomes., Methods: We randomly assigned patients with ischemic stroke who were receiving 0.9 mg of alteplase per kilogram of body weight less than 4.5 hours after the onset of ischemic stroke either to undergo endovascular thrombectomy with the Solitaire FR (Flow Restoration) stent retriever or to continue receiving alteplase alone. All the patients had occlusion of the internal carotid or middle cerebral artery and evidence of salvageable brain tissue and ischemic core of less than 70 ml on computed tomographic (CT) perfusion imaging. The coprimary outcomes were reperfusion at 24 hours and early neurologic improvement (≥8-point reduction on the National Institutes of Health Stroke Scale or a score of 0 or 1 at day 3). Secondary outcomes included the functional score on the modified Rankin scale at 90 days., Results: The trial was stopped early because of efficacy after 70 patients had undergone randomization (35 patients in each group). The percentage of ischemic territory that had undergone reperfusion at 24 hours was greater in the endovascular-therapy group than in the alteplase-only group (median, 100% vs. 37%; P<0.001). Endovascular therapy, initiated at a median of 210 minutes after the onset of stroke, increased early neurologic improvement at 3 days (80% vs. 37%, P=0.002) and improved the functional outcome at 90 days, with more patients achieving functional independence (score of 0 to 2 on the modified Rankin scale, 71% vs. 40%; P=0.01). There were no significant differences in rates of death or symptomatic intracerebral hemorrhage., Conclusions: In patients with ischemic stroke with a proximal cerebral arterial occlusion and salvageable tissue on CT perfusion imaging, early thrombectomy with the Solitaire FR stent retriever, as compared with alteplase alone, improved reperfusion, early neurologic recovery, and functional outcome. (Funded by the Australian National Health and Medical Research Council and others; EXTEND-IA ClinicalTrials.gov number, NCT01492725, and Australian New Zealand Clinical Trials Registry number, ACTRN12611000969965.).

Background: Early neurological recovery after intravenous thrombolysis (IVT) is associated with favorable outcome after acute ischemic stroke. Leukoaraiosis, a marker of chronic ischemia, is a possible negative predictive factor of early recovery. However, its negative attenuating effects remain inadequately studied, leading to uncertainty in the prediction of outcomes after IVT. We aim to determine the influence of leukoaraiosis on early neurologic recovery., Methods: We included consecutive acute ischemic stroke patients who received IVT between 2007 and 2011. The following data were included: demographics, vascular risk factors, stroke type, National Institutes of Health Stroke Scale (NIHSS) at onset, and at 24 hours after IVT. Baseline computed tomography (CT) brain scans were analyzed. Two blinded assessors rated the CT scans using the van Swieten scale for leukoaraiosis. Median regression was used to assess the relationship between leukoaraiosis and neurologic recovery., Results: We included 158 patients. The median (interquartile range [IQR]) age was 77 (68-84) and 71 (45%) were female. The median (IQR) NIHSS was 13 (7-18.75) at baseline and 7.5 (2-16) at 24 hours. After taking into account variables independently associated with leukoaraiosis, median regression analysis failed to demonstrate the association between the presence of leukoaraiosis and early neurologic recovery (NIHSS relative one) after IVT, for either of the 3 prespecified dichotomization-based definitions of leukoaraiosis., Conclusions: In our sample, there was no evidence of the association between the degree of leukoaraiosis and early neurological recovery after IVT., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Intra-arterial (IA) therapy for stroke is an increasingly utilised management approach for acute ischaemic stroke. We aimed to correlate radiological characteristics and recanalisation success with radiological and functional outcomes at 90 days in patients treated with IA therapy. This was a single centre, retrospective study investigating the correlation between pre-procedural Computed Tomography-Angiogram Source Image (CTA-SI) Alberta Stroke Program Early Computed Tomography Score (ASPECTS), recanalisation success, and functional outcome at 90 days in patients with an acute ischaemic stroke from 2007-2012. Outcome measures were pre-procedural non-contrast computed tomography (NCCT), CTA-SI, and post-procedural NCCT ASPECTS that were obtained and analysed by three blinded reviewers, recanalisation success (Thrombolysis in Cerebral Infarction [TICI] 2b-3) and favourable clinical outcome (90 day modified Rankin scale [mRS] score ≤ 2). Forty-four patients satisfied the inclusion criteria. The mean age was 64.2 years (standard deviation: 14.9; median: 66.5; interquartile range [IQR]: 54.5-76.5). The median National Institutes of Health Stroke Scale score was 17 (IQR: 13.5-20). Twenty-one (47.7%) patients achieved a mRS score ≤ 2. The 90 day mortality rate was 25.0% (n=11). Of the patients who achieved TICI ≥ 2b-3, 65.5% (19/29) achieved mRS 2. There was a statistically significant association between recanalisation success (TICI 2b) and favourable neurological outcome at 90 days (odds ratio [OR] 25.22, 95% confidence interval [CI]: 2.86-222.37, p<0.005). Patients with high pre-procedural CTA-SI ASPECTS are significantly more likely to have high post-procedural NCCT score (OR 23.36, 95% CI: 3.26-166.92, p=0.002). Recanalisation success was strongly associated with good clinical outcome, unaffected by known predictive factors, which included age and stroke severity. This association was unattenuated by CTA-SI ASPECTS., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Evidence from recent randomized controlled studies comparing intra-arterial (IA) therapy with intravenous tissue plasminogen activator highlighted the mismatch between recanalization success and clinical outcomes in patients presenting with acute ischemic stroke. There is emerging interest in the impact of arterial collateralization, as determined by leptomeningeal anastomoses (LMAs), on the treatment outcomes of IA therapy. The system of LMA constitutes the secondary network of cerebral collateral circulation apart from the Circle of Willis. Both anatomic and angiographic studies confirmed significant interindividual variability in LMA. This review aims to outline the current understanding of arterial collateralization and its impact on outcomes after IA therapy for acute ischemic stroke, underpinning the possible role of arterial collateralization assessment as a selection tool for patients most likely to benefit from IA therapy., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Intravenous recombinant tissue plasminogen activator is associated with significant recanalisation failure in the setting of large artery occlusion. Endovascular treatment by stentriever achieves improved rates of recanalisation but its impact on clinical outcomes remains unclear. We hypothesise that successful recanalisation, unattentuated by age and stroke severity, is associated with improved clinical outcomes in patients treated with the Solitaire stentriever (ev3 Endovascular, Plymouth, MN, USA). We conducted a retrospective study of 60 consecutive acute ischaemic stroke patients treated with the Solitaire stentriever. The data included demographics, vascular risk factors, ictal onset time, National Institutes of Health Stroke Scale (NIHSS) score at presentation, angiographic findings, post-procedure imaging, and clinical follow-up. Recanalisation success was defined as a thrombolysis in cerebral infarction score (TICI) ≥ 2b. Good clinical outcome was defined as a modified Rankin Scale score (mRS) ≤ 2 at 3 months. Of the 60 patients, the mean age was 64.1 (standard deviation 13.4) years and 68.3% were men. Median NIHSS score at presentation was 18 (interquartile range 14-22). Successful recanalisation (TICI ≥ 2b) was achieved in 44 patients (73.3%). Of these 44 patients, 25 patients (56.8%) achieved mRS ≤ 2 at 3months. Multiple logistic regression showed significant association between recanalisation success and improved clinical outcome (p=0.019). Of all patients, four (6.7%) developed symptomatic intracranial haemorrhage. Overall mortality was 28.3%. In conclusion, the Solitaire stentriever was associated with improved recanalisation rates. We showed that successful recanalisation is associated with good clinical outcomes after adjustments for age, sex and stroke severity., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Introduction: Stroke is a major cause of death and disability. Accurately predicting stroke outcome from a set of predictive variables may identify high-risk patients and guide treatment approaches, leading to decreased morbidity. Logistic regression models allow for the identification and validation of predictive variables. However, advanced machine learning algorithms offer an alternative, in particular, for large-scale multi-institutional data, with the advantage of easily incorporating newly available data to improve prediction performance. Our aim was to design and compare different machine learning methods, capable of predicting the outcome of endovascular intervention in acute anterior circulation ischaemic stroke., Method: We conducted a retrospective study of a prospectively collected database of acute ischaemic stroke treated by endovascular intervention. Using SPSS®, MATLAB®, and Rapidminer®, classical statistics as well as artificial neural network and support vector algorithms were applied to design a supervised machine capable of classifying these predictors into potential good and poor outcomes. These algorithms were trained, validated and tested using randomly divided data., Results: We included 107 consecutive acute anterior circulation ischaemic stroke patients treated by endovascular technique. Sixty-six were male and the mean age of 65.3. All the available demographic, procedural and clinical factors were included into the models. The final confusion matrix of the neural network, demonstrated an overall congruency of ∼ 80% between the target and output classes, with favourable receiving operative characteristics. However, after optimisation, the support vector machine had a relatively better performance, with a root mean squared error of 2.064 (SD: ± 0.408)., Discussion: We showed promising accuracy of outcome prediction, using supervised machine learning algorithms, with potential for incorporation of larger multicenter datasets, likely further improving prediction. Finally, we propose that a robust machine learning system can potentially optimise the selection process for endovascular versus medical treatment in the management of acute stroke.

Background: Early decompressive hemicraniectomy following malignant middle cerebral artery (MCA) infarction reduces mortality and improves clinical outcome. Imaging predictors of malignant infarction may serve as 'red flags', prompting intensive neurological monitoring and timely intervention. Our objective is to investigate whether lower ASPECTS (Alberta Stroke Program Early CT Score) is associated with malignant MCA infarction., Methods: A retrospective cohort study of all patients with MCA territory ischemic strokes who were admitted to the Royal Melbourne Hospital (RMH) between 1 January 2009 and 31 December 2009 (226 patients included). The main outcome measures were ASPECTS on admission for each patient and the development of malignant MCA infarction., Results: One-hundred-and-eight patients out of 226 (48%) developed malignant MCA infarction. Good (>0.8) inter-rater agreement between observers scoring ASPECTS was observed using weighted kappa, intra-class correlation coefficient and Lin's concordance coefficients. Using receiver operating characteristic (ROC) curve analysis, we validated that ASPECTS 7 was the optimal cut-off score to determine progression to malignant infarction, providing 50% sensitivity and 86% specificity. One hundred and fifty six patients had ASPECTS >7 (69%) and 70 patients had ASPECTS ≤7 (31%). Patients with ASPECTS ≤7 were significantly younger than those with ASPECTS >7, with the median age of each group being 72.5 and 78 respectively (p = 0.02); otherwise the groups were well-matched. With ASPECTS ≤7, 54 out of 70 patients (77%) developed malignant MCA infarction, compared with 54 out of 156 patients (35%) with ASPECTS >7 (age-adjusted OR = 0.12, 95% CI: 0.06, 0.25; p < 0.0001). If ASPECTS ≤7 is a positive result, then the positive predictive value is 77% and the negative predictive value is 65%. The median ASPECTS for developing malignant MCA infarction was 7.5 (IQR: 5 to 10), while the median ASPECTS for not developing MCA infarction was 10 (IQR: 8 to 10), resulting in a significant age-adjusted median difference of 2 (95% CI: 0.8, 3.2; p < 0.0001). We also found that coma on admission is associated with the development of malignant MCA infarction (OR = 22.63, 95% CI: 1.3, 393.7; p = 0.0323) and that a history of hypertension is not associated with the development of malignant MCA infarction (OR = 0.9707, 95% CI: 0.54, 1.75; p = 0.9213)., Conclusions: ASPECTS ≤7 on initial brain CT in a patient with MCA infarction is associated with the development of malignant MCA infarction. We recommend close monitoring of, and early consideration of decompressive hemicraniectomy for, acute stroke patients with ASPECTS ≤7., (© 2014 S. Karger AG, Basel.)

Background and Hypothesis: Thrombolysis with tissue plasminogen activator is proven to reduce disability when given within 4·5 h of ischemic stroke onset. However, tissue plasminogen activator only succeeds in recanalizing large vessel arterial occlusion in a minority of patients. We hypothesized that anterior circulation ischemic stroke patients, selected with 'dual target' vessel occlusion and evidence of salvageable brain using computed tomography or magnetic resonance imaging 'mismatch' within 4·5 h of onset, would have improved reperfusion and early neurological improvement when treated with intra-arterial clot retrieval after intravenous tissue plasminogen activator compared with intravenous tissue plasminogen activator alone., Study Design: EXTEND-IA is an investigator-initiated, phase II, multicenter prospective, randomized, open-label, blinded-endpoint study. Ischemic stroke patients receiving standard 0·9 mg/kg intravenous tissue plasminogen activator within 4·5 h of stroke onset who have good prestroke functional status (modified Rankin Scale <2, no upper age limit) will undergo multimodal computed tomography or magnetic resonance imaging. Patients who also meet dual target imaging criteria: vessel occlusion (internal carotid or middle cerebral artery) and mismatch (perfusion lesion : ischemic core mismatch ratio >1·2, absolute mismatch >10 ml, ischemic core volume <70 ml) will be randomized to either clot retrieval with the Solitaire FR device after full dose intravenous tissue plasminogen activator, or tissue plasminogen activator alone., Study Outcomes: The coprimary outcome measure will be reperfusion at 24 h and favorable clinical response (reduction in National Institutes of Health Stroke Scale by ≥8 points or reaching 0-1) at day 3. Secondary outcomes include modified Rankin Scale at day 90, death, and symptomatic intracranial hemorrhage., (© 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization.)

Intra-arterial therapy (IAT) provides superior recanalisation rates, approaching 80% for the current generation of endovascular devices. Furthermore, IAT may allow for an extended therapeutic window beyond that which is permissible for intravenous thrombolysis. However, the improved recanalisation rates are not matched by concordant clinical outcomes, leading to an invigorated search for predictors of clinical outcome. There is emerging evidence that younger age, mild-moderate stroke, and shorter vessel occlusion time are associated with better clinical outcome after IAT. This review aims to critically appraise current evidence that may inform changes in the selective inclusion of clinical factors in the future design and trial of IAT., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Background Endovascular thrombectomy (ET) is safe, effective, and cost-effective for large artery occlusion ischemic stroke, even if under different selection criteria. Purpose To study the preferences for ET selection criteria by surveying clinicians and consumers, where number needed to treat to achieve functional independence is the only factor being considered. Methods A survey providing visual representation of the proportion of patients treated and expected functional outcomes, based on the selection criteria in each of the recent randomized trials of ET, was distributed nationwide in Australia and New Zealand to clinicians and consumers. The preferred selection criteria were identified by the frequency of first choice and using decision-analysis techniques to assess consensus by treating respondents as a panel of experts and aggregating their preferences on selection criteria. Results 104 clinicians and 107 consumer respondents (43/107 (40%) stroke survivors) took part in the study. Selection criteria of EXTEND-IA were ranked as the most preferred by the consensus process analysis and were the first choice of 64 individual clinicians (61.5%; 95% CI 52% to 71%). ESCAPE trial selection criteria were ranked as the most preferred option and chosen by 42 individual consumers (39%; 95% CI 29% to 48%). Most clinicians based their choice on the ratio of patients benefiting from ET, while consumers considered the absolute number of patients benefiting. Conclusions Consumers favor maximization of the absolute number achieving good outcome in comparison with clinicians. This finding suggests that less restrictive criteria may be favored in clinical practice. [ABSTRACT FROM AUTHOR]

Background: The risks of intracranial haemorrhage (ICH) post intra-arterial therapy (IAT) for stroke are not well understood. We aimed to study the influence of recanalization status post IAT for anterior circulation stroke and posterior circulation stroke on ICH development.Methods: Retrospective analysis of 193 patients in a prospectively collected database of IAT stroke patients was performed. Successful recanalization was defined as a Thrombolysis in Cerebral Infarction Score of 2b or 3 and symptomatic ICH (SICH) as parenchymal hematoma type 2 (PH2) with neurological deterioration. The association between the recanalization status and ICH/SICH was investigated using logistic regression models adjusted for baseline characteristics selected by univariate analyses.Results: One hundred and thirty-six patients had successful recanalization post procedure, 41 patients developed ICH and 10 patients SICH. There was a statistically significant baseline imbalance between the groups with and without successful recanalization on gender, baseline National Institute of Health Stroke Scale (NIHSS) score, the use of intravenous tPA and intra-arterial urokinase (p < 0.05). Logistic regression analysis adjusted for the above variables and the time to digital subtraction angiography demonstrated a statistically significant association between successful recanalization and ICH (odds ratio 0.42; 95% CI 0.19, 0.95; p = 0.04).Conclusion: Successful recanalization post endovascular therapy is statistically significantly and negatively associated with ICH. [ABSTRACT FROM AUTHOR]

Abstract: Cerebral venous thrombosis (CVT) is a rare stroke subtype with a highly variable clinical course. There is limited information on clinical deterioration in these patients, and imaging predictors of deterioration have not been studied adequately. Therefore, we aimed to investigate the radiological predictors of clinical deterioration in patients with CVT. We conducted a retrospective study of 106 consecutive patients from 1997 to 2010. All patients were confirmed as having CVT using imaging techniques. The following clinical data were collected: patient demographics, clinical presentation, radiological findings, treatment and clinical deterioration. Of the 106 patients, there were 77 females and 29 males, with a mean age of 43years (range 19–79years). The common symptoms of clinical presentation included headache (72%), seizure (29%) and severe motor impairment (20%). Overall, 34% of the patients with CVT developed clinical deterioration during hospital admission. Univariate analysis showed venous infarcts and hyperintensity on diffusion-weighted imaging (DWI) as predictors of clinical deterioration. Parenchymal haemorrhage, vasogenic oedema, midline shift and thrombosis location were not predictive of clinical deterioration. In conclusion, our study showed that venous infarcts and hyperintensity on DWI were associated with clinical deterioration in patients with CVT. These findings suggest that close monitoring is necessary in these groups of patients as they may require more aggressive therapy. [Copyright &y& Elsevier]

Abstract: Intracranial arterial dissection is relatively rare and generally considered to have a worse outcome than extracranial arterial dissection. It is a clinically significant entity that can cause severely disabling ischaemic stroke or subarachnoid haemorrhage (SAH). Only a few large case series of intracranial arterial dissection have been reported, particularly in the anterior circulation, but it is being increasingly recognized with advances in non-invasive angiographic diagnostic procedures. Patients with posterior circulation dissection appear to present more commonly with SAH and are traditionally said to have a worse outcome. Treatment options remain controversial and include medical therapy, as well as endovascular and surgical intervention. We reviewed the clinical features and outcome of 25 patients who had been treated for intracranial dissection at The Royal Melbourne Hospital over a period of 5 years. We recorded patient age, clinical presenting features, neuroimaging findings, treatment, and outcome assessment at 90 days using the modified Rankin Score (mRS). Eleven patients had anterior circulation dissection, while 14 had posterior circulation dissection; and overall 12 patients had cerebral ischaemia while 13 had subarachnoid haemorrhage (SAH). Almost all intracranial arterial dissections occurred spontaneously, without a history of trauma. Patients were relatively young, especially those in the group with ischaemia, with an average age of 39 years. Hypertension was the most commonly identified vascular risk factor. Eight out of 12 patients with ischaemia (66.7%) had anterior circulation dissection, while posterior circulation dissection occurred in 10 of 13 patients with SAH (76.9%). Location of anterior circulation dissection was variable, while the terminal vertebral artery segment was most commonly involved in the posterior circulation group. Most of the patients in the ischaemic group received medical therapy (n =10/12), while 10 out of 13 (76.9%) patients with SAH underwent endovascular and/or surgical intervention. There was a trend towards more favourable outcome at 90 days (mRS ⩾3) in the ischaemic group (n =10/12, 83.3%) compared to the SAH group (n =6/13, 46.2%), but this did not reach statistical significance (p value=0.097). The mortality rate was 16.7% (n =2/12) in the ischaemia group, and 7.7% in the SAH group (n =1/13), not significant. Among all the ischaemic group patients who received medical therapy, there were no deaths or development of secondary intracranial bleeding complications including SAH at 90 days. Our series suggest that it is possible to divide patients with intracranial dissection into two groups: (i) an ischaemia group, associated with a more favourable clinical outcome even when treated with antiplatelet or anticoagulation therapy; or (ii) a SAH group with a less favourable prognosis. The mortality rate, especially in patients with SAH who are generally treated with endovascular and/or surgical intervention, is less than previously reported. Anterior circulation involvement appears more common than traditionally perceived. The spontaneous occurrence of intracranial dissection in a relatively young age group, the predominant site of dissection in the artery at some distance from its tethered proximal segment, and the commonly observed hypertension, together raise the possibility of spontaneous dissection in arteries prematurely weakened by accelerated atherosclerosis. [Copyright &y& Elsevier]

A 57-year-old male patient with hereditary hemorrhagic telangiectasia presented with an acute right middle cerebral artery ischemic stroke. Investigations revealed a right middle cerebral artery M2 occlusion, hypoxemia, and a large pulmonary arteriovenous malformation and right lower limb deep venous thrombosis. Closure of the pulmonary arteriovenous malformation was successfully performed with an Amplatzer device. Catheter closure of pulmonary arteriovenous malformations in patients with hereditary hemorrhagic telangiectasia is a recognized treatment modality to prevent recurrent ischemic stroke and other embolic and hemorrhagic complications. [Copyright &y& Elsevier]

Objective: Pipeline embolization device (PED) implantation is a novel endovascular treatment option for the treatment of intracranial aneurysms. It is emerging as a useful alternative to coiling and to open surgery, and its use is increasing worldwide. We performed a literature review to examine its efficacy, technical challenges, and safety. Methods: PubMed database was used to identify all articles relating to PED. Results: The review outlines the indications for PED, its technical aspects, complications, and clinical outcomes. Conclusions: PED offers an alternative to endovascular coiling for aneurysms with complex morphology. The indication for its use has evolved from the limited scope of treatment of giant aneurysms with wide necks to the inclusion of smaller aneurysms. The procedural safety profile of PED is comparable with or possibly superior to balloon-remodeling or stent-assisted coil embolization in specific circumstances. However, questions remain regarding the incidence of post-procedural subarachnoid hemorrhage. Ongoing monitoring and meticulous documentation of PED postimplantation safety is strongly recommended. [ABSTRACT FROM AUTHOR]