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Introduction: The impact of leptomeningeal collateralization on the efficacy of mechanical thrombectomy (MT) in patients with anterior circulation large vessel occlusion (aLVO) presenting in the 6-24 h time window remains poorly elucidated., Patients and Methods: Retrospective multicenter study of aLVO patients presenting between 6 and 24 h after stroke onset who received MT plus Best Medical Treatment (BMT) or BMT alone. Leptomeningeal collateralization was assessed using single-phase computed tomography angiography (grade 0: no filling; grade 1: filling ⩽50%; grade 2: filling >50% but <100%; grade 3: filling 100% of the occluded territory). Inverse probability of treatment weighted ordinal regression was performed to assess the association between treatment and shift of the modified Rankin Scale (mRS) score toward lower categories at 3 months. We used interaction analysis to explore differential treatment effects on functional outcomes (probabilities for each mRS subcategory at 3 months) at different collateral grades., Results: Among 363 included patients, 62% received MT + BMT. Better collateralization was associated with better functional outcomes at 3 months in the BMT alone group (collateral grade 1 vs 0: acOR 5.06, 95% CI 2.33-10.99). MT + BMT was associated with higher odds of favorable functional outcome at 3 months (acOR 1.70, 95% CI 1.11-2.62) which was consistent after adjustment for collateral status (acOR 1.54, 95% CI 1.01-2.35). Regarding treatment effect modification, patients with absent collateralization had higher probabilities for a mRS of 0-4 and a lower mortality at 3 months for the MT + BMT group., Discussion and Conclusion: In the 6-to-24-h time window, aLVO patients with absent leptomeningeal collateralization benefit most from MT + BMT, indicating potential advantages for this group despite their poorer baseline prognosis., Competing Interests: Declaration of conflicting interestThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: MK received speaker honoraria from Medtronic. GMK is on a scientific advisory board of Bayer AG. CWC is member of the Medical and Scientific Advisory Boards of iSchemaView. LHB received personal fees from Claret Medical and InnovHeart. GMDM received speaker honoraria from Medtronic. The remaining authors report no conflicts of interests relevant to this study.

Quantitative susceptibility mapping (QSM) is a novel processing method for gradient-echo magnetic resonance imaging (MRI). Higher magnetic susceptibility in cortical veins have been observed on susceptibility maps in the ischemic hemisphere of stroke patients, indicating an increased oxygen extraction fraction (OEF). Our goal was to investigate susceptibility in veins of stroke patients after successful recanalization in order to analyze the value of QSM in predicting tissue prognosis and clinical outcome. We analyzed MR images of 23 patients with stroke due to unilateral middle cerebral artery (MCA)-M1/M2 occlusion acquired 24-72 h after successful thrombectomy. The susceptibilities of veins were obtained from QSM and compared between the stroke territory, the ipsilateral non-ischemic MCA territory and the contralateral MCA territory. As outcome variables, early infarct size and functional disability (modified Rankin Scale, mRS) after 3-5 months was used. The median susceptibility value of cortical veins in the ischemic core was 41% lower compared to the ipsilateral non-ischemic MCA territory and 38% lower than on the contralateral MCA territory. Strikingly, in none of the patients prominent vessels with high susceptibility signal were found after recanalization. Venous susceptibility values within the infarct did not correlate with infarct volume or functional disability after 3-5 months. Low venous susceptibility within the infarct core after successful recanalization of the occluded vessel likely indicates poor oxygen extraction arising from tissue damage. We did not identify peri-infarct tissue with increased susceptibility values as potential surrogate of former penumbral areas. We found no correlation of QSM parameters with infarct size or outcome., (© 2021. The Author(s).)

Objective: Thrombectomy-related emboli (TRE) represent a potentially dangerous complication of thrombectomy procedures for acute ischemic stroke. The aim of this study was to compare the rate of TRE in aspiration thrombectomy (ASP) and stent retriever thrombectomy techniques., Methods: We retrospectively compared clinical and radiologic outcomes of 2 groups of consecutive patients with stroke, ASP group and SRT group, with TRE rates as the primary study endpoint. Emboli were classified as either affected territory emboli or unaffected territory emboli (uTRE). Relevant literature was also reviewed., Results: The ASP group had better rates of successful recanalization (97.1% vs. 77.1%, P = 0.02), mean number of passes per case (2.0 vs. 3.3, P = 0.04), and mean operative time (34.1 minutes vs. 84.8 minutes, P < 0.0001). Thrombectomy technique (ASP vs. SRT) did not appear to predict rates of either affected territory emboli (odds ratio [OR] = 1.24, 95% confidence interval [CI] 0.33-4.63, P = 0.74) or uTRE (OR = 5.67, 95% CI 0.60-53.42, P = 0.13). Longer operative time was linked to higher uTRE rates (OR = 1.03, 95% CI 1.01-1.05, P = 0.02). ASP technique (OR 0.1, 95% CI 0.01-0.88; P = 0.04) and shorter operative time (OR = 0.98, 95% CI 0.97-0.99, P = 0.03) were linked to better rates of successful recanalization., Conclusions: The applied thrombectomy technique (ASP vs. SRT) is not an independent predictor of TRE rates. Operative time tends to affect the rates of uTRE and successful recanalization. The ASP technique offers higher rates of successful recanalization in less operative time., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: The ThRombolysis in Ischemic Stroke Patients (TRISP) collaboration aims to address clinically relevant questions about safety and outcomes of intravenous thrombolysis (IVT) and endovascular thrombectomy. The findings can provide observational information on treatment of patients derived from everyday clinical practice., Participants: TRISP is an open, investigator-driven collaborative research initiative of European stroke centres with expertise in treatment with revascularisation therapies and maintenance of hospital-based registries. All participating centres made a commitment to prospectively collect data on consecutive patients with stroke treated with IVT using standardised definitions of variables and outcomes, to assure accuracy and completeness of the data and to adapt their local databases to answer novel research questions., Findings to Date: Currently, TRISP comprises 18 centres and registers >10 000 IVT-treated patients. Prior TRISP projects provided evidence on the safety and functional outcome in relevant subgroups of patients who were excluded, under-represented or not specifically addressed in randomised controlled trials (ie, pre-existing disability, cervical artery dissections, stroke mimics, prior statin use), demonstrated deficits in organisation of acute stroke care (ie, IVT during non-working hours, effects of onset-to-door time on onset-to-needle time), evaluated the association between laboratory findings on outcome after IVT and served to develop risk estimation tools for prediction of haemorrhagic complications and functional outcome after IVT., Future Plans: Further TRISP projects to increase knowledge of the effect and safety of revascularisation therapies in acute stroke are ongoing. TRISP welcomes participation and project proposals of further centres fulfilling the outlined requirements. In the future, TRISP will be extended to include patients undergoing endovascular thrombectomy., Competing Interests: Competing interests: JFS has received speaker honoraria from W L Gore & Associates GmbH and travel support from Bayer and Boehringer-Ingelheim; HG has received research support from the Swiss National Science Foundation; AZ has received funding for speaker honoraria and consulting fees from Boehringer-Ingelheim and Medtronic-Covidien and consulting fees from Nestec; GK received grants from Swiss Parkinson Association, Swiss Heart Association, Swiss National Science Foundation and served on advisory boards for Boehringer-Ingelheim, Bayer, Daiichi Sankyo (Schweiz) AG, Zambon, Nestle, GE Healthcare within the last two years; YB received honoraria or consulting fees from AstraZeneca France, Daiichi-Sankyo, BMS-Pfizer, Covidiem, Bayer and MSD France; PM received research grants from the Swiss National Science Foundation, the Swiss Heart Foundation; speaker fees from Boehringer-Ingelheim, Bayer, Covidien and Stryker; honoraria from scientific advisory boards from Boehringer-Ingelheim, Bayer, Pfizer, Amgen; consulting fees from Pierre-Fabre and Astra-Zeneca; and travel support from Boehringer-Ingelheim and Bayer. All this support is received by the institution (CHUV) and is used for stroke education and research; DL participated during the last 5 years to 1 advisory boards, symposia or trials sponsored by Sanofi Aventis, BMS, Astrazeneca, Boeringher-Ingelheim, Servier, Ebewe, CoLucid Pharm, Brainsgate, Photothera, Lundbeck, GSK, Bayer, Pfizer et Allergan (honorarium paid to Adrinord or research account of the hospital) and was an associated editor of the Journal of neurology, neurosurgery and psychiatry 2004-2010 (personal financial compensation); CHN has received funding for travel or speaker honoraria from Bayer, Boehringer-Ingelheim, Takeda, and BMS/Pfizer; PJN has received consulting fees from Boehringer-Ingelheim; STE has received funding for travel or speaker honoraria from Bayer and Boehringer-Ingelheim, he has served on scientific advisory boards for Bayer, Boehringer-Ingelheim, BMS/Pfizer and Covidien and on the editorial board of Stroke. He has received an educational grant from Pfizer and research support from the Science Funds (Wissenschaftsfonds) of the University Hospital Basel, the University Basel, the Swiss Heart Foundation and the Swiss National Science Foundation., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Ischemic stroke is caused by a disruption in blood supply to a region of the brain. It induces dysfunction of brain cells and networks, resulting in sudden neurological deficits. The cause of stroke is vascular, but the consequences are neurological. Decades of research have focused on finding new strategies to reduce the neural damage after cerebral ischemia. However, despite the incredibly huge investment, all strategies targeting neuroprotection have failed to demonstrate clinical efficacy. Today, treatment for stroke consists of dealing with the cause, attempting to remove the occluding blood clot and recanalize the vessel. However, clinical evidence suggests that the beneficial effect of post-stroke recanalization may be hampered by the occurrence of microvascular reperfusion failure. In short: recanalization is not synonymous with reperfusion. Today, clinicians are confronted with several challenges in acute stroke therapy, even after successful recanalization: (1) induce reperfusion, (2) avoid hemorrhagic transformation (HT), and (3) avoid early or late vascular reocclusion. All these parameters impact the restoration of cerebral blood flow after stroke. Recent advances in understanding the molecular consequences of recanalization and reperfusion may lead to innovative therapeutic strategies for improving reperfusion after stroke. In this review, we will highlight the importance of restoring normal cerebral blood flow after stroke and outline molecular mechanisms involved in blood flow regulation., Competing Interests: The authors declare no conflict of interest.

Distinct patient characteristics have been proposed for ischaemic stroke in the anterior versus posterior circulation. However, data on functional outcome according to stroke territory in patients with acute stroke treatment are conflicting and information on outcome predictors is scarce. In this retrospective study, we analysed functional outcome in 517 patients with stroke and thrombolysis and/or thrombectomy treated at the University Hospital Zurich. We compared clinical factors and performed multivariate logistic regression analyses investigating the effect of outcome predictors according to stroke territory. Of the 517 patients included, 80 (15.5%) suffered a posterior circulation stroke (PCS). PCS patients were less often female (32.5% vs. 45.5%, p = 0.031), received thrombectomy less often (28.7% vs. 48.3%, p = 0.001), and had lower median admission NIHSS scores (5 vs. 10, p < 0.001) as well as a better median three months functional outcome (mRS 1 vs. 2, p = 0.010). Predictors for functional outcome were admission NIHSS (OR 0.864, 95% CI 0.790–0.944, p = 0.001) in PCS and age (OR 0.952, 95% CI 0.935–0.970, p < 0.001), known symptom onset (OR 1.869, 95% CI 1.111–3.144, p = 0.018) and admission NIHSS (OR 0.840, 95% CI 0.806–0.876, p < 0.001) in ACS. Acutely treated PCS and ACS patients differed in their baseline and treatment characteristics. We identified specific functional outcome predictors of thrombolysis and/or thrombectomy success for each stroke territory. [ABSTRACT FROM AUTHOR]

Background and purpose: Stroke is a dreaded complication in patients with cancer. Besides paraneoplastic coagulopathy, chemotherapy, radiotherapy and tumor‐directed invasive procedures, circulating cancer cells may contribute to thrombus formation and embolic stroke. However, the incidence of tumor cells within the blood clots of cancer patients with stroke is unknown and the role of circulating tumor cells in the formation of cerebrovascular thrombi remains unclear. Methods: All patients who had undergone cerebrovascular thrombectomy at the University Hospital Zurich between 2014 and 2017 were screened for history of cancer. Clinical information was retrieved from the local stroke registry and the electronic charts and thrombi underwent a thorough histopathological re‐review. Results: Thirty‐two of 182 patients (18%) with thrombectomy had a history of cancer. The majority of patients had advanced stage cancer. However, even after extensive histopathological re‐review, only one specimen revealed tumor cells in the thrombus: a 75‐year‐old patient with acute occlusion of the middle cerebral artery who had been diagnosed with non‐small‐cell lung cancer 8.1 months prior to stroke. Conclusions: The presence of cancer cells in clots from cerebrovascular thrombectomy, indicative of a direct involvement of circulating tumor cells in the causation of stroke, is rare. [ABSTRACT FROM AUTHOR]