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Background: The historical development of interventional stroke treatment shows a wide variation of different techniques and materials used. Thus, the question of the present work is whether the technical and procedural differences of thrombectomy techniques lead to different technical and clinical results. Methods and results: Analysis of a mixed retrospective/prospective database of all endovascular treated patients with an occlusion of the Carotid-T or M1 segment of the MCA at a single comprehensive stroke center since 2008. Patients were classified regarding the technical approach used. Six hundred sixty-eight patients were available for the final analysis. Reperfusion rates ranged between 56% and 100% depending on the technical approach. The use of balloon guide catheters and most recently the establishment of combination techniques using balloon guide catheters, aspiration catheters and stent retrievers have shown a further significant increase in the rates of successful recanalization, full recanalization and first-pass recanalization. Additionally, the technical development of interventional techniques has led to a subsequent drop in complications, embolization into previously unaffected territories in particular. Conclusion: Technical success of MT has improved substantially over the past decade owing to improved materials and procedural innovations. Combination techniques including flow modulation have emerged to be the most effective approach and should be considered as a standard of care. Level of evidence: Level 3, retrospective study. [ABSTRACT FROM AUTHOR]

Background: Repeated mechanical thrombectomy for acute stroke treatment in individual patients has been proven feasible. However, less is known about the etiology of recurrent vessel occlusions after prior thrombectomy. We aimed to understand if the etiology of such recurrent events differs from the first stroke. Methods: Retrospectively, we identified all patients at our center who received a repeated mechanical thrombectomy between 2007 and 2019. Clinical data were retrieved from medical records. Etiology of stroke was evaluated retrospectively, and angiographic studies were revisited. Results: Twenty-three patients (1.5%) were identified. Median age was 68 years (IQR 56–77). Median NIHSS at first admission was 11 points (IQR 5–15). In nine cases (39.1%), the recurrent vessel occlusion was located exactly at the same position as the prior occlusion. Overall, five (21.7%) patients had a remarkable extracranial pathology as likely cause of stroke recurrence. In 16 patients (69.6%), the etiology of the first stroke and its recurrence was considered as likely being the same, mostly of cardioembolic or unknown origin. In the seven remaining patients (30.4%), the cause of stroke possibly differed from the first event, with five patients (21.7%) having a postinterventional intracranial intimal lesion as possible cause of stroke. Conclusion: Incidence of repeated thrombectomy was low. However, the high number of patients with known origin of stroke etiology raises the question how their monitoring may be optimized. The number of patients with remarkable extracranial pathologies or intracranial endothelial lesions supports current clinical practice to pay attention to final angiographic series. [ABSTRACT FROM AUTHOR]

Introduction: Despite targeted standard therapy, aneurysmal subarachnoid hemorrhage (aSAH) frequently leads to cerebral vasospasms (CVS) of large cerebral arteries, reduced oxygen supply of brain tissue, known as delayed cerebral ischemia (DCI), subsequent development of manifest cerebral infarction and poor neurological outcome., Research Question: The primary aim was to evaluate the efficacy of endovascular spasmolysis (eSL) as a rescue therapy for delayed ischemic neurological deficits (DIND) occurring despite maximum conservative treatment, with the potential benefit of preventing permanent ischemic deficits, and thus, improving overall neurological outcomes., Material and Methods: In our retrospective, monocentric study, we included 310 patients developing CVS during hospitalization and evaluated their clinical and radiographic outcomes. Severe vasospasm was defined by a mean velocity of >200 cm/s in transcranial Doppler ultrasound and/or occurrence of new neurological deficits, and/or decrease of at least 2 points on the Glasgow Coma Scale (GCS), respectively., Results: 92 patients (29.7%) underwent eSL due to persistent symptoms despite conservative therapy. Among endovascularly treated patients, 86% (n = 79) improved angiographically, 71% (n = 44) of 62 patients who underwent eSL due to symptomatic deterioration improved clinically. Clinical worsening due to progressive CVS occurred in 18% of cases (n = 11). Periprocedural complications were observed in 4% (n = 4)., Discussion and Conclusion: eSL emerges as a safe and effective therapy for individuals experiencing DIND triggered by large-artery vasospasm following aSAH. The implementation of a standardized, multi-step process for detection and management, coupled with criteria for endovascular interventions, proves to be an efficient preventative approach to enhance neurological outcomes after aSAH., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Background: Evidence from randomized controlled trials has shown a benefit for endovascular treatment in basilar artery occlusion. We aimed to show the effect of the recanalization result on outcome and determine the role of underlying basilar stenosis in a real-world setting., Methods: A retrospective, single-center study of patients who received endovascular treatment for basilar artery occlusion from March 2008 to June 2022 was conducted. Clinical and outcome characteristics were gathered. Multivariate logistic regression analysis was performed to predict poor outcomes (post-treatment mRS 5 or 6). MRS shift analysis was performed., Results: This study includes 210 patients (mean age, 71.4 years +/- 13.3 [standard deviation]; 124 men). The variables age (OR, 1.04; 95% CI: 1.01-1.08; p = 0.014), underlying basilar stenosis (OR: 4.86; 95% CI: 2.15-10.98; p < 0.001), admission NHISS (OR: 1.09; 95% CI: 1.04-1.13; p < 0.001), and TICI (OR: 1.89; 95% CI: 1.09-3.25; p = 0.022) independently predicted a poor outcome. Patients with occlusions due to underlying stenosis had significantly worse recanalization rates. Median post-treatment mRS in all patients with embolic occlusion was 4; IQR, 2-5 (only patients with embolic occlusion: mTICI 0-2a, median: 5 [IQR, 4-5.5]; mTICI 2b, median: 4 [IQR, 2.5-6]; mTICI 3, median: 3 [IQR, 1-5]; p = 0.037). Median post-treatment mRS in all patients with occlusions due to underlying stenosis was 5; IQR, 4-6 (only patients with embolic occlusions: mTICI 0-2a, median: 6 [IQR, 4.5-6]; mTICI 2b, median: 6 [IQR, 4.25-6]; mTICI 3, median: 5 [IQR, 3.5-5.25]; p = 0.059)., Conclusions: Successful recanalization is essential for preventing poor outcomes in basilar artery occlusion. Underlying basilar stenosis diminishes the effect of successful recanalization on the overall outcome.

Arterial spin labeling (ASL) is a contrast agent-free magnetic resonance imaging (MRI) technique to measure cerebral blood flow (CBF). We sought to investigate effects of CBF within the infarct on outcome and risk of hemorrhagic transformation (HT). In 111 patients (median age: 74 years, 50 men) who had undergone mechanical thrombectomy (MT) for ischemic stroke of the anterior circulation (median interval: 4 days between MT and MRI), post-stroke %CBF difference from pseudo-continuous ASL was calculated within the diffusion-weighted imaging (DWI)-positive infarct territory following lesion segmentation in relationship to the unaffected contralateral side. Functional independence was defined as a modified Rankin Scale (mRS) of 0-2 at 90 days post-stroke. %CBF difference, pre-stroke mRS, and infarct volume were independently associated with functional independence in a multivariate regression model. %CBF difference was comparable between patients with and without HT. A subcohort of 10 patients with decreased infarct-CBF despite expanded Treatment in Cerebral Infarction (eTICI) 2c or 3 recanalization was identified (likely related to the no-reflow phenomenon). Outcome was significantly worse in this group compared to the remaining cohort. In conclusion, ASL-derived %CBF difference from the DWI-positive infarct territory independently predicted functional independence, but %CBF difference was not significantly associated with an increased risk of HT., 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: Outside the submitted work, CZ has received speaker honoraria from Bayer-Schering. SK is employed by Philips GmbH, Hamburg, Germany. All other authors declare no conflict of interest.

Objectives: Basilar artery occlusion (BAO) may be etiologically attributed to embolism or in situ thrombosis due to basilar stenosis (BS). Patients with BAO due to BS (BAOS) are known to have worse outcomes than patients with embolic occlusions (BAOE). BAOS occurs more proximally in the basilar artery (BA) than BAOE. We hypothesize that differing brain stem infarct patterns contribute to outcome differences between these stroke etiologies., Methods: This retrospective study includes 199 consecutive patients with BAO who received endovascular treatment at a single center. Final infarction in brain parenchyma dependent on the posterior circulation was graded semiquantitatively on magnetic resonance imaging (MRI). Associations to underlying stenosis and angiographic and clinical outcome variables were tested. The primary endpoint was early good clinical outcome (EGCO, mRS score ≤ 3 at discharge)., Results: Infarct extension of the medulla oblongata (OR = 0.25; 95% CI = 0.07-0.86; p = 0.03), the inferior pons (OR = 0.328; 95% CI = 0.17-0.63; p = 0.001), the superior pons (OR = 0.57; 95% CI = 0.33-0.99; p = 0.046), and the occipital lobes (OR = 0.46; 95% CI = 0.26-0.80; p = 0.006) negatively predicted EGCO. Infarct extension for other posterior-circulation-dependent brain regions was not independently associated with unfavorable early outcomes. Patients with BAOS had more proximal occlusions and greater infarct volumes in the inferior brain stem. Successful reperfusion (mTICI 2b-3) occurred more often in patients with BAOE than in BAOS (BAOE: 131 (96.3%); BAOS: 47 (83.9%), p = 0.005)., Conclusion: Unfavorable early outcomes in patients with BAOS may be explained by a higher likelihood of inferior brain stem infarcts and lower rates of reperfusion success., Clinical Relevance Statement: Basilar artery occlusion due to underlying stenosis is associated with a poorer prognosis than that caused by embolism; these results suggest that aggressive endovascular therapy, usually involving the placement of a permanent stent, may be warranted in these patients., Key Points: Inferior brain stem and occipital infarcts are prognostically unfavorable in basilar artery occlusion. Basilar artery occlusion due to stenosis occurs more proximally and is associated with worse outcomes. Differentiating etiologies of basilar artery occlusion may influence how aggressively treated the occlusion is., (© 2024. The Author(s).)

Background: Endovascular therapy for acute ischemic stroke has been shown to be highly effective in selected patients. However, the ideal criteria for patient selection are still debated. It is well known that collateral flow is an important factor, but the assessment is often subjective and time-consuming. Relative cerebral blood volume (rCBV) is a putative indicator of collateral capacity and can be quickly and easily determined by automated quantitative analysis. We investigated the relationship between rCBV of the affected region and clinical outcome in patients with acute ischemic stroke after endovascular therapy., Methods: We conducted a retrospective study on consecutive patients between January 2017 and May 2019. Patients with acute ischemic stroke of the anterior circulation who underwent imaging including computed tomography perfusion and were treated with mechanical thrombectomy (MT) were eligible for inclusion. rCBV was calculated automatically with RAPID software by dividing the average cerebral blood volume (CBV) of the affected region (time-to-maximum (Tmax) > 6 s) by the CBV of the unaffected contralateral side. The primary outcome was determined by the modified Rankin Scale (mRS) after 90 days. Good clinical outcome was defined as mRS ≤ 2. We compared means, performed mono- and multivariate logistical regression and calculated a receiver operating characteristic (ROC)-analysis to determine the ideal cutoff value to predict clinical outcomes., Results: 155 patients were enrolled in this study. 66 patients (42.58%) had good clinical outcomes. Higher rCBV was associated with good clinical outcome (p < 0.001), even after adjustment for the patients' status according to mRS and National Institute of Health Stroke Scale (NIHSS) age and Alberta stroke program early computed tomography score (ASPECTS) at baseline (p = 0.006). ROC-analysis revealed 0.650 (confidence interval: 0.616-0.778) as the optimal cutoff value., Conclusion: Higher rCBV at baseline is associated with good clinical long-term outcomes in patients with acute ischemic stroke treated by MT. In this study we provide the biggest collective so far that gives evidence that rCBV can be a valuable tool to identify patients who might benefit from MT and are able give a threshold to help to offer patients MT in borderline cases., (© 2024. The Author(s).)

Background: Acute basilar artery occlusion (BAO) is a severe disease that is associated with an 85% mortality rate if untreated. Several studies have analyzed the use of mechanical thrombectomy (MT) in the different scenarios of BAO. However, the results remain conflicting and the role of MT as standard of care for vertebrobasilar tandem occlusions (VBTO) has not been confirmed. Our goal was to assess technical feasibility, safety, and functional outcome of endovascular treatment of VBTO in comparison to isolated BAO (IBAO)., Methods: We retrospectively reviewed all prospectively collected patients with acute BAO from six tertiary centers between September 2016 and November 2021. Patients were subsequently divided into two groups: VBTO and IBAO. Baseline data, procedural details, and outcomes were compared between groups., Results: A total of 190 patients were included, 55 presenting with a VBTO and 135 with IBAO. Successful recanalization was equally common in both groups (89.1% and 86.0%). Rates of favorable functional outcome (modified Rankin Scale: 0-2) were higher in patients with VBTO compared to IBAO (36.4% vs. 25.2%, p = 0.048) and mortality was lower (29.1% vs. 33.3%). However, these associations faded after adjustment for confounders (adjusted odds ratio [aOR] 0.86, 95% CI 0.35-2.05; aOR 0.93, 95% CI 0.35-2.45). Rates of symptomatic intracranial hemorrhage did not differ between the groups (VBTO: 7.3% vs. IBAO: 4.2%; p = 0.496)., Conclusion: Endovascular treatment of VBTO is technically feasible and safe with similar rates of successful recanalization, favorable functional outcome, and mortality to those in patients with IBAO., 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: Dr Heldner reports grants from the Bangerter Foundation and Amgen Advisory board participation, not related to the present study. Dr Kaesmacher reports grants from the Swiss Academy of Medical Sciences/Bangerter Foundation, Swiss Stroke Society, and Clinical Trials Unit Bern during the conduct of the study. Dr Mordasini reports research support from Siemens, Cerenovus, iSchemaview, Medtronic and Stryker, and receipt of honoraria and consultation fees from Medtronic, Cerenovus, Phenox, and Microvention paid to the institution, not related to the present study.

Background: Numerous questions regarding procedural details of distal stroke thrombectomy remain unanswered. This study assesses the effect of anesthetic strategies on procedural, clinical and safety outcomes following thrombectomy for distal medium vessel occlusions (DMVOs)., Methods: Patients with isolated DMVO stroke from the TOPMOST registry were analyzed with regard to anesthetic strategies (ie, conscious sedation (CS), local (LA) or general anesthesia (GA)). Occlusions were in the P2/P3 or A2-A4 segments of the posterior and anterior cerebral arteries (PCA and ACA), respectively. The primary endpoint was the rate of complete reperfusion (modified Thrombolysis in Cerebral Infarction score 3) and the secondary endpoint was the rate of modified Rankin Scale score 0-1. Safety endpoints were the occurrence of symptomatic intracranial hemorrhage and mortality., Results: Overall, 233 patients were included. The median age was 75 years (range 64-82), 50.6% (n=118) were female, and the baseline National Institutes of Health Stroke Scale score was 8 (IQR 4-12). DMVOs were in the PCA in 59.7% (n=139) and in the ACA in 40.3% (n=94). Thrombectomy was performed under LA±CS (51.1%, n=119) and GA (48.9%, n=114). Complete reperfusion was reached in 73.9% (n=88) and 71.9% (n=82) in the LA±CS and GA groups, respectively (P=0.729). In subgroup analysis, thrombectomy for ACA DMVO favored GA over LA±CS (aOR 3.07, 95% CI 1.24 to 7.57, P=0.015). Rates of secondary and safety outcomes were similar in the LA±CS and GA groups., Conclusion: LA±CS compared with GA resulted in similar reperfusion rates after thrombectomy for DMVO stroke of the ACA and PCA. GA may facilitate achieving complete reperfusion in DMVO stroke of the ACA. Safety and functional long-term outcomes were comparable in both groups., Competing Interests: Competing interests: JF: Consulting fees from Cerenovus, Medtronic, Phenox, Penumbra, Roche, Tonbridge; participation on a Data Safety Monitoring Board of Stryker and Phenox; stock holdings for Tegus and Vastrax, Associate Editor for JNIS. RC: Consultant and/or proctor for BALT, Stryker, Microvention, Rapid Medical, Siemens Medical Systems. MM: Institutional grants: Balt, Medtronic, MicroVention, Stryker. AG: Proctor/consultant/speaker for Medtronic, Stryker and Penumbra. MM-G: Consultant for Medtronic, Stryker and Balt, Associate Editor for JNIS. FD: Grant from Cerenovus/ Johnson&Johnson, consulting fees from Cerus Endovascular, Balt, Cerenovus/Johnson&Johnson, honoraria for lectures Asahi, Cerenovus/Johnson&Johnson, Acandis, Stryker, Advisory Board Cerenovus Johnson&Johsno, Associate Editor for JNIS. JK: Grants from SAMW/Bangerter, grants from Swiss Stroke Society, and grants from Clinical Trial Unit Bern outside the submitted work. LLLY: Consultant for Stryker, SeeMode, and See-mode, Cerenovus honoraria, Jakarta Neuroupdate honorarium, Research Support from National Medical research Council (NMRC) Singapore and Ministry of Health (MOH). Stock holdings for Cereflo, SNVIS vice president. BT: Grants from ExxonMobil-NUS Research Fellowship for Clinicians. PN: Consultant/Proctor for Balt, Cerenovus, Medtronic, Penumbra, Stryker. AG: Honoraria for lectures from Stryker Neurovascular, Medtronic, Penumbra. BG: grants from the French Ministry of Health and is the primary investigator of the TITAN, DIRECT ANGIO, and IA-RESCUE trial; consulting fees from Air Liquide, MIVI, Medtronic, Microvention, and Penumbra. LM: Compensation as a speaker for Balt Prime. GB: Compensation as a speaker for Balt Prime., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Prompt endovascular treatment of patients with stroke due to intracranial Large Vessel Occlusion (LVO) is a major challenge in rural areas because neurointerventionalists are usually not available. As a result, treatment is delayed, and clinical outcomes are worse compared with patients primarily treated in comprehensive stroke centers (CSC). To address this problem, we present a concept in which interdisciplinary, on-site endovascular treatment is performed in a Primary Stroke Center (PSC) by a team of interventional neuroradiologists and cardiologists: the Rendez-Vous approach., Methods: Thirty-five patients with LVO who underwent interdisciplinary thrombectomy on-site at the PSC as part of the Rendez-Vous concept were compared with 72 patients who were transferred from a PSCs to the CSC for thrombectomy when diagnosed with LVO in terms of temporal sequences and clinical outcomes., Results: Patients treated on-site at the PSC as part of the Rendez-Vous approach were managed as successfully and without an increase in complication rates compared with patients treated secondarily at a CSC (91.7% successful interventions in Rendez-Vous vs. 87.3% in control group, p = 0.57). The time from diagnosis of LVO to groin puncture was reduced by mean 74.3 min with the Rendez-Vous concept (p < 0.01). Regarding the clinical outcome, a functionally independent status was achieved in 45.5% in the Rendez-Vous group and in 22.6% in the control group (p = 0.029)., Conclusion: Thanks to interdisciplinary teamwork between cardiology and interventional neuroradiology in local PSCs, times to successful reperfusion can be reduced. This has a potentially positive impact on the clinical outcome of stroke patients., (© 2023. The Author(s).)

Background: Post-stroke diffusion weighted imaging (DWI) signal transformation of the infarct core, which results in high apparent diffusion coefficient (ADC) values and variable DWI signal intensity, is completed no later than 1 month after onset of ischemia. We observed frequent exceptions to this timeline of change in DWI signal, which led to uncertainties in further clinical patient management., Methods: A prospective single-center study of patients treated with mechanical thrombectomy of a large vessel occlusion in the anterior circulation was conducted. Patients received high-resolution MRI at 3T, including DWI, in the acute post-stroke phase and in the follow-up after 3-12 months., Results: Overall, 78 patients (45 men) of mean age 63.6 years were evaluated. We identified persisting or new diffusion restriction in 29 of the 78 patients (37.2%) on follow-up imaging. Diffusion restrictions in a different location from the infarct core, representing new (sub-)acute ischemia, were observed in four patients (5.1%). Smaller areas of persisting diffusion restriction (pDWI lesions with high DWI signal and reduced ADC values) within the former infarct core were observed in 25 patients (32.1%) without clinical evidence of recurrent stroke, but with worse outcome scores at follow-up compared with patients without pDWI lesions. The presence of pDWI lesions is associated with a large primary infarct core (multivariate regression OR 1.03 (95% CI 1.01 to 1.05); p<0.01), mediating the relationship between pDWI lesions and clinical outcome., Conclusion: Smaller foci of persisting diffusion restriction (pDWI lesions) in the follow-up after endovascular treatment for stroke are frequent and likely represent a slowed ADC signal progression within a formerly large infarct core., Competing Interests: Competing interests: Outside the submitted work, CZ has received speaker honoraria from Bayer-Schering. He serves as a co-editor on the advisory board of Clinical Neuroradiology and is president of the German Society of Neuroradiology (DGNR). All the other authors declare no conflict of interest., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Purpose: Inflammation has been linked to poor prognoses in cardio- and cerebrovascular conditions. As it is known to increase after ischemia, C-reactive protein (CRP) may serve as a surrogate for systemic inflammation and thus be a hallmark of increased tissue vulnerability. The question arises whether CRP in the acute phase of ischemic stroke, prior to mechanical thrombectomy (MT), might help predict outcomes., Materials and Methods: A single-center collective of patients with large-vessel occlusion, who were treated via MT, was analyzed in this observational case-control study. Univariate and multivariate models were designed to test the prognostic value of inflammatory markers (CRP and leukocytosis) in predicting clinical outcomes (modified Rankin score >2) and all-cause mortality 90 days after MT., Results: A total of 676 ischemic stroke patients treated with MT were included. Of these, 313 (46.3%) showed elevated CRP levels (≥5 mg/l) on admission. Poor clinical outcome and mortality at 90 days occurred in 113 (16.7%) and 335 (49.6%) patients and significantly more frequently when initial CRP levels were elevated [213 (64.5%) vs. 122 (42.1%), p < 0.0001, and 79 (25.2%) vs. 34 (9.4%), p < 0.0001, respectively]. CRP levels were highly predictive for impaired outcomes, especially in patients with atrial fibrillation, in both univariate and multivariate models. Interestingly, patients with initially elevated CRP levels also showed more pronounced increases in CRP post-MT., Conclusion: Poor outcome and death occur significantly more often in stroke patients with elevated CRP levels before MT. Our findings suggest that stroke patients with atrial fibrillation and elevated inflammatory markers are of particular risk for poor outcomes., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Finck, Sperl, Hernandez-Petzsche, Boeckh-Behrens, Maegerlein, Wunderlich, Zimmer, Kirschke and Berndt.)

Background: Prompt endovascular care of patients with ischemic stroke due to large vessel occlusion (LVO) remains a major challenge in rural regions as primary stroke centers (PSC) usually cannot provide neuro-interventional services. Objective The core content of the Flying Intervention Team (FIT) project is to perform thrombectomy on-site at a local PSC after the neuro-interventionalist has been transported via helicopter to the target hospital. An important and so far unanswered question is whether mechanical thrombectomy can be performed as safely and successfully on-site as in a specialized comprehensive stroke center (CSC)., Methods: Comparison of 100 FIT thrombectomies on site in 14 different PSCs with 128 control thrombectomies at 1 CSC (79 drip-and-ship, 49 mothership) performed by a single interventionalist with respect to technical-procedural success parameters, procedural times, and complications., Results: There were no significant differences between the two groups in terms of technical success (95.0% successful interventions in FIT group vs. 94.5% in control group, p = 0.60) and complications (3% major complications in FIT vs. 1.6% in control group, p = 0.47). Regarding time from onset to groin puncture, there was no difference between FIT and the entire control group (182 vs. 183 min, p = 0.28), but a trend in favor of FIT compared with the drip-and-ship control subgroup (182 vs. 210 min, p = 0.096)., Conclusions: Airborne neuro-interventional thrombectomy service is a feasible approach for rural regions. If performed by experienced neuro-interventionalists, technical success and complication rates are comparable to treatment in a specialized neuro-interventional department., (© 2022. The Author(s).)

Background and Purpose: Acute ischemic stroke due to basilar artery occlusion (BAO) causes the most severe strokes and has a poor prognosis. Data regarding efficacy of endovascular thrombectomy in BAO are sparse. Therefore, in this study, we performed an analysis of the therapy of patients with BAO in routine clinical practice., Methods: Patients enrolled between June 2015 and December 2019 in the German Stroke Registry-Endovascular Treatment (GSR-ET) were analyzed. Primary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score of 2b-3), substantial neurological improvement (≥8-point National Institute of Health Stroke Scale [NIHSS] score reduction from admission to discharge or NIHSS score at discharge ≤1), and good functional outcome at 3 months (modified Rankin Scale [mRS] score of 0-2)., Results: Out of 6635 GSR-ET patients, 640 (9.6%) patients (age 72.2 ± 13.3, 43.3% female) experienced BAO (median [interquartile range] NIHSS score 17 [8, 27]). Successful reperfusion was achieved in 88.4%. Substantial neurological improvement at discharge was reached by 45.5%. At 3-month follow-up, good clinical outcome was observed in 31.1% of patients and the mortality rate was 39.2%. Analysis of mTICI3 versus mTICI2b groups showed considerable better outcome in those with mTICI3 (38.9% vs. 24.4%; p = 0.005). The strongest predictors of good functional outcome were intravenous thrombolysis (IVT) treatment (odds ratio [OR] 3.04, 95% confidence interval [CI] 1.76-5.23) and successful reperfusion (OR 4.92, 95% CI 1.15-21.11), while the effect of time between symptom onset and reperfusion seemed to be small., Conclusions: Acute reperfusion strategies in BAO are common in daily practice and can achieve good rates of successful reperfusion, neurological improvement and good functional outcome. Our data suggest that, in addition to IVT treatment, successful and, in particular, complete reperfusion (mTICI3) strongly predicts good outcome, while time from symptom onset seemed to have a lower impact., (© 2023 The Authors. European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.)

Mechanical thrombectomy (MT) is frequently performed for distal medium vessel occlusions (DMVO) of the anterior circulation in acute stroke patients. However, evidence for its clinical benefit remains scarce. In this study, we aim to investigate clinical course and safety outcomes of MT in comparison to standard medical therapy (SMT) in DMVO. This single-center retrospective observational study included 138 consecutive patients treated for DMVO of the anterior circulation between 2015 and 2021. To reduce the risk of selection bias, propensity score matching (PSM) of patients with MT versus SMT was performed for the covariates NIHSS and mRS at admission. Out of all 138 patients, 48 (34.8%) received MT and 90 (65.2%) received SMT only. Overall, patients treated with MT showed significantly higher NIHSS and mRS scores at admission. Post 1:1 PSM, there was a trend toward a better NIHSS improvement in patients with MT (median 4 vs. 1, P = 0.1). No significant differences were observed in the occurrence of symptomatic intracranial hemorrhage or mortality between the groups before and after PSM. A subgroup analysis showed significantly higher NIHSS improvement (median 5 versus 1, P = 0.01) for patients with successful MT (≥ mTICI 2b). Mechanical thrombectomy for distal medium vessel occlusions (DMVO) in the anterior circulation appeared safe and feasible. Successful recanalization was associated with clinical improvement. Larger, multi-center, randomized-controlled trials are required to corroborate these findings., (© 2023. The Author(s).)

Background Evidence supporting a potential benefit of thrombectomy for distal medium vessel occlusions (DMVOs) of the anterior cerebral artery (ACA) is, to the knowledge of the authors, unknown. Purpose To compare the clinical and safety outcomes between mechanical thrombectomy (MT) and best medical treatment (BMT) with or without intravenous thrombolysis for primary isolated ACA DMVOs. Materials and Methods Treatment for Primary Medium Vessel Occlusion Stroke, or TOPMOST, is an international, retrospective, multicenter, observational registry of patients treated for DMVO in daily practice. Patients treated with thrombectomy or BMT alone for primary ACA DMVO distal to the A1 segment between January 2013 and October 2021 were analyzed and compared by one-to-one propensity score matching (PSM). Early outcome was measured by the median improvement of National Institutes of Health Stroke Scale (NIHSS) scores at 24 hours. Favorable functional outcome was defined as modified Rankin scale scores of 0-2 at 90 days. Safety was assessed by the occurrence of symptomatic intracerebral hemorrhage and mortality. Results Of 154 patients (median age, 77 years; quartile 1 [Q1] to quartile 3 [Q3], 66-84 years; 80 men; 94 patients with MT; 60 patients with BMT) who met the inclusion criteria, 110 patients (median age, 76 years; Q1-Q3, 67-83 years; 50 men; 55 patients with MT; 55 patients with BMT) were matched. DMVOs were in A2 (82 patients; 53%), A3 (69 patients; 45%), and A3 (three patients; 2%). After PSM, the median 24-hour NIHSS point decrease was -2 (Q1-Q3, -4 to 0) in the thrombectomy and -1 (Q1-Q3, -4 to 1.25) in the BMT cohort ( P = .52). Favorable functional outcome (MT vs BMT, 18 of 37 [49%] vs 19 of 39 [49%], respectively; P = .99) and mortality (MT vs BMT, eight of 37 [22%] vs 12 of 39 [31%], respectively; P = .36) were similar in both groups. Symptomatic intracranial hemorrhage occurred in three (2%) of 154 patients. Conclusion Thrombectomy appears to be a safe and technically feasible treatment option for primary isolated anterior cerebral artery occlusions in the A2 and A3 segment with clinical outcomes similar to best medical treatment with and without intravenous thrombolysis. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Zhu and Wang in this issue.

Objectives: Endovascular treatment of acute stroke patients with large vessel occlusions is well established. But tandem lesions of the internal carotid artery and the intracranial anterior circulation remain a challenge regarding the technical conditions and the putative higher risk of hemorrhage due to often required antiplatelet therapy.This study aims to evaluate the clinical outcome and the risk of hemorrhage after endovascular treatment of tandem lesions, with special regard to the periprocedural antiplatelet regimen., Materials and Methods: In this retrospective study, we included 63 consecutive stroke patients with endovascular treated tandem lesions. One hundred eleven patients with a solitary intracranial occlusion were matched using a "propensity score-matched analysis" with the covariates sex, age, wake-up stroke, iv-thrombolysis and NIHSS., Results: Rates of successful recanalization (mTICI 2b/3) and periprocedural complications were equal in both groups (P = 0.19; P = 0.35). The rate of good clinical outcome (mRS≤2) was similar, and the incidence of symptomatic hemorrhages was not significantly different (7.9% tandem lesions vs. 5.4% isolated intracranial occlusion, P = 0.51). Even intensified antiplatelet therapy in patients with tandem lesions did not increase the rate of symptomatic intracranial hemorrhages (P = 0.87)., Conclusions: Clinical outcome and symptomatic intracranial hemorrhages did not differ significantly between endovascular treated patients with tandem lesions and matched patients with solitary intracranial occlusions, regardless of the antiplatelet regimen. Therefore, the complex technical requirements for recanalization of a tandem lesion and the putative higher risk should not result in reluctant treatment that would decrease the chance of a good clinical outcome., Competing Interests: The authors declare no conflict of interest., (© 2023 The Authors. Published by Elsevier Ltd.)

Objective: Here we compare the procedural and clinical outcome of patients undergoing thrombectomy with running thrombolysis to matched controls with completed intravenous therapy and an only marginally overlapping activity., Methods: Patients from 25 sites in Germany were included, who presented with an acute ischemic stroke. Patients' baseline characteristics (including ASPECTS, NIHSS and mRS), grade of reperfusion, and functional outcome 24 h and at day 90 after intervention were extracted from the German Stroke Registry (n = 2566). In a case-control design we stepwise matched the groups due to age, sex and time to groin puncture and time to flow restoration., Results: In the initial cohort (overlap group n = 864, control group n = 1702) reperfusion status (median TICI in overlap group vs. control group: 3 vs. 2b), NIHSS after 24 h, early neurological improvement parameters, mRS at 24 h and at day 90 were significantly better in the overlap group (p < 0.001) with a similar risk of bleeding (2.9% vs. 2.4%) and death (18% vs. 22%). After adjustment mRS at day 90 still showed a trend for lower disability scores in the overlap group (3 IQR 1-5 vs. 3 IQR 1-6, p = 0.09). While comparable bleeding risk could be maintained (4% in both groups), there were significantly more deaths in the control group (18% vs. 30%, p = 0.006)., Conclusion: The presented results support the approach of continuing and completing a simultaneous administration of intravenous thrombolysis during mechanical thrombectomy procedures., (© 2022. The Author(s).)