Search

Background and Purpose We compared the outcomes of endovascular therapy (EVT) in an extended time window in patients with large-vessel occlusion (LVO) between patients with and without pre-stroke disability. Methods In this prespecified analysis of the multinational CT for Late Endovascular Reperfusion study (66 participating sites, 10 countries between 2014 and 2022), we analyzed data from patients with acute ischemic stroke with a pre-stroke modified Rankin Scale (mRS) score of 0–4 and LVO who underwent EVT 6–24 hours from the time last seen well. The primary outcome was the composite of functional independence (FI; mRS score 0–2) or return to the pre-stroke mRS score (return of Rankin, RoR) at 90 days. Outcomes were compared between patients with pre-stroke disability (pre-stroke mRS score 2–4) and those without (mRS score 0–1). Results A total of 2,231 patients (median age, 72 years; median National Institutes of Health Stroke Scale score, 16) were included in the present analysis. Of these, 564 (25%) had pre-stroke disability. The primary outcome (FI or RoR) was observed in 30.7% of patients with pre-stroke disability (FI, 16.5%; RoR, 30.7%) compared to 44.1% of patients without (FI, 44.1%; RoR, 13.0%) (P

Background and Purpose Posterior cerebral artery occlusion (PCAo) can cause long-term disability, yet randomized controlled trials to guide optimal reperfusion strategy are lacking. We compared the outcomes of PCAo patients treated with endovascular thrombectomy (EVT) with or without intravenous thrombolysis (IVT) to patients treated with IVT alone. Methods From the multicenter retrospective Posterior cerebraL ArTery Occlusion (PLATO) registry, we included patients with isolated PCAo treated with reperfusion therapy within 24 hours of onset between January 2015 and August 2022. The primary outcome was the distribution of the modified Rankin Scale (mRS) at 3 months. Other outcomes comprised 3-month excellent (mRS 0–1) and independent outcome (mRS 0–2), early neurological improvement (ENI), mortality, and symptomatic intracranial hemorrhage (sICH). The treatments were compared using inverse probability weighted regression adjustment. Results Among 724 patients, 400 received EVT+/-IVT and 324 IVT alone (median age 74 years, 57.7% men). The median National Institutes of Health Stroke Scale score on admission was 7, and the occluded segment was P1 (43.9%), P2 (48.3%), P3–P4 (6.1%), bilateral (1.0%), or fetal posterior cerebral artery (0.7%). Compared to IVT alone, EVT+/-IVT was not associated with improved functional outcome (adjusted common odds ratio [OR] 1.07, 95% confidence interval [CI] 0.79–1.43). EVT increased the odds for ENI (adjusted OR [aOR] 1.49, 95% CI 1.05–2.12), sICH (aOR 2.87, 95% CI 1.23–6.72), and mortality (aOR 1.77, 95% CI 1.07–2.95). Conclusion Despite higher odds for early improvement, EVT+/-IVT did not affect functional outcome compared to IVT alone after PCAo. This may be driven by the increased risk of sICH and mortality after EVT.

Background With the expanding eligibility for endovascular therapy (EVT) of patients presenting in the late window (6–24 hours after last known well), we aimed to derive a score to predict favorable outcomes associated with EVT versus best medical management. Methods and Results A multinational observational cohort of patients from the CLEAR (Computed Tomography for Late Endovascular Reperfusion) study with proximal intracranial occlusion (2014–2022) was queried (n=58 sites). Logistic regression analyses were used to derive a 9‐point score for predicting good functional outcome (modified Rankin Scale score 0–2 or return to premorbid modified Rankin Scale score) at 90 days, with sensitivity analyses for prespecified subgroups conducted using bootstrapped random forest regressions. Secondary outcomes included 90‐day functional independence (modified Rankin Scale score 0–2), poor outcome (modified Rankin Scale score 5–6), and 90‐day survival. The score was externally validated with a single‐center cohort (2014–2023). Of the 3231 included patients (n=2499 EVT), a 9‐point score included age, early computed tomography ischemic changes, and stroke severity, with higher points indicating a higher probability of a good functional outcome. The areas under the curve for the primary outcome among EVT and best medical management subgroups were 0.72 (95% CI, 0.70–0.74) and 0.87 (95% CI, 0.84–0.90), respectively, with similar performance in the external validation cohort (area under the curve, 0.71 [95% CI, 0.66–0.76]). There was a significant interaction between the score and EVT for good functional outcome, functional independence, and poor outcome (all Pinteraction

Background Rapid expansion of mechanical thrombectomy and swift manufacturing development has translated into significant evolution of large‐bore catheter technology. The objective of this study was to evaluate the association among diverse structural components of large‐bore aspiration catheters on procedural performance. Methods Retrospective analysis of a prospectively maintained mechanical thrombectomy consortium (SVIN [Society of Vascular Interventional Neurology] Registry) treated with stand‐alone contact aspiration for the first pass in the middle cerebral artery M1 or intracranial internal carotid artery occlusions from 2012 to 2021. Catheters were stratified on the basis of construction materials, tip technology, catheter sizing, and catheter lining. Factors associated with first‐pass effect (first‐pass eTICI 2c–3 reperfusion) as well as speed of clot engagement were analyzed. Results We identified 983 patients with proximal occlusion and aspiration as the first‐pass technique. First‐pass effect was observed in 34% and associated with age (odds ratio [OR], 1.02 [95% CI, 1.01–1.03]), cardioembolic stroke pathogenesis (OR, 1.69 [95% CI, 1.77–2.41]), middle cerebral artery M1 (OR, 2.74 [95% CI, 1.09–1.87]), nongeneral anesthesia (OR, 0.55 [95% CI, 0.39–0.767]), as well as with 0.070‐inch (OR, 2.04 95% CI, 1.01–3.78]), and 0.088‐inch (OR, 3.90 [95% CI, 1.58–9.61]) distal catheter inner diameter in the adjusted analysis. Mean time from arterial access to clot contact was 17 minutes, with faster times observed in younger patients (OR, 0.99 [95% CI, 0.98–0.996]) as well as with the use of aspiration catheters with shorter length of distal outer hydrophilic coating (18–30 cm) on multivariable regression (OR, 0.30 [95% CI, 0.11–0.82]). Conclusion Larger aspiration catheter distal inner diameter was associated with higher rates of first‐pass effect. Aspiration catheter construction components were found to influence times from arterial access to clot contact.

Abstract Objective Renal function can modify the outcomes of large vessel occlusion (LVO) stroke across stroke etiologies in disparate degrees. The presence of renal function deficit can also impair the pharmacokinetics of tirofiban. Hence, this study aimed to investigate the roles of renal function in determining efficacy and safety of intravenous tirofiban before endovascular treatment (EVT) for acute ischemic stroke patients with large vessel occlusion (LVO). Methods This study was a post hoc exploratory analysis of the RESCUE‐BT trial. The primary outcome was the proportion of patients achieving functional independence (modified Rankin scale 0–2) at 90 days, and the primary safety outcome was the rate of symptomatic intracranial hemorrhage (sICH). Results Among 908 individuals with available serum creatinine, decreased estimated glomerular filtration rate (eGFR) status was noted more commonly in patients with cardioembolic stroke (CE), while large artery atherosclerosis (LAA) was predominant in patients with normal renal function. In LAA with normal renal function, tirofiban was associated with higher rates of functional independence at 90 days (41.67% vs 59.80%, p = 0.003). However, for LVO patients with renal dysfunction, tirofiban did not improve functional outcomes for any of the etiologies (LAA, p = 0.876; CE, p = 0.662; others, p = 0.894) and significantly increased the risk of sICH among non‐LAA patients (p = 0.020). Mediation analysis showed tirofiban reduced thrombectomy passes (12.27%) and drug/placebo to recanalization time (14.25%) mediated its effects on functional independence. Conclusion This present study demonstrated the importance of evaluating renal function before administering intravenous tirofiban among patients with LVO who are planned to undergo EVT.

Objective: Internal Jugular Vein Stenosis (IJVS) is hypothesized to play a role in the pathogenesis of diverse neurological diseases. We sought to evaluate differences in IJVS assessment between CT and MRI in a retrospective patient cohort. Methods: We included consecutive patients who had both MRI of the brain and CT of the head and neck with contrast from 1 June 2021 to 30 June 2022 within the same admission. The degree of IJVS was categorized into five grades (0–IV). Results: A total of 35 patients with a total of 70 internal jugular (IJ) veins were included in our analysis. There was fair intermodality agreement in stenosis grades (κ = 0.220, 95% C.I. = [0.029, 0.410]), though categorical stenosis grades were significantly discordant between imaging modalities, with higher grades more frequent in MRI (χ2 = 27.378, p = 0.002). On CT-based imaging, Grade III or IV stenoses were noted in 17/70 (24.2%) IJs, whereas on MRI-based imaging, Grade III or IV stenoses were found in 40/70 (57.1%) IJs. Among veins with Grade I-IV IJVS, MRI stenosis estimates were significantly higher than CT stenosis estimates (77.0%, 95% C.I. [35.9–55.2%] vs. 45.6%, 95% C.I. [35.9–55.2%], p < 0.001). Conclusion: MRI with contrast overestimates the degree of IJVS compared to CT with contrast. Consideration of this discrepancy should be considered in diagnosis and treatment planning in patients with potential IJVS-related symptoms.

Basilar artery occlusion (BAO) is a neurological emergency associated with a high risk for adverse outcomes. This review provides evidence on the therapeutic efficacy of intravenous thrombolysis (IVT) and endovascular therapy (EVT) in the treatment of BAO. Historically considered the primary intervention for acute ischemic stroke, IVT has been progressively combined with EVT, which has emerged from recent studies demonstrating clinical benefits, notably in patients presenting with severe stroke. Several randomised controlled trials have shown that EVT improves patient outcomes in select clinical contexts. Future research directions could address therapeutic treatment thresholds, combination strategies, and long-term outcomes.

Background Prior studies have shown benefit for endovascular therapy (EVT) in patients with large‐vessel occlusion and severe deficits, as captured by the National Institutes of Health Stroke Scale (NIHSS). However, the benefit of EVT in patients with NIHSS score of

Background Prior studies have shown benefit for endovascular therapy (EVT) in patients with large‐vessel occlusion and severe deficits, as captured by the National Institutes of Health Stroke Scale. However the benefit of EVT in patients with National Institutes of Health Stroke Scale score

ImportanceStroke-to-recanalization time is a strong predictor of outcomes in anterior circulation large-vessel occlusion (LVO). The authors aimed to evaluate functional outcomes in early (

Background The optimal reperfusion technique in patients with isolated posterior cerebral artery (PCA) occlusion is uncertain. We compared clinical and technical outcomes with first‐line stent retriever (SR), contact aspiration (CA), or combined techniques in patients with isolated PCA occlusion. Methods This international case–control study was conducted at 30 sites in Europe and North America and included consecutive patients with isolated PCA occlusion presenting within 24 hours of time last seen well from January 2015 to August 2022. The primary outcome was the first‐pass effect (FPE), defined as expanded Treatment in Cerebral Infarction (TICI) 2c/3 on the first pass. Patients treated with SR, CA, or combined technique were compared with multivariable logistic regression. Results There were 326 patients who met inclusion criteria, 56.1% male, median age 75 (interquartile range 65–82) years, and median National Institutes of Health Stroke Scale score 8 (5–12). Occlusion segments were PCA‐P1 (53.1%), P2 (40.5%), and other (6.4%). Intravenous thrombolysis was administered in 39.6%. First‐line technique was SR, CA, and combined technique in 43 (13.2%), 106 (32.5%), and 177 (54.3%) patients, respectively; FPE was achieved in 62.8%, 42.5%, and 39.6%, respectively. FPE was lower in patients treated with first‐line CA or combined technique compared with SR (CA versus SR: adjusted odds ratio 0.45 [0.19–1.06]; P=0.07; combined versus SR: adjusted odds ratio 0.35 [0.016–0.80]; P=0.01). There were lower odds of functional independence (modified Rankin scale score 0–2) in the first‐line CA versus SR alone group (adjusted odds ratio 0.52 [0.28–0.95]; P=0.04). FPE was associated with higher rates of favorable outcomes (modified Rankin scale score 0–2: 58% versus 43.4%; P=0.01; modified Rankin scale score 0–1: 36.6% versus 25.8%; P=0.05). Overall, symptomatic intracranial hemorrhage was present in 5.6% (18/326) and mortality in 10.9% (35/326) without difference between first‐line technique. Conclusion In patients with isolated PCA occlusion, SR was associated with a higher rate of FPE compared with CA or combined techniques with no difference in final successful reperfusion. Functional independence at 90 days was more likely with first‐line SR compared with CA. FPE was associated with better 90‐day clinical outcomes.

Background and Purpose Effect of endovascular therapy (EVT) in acute large vessel occlusion (LVO) patients with tandem lesions (TLs) within 6–24 hours after last known well (LKW) remains unclear. We evaluated the clinical and safety outcomes among TL-LVO patients treated within 6–24 hours. Methods This multicenter cohort was divided into two groups, based on LKW to puncture time: early window (

Background and Purpose Randomized trials proved the benefits of mechanical thrombectomy (MT) for select patients with large vessel occlusion (LVO) within 24 hours of last-known-well (LKW). Recent data suggest that LVO patients may benefit from MT beyond 24 hours. This study reports the safety and outcomes of MT beyond 24 hours of LKW compared to standard medical therapy (SMT). Methods This is a retrospective analysis of LVO patients presented to 11 comprehensive stroke centers in the United States beyond 24 hours from LKW between January 2015 and December 2021. We assessed 90-day outcomes using the modified Rankin Scale (mRS). Results Of 334 patients presented with LVO beyond 24 hours, 64% received MT and 36% received SMT only. Patients who received MT were older (67±15 vs. 64±15 years, P=0.047) and had a higher baseline National Institutes of Health Stroke Scale (NIHSS; 16±7 vs.10±9, P

Introduction Tandem Lesions (TLs) pose unique challenges in the endovascular management of acute ischemic stroke.(1) The absence of anterograde blood flow in the carotid occluded segment may limit the effectiveness of endovascular interventions, resulting in delayed reperfusion or suboptimal recanalization.(2,3) Thus, the presence of unpaired blood flow through the ICA in the context of TLs is believed to exacerbate the extension of ischemic lesions. (4,5) This study compared the clinical and procedural outcomes of patients with TLs and extracranial internal carotid artery occlusion versus those with stenosis. Methods A retrospective analysis was performed on a multicenter cohort of patients with TLs who underwent endovascular treatment. The patients were categorized into two groups: those with extracranial ICA stenosis and those with occlusion. Clinical outcomes, including functional independence, hemorrhagic events, and procedural time metrics including puncture to reperfusion time were assessed. Sensitivity analyses were conducted to evaluate these differences segregating patients according to varying degrees of stenosis, and in pre‐specified subgroups. Results A total of 513 patients with TLs were included in the study. 281 (54.8%) presented with ICA occlusion, and 232 (45.2%) presented stenosis >=70% (Table 1). The comparison between the stenosis and occlusion groups revealed no significant differences in the main outcomes, including mTICI 2c‐3 (47.5% vs. 50.6%, aOR 1.07, 95% CI 0.70‐1.64, p=.751) (Figure 1), mRS 0‐2 at 90 days (43.6% vs. 48.9%, aOR 0.79, 95% CI 0.52‐1.20, p=.271), sICH rates (4.7% vs. 5.6%, aOR 0.72, 95% CI 0.31‐1.71, p=.458), and puncture to reperfusion time (58 [40‐80.5] vs. 52.5 [35.2‐80], ratio 1.04, 95% CI 0.88‐1.23, p=.64). Similar analyses performed comparing different degrees of stenosis and occlusion, and in patients treated with the antegrade approach only, did not show significant differences either. Conclusion Our findings indicate that although more severe degrees of stenosis or occlusion of the ICA prolong the time from puncture to reperfusion, no significant differences in clinical outcomes exist. The clinical implications of these findings need to be further evaluated to fully comprehend the specific needs of patients affected by TLs.

Introduction Recent randomized controlled trials (RCT) failed to demonstrate the non‐inferiority of skipping IV tPA in patients with planned endovascular therapy (EVT). None of these studies included patients from the US due to regulatory challenges. Given that practice patterns vary relative to Asia, Australia, and Europe, we sought to address this topic using a validated alternative to RCTs, regression discontinuity (RD). Methods From the prospectively collected SVIN Registry encompassing all consecutive patients treated with EVT from 12 centers across the US, we identified patients from 12/2010 – 12/2021. RD design achieves quasi‐randomization and can determine causal effects by analyzing subjects on immediately adjacent sides of a cutoff. Here, we take advantage of the sharp drop in the likelihood of IV tPA treatment at the 4.5‐hour mark from the patients’ last known well time. Subjects immediately on either side of the cutoff have markedly different probabilities of receiving the treatment while sharing similar characteristics in other relevant aspects. Patients were excluded if they underwent EVT after inter‐hospital transfer, were inpatient at the time of acute ischemic stroke (AIS), received IV tPA outside the 4.5‐hour window, or were treated with EVT after the 10‐hour window, as these patients would not contribute to the RD analysis. The primary outcome was a good functional outcome defined as 90‐day mRS 0‐2 and was analyzed using validated RD analysis methods with local linear regressions and triangular kernel weights. Secondary endpoints included rates of symptomatic intracranial hemorrhage and substantial reperfusion. Results Among 961 patients who met inclusion criteria, all 12 EVT centers within the SVIN Registry were represented. The median age was 70 [IQR 58‐79], 48% were female, NIHSS was 17, and the most common occlusion location was M1 MCA (45%). There were no substantial differences in presentation characteristics between patients treated with IV tPA and without. We observed a significant fall (30%) in the probability of tPA around the cutoff time of 235 minutes from the last known well to hospital arrival (allowing 35 minutes for in‐hospital evaluation from the 4.5‐hour cutoff), while there were no significant differences in other relevant features including age, NIHSS, ASPECTS, and final reperfusion grade at the cutoff, validating the underlying RD assumptions (Figure A). In RD analysis, we observed no association between IV tPA treatment and functional independence at 90‐days in patients undergoing EVT (risk difference ‐0.29 (95% CI [‐2.75 to 2.15]) (Figure B), nor in the secondary outcomes of excellent outcomes (mRS 0‐1) at 90 days, mortality, symptomatic ICH or first pass reperfusion. Conclusion Here, we perform what we believe to be the strongest study to date examining the benefit of IV tPA in patients undergoing EVT for LVO AIS in a US‐based cohort, and we find no evidence of association with 90‐day functional independence, consistent with findings of RCTs performed outside the US.

Introduction Mechanical thrombectomy (MT) often fails to achieve successful reperfusion in up to 20% of acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) [1, 2]. Rescue strategies options, including balloon angioplasty alone, rescue stenting (RS) alone, or stent with balloon angioplasty, have shown promise in observational studies and meta‐analyses [3, 4]. We aimed to evaluate the association between RS with functional outcomes compared to medical management (MM) in anterior circulation LVO‐AIS patients who underwent failed MT. Methods This retrospective cohort study utilized prospectively collected data from the Society of Vascular and Interventional Neurology (SVIN) Registry, including adult patients with AIS who experienced a failed MT at 14 comprehensive stroke centers. A failed MT was defined as a modified Thrombolysis in Cerebral Infarction (mTICI) score of 0 to 2a after multiple attempts to clot retrieval. The patients were divided into two groups: those who received RS and those who only received MM. The primary efficacy outcome was the shift in the degree of disability, as measured by the modified Rankin Scale (mRS), at 90 days. Additional outcomes included functional independence (defined as a 90‐day mRS score of 0‐2), symptomatic intracranial hemorrhage (sICH), and mortality at 90 days. These outcomes were assessed using uni‐ and multivariable logistic regression models. Results A total of 642 patients were included in the analysis. The RS group consisted of 294 (45.8%) patients, while the MM group comprised 348 (54.2%) patients. A mTICI score of 2b‐3 was achieved in 242/293 (82.6%) patients in the RS group. Compared to the MM group, the RS showed a favorable shift in the overall 90‐day mRS distribution (adjusted common odds ratio [OR]=1.97, 95% CI 1.36–2.85, p=

Introduction The optimal reperfusion technique in patients with isolated posterior cerebral artery (PCA) occlusion is uncertain. Previous studies in LVO and MeVO have demonstrated a correlation between good clinical outcomes and the first pass effect (FPE, eTICI 2c/3 on the first pass) but no differences in FPE rates or clinical outcomes between first‐line endovascular therapy techniques.1‐6 We compared clinical and technical outcomes with first‐line stent‐retriever (SR), contact aspiration (CA), or combined techniques in patients with isolated PCA occlusion. Methods This international cohort study was conducted at 30 sites in Europe and North America and included consecutive patients with isolated PCA occlusion and pre‐stroke modified Rankin Scale (mRS) 0‐3, presenting within 24 hours of time last seen well from January 2015 to August 2022.7 The primary outcome was the first‐pass effect (FPE), defined as eTICI 2c/3 on the first pass. Secondary outcomes included final successful reperfusion (eTICI 2b‐3), 90‐day excellent outcome (mRS 0 to 1), 90‐day functional independence (mRS 0 to 2), sICH, and 90‐day mortality. Patients treated with SR, CA, or combined technique were compared with multivariable logistic regression. This study was registered under NCT05291637. Results There were 326 patients who met inclusion criteria, consisting of 56.1% male, median age 75 (IQR 65‐82) years and median NIHSS 8 (5‐12). Occlusion segments were PCA P1 (53.1%), P2 (40.5%), and other (6.4%). Intravenous thrombolysis was administered in 39.6%. First‐line technique was SR, CA, and combined technique in 43 (13.2%), 106 (32.5%), and 177 (54.3%) patients, respectively; FPE was achieved in 62.8%, 42.5%, and 39.6%, respectively. Compared to SR, FPE was lower in patients treated with first‐line combined technique and similar in patients treated with first‐line CA (combined vs. SR: aOR 0.35 [0.016‐0.80], p=0.01; CA vs. SR: aOR 0.45 [0.19‐1.06], p=0.07). Final successful reperfusion (eTICI 2b‐3) was present in 81% of cases with no differences between treatment groups. Excellent outcome (mRS 0‐1) occurred in 30.7% of patients and functional independence (mRS 0‐2) occurred in 50.0% of patients. There were lower odds of functional independence in the first‐line CA versus SR alone group (aOR 0.52 [0.28‐0.95], p=0.04). FPE was associated with higher rates of favorable outcomes (mRS 0‐2: 58% vs. 43.4%, p=0.01; mRS 0‐1: 36.6% vs. 25.8%, p=0.05). sICH was observed in 5.6% (18/326) and mortality in 10.9% (35/326) with no differences between first‐line technique. Conclusion In patients with isolated PCA occlusion undergoing EVT, first line SR was associated with a higher rate of FPE compared to CA or combined techniques with no difference in final successful reperfusion. Functional independence at 90‐days was more likely with first‐line SR compared to CA in adjusted analyses. FPE was associated with higher rates of 90‐day excellent outcomes and functional independence. No difference in sICH or mortality was noted across the three techniques. As the endovascular field evolves to treat patients with distal vessel occlusion and milder severity of stroke, optimizing the efficacy and safety of the procedure is essential.8

Introduction Rapid expansion of mechanical thrombectomy and swift manufacturing development has translated into significant evolution of large bore catheter technology. The objective of this study was to evaluate the association among diverse structural components of large bore aspiration catheters on procedural performance. Methods Retrospective analysis of a prospectively maintained mechanical thrombectomy consortium (SVIN Registry) treated with stand‐alone contact aspiration for the first pass in the MCA M1 or intracranial ICA occlusions from 2012‐2021. Catheters were stratified based on construction materials, tip technology, catheter sizing, and catheter lining. Factors associated with first pass effect (FPE ‐ first‐pass eTICI2c‐3 reperfusion) as well as speed of clot engagement were analyzed. Results We identified 983 patients with proximal occlusion and aspiration as the first pass technique. FPE was observed in 34% and associated with age (OR:1.016;95%CI:1.006‐1.027), cardioembolic stroke etiology (OR:1.685;95%CI:1.77 ‐2.41), MCA M1(OR:2.737;95%CI:1.091 ‐1.867), non‐general anesthesia (OR:0.546;95%CI:0.389 ‐0.767), as well as with 0.070” (OR:2.038;95%CI:1.099 ‐3.779) and 0.088” (OR:3.899;95%CI:1.582 ‐9.606) distal catheter inner diameter in the adjusted analysis. Median time from arterial access to clot contact was 17 minutes with faster times observed in younger patients (OR:0.986;95%CI:0.975 ‐0.996) as well as with the use of aspiration catheters with shorter length of distal outer hydrophilic coating (18‐30cm) on multivariable regression (OR:0.303; 95%CI:0.113‐0.816). Conclusion Larger aspiration catheter distal inner diameter was associated with higher rates of FPE. Aspiration catheters with reduced distal tip hydrophilic coating were associated with faster arterial access to clot contact time.

Introduction Cerebral Venous Thrombosis (CVT) is a rare cerebrovascular condition causing death or functional dependency in 10‐15%. Although Endovascular Therapy (EVT) is deployed variably across centers for managing CVT, the determinants and consequences of such use remain under‐explored. We examined the demographic and clinical correlates of EVT use in CVT and assessed its impact on patient outcomes utilizing a national database. Methods We identified CVT cases from 2015 to 2020 in the National Inpatient Sample, with EVT as the primary exposure. CVT and other diagnoses, and EVT and other procedures, were identified using standard ICD 10 codes. A backward stepwise regression model (at p

Introduction Tandem lesions (TLs) are present in up to 15% of patients with stroke due to acute large vessel occlusions.(1) Nevertheless, published research on endovascular treatment outcomes in this population is scarce. Although TLs are most commonly of atherosclerotic etiology, some patients present with dissection of the ICA.(2, 3) In this study, we compared the clinical outcomes of TL patients with the two etiologies. Methods A retrospective analysis was performed on a multicenter cohort of patients with TLs who underwent endovascular treatment. The patients were categorized into two groups according to the etiology of the ICA lesion: atherosclerosis and dissection. Patients were matched by baseline characteristics. Clinical outcomes, including recanalization success, functional independence and hemorrhagic events were assessed with multivariable analyses. Results Of 691 patients from the database, 526 met the inclusion criteria of this study. 467 (88.8%) patients presented with atherosclerosis of the ICA, and 59 (11.2%) patients presented dissection. Univariable differences were found in median age (69 y. [IQR 61 ‐ 76] vs. 52 y. [IQR 44 ‐ 63], p

Background and objectivesEndovascular thrombectomy (EVT) improves long-term outcomes and decreases mortality in ischemic stroke patients. However, a significant proportion of patients do not benefit from EVT recanalization, a phenomenon known as futile recanalization or reperfusion without functional independence (RFI). In this study, we aim to identify the major stroke risk factors and patient characteristics associated with RFI.MethodsThis is a retrospective cohort study of 297 consecutive patients with ischemic stroke who received EVT at three academic stroke centers in China from March 2019 to March 2022. Patient age, sex, modified Rankin Scale (mRS), National Institute of Health Stroke Scale (NIHSS), Alberta stroke program early CT score (ASPECTS), time to treatment, risk factors and comorbidities associated with cerebrovascular diseases were collected, and potential associations with futile recanalization were assessed. RFI was successful reperfusion defined as modified thrombolysis in cerebral infarction (mTICI) ≥ 2b without functional independence at 90 days (mRS ≥ 3).ResultsOf the 297 initial patients assessed, 231 were included in the final analyses after the application of the inclusion and exclusion criteria. Patients were divided by those who had RFI (n = 124) versus no RFI (n = 107). Older age (OR 1.041, 95% CI 1.004 to 1.073; p = 0.010), chronic kidney disease (OR 4.399, 0.904–21.412; p = 0.067), and higher 24-h NIHSS (OR 1.284, 1.201–1.373; p

Background Preliminary in vitro and early clinical experience of the Tenzing 7 delivery catheter demonstrated high success rates of aspiration catheter intracranial delivery with minimal complications. This study aimed to examine the efficacy, safety, and efficiency of the Tenzing 7 delivery catheter to deliver therapeutic devices in aspiration mechanical thrombectomy for acute ischemic strokes using clinical experience from multiple institutions. Methods We performed a retrospective analysis of prospectively collected data from patients with acute ischemic stroke treated with aspiration mechanical thrombectomy using the Tenzing 7 delivery catheter between January 2020 and July 2022 at 6 high volume stroke centers. Primary efficacy outcome was success in aspiration catheter delivery to the face of the thrombus, and primary safety end point was rate of procedural complication. Results Of a total of 176 patients (mean age 70.1±14.9 years, 56.3% female, 89.2% middle cerebral artery occlusions), first‐pass effect (modified Thrombolysis in Cerebral Infarction score≥2B) was achieved in 90/166 (54.2%) successfully revascularized patients. Tenzing 7 delivered the aspiration catheter of choice to the site of occlusion in 95.9% of cases; the clot was not crossed with Tenzing 7 in 69% of cases. Successful recanalization (modified Thrombolysis in Cerebral Infarction score≥2B) was achieved in 94.9% of cases requiring a median of 1 pass (interquartile range 1–3). Nonflow limiting vessel dissection unrelated to Tenzing 7 occurred in 4 patients (2.3%), and intracranial vessel perforation unrelated to Tenzing 7 occurred in 4 cases (2.3%). Conclusion This multicenter clinical experience using Tenzing 7 in mechanical thrombectomy demonstrated high rates of technical success and a modest complication rate, similar to the published rates of technical success with other thrombectomy techniques. The Tenzing 7 delivery catheter is effective and safe for the delivery of the aspiration catheter in patients undergoing thrombectomy for acute ischemic stroke.

Background For acute proximal intracranial artery occlusions, contact aspiration may be more effective than stent‐retriever for first‐line reperfusion therapy. Due to the lack of data regarding medium vessel occlusion thrombectomy, we evaluated outcomes according to first‐line technique in a large, multicenter registry. Methods Imaging, procedural, and clinical outcomes of patients with acute proximal medium vessel occlusions (M2, A1, or P1) or distal medium vessel occlusions (M3, A2, P2, or further) treated at 37 sites in 10 countries were analyzed according to first‐line endovascular technique (stent‐retriever versus aspiration). Multivariable logistic regression and propensity‐score matching were used to estimate the odds of the primary outcome, expanded Thrombolysis in Cerebral Infarction score of 2b–3 (“successful recanalization”), as well as secondary outcomes (first‐pass effect, expanded Thrombolysis in Cerebral Infarction 2c‐3, intracerebral hemorrhage, and 90‐day modified Rankin scale, 90‐day mortality) between treatment groups. Results Of the 440 included patients (44.5% stent‐retriever versus 55.5% aspiration), those treated with stent‐retriever had lower baseline Alberta Stroke Program Early Computed Tomography Scale scores (median 8 versus 9; P

Background and Purpose The optimal management of patients with acute basilar artery occlusion (BAO) is uncertain. We aimed to evaluate the safety and efficacy of endovascular thrombectomy (EVT) compared to medical management (MM) for acute BAO through a meta-analysis of randomized controlled trials (RCTs). Methods We performed a systematic review and meta-analysis of RCTs of patients with acute BAO. We analyzed the pooled effect of EVT compared to MM on the primary outcome (modified Rankin Scale [mRS] of 0–3 at 3 months), secondary outcome (mRS 0–2 at 3 months), symptomatic intracranial hemorrhage (sICH), and 3-month mortality rates. For each study, effect sizes were computed as odds ratios (ORs) with random effects and Mantel-Haenszel weighting. Results Four RCTs met inclusion criteria including 988 patients. There were higher odds of mRS of 0-3 at 90 days in the EVT versus MM group (45.1% vs. 29.1%, OR 1.99, 95% confidence interval [CI] 1.04–3.80; P=0.04). Patients receiving EVT had a higher sICH compared to MM (5.4% vs. 0.8%, OR 7.89, 95% CI 4.10–15.19; P

Advances in acute ischemic stroke (AIS) treatment have been contingent on innovations in neuroimaging. Neuroimaging plays a pivotal role in the diagnosis and prognosis of ischemic stroke and large vessel occlusion, enabling triage decisions in the emergent care of the stroke patient. Current imaging protocols for acute stroke are dependent on the available resources and clinicians’ preferences and experiences. In addition, differential application of neuroimaging in medical decision-making, and the rapidly growing evidence to support varying paradigms have outpaced guideline-based recommendations for selecting patients to receive intravenous or endovascular treatment. In this review, we aimed to discuss the various imaging modalities and approaches used in the diagnosis and treatment of AIS.

Background:. Sacral (S1) pedicle screw misplacement in posterior percutaneous fixation (PPF) can be related to anatomical variability and a lack of reliable radiographic landmarks. This study highlights a reproducible anatomical landmark (the “V” sign) for the safe localization of the S1 pedicle entry point under fluoroscopy. Methods:. Human cadavers (n = 14) were dissected for the anatomical description of the “V” landmark and its relationship with the entry point of the S1 pedicle screw. The “V” landmark was defined medially by the lateral border of the superior articulating process of S1 and laterally by the posterior projection of the sacral ala. The mean distance was measured between the bottom point of the “V” landmark and the anatomical entry point to the S1 pedicle (V-S1 entry point distance). A similar measurement was conducted on computed tomography (CT) scans of 135 patients who underwent PPF using the “V” sign as a landmark for S1 pedicle screw placement (270 screws). These were retrospectively evaluated for appropriateness of S1 screw entry points and for proper S1 screw alignment and breaches. Results:. In the 14 cadavers, irrespective of the laterality and sex, the V-S1 entry point distance averaged 11.7 mm. On the medial-lateral axis, all entry points converged within 2 mm of a vertical line intersecting the base of the “V.” Additionally, the CT scan analysis (135 patients, 270 screws) revealed an optimal entry point for 100% of the screws and a 3.3% (n = 9 screws) breach rate. Six of the 9 identified breaches were minor, and only 1 (0.4% of the 270 screws) warranted revision. Conclusions:. The “V” sign serves as a reliable anatomical and radiographic landmark for identifying the S1 pedicle entry point under fluoroscopic guidance. This landmark can help surgeons overcome the radiographic ambiguity of the sacral anatomy and ultimately reduces the rate of S1 pedicle screw misplacement. Level of evidence:. Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background and objectiveEndovascular thrombectomy (EVT) has become the gold standard in the treatment of acute stroke patients. However, not all patients respond well to this treatment despite successful attempts. In this study, we aimed to identify variables associated with the failure of improvements following EVT.MethodsWe retrospectively analyzed prospectively collected data of 292 ischemic stroke patients with large vessel occlusion who underwent EVT at three academic stroke centers in China from January 2019 to February 2022. All patients were above 18 years old and had symptoms onset ≤6 h. A decrease of more than 4 points on the National Institute of Health Stroke Scale (NIHSS) after 24 h compared with admission or an NIHSS of 0 or 1 after 24 h was defined as early neurological improvement (ENI), whereas a lack of such improvement in the NIHSS was defined as a failure of early neurological improvement (FENI). A favorable outcome was defined as a modified Rankin scale (mRS) score of 0–2 after 90 days.ResultsA total of 183 patients were included in the final analyses, 126 of whom had FENI, while 57 had ENI. Favorable outcomes occurred in 80.7% of patients in the ENI group, in contrast to only 22.2% in the FENI group (p

BackgroundThe Alberta Stroke Program Early CT Score (ASPECTS) is used to quantify the extent of injury to the brain following acute ischemic stroke (AIS) and to inform treatment decisions. The e-ASPECTS software uses artificial intelligence methods to automatically process non-contrast CT (NCCT) brain scans from patients with AIS affecting the middle cerebral artery (MCA) territory and generate an ASPECTS. This study aimed to evaluate the impact of e-ASPECTS (Brainomix, Oxford, UK) on the performance of US physicians compared to a consensus ground truth.MethodsThe study used a multi-reader, multi-case design. A total of 10 US board-certified physicians (neurologists and neuroradiologists) scored 54 NCCT brain scans of patients with AIS affecting the MCA territory. Each reader scored each scan on two occasions: once with and once without reference to the e-ASPECTS software, in random order. Agreement with a reference standard (expert consensus read with reference to follow-up imaging) was evaluated with and without software support.ResultsA comparison of the area under the curve (AUC) for each reader showed a significant improvement from 0.81 to 0.83 (p = 0.028) with the support of the e-ASPECTS tool. The agreement of reader ASPECTS scoring with the reference standard was improved with e-ASPECTS compared to unassisted reading of scans: Cohen's kappa improved from 0.60 to 0.65, and the case-based weighted Kappa improved from 0.70 to 0.81.ConclusionDecision support with the e-ASPECTS software significantly improves the accuracy of ASPECTS scoring, even by expert US neurologists and neuroradiologists.

Background Clinical and radiographic outcomes after mechanical thrombectomy in the setting of COVID‐19 infection remain poorly characterized. We sought to determine how COVID‐19 status affects mechanical thrombectomy outcomes in the real‐world setting in the United States. Methods The prospectively maintained multicenter mechanical thrombectomy registry from the Society of Vascular and Interventional Neurology was queried for baseline clinical characteristics among patients with and without COVID‐19 who underwent mechanical thrombectomy between March 1 and December 31, 2020 at 12 sites. Primary outcome was the likelihood of good neurological outcomes (90 day modified Rankin scale 0–2) among patients with COVID‐19 treated with endovascular thrombectomy, which was assessed using multivariable logistic regression adjusted for age, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and substantial reperfusion (modified Thrombolysis in Cerebral Infarction 2b, 2c, and 3). Secondary outcomes included National Institutes of Health Stroke Scale at 24 hours. Results Among 915 patients who underwent mechanical thrombectomy during the study period, 51 patients were positive for COVID‐19 (5.6%). Univariate analysis revealed that compared with patients who were COVID‐19 negative, patients who were positive for COVID‐19 were more likely to be male, nonsmokers, have lower Alberta Stroke Program Early CT Score, and present with intracranial internal carotid artery occlusions (Table 1). They were also less likely to achieve successful reperfusion. Multivariable analysis, however, failed to identify any independent associations with COVID‐19 positive status. Conclusion In our cohort, patients postive for COVID‐19 with acute ischemic stroke who undergo mechanical thrombectomy have similar baseline characteristics, imaging features, procedural, and clinical outcomes compared to patients who are negative for COVID‐19 in multivariate analysis. Further analyses are warranted.

Background We identified risk factors, derived and validated a prognostic score for poor neurological outcome and death for use in cerebral venous thrombosis (CVT). Methods We performed an international multicenter retrospective study including consecutive patients with CVT from January 2015 to December 2020. Demographic, clinical, and radiographic characteristics were collected. Univariable and multivariable logistic regressions were conducted to determine risk factors for poor outcome, mRS 3-6. A prognostic score was derived and validated. Results A total of 1,025 patients were analyzed with median 375 days (interquartile range [IQR], 180 to 747) of follow-up. The median age was 44 (IQR, 32 to 58) and 62.7% were female. Multivariable analysis revealed the following factors were associated with poor outcome at 90- day follow-up: active cancer (odds ratio [OR], 11.20; 95% confidence interval [CI], 4.62 to 27.14; P

As of May 2022, there have been more than 400 million cases (including re-infections) of the systemic acute respiratory syndrome-coronavirus 2 (SARS-CoV-2), and nearly 5 million deaths worldwide. Not only has the coronavirus disease 2019 (COVID-19) pandemic been responsible for diagnosis and treatment delays of a wide variety of conditions, and overwhelmed the allocation of healthcare resources, it has impacted the epidemiology and management of cerebrovascular disease. In this narrative review, we summarize the changing paradigms and latest data regarding the complex relationship between COVID-19 and cerebrovascular disease. Paradoxically, although SARS-CoV-2 has been associated with many thrombotic complications—including ischemic stroke—there have been global declines in ischemic stroke and other cerebrovascular diseases. These epidemiologic shifts may be attributed to patient avoidance of healthcare institutions due to fear of contracting the novel human coronavirus, and also related to declines in other transmissible infectious illnesses which may trigger ischemic stroke. Despite the association between SARS-CoV-2 and thrombotic events, there are inconsistent data regarding targeted antithrombotics to prevent venous and arterial events. In addition, we provide recommendations for the conduct of stroke research and clinical trial planning during the ongoing COVID-19 pandemic, and for future healthcare crises.

Background and Purpose Recent studies suggested an increased incidence of cerebral venous thrombosis (CVT) during the coronavirus disease 2019 (COVID-19) pandemic. We evaluated the volume of CVT hospitalization and in-hospital mortality during the 1st year of the COVID-19 pandemic compared to the preceding year. Methods We conducted a cross-sectional retrospective study of 171 stroke centers from 49 countries. We recorded COVID-19 admission volumes, CVT hospitalization, and CVT in-hospital mortality from January 1, 2019, to May 31, 2021. CVT diagnoses were identified by International Classification of Disease-10 (ICD-10) codes or stroke databases. We additionally sought to compare the same metrics in the first 5 months of 2021 compared to the corresponding months in 2019 and 2020 (ClinicalTrials.gov Identifier: NCT04934020). Results There were 2,313 CVT admissions across the 1-year pre-pandemic (2019) and pandemic year (2020); no differences in CVT volume or CVT mortality were observed. During the first 5 months of 2021, there was an increase in CVT volumes compared to 2019 (27.5%; 95% confidence interval [CI], 24.2 to 32.0; P

Introduction Two recent trials demonstrated a benefit for endovascular thrombectomy (EVT) in the treatment of basilar artery occlusion (BAO). Considering the expected increase in the utilization of EVT for BAO, we sought to understand the technique preferences of neurointerventionalists currently performing EVT for BAO. Methods We conducted an international online survey of physician opinions on the use of EVT in BAO between January to March 2022. The survey was distributed through stroke and neurointerventional organizations. Survey questions examined selection of patients for the procedure and the techniques currently used for EVT in BAO. Results More than 3,000 participants were invited yielding 1,245 respondents, of which 543 were classified as neurointerventionalists across 52 countries and included in this analysis. Most neurointerventionalists would proceed to EVT for occlusions of the V4 segment, the basilar artery, or the PCA, without regard for prior IVT. For BAO of embolic etiology, aspiration only thrombectomy was the preferred method with 50.3% of neurointerventionalists. For BAO of intracranial atherosclerotic disease (ICAD) etiology, combined stent retriever and aspiration thrombectomy was the preferred method with 40.5% of neurointerventionalists (Figure 1). The majority of neurointerventionalists (88.0%) would proceed to stenting after three or fewer failed passes for patients with BAO of ICAD etiology. In patients undergoing stenting, aspirin and clopidogrel was the most common antiplatelet regime (52.4%). Conclusions Amongst the surveyed neurointerventionalists, the most common techniques for EVT of patients with BAO were contact aspiration or combined stent retriever with aspiration thrombectomy. For patients with BAO due to ICAD, the majority of neurointerventionalists were willing to stent and do so most often after three or fewer failed passes and with the use of dual antiplatelet medications. Further study is needed to determine the optimal technique for EVT of BAO with or without ICAD.

Introduction Mechanical thrombectomy has become the standard of care to treat acute ischemic stroke patients with large vessel occlusions. Device performance and physician technique have developed since early trials proving the efficacy of the procedure1‐3. One of these techniques, direct aspiration first pass technique (ADAPT)4involves navigating a large‐bore catheter to the face of the clot and initiating suction. Navigating large‐bore catheters through intracranial neurovasculature has been accomplished using microcatheters and/or guidewires. Due to the large sizes of these aspiration catheters, the microcatheters used to help deliver the aspiration catheters into the brain form a “ledge” between the disparate lumens and prevent progression of the aspiration catheter into the distal neurovasculature and increase the risk of damaging arteries during advancement. A novel navigation support catheter, the Tenzing Delivery Catheter, has shown promising benchtop performance assisting large‐bore aspiration catheter delivery to the occlusion sitein vitro5. It demonstrated superior performance over traditional microcatheter/guidewire techniques in delivering the aspiration catheter to the occlusion in this model. While limited initial clinical experience from examining a small sample group appears to confirm this observation, a cumulative, large‐scale analysis of experience using the Tenzing catheter in clinical practice to further examine its safety, efficacy, and usability has not yet been performed. With that in mind, this study serves as an initial multicenter first‐experience investigation to assess the aforementioned factors and determine the utilization potential of Tenzing catheters. Methods This study was conducted via retrospective chart review across three institutions. Patients included in the study are 18 years old or older, underwent a thrombectomy procedure between January 1, 2020 and July 31, 2022, and whose procedures involved the use of the Tenzing delivery catheter system. Our primary outcome measures were success in delivering aspiration catheter, post treatment thrombus, and perioperative complications. Results In our sample size of n = 95, inclusive of patients from multiple institutions, it was found that in 96% of cases, the Tenzing catheter was successfully delivered to the occlusion site and successful reperfusion (mTICI less than or equal to 2b) was achieved in 90% of cases.In the majority of cases, the Tenzing delivery catheter was used to deliver an aspiration catheter to a middle cerebral artery occlusion (75%). Tenzing was advanced past the occlusion location (identified as the angiographic limit of contrast) in 59% of cases. Secondary emboli were observed 11% of the time. Other procedural complications were observed in 8% of patients while none was seen in 74%. On average, the median NIHSS decreased from 17 pre‐treatment to 10 post‐treatment. Conclusions Based on these findings, we conclude that the Tenzing Delivery Catheter is a safe and efficacious instrument in thrombectomy procedures. Given its high rate of revascularization and delivery success with few complications as demonstrated in this multicenter study.Future studies with larger patient volume are necessary to evaluate this important delivery catheter as it is used more frequently around the world.

Introduction Despite the irrefutable benefit of mechanical thrombectomy for patients with isolated intracranial large vessel occlusions (LVO), the effect of endovascular treatment in patients with tandem lesions remains unclear. In this study from the multi‐center PICASSO registry, we compare efficacy and safety outcomes in TLs patients treated in the early versus late window. Methods In this study, we used the data from the multi‐center PICASSO (Proximal Internal Carotid Artery Acute Stroke Secondary to Tandem Occlusion Thrombectomy) registry. PICASSO collaboration is a retrospective observational registry from 17 stroke centers. We compared efficacy and safety outcomes in TLs patients treated in the early versus late window. Patients were divided into two groups depending on last known well (LKW) to puncture time: Early time‐window group (

Introduction There are two approaches for treating stroke patients with tandem occlusions: the anterograde approach (AA, extracranial lesions first) and the retrograde approach (RA, intracranial lesion first). Both techniques are associated with favorable functional outcomes. We aimed to compare both techniques for efficacy and safety outcomes in a multicenter study. Methods Patient data were pooled from 17 centers and divided into AA and RA groups. We performed multivariable logistic regressions to evaluate the association between each group with efficacy and safety outcomes. Results 552 patients were included in the study, 270 (48.4%) were treated with the AA, and 288 (51.6%) with the RA. There were no differences between groups for functional outcome (mRS 0–2) at 90 days (aOR = 0.93, 95%CI: 0.58‐1.48, p = 0.75), and successful reperfusion [mTICI >2b] (aOR = 0.83, 95%CI: 0.44‐1.56, p = 0.57). Similarly, we did not observe any differences for safety outcomes related to sICH (OR = 0.57, 95%CI: 0.25‐1.29, p = 0.18), parenchymal hematoma type 2 (OR = 0.61, 95%CI: 0.3‐1.22, p = 0.16), and all‐cause mortality at 90 days (OR = 1.22, 95%CI: 0.66‐2.26, p = 0.52). However, the median puncture‐to‐reperfusion time was higher in AA compared with RA [59 minutes (IQR: 38–92) vs 53.5 minuntes (IQR: 37–87)]. Conclusions The AA and RA approaches for the treatment of tandem occlusions seem to achieve similar efficacy and safety outcomes. These results are consistent with those of a previous multi‐center study. Additionally, and in line with previous research, there is a puncture‐to‐reperfusion time difference between both approaches, which suggests a potential benefit when using the RA. However, further prospective randomized studies are needed to elucidate its benefit in achieving better clinical outcomes.

Background Two recent trials demonstrated a benefit for endovascular therapy (EVT) in the treatment of basilar artery occlusion (BAO). In light of the expected increase in the use of EVT for BAO, we sought to understand the technique preferences of neurointerventionalists performing EVT for BAO. Methods We conducted an international online survey of physician opinions on the use of EVT in BAO between January and March 2022. The survey was distributed through stroke and neurointerventional organizations. Survey questions examined selection of patients for the procedure and the techniques currently used for EVT in BAO. Responses from neurointerventionalists were analyzed. Results More than 3000 participants were invited yielding 1245 respondents, of whom 543 were classified as neurointerventionalists across 52 countries and included in this analysis. Most neurointerventionalists would proceed to EVT for occlusions of the V4 segment, the basilar artery, or the posterior cerebral artery, without regard for prior intravenous thrombolysis. For BAO of embolic etiology, aspiration only thrombectomy was the preferred method of 50.3% of neurointerventionalists. For BAO of intracranial atherosclerotic disease etiology, combined stent retriever and aspiration thrombectomy was the preferred method of 40.5% of neurointerventionalists. The majority of neurointerventionalists (88.0%) would proceed to stenting after 3 or fewer failed passes for patients with BAO of intracranial atherosclerotic disease etiology. In patients undergoing stenting, aspirin and clopidogrel was the most common antiplatelet regime (52.4%). Conclusions Among the surveyed neurointerventionalists, the most common techniques for EVT of patients with BAO were contact aspiration or combined stent retriever with aspiration thrombectomy. For patients with BAO due to intracranial atherosclerotic disease, the majority of neurointerventionalists were willing to stent and do so most often after 3 or fewer failed passes and with the use of dual antiplatelet medications. Further study is needed to determine the optimal technique for EVT of BAO with or without intracranial atherosclerotic disease. Key Words

Background Current stroke guidelines recommend advanced imaging (computed tomography [CT] perfusion or magnetic resonance imaging) prior to endovascular therapy (EVT) in patients with late presentation of large vessel occlusion. Adherence to guidelines may be constrained by resources or timely access to imaging. We sought to understand the factors which influence late window imaging selection for EVT candidates with large vessel occlusion. Methods We conducted an international survey from January to May 2022. The questions aimed to identify advanced imaging and treatment decisions based on access to imaging, time delays, and simulated patient scenarios. Results There were 3000 invited participants and 1506 respondents, the majority (89.6%) from comprehensive stroke centers in high‐income countries. Neurointerventionalists comprised 31.8% and noninterventionalists 68.2% of respondents. Overall, 70.7% reported routine use of advanced imaging for late EVT selection, and 63.6% reported its usage in every case. There was greater availability of advanced imaging in comprehensive stroke centers versus primary stroke centers (67.0% versus 33.7%; P

Background Recent clinical trials investigating endovascular therapy in the extended time window have opened new treatment paradigms for patients with late‐presenting large vessel occlusion stroke. The aim of this guideline is to provide up‐to‐date recommendations for the diagnosis, selection, and medical or endovascular treatment of patients with large vessel occlusion presenting in the extended time window. Methods The Society of Vascular and Interventional Neurology Guidelines and Practice Standards committee assembled a writing group and recruited interdisciplinary experts to review and evaluate the current literature. Recommendations were assigned by the writing group using the Society of Vascular and Interventional Neurology Guidelines and Practice Standards Class of Recommendation/Level of Evidence algorithm and Society of Vascular and Interventional Neurology Guidelines and Practice Standards guideline format. The final guideline was approved by all members of the writing group, the Guidelines and Practice Standards committee, and the Society of Vascular and Interventional Neurology board of directors. Results Literature review yielded 3 high‐quality randomized trials and several observational studies that have been extracted to derive the enclosed summary recommendations. In patients with large vessel occlusion presenting in the 6‐ to 24‐hour window and with clinical–imaging mismatch as defined by the DAWN (Diffusion‐Weighted Imaging or Computed Tomography Perfusion Assessment With Clinical Mismatch in the Triage of Wake‐Up and Late Presenting Strokes Undergoing Neurointervention With Trevo) and DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke) studies, endovascular therapy is recommended. Noncontrast computed tomography can be used to evaluate infarct size as the sole imaging modality for patient selection, particularly when access to computed tomography perfusion or magnetic resonance imaging is limited or if their performance would incur substantial delay to treatment. In addition, several clinical questions were reviewed based on the available evidence and consensus grading. Conclusions These guidelines provide practical recommendations based on recent evidence on the diagnosis, selection, and treatment of patients with large vessel occlusion stroke presenting in the extended time window.

Not in the history of transmissible illnesses has there been an infection as strongly associated with acute cerebrovascular disease as the novel human coronavirus SARS-CoV-2. While the risk of stroke has known associations with other viral infections, such as influenza and human immunodeficiency virus, the risk of ischemic and hemorrhagic stroke related to SARS-CoV-2 is unprecedented. Furthermore, the coronavirus disease 2019 (COVID-19) pandemic has so profoundly impacted psychosocial behaviors and modern medical care that we have witnessed shifts in epidemiology and have adapted our treatment practices to reduce transmission, address delayed diagnoses, and mitigate gaps in healthcare. In this narrative review, we summarize the history and impact of the COVID-19 pandemic on cerebrovascular disease, and lessons learned regarding the management of patients as we endure this period of human history.

Background The COVID‐19 pandemic has disproportionately affected Black and Hispanic communities, whose stroke care has been previously shown to experience existing disparities. We sought to evaluate how these disparities in stroke care and in‐hospital mortality have been affected by the COVID‐19 pandemic. Methods In this retrospective observational cohort study, we evaluated stroke hospitalizations in the Society of Vascular and Interventional Neurology COVID‐19 registry. We compared stroke characteristics between non‐Hispanic White, non‐Hispanic Black, and Hispanic patients pre–COVID‐19 and post–COVID‐19 (March–July 2019 versus March–July 2020) and evaluated whether racial and ethnic differences present before the pandemic were exacerbated during the pandemic. Our primary outcome was in‐hospital mortality/discharge to hospice, and secondary outcomes were acute treatment use. Results Of the 4908 included patients, numerically fewer non‐Hispanic White and Hispanic patients were evaluated during COVID‐19. Non‐Hispanic White and non‐Hispanic Black patients with large‐vessel occlusion were more likely to undergo thrombectomy (P

Background The best management of basilar artery occlusion (BAO) remains uncertain. The BASICS (Basilar Artery International Cooperation Study) and the BEST (Basilar Artery Occlusion Endovascular Intervention Versus Standard Medical Treatment) trials reported neutral results. We sought to understand physicians’ approaches to BAOs and whether further BAO randomized controlled trials were warranted. Methods We conducted an online international survey from January to March 2022 to stroke neurologists and neurointerventionalists. Survey questions were designed to examine clinical and imaging parameters under which clinicians would offer (or rescind) a patient with BAO to endovascular therapy (EVT) or best medical management versus enrollment into a randomized clinical trial. Results Of >3002 invited participants, 1245 responded (41.4% response rate) from 73 countries, including 54.7% stroke neurologists and 43.6% neurointerventionalists. More than 95% of respondents would offer EVT to patients with BAO, albeit in various clinical circumstances. There were 70.0% of respondents who indicated that the BASICS and BEST trials did not change their practice. Only 22.1% of respondents would perform EVT according to anterior circulation occlusion criteria. The selection of patients for BAO EVT by clinical severity, timing, and imaging modality differed according to geography, specialty, and country income level. Over 80% of respondents agreed that further randomized clinical trials for BAO were warranted. Moreover, 45.6% of respondents indicated they would find it acceptable to enroll all trial‐eligible patients into the medical arm of a BAO trial, whereas 26.3% would not enroll. Conclusion Most stroke physicians continue to believe in the efficacy of EVT in selected patients with BAO in spite of BEST and BASICS. There is no consensus on which selection criteria to use, and few clinicians would use anterior circulation occlusion criteria for BAOs. Further randomized clinical trials for BAO are warranted.

Background Compared with non‐Hispanic White patients, non‐Hispanic Black (NHB) and Hispanic populations are less likely to receive acute treatment for ischemic stroke, and when they do, it can be delayed. We evaluated the interaction between arrival method and race or ethnicity on door‐to‐arterial puncture (DTAP) time in thrombectomy. Methods We conducted a retrospective observational cohort study of consecutive adults who underwent endovascular thrombectomy from 14 US Comprehensive Stroke Centers (January 1, 2019–July 31, 2020). DTAP was assessed in a linear mixed model including an interaction term for race or ethnicity and arrival method. Results Of the 1908 included patients, 356 of whom were Hispanic, Hispanic and NHB patients experienced significant delays in DTAP compared with non‐Hispanic White patients (adjusted βHisp=0.32, 95% CI, 0.08–0.55; βNHB=0.23; 95% CI, 0.04–0.41). More severe deficits were associated with shorter DTAP (βNIHSS per point −0.03; 95% CI −0.04 to −0.03), and arrival via emergency medical services or private vehicle versus transfer were associated with longer delays (βEMS=0.57; 95% CI, 0.41–0.74; βPV=1.27; 95% CI, 0.85–1.70). There was a significant interaction between Hispanic ethnicity and emergency medical services (P=0.03) or private vehicle arrival (P=0.04) in a direction favoring shorter treatment delays. Sites that treated a minority population of Hispanic patients (

Background The Society of Vascular & Interventional Neurology Guidelines and Practice Standards committee established the “Brief Practice Update” format to provide up‐to‐date recommendations on focused clinical topics with emerging clinical trial results. For our inaugural Brief Practice Update, we review current evidence and provide recommendations for administering intravenous thrombolysis before mechanical thrombectomy; combination therapy (mechanical thrombectomy plus intravenous thrombolysis) versus stand‐alone mechanical thrombectomy approach in acute ischemic stroke secondary to emergent large vessel occlusion. Methods The Society of Vascular & Interventional Neurology Guidelines and Practice Standards committee members formed a writing group to review results of the most recent clinical trials of pre‐mechanical thrombectomy intravenous thrombolysis. The group summarized recent clinical data to provide recommendations for clinical practice. Brief Practice Update recommendations were vetted by the Guidelines and Practice Standards quality committee to ensure adherence to Society of Vascular & Interventional Neurology standard evaluation of evidence and endorsement was obtained following formal review by the Board of Directors. Results We present a focused review of recently published clinical trials and a meta‐analysis of combination intravenous thrombolysis and mechanical thrombectomy versus a stand‐alone direct‐to‐mechanical thrombectomy treatment approach in ischemic stroke patients with emergent large vessel occlusion. Level of evidence and class of recommendation were vetted by the Guidelines and Practice Standards committee. Conclusions We share general recommendations on pre‐mechanical thrombectomy thrombolysis, using analysis of available evidence from recent randomized clinical trial data. Recommendations provided by the Society of Vascular & Interventional Neurology Brief Practice Update are not intended to replace an individualized approach to clinical decision making and patient care.

Background A better understanding of real‐world practice patterns in the endovascular treatment for large vessel occlusion acute ischemic stroke is needed. Here, we report the methods and initial results of the Society of Vascular and Interventional Neurology (SVIN) Registry. Methods The SVIN Registry is an ongoing prospective, multicenter, observational registry capturing patients with large vessel occlusion acute ischemic stroke undergoing endovascular treatment since November 2018. Participating sites also contributed pre‐SVIN Registry data collected per institutional prospective registries, and these data were combined with the SVIN Registry in the SVIN Registry+ cohort. Results There were 2088 patients treated across 11 US centers included in the prospective SVIN Registry and 5372 in SVIN Registry+. In the SVIN Registry cohort, the median number of enrollments per institution was 160 [interquartile range 53–243]. Median age was 67 [58–79] years, 49% were women, median National Institutes of Health Stroke Scale 16 [10–21], Alberta stroke program early CT score 9 [7–10], and 20% had baseline modified Rankin scale (mRS)≥2. The median last‐known normal to puncture time was 7.7 [3.1–11.5] hours, and puncture‐to‐reperfusion was 33 [23–52] minutes. The predominant occlusion site was the middle cerebral artery‐M1 (45%); medium vessel occlusions occurred in 97(4.6%) patients. The median number of passes was 1 [1–3] with 93% achieving expanded Treatment In Cerebral Ischemia2b50–3 reperfusion and 51% expanded Treatment In Cerebral Ischemia3/complete reperfusion. Symptomatic intracranial hemorrhage occurred in 5.3% of patients, with 37.3% functional independence (mRS0–2) and 26.4% mortality rates at 90‐days. Multivariable regression indicated older age, longer last‐normal to reperfusion, higher baseline National Institutes of Health Stroke Scale and glucose, lower Alberta stroke program early CT score, heart failure, and general anesthesia associated with lower 90‐day chances of mRS0–2 at 90‐days. Demographic, imaging, procedural, and clinical outcomes were similar in the SVIN Registry+. A comparison between AHA Guidelines‐eligible patients from the SVIN Registry against the Highly Effective Reperfusion evaluated in Multiple Endovascular Stroke Trials study population demonstrated comparable clinical outcomes. Conclusions The prospective SVIN Registry demonstrates that satisfactory procedural and clinical outcomes can be achieved in real‐world practice, serving as a platform for local quality improvement and the investigation of unexplored frontiers in the endovascular treatment of acute stroke.

Abstract Objective To describe the frequency and the distribution of degenerative disc disease (DDD) detected in athletes who underwent spine MRI in the 2016 Summer Olympic Games in Rio de Janeiro. Methods Data on spine MRI examinations from the 2016 Summer Olympics were retrospectively analyzed. We assessed the frequency of DDD of the cervical (Cs), thoracic (Ts), and lumbar (Ls) spine using Pfirrmann’s classification. Grade II and III were considered as mild, grade IV as moderate, and grade V as severe disc degeneration. Data were analyzed according to the location of the degenerative disc, type of sport, age-groups, and gender of the athletes. Results One hundred out of 11,274 athletes underwent 108 spine MRI’s (21 C, 6 T, and 81 L) (53% Females (F), 47% Males (M)). The frequency of DDD was 40% (42% F, 58% M) over the entire spine (28% mild, 9% moderate and 3% severe). There were 58% (12%F, 88%M) of the cervical spine discs that showed some degree of degeneration (44% mild, 13.5% moderate and 1% severe). Athletics, Boxing, and Swimming were the sports most affected by DDD in the Cs. There were 12.5% of the thoracic discs that showed some degree of degeneration, all were mild DDD and were exclusively seen in female athletes. There were 39% (53% F, 47% M) of the lumbar discs with DDD (26% mild, 9% moderate, and 4% severe). Conclusion Athletes who underwent spine MRI during the 2016 Summer Olympic Games show a high frequency of DDD of cervical and lumbar spines. Recognition of these conditions is important to develop training techniques that may minimize the development of degenerative pathology of the spine.

Background Fetal posterior cerebral artery (FPCA) occlusion is a rare but potentially disabling cause of stroke. While endovascular treatment is established for acute large vessel occlusion stroke, FPCA occlusions were excluded from acute ischemic stroke trials. We aim to report the feasibility, safety, and outcome of mechanical thrombectomy in acute FPCA occlusions. Methods We performed a multicenter retrospective review of consecutive patients who underwent mechanical thrombectomy of acute FPCA occlusion. Primary FPCA occlusion was defined as an occlusion that was identified on the pre‐procedure computed tomography angiography or baseline angiogram whereas a secondary FPCA occlusion was defined as an occlusion that occurred secondary to embolization to a new territory after recanalization of a different large vessel occlusion. Demographics, clinical presentation, imaging findings, endovascular treatment, and outcome were reviewed. Results There were 25 patients with acute FPCA occlusion who underwent mechanical thrombectomy, distributed across 14 centers. Median National Institutes of Health Stroke Scale on presentation was 16. There were 76% (19/25) of patients who presented with primary FPCA occlusion and 24% (6/25) of patients who had a secondary FPCA occlusion. The configuration of the FPCA was full in 64% patients and partial or “fetal‐type” in 36% of patients. FPCA occlusion was missed on initial computed tomography angiography in 21% of patients with primary FPCA occlusion (4/19). The site of occlusion was posterior communicating artery in 52%, P2 segment in 40% and P3 in 8% of patients. Thrombolysis in cerebral infarction 2b/3 reperfusion was achieved in 96% of FPCA patients. There were no intraprocedural complications. At 90 days, 48% (12/25) were functionally independent as defined by modified Rankin scale≤2. Conclusions Endovascular treatment of acute FPCA occlusion is safe and technically feasible. A high index of suspicion is important to detect occlusion of the FPCA in patients presenting with anterior circulation stroke syndrome and patent anterior circulation. Novelty and significance This is the first multicenter study showing that thrombectomy of FPCA occlusion is feasible and safe.