Outcomes and Safety of Revascularization Approaches for Stroke Related to Isolated Vertebral Artery Occlusions (BRAVO)

 'Better' and 'may' signify COMPLETE FUCKING FAILURE OF 100% RECOVERY! Don't you even know that is the only goal in stroke and you aren't even measuring that. With NO measurements, you'll never get there! 

Here is your business101 requirements. Not measuring 100% recovery is the height of incompetence!

“What's measured, improves.” So said management legend and author Peter F. Drucker ) 

The latest here:

Outcomes and Safety of Revascularization Approaches for Stroke Related to Isolated Vertebral Artery Occlusions (BRAVO)

Alexander Salerno, MD, PhD https://orcid.org/0000-0001-8494-5527 alexander.salerno@chuv.ch, 

Vincent Dunet, MD https://orcid.org/0000-0002-9897-4561, 

Marek Sykora, MD, PhD https://orcid.org/0000-0003-3508-2176, 

Philipp Baumgartner, MD https://orcid.org/0000-0003-1525-2019, 

Visnja Padjen, MD, PhD https://orcid.org/0000-0002-6126-8305, 

Guido Bigliardi, MD https://orcid.org/0000-0001-5312-7206, 

Dylan Ryan, MD https://orcid.org/0000-0001-7254-0020, … Show All … on behalf of the EVA-TRISP and BRAVO Investigators

Abstract

BACKGROUND:

The best revascularization strategy for acute ischemic stroke from isolated vertebral artery occlusion remains unclear.

METHODS:

This retrospective, international, multicenter cohort study included patients from 30 comprehensive stroke centers across Europe (n=23), North America (n=5), and Asia (n=2) between 2016 and 2022. Eligible patients presented with acute ischemic stroke within 24 hours of last seen well and had imaging-confirmed isolated vertebral artery occlusion. Two treatment comparisons were analyzed: intravenous thrombolysis (IVT)-only versus conservative treatment (Cx), and endovascular treatment (EVT)±IVT versus medical management (Cx and IVT). The primary outcome was the shift in 3-month modified Rankin Scale (mRS) score; secondary outcomes included early neurological improvement (24-hour-delta National Institutes of Health Stroke Scale score), recanalization, early neurological deterioration of ischemic origin, symptomatic intracerebral hemorrhage, and 3-month mortality. Analyses were adjusted using inverse probability of treatment weighting (IPTW).

RESULTS:

Among 494 patients, 143 (29%) received Cx, 218 (44%) IVT-only, and 133 (27%) EVT±IVT. Compared with Cx, IVT-only showed similar 3-month mRS score (IPTW-adjusted odds ratio [aOR] mRS shift score, 1.32 [95% CI, 0.80–2.18]), greater early neurological improvement (IPTW-adjusted-β coefficient, −1 [95% CI, −2.05 to 0.05]), and higher recanalization rates (IPTW-aOR, 4.33 [95% CI, 1.36–13.78]). Compared with MM (=IVT+Cx), EVT±IVT was associated with an unfavorable mRS shift score (IPTW-aOR mRS shift score, 0.51 [95% CI, 0.35–0.74]), higher early neurological deterioration of ischemic origin (IPTW-aOR, 9.06 [95% CI, 2.86–28.67]), and symptomatic intracerebral hemorrhage (IPTW-aOR, 6.05 [95% CI, 1.14–32.1]) though recanalization was over 4-fold higher (OR, 4.64 [95% CI, 1.90–11.33]). Patients with National Institutes of Health Stroke Scale score ≥10 showed point estimates favoring EVT+IVT (Pinteraction=0.025).

CONCLUSIONS:

IVT-only appeared safe and was associated with better early recovery and recanalization. EVT±IVT showed overall worse outcomes, potentially due to increased early neurological deterioration of ischemic origin and symptomatic intracerebral hemorrhage rates, but may confer benefit in moderate-to-severe strokes, warranting prospective trials in symptomatic isolated vertebral artery occlusion.

Graphical Abstract

Despite robust evidence demonstrating the benefits of revascularization treatments for large vessel occlusions in anterior circulation strokes, the optimal acute management of occlusive posterior circulation (PC) acute ischemic strokes (AISs) other than basilar artery occlusion (BAO) remains less clear.

High relative cerebral blood volume strongly predicts early neurological improvement and good functional outcome in ischemic stroke patients undergoing mechanical thrombectomy

 Are these a solution? You mean your incompetent? doctor and hospital have nothing to deliver better blood flow and oxygen to your brain immediately post stroke! And your board of directors is so incompetent they don't recognize incompetence in their hospital?

Dose Escalation and Safety of Capsaicin for Cerebral Perfusion Augmentation July 2021

cerebral blood flow (51 posts to December 2015)

oxygen delivery (41 posts to June 2016)

High relative cerebral blood volume strongly predicts early neurological improvement and good functional outcome in ischemic stroke patients undergoing mechanical thrombectomy

Paweł Wrona, Dominik Wróbel, Julia Staniszewska, Gabriela Kapral, Milena Derechowska, Gabriela Turaj, Tadeusz Popiela, Agnieszka Słowik, Wojciech Turaj

DOI: 10.5603/pjnns.106870

Pubmed: 41705962

Abstract

Aim of the study. Despite advancements in mechanical thrombectomy (MT) in the treatment of acute ischemic stroke (AIS) due to large vessel occlusion, nearly half of patients with successful recanalization do not achieve good functional outcome (GFO). We aimed to analyze the association between novel perfusion-based biomarkers and prognosis after AIS.Clinical rationale for the study. The role of perfusion imaging biomarkers, particularly relative cerebral blood volume (rCBV), as an indicator of tissue-level collateral circulation and a predictor of post-MT clinical trajectory remains insufficiently explored.

Material and methods. This single-center retrospective study included patients with anterior circulation AIS who achieved successful recanalization following MT at the Comprehensive Stroke Center, University Hospital, Krakow, between January 2019 and July 2023. We evaluated the predictive value of rCBV for early neurological improvement (ENI) and long-term GFO and compared its prognostic utility with other perfusion-based parameters. Furthermore, we assessed the extent to which the effect of rCBV on GFO was mediated by its influence on ENI. Early neurological improvement was defined as a ≥ 4-point reduction in the National Institutes of Health Stroke Scale score or complete symptom resolution within 24 hours post-admission. GFO was defined as a modified Rankin Scale score of < 3 at 90 days.

Results. Relative cerebral blood volume was an independent predictor of 90-day GFO after multivariable adjustment (adjusted odds ratio [aOR] = 1.38; 95% confidence interval [CI]: 1.19–1.6; p < 0.001). Additionally, total hypoperfusion volume (T6max) independently contributed to GFO prediction when included alongside rCBV (aOR = 0.96 per 10 mL increase; 95% CI: 0.94–0.99; p = 0.019), enhancing prognostic accuracy. Relative cerebral blood volume was also a strong predictor of ENI (aOR = 1.35; 95% CI: 1.19–1.54; p < 0.001), with 35% (4–67%; p = 0.029) of its effect on GFO mediated through its impact on ENI.

Conclusion and clinical implications. Relative cerebral blood volume is a robust predictor of both early neurological recovery and long-term functional outcome following MT. Moreover, T6max provides independent prognostic value when assessed in conjunction with rCBV, suggesting that these parameters complement each other. Their combined assessment provides a more comprehensive understanding of ischemic tissue fate, aiding clinical decision-making in patients selected for MT.

(My conclusion, you completely failed in your research; DIDN'T CREATE A PROTOCOL TO DELIVER THE BETTER BLOOD FLOW!)

Keywords: mechanical thrombectomycomputed tomography perfusionacute ischemic strokerelative cerebral blood volume

Article available in PDF format

Association between endothelial function and early neurological improvement in atrial fibrillation-related ischemic stroke

'Associations' DO NOTHING FOR SURVIVOR RECOVERY! Are you that blitheringly stupid you don't know that survivors would like recovery rather than a completely fucking useless 'association'?  By not writing a protocol on this, you were actually WORSE THAN USELESS! You're all fired!

 Association between endothelial function and early neurological improvement in atrial fibrillation-related ischemic stroke

So Young Yang^1,2Sung Hee Ahn³Jeonggeun Moon²Yeong-Bae Lee⁴Dae-il Chang⁴Sang Hee Ha^4*

• ¹Department of Cardiology, Kyung Hee University College of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
• ²Department of Cardiology, Gil Medical Center, Gacheon University, Incheon, Republic of Korea
• ³Department of Big Data Management and Engineering, Namseoul University, Chungcheongnam-do, Republic of Korea
• ⁴Department of Neurology, Gil Medical Center, Gacheon University, Incheon, Republic of Korea

Background: Understanding the factors related to early neurological improvement (ENI) is crucial in managing atrial fibrillation-related ischemic stroke (AF-stroke), as ENI indicates better long-term outcomes. We investigated the association between endothelial function, measured via flow-mediated dilation (FMD), and the occurrence of ENI in patients with AF-stroke.

Methods: We reviewed patients with acute AF-stroke within 7 days of FMD between April 2019 and April 2025. ENI was defined as a ≥2-point decrease in National Institutes of Health Stroke Scale (NIHSS) or ≥1-point reduction in motor NIHSS items within 24 h in non-thrombolysis patients. For thrombolysis patients, ENI was a ≥8-point reduction or NIHSS 0–1 at 24 h. FMD was measured during hospitalization and expressed as %FMD = (peak diameter − baseline diameter) / Baseline diameter × 100. Multivariable analysis identified the factors associated with ENI and explored their relationship with FMD.

Results: Among the 169 patients diagnosed with AF-stroke, 77 (44.4%) experienced ENI. Those with ENI had higher NIHSS (7 [4–13] vs. 2 [1–5], p < 0.001), more confluent (38.7% vs. 25.5%) and scattered with confluent pattern (29.3% vs. 18.1%, p = 0.007), and higher %FMD (6.5% ± 2.5% vs. 5.3 ± 2.2%, p = 0.001). Multivariable analysis revealed a higher initial NIHSS score (adjusted odds ratio [aOR]: 1.329, p < 0.001) and a history of smoking (aOR: 4.532, p = 0.004), and higher %FMD score (aOR: 1.179; p = 0.043) were independently associated with ENI. Subgroup analysis demonstrated a stronger association between high %FMD and ENI in patients with concomitant vascular risk factors, such as hypertension and dyslipidemia.

Conclusion: Endothelial function was associated with ENI in patients with AF-stroke.

1 Introduction

More than 20% of stroke cases are caused by cardiac embolism attributable to atrial fibrillation (AF) (1). Compared to strokes of other etiologies, AF-related ischemic stroke (AF-stroke) is associated with greater severity and a higher risk of disability and mortality (2). This may be due to large infarct volumes resulting from the abrupt occlusion of blood flow by a clot originating in the heart, often without sufficient time for collateral circulation to compensate (3). Numerous studies have shown that AF-stroke is associated with a lower likelihood of early neurological improvement (ENI) (2, 4, 5). Nevertheless, ENI can still occur in a subset of patients with AF-stroke and is associated with favorable functional outcomes (6).

Several factors have been linked to ENI, including successful recanalization, collateral status, and smaller infarct core size (6–8). Additionally, the endothelium plays multiple roles in stroke pathophysiology and recovery by regulating vascular tone, maintaining blood–brain barrier (BBB) integrity, modulating inflammatory responses, and influencing thrombotic and fibrinolytic balance (9–11). Patients who have experienced acute ischemic stroke (AIS) with impaired FMD are associated with early neurological deterioration and poor long-term outcome (12). Furthermore, endothelial function is associated with the development of AF and AF-stroke by promoting atrial remodeling, thrombogenesis, and hemodynamic alterations (13, 14). However, whether endothelial function influences the capacity for early neurological recovery in patients with AF-stroke remains unclear.

Brachial artery flow-mediated dilation (FMD), assessed using high-resolution ultrasonography, is a widely used tool to evaluate endothelial function (15). In this study, we aimed to identify the factors associated with ENI in patients with AF-stroke, with a particular focus on the role of endothelial function as measured by FMD.

More at link.

A machine learning-based predictive nomogram for early neurological improvement after thrombolysis in acute ischemic stroke

Predictions don't get you recovered! What are the EXACT PROTOCOLS THAT DELIVER RECOVERY?  If you can't do proper stroke research; get the hell out and do something simpler like basket weaving!

A machine learning-based predictive nomogram for early neurological improvement after thrombolysis in acute ischemic stroke

Bing-Hua Lv^1†Hao-wei Deng^1†Zuo-yv Qin¹Ning-qin Meng²Gui-ming Weng¹Rui-Ting Hu^3*Chao Qin^1*

• ¹Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
• ²Department of Rheumatology and Immunology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
• ³Department of Neurology, Minzu Hospital of Guangxi Medical University, Nanning, China

Background: Early neurological improvement (ENI) is a critical prognostic indicator for acute ischemic stroke (AIS) patients undergoing intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA). This study aimed to develop and validate a machine learning (ML)-based model for predicting ENI using clinical and biochemical data.

Methods: Clinical data from 217 AIS patients (97 ENI, 120 non-ENI) were retrospectively analyzed. Significant baseline differences were identified between groups, including hemorrhage, onset-to-needle time (ONT), neutrophil-to-lymphocyte ratio (NLR), weight, and activated partial thromboplastin time (APTT). Four ML algorithms, including Multilayer Perceptron (MLP), Random Forest (RF), Support Vector Machine (SVM), and XGBoost, were implemented. Model performance was evaluated via area under the receiver operating characteristic curve (AUC). Key predictors were identified by intersecting top-ranked features from all algorithms, followed by logistic regression modeling and nomogram visualization.

Results: The MLP model achieved the highest AUC (0.77) in the testing set, outperforming RF (0.72), SVM (0.63), and XGBoost (0.68). Six overlapping parameters, including APTT, ALT/AST ratio, ONT, mean corpuscular hemoglobin concentration (MCHC), weight, and NLR, were selected as core predictors. The logistic regression model incorporating these parameters yielded an AUC of 0.74, while the nomogram demonstrated that the predictive model exhibited strong discriminative ability (C-index: 0.817) for predicting ENI in rt-PA-treated AIS patients.

Conclusion: This ML-based model effectively predicts ENI in rt-PA-treated AIS patients by integrating critical clinical and biochemical markers. Its application may optimize personalized treatment strategies, enhance clinical decision-making, and improve patient outcomes.

Predictors of failure of early neurological improvement in early time window following endovascular thrombectomy: a multi-center study

 

What fucking stupidity! All you are doing is predicting failure to recover! Survivors want recovery. Create protocols that will do that! Useless.

Predictors of failure of early neurological improvement in early time window following endovascular thrombectomy: a multi-center study

Yuzheng Lai¹ Francesco Diana² Mohammad Mofatteh³ Thanh N. Nguyen⁴ Eric Jou⁵ Sijie Zhou⁶ Hao Sun¹ Jianfeng He¹ Wenshan Yan¹ Yiying Chen¹ Mingzhu Feng⁷ Junbin Chen⁸ Jicai Ma⁸ Xinyuan Li⁹ Heng Meng^10* Mohamad Abdalkader^4* Yimin Chen^7,11*

• ¹Department of Neurology, Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine (Nanhai District Hospital of Traditional Chinese Medicine of Foshan City), Foshan, China
• ²Department of Neuroradiology, A.O.U. San Giovanni di Dio e Ruggi d’Aragona, University of Salerno, Salerno, Italy
• ³School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, United Kingdom
• ⁴Department of Radiology, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
• ⁵School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
• ⁶Department of Surgery of Cerebrovascular Diseases, First People’s Hospital of Foshan, Foshan, China
• ⁷Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People’s Hospital, Foshan, China
• ⁸Department of Neurology, The Affiliated Yuebei People’s Hospital of Shantou University Medical College, Shaoguan, China
• ⁹The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
• ¹⁰Department of Neurology, The First Affiliated Hospital of Jinan University, Clinical Neuroscience Institute of Jinan University, Guangzhou, China
• ¹¹Neuro International Collaboration (NIC), Foshan, China

Background and objective: Endovascular 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.

Methods: We 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.

Results: A 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 < 0.001). Mortality was 7.0% in the ENI group in comparison to 42.1% in the FENI group (p < 0.001). The multiple logistic regression model showed that diabetes mellitus [OR (95% CI), 2.985 (1.070–8.324), p = 0.037], pre-stroke mRS [OR (95% CI), 6.221 (1.421–27.248), p = 0.015], last known well to puncture time [OR (95% CI), 1.010 (1.003–1.016), p = 0.002], modified thrombolysis in cerebral infarction = 3 [OR (95% CI), 0.291 (0.122–0.692), p = 0.005], and number of mechanical thrombectomy passes [OR (95% CI), 1.582 (1.087–2.302), p = 0.017] were the predictors of FENI.

Conclusion: Diabetes mellitus history, pre-stroke mRS, longer last known well-to-puncture time, lack of modified thrombolysis in cerebral infarction = 3, and the number of mechanical thrombectomy passes are the predictors of FENI. Future large-scale studies are required to validate these findings.